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Electrochemotherapy of Primary Colon Rectum Cancer and Local Recurrence: Case Report and Prospective Analysis. J Clin Med 2022; 11:jcm11102745. [PMID: 35628872 PMCID: PMC9143872 DOI: 10.3390/jcm11102745] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 05/05/2022] [Accepted: 05/09/2022] [Indexed: 12/21/2022] Open
Abstract
Purpose: Surgery, radiotherapy, and oncological treatment (chemotherapy and antineoplastic antibodies) are standard treatments of rectal cancer. ECT has shown its effectiveness and suitability in deep solid tumors conducted in both preclinical and clinical studies. We show here an update and preliminary results with locally advanced rectum cancer (LARC) treated with ECT. Methods: Two patients with major clinical response to restaging after neoadjuvant treatment for LARC were subjected to ECT 12 weeks after completing chemo-radiation therapy. One patient was subjected to ECT on a colorectal local recurrence formed after neoadjuvant treatment for LARC and surgery. Computed Tomography and Magnetic Resonance Imaging were used to assess ECT response. Results: The results showed stable disease in two of the three patients treated, while one patient achieved a complete response. The local control of disease is maintained in the patient follow-up. For each patient, a reduction in pain was observed and for the patient with local recurrence, a reduction in bleeding present before ECT was also achieved. Conclusion: Preliminary results showed that ECT is a safe and effective treatment in patients with a major clinical response or local recurrence after neoadjuvant therapy for LARC and allows a reduction in pain and bleeding with a consequent improvement to quality of life.
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Rega D, Granata V, Petrillo A, Pace U, Sassaroli C, Di Marzo M, Cervone C, Fusco R, D’Alessio V, Nasti G, Romano C, Avallone A, Pecori B, Botti G, Tatangelo F, Maiolino P, Delrio P. Organ Sparing for Locally Advanced Rectal Cancer after Neoadjuvant Treatment Followed by Electrochemotherapy. Cancers (Basel) 2021; 13:cancers13133199. [PMID: 34206858 PMCID: PMC8267997 DOI: 10.3390/cancers13133199] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 06/23/2021] [Accepted: 06/23/2021] [Indexed: 12/21/2022] Open
Abstract
Simple Summary This is a Phase II randomized controlled trial conducted with the aim of investigating whether the use of Electrochemotherapy after neoadjuvant therapy (ECT) and before surgery in patients with major clinical response allows for a more conservative surgical approach in patients with Locally Advanced Rectal Cancer (LARC) in comparison with the control group that will not receive ECT. The treatment response, in both the control arm and in the treatment arm, will be assessed using the histopathological tumor regression grade on tissue specimens after local excision. Abstract Background: Currently, 45–55% of rectal cancer patients receive preoperative chemo- radio-therapy for Locally Advanced Rectal Cancer (LARC). The idea of our study is to use Electrochemotherapy (ECT) before surgery, in patients with major clinical response after neoadjuvant therapy, to allow for a more conservative surgical approach. Objective: To evaluate the increase of the complete response rate after neoadjuvant treatment in LARC and to spare organ function due to total mesorectal excision (TME). Patients and Methods: This is a Phase II randomized controlled trial enrolling 70 patients that will be developed in two stages. In the first step, 28 patients will be enrolled: 14 of these will receive ECT for four weeks after neo-adjuvant treatment and then local excision (treatment group) and 14 patients will receive neo-adjuvant treatment and then local excision (control group). If an increase of response rate is observed in the first stage, and/or feasibility/safety is demonstrated, the second stage of the trial will be performed, enrolling an additional 42 patients. The treatment response. in both the control arm and the treatment arm, will be assessed using the histopathological tumor regression grade on tissue specimens after local excision.
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Affiliation(s)
- Daniela Rega
- Division of Colorectal Surgery, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, I-80131 Naples, Italy; (D.R.); (U.P.); (C.S.); (M.D.M.); (C.C.); (P.D.)
| | - Vincenza Granata
- Division of Radiology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, I-80131 Naples, Italy;
- Correspondence:
| | - Antonella Petrillo
- Division of Radiology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, I-80131 Naples, Italy;
| | - Ugo Pace
- Division of Colorectal Surgery, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, I-80131 Naples, Italy; (D.R.); (U.P.); (C.S.); (M.D.M.); (C.C.); (P.D.)
| | - Cinzia Sassaroli
- Division of Colorectal Surgery, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, I-80131 Naples, Italy; (D.R.); (U.P.); (C.S.); (M.D.M.); (C.C.); (P.D.)
| | - Massimiliano Di Marzo
- Division of Colorectal Surgery, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, I-80131 Naples, Italy; (D.R.); (U.P.); (C.S.); (M.D.M.); (C.C.); (P.D.)
| | - Carmela Cervone
- Division of Colorectal Surgery, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, I-80131 Naples, Italy; (D.R.); (U.P.); (C.S.); (M.D.M.); (C.C.); (P.D.)
| | - Roberta Fusco
- IGEA SpA Medical Division-Oncology, Via Casarea 65, Casalnuovo di Napoli, I-80013 Napoli, Italy; (R.F.); (V.D.)
| | - Valeria D’Alessio
- IGEA SpA Medical Division-Oncology, Via Casarea 65, Casalnuovo di Napoli, I-80013 Napoli, Italy; (R.F.); (V.D.)
| | - Guglielmo Nasti
- Division of Abdominal Medical Oncology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, I-80131 Naples, Italy; (G.N.); (C.R.); (A.A.)
| | - Carmela Romano
- Division of Abdominal Medical Oncology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, I-80131 Naples, Italy; (G.N.); (C.R.); (A.A.)
| | - Antonio Avallone
- Division of Abdominal Medical Oncology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, I-80131 Naples, Italy; (G.N.); (C.R.); (A.A.)
| | - Biagio Pecori
- Division of Abdominal Radiotherapy, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, I-80131 Naples, Italy;
| | - Gerardo Botti
- Division of Pathological Anatomy, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, I-80131 Naples, Italy; (G.B.); (F.T.)
| | - Fabiana Tatangelo
- Division of Pathological Anatomy, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, I-80131 Naples, Italy; (G.B.); (F.T.)
| | - Piera Maiolino
- Division of Pharmacy, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, I-80131 Naples, Italy;
| | - Paolo Delrio
- Division of Colorectal Surgery, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, I-80131 Naples, Italy; (D.R.); (U.P.); (C.S.); (M.D.M.); (C.C.); (P.D.)
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Validation of the standardized index of shape tool to analyze DCE-MRI data in the assessment of neo-adjuvant therapy in locally advanced rectal cancer. Radiol Med 2021; 126:1044-1054. [PMID: 34041663 DOI: 10.1007/s11547-021-01369-1] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 05/05/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE Standardized index of shape (SIS) tool validation to examine dynamic contrast enhanced-magnetic resonance imaging (DCE-MRI) in preoperative chemo-radiation therapy (pCRT) assessment of locally advanced rectal cancer (LARC) in order to guide the surgeon versus more or less conservative treatment. MATERIALS AND METHODS A total of 194 patients (January 2008-November 2020), with III-IV locally advanced rectal cancer and subjected to pCRT were included. Three expert radiologists performed DCE-MRI analysis using SIS tool. Degree of absolute agreement among measurements, degree of consistency among measurements, degree of reliability and level of variability were calculated. Patients with a pathological tumour regression grade (TRG) 1 or 2 were classified as major responders (complete responders have TRG 1). RESULTS Good significant correlation was obtained between SIS measurements (range 0.97-0.99). The degree of absolute agreement ranges from 0.93 to 0.99, the degree of consistency from 0.81 to 0.9 and the reliability from 0.98 to 1.00 (p value < < 0.001). The variability coefficient ranges from 3.5% to 26%. SIS value obtained to discriminate responders by non-responders a sensitivity of 95.9%, a specificity of 84.7% and an accuracy of 91.8% while to detect complete responders, a sensitivity of 99.2%, a specificity of 63.9% and an accuracy of 86.1%. CONCLUSION SIS tool is suitable to assess pCRT response both to identify major responders and complete responders in order to guide the surgeon versus more or less conservative treatment.
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Jin F, Luo H, Zhou J, Wu Y, Sun H, Liu H, Zheng X, Wang Y. Dose-time fractionation schedules of preoperative radiotherapy and timing to surgery for rectal cancer. Ther Adv Med Oncol 2020; 12:1758835920907537. [PMID: 32165928 PMCID: PMC7052459 DOI: 10.1177/1758835920907537] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 01/20/2020] [Indexed: 02/01/2023] Open
Abstract
Chemoradiotherapy (CRT) is extensively used prior to surgery for rectal cancer to provide significantly better local control, but the radiotherapy (RT), as the other component of CRT, has been subject to less interest than the drug component in recent years. With considerable developments in RT, the use of advanced techniques, such as intensity-modulated radiotherapy (IMRT) in rectal cancer, is garnering more attention nowadays. The radiation dose can be better conformed to the target volumes with possibilities for synchronous integrated boost without increased complications in normal tissue. Hopefully, both local recurrence and toxicities can be further reduced. Although those seem to be of interest, many issues remain unresolved. There is no international consensus regarding the radiation schedule for preoperative RT for rectal cancer. Moreover, an enormous disparity exists regarding the RT delivery. With the advent of IMRT, variations will likely increase. Moreover, time to surgery is also quite variable, as it depends upon the indication for RT/CRT in the clinical practices. In this review, we discuss the options and problems related to both the dose-time fractionation schedule and time to surgery; furthermore, it addresses the research questions that need answering in the future.
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Affiliation(s)
- Fu Jin
- Department of Radiation Oncology, Chongqing
University Cancer Hospital & Chongqing Cancer Institute & Chongqing
Cancer Hospital, Chongqing, People’s Republic of China
| | - Huanli Luo
- Department of Radiation Oncology, Chongqing
University Cancer Hospital & Chongqing Cancer Institute & Chongqing
Cancer Hospital, Chongqing, People’s Republic of China
| | - Juan Zhou
- Forensic Identification Center, Southwest
University of Political Science and Law, Chongqing, PR China
| | - Yongzhong Wu
- Department of Radiation Oncology, Chongqing
University Cancer Hospital & Chongqing Cancer Institute & Chongqing
Cancer Hospital, Chongqing, People’s Republic of China
| | - Hao Sun
- Department of Gynecologic Oncology, Chongqing
University Cancer Hospital & Chongqing Cancer Institute & Chongqing
Cancer Hospital, Chongqing, PR China
| | - Hongliang Liu
- Department of Anesthesiology, Chongqing
University Cancer Hospital & Chongqing Cancer Institute & Chongqing
Cancer Hospital, Chongqing, PR China
| | - Xiaodong Zheng
- Department of Science Education, Chongqing
University Cancer Hospital & Chongqing Cancer Institute & Chongqing
Cancer Hospital, Chongqing, PR China
| | - Ying Wang
- Department of Radiation Oncology, Chongqing
University Cancer Hospital & Chongqing Cancer Institute & Chongqing
Cancer Hospital, 181 Hanyu Road, Shapingba District, Chongqing 400030,
China
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Petrillo A, Fusco R, Granata V, Filice S, Sansone M, Rega D, Delrio P, Bianco F, Romano GM, Tatangelo F, Avallone A, Pecori B. Assessing response to neo-adjuvant therapy in locally advanced rectal cancer using Intra-voxel Incoherent Motion modelling by DWI data and Standardized Index of Shape from DCE-MRI. Ther Adv Med Oncol 2018; 10:1758835918809875. [PMID: 30479672 PMCID: PMC6243411 DOI: 10.1177/1758835918809875] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 09/24/2018] [Indexed: 12/16/2022] Open
Abstract
Background: Our aim was to investigate preoperative chemoradiation therapy (pCRT) response in locally advanced rectal cancer (LARC) comparing standardized index of shape (SIS) obtained from dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) with intravoxel-incoherent-motion-modelling-derived parameters by diffusion-weighted imaging (DWI). Materials and methods: Eighty-eight patients with LARC were subjected to MRI before and after pCRT. Apparent diffusion coefficient (ADC), tissue diffusion (Dt), pseudodiffusion (Dp) and perfusion fraction (f) were calculated and percentage changes ∆ADC, ∆Dt, ∆Dp, ∆f were computed. SIS was derived comparing DCE-MRI pre- and post-pCRT. Nonparametric tests and receiver operating characteristic (ROC) curves were performed. Results: A total of 52 patients were classified as responders (tumour regression grade; TRG ⩽ 2) and 36 as not-responders (TRG > 3). Mann–Whitney U test showed statistically significant differences in SIS, ∆ADC and ∆Dt between responders and not-responders and between complete responders (19 patients with TRG = 1) versus incomplete responders. The best parameters to discriminate responders by nonresponders were SIS and ∆ADC, with an accuracy of 91% and 82% (cutoffs of −5.2% and 18.7%, respectively); the best parameters to detect pathological complete responders were SIS, ∆f and ∆Dp with an accuracy of 78% (cutoffs of 38.5%, 60.0% and 83.0%, respectively). No increase of performance was observed by combining linearly each possible couple of parameters or combining all parameters. Conclusion: SIS allows assessment of preoperative treatment response with high accuracy guiding the surgeon versus more or less conservative treatment. DWI-derived parameters reached less accuracy compared with SIS and combining linearly DCE- and DWI-derived parameters; no increase of accuracy was obtained.
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Affiliation(s)
- Antonella Petrillo
- Radiology Unit, ‘Istituto Nazionale Tumori, IRCCS, Fondazione G Pascale’, Naples, Italy
| | | | - Vincenza Granata
- Radiology Unit, ‘Istituto Nazionale Tumori, IRCCS, Fondazione G Pascale’, Naples, Italy
| | - Salvatore Filice
- Radiology Unit, ‘Istituto Nazionale Tumori, IRCCS, Fondazione G Pascale’, Naples, Italy
| | - Mario Sansone
- Department of Electrical Engineering and Information Technologies, University ‘Federico II’ of Naples, Naples, Italy
| | - Daniela Rega
- Gastrointestinal Surgical Oncology Unit, ‘Istituto Nazionale Tumori, IRCCS, Fondazione G Pascale’, Naples, Italy
| | - Paolo Delrio
- Gastrointestinal Surgical Oncology Unit, ‘Istituto Nazionale Tumori, IRCCS, Fondazione G Pascale’, Naples, Italy
| | - Francesco Bianco
- Gastrointestinal Surgical Oncology Unit, ‘Istituto Nazionale Tumori, IRCCS, Fondazione G Pascale’, Naples, Italy
| | - Giovanni Maria Romano
- Gastrointestinal Surgical Oncology Unit, ‘Istituto Nazionale Tumori, IRCCS, Fondazione G Pascale’, Naples, Italy
| | - Fabiana Tatangelo
- Diagnostic Pathology Unit, ‘Istituto Nazionale Tumori, IRCCS, Fondazione G Pascale’, Naples, Italy
| | - Antonio Avallone
- Gastrointestinal Medical Oncology Unit, ‘Istituto Nazionale Tumori, IRCCS, Fondazione G Pascale’, Naples, Italy
| | - Biagio Pecori
- Radiotherapy Unit, ‘Istituto Nazionale Tumori, IRCCS, Fondazione G Pascale’, Naples, Italy
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DCE-MRI time-intensity curve visual inspection to assess pathological response after neoadjuvant therapy in locally advanced rectal cancer. Jpn J Radiol 2018; 36:611-621. [PMID: 30039258 DOI: 10.1007/s11604-018-0760-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 07/17/2018] [Indexed: 01/26/2023]
Abstract
PURPOSE To investigate the potential of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) to discriminate responder from non-responder patients after preoperative chemoradiotherapy (pCRT) in locally advanced rectal cancer (LARC). MATERIALS AND METHODS One hundred and fifty-eight consecutive patients were enrolled in this prospective study. We compared morphological MRI (mMRI) using T2-weighted images about tumor presence and invasiveness, and functional DCE-MRI using time-intensity curve (TIC) visual inspection (qMRI), classifying TIC shape into three types: type 1, persistent enhancement; type 2, high enhancement with plateau; type 3, high enhancement with wash-out. Clinical TNM was obtained before and after CRT by radiological consensus of two expert radiologists. Pathological tumor-nodes-metastasis classification and tumor regression grade (TRG) were confirmed as the golden standard. Non-parametric test, sensitivity, specificity, and positive and negative predictive values were calculated. RESULTS Ninety-eight patients (62%) were classified as responders (TRG ≤ 2), while 60 (38%) were classified as non-responders. Sensitivity, specificity, and accuracy were 52, 78, and 62% for mMRI, and 81, 85, and 82% for qMRI, respectively. CONCLUSIONS TIC visual inspection may be one of the potential biomarkers over morphological analysis using DCE-MRI data to assess pathological response after pCRT in LARC.
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Petrillo A, Fusco R, Petrillo M, Granata V, Delrio P, Bianco F, Pecori B, Botti G, Tatangelo F, Caracò C, Aloj L, Avallone A, Lastoria S. Standardized Index of Shape (DCE-MRI) and Standardized Uptake Value (PET/CT): Two quantitative approaches to discriminate chemo-radiotherapy locally advanced rectal cancer responders under a functional profile. Oncotarget 2018; 8:8143-8153. [PMID: 28042958 PMCID: PMC5352389 DOI: 10.18632/oncotarget.14106] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 11/21/2016] [Indexed: 01/22/2023] Open
Abstract
Purpose To investigate dynamic contrast enhanced-MRI (DCE-MRI) in the preoperative chemo-radiotherapy (CRT) assessment for locally advanced rectal cancer (LARC) compared to18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT). Methods 75 consecutive patients with LARC were enrolled in a prospective study. DCE-MRI analysis was performed measuring SIS: linear combination of percentage change (Δ) of maximum signal difference (MSD) and wash-out slope (WOS). 18F-FDG PET/CT analysis was performed using SUV maximum (SUVmax). Tumor regression grade (TRG) were estimated after surgery. Non-parametric tests, receiver operating characteristic were evaluated. Results 55 patients (TRG1-2) were classified as responders while 20 subjects as non responders. ΔSIS reached sensitivity of 93%, specificity of 80% and accuracy of 89% (cut-off 6%) to differentiate responders by non responders, sensitivity of 93%, specificity of 69% and accuracy of 79% (cut-off 30%) to identify pathological complete response (pCR). Therapy assessment via ΔSUVmax reached sensitivity of 67%, specificity of 75% and accuracy of 70% (cut-off 60%) to differentiate responders by non responders and sensitivity of 80%, specificity of 31% and accuracy of 51% (cut-off 44%) to identify pCR. Conclusions CRT response assessment by DCE-MRI analysis shows a higher predictive ability than 18F-FDG PET/CT in LARC patients allowing to better discriminate significant and pCR.
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Affiliation(s)
- Antonella Petrillo
- Radiology Unit, Department of Diagnostic Imaging, Radiant and Metabolic Therapy, "Istituto Nazionale Tumori Fondazione Giovanni Pascale - IRCCS", 80131, Naples, Italy
| | - Roberta Fusco
- Radiology Unit, Department of Diagnostic Imaging, Radiant and Metabolic Therapy, "Istituto Nazionale Tumori Fondazione Giovanni Pascale - IRCCS", 80131, Naples, Italy
| | - Mario Petrillo
- Radiology Unit, Department of Diagnostic Imaging, Radiant and Metabolic Therapy, "Istituto Nazionale Tumori Fondazione Giovanni Pascale - IRCCS", 80131, Naples, Italy
| | - Vincenza Granata
- Radiology Unit, Department of Diagnostic Imaging, Radiant and Metabolic Therapy, "Istituto Nazionale Tumori Fondazione Giovanni Pascale - IRCCS", 80131, Naples, Italy
| | - Paolo Delrio
- Gastrointestinal Surgical Oncology Unit, Department of Abdominal Oncology, "Istituto Nazionale Tumori Fondazione Giovanni Pascale - IRCCS", 80131, Naples, Italy
| | - Francesco Bianco
- Gastrointestinal Surgical Oncology Unit, Department of Abdominal Oncology, "Istituto Nazionale Tumori Fondazione Giovanni Pascale - IRCCS", 80131, Naples, Italy
| | - Biagio Pecori
- Radiotherapy Unit, Department of Diagnostic Imaging, Radiant and Metabolic Therapy, "Istituto Nazionale Tumori Fondazione Giovanni Pascale - IRCCS", 80131, Naples, Italy
| | - Gerardo Botti
- Scientific Director, "Istituto Nazionale Tumori Fondazione Giovanni Pascale - IRCCS", 80131, Naples, Italy
| | - Fabiana Tatangelo
- Diagnostic Pathology Unit, Department of Diagnostic and Laboratory Pathology "Istituto Nazionale Tumori Fondazione Giovanni Pascale - IRCCS", 80131, Naples, Italy
| | - Corradina Caracò
- Nuclear Medicine Unit, Department of Diagnostic Imaging, Radiant and Metabolic Therapy, "Istituto Nazionale Tumori Fondazione Giovanni Pascale - IRCCS", 80131, Naples, Italy
| | - Luigi Aloj
- Nuclear Medicine Unit, Department of Diagnostic Imaging, Radiant and Metabolic Therapy, "Istituto Nazionale Tumori Fondazione Giovanni Pascale - IRCCS", 80131, Naples, Italy
| | - Antonio Avallone
- Gastrointestinal Medical Oncology Unit, Department of Abdominal Oncology, "Istituto Nazionale Tumori Fondazione Giovanni Pascale - IRCCS", 80131, Naples, Italy
| | - Secondo Lastoria
- Nuclear Medicine Unit, Department of Diagnostic Imaging, Radiant and Metabolic Therapy, "Istituto Nazionale Tumori Fondazione Giovanni Pascale - IRCCS", 80131, Naples, Italy
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Fusco R, Petrillo M, Granata V, Filice S, Sansone M, Catalano O, Petrillo A. Magnetic Resonance Imaging Evaluation in Neoadjuvant Therapy of Locally Advanced Rectal Cancer: A Systematic Review. Radiol Oncol 2017; 51:252-262. [PMID: 28959161 PMCID: PMC5611989 DOI: 10.1515/raon-2017-0032] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 06/21/2017] [Indexed: 02/07/2023] Open
Abstract
Background The aim of the study was to present an update concerning several imaging modalities in diagnosis, staging and pre-surgery treatment response assessment in locally advanced rectal cancer (LARC). Modalities include: traditional morphological magnetic resonance imaging (MRI), functional MRI such as dynamic contrast enhanced MRI (DCE-MRI) and diffusion weighted imaging (DWI). A systematic review about the diagnostic accuracy in neoadjuvant therapy response assessment of MRI, DCE-MRI, DWI and Positron Emission Tomography/Computed Tomography (PET/CT) has been also reported. Methods Several electronic databases were searched including PubMed, Scopus, Web of Science, and Google Scholar. All the studies included in this review reported findings about therapy response assessment in LARC by means of MRI, DCE-MRI, DWI and PET/CT with details about diagnostic accuracy, true and false negatives, true and false positives. Forest plot and receiver operating characteristic (ROC) curves analysis were performed. Risk of bias and the applicability at study level were calculated. Results Twenty-five papers were identified. ROC curves analysis demonstrated that multimodal imaging integrating morphological and functional MRI features had the best accuracy both in term of sensitivity and specificity to evaluate preoperative therapy response in LARC. DCE-MRI following to PET/CT showed high diagnostic accuracy and their results are also more reliable than conventional MRI and DWI alone. Conclusions Morphological MRI is the modality of choice for rectal cancer staging permitting a correct assessment of the disease extent, of the lymph node involvement, of the mesorectal fascia and of the sphincter complex for surgical planning. Multimodal imaging and functional DCE-MRI may also help in the assessment of treatment response allowing to guide the surgeon versus conservative strategies and/or tailored approach such as “wait and see” policy.
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Affiliation(s)
- Roberta Fusco
- Radiology Unit, Dipartimento di Supporto ai Percorsi Oncologici Area Diagnostica, Istituto Nazionale Tumori - IRCCS -Fondazione G. Pascale, Via Mariano Semmola, Naples, Italy
| | - Mario Petrillo
- Radiology Unit, Dipartimento di Supporto ai Percorsi Oncologici Area Diagnostica, Istituto Nazionale Tumori - IRCCS -Fondazione G. Pascale, Via Mariano Semmola, Naples, Italy
| | - Vincenza Granata
- Radiology Unit, Dipartimento di Supporto ai Percorsi Oncologici Area Diagnostica, Istituto Nazionale Tumori - IRCCS -Fondazione G. Pascale, Via Mariano Semmola, Naples, Italy
| | - Salvatore Filice
- Radiology Unit, Dipartimento di Supporto ai Percorsi Oncologici Area Diagnostica, Istituto Nazionale Tumori - IRCCS -Fondazione G. Pascale, Via Mariano Semmola, Naples, Italy
| | - Mario Sansone
- Department of Electrical Engineering and Information Technologies, Università degli Studi di Napoli Federico II, Via Claudio, Naples, Italy
| | - Orlando Catalano
- Radiology Unit, Dipartimento di Supporto ai Percorsi Oncologici Area Diagnostica, Istituto Nazionale Tumori - IRCCS -Fondazione G. Pascale, Via Mariano Semmola, Naples, Italy
| | - Antonella Petrillo
- Radiology Unit, Dipartimento di Supporto ai Percorsi Oncologici Area Diagnostica, Istituto Nazionale Tumori - IRCCS -Fondazione G. Pascale, Via Mariano Semmola, Naples, Italy
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Ostwal V, Engineer R, Ramaswamy A, Sahu A, Zanwar S, Arya S, Chopra S, Bal M, Patil P, Desouza A, Saklani A. Surgical outcomes of post chemoradiotherapy unresectable locally advanced rectal cancers improve with interim chemotherapy, is FOLFIRINOX better than CAPOX? J Gastrointest Oncol 2016; 7:958-967. [PMID: 28078119 DOI: 10.21037/jgo.2016.08.11] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Role of chemotherapy in patients who continue to have unresectable disease after pre-operative chemo-radiotherapy (CRT) remains largely unaddressed. METHODS Patients with LA rectal cancer from January 2013 to June 2015 were evaluated. Post-CRT, patients, who were deemed unresectable, were considered for further interim chemotherapy (i-CT). RESULTS Seventy six patients (15%) with median age of 38.5 years received i-CT after CRT. About 61.8% patients receiving i-CT managed to undergo a definitive surgery and the extent of surgery was reduced in 48.7% patients. With the median follow up of 19 months, the estimated 2-year event free survival (EFS) of 48% and OS was 56%. The estimated 2-year OS was 81% in mucinous tumors whereas it was 44.4% in signet ring pathology (P=0.045). The 2-year OS of 86% for whom surgery was done vs. 38% (2-year OS) in whom surgery was not done (P=0.011). Survival was better in conservative surgery group vs. total pelvic exenteration (TPE) vs. no surgery (2-year OS: 84% vs. 59.1% vs. 38%; P=0.033). In the CAPE-OX group, 71.4% (14/23) underwent surgery whereas 75.9% (29/47) in the 5-FU plus irinotecan plus oxaliplatin (FOLFIRINOX) group with EFS (P=0.570) and OS (P=0.120). In conservative surgery group, OS was better in FOLFIRINOX (2-year OS: 95.7%) vs. capecitabine plus oxaliplatin (CAPOX) (2-year OS: 70%) (P=0.012). CONCLUSIONS i-CT can lead to improved resection rates, improved survivals and downstaging with acceptable toxicity. FOLFIRINOX appears to better over CAPOX, specifically in whom conservative surgery is feasible.
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Affiliation(s)
- Vikas Ostwal
- Department of Medical Oncology, TMH, Mumbai 400012, India
| | - Reena Engineer
- Department of Radiation Oncology, TMH, Mumbai 400012, India
| | | | - Arvind Sahu
- Department of Medical Oncology, TMH, Mumbai 400012, India
| | - Saurabh Zanwar
- Department of Medical Oncology, TMH, Mumbai 400012, India
| | - Suprita Arya
- Department of Radiology, TMH, Mumbai 400012, India
| | - Supriya Chopra
- Department of Radiation Oncology, TMH, Mumbai 400012, India
| | - Munita Bal
- Department of Pathology, TMH, Mumbai 400012, India
| | - Prachi Patil
- Department of Medical Gastroenterology, TMH, Mumbai 400012, India
| | - Ashwin Desouza
- Department of Surgical Oncology, TMH, Mumbai 400012, India
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Siddiqui MRS, Bhoday J, Battersby NJ, Chand M, West NP, Abulafi AM, Tekkis PP, Brown G. Defining response to radiotherapy in rectal cancer using magnetic resonance imaging and histopathological scales. World J Gastroenterol 2016; 22:8414-8434. [PMID: 27729748 PMCID: PMC5055872 DOI: 10.3748/wjg.v22.i37.8414] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 07/04/2016] [Accepted: 08/01/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To define good and poor regression using pathology and magnetic resonance imaging (MRI) regression scales after neo-adjuvant chemotherapy for rectal cancer.
METHODS A systematic review was performed on all studies up to December 2015, without language restriction, that were identified from MEDLINE, Cochrane Controlled Trials Register (1960-2015), and EMBASE (1991-2015). Searches were performed of article bibliographies and conference abstracts. MeSH and text words used included “tumour regression”, “mrTRG”, “poor response” and “colorectal cancers”. Clinical studies using either MRI or histopathological tumour regression grade (TRG) scales to define good and poor responders were included in relation to outcomes [local recurrence (LR), distant recurrence (DR), disease-free survival (DFS), and overall survival (OS)]. There was no age restriction or stage of cancer restriction for patient inclusion. Data were extracted by two authors working independently and using pre-defined outcome measures.
RESULTS Quantitative data (prevalence) were extracted and analysed according to meta-analytical techniques using comprehensive meta-analysis. Qualitative data (LR, DR, DFS and OS) were presented as ranges. The overall proportion of poor responders after neo-adjuvant chemo-radiotherapy (CRT) was 37.7% (95%CI: 30.1-45.8). There were 19 different reported histopathological scales and one MRI regression scale (mrTRG). Clinical studies used nine and six histopathological scales for poor and good responders, respectively. All studies using MRI to define good and poor response used one scale. The most common histopathological definition for good response was the Mandard grades 1 and 2 or Dworak grades 3 and 4; Mandard 3, 4 and 5 and Dworak 0, 1 and 2 were used for poor response. For histopathological grades, the 5-year outcomes for poor responders were LR 3.4%-4.3%, DR 14.3%-20.3%, DFS 61.7%-68.1% and OS 60.7-69.1. Good pathological response 5-year outcomes were LR 0%-1.8%, DR 0%-11.6%, DFS 78.4%-86.7%, and OS 77.4%-88.2%. A poor response on MRI (mrTRG 4,5) resulted in 5-year LR 4%-29%, DR 9%, DFS 31%-59% and OS 27%-68%. The 5-year outcomes with a good response on MRI (mrTRG 1,2 and 3) were LR 1%-14%, DR 3%, DFS 64%-83% and OS 72%-90%.
CONCLUSION For histopathology regression assessment, Mandard 1, 2/Dworak 3, 4 should be used for good response and Mandard 3, 4, 5/Dworak 0, 1, 2 for poor response. MRI indicates good and poor response by mrTRG1-3 and mrTRG4-5, respectively.
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11
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Rega D, Pecori B, Scala D, Avallone A, Pace U, Petrillo A, Aloj L, Tatangelo F, Delrio P. Evaluation of Tumor Response after Short-Course Radiotherapy and Delayed Surgery for Rectal Cancer. PLoS One 2016; 11:e0160732. [PMID: 27548058 PMCID: PMC4993446 DOI: 10.1371/journal.pone.0160732] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Accepted: 07/25/2016] [Indexed: 12/30/2022] Open
Abstract
Purpose Neoadjuvant therapy is able to reduce local recurrence in rectal cancer. Immediate surgery after short course radiotherapy allows only for minimal downstaging. We investigated the effect of delayed surgery after short-course radiotherapy at different time intervals before surgery, in patients affected by rectal cancer. Methods From January 2003 to December 2013 sixty-seven patients with the following characteristics have been selected: clinical (c) stage T3N0 ≤ 12 cm from the anal verge and with circumferential resection margin > 5 mm (by magnetic resonance imaging); cT2, any N, < 5 cm from anal verge; and patients facing tumors with enlarged nodes and/or CRM+ve who resulted unfit for chemo-radiation, were also included. Patients underwent preoperative short-course radiotherapy with different interval to surgery were divided in three groups: A (within 6 weeks), B (between 6 and 8 weeks) and C (after more than 8 weeks). Hystopatolgical response to radiotherapy was measured by Mandard’s modified tumor regression grade (TRG). Results All patients completed the scheduled treatment. Sixty-six patients underwent surgery. Fifty-three of which (80.3%) received a sphincter saving procedure. Downstaging occurred in 41 cases (62.1%). The analysis of subgroups showed an increasing prevalence of TRG 1–2 prolonging the interval to surgery (group A—16.7%, group B—36.8% and 54.3% in group C; p value 0.023). Conclusions Preoperative short-course radiotherapy is able to downstage rectal cancer if surgery is delayed. A higher rate of TRG 1–2 can be obtained if interval to surgery is prolonged to more than 8 weeks.
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Affiliation(s)
- Daniela Rega
- Colorectal Surgical Oncology, Istituto Nazionale per lo Studio e la Cura dei Tumori–“Fondazione Giovanni Pascale” IRCCS, Naples, Italy
- * E-mail:
| | - Biagio Pecori
- Division of Radiotherapy, Department of Diagnostic Imaging, Radiant and Metabolic Therapy, Istituto Nazionale per lo Studio e la Cura dei Tumori–“Fondazione Giovanni Pascale” IRCCS, Naples, Italy
| | - Dario Scala
- Colorectal Surgical Oncology, Istituto Nazionale per lo Studio e la Cura dei Tumori–“Fondazione Giovanni Pascale” IRCCS, Naples, Italy
| | - Antonio Avallone
- Division of Gastrointestinal Medical Oncology, Istituto Nazionale per lo Studio e la Cura dei Tumori–“Fondazione Giovanni Pascale” IRCCS, Naples, Italy
| | - Ugo Pace
- Colorectal Surgical Oncology, Istituto Nazionale per lo Studio e la Cura dei Tumori–“Fondazione Giovanni Pascale” IRCCS, Naples, Italy
| | - Antonella Petrillo
- Division of Radiology, Department of Diagnostic Imaging, Radiant and Metabolic Therapy, Istituto Nazionale per lo Studio e la Cura dei Tumori–“Fondazione Giovanni Pascale” IRCCS, Naples, Italy
| | - Luigi Aloj
- Nuclear Medicine Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori–“Fondazione Giovanni Pascale” IRCCS, Naples, Italy
| | - Fabiana Tatangelo
- Pathology Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori–“Fondazione Giovanni Pascale” IRCCS, Naples, Italy
| | - Paolo Delrio
- Colorectal Surgical Oncology, Istituto Nazionale per lo Studio e la Cura dei Tumori–“Fondazione Giovanni Pascale” IRCCS, Naples, Italy
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Avallone A, Pecori B, Bianco F, Aloj L, Tatangelo F, Romano C, Granata V, Marone P, Leone A, Botti G, Petrillo A, Caracò C, Iaffaioli VR, Muto P, Romano G, Comella P, Budillon A, Delrio P. Critical role of bevacizumab scheduling in combination with pre-surgical chemo-radiotherapy in MRI-defined high-risk locally advanced rectal cancer: Results of the BRANCH trial. Oncotarget 2016; 6:30394-407. [PMID: 26320185 PMCID: PMC4745808 DOI: 10.18632/oncotarget.4724] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Accepted: 07/17/2015] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND We have previously shown that an intensified preoperative regimen including oxaliplatin plus raltitrexed and 5-fluorouracil/folinic acid (OXATOM/FUFA) during preoperative pelvic radiotherapy produced promising results in locally advanced rectal cancer (LARC). Preclinical evidence suggests that the scheduling of bevacizumab may be crucial to optimize its combination with chemo-radiotherapy. PATIENTS AND METHODS This non-randomized, non-comparative, phase II study was conducted in MRI-defined high-risk LARC. Patients received three biweekly cycles of OXATOM/FUFA during RT. Bevacizumab was given 2 weeks before the start of chemo-radiotherapy, and on the same day of chemotherapy for 3 cycles (concomitant-schedule A) or 4 days prior to the first and second cycle of chemotherapy (sequential-schedule B). Primary end point was pathological complete tumor regression (TRG1) rate. RESULTS The accrual for the concomitant-schedule was early terminated because the number of TRG1 (2 out of 16 patients) was statistically inconsistent with the hypothesis of activity (30%) to be tested. Conversely, the endpoint was reached with the sequential-schedule and the final TRG1 rate among 46 enrolled patients was 50% (95% CI 35%-65%). Neutropenia was the most common grade ≥ 3 toxicity with both schedules, but it was less pronounced with the sequential than concomitant-schedule (30% vs. 44%). Postoperative complications occurred in 8/15 (53%) and 13/46 (28%) patients in schedule A and B, respectively. At 5 year follow-up the probability of PFS and OS was 80% (95%CI, 66%-89%) and 85% (95%CI, 69%-93%), respectively, for the sequential-schedule. CONCLUSIONS These results highlights the relevance of bevacizumab scheduling to optimize its combination with preoperative chemo-radiotherapy in the management of LARC.
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Affiliation(s)
- Antonio Avallone
- Gastrointestinal Medical Oncology Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" - IRCCS, 80131, Napoli, Italy
| | - Biagio Pecori
- Radiotherapy Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" - IRCCS, 80131, Napoli, Italy
| | - Franco Bianco
- Gastrointestinal Surgery, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" - IRCCS, 80131, Napoli, Italy
| | - Luigi Aloj
- Nuclear Medicine Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" - IRCCS, 80131, Napoli, Italy
| | - Fabiana Tatangelo
- Pathology Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" - IRCCS, 80131, Napoli, Italy
| | - Carmela Romano
- Gastrointestinal Medical Oncology Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" - IRCCS, 80131, Napoli, Italy
| | - Vincenza Granata
- Radiology Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" - IRCCS, 80131, Napoli, Italy
| | - Pietro Marone
- Endoscopy Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" - IRCCS, 80131, Napoli, Italy
| | - Alessandra Leone
- Experimental Pharmacology Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" - IRCCS, 80131, Napoli, Italy
| | - Gerardo Botti
- Pathology Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" - IRCCS, 80131, Napoli, Italy
| | - Antonella Petrillo
- Radiology Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" - IRCCS, 80131, Napoli, Italy
| | - Corradina Caracò
- Nuclear Medicine Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" - IRCCS, 80131, Napoli, Italy
| | - Vincenzo R Iaffaioli
- Gastrointestinal Medical Oncology Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" - IRCCS, 80131, Napoli, Italy
| | - Paolo Muto
- Radiotherapy Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" - IRCCS, 80131, Napoli, Italy
| | - Giovanni Romano
- Gastrointestinal Surgery, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" - IRCCS, 80131, Napoli, Italy
| | - Pasquale Comella
- Gastrointestinal Medical Oncology Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" - IRCCS, 80131, Napoli, Italy
| | - Alfredo Budillon
- Experimental Pharmacology Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" - IRCCS, 80131, Napoli, Italy
| | - Paolo Delrio
- Colorectal Surgery Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" - IRCCS, 80131, Napoli, Italy
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13
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Siddiqui MRS, Gormly KL, Bhoday J, Balyansikova S, Battersby NJ, Chand M, Rao S, Tekkis P, Abulafi AM, Brown G. Interobserver agreement of radiologists assessing the response of rectal cancers to preoperative chemoradiation using the MRI tumour regression grading (mrTRG). Clin Radiol 2016; 71:854-62. [PMID: 27381221 DOI: 10.1016/j.crad.2016.05.005] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 03/13/2016] [Accepted: 05/03/2016] [Indexed: 02/07/2023]
Abstract
AIM To investigate whether the magnetic resonance imaging (MRI) tumour regression grading (mrTRG) scale can be taught effectively resulting in a clinically reasonable interobserver agreement (>0.4; moderate to near perfect agreement). MATERIALS AND METHODS This study examines the interobserver agreement of mrTRG, between 35 radiologists and a central reviewer. Two workshops were organised for radiologists to assess regression of rectal cancers on MRI staging scans. A range of mrTRGs on 12 patient scans were used for assessment. RESULTS Kappa agreement ranged from 0.14-0.82 with a median value of 0.57 (95% CI: 0.37-0.77) indicating good overall agreement. Eight (26%) radiologists had very good/near perfect agreement (κ>0.8). Six (19%) radiologists had good agreement (0.8≥κ>0.6) and a further 12 (39%) had moderate agreement (0.6≥κ>0.4). Five (16%) radiologists had a fair agreement (0.4≥κ>0.2) and two had poor agreement (0.2>κ). There was a tendency towards good agreement (skewness: 0.92). In 65.9% and 90% of cases the radiologists were able to correctly highlight good and poor responders, respectively. CONCLUSIONS The assessment of the response of rectal cancers to chemoradiation therapy may be performed effectively using mrTRG. Radiologists can be taught the mrTRG scale. Even with minimal training, good agreement with the central reviewer along with effective differentiation between good and intermediate/poor responders can be achieved. Focus should be on facilitating the identification of good responders. It is predicted that with more intensive interactive case-based learning a κ>0.8 is likely to be achieved. Testing and retesting is recommended.
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Affiliation(s)
- M R S Siddiqui
- Department of Colorectal Surgery, Croydon University Hospital, Croydon CR7 7YE, UK; Department of Radiology, Royal Marsden Hospital, Sutton, Surrey SM2 5PT, UK; Imperial College London, London, UK
| | - K L Gormly
- Dr Jones and Partners, Adelaide, South Australia, Australia
| | - J Bhoday
- Department of Colorectal Surgery, Croydon University Hospital, Croydon CR7 7YE, UK; Department of Radiology, Royal Marsden Hospital, Sutton, Surrey SM2 5PT, UK; Imperial College London, London, UK
| | - S Balyansikova
- Department of Radiology, Royal Marsden Hospital, Sutton, Surrey SM2 5PT, UK
| | - N J Battersby
- Department of Radiology, Royal Marsden Hospital, Sutton, Surrey SM2 5PT, UK
| | - M Chand
- Department of Surgery, University College London, London, UK
| | - S Rao
- Department of Radiology, Royal Marsden Hospital, Sutton, Surrey SM2 5PT, UK
| | - P Tekkis
- Department of Surgery, Royal Marsden Hospital, Fulham Rd, London SW3 6JJ, UK; Imperial College London, London, UK
| | - A M Abulafi
- Department of Colorectal Surgery, Croydon University Hospital, Croydon CR7 7YE, UK
| | - G Brown
- Department of Radiology, Royal Marsden Hospital, Sutton, Surrey SM2 5PT, UK; Imperial College London, London, UK.
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MRI for Assessing Response to Neoadjuvant Therapy in Locally Advanced Rectal Cancer Using DCE-MR and DW-MR Data Sets: A Preliminary Report. BIOMED RESEARCH INTERNATIONAL 2015; 2015:514740. [PMID: 26413528 PMCID: PMC4564611 DOI: 10.1155/2015/514740] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 05/08/2015] [Accepted: 05/13/2015] [Indexed: 12/14/2022]
Abstract
To evaluate MRI for neoadjuvant therapy response assessment in locally advanced rectal cancer (LARC) using dynamic contrast enhanced-MRI (DCE-MRI) and diffusion weighted imaging (DWI), we have compared magnetic resonance volumetry based on DCE-MRI (V(DCE)) and on DWI (V(DWI)) scans with conventional T2-weighted volumetry (V(C)) in LARC patients after neoadjuvant therapy. Twenty-nine patients with LARC underwent MR examination before and after neoadjuvant therapy. A manual segmentation was performed on DCE-MR postcontrast images, on DWI (b-value 800 s/mm2), and on conventional T2-weighted images by two radiologists. DCE-MRI, DWI, and T2-weigthed volumetric changes before and after treatment were evaluated. Nonparametric sample tests, interobserver agreement, and receiver operating characteristic curve (ROC) were performed. Diagnostic performance linked to DCE-MRI volumetric change was superior to T2-w and DW-MRI volumetric changes performance (specificity 86%, sensitivity 93%, and accuracy 93%). Area Under ROC (AUC) of V(DCE) was greater than AUCs of V(C) and V(DWI) resulting in an increase of 15.6% and 11.1%, respectively. Interobserver agreement between two radiologists was 0.977, 0.864, and 0.756 for V(C), V(DCE), and V(DWI), respectively. V(DCE) seems to be a promising tool for therapy response assessment in LARC. Further studies on large series of patients are needed to refine technique and evaluate its potential value.
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De Rosa M, Pace U, Rega D, Costabile V, Duraturo F, Izzo P, Delrio P. Genetics, diagnosis and management of colorectal cancer (Review). Oncol Rep 2015; 34:1087-96. [PMID: 26151224 PMCID: PMC4530899 DOI: 10.3892/or.2015.4108] [Citation(s) in RCA: 226] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 05/12/2015] [Indexed: 12/14/2022] Open
Abstract
Colorectal cancer (CRC) is the third most common type of cancer worldwide and a leading cause of cancer death. Surgery represents the mainstay of treatment in early cases but often patients are primarily diagnosed in an advanced stage of disease and sometimes also distant metastases are present. Neoadjuvant therapy is therefore needed but drug resistance may influence response and concur to recurrent disease. At molecular level, it is a very heterogeneous group of diseases with about 30% of hereditary or familial cases. During colorectal adenocarcinomas development, epithelial cells from gastrointestinal trait acquire sequential genetic and epigenetic mutations in specific oncogenes and/or tumour suppressor genes, causing CRC onset, progression and metastasis. Molecular characterization of cancer associated mutations gives valuable information about disease prognosis and response to the therapy. Very early diagnosis and personalized care, as well as a better knowledge of molecular basis of its onset and progression, are therefore crucial to obtain a cure of CRC. In this review, we describe updated genetics, current diagnosis and management of CRC pointing out the extreme need for a multidisciplinary approach to achieve the best results in patient outcomes.
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Affiliation(s)
- Marina De Rosa
- Department of Molecular Medicine and Medical Biotechnology, University of Naples 'Federico II', I-80131 Naples, Italy
| | - Ugo Pace
- Colorectal Surgical Oncology-Abdominal Oncology Department, Istituto Nazionale per lo Studio e la Cura dei Tumori, 'Fondazione Giovanni Pascale' IRCCS, I-80131 Naples, Italy
| | - Daniela Rega
- Colorectal Surgical Oncology-Abdominal Oncology Department, Istituto Nazionale per lo Studio e la Cura dei Tumori, 'Fondazione Giovanni Pascale' IRCCS, I-80131 Naples, Italy
| | - Valeria Costabile
- Department of Molecular Medicine and Medical Biotechnology, University of Naples 'Federico II', I-80131 Naples, Italy
| | - Francesca Duraturo
- Department of Molecular Medicine and Medical Biotechnology, University of Naples 'Federico II', I-80131 Naples, Italy
| | - Paola Izzo
- Department of Molecular Medicine and Medical Biotechnology, University of Naples 'Federico II', I-80131 Naples, Italy
| | - Paolo Delrio
- Colorectal Surgical Oncology-Abdominal Oncology Department, Istituto Nazionale per lo Studio e la Cura dei Tumori, 'Fondazione Giovanni Pascale' IRCCS, I-80131 Naples, Italy
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Avallone A, Aloj L, Aprile G, Rosati G, Budillon A. A perspective on the current treatment strategies for locally advanced rectal cancer. Int J Biochem Cell Biol 2015; 65:192-6. [PMID: 26055517 DOI: 10.1016/j.biocel.2015.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 05/30/2015] [Accepted: 06/01/2015] [Indexed: 12/17/2022]
Abstract
The introduction of total mesorectal excision (TME) and preoperative multimodality treatment have substantially improved the management of rectal cancer reducing local recurrence and increasing sphincter-saving surgery; distant metastases however remain a clinical challenge. Besides, although surgery remains the mainstay for cure of rectal cancer with the multimodality approach (chemotherapy, radiotherapy and surgery) being the standard of care for the majority of rectal cancer patients, there is a need of individualized risk-adapted treatment schemes based on clinico-pathological features because of treatment-induced morbidity and quality of life deterioration. This short viewpoint describes the emerging strategies addressing all these issues.
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Affiliation(s)
- Antonio Avallone
- Gastrointestinal Medical Oncology Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori 'Fondazione Giovanni Pascale' - IRCCS, Napoli, Italy.
| | - Luigi Aloj
- Nuclear Medicine Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori 'Fondazione Giovanni Pascale' - IRCCS, Napoli, Italy
| | - Giuseppe Aprile
- Department of Medical Oncology, University and General Hospital, Udine, Italy
| | - Gerardo Rosati
- Medical Oncology Unit, S. Carlo Hospital, Potenza, Italy
| | - Alfredo Budillon
- Experimental Pharmacology Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori 'Fondazione Giovanni Pascale' - IRCCS, Napoli, Italy
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Standardized Index of Shape (SIS): a quantitative DCE-MRI parameter to discriminate responders by non-responders after neoadjuvant therapy in LARC. Eur Radiol 2015; 25:1935-45. [PMID: 25577525 DOI: 10.1007/s00330-014-3581-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 12/15/2014] [Accepted: 12/19/2014] [Indexed: 01/02/2023]
Abstract
OBJECTIVES To investigate the potential of DCE-MRI to discriminate responders from non-responders after neoadjuvant chemo-radiotherapy (CRT) for locally advanced rectal cancer (LARC). We investigated several shape parameters for the time-intensity curve (TIC) in order to identify the best combination of parameters between two linear parameter classifiers. METHODS Seventy-four consecutive patients with LARC were enrolled in a prospective study approved by our ethics committee. Each patient gave written informed consent. After surgery, pathological TNM and tumour regression grade (TRG) were estimated. DCE-MRI semi-quantitative analysis (sqMRI) was performed to identify the best parameter or parameter combination to discriminate responders from non-responders in response monitoring to CRT. Percentage changes of TIC shape descriptors from the baseline to the presurgical scan were assessed and correlated with TRG. Receiver operating characteristic analysis and linear classifier were applied. RESULTS Forty-six patients (62.2%) were classified as responders, while 28 subjects (37.8%) were considered as non-responders. sqMRI reached a sensitivity of 93.5% and a specificity of 82.1% combining the percentage change in Maximum Signal Difference (ΔMSD) and Wash-out Slope (ΔWOS), the Standardized Index of Shape (SIS). CONCLUSIONS SIS obtains the best result in discriminating responders from non-responders after CRT in LARC, with a cut-off value of -3.0%. KEY POINTS • DCE-MRI shape descriptors are investigated to assess preoperative CRT response in LARC. • Identification of the best TIC shape descriptors combination through a linear classifier. • Identification of a single MRI index to predict neoadjuvant treatment response.
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Cienfuegos JA, Rotellar F, Baixauli J, Beorlegui C, Sola JJ, Arbea L, Pastor C, Arredondo J, Hernández-Lizoáin JL. Impact of perineural and lymphovascular invasion on oncological outcomes in rectal cancer treated with neoadjuvant chemoradiotherapy and surgery. Ann Surg Oncol 2014; 22:916-23. [PMID: 25190129 DOI: 10.1245/s10434-014-4051-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND The prognostic significance of perineural and/or lymphovascular invasion (PLVI) and its relationship with tumor regression grade (TRG) in patients with locally advanced rectal cancer (LARC) treated with neoadjuvant chemoradiotherapy (CRT) and surgery. METHODS A total of 324 patients with LARC were treated with CRT and operated on between January 1992 and June 2007. Tumors were graded using a quantitative 5-grade TRG classification and the presence of PLVI was histologically studied. RESULTS At a median follow-up of 79.0 months (range 3-250 months), a total of 80 patients (24.7%) relapsed. The observed 5- and 10-year overall survival (OS) was 83.2 and 74.9 %, respectively. The 5- and 10-year disease-free survival (DFS) was 75.1 and 71.4%, respectively. A significant correlation was found between the TRG and survival (log rank, p < 0.001). The 10-year OS was 32.7% for grade 1, 63.8% for grade 2, 75.0% for grade 3, 90.4% for grade 3+, and 96.0%,for grade 4. The 10-year DFS was 31.8% for grade 1, 58.6% for grade 2, 70.4% for grade 3, 88.4% for grade 3+, and 97.1% for grade 4. In patients with PLVI, the TRG had no impact on survival. When excluding patients with PLVI, the TRG was an independent prognostic factor for OS and DFS. CONCLUSIONS The presence of PLVI is a more powerful prognostic factor than TRG in LARC patients treated with neoadjuvant CRT followed by surgery. PLVI denotes an aggressive phenotype, suggesting that these patients may benefit from adjuvant systemic therapy.
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Affiliation(s)
- J A Cienfuegos
- Department of General Surgery, Clínica Universidad de Navarra, School of Medicine, University of Navarra, Pamplona, Spain,
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D'Alterio C, Avallone A, Tatangelo F, Delrio P, Pecori B, Cella L, Pelella A, D'Armiento FP, Carlomagno C, Bianco F, Silvestro L, Pacelli R, Napolitano M, Iaffaioli RV, Scala S. A prognostic model comprising pT stage, N status, and the chemokine receptors CXCR4 and CXCR7 powerfully predicts outcome in neoadjuvant resistant rectal cancer patients. Int J Cancer 2014; 135:379-90. [PMID: 24375277 DOI: 10.1002/ijc.28689] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Revised: 12/03/2013] [Accepted: 12/12/2013] [Indexed: 01/15/2023]
Abstract
Despite the optimization of the local treatment of advanced rectal cancer (LARC), combination of preoperative chemoradiotherapy (CRT) and surgery, approximately one third of patients will develop distant metastases. Since the chemokine receptor CXCR4 has been implicated in metastasis development and prognosis in colorectal cancer, the role of the entire axis CXCR4-CXCL12-CXCR7 was evaluated to identify high relapse risk rectal cancer patients. Tumor specimens of 68 LARC patients undergoing surgery after neoadjuvant-CRT were evaluated for CXCR4, CXCR7, and CXCL12 expression through immunohistochemistry. Multivariable prognostic model was developed using classical prognostic factors along with chemokine receptor expression profiles. High CXCR4 correlated with a shorter relapse-free survival (RFS) (p = 0.0006) and cancer specific survival (CSS) (p = 0.0004). Concomitant high CXCR4-negative/low CXCR7 or high CXCR4-negative/low CXCL12 significantly impaired RFS (p = 0.0003 and p = 0.0043) and CSS (p = 0.0485 and p = 0.0026). High CXCR4/N+ identified the worst prognostic category for RFS (p < 0.0001) and CSS (p = 0.0003). The optimal multivariable predictive model for RFS was a five-variable model consisting of gender, pT stage, N status, CXCR4, and CXCR7 (AUC = 0.92, 95% CI = 0.77-0.98). The model is informative and supportive for adjuvant treatment and identifies CXCR4 as a new therapeutic target in rectal cancer.
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Affiliation(s)
- Crescenzo D'Alterio
- Department of Oncological Immunology, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale"-IRCCS-ITALIA, via M. Semmola, 80131, Naples, Italy
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20
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Avallone A, Di Gennaro E, Silvestro L, Iaffaioli VR, Budillon A. Targeting thymidylate synthase in colorectal cancer: critical re-evaluation and emerging therapeutic role of raltitrexed. Expert Opin Drug Saf 2013; 13:113-29. [PMID: 24093908 DOI: 10.1517/14740338.2014.845167] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION 5-fluorouracil continues to be the cornerstone of treatment for colorectal cancer. Although fluoropyrimidines are generally considered as well-tolerated drugs, severe toxicities can be a major clinical problem, and the recommended prolonged infusion of 5-fluorouracil provokes discomfort in patients. Raltitrexed (Tomudex), a quinazoline analogue of folinic acid, is a selective and direct thymidylate synthase (TS) inhibitor with a convenient 3-weekly schedule of administration. AREAS COVERED In this review, through critical insight into the mechanism of action and main clinical experiences, the authors suggest the necessity to reconsider raltitrexed as a valuable anticancer drug and as a suitable option for colorectal cancer. The authors highlight its emerging therapeutic role in clinical practice for patients with fluoropyrimidine-induced cardiotoxicity or a significant history of cardiac disease. EXPERT OPINION This review discusses if TS could still be a relevant target for colorectal cancer in the era of molecular therapy and if raltitrexed should still be considered a drug with a life-threatening toxicity. Furthermore, this review discusses the principal combination clinical experiences of raltitrexed and its emerging therapeutic role in clinical practice as a suitable option for colorectal cancer patients with fluoropyrimidine-induced cardiotoxicity or a significant history of cardiac disease.
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Affiliation(s)
- Antonio Avallone
- Gastrointestinal Medical Oncology Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori 'Fondazione Giovanni Pascale' - IRCCS , Via M. Semmola - 80131 Napoli , Italy +39 081 5903629 ; +39 081 5903813 ;
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21
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Early FDG PET response assessment of preoperative radiochemotherapy in locally advanced rectal cancer: correlation with long-term outcome. Eur J Nucl Med Mol Imaging 2012; 39:1848-57. [PMID: 23053320 DOI: 10.1007/s00259-012-2229-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Accepted: 08/09/2012] [Indexed: 12/16/2022]
Abstract
PURPOSE The aim of the present study is to prospectively evaluate the prognostic value of previously defined [(18)F]2-fluoro-2-deoxy-D-glucose positron emission tomography (FDG PET) criteria of early metabolic response in patients with locally advanced rectal cancer (LARC) after long-term follow-up. METHODS Forty-two patients with poor prognosis LARC underwent three biweekly courses of chemotherapy with oxaliplatin, raltitrexed and 5-fluorouracil modulated by levofolinic acid during pelvic radiotherapy. FDG PET studies were performed before and 12 days after the beginning of the chemoradiotherapy (CRT) treatment. Total mesorectal excision (TME) was carried out 8 weeks after completion of CRT. A previously identified cutoff value of ≥52 % reduction of the baseline mean FDG standardized uptake value (SUV(mean)) was applied to differentiate metabolic responders from non-responders and correlated to tumour regression grade (TRG) and survival. RESULTS Twenty-two metabolic responders showed complete (TRG1) or subtotal tumour regression (TRG2) and demonstrated a statistically significantly higher 5-year relapse-free survival (RFS) compared with the 20 non-responders (86 vs 55 %, p = .014) who showed TRG3 and TRG4 pathologic responses. A multivariate analysis demonstrated that early ∆SUV(mean) was the only pre-surgical parameter correlated to the likelihood of recurrence (p = .05). CONCLUSION This study is the first prospective long-term evaluation demonstrating that FDG PET is not only an early predictor of pathologic response but is also a valuable prognostic tool. Our results indicate the potential of FDG PET for optimizing multidisciplinary management of patients with LARC.
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Martin ST, Heneghan HM, Winter DC. Systematic review and meta-analysis of outcomes following pathological complete response to neoadjuvant chemoradiotherapy for rectal cancer. Br J Surg 2012; 99:918-28. [PMID: 22362002 DOI: 10.1002/bjs.8702] [Citation(s) in RCA: 442] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2012] [Indexed: 12/16/2022]
Abstract
BACKGROUND Following neoadjuvant chemoradiotherapy (CRT) and interval proctectomy, 15-20 per cent of patients are found to have a pathological complete response (pCR) to combined multimodal therapy, but controversy persists about whether this yields a survival benefit. This systematic review evaluated current evidence regarding long-term oncological outcomes in patients found to have a pCR to neoadjuvant CRT. METHODS Three major databases (PubMed, MEDLINE and the Cochrane Library) were searched. The systematic review included all original articles reporting long-term outcomes in patients with rectal cancer who had a pCR to neoadjuvant CRT, published in English, from January 1950 to March 2011. RESULTS A total of 724 studies were identified for screening. After applying inclusion and exclusion criteria, 16 studies involving 3363 patients (1263 with pCR and 2100 without) were included (mean age 60 years, 65·0 per cent men). Some 73·4 per cent had a sphincter-saving procedure. Mean follow-up was 55·5 (range 40-87) months. For patients with a pCR, the weighted mean local recurrence rate was 0·7 (range 0-2·6) per cent. Distant failure was observed in 8·7 per cent. Five-year overall and disease-free survival rates were 90·2 and 87·0 per cent respectively. Compared with non-responders, a pCR was associated with fewer local recurrences (odds ratio (OR) 0·25; P = 0·002) and less frequent distant failure (OR 0·23; P < 0·001), with a greater likelihood of being alive (OR 3·28; P = 0·001) and disease-free (OR 4·33, P < 0·001) at 5 years. CONCLUSION A pCR following neoadjuvant CRT is associated with excellent long-term survival, with low rates of local recurrence and distant failure.
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Affiliation(s)
- S T Martin
- Institute for Clinical Outcomes, Research and Education and Department of Colorectal Surgery, St Vincent's University Hospital, Dublin, Ireland.
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Yu SKT, Patel UB, Tait DM, Brown G. Primary staging and response assessment postchemoradiotherapy in rectal cancer. COLORECTAL CANCER 2012. [DOI: 10.2217/crc.11.3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
SUMMARY Initial assessment of newly diagnosed patients with rectal cancer includes clinical examination, colonoscopy, pelvic MRI and CT scan of the thorax, abdomen and pelvis. Radiological staging can objectively evaluate both surgical and biological prognostic features of rectal cancer. MRI has emerged to be the most useful preoperative prognostic staging tool and it can predict the risk of tumor involvement of surgical circumferential resection margin. An agreed definition of favorable tumor response to chemoradiotherapy is controversial. The importance of detecting and assessing good versus poor responders to chemoradiotherapy is of increasing relevance. MRI has been found to be useful in assessing tumor response postchemoradiotherapy, especially the assessment of potential circumferential resection margin and magnetic resonance tumor regression grade. These imaging markers predict survival outcomes for good and poor responders and provide an opportunity for clinicians to offer additional neoadjuvant and adjuvant treatments to reduce local or distance failure for the poor responders.
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Affiliation(s)
- Stanley KT Yu
- The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey SM2 5PT, UK
| | - Uday B Patel
- The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey SM2 5PT, UK
| | - Diana M Tait
- The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey SM2 5PT, UK
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