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Socha J, Glynne-Jones R, Bujko K. Oncological risks associated with the planned watch-and-wait strategy using total neoadjuvant treatment for rectal cancer: A narrative review. Cancer Treat Rev 2024; 129:102796. [PMID: 38968742 DOI: 10.1016/j.ctrv.2024.102796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 06/27/2024] [Accepted: 06/28/2024] [Indexed: 07/07/2024]
Abstract
Overall survival benefit of total neoadjuvant treatment (TNT) remains unconfirmed. Thus, in our opinion, the main rationale for using TNT is a planned watch-and-wait (w&w) strategy to improve patients' long-term quality of life through organ preservation. The OPRA randomized trial, which examined a planned w&w strategy using TNT, showed a higher organ preservation rate but also a higher regrowth rate compared to studies on the opportunistic w&w strategy. Higher rates of complete clinical response with TNT did not improve disease-free survival compared to historical controls. Therefore, the gain in organ-sparing capability might not be balanced by the increased oncological risk. The ultimate local failure rate in the intention-to-treat analysis of the OPRA trial was 13% for induction chemotherapy and 16% for consolidation chemotherapy, which seems higher than expected compared to 8% in a meta-analysis of w&w studies or 12% after TNT and surgery in the PRODIGE-23 and RAPIDO trials, which enrolled patients with more advanced cancers than the OPRA trial. Other studies also suggest worse local control when surgery is delayed for radio-chemoresistant cancers. Our review questions the safety of the planned w&w strategy using TNT in unselected patients. To reduce the oncological risk while maintaining high organ preservation rates, we suggest that the planned w&w strategy using TNT requires a two-tier patient selection process: before treatment and after tumor response assessment at the midpoint of consolidation chemotherapy. These robust selections should identify patients who are unlikely to achieve organ preservation with TNT and would be better managed by preoperative chemoradiotherapy (without consolidation chemotherapy) and surgery, or by discontinuing consolidation chemotherapy and proceeding directly to surgery.
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Affiliation(s)
- Joanna Socha
- Department of Radiotherapy, Regional Oncology Centre, Bialska 104/118, 42-200 Częstochowa, Poland.
| | - Robert Glynne-Jones
- Radiotherapy Department, Mount Vernon Centre for Cancer Treatment, Rickmansworth Rd, Northwood HA6 2RN, UK.
| | - Krzysztof Bujko
- Department of Radiotherapy I, Maria Skłodowska-Curie National Research Institute of Oncology, Roentgena 5, 02-781 Warsaw, Poland.
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2
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Sullo FG, Passardi A, Gallio C, Molinari C, Marisi G, Pozzi E, Solaini L, Bittoni A. Advancing Personalized Medicine in the Treatment of Locally Advanced Rectal Cancer. J Clin Med 2024; 13:2562. [PMID: 38731090 PMCID: PMC11084727 DOI: 10.3390/jcm13092562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 04/12/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024] Open
Abstract
Rectal cancer presents a significant burden globally, often requiring multimodal therapy for locally advanced cases. Long-course chemoradiotherapy (LCRT) and short-course radiotherapy (SCRT) followed by surgery have been conventional neoadjuvant approaches. Recent trials favor LCRT due to improved local control. However, distant tumor recurrence remains a concern, prompting the exploration of total neoadjuvant therapy (TNT) as a comprehensive treatment strategy. Immune checkpoint inhibitors (ICIs) show promise, particularly in mismatch repair-deficient (dMMR) or microsatellite instability-high (MSI-H) tumors, potentially revolutionizing neoadjuvant regimens. Nonoperative management (NOM) represents a viable alternative post-neoadjuvant therapy for selected patients achieving complete clinical response (cCR). Additionally, monitoring minimal residual disease (MRD) using circulating tumor DNA (ctDNA) emerges as a non-invasive method for the assessment of treatment response. This review synthesizes current evidence on TNT, ICIs, NOM, and ctDNA, elucidating their implications for rectal cancer management and highlighting avenues for future research and clinical application.
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Affiliation(s)
- Francesco Giulio Sullo
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, via P. Maroncelli 40, 47014 Meldola, Italy; (F.G.S.); (C.G.); (A.B.)
| | - Alessandro Passardi
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, via P. Maroncelli 40, 47014 Meldola, Italy; (F.G.S.); (C.G.); (A.B.)
| | - Chiara Gallio
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, via P. Maroncelli 40, 47014 Meldola, Italy; (F.G.S.); (C.G.); (A.B.)
| | - Chiara Molinari
- Biosciences Laboratory, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, via P. Maroncelli 40, 47014 Meldola, Italy; (C.M.); (G.M.)
| | - Giorgia Marisi
- Biosciences Laboratory, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, via P. Maroncelli 40, 47014 Meldola, Italy; (C.M.); (G.M.)
| | - Eleonora Pozzi
- Department of Medical and Surgical Science, University of Bologna, 47121 Forlì, Italy (L.S.)
| | - Leonardo Solaini
- Department of Medical and Surgical Science, University of Bologna, 47121 Forlì, Italy (L.S.)
| | - Alessandro Bittoni
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, via P. Maroncelli 40, 47014 Meldola, Italy; (F.G.S.); (C.G.); (A.B.)
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Safont MJ, García-Figueiras R, Hernando-Requejo O, Jimenez-Rodriguez R, Lopez-Vicente J, Machado I, Ayuso JR, Bustamante-Balén M, De Torres-Olombrada MV, Domínguez Tristancho JL, Fernández-Aceñero MJ, Suarez J, Vera R. Interdisciplinary Spanish consensus on a watch-and-wait approach for rectal cancer. Clin Transl Oncol 2024; 26:825-835. [PMID: 37787973 DOI: 10.1007/s12094-023-03322-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 09/07/2023] [Indexed: 10/04/2023]
Abstract
Watch-and-wait has emerged as a new strategy for the management of rectal cancer when a complete clinical response is achieved after neoadjuvant therapy. In an attempt to standardize this new clinical approach, initiated by the Spanish Cooperative Group for the Treatment of Digestive Tumors (TTD), and with the participation of the Spanish Association of Coloproctology (AECP), the Spanish Society of Pathology (SEAP), the Spanish Society of Gastrointestinal Endoscopy (SEED), the Spanish Society of Radiation Oncology (SEOR), and the Spanish Society of Medical Radiology (SERAM), we present herein a consensus on a watch-and-wait approach for the management of rectal cancer. We have focused on patient selection, the treatment schemes evaluated, the optimal timing for evaluating the clinical complete response, the oncologic outcomes after the implementation of this strategy, and a protocol for surveillance of these patients.
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Affiliation(s)
- Maria Jose Safont
- Oncology Department, Consorcio Hospital General Universitario de Valencia. Valencia University, Av. de les Tres Creus, 2, 46014, València, Spain.
| | - Roberto García-Figueiras
- Radiology Department, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | | | | | - Jorge Lopez-Vicente
- Gastroenterology Department, Hospital Universitario de Mostoles, Mósteles, Spain
| | - Isidro Machado
- Instituto Valenciano de Oncología, Valencia, Spain
- Pathology Department, Patologika Laboratory QuironSalud, Valencia, Spain
- Pathology Department, University of Valencia, Valencia, Spain
| | | | - Marco Bustamante-Balén
- Gastrointestinal Endoscopy Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | | | | | - Mª Jesús Fernández-Aceñero
- Surgical Pathology Department, Hospital Clínico San Carlos, IdiSSC, Universidad Complutense de Madrid, Madrid, Spain
| | - Javier Suarez
- General Surgery Department, Hospital Universitario de Navarra, Pamplona, Spain
| | - Ruth Vera
- Medical Oncology Department, Hospital Universitario de Navarra, Instituto de Investigación (Idisna), Pamplona, Spain
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Socha J, Bujko K. The ultimate local failure rate after the watch-and-wait strategy for rectal cancer: a systematic review of literature and meta-analysis. Acta Oncol 2023; 62:1052-1065. [PMID: 37632521 DOI: 10.1080/0284186x.2023.2245553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 08/02/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND We hypothesise that a high rate of tumour regrowth after the watch-and-wait (w&w) strategy may lead, despite salvage surgery, to a significant impairment of ultimate local control compared with immediate surgery. MATERIALS AND METHODS To test this hypothesis, we conducted meta-analyses of studies on the w&w strategy (both opportunistic and planned) with an ultimate local failure rate as an endpoint in three patient groups: (1) in all starting radio(chemo)therapy as potential w&w candidates, (2) in a subgroup starting w&w, and (3) in a subgroup with regrowth. RESULTS We identified eight studies for evaluation of local failure in group 1 (N = 837) and 36 studies in group 2 (N = 1914) and in group 3 (N = 439). The meta-analysis revealed an ultimate local failure rate of 8.0% (95% CI 4.8%-12.1%) in group 1 and 5.4% (95% CI 3.9%-7.1) in group 2. These rates are similar to those reported in the literature following preoperative chemoradiation and surgery. However, in the most unfavourable group 3 (with regrowth), the rate of ultimate local failure was 24.1% (95% CI 17.9%-30.9%), with the most common causes being patients' refusal of salvage total mesorectal excision (TME) (9.1%), recurrence after salvage TME (7.8%), distant metastases (4.1%), frailty (2.4%), and pelvic tumour unresectability (1.7%). CONCLUSION Nearly 25% of patients with regrowth (unfavourable subgroup) experienced ultimate local failure, primarily due to refusing salvage TME. The risk of ultimate local failure in patients initiating radio(chemo)therapy as potential w&w candidates, or in patients starting w&w, appears comparable to that reported after preoperative chemoradiation and surgery. However, this comparison may be biased, because w&w studies included more early tumours compared with surgical studies.
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Affiliation(s)
- Joanna Socha
- Department of Radiotherapy, Military Institute of Medicine - National Research Institute, Warsaw, Poland
- Department of Radiotherapy, Regional Oncology Centre, Częstochowa, Poland
| | - Krzysztof Bujko
- Department of Radiotherapy I, Maria Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
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Di Costanzo G, Ascione R, Ponsiglione A, Tucci AG, Dell’Aversana S, Iasiello F, Cavaglià E. Artificial intelligence and radiomics in magnetic resonance imaging of rectal cancer: a review. EXPLORATION OF TARGETED ANTI-TUMOR THERAPY 2023; 4:406-421. [PMID: 37455833 PMCID: PMC10344900 DOI: 10.37349/etat.2023.00142] [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: 12/28/2022] [Accepted: 03/01/2023] [Indexed: 07/18/2023] Open
Abstract
Rectal cancer (RC) is one of the most common tumours worldwide in both males and females, with significant morbidity and mortality rates, and it accounts for approximately one-third of colorectal cancers (CRCs). Magnetic resonance imaging (MRI) has been demonstrated to be accurate in evaluating the tumour location and stage, mucin content, invasion depth, lymph node (LN) metastasis, extramural vascular invasion (EMVI), and involvement of the mesorectal fascia (MRF). However, these features alone remain insufficient to precisely guide treatment decisions. Therefore, new imaging biomarkers are necessary to define tumour characteristics for staging and restaging patients with RC. During the last decades, RC evaluation via MRI-based radiomics and artificial intelligence (AI) tools has been a research hotspot. The aim of this review was to summarise the achievement of MRI-based radiomics and AI for the evaluation of staging, response to therapy, genotyping, prediction of high-risk factors, and prognosis in the field of RC. Moreover, future challenges and limitations of these tools that need to be solved to favour the transition from academic research to the clinical setting will be discussed.
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Affiliation(s)
- Giuseppe Di Costanzo
- Department of Radiology, Santa Maria delle Grazie Hospital, ASL Napoli 2 Nord, 80078 Pozzuoli, Italy
| | - Raffaele Ascione
- Department of Radiology, Santa Maria delle Grazie Hospital, ASL Napoli 2 Nord, 80078 Pozzuoli, Italy
| | - Andrea Ponsiglione
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Anna Giacoma Tucci
- Department of Radiology, Santa Maria delle Grazie Hospital, ASL Napoli 2 Nord, 80078 Pozzuoli, Italy
| | - Serena Dell’Aversana
- Department of Radiology, Santa Maria delle Grazie Hospital, ASL Napoli 2 Nord, 80078 Pozzuoli, Italy
| | - Francesca Iasiello
- Department of Radiology, Santa Maria delle Grazie Hospital, ASL Napoli 2 Nord, 80078 Pozzuoli, Italy
| | - Enrico Cavaglià
- Department of Radiology, Santa Maria delle Grazie Hospital, ASL Napoli 2 Nord, 80078 Pozzuoli, Italy
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Beets GL. Near-complete response following neoadjuvant therapy in rectal cancer: wait a bit longer? Br J Surg 2023:znad165. [PMID: 37364285 DOI: 10.1093/bjs/znad165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 05/12/2023] [Indexed: 06/28/2023]
Affiliation(s)
- Geerard L Beets
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
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7
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Wong C, Fu Y, Li M, Mu S, Chu X, Fu J, Lin C, Zhang H. MRI-Based Artificial Intelligence in Rectal Cancer. J Magn Reson Imaging 2023; 57:45-56. [PMID: 35993550 DOI: 10.1002/jmri.28381] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/19/2022] [Accepted: 07/20/2022] [Indexed: 02/03/2023] Open
Abstract
Rectal cancer (RC) accounts for approximately one-third of colorectal cancer (CRC), with death rates increasing in patients younger than 50 years old. Magnetic resonance imaging (MRI) is routinely performed for tumor evaluation. However, the semantic features from images alone remain insufficient to guide treatment decisions. Functional MRIs are useful for revealing microstructural and functional abnormalities and nevertheless have low or modest repeatability and reproducibility. Therefore, during the preoperative evaluation and follow-up treatment of patients with RC, novel noninvasive imaging markers are needed to describe tumor characteristics to guide treatment strategies and achieve individualized diagnosis and treatment. In recent years, the development of artificial intelligence (AI) has created new tools for RC evaluation based on MRI. In this review, we summarize the research progress of AI in the evaluation of staging, prediction of high-risk factors, genotyping, response to therapy, recurrence, metastasis, prognosis, and segmentation with RC. We further discuss the challenges of clinical application, including improvement in imaging, model performance, and the biological meaning of features, which may also be major development directions in the future. EVIDENCE LEVEL: 5 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Chinting Wong
- Department of Nuclear Medicine, The First Hospital of Jilin University, Changchun, China
| | - Yu Fu
- Department of Radiology, The First Hospital of Jilin University, Jilin Provincial Key Laboratory of Medical Imaging and Big Data, Changchun, China
| | - Mingyang Li
- Department of Radiology, The First Hospital of Jilin University, Jilin Provincial Key Laboratory of Medical Imaging and Big Data, Changchun, China
| | - Shengnan Mu
- Department of Radiology, The First Hospital of Jilin University, Jilin Provincial Key Laboratory of Medical Imaging and Big Data, Changchun, China
| | - Xiaotong Chu
- Department of Radiology, The First Hospital of Jilin University, Jilin Provincial Key Laboratory of Medical Imaging and Big Data, Changchun, China
| | - Jiahui Fu
- Department of Radiology, The First Hospital of Jilin University, Jilin Provincial Key Laboratory of Medical Imaging and Big Data, Changchun, China
| | - Chenghe Lin
- Department of Nuclear Medicine, The First Hospital of Jilin University, Changchun, China
| | - Huimao Zhang
- Department of Radiology, The First Hospital of Jilin University, Jilin Provincial Key Laboratory of Medical Imaging and Big Data, Changchun, China
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8
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Socha J, Bujko K. A watch-and-wait strategy or local excision in complete clinical responders after radiation for early-stage rectal cancer. THE LANCET. HEALTHY LONGEVITY 2022; 3:e807-e808. [PMID: 36403588 DOI: 10.1016/s2666-7568(22)00240-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 10/07/2022] [Indexed: 11/19/2022] Open
Affiliation(s)
- Joanna Socha
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland; Department of Radiotherapy, Regional Oncology Center, Czestochowa, Poland
| | - Krzysztof Bujko
- Department of Radiotherapy I, Maria Skłodowska-Curie National Research Institute of Oncology, Warsaw 02-781, Poland.
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9
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Tumour-stroma ratio to predict pathological response to neo-adjuvant treatment in rectal cancer. Surg Oncol 2022; 45:101862. [DOI: 10.1016/j.suronc.2022.101862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 09/05/2022] [Accepted: 10/02/2022] [Indexed: 11/21/2022]
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Asoglu O, Bulut A, Aliyev V, Piozzi GN, Guven K, Bakır B, Goksel S. Chemoradiation and consolidation chemotherapy for rectal cancer provides a high rate of organ preservation with a very good long-term oncological outcome: a single-center cohort series. World J Surg Oncol 2022; 20:358. [PMCID: PMC9646475 DOI: 10.1186/s12957-022-02816-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/27/2022] [Indexed: 11/11/2022] Open
Abstract
Abstract
Aim
To report long-term oncological outcomes and organ preservation rate with a chemoradiotherapy-consolidation chemotherapy (CRT-CNCT) treatment for locally advanced rectal cancer (LARC).
Method
Retrospective analysis of prospectively maintained database was performed. Oncological outcomes of mid-low LARC patients (n=60) were analyzed after a follow-up of 63 (50–83) months. Patients with clinical complete response (cCR) were treated with the watch-and-wait (WW) protocol. Patients who could not achieve cCR were treated with total mesorectal excision (TME) or local excision (LE).
Results
Thirty-nine (65%) patients who achieved cCR were treated with the WW protocol. TME was performed in 15 (25%) patients and LE was performed in 6 (10%) patients. During the follow-up period, 10 (25.6%) patients in the WW group had regrowth (RG) and 3 (7.7%) had distant metastasis (DM). Five-year overall survival (OS) and disease-free survival (DFS) were 90.1% and 71.6%, respectively, in the WW group. Five-year OS and DFS were 94.9% (95% CI: 88–100%) and 80% (95% CI: 55.2–100%), respectively, in the RG group. For all patients (n=60), 5-year TME-free DFS was 57.3% (95% CI: 44.3–70.2%) and organ preservation-adapted DFS was 77.5% (95% CI: 66.4–88.4%). For the WW group (n=39), 5-year TME-free DFS was 77.5% (95% CI: 63.2–91.8%) and organ preservation-adapted DFS was 85.0% (95% CI: 72.3–97.8%).
Conclusion
CRT-CNCT provides cCR as high as 2/3 of LARC patients. Regrowths, developed during follow-up, can be successfully salvaged without causing oncological disadvantage if strict surveillance is performed.
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Ghadimi M, Rödel C, Hofheinz R, Flebbe H, Grade M. Multimodal Treatment of Rectal Cancer. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:570-580. [PMID: 35791271 PMCID: PMC9743213 DOI: 10.3238/arztebl.m2022.0254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 03/03/2022] [Accepted: 06/14/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Colorectal cancer is one of the three most common types of cancer in Germany. Approximately 30% of these cancers are located in the rectum, corresponding to about 18 000 new cases per year. METHODS This review is based on publications retrieved by a selective search in the PubMed database, including current guidelines and recommendations. RESULTS Specialized imaging, particularly magnetic resonance imaging, is essential for treatment planning. In very early stages of this disease, tumors without risk factors can be excised locally. Otherwise, radical surgical resection with lymphadenectomy remains the standard treatment, and can be performed either minimally invasive or open. At present, neoadjuvant treatment plans are evolving in the direction of total neoadjuvant therapy. In addition, recent studies investigate whether the improved efficacy of neoadjuvant therapy might now enable patients with a complete clinical remission to be spared from surgical resection (organ-preserving watch-and-wait strategy). CONCLUSION The treatment of rectal cancer is a prime example of an interdisciplinary, multimodal approach. In the past, the focus was mainly on improving oncologic outcomes; at present, increasing attention is being devoted to the patients' quality of life as well and the functional aspects of the various modes of treatment.
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Affiliation(s)
- Michael Ghadimi
- Department of General, Visceral and Pediatric Surgery, University Medical Center Göttingen
| | - Claus Rödel
- Department of Radiotherapy and Oncology, Goethe University Frankfurt am Main
| | - Ralf Hofheinz
- Department of Medical Hematology and Oncology, University Hospital Mannheim, University of Heidelberg
| | - Hannah Flebbe
- Department of General, Visceral and Pediatric Surgery, University Medical Center Göttingen
| | - Marian Grade
- Department of General, Visceral and Pediatric Surgery, University Medical Center Göttingen,*Universitätsmedizin Göttingen Klinik für Allgemein-, Viszeral- und Kinderchirurgie Robert-Koch-Strasse 40, D-37075 Göttingen, Germany
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Custers PA, Beets GL, Melenhorst J. Response to the comment on 'Selected stage IV rectal cancer patients managed by the watch-and-wait approach after pelvic radiotherapy: a good alternative to total mesorectal excision surgery?'. Colorectal Dis 2022; 24:878-879. [PMID: 35258148 DOI: 10.1111/codi.16109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 02/27/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Petra A Custers
- Department of Surgery, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands.,GROW School for Oncology and Developmental Biology - Maastricht University, Maastricht, The Netherlands
| | - Geerard L Beets
- Department of Surgery, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands.,GROW School for Oncology and Developmental Biology - Maastricht University, Maastricht, The Netherlands
| | - Jarno Melenhorst
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
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Custers PA, Hupkens BJP, Grotenhuis BA, Kuhlmann KFD, Breukink SO, Beets GL, Melenhorst J, Buijsen J, Festen S, de Graaf EJR, Haak HE, Hilling DE, Hoff C, Intven M, Komen N, Kusters M, van Leerdam ME, Peeters KCMJ, Peters FP, Pronk A, van der Sande ME, Schreurs WH, Sonneveld DJA, Talsma AK, Tuynman JB, Valkenburg‐van Iersel LBJ, Vermaas M, de Vos‐Geelen J, van Westreenen HL, de Wilt JHW, Zimmerman DDE. Selected stage IV rectal cancer patients managed by the watch-and-wait approach after pelvic radiotherapy: a good alternative to total mesorectal excision surgery? Colorectal Dis 2022; 24:401-410. [PMID: 35060263 PMCID: PMC9305558 DOI: 10.1111/codi.16034] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 12/16/2021] [Accepted: 12/20/2021] [Indexed: 12/18/2022]
Abstract
AIM The aim of this study was to assess the clinical and oncological outcome of a selected group of stage IV rectal cancer patients managed by the watch-and-wait approach following a (near-)complete response of the primary rectal tumour after radiotherapy. METHOD Patients registered in the Dutch watch-and-wait registry since 2004 were selected when diagnosed with synchronous stage IV rectal cancer. Data on patient characteristics, treatment details, follow-up and survival were collected. The 2-year local regrowth rate, organ-preservation rate, colostomy-free rate, metastatic progression-free rate and 2- and 5-year overall survival were analysed. RESULTS After a median follow-up period of 35 months, local regrowth was observed in 17 patients (40.5%). Nine patients underwent subsequent total mesorectal excision, resulting in a permanent colostomy in four patients. The 2-year local regrowth rate was 39.9%, the 2-year organ-preservation rate was 77.1%, the 2-year colostomy-free rate was 88.1%, and the 2-year metastatic progression-free rate was 46.7%. The 2- and 5-year overall survival rates were 92.0% and 67.5%. CONCLUSION The watch-and-wait approach can be considered as an alternative to total mesorectal excision in a selected group of stage IV rectal cancer patients with a (near-)complete response following pelvic radiotherapy. Despite a relatively high regrowth rate, total mesorectal excision and a permanent colostomy can be avoided in the majority of these patients.
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Affiliation(s)
- Petra A. Custers
- Department of SurgeryNetherlands Cancer Institute – Antoni van LeeuwenhoekAmsterdamThe Netherlands,GROW School for Oncology and Developmental Biology – Maastricht UniversityMaastrichtThe Netherlands
| | - Britt J. P. Hupkens
- Department of RadiotherapyMaastricht University Medical Centre (MAASTRO)MaastrichtThe Netherlands
| | - Brechtje A. Grotenhuis
- Department of SurgeryNetherlands Cancer Institute – Antoni van LeeuwenhoekAmsterdamThe Netherlands
| | - Koert F. D. Kuhlmann
- Department of SurgeryNetherlands Cancer Institute – Antoni van LeeuwenhoekAmsterdamThe Netherlands
| | | | - Geerard L. Beets
- Department of SurgeryNetherlands Cancer Institute – Antoni van LeeuwenhoekAmsterdamThe Netherlands,GROW School for Oncology and Developmental Biology – Maastricht UniversityMaastrichtThe Netherlands
| | - Jarno Melenhorst
- Department of SurgeryMaastricht University Medical CentreMaastrichtThe Netherlands
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Gerard JP, Montagne L, Thamphya B, Doyen J, Schiappa R, Benezery K, Gourgou S, Dejean C, Hannoun-Levi JM. Propensity score analysis of radical proctectomy versus organ preservation using contact X-ray brachytherapy for rectal cancer. Clin Transl Radiat Oncol 2022; 33:70-76. [PMID: 35118202 PMCID: PMC8791854 DOI: 10.1016/j.ctro.2021.12.007] [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: 09/15/2021] [Revised: 12/14/2021] [Accepted: 12/19/2021] [Indexed: 11/25/2022] Open
Abstract
Key objective: the goal provides data to evaluate the oncological risk of performing a planned- conservative strategy in selected patients presenting early T2-T3 rectal adenocarcinoma. Knowledge generated: This propensity score analysis on 72 patients, comparing neoadjuvant chemoradiotherapy followed by radical surgery with planned organ preservation using combined chemoradiotherapy and contact X-ray brachytherapy boost, showed no detrimental oncological safety results after 5 year follow-up. Relevance: This study supplies additional arguments in favor of organ preservation for selected early rectal T2-T3.
Introduction Radical proctectomy (RP-TME) with neo adjuvant chemoradiotherapy (nCRT) remains the standard treatment for T2-T3 rectal cancer. Organ preservation (OP) using CRT and a “watch and wait” strategy (W&W) is a field of research. Planned organ preservation can be proposed for early T1-T3 using contact X-ray brachytherapy (CXB). We compared the oncological outcomes of both approaches using a propensity score matched-cohort analysis. Material and methods For comparative analyses between patients with nCRT + RP-TME and patients with CXB + CRT, propensity scores were calculated with logistic regression and multiple imputations for missing data. The variables included in the propensity score model were PS status, T-N stage and rectal circumference extension. Patients were matched 1:1 using the nearest neighbor method with a 0.1 caliper restriction. The 5-year Cancer Specific survival was the primary end point. Results The Accord 12 phase III trial included 584 patients who treated with nCRT + RP-TME. The CXB cohort included 71 patients with a planned OP. To select OP patient candidate, T4, tumor with extension >66% circumference were eliminated and only patients treated with CXB + CRT were analyzed in the CXB cohort resulting in a total of 374 patients. A one to one paired cohort with 36 patients in each group was derived. These two cohorts were well matched for all confounding factors except for age. The 5-year cancer specific rate showed no significant difference between the two groups (89% in Accord 12 vs 82% in CXB; p = 0.84). At 5 years, rate of metastasis (15% vs 22%, p = 0.54) showed no significant difference. In the CXB group 33/36 patients preserved their rectum. Conclusion The organ preservation strategy using CXB boost yielded a 5-year cancer specific survival rate similar to patients treated with RP-TME. In selected early T2-3 rectal adenocarcinoma an organ preservation strategy could be offered as a reasonable option.
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15
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Socha J, Bujko K. Comment on Timing of Surgery For Patients With Rectal Cancers Not Responding to Preoperative Chemoradiation. JAMA Surg 2022; 157:549-550. [PMID: 35195691 DOI: 10.1001/jamasurg.2021.7591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Joanna Socha
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland
| | - Krzysztof Bujko
- Department of Radiotherapy I, Maria Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
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16
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Park IJ. Watch and wait strategies for rectal cancer A systematic review. PRECISION AND FUTURE MEDICINE 2021. [DOI: 10.23838/pfm.2021.00177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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17
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Fokas E, Appelt A, Glynne-Jones R, Beets G, Perez R, Garcia-Aguilar J, Rullier E, Smith JJ, Marijnen C, Peters FP, van der Valk M, Beets-Tan R, Myint AS, Gerard JP, Bach SP, Ghadimi M, Hofheinz RD, Bujko K, Gani C, Haustermans K, Minsky BD, Ludmir E, West NP, Gambacorta MA, Valentini V, Buyse M, Renehan AG, Gilbert A, Sebag-Montefiore D, Rödel C. International consensus recommendations on key outcome measures for organ preservation after (chemo)radiotherapy in patients with rectal cancer. Nat Rev Clin Oncol 2021; 18:805-816. [PMID: 34349247 DOI: 10.1038/s41571-021-00538-5] [Citation(s) in RCA: 78] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2021] [Indexed: 02/07/2023]
Abstract
Multimodal treatment strategies for patients with rectal cancer are increasingly including the possibility of organ preservation, through nonoperative management or local excision. Organ preservation strategies can enable patients with a complete response or near-complete clinical responses after radiotherapy with or without concomitant chemotherapy to safely avoid the morbidities associated with radical surgery, and thus to maintain anorectal function and quality of life. However, standardization of the key outcome measures of organ preservation strategies is currently lacking; this includes a lack of consensus of the optimal definitions and selection of primary end points according to the trial phase and design; the optimal time points for response assessment; response-based decision-making; follow-up schedules; use of specific anorectal function tests; and quality of life and patient-reported outcomes. Thus, a consensus statement on outcome measures is necessary to ensure consistency and facilitate more accurate comparisons of data from ongoing and future trials. Here, we have convened an international group of experts with extensive experience in the management of patients with rectal cancer, including organ preservation approaches, and used a Delphi process to establish the first international consensus recommendations for key outcome measures of organ preservation, in an attempt to standardize the reporting of data from both trials and routine practice in this emerging area.
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Affiliation(s)
- Emmanouil Fokas
- Department of Radiotherapy of Oncology, University of Frankfurt, Frankfurt, Germany.
- German Cancer Research Center (DKFZ), Heidelberg, Germany.
- German Cancer Consortium (DKTK), Frankfurt, Germany.
- Frankfurt Cancer Institute (FCI), Frankfurt, Germany.
| | - Ane Appelt
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - Robert Glynne-Jones
- Department of Radiotherapy, Mount Vernon Centre for Cancer Treatment, Northwood, UK
| | - Geerard Beets
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, Netherlands
- Department of Surgery, Netherlands Cancer Institute Amsterdam, Amsterdam, Netherlands
| | - Rodrigo Perez
- Department of Surgery, Angelita & Joaquim Institute, São Paulo, Brazil
| | - Julio Garcia-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Eric Rullier
- Department of Colorectal Surgery, Haut-Lévèque Hospital, Centre Hospitalier Universitaire (CHU) Bordeaux, Bordeaux, France
| | - J Joshua Smith
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Corrie Marijnen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Femke P Peters
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Maxine van der Valk
- Department of Surgery, Netherlands Cancer Institute Amsterdam, Amsterdam, Netherlands
| | - Regina Beets-Tan
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, Netherlands
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Arthur S Myint
- The Clatterbridge Cancer Centre, Royal Liverpool University Hospital, Liverpool, UK
| | | | - Simon P Bach
- Academic Department of Surgery, University of Birmingham, Birmingham, UK
| | - Michael Ghadimi
- Department of General, Visceral, and Paediatric Surgery, University Medical Center, Göttingen, Germany
| | - Ralf D Hofheinz
- Department of Medical Oncology, University Hospital Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Krzysztof Bujko
- Department of Radiotherapy, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Cihan Gani
- Department of Radiation Oncology, University Hospital and Medical Faculty Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
- German Cancer Research Center (DKFZ) Heidelberg and German Consortium for Translational Cancer Research (DKTK) Partner Site Tübingen, Tübingen, Germany
| | - Karin Haustermans
- Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Bruce D Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ethan Ludmir
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nicholas P West
- Division of Pathology and Data Analytics, Leeds Institute of Medical Research at St. James's, School of Medicine, University of Leeds, Leeds, UK
| | - Maria A Gambacorta
- Department of Radiation Oncology and Medical Oncology, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Vincenzo Valentini
- Department of Radiation Oncology and Medical Oncology, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marc Buyse
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics, Hasselt University, Diepenbeek, Belgium
- International Drug Development Institute, San Francisco, CA, USA
| | - Andrew G Renehan
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Colorectal and Peritoneal Oncology Centre, Christie NHS Foundation Trust, Manchester, UK
| | - Alexandra Gilbert
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | | | - Claus Rödel
- Department of Radiotherapy of Oncology, University of Frankfurt, Frankfurt, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- German Cancer Consortium (DKTK), Frankfurt, Germany
- Frankfurt Cancer Institute (FCI), Frankfurt, Germany
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18
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Bahadoer RR, Peeters KCMJ, Beets GL, Figueiredo NL, Bastiaannet E, Vahrmeijer A, Temmink SJD, Meershoek-Klein Kranenbarg WME, Roodvoets AGH, Habr-Gama A, Perez RO, van de Velde CJH, Hilling DE. Watch and wait after a clinical complete response in rectal cancer patients younger than 50 years. Br J Surg 2021; 109:114-120. [PMID: 34738104 DOI: 10.1093/bjs/znab372] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 09/21/2021] [Accepted: 09/23/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Young-onset rectal cancer, in patients less than 50 years, is expected to increase in the coming years. A watch-and-wait strategy is nowadays increasingly practised in patients with a clinical complete response (cCR) after neoadjuvant treatment. Nevertheless, there may be reluctance to offer organ preservation treatment to young patients owing to a potentially higher oncological risk. This study compared patients aged less than 50 years with those aged 50 years or more to identify possible differences in oncological outcomes of watch and wait. METHODS The study analysed data from patients with a cCR after neoadjuvant therapy in whom surgery was omitted, registered in the retrospective-prospective, multicentre International Watch & Wait Database (IWWD). RESULTS In the IWWD, 1552 patients met the inclusion criteria, of whom 199 (12.8 per cent) were aged less than 50 years. Patients younger than 50 years had a higher T category of disease at diagnosis (P = 0.011). The disease-specific survival rate at 3 years was 98 (95 per cent c.i. 93 to 99) per cent in this group, compared with 97 (95 to 98) per cent in patients aged over 50 years (hazard ratio (HR) 1.67, 95 per cent c.i. 0.76 to 3.64; P = 0.199). The cumulative probability of local regrowth at 3 years was 24 (95 per cent c.i. 18 to 31) per cent in patients less than 50 years and 26 (23 to 29) per cent among those aged 50 years or more (HR 1.09, 0.79 to 1.49; P = 0.603). Both groups had a cumulative probability of distant metastases of 10 per cent at 3 years (HR 1.00, 0.62 to 1.62; P = 0.998). CONCLUSION There is no additional oncological risk in young patients compared with their older counterparts when following a watch-and-wait strategy after a cCR. In light of a shared decision-making process, watch and wait should be also be discussed with young patients who have a cCR after neoadjuvant treatment.
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Affiliation(s)
- Renu R Bahadoer
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Koen C M J Peeters
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Geerard L Beets
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands.,GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands
| | - Nuno L Figueiredo
- Digestive Unit, Champalimaud Foundation, Lisbon, Portugal.,Colorectal Surgery, Hospital Lusíadas, Lisbon, Portugal
| | - Esther Bastiaannet
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands.,Department of Medical Oncology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Alexander Vahrmeijer
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | | | | | - Annet G H Roodvoets
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | | | | | | | - Denise E Hilling
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands.,Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, University Medical Centre Rotterdam, Rotterdam, the Netherlands
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19
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Valadão M, Cesar D, Véo CAR, Araújo RO, do Espirito Santo GF, Oliveira de Souza R, Aguiar S, Ribeiro R, de Castro Ribeiro HS, de Souza Fernandes PH, Oliveira AF. Brazilian society of surgical oncology: Guidelines for the surgical treatment of mid-low rectal cancer. J Surg Oncol 2021; 125:194-216. [PMID: 34585390 DOI: 10.1002/jso.26676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 09/08/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Colorectal cancer (CRC) is the third leading cause of cancer in North America, Western Europe, and Brazil, and represents an important public health problem. It is estimated that approximately 30% of all the CRC cases correspond to tumors located in the rectum, requiring complex multidisciplinary treatment. In an effort to provide surgeons who treat rectal cancer with the most current information based on the best evidence in the literature, the Brazilian Society of Surgical Oncology (SBCO) has produced the present guidelines for rectal cancer treatment that is focused on the main topics related to daily clinical practice. OBJECTIVES The SBCO developed the present guidelines to provide recommendations on the main topics related to the treatment of mid-low rectal cancer based on current scientific evidence. METHODS Between May and June 2021, 11 experts in CRC surgery met to develop the guidelines for the treatment of mid-low rectal cancer. A total of 22 relevant topics were disseminated among the participants. The methodological quality of a final list with 221 sources was evaluated, all the evidence was examined and revised, and the treatment guideline was formulated by the 11-expert committee. To reach a final consensus, all the topics were reviewed via a videoconference meeting that was attended by all 11 of the experts. RESULTS The prepared guidelines contained 22 topics considered to be highly relevant in the treatment of mid-low rectal cancer, covering subjects related to the tests required for staging, surgical technique-related aspects, recommended measures to reduce surgical complications, neoadjuvant strategies, and nonoperative treatments. In addition, a checklist was proposed to summarize the important information and offer an updated tool to assist surgeons who treat rectal cancer provide the best care to their patients. CONCLUSION These guidelines summarize concisely the recommendations based on the most current scientific evidence on the most relevant aspects of the treatment of mid-low rectal cancer and are a practical guide that can help surgeons who treat rectal cancer make the best therapeutic decision.
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Affiliation(s)
- Marcus Valadão
- Division of Abdominal-Pelvic Surgery, Instituto Nacional de Cancer, Rio de Janeiro, Brazil
| | - Daniel Cesar
- Division of Abdominal-Pelvic Surgery, Instituto Nacional de Cancer, Rio de Janeiro, Brazil
| | | | - Rodrigo Otávio Araújo
- Division of Abdominal-Pelvic Surgery, Instituto Nacional de Cancer, Rio de Janeiro, Brazil
| | | | | | - Samuel Aguiar
- Department of Surgical Oncology, AC Camargo Cancer Center, São Paulo, Brazil
| | - Reitan Ribeiro
- Department of Surgical Oncology, Erasto Gaertner Hospital, Curitiba, Brazil
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20
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Santiago I, Barata MJ, Figueiredo N, Parés O, Matos C. Early conformational changes at tumour bed and long term response after neoadjuvant therapy in locally-advanced rectal cancer. Eur J Radiol 2021; 140:109742. [PMID: 33971571 DOI: 10.1016/j.ejrad.2021.109742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 03/24/2021] [Accepted: 04/23/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To evaluate how changes in tumour scar depth angle and thickness in the post-neoadjuvant period relate to long-term response in locally-advanced rectal cancer patients. METHODS Informed consent was obtained from all patients and institutional review board approved this retrospective study. Sixty-nine consecutive locally-advanced rectal cancer patients who underwent neoadjuvant therapy and were selected for "Watch-and-Wait" were enrolled. Two radiologists, O1 and O2, blindly and independently reviewed the 1st and 2nd post-neoadjuvant therapy pelvic MRI T2-weighted images and recorded depth angle and thickness of the tumour scar. Value changes were calculated by simple subtraction (2nd-1st). Mann-Whitney U test was employed to assess for significant differences between sustained clinical complete responders (SCR), defined as patients with pathologic complete response or clinical complete response with a minimum follow-up of 1 year; and non-sustained complete responders (non-SCR). Interobserver agreement was estimated using intraclass correlation coefficient (ICC). Data on mrTRG, DWI and endoscopy at 1st and 2nd timepoints were retrieved for comparison. RESULTS In SCR, depth angle change between 1st (med = 10 weeks after end of radiotherapy) and 2nd (med = 23 weeks after end of radiotherapy) timepoints was significantly different (O1:p = 0.004; O2:p = 0.010): the SCR group showed a depth angle reduction (O1:med=-4.45; O2:med=-2.35), whereas non-SCRs showed a depth angle increase (O1:med=+2.60; O2:med=+7.40). Also, at 2nd timepoint, SCR scars were significantly thinner both for O1 (p = 0.003; SCR:med = 7.05 mm; non-SCR:med = 9.4 mm) and O2 (p = 0.006; SCR:med = 6.45 mm; non-SCR:med = 8.2 mm). A depth angle increase >21º between 1st and 2nd timepoints and a scar thickness >10 mm at 2nd timepoint were not sensitive but were highly specific for a non-SCR (91/94 %) for both observers. Interobserver agreement was good for scar depth angle change (ICC = 0.65) and excellent for scar thickness at 2nd timepoint (ICC = 0.84). Of the retrieved data, only DWI at 2nd timepoint was discriminative (p = 0.043) providing a similar sensitivity (33 %) and a slightly lower specificity (87.5 %). CONCLUSION Tumour scar expansion >21° between 1st and 2nd post-neoadjuvancy MRI and a scar thickness >10 mm at 2nd post-neoadjuvancy MRI may consistently indicate a non-SCR with high specificity in locally-advanced rectal cancer patients.
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Affiliation(s)
- Inês Santiago
- Radiology Department, Champalimaud Foundation, Avenida Brasília, Lisbon, 1400-038, Portugal; Nova Medical School, Campo Mártires da Pátria 130, Lisbon, 1169-056, Portugal.
| | - Maria-João Barata
- Radiology Department, Champalimaud Foundation, Avenida Brasília, Lisbon, 1400-038, Portugal
| | - Nuno Figueiredo
- Colorectal Surgery, Digestive Unit, Champalimaud Foundation, Avenida Brasília, Lisbon, 1400-038, Portugal
| | - Oriol Parés
- Radiation Oncology Department, Champalimaud Foundation, Avenida Brasília, Lisbon, 1400-038, Portugal
| | - Celso Matos
- Radiology Department, Champalimaud Foundation, Avenida Brasília, Lisbon, 1400-038, Portugal
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Jankowski M, Pietrzak L, Rupiński M, Michalski W, Hołdakowska A, Paciorek K, Rutkowski A, Olesiński T, Cencelewicz A, Szczepkowski M, Zegarski W, Reszke J, Richter P, Wawok P, Małecki K, Bębenek M, Szelachowska J, Mazurek M, Gisterek I, Polkowski W, Jankiewicz M, Styliński R, Socha J, Bujko K. Watch-and-wait strategy in rectal cancer: Is there a tumour size limit? Results from two pooled prospective studies. Radiother Oncol 2021; 160:229-235. [PMID: 34023328 DOI: 10.1016/j.radonc.2021.05.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/06/2021] [Accepted: 05/12/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Frequency and predictive factors for a clinical complete response (cCR) in unselected patients are unclear. MATERIAL AND METHODS Two prospective observational studies were designed and pooled to explore predictive factors for cCR. Both studies evaluated the watch-and-wait strategy in consecutive patients; the first single-institutional study in elderly with a small tumour, the second multi-institutional study in all the patients receiving standard of care preoperative radiotherapy. RESULTS Four hundred and ninety patients were analysed. Short-course radiotherapy alone, or with consolidation chemotherapy or chemoradiation was given to 40.6%, 40.2% and 19.2% of the patients, respectively. The median interval from the radiation start to the first tumour response assessment was 10.2 weeks for short-course radiation and 13.2 weeks for chemoradiation. Seventy-three patients had cCR and 71 underwent w&w with the median follow-up of 24 months. The regrowth rate was 26.8%. cCR rate was 39.0% for low-risk cancer (cT1-2N0), 16.8% for intermediate-risk (cT3 with unthreatened mesorectal fascia [MRF-] or cT2N+) and 5.4% for high-risk (cT4 or MRF+). In the multivariable analysis, tumour volume (or tumour length and circumferential extent) and cN status were significant predictors for cCR. In circular cancers or with a length ≥7 cm (n = 184), cCR rate was only 2.7%, sustained cCR 1.6% and the sensitivity of cCR diagnosis 23.1%. None of 27 patients with a tumour larger than 120 cm3 achieved cCR. CONCLUSIONS Considering watch-and-wait strategy is questionable in patients with circular tumours or with tumour length ≥7 cm.
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Affiliation(s)
- Michał Jankowski
- Chair of Surgical Oncology, Collegium Medicum Nicolaus Copernicus University, Oncology Center-Prof Franciszek Łukaszczyk Memorial Hospital, Bydgoszcz, Poland
| | - Lucyna Pietrzak
- Department of Radiotherapy I, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Maciej Rupiński
- Department of Gastroenterological Oncology, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Wojciech Michalski
- Bioinformatics and Biostatistics Unit, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Anna Hołdakowska
- Department of Radiology, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Karol Paciorek
- Department of Radiotherapy I, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Andrzej Rutkowski
- Department of Gastroenterological Oncology, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Tomasz Olesiński
- Department of Gastroenterological Oncology, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Anna Cencelewicz
- Department of Gastroenterological Oncology, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Marek Szczepkowski
- Clinical Department of Colorectal, General and Oncological Surgery, Centre of Postgraduate Medical Education, Bielanski Hospital, Warsaw, Poland
| | - Wojciech Zegarski
- Chair of Surgical Oncology, Collegium Medicum Nicolaus Copernicus University, Oncology Center-Prof Franciszek Łukaszczyk Memorial Hospital, Bydgoszcz, Poland
| | - Joanna Reszke
- Department of Radiotherapy, Collegium Medicum Nicolaus Copernicus University Oncology Center-Prof Franciszek Łukaszczyk Memorial Hospital, Bydgoszcz, Poland
| | - Piotr Richter
- Ist Department of General Surgery, Jagiellonian Medical University College, Kraków, Poland
| | - Przemysław Wawok
- Ist Department of General Surgery, Jagiellonian Medical University College, Kraków, Poland
| | - Krzysztof Małecki
- Department of Radiotherapy, University Children's Hospital, Kraków, Poland
| | - Marek Bębenek
- Department of Surgery, Lower Silesian Oncological Centre, Wrocław, Poland
| | - Jolanta Szelachowska
- Department of Oncology, Wroclaw Medical University, Wrocław, Poland; Department of Radiotherapy, Wrocław Comprehensive Cancer Centre, Wrocław, Poland
| | - Marek Mazurek
- Department of General and Oncological Surgery, Pope John Paul II Public Hospital, Zamość, Poland
| | - Iwona Gisterek
- Department of Radiotherapy, Nu-Med Group, Zamość, Poland
| | | | | | - Roman Styliński
- 1st Department of General Surgery, Transplantology and Nutritional Therapy, Medical University of Lublin, Poland
| | - Joanna Socha
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland; Department of Radiotherapy, Regional Oncology Center, Czestochowa, Poland
| | - Krzysztof Bujko
- Department of Radiotherapy I, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland.
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22
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Beard BW, Rettig RL, Ryoo JJ, Parker RA, McLemore EC, Attaluri V. Watch-and-Wait Compared to Operation for Patients with Complete Response to Neoadjuvant Therapy for Rectal Cancer. J Am Coll Surg 2020; 231:681-692. [PMID: 33121903 DOI: 10.1016/j.jamcollsurg.2020.08.775] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/24/2020] [Accepted: 08/24/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Trimodality therapy with neoadjuvant chemoradiation (nCRT), surgery, and adjuvant chemotherapy is the standard treatment for locally advanced rectal cancer. There is evidence that surgery can be deferred in patients with complete response (CR) to nCRT, a strategy termed "watch-and-wait" (WW). We compare WW to surgery in patients with CR to nCRT. STUDY DESIGN We reviewed records of patients treated with nCRT for nonmetastatic rectal cancer at our institution. Complete endoscopic response (CER) was defined as negative digital rectal exam and negative endoscopy at the end of neoadjuvant therapy (NAT). Clinical complete response (cCR) was defined as CER with negative rectal MRI. Patients with CER refusing surgery were offered WW, which included strict surveillance with digital rectal exam and endoscopy. RESULTS From January 2015 through February 2019, 465 patients completed nCRT; 406 patients had response assessment, of which 95 (23%) had CER. Of these patients, 53 patients underwent WW and 42 patients had surgery. Median follow-up was 35 months. In the WW group, 3-year freedom from local regrowth was 85%. In the surgical and WW groups, 3-year overall survival, rectal cancer-specific survival, and freedom from nonregrowth recurrence were 100% vs 88% (p = 0.03), 100% vs 95% (p = 0.16), and 92% vs 85% (p = 0.36), respectively. Of the 6 WW patients with local regrowth, 5 (83%) eventually developed distant recurrence. CONCLUSIONS WW in lieu of surgery appears to be a safe and feasible treatment approach for patients achieving CR to nCRT. Careful evaluation to confirm cCR after nCRT is valuable in selecting patients for WW.
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Affiliation(s)
- Bryce W Beard
- Departments of Radiation Oncology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA.
| | - Robert L Rettig
- Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Joan J Ryoo
- Departments of Radiation Oncology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Rex A Parker
- Radiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | | | - Vikram Attaluri
- Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA; Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
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Collée GE, van der Wilk BJ, van Lanschot JJB, Busschbach JJ, Timmermans L, Lagarde SM, Kranenburg LW. Interventions that Facilitate Shared Decision-Making in Cancers with Active Surveillance as Treatment Option: a Systematic Review of Literature. Curr Oncol Rep 2020; 22:101. [PMID: 32725550 PMCID: PMC7387328 DOI: 10.1007/s11912-020-00962-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE OF REVIEW Medical decisions concerning active surveillance are complex, especially when evidence on superiority of one of the treatments is lacking. Decision aids have been developed to facilitate shared decision-making on whether to pursue an active surveillance strategy. However, it is unclear how these decision aids are designed and which outcomes are considered relevant. The purpose of this study is to systematically review all decision aids in the field of oncological active surveillance strategies and outcomes used by authors to assess their efficacy. RECENT FINDINGS A search was performed in Embase, Medline, Web of Science, Cochrane, PsycINFO Ovid and Google Scholar until June 2019. Eligible studies concerned interventions aiming to facilitate shared decision-making for patients confronted with several treatment alternatives, with active surveillance being one of the treatment alternatives. Twenty-three eligible articles were included. Twenty-one articles included patients with prostate cancer, one with thyroid cancer and one with ovarian cancer. Interventions mostly consisted of an interactive web-based decision aid format. After categorization of outcomes, seven main groups were identified: knowledge, involvement in decision-making, decisional conflict, treatment preference, decision regret, anxiety and health-related outcomes. Although active surveillance has been implemented for several malignancies, interventions that facilitate shared decision-making between active surveillance and other equally effective treatment alternatives are scarce. Future research should focus on developing interventions for malignancies like rectal cancer and oesophageal cancer as well. The efficacy of interventions is mostly assessed using short-term outcomes.
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Affiliation(s)
- G E Collée
- Department of Psychiatry, Section Medical Psychology and Psychotherapy, Erasmus MC - University Medical Centre, Rotterdam, Netherlands
| | - B J van der Wilk
- Department of Surgery, Erasmus MC - University Medical Centre, Dr. Molewaterplein 40 P.O. Box 2040, Suite Na-2119, 3015 GD, Rotterdam, Netherlands.
| | - J J B van Lanschot
- Department of Surgery, Erasmus MC - University Medical Centre, Dr. Molewaterplein 40 P.O. Box 2040, Suite Na-2119, 3015 GD, Rotterdam, Netherlands
| | - J J Busschbach
- Department of Psychiatry, Section Medical Psychology and Psychotherapy, Erasmus MC - University Medical Centre, Rotterdam, Netherlands
| | - L Timmermans
- Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, Netherlands
| | - S M Lagarde
- Department of Surgery, Erasmus MC - University Medical Centre, Dr. Molewaterplein 40 P.O. Box 2040, Suite Na-2119, 3015 GD, Rotterdam, Netherlands
| | - L W Kranenburg
- Department of Psychiatry, Section Medical Psychology and Psychotherapy, Erasmus MC - University Medical Centre, Rotterdam, Netherlands
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Zhang ZY, Yao QZ, Liu HY, Guo QN, Qiu PJ, Chen JP, Lin JQ. Metabolic reprogramming-associated genes predict overall survival for rectal cancer. J Cell Mol Med 2020; 24:5842-5849. [PMID: 32285560 PMCID: PMC7214181 DOI: 10.1111/jcmm.15254] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 03/08/2020] [Accepted: 03/13/2020] [Indexed: 02/06/2023] Open
Abstract
Metabolic reprogramming has become a hot topic recently in the regulation of tumour biology. Although hundreds of altered metabolic genes have been reported to be associated with tumour development and progression, the important prognostic role of these metabolic genes remains unknown. We downloaded messenger RNA expression profiles and clinicopathological data from The Cancer Genome Atlas and the Gene Expression Omnibus database to uncover the prognostic role of these metabolic genes. Univariate Cox regression analysis and lasso Cox regression model were utilized in this study to screen prognostic associated metabolic genes. Patients with high‐risk demonstrated significantly poorer survival outcomes than patients with low‐risk in the TCGA database. Also, patients with high‐risk still showed significantly poorer survival outcomes than patients with low‐risk in the GEO database. What is more, gene set enrichment analyses were performed in this study to uncover significantly enriched GO terms and pathways in order to help identify potential underlying mechanisms. Our study identified some survival‐related metabolic genes for rectal cancer prognosis prediction. These genes might play essential roles in the regulation of metabolic microenvironment and in providing significant potential biomarkers in metabolic treatment.
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Affiliation(s)
- Zhong-Yi Zhang
- Departments of Oncological Surgery, the Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Qing-Zhi Yao
- Departments of Oncological Surgery, the Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Hui-Yong Liu
- Departments of Oncological Surgery, the Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Qiao-Nan Guo
- Departments of Oncological Surgery, the Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Peng-Jun Qiu
- Departments of Oncological Surgery, the Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Jian-Peng Chen
- Departments of Oncological Surgery, the Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Jian-Qing Lin
- Departments of Oncological Surgery, the Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
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