Predicting poor response to neoadjuvant chemoradiotherapy for locally advanced rectal cancer: Model constructed using pre-treatment MRI features of structured report template

Predicting the response to neoadjuvant chemoradiation for rectal cancer using nomograms based on MRI tumour regression grade

PURPOSE

This study aimed to develop nomograms that combine clinical factors and MRI tumour regression grade to predict the pathological response of mid-low locally advanced rectal cancer to neoadjuvant chemoradiotherapy.

METHODS

The retrospective study included 204 patients who underwent neoadjuvant chemoradiotherapy and surgery between January 2013 and December 2021. Based on pathological tumour regression grade, patients were categorized into four groups: complete pathological response (pCR, n=45), non-complete pathological response (non-pCR; n=159), good pathological response (pGR, n=119), and non-good pathological response (non-pGR, n=85). The patients were divided into a training set and a validation set in a 7:3 ratio. Based on the results of univariate and multivariate analyses in the training set, two nomograms were respectively constructed to predict complete and good pathological responses. Subsequently, these predictive models underwent validation in the independent validation set. The prognostic performances of the models were evaluated using the area under the curve (AUC).

RESULTS

The nomogram predicting complete pathological response incorporates tumour length, post-treatment mesorectal fascia involvement, white blood cell count, and MRI tumour regression grade. It yielded an AUC of 0.787 in the training set and 0.716 in the validation set, surpassing the performance of the model relying solely on MRI tumour regression grade (AUCs of 0.649 and 0.530, respectively). Similarly, the nomogram predicting good pathological response includes the distance of the tumour's lower border from the anal verge, post-treatment mesorectal fascia involvement, platelet/lymphocyte ratio, and MRI tumour regression grade. It achieved an AUC of 0.754 in the training set and 0.719 in the validation set, outperforming the model using MRI tumour regression grade alone (AUCs of 0.629 and 0.638, respectively).

CONCLUSIONS

Nomograms combining MRI tumour regression grade with clinical factors may be useful for predicting pathological response of mid-low locally advanced rectal cancer to neoadjuvant chemoradiotherapy. The proposed models could be applied in clinical practice after validation in large samples.

Magnetic resonance imaging-based radiomics analysis for prediction of treatment response to neoadjuvant chemoradiotherapy and clinical outcome in patients with locally advanced rectal cancer: A large multicentric and validated study

Our study investigated whether magnetic resonance imaging (MRI)-based radiomics features could predict good response (GR) to neoadjuvant chemoradiotherapy (nCRT) and clinical outcome in patients with locally advanced rectal cancer (LARC). Radiomics features were extracted from the T2 weighted (T2W) and Apparent diffusion coefficient (ADC) images of 1070 LARC patients retrospectively and prospectively recruited from three hospitals. To create radiomic models for GR prediction, three classifications were utilized. The radiomic model with the best performance was integrated with important clinical MRI features to create the combined model. Finally, two clinical MRI features and ten radiomic features were chosen for GR prediction. The combined model, constructed with the tumor size, MR-detected extramural venous invasion, and radiomic signature generated by Support Vector Machine (SVM), showed promising discrimination of GR, with area under the curves of 0.799 (95% CI, 0.760-0.838), 0.797 (95% CI, 0.733-0.860), 0.754 (95% CI, 0.678-0.829), and 0.727 (95% CI, 0.641-0.813) in the training and three validation datasets, respectively. Decision curve analysis verified the clinical usefulness. Furthermore, according to Kaplan-Meier curves, patients with a high likelihood of GR as determined by the combined model had better disease-free survival than those with a low probability. This radiomics model was developed based on large-sample size, multicenter datasets, and prospective validation with high radiomics quality score, and also had clinical utility.

Prediction of pathological complete response and prognosis in locally advanced rectal cancer

BACKGROUND

Colorectal cancer is currently the third most common malignant tumor and the second leading cause of cancer-related death worldwide. Neoadjuvant chemoradiotherapy (nCRT) is standard for locally advanced rectal cancer (LARC). Except for pathological examination after resection, it is not known exactly whether LARC patients have achieved pathological complete response (pCR) before surgery. To date, there are no clear clinical indicators that can predict the efficacy of nCRT and patient outcomes.

AIM

To investigate the indicators that can predict pCR and long-term outcomes following nCRT in patients with LARC.

METHODS

Clinical data of 128 LARC patients admitted to our hospital between September 2013 and November 2022 were retrospectively analyzed. Patients were categorized into pCR and non-pCR groups. Univariate analysis (using the χ² test or Fisher’s exact test) and logistic multivariate regression analysis were used to study clinical predictors affecting pCR. The 5-year disease-free survival (DFS) and overall survival (OS) rates were calculated using Kaplan-Meier analysis, and differences in survival curves were assessed with the log-rank test.

RESULTS

Univariate analysis showed that pretreatment carcinoembryonic antigen (CEA) level, lymphocyte-monocyte ratio (LMR), time interval between neoadjuvant therapy completion and total mesorectal excision, and tumor size were correlated with pCR. Multivariate results showed that CEA ≤ 5 ng/mL (P = 0.039), LMR > 2.73 (P = 0.023), and time interval > 10 wk (P = 0.039) were independent predictors for pCR. Survival analysis demonstrated that patients in the pCR group had significantly higher 5-year DFS rates (94.7% vs 59.7%, P = 0.002) and 5-year OS rates (95.8% vs 80.1%, P = 0.019) compared to the non-pCR group. Tumor deposits (TDs) were significantly correlated with shorter DFS (P = 0.002) and OS (P < 0.001).

CONCLUSION

Pretreatment CEA, LMR, and time interval contribute to predicting nCRT efficacy in LARC patients. Achieving pCR demonstrates longer DFS and OS. TDs correlate with poor prognosis.

Prediction of pathological complete response and prognosis in locally advanced rectal cancer

BACKGROUND

Colorectal cancer is currently the third most common malignant tumor and the second leading cause of cancer-related death worldwide. Neoadjuvant chemoradiotherapy (nCRT) is standard for locally advanced rectal cancer (LARC). Except for pathological examination after resection, it is not known exactly whether LARC patients have achieved pathological complete response (pCR) before surgery. To date, there are no clear clinical indicators that can predict the efficacy of nCRT and patient outcomes.

AIM

To investigate the indicators that can predict pCR and long-term outcomes following nCRT in patients with LARC.

METHODS

Clinical data of 128 LARC patients admitted to our hospital between September 2013 and November 2022 were retrospectively analyzed. Patients were categorized into pCR and non-pCR groups. Univariate analysis (using the χ 2 test or Fisher's exact test) and logistic multivariate regression analysis were used to study clinical predictors affecting pCR. The 5-year disease-free survival (DFS) and overall survival (OS) rates were calculated using Kaplan-Meier analysis, and differences in survival curves were assessed with the log-rank test.

RESULTS

Univariate analysis showed that pretreatment carcinoembryonic antigen (CEA) level, lymphocyte-monocyte ratio (LMR), time interval between neoadjuvant therapy completion and total mesorectal excision, and tumor size were correlated with pCR. Multivariate results showed that CEA ≤ 5 ng/mL (P = 0.039), LMR > 2.73 (P = 0.023), and time interval > 10 wk (P = 0.039) were independent predictors for pCR. Survival analysis demonstrated that patients in the pCR group had significantly higher 5-year DFS rates (94.7% vs 59.7%, P = 0.002) and 5-year OS rates (95.8% vs 80.1%, P = 0.019) compared to the non-pCR group. Tumor deposits (TDs) were significantly correlated with shorter DFS (P = 0.002) and OS (P < 0.001).

CONCLUSION

Pretreatment CEA, LMR, and time interval contribute to predicting nCRT efficacy in LARC patients. Achieving pCR demonstrates longer DFS and OS. TDs correlate with poor prognosis.

A Rulefit-based prognostic analysis using structured MRI report to select potential beneficiaries from induction chemotherapy in advanced nasopharyngeal carcinoma: A dual-centre study

BACKGROUND AND PURPOSE

Structured MRI report facilitate prognostic prediction for nasopharyngeal carcinoma (NPC). However, the intrinsic association among structured variables is not fully utilised. This study aimed to investigate the performance of a Rulefit-based model in feature integration behind structured MRI report and prognostic prediction in advanced NPC.

MATERIALS AND METHODS

We retrospectively enrolled 1207 patients diagnosed with non-metastatic advanced NPC from two centres, and divided into training (N = 544), internal testing (N = 367), and external testing (N = 296) cohorts. Machine learning algorithms including multivariate analysis, deep learning, Lasso, and Rulefit were used to establish corresponding prognostic models. The concordance indices (C- indices) of three clinical and six combined models with different algorithms for overall survival (OS) prediction were compared. Survival benefits of induction chemotherapy (IC) were calculated among risk groups stratified by different models. A website was established for individualised survival visualisation.

RESULTS

Incorporating structured variables into Stage model significantly improved the prognostic prediction performance. Six prognostic rules with structured variables were identified by Rulefit. OS prediction of Rules model was comparable to Lasso model in internal testing cohort (C-index: 0.720 vs. 0.713, P = 0.100) and achieved the highest C-index of 0.711 in external testing cohort, indicating better generalisability. The Rules model stratified patients into risk groups with significant 5-year OS differences in each cohort, and revealed significant survival benefits from additional IC in high-risk group.

CONCLUSION

The Rulefit-based Rules model, with the revelation of intrinsic associations behind structured variables, is promising in risk stratification and guiding individualised IC treatment for advanced NPC.

Radiomics from Mesorectal Blood Vessels and Lymph Nodes: A Novel Prognostic Predictor for Rectal Cancer with Neoadjuvant Therapy

The objective of our study is to investigate the predictive value of various combinations of radiomic features from intratumoral and different peritumoral regions of interest (ROIs) for achieving a good pathological response (pGR) following neoadjuvant chemoradiotherapy (nCRT) in patients with locally advanced rectal cancer (LARC). This retrospective study was conducted using data from LARC patients who underwent nCRT between 2013 and 2021. Patients were divided into training and validation cohorts at a ratio of 4:1. Intratumoral ROIs (ROI_ITU) were segmented on T2-weighted imaging, while peritumoral ROIs were segmented using two methods: ROI_{PTU_2mm}, ROI_{PTU_4mm}, and ROI_{PTU_6mm}, obtained by dilating the boundary of ROI_ITU by 2 mm, 4 mm, and 6 mm, respectively; and ROI_{MR_F} and ROI_{MR_BVLN}, obtained by separating the fat and blood vessels + lymph nodes in the mesorectum. After feature extraction and selection, 12 logistic regression models were established using radiomics features derived from different ROIs or ROI combinations, and five-fold cross-validation was performed. The average area under the receiver operating characteristic curve (AUC) was used to evaluate the performance of the models. The study included 209 patients, consisting of 118 pGR and 91 non-pGR patients. The model that integrated ROI_ITU and ROI_{MR_BVLN} features demonstrated the highest predictive ability, with an AUC (95% confidence interval) of 0.936 (0.904-0.972) in the training cohort and 0.859 (0.745-0.974) in the validation cohort. This model outperformed models that utilized ROI_ITU alone (AUC = 0.779), ROI_{MR_BVLN} alone (AUC = 0.758), and other models. The radscore derived from the optimal model can predict the treatment response and prognosis after nCRT. Our findings validated that the integration of intratumoral and peritumoral radiomic features, especially those associated with mesorectal blood vessels and lymph nodes, serves as a potent predictor of pGR to nCRT in patients with LARC. Pending further corroboration in future research, these insights could provide novel imaging markers for refining therapeutic strategies.

Radiomics of locally advanced rectal cancer: machine learning-based prediction of response to neoadjuvant chemoradiotherapy using pre-treatment sagittal T2-weighted MRI

PURPOSE

Variable response to neoadjuvant chemoradiotherapy (nCRT) is observed among individuals with locally advanced rectal cancer (LARC), having a significant impact on patient management. In this work, we aimed to investigate the potential value of machine learning (ML)-based magnetic resonance imaging (MRI) radiomics in predicting therapeutic response to nCRT in patients with LARC.

MATERIALS AND METHODS

Seventy-six patients with LARC were included in this retrospective study. Radiomic features were extracted from pre-treatment sagittal T2-weighted MRI images, with 3D segmentation. Dimension reduction was performed with a reliability analysis, pair-wise correlation analysis, analysis of variance, recursive feature elimination, Kruskal-Wallis, and Relief methods. Models were created using four different algorithms. In addition to radiomic models, clinical only and different combined models were developed and compared. The reference standard was tumor regression grade (TRG) based on the Modified Ryan Scheme (TRG 0 vs TRG 1-3). Models were compared based on net reclassification index (NRI). Clinical utility was assessed with decision curve analysis (DCA).

RESULTS

Number of features with excellent reliability is 106. The best result was achieved with radiomic only model using eight features. The area under the curve (AUC), accuracy, sensitivity, and specificity for validation were 0.753 (standard deviation [SD], 0.082), 81.1%, 83.8%, and 75.0%; for testing, 0.705 (SD, 0.145), 73.9%, 81.2%, and 57.1%, respectively. Based on the clinical only model as reference, NRI for radiomic only model was the best. DCA also showed better clinical utility for radiomic only model.

CONCLUSIONS

ML-based T2-weighted MRI radiomics might have a potential in predicting response to nCRT in patients with LARC.

Value of texture analysis based on dynamic contrast-enhanced magnetic resonance imaging in preoperative assessment of extramural venous invasion in rectal cancer

Objective

Accurate preoperative assessment of extramural vascular invasion (EMVI) is critical for the treatment and prognosis of rectal cancer. The aim of our research was to develop an assessment model by texture analysis for preoperative prediction of EMVI.

Materials and methods

This study enrolled 44 rectal patients as train cohort, 7 patients as validation cohort and 18 patients as test cohort. A total of 236 texture features from DCE MR imaging quantitative parameters were extracted for each patient (59 features of Ktrans, Kep, Ve and Vp), and key features were selected by least absolute shrinkage and selection operator regression (LASSO). Finally, clinical independent risk factors, conventional MRI assessment, and T-score were incorporated to construct an assessment model using multivariable logistic regression.

Results

The T-score calculated using the 4 selected key features were significantly correlated with EMVI (p < 0.010). The area under the receiver operating characteristic curve (AUC) was 0.797 for discriminating between EMVI-positive and EMVI-negative patients with a sensitivity of 88.2% and specificity of 70.4%. The conventional MRI assessment of EMVI had a sensitivity of 23.53% and a specificity of 96.30%. The assessment model showed a greatly improved performance with an AUC of 0.954 (sensitivity, 88.2%; specificity, 92.6%) in train cohort, 0.833 (sensitivity, 66.7%; specificity, 100%) in validation cohort and 0.877 in test cohort, respectively.

Conclusions

The assessment model showed an excellent performance in preoperative assessment of EMVI. It demonstrates strong potential for improving the accuracy of EMVI assessment and provide a reliable basis for individualized treatment decisions.

Review of Radiomics- and Dosiomics-based Predicting Models for Rectal Cancer

By breaking the traditional medical image analysis framework, precision medicine-radiomics has attracted much attention in the past decade. The use of various mathematical algorithms offers radiomics the ability to extract vast amounts of detailed features from medical images for quantitative analysis and analyzes the confidential information related to the tumor in the image, which can establish valuable disease diagnosis and prognosis models to support personalized clinical decisions. This article summarizes the application of radiomics and dosiomics in radiation oncology. We focus on the application of radiomics in locally advanced rectal cancer and also summarize the latest research progress of dosiomics in radiation tumors to provide ideas for the treatment of future related diseases, especially 125I CT-guided radioactive seed implant brachytherapy.

Machine learning-based multiparametric MRI radiomics for predicting poor responders after neoadjuvant chemoradiotherapy in rectal Cancer patients

BACKGROUND

The purpose of this study was to investigate and validate multiparametric magnetic resonance imaging (MRI)-based machine learning classifiers for early identification of poor responders after neoadjuvant chemoradiotherapy (nCRT) in patients with locally advanced rectal cancer (LARC).

METHODS

Patients with LARC who underwent nCRT were included in this retrospective study (207 patients). After preprocessing of multiparametric MRI, radiomics features were extracted and four feature selection methods were used to select robust features. The selected features were used to build five machine learning classifiers, and 20 (four feature selection methods × five machine learning classifiers) predictive models for the screening of poor responders were constructed. The predictive models were evaluated according to the area under the curve (AUC), F1 score, accuracy, sensitivity, and specificity.

RESULTS

Eighty percent of all predictive models constructed achieved an AUC of more than 0.70. A predictive model using a support vector machine classifier with the minimum redundancy maximum relevance (mRMR) selection method followed by the least absolute shrinkage and selection operator (LASSO) selection method showed superior prediction performance, with an AUC of 0.923, an F1 score of 88.14%, and accuracy of 91.03%. The predictive performance of the constructed models was not improved by ComBat compensation.

CONCLUSIONS

In rectal cancer patients who underwent neoadjuvant chemoradiotherapy, machine learning classifiers with radiomics features extracted from multiparametric MRI were able to accurately discriminate poor responders from good responders. The techniques should provide additional information to guide patient-tailored treatment.

Local tuning of radiomics-based model for predicting pathological response to neoadjuvant chemoradiotherapy in locally advanced rectal cancer

PURPOSE

This study aims to further enhance a validated radiomics-based model for predicting pathologic complete response (pCR) after chemo‑radiotherapy in locally advanced rectal cancer (LARC) for use in clinical practice.

METHODS

A generalized linear model (GLM) to predict pCR in LARC patients previously trained in Europe and validated with an external inter-continental cohort (59 patients), was first examined with further 88 intercontinental patient datasets to assess its reproducibility; then new radiomics and clinical features, and validation methods were investigated to build a new model for enhancing the pCR prediction for patients admitted to our department. The patients were divided into training group (75%) and validation group (25%) according to their demographic. The least absolute shrinkage and selection operator (LASSO) logistic regression was used to reduce the dimensionality of the extracted features of the training group and select the optimal ones; the performance of the reference GLM and enhanced models was compared through the area under curve (AUC) of the receiver operating characteristics.

RESULTS

The value of AUC of the reference model was 0.831 (95% CI, 0.701-0.961), and 0.828 (95% CI, 0.700-0.956) in the original and new validation cohorts, respectively, showing a reproducibility in the applicability of the GLM model. Eight features were found to be significant with LASSO and used to establish an enhanced model. The AUC of the enhanced model of 0.926 (95% CI, 0.859-0.993) for training, and 0.926 (95% CI, 0.767-1.00) for the validation group shows better performance than the reference model.

CONCLUSIONS

The GLM model shows good reproducibility in predicting pCR in LARC; the enhanced model has the potential to improve prediction accuracy and may be a candidate in clinical practice.

Survival impact of concurrent chemoradiotherapy for elderly patients with synchronous oligometastatic esophageal squamous cell carcinoma: A propensity score matching and landmark analyses

PURPOSE

To evaluate the potential benefits of concurrent chemoradiotherapy (CCRT), and to establish a nomogram for predicting survival outcomes of elderly patients with synchronous oligometastatic esophageal squamous cell carcinoma (SOEC).

MATERIALS AND METHODS

This study eventually enrolled 314 elderly patients who initially diagnosed with SOEC from two centers. Treatment responses and outcomes of 151 patients receiving CCRT and 163 patients undergoing chemotherapy alone (CT) were compared. Propensity score matching and landmark analyses were performed to control potential confounding factors. A nomogram was established on the basis of the Cox regression model.

RESULTS

After a median follow-up of 42.3 months, CCRT was superior to CT alone in objective response rate (ORR, 59.6% vs. 39.9%, P < 0.001), median progression-free survival (PFS, 10.0 vs. 7.2 months, P < 0.001), and median overall survival (OS, 18.5 vs. 15.6 months, P < 0.001). The propensity score matching (PSM) and landmark analyses redemonstrated the same trend (P < 0.01). On hierarchical analysis, patients with 1-3 metastatic lesions involving one organ displayed longer median PFS (9.0 vs. 7.8 months, P = 0.008) and OS (17.8 vs. 15.2 months, P < 0.001) than those with 4-5 metastatic lesions involving 2-3 organs. The major toxicities of grade III or higher for CCRT included leukocytopenia (23.2%), radiation esophagitis (7.3%), and radiation pneumonitis (8.6%). Cox multivariate analysis showed that the number of metastatic lesions (P = 0.012) and tumor response (P < 0.001) were independent prognostic factors associated with OS. A nomogram was established by incorporating the number of metastatic lesions and tumor response, with a concordance index of 0.743 after internal cross-validation. Calibration curves and decision curve analysis confirmed that nomogram had a favorable predictive value for individualized survival.

CONCLUSIONS

Compared with CT alone, CCRT exhibited superior efficacy and acceptable toxicity in the first-line treatment for elderly patients with SOEC. The current study supports the oligometastatic definition of ≤3 metastatic lesions involving one organ for esophageal cancer patients. The constructed nomogram can effectively predict the individualized survival.

Development and validation of an MRI-based radiomic nomogram to distinguish between good and poor responders in patients with locally advanced rectal cancer undergoing neoadjuvant chemoradiotherapy

PURPOSE

In the clinical management of patients with locally advanced rectal cancer (LARC), the early identification of poor and good responders after neoadjuvant chemoradiotherapy (N-CRT) is essential. Therefore, we developed and validated predictive models including MRI findings from the structured report template, clinical and radiomics parameters to differentiate between poor and good responders in patients with locally advanced rectal cancer who underwent neoadjuvant chemoradiotherapy.

METHODS

Preoperative multiparametric MRI from 183 patients with locally advanced rectal cancer (122 in the training cohort, 61 in the validation cohort) was included in this retrospective study. After preprocessing, radiomic features were extracted and two methods of feature selection was applied to reduce the number of radiomics features. Logistic regression (LR) and random forest (RF) machine learning classifiers were trained to identify good responders from poor responders. Multivariable logistic regression analysis was used to incorporate the radiomic signature and clinical risk factors into a nomogram. Classifier performance was evaluated using the area under the curve (AUC), accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

RESULTS

For the differentiation of poor and good responders, the radiomics model with an LR classifier achieved AUCs of 0.869 and 0.842 for the training and validation cohorts, respectively. The nomogram showed the highest reproducibility and prognostic ability in the training and validation cohorts, with AUCs of 0.923 (95% confidence interval, 0.872-0.975) and 0.898 (0.819-0.978), respectively. Additionally, the nomogram achieved significant risk stratification of patients in respect to progression free survival (PFS).

CONCLUSIONS

The nomogram accurately differentiated good and poor responders in patients with LARC undergoing N-CRT, and showed significant performance for predicting PFS.