Impact of T and N substage on survival and disease relapse in adjuvant rectal cancer: a pooled analysis

A Prospective Study on the Roles of the Lymphocyte-to-Monocyte Ratio (LMR), Neutrophil-to-Lymphocyte Ratio (NLR), and Platelet-to-Lymphocyte Ratio (PLR) in Patients with Locally Advanced Rectal Cancer

Rectal cancer constitutes over one-third of all colorectal cancers (CRCs) and is one of the leading causes of cancer-related deaths in developed countries. In order to identify high-risk patients and better adjust therapies, new markers are needed. Systemic inflammatory response (SIR) markers such as LMR, NLR, and PLR have proven to be highly prognostic in many malignancies, including CRC; however, their roles in locally advanced rectal cancer (LARC) are conflicting and lack proper validation. Sixty well-selected patients with LARC treated at the Maria Sklodowska-Curie National Research Institute of Oncology in Warsaw, Poland, between August 2017 and December 2020 were prospectively enrolled in this study. The reproducibility of the pre-treatment levels of the SIR markers, their correlations with clinicopathological characteristics, and their prognostic value were evaluated. There was a significant positive correlation between LMR and cancer-related inflammatory infiltrate (r = 0.38, p = 0.044) and PD-L1 expression in tumor cells, lymphocytes, and macrophages (combined positive score (CPS)) (r = 0.45, p = 0.016). The PLR level was correlated with nodal involvement (p = 0.033). The SIR markers proved to be only moderately reproducible and had no significant prognostic value. In conclusion, the LMR was associated with local cancer-related inflammation and PD-L1 expression in tumor microenvironments. The validity of SIR indices as biomarkers in LARC requires further investigation.

Effectiveness of radiotherapy for local control in T3N0 rectal cancer managed with total mesorectal excision: a meta-analysis

Introduction: The total mesorectal excision (TME) significantly improved rectal cancer outcomes. Radiotherapy’s benefit in T3N0 rectal cancer patients managed with TME has not been clearly demonstrated. A systematic review and meta-analysis were undertaken to determine whether radiotherapy altered the risk of locoregional recurrence (LR) in T3N0 rectal cancer patients managed with a TME.

Materials and Methods: Studies indexed on PubMed or Embase were systematically searched from inception to October 18, 2020. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were observed for the literature search, study screening, and data extraction; the Newcastle Ottawa Scale evaluated bias; Grades of Recommendation, Assessment, Development, and Evaluation Working Group system evaluated certainty; and all were performed independently by at least two investigators. Studies that reported LR data specific to T3N0 rectal cancer patients managed with TME, treated with and without radiotherapy, were included. Data was pooled using a random-effects model. Meta-analyses of the relative risk of local recurrence were conducted.

Results: Five retrospective cohort studies involving 932 unique patients reported LR outcomes; no prospective studies met eligibility criteria. Median follow-up ranged from 38.4–78 months. Adjuvant radiotherapy was provided in 3 studies. Chemotherapy was delivered and reported in 4 studies, providing both concurrent and adjuvant chemotherapy. A non-significant LR reduction with radiotherapy alongside TME was estimated, mean relative risk (RR) 0.63 (95% Confidence Interval 0.31–1.29; I² = 41.8%).

Conclusions: A non-significant LR benefit with radiotherapy’s addition was estimated. Meta-analysis of exclusively retrospective cohort studies was concerning for biased results. Adequately powered randomized trials are warranted.

The number of cycles of adjuvant chemotherapy in stage III and high-risk stage II rectal cancer: a nomogram and recursive partitioning analysis

Objective

The prognostic role of the number of cycles of adjuvant chemotherapy (ACT) after total mesorectal excision in stage III and high-risk stage II rectal cancer is unknown. As a result of this, our study was designed to assess the effect of the number of cycles of ACT on the prediction of cancer-specific survival.

Methods

Four hundred patients that were diagnosed as stage III and high-risk stage II rectal cancer from January 2012 to January 2018 and who had received total mesorectal excision were enrolled in this study. A nomogram incorporating the number of cycles of ACT was also developed in this study. For internal validation, the bootstrap method was used and the consistency index was used to evaluate the accuracy of the model. The patients were stratified into risk groups according to their tumor characteristics by recursive partitioning analysis.

Results

We found that the risk of death was decreased by 26% (HR = 0.74, 95% CI: 0.61–0.89, P = 0.0016) with each increasing ACT cycle. The N stage, positive lymph node ratio (PLNR), carcinoembryonic antigen, neutrophil-to-lymphocyte ratio, and the number of cycles of ACT were chosen and entered into the nomogram model. Recursive partitioning analysis-based risk stratification revealed a significant difference in the prognosis in rectal cancer patients with high-risk, intermediate-risk, and low-risk (3-year cancer-specific survival: 0.246 vs. 0.795 vs. 0.968, P < 0.0001). Seven or more cycles of ACT yielded better survival in patients with PLNR ≥ 0.28 but not in patients with PLNR < 0.28.

Conclusion

In conclusion, the nomogram prognosis model based on the number of cycles of ACT predicted individual prognosis in rectal cancer patients who had undergone total mesorectal excision. These findings further showed that in patients with PLNR ≥ 0.28, no fewer than 7 cycles of ACT are needed to significantly reduce the patient’s risk of death.

Report from the 20th annual Western Canadian Gastrointestinal Cancer Consensus Conference; Saskatoon, Saskatchewan; 28-29 September 2018

The 20th annual Western Canadian Gastrointestinal Cancer Consensus Conference was held in Saskatoon, Saskatchewan, 28-29 September 2018. This interactive multidisciplinary conference is attended by health care professionals from across Western Canada (British Columbia, Alberta, Saskatchewan, and Manitoba) who are involved in the care of patients with gastrointestinal cancers. In addition, invited speakers from other provinces participate. Surgical, medical, and radiation oncologists, and allied health care professionals participated in presentations and discussion sessions for the purpose of developing the recommendations presented here. This consensus statement addresses current issues in the management of colorectal cancers.

Pathologic Staging Inconsistency Between ypT4N0 (stage II) and ypT1-2N1 (stage III) After Preoperative Chemoradiotherapy and Total Mesorectal Excision in Rectal Cancer: A Multi-Institutional Study

BACKGROUND

In the Surveillance, Epidemiology, and End Results population-based data, the survival curves reversed between T4N0 (stages IIB or IIC) and T1-2N1 (stage IIIA) in rectal cancer. However, T4N0 had a higher stage than T1-2N1 in the current colorectal staging system.

PATIENTS AND METHODS

We analyzed 1804 patients with rectal cancer who were treated with preoperative chemoradiotherapy and curative surgery. We grouped patients by pathologic stage, and recurrence-free survival (RFS) and overall survival rates were calculated and compared for each stage. We evaluated prognostic factors that influenced recurrence and survival.

RESULTS

In the recurrence and survival analysis, 3-year RFS rates were 95.9% for ypStage 0, 94.0% for ypStage I, 78.9% for ypStage IIA, 55.8% for ypStage IIB/C, 80.2% for ypStage IIIA, 64.6% for ypStage IIIB, and 44.9% for ypStage IIIC. Patients with ypStage IIB/C showed significantly worse RFS (P = .004) than did those with ypStage IIIA. The ypStage IIB/C group showed significantly higher rates of both locoregional recurrence (24.3% vs. 5.5%; P = .02) and distant metastasis (31.6% vs. 17.1%; P = .048) than did the ypStage IIIA group. Compared with ypStage IIIA, ypStage IIB/C showed significantly higher pre-chemoradiotherapy carcinoembryonic antigen (P = .004), circumferential radial margin involvement (P = .001), and positive perineural invasion (P = .014).

CONCLUSION

Patients with rectal cancer staged ypT4N0 were associated with higher locoregional recurrence and distant metastasis rates than those staged ypT1-2N1 in the current staging system.

Selective use of radiation for locally advanced rectal cancer: one size does not fit all

The last three decades have seen several major advances in the multidisciplinary management of locally advanced rectal cancer (LARC). Although rectal cancer management varies globally, the standard of care for clinical stage II/III rectal cancer in North America remains chemoradiation followed by total mesorectal excision and adjuvant therapy. In this review we evaluate the evidence for neoadjuvant therapy in LARC and the variety of treatment options available. We identify heterogeneity of outcomes in stage II/III rectal cancer, leading to the potential for overtreatment. The PROSPECT Trial is a multicenter, international effort to determine whether a selective approach to provision of radiotherapy in stage II/III LARC is a viable treatment option. Unlike many other studies, the aim of PROSPECT is to reduce treatment rather than increase the intensity of preoperative therapy. LARC is a heterogeneous disease with varying risk of relapse. Studies are underway to attempt to individualize care to avoid overtreatment while maintaining excellent oncologic outcomes.

[A change in the expression of membrane-associated proteins and cytoplasmic actin isoforms in the progression of human colon tumors]

Tumor progression is a complex process that also involves the restructuring of the actin cytoskeleton and the weakening of intercellular adhesive contacts due to the tumor cells that pass through the epithelial-mesenchymal transition (EMT).

AIM

Тo identify correlations between clinical features, risk of progression and/or recurrence of human colon adenocarcinomas (CAC), and EMT-related tumor markers.

MATERIAL AND METHODS

Descending colon and sigmoid colon adenocarcinoma samples were examined immunohistochemically. Formalin-fixed paraffin-embedded tissue sections were incubated with antigen-specific antibodies, then secondary antibodies labeled with fluorochromes, and the fluorescence intensity of microscopy images was analyzed.

RESULTS

The cells of a tumor compared to those of intact colon tissue showed a weak staining of E-cadherin in the cell-cell contact areas. The reduced membrane staining and nuclear localization of β-catenin were detected in moderately (G2) and poorly (G3) differentiated tumors. There were substantially decreased β-actin levels in almost all tumor samples and increased γ-actin ones, mainly in the samples belonging to stage IV disease.

CONCLUSION

A correlation was found between stage, tumor differentiation grade, risk for relapse or progression of disease, and the impaired expression of different EMT markers: total or partial loss of E-cadherin expression, β-catenin reorganization in cell-cell contacts, and a change in the ratio of cytoplasmic actin isoforms in the late stages of CAC development. We believe that these molecular markers may have a prognostic potential.

Tumor location is an independent predictive factor for distant metastasis and metastatic sites of rectal adenocarcinoma in patients receiving total mesorectal excision

Background and Objectives: To evaluate the predictive factor for and patterns of distant metastasis in patients with rectal adenocarcinoma receiving total mesorectal excision (TME). Methods: We enrolled 217 consecutive patients who had histologically confirmed rectal adenocarcinoma and underwent surgery at Taipei Medical University- Wanfang Hospital between January 2000 and December 2014. TME was performed in all patients undergoing a sphincter-sparing procedure or abdominal perineal resection of rectal cancer. We performed univariate and multivariate Cox regression analyses of the distant metastasis rate in all patients to evaluate predictive factors. Overall survival (OS) rates were calculated using the Kaplan-Meier method, and Kaplan-Meier survival curves were compared using the log-rank test. Results: A multivariate Cox regression analysis of the distant metastasis rate in patients with rectal adenocarcinoma identified tumor locations and American Joint Committee on Cancer (AJCC) stages as prognostic risk factors. The adjusted hazard ratios (aHRs) of distant metastasis for the upper-third, middle-third, and AJCC stage I-II cancers were 0.08 (95% CI, 0.01-0.69; p = 0.021), 0.41 (95% CI, 0.15-0.99; p = 0.047), and 0.20 (95% CI, 0.10-0.66; p = 0.008), respectively. The 5-year lung metastasis rates among patients with upper-, middle-, and lower-third rectal cancers were 0%, 3.37%, and 13.33%, respectively (log-rank, p = 0.001), and the 5-year liver metastasis rates among patients with upper-, middle-, and lower-third rectal cancers were 2.12%, 9.10%, and 11.76%, respectively (log-rank, p = 0.096). The 5-year OS rates also differed with different rectal adenocarcinoma locations. The 5-year OS rates for upper, middle, and lower rectal cancers were 96%, 86%, and 64%, respectively (log-rank, p < 0.001). Conclusion: A poor OS rate and high lung or liver metastasis rate were observed in distal rectal adenocarcinoma. Longer intensive surveillance of the chest, abdomen, and pelvis after TME in distal rectal adenocarcinoma could be necessary.

Potential Role of Single Nucleotide Polymorphisms of XRCC1, XRCC3, and RAD51 in Predicting Acute Toxicity in Rectal Cancer Patients Treated With Preoperative Radiochemotherapy

OBJECTIVES

To investigate the association between polymorphisms of DNA repair genes and xenobiotic with acute adverse effects in locally advanced rectal cancer patients treated with neoadjuvant radiochemotherapy.

METHODS

Sixty-seven patients were analyzed for the current study. Genotypes in DNA repair genes XRCC1 (G28152A), XRCC3 (A4541G), XRCC3 (C18067T), RAD51 (G315C), and GSTP1 (A313G) were determined by pyrosequencing technology.

RESULTS

The observed grade ≥3 acute toxicity rates were 23.8%. Chemotherapy and radiotherapy were interrupted for 46 and 14 days, respectively, due to critical complications. Four patients were hospitalized, 6 patients had been admitted to the ER, and 5 patients received invasive procedures (2 bladder catheters, 2 blood transfusions, and 1 growth factor therapy).RAD51 correlated with acute severe gastrointestinal toxicity in heterozygosity (Aa) and homozygosity (AA) (P=0.036). Grade ≥3 abdominal/pelvis pain toxicity was higher in the Aa group (P=0.017) and in the Aa+AA group (P=0.027) compared with homozygous (aa) patients. Acute skin toxicity of any grade occurred in 55.6% of the mutated patients versus 22.8% in the wild-type group (P=0.04) for RAD51. XRCC1 correlated with skin toxicity of any grade in the Aa+AA group (P=0.03) and in the Aa group alone (P=0.044). Grade ≥3 urinary frequency/urgency was significantly higher in patients with AA (P=0.01), Aa (P=0.022), and Aa+AA (P=0.031) for XRCC3 compared with aa group.

CONCLUSIONS

Our study suggested that RAD51, XRCC1, and XRCC3 polymorphisms may be predictive factors for radiation-induced acute toxicity in rectal cancer patients treated with preoperative combined therapy.

Impact of neoadjuvant and adjuvant radiotherapy on disease-specific survival in patients with stages II-IV rectal cancer

Objectives

The purposes of this study were to determine whether neoadjuvant or adjuvant radiotherapy affected disease-specific survival (DSS) in patients with rectal cancer and whether stratification by tumor stage affected the results.

Results

55.5% patients had neoadjuvant-radiotherapy (NRT), and 18.3% patients had adjuvant- radiotherapy (ART). Multivariable models showed that treatment type was independently associated with DSS. Patients with stages III/IV tumors who received ART plus chemotherapy had significantly worse DSS than did those who received NRT plus chemotherapy (NCRT) (P = 0.03). Among patients with stage II tumors, those who received ART plus chemotherapy and those who received NCRT had similar DSS. Further stratification by risk group revealed that patients with stage IIIA tumors who received ART plus chemotherapy had significantly better DSS than did those who received NCRT (P = 0.04). The ART plus chemotherapy and NCRT groups had similar DSS in patients with stage IIA tumors. Among high-risk patients (T3N+/T4), the NCRT group had significantly better DSS than did the ART plus chemotherapy group. Patients who underwent surgery only had the worst DSS of all the treatment groups.

Materials and Methods

From the Surveillance, Epidemiology, and End Results database, patients diagnosed with stages II-IV rectal cancer from 2004-2014 were identified. Clinicopathologic features, treatments, and DSS in different treatment groups were compared.

Conclusions

NCRT or ART plus chemotherapy can reduce deaths from rectal cancer. Patients with stage IIIA tumors will benefit most from ART plus chemotherapy, whereas NCRT should be recommended to patients with stages II, IIIB, or higher tumors.

Magnetic Resonance Imaging Evaluation in Neoadjuvant Therapy of Locally Advanced Rectal Cancer: A Systematic Review

Background

The aim of the study was to present an update concerning several imaging modalities in diagnosis, staging and pre-surgery treatment response assessment in locally advanced rectal cancer (LARC). Modalities include: traditional morphological magnetic resonance imaging (MRI), functional MRI such as dynamic contrast enhanced MRI (DCE-MRI) and diffusion weighted imaging (DWI). A systematic review about the diagnostic accuracy in neoadjuvant therapy response assessment of MRI, DCE-MRI, DWI and Positron Emission Tomography/Computed Tomography (PET/CT) has been also reported.

Methods

Several electronic databases were searched including PubMed, Scopus, Web of Science, and Google Scholar. All the studies included in this review reported findings about therapy response assessment in LARC by means of MRI, DCE-MRI, DWI and PET/CT with details about diagnostic accuracy, true and false negatives, true and false positives. Forest plot and receiver operating characteristic (ROC) curves analysis were performed. Risk of bias and the applicability at study level were calculated.

Results

Twenty-five papers were identified. ROC curves analysis demonstrated that multimodal imaging integrating morphological and functional MRI features had the best accuracy both in term of sensitivity and specificity to evaluate preoperative therapy response in LARC. DCE-MRI following to PET/CT showed high diagnostic accuracy and their results are also more reliable than conventional MRI and DWI alone.

Conclusions

Morphological MRI is the modality of choice for rectal cancer staging permitting a correct assessment of the disease extent, of the lymph node involvement, of the mesorectal fascia and of the sphincter complex for surgical planning. Multimodal imaging and functional DCE-MRI may also help in the assessment of treatment response allowing to guide the surgeon versus conservative strategies and/or tailored approach such as “wait and see” policy.

Reduced pelvic field sparing anastomosis for postoperative radiotherapy in selected patients with mid-upper rectal cancer

The aim of this study was to report the clinical results of reduced pelvic field radiotherapy (RT), excluding the anastomotic site, after total mesorectal excision in selected patients with rectal cancer. Between 2011 and 2014, 99 patients underwent upfront surgery for clinically less-advanced tumors but were finally diagnosed as pT3/N+. Among them, 50 patients with mid-upper rectal cancer who received postoperative RT with a reduced pelvic field were included in this retrospective review. This group was composed of patients with high seated tumors, complete resection with a clear circumferential resection margin, and no complication during surgery. We investigated treatment outcomes, toxicity and the effect of RT-field reduction on organs-at risk in 5 randomly selected patients. During the median follow-up period of 42 months (range: 15-59 months), tumors recurred in 9 patients (18%). The 3-year overall and disease-free survival were 98% and 81%, respectively. Distant metastasis was the dominant failure pattern (n = 8, 16%), while no recurrences occurred at or near anastomotic sites. No anastomotic complications were found on pelvic examination, images and/or colonoscopy. Reported acute and late RT-related toxicities were mostly mild to moderate, with only small numbers of Grade 3 toxicities. None of the patients developed Grade 4-5 acute or late toxicity. With a caudally reduced field, 64% reduction in absolute anastomotic exposure at the maximum dose was achieved compared with the traditional whole-pelvic field (P = 0.008). The reduced pelvic field RT was able to minimize late anastomotic complication without increasing its recurrence in selected patients with mid-upper rectal cancer in the postoperative setting.

An update on the multimodality of localized rectal cancer

New strategies have reduced the local recurrence (LR) rate and extended the duration of overall survival (OS) in patients with localized rectal cancer (RC) in recent decades. The mainstay of curative treatment remains radical surgery; however, downsizing the tumor by neo-adjuvant chemo-radiotherapy and adjuvant cytotoxic therapy for systemic disease has shown significant additional benefit. The standardization of total mesorectal excision (TME), radiation treatment (RT) dose and fractionation, and optimal timing and sequencing of treatment modalities with the use of prolonged administration of fluoropyrimidine concurrent with RT have significantly decreased the rates of LR in locally advanced rectal cancer (LARC) patients. This review focuses on the optimization of multi-modality therapies in patients with localized RC.

A population-based study elicits a reverse correlation between age and overall survival in elderly patients with rectal carcinoma receiving adjuvant chemotherapy

Colorectal cancer is the third most common cancer and the fourth most common cause of cancer-related death globally. This population-based study aimed to explore the predictive factors that affected the overall survival of rectal cancer patients receiving adjuvant chemotherapy plus radical surgery using a Cox proportional hazards modeling approach. A total of 619 patients with rectal cancer who underwent surgery were enrolled between October 2006 and May 2013. Clinical characteristics of the patients were compared among the groups and potential prognostic factors were analyzed using the spss program, version 19.0. Patients aged ≥ 70 years have distinctive characteristics such as lager tumour size (≥ 5 cm), damaged micturition and higher incidence of diabetes compared to younger and middle-aged patients. Male gender, tumour size (≥ 5 cm), poor differentiation, later stage, adjuvant chemotherapy, damaged micturition, hypertension or diabetes are associated with a worse prognosis for rectal cancer patients (P < 0.05). However, smoking is a favourable factor to the patients (P = 0.018). Age of ≥ 70 years is an independent prognostic factor for patients with rectal cancer after surgery (P = 0.000) and elderly patients with Stage II and III disease receiving adjuvant chemotherapy show a favourable prognosis. The elderly patients who suffered from diabetes receiving adjuvant chemotherapy have a poor prognosis. Further prospective and large population studies are warranted to confirm the findings of this study.

Irradiation of Very Locally Advanced and Recurrent Rectal Cancer

Adjuvant therapy with chemoradiation or short-course radiation in addition to improvements in surgical technique has led to improved outcomes for patients with locally advanced rectal cancer. Local recurrence rates of less than 10% and 5-year survival rate of 60% or higher is expected. However, for patients with very locally advanced primary or locally recurrent disease in whom surgical resection is likely to be associated with incomplete resection, survival and disease control rates are poor and standard doses of adjuvant radiation or chemoradiation are relatively ineffective. Dose-escalation approaches with intraoperative radiation (IORT) have been explored in both the primary and recurrent setting. Although high-level evidence is lacking, available data suggest improvements in local and distant control leading to improved survival with IORT approaches. This review summarizes the evidence for dose-escalation approaches with IORT for patients with very locally advanced and recurrent rectal cancer.

Reporting of the circumferential tumour margin involvement and preoperative levels of carcinoembryonic antigen as prognostic risk factors in colorectal cancer patients

BACKGROUND AND STUDY AIMS

The two very important prognostic risk factors of colorectal cancer are circumferential tumour margin (CTM) involvement and preoperative levels of carcinoembryonic antigen (CEA). The aim of this study is to monitor the frequency of reporting of the CTM in the postoperative pathology reports after colorectal cancer resection in addition to monitoring the frequency of reporting of preoperative levels of CEA and exploring the possibility of improving the frequency of reporting of both.

PATIENTS AND METHODS

Reports of the CTM and preoperative level of CEA were found in 730 (664 retrospective and 66 prospective) patients with colorectal cancer. The possibility of improving the incidence of reporting was estimated by comparing the reporting frequency of both (retrospective and prospective) groups.

RESULTS

The percentage of reporting the involvement of the CTM was 46.08% and 81.81% for the retrospective group and the prospective group, respectively. The percentage of reporting the preoperative CEA levels was 40.9% and 68.7% for the retrospective and the prospective groups, respectively. There was a statistically significant difference in reporting both CTMs and the preoperative level of CEA between retrospective and prospective groups to the side of prospective group in which the p-value was <0.0001 for both groups.

CONCLUSION

There was inadequate reporting of both the CTM involvement and preoperative levels of CEA in the retrospective patients with statistically significant improvement of this reporting in patients in the prospective group. This may point to the unawareness of the importance of both in the prognosis of colorectal cancer, which may be because both are not involved in the widely used tumour, node, metastasis (TNM) staging system.

Colorectal cancer: all hands on deck

The past 50 years has seen substantial progress in our understanding of and in the management of colorectal cancer (CRC). Surveillance colonoscopy with resection of premalignant polyps has led to a decreased incidence of CRC even though compliance with the recommendations is suboptimal. Epidemiologic and genetic information allow us to identify individuals at risk for cancer and should allow us to prevent the disease in many individuals. Patients diagnosed with metastatic CRC live much longer than in the past, and some with metastatic disease are cured. This is attributed to many factors, including cross-sectional imaging that identifies metastases earlier, new surgical and radiation techniques, and numerous new chemotherapies. Higher resolution imaging modalities have improved the ability to find limited and resectable metastatic disease; surgical advances include laparoscopic-assisted procedures and safer and more extensive hepatic resection; and radiation techniques allow for higher dose and less morbidity. Biologic therapies have not yet been maximized, but we are learning when and where some should be used. Soon we expect to be staging patients by biologic and genetic characteristics rather than by gross pathology-treating patients based on biologic features but preferably identifying people at risk and preventing CRC altogether.

The influence of neoadjuvant therapy for the prognosis in patients with rectal carcinoma: a retrospective study

Rectal cancer, defined as a cancerous lesion of the colon distal to the rectosigmoid junction, is the fourth most common cancer cause of death globally. There were 474 patients with rectal cancer who underwent surgery between October 2007 and May 2013 enrolled in our center. Patients were respectively categorized by neoadjuvant therapy. This study aimed to explore the predictive factors that affected the Progression-free survival and overall survival of the patients with rectal cancer. Clinical characteristics of patients were compared with the groups and potential prognostic factors were analyzed by SPSS 19.0. In our study, neoadjuvant therapy increased the anus-retained rate (64.4 vs 53.4 % P = 0.016) and remission rate in the treatment group, compared to the non-treatment group (62.6 vs 34.8 %; P = 0.000). The neoadjuvant concurrent chemoradiotherapy, more operative duration, anus retained and micturition damaged are positive prognostic factors of PFS to patients. Poor differentiation, the tumor of ulcer, invasive, and pT4 stage, contributed the poor factors for PFS of patients (P < 0.05). Additionally, the patients with neoadjuvant concurrent chemoradiotherapy and adjuvant chemotherapy underwent the better prognosis of OS. Adjuvant chemotherapy cannot increase PFS of the patients who accepted neoadjuvant therapy after surgery get pCR, but can improve OS. The anus-retained and neoadjuvant radiotherapy, duration of surgery in rectal cancer have the positive correlation. Micturition damaged and neoadjuvant radiotherapy were positively correlated as well. In conclusion, adjuvant chemotherapy does not improve the PFS of patients with pCR to neoadjuvant therapy, but is good for OS. Further prospective and large population-based clinical studies are needed to establish clinical guidelines for the use of neoadjuvant therapy and adjuvant chemotherapy in patients with rectal cancer.

Impact of Postoperative Chemoradiotherapy versus Chemotherapy Alone on Recurrence and Survival in Patients with Stage II and III Upper Rectal Cancer: A Propensity Score-Matched Analysis

Purpose

To compare the impact of postoperative chemoradiotherapy (CRT) versus adjuvant chemotherapy alone on recurrence and survival in patients with stage II and III upper rectal cancer undergoing curative resection.

Materials and Methods

From our institutional database, 190 patients who underwent primary curative resection between 2003 and 2010 for stage II or III upper rectal cancer were identified. None of the patients received preoperative CRT. Of these, 136 patients received postoperative chemotherapy alone (the CTx group) and 54 patients received postoperative CRT (the CRT group). The CRT group had poorer prognostic features (pT4, pN2, poor differentiation, or involved resection margin) compared with the CTx group. To reduce the impact of treatment selection bias on treatment outcomes, propensity score-matching analysis was used.

Results

The matched cohort consisted of 50 CRT and 50 CTx patients with a median follow-up period of 76 and 63 months, respectively. In the matched cohort, CRT resulted in an improved 5-year local control (98.0% vs. 85.2%, p = 0.024) and overall survival rate (89.9% vs. 69.8%, p = 0.021) compared with CTx. In the subgroup analysis to identify subpopulations of patients that benefit most from receiving CRT, local recurrence did not occur in patients who did not have poor prognostic features regardless of the receipt of CRT. For patients with any poor prognostic features, CRT resulted in an improved 5-year local control compared with CTx (96.4% vs. 70.7%, p = 0.013).

Conclusions

After adjusting for clinicopathologic factors by propensity score-matching, postoperative CRT was associated with improved local control and overall survival in stage II and III upper rectal cancer. Our results suggest that surgery followed by chemotherapy alone is acceptable for patients who did not have poor prognostic features, while additional radiotherapy should be given for patients who have any poor prognostic features.

Rectal cancer resection and circumferential margin rates in Canada: a population-based study

INTRODUCTION [...]

Locally advanced rectal cancer: time for precision therapeutics

The year 2015 marks the 30th anniversary of the publication of NSABP-R01, a landmark trial demonstrating the benefit of adding pelvic radiation to the treatment regimen for locally advanced rectal cancer with a resultant decrease in local recurrence from 25% to 16%. These results ushered in the era of multimodal therapy for rectal cancer, heralding modern treatment and changing the standard of care in the United States. We have seen many advances over the past 3 decades, including optimization of the administration and timing of radiation, widespread adoption of total mesorectal excision (TME), and the implementation of more effective systemic chemotherapy. The current standard is neoadjuvant chemoradiation with 5-fluorouracil (5-FU) and a radiosensitizer, TME, and adjuvant chemotherapy including 5-FU and oxaliplatin. The results of this regimen have been impressive, with a reported local recurrence rate of less than 10%. However, the rates of distant relapse remain 30% to 40%, indicating room for improvement. In addition, trimodality therapy is arduous and many patients are unable to complete the full course of treatment. In this article we discuss the current standard of care and alternative strategies that have evolved in an attempt to individualize therapy according to risk of recurrence.

Outcomes in non-metastatic colorectal cancer

The measurement of outcomes in non-metastatic colon and rectal cancer patients is a multi-dimensional endeavor involving prediction tools, standard of care, and best treatment guidelines. Socioeconomic, demographic, and racial impacts on outcome must be carefully considered. Consideration must also be given to measures of cost, quality, and healthcare delivery in response to initiatives meant to optimize patient health while maintaining quality of life.

Is adjuvant radiotherapy warranted in resected pT1-2 node-positive rectal cancer?

Background

Stage T1-2 rectal cancers are unlikely to have lymph node metastases and neoadjuvant therapy is not routinely administered. Postoperative management is controversial if lymph node metastases are detected in the resected specimen. We studied the outcomes of patients with pT1-2 node-positive rectal cancer in order to determine whether adjuvant radiotherapy was beneficial.

Methods

We conducted a retrospective analysis of 284 patients with pathological T1-2 node-positive rectal cancer from a single institution. Outcomes, including local recurrence (LR), distant metastasis (DM), disease free survival (DFS) and overall survival (OS), were studied in patients with detailed TN staging and different adjuvant treatment modalities.

Results

The overall 5-year LR, DM, DFS and OS rates for all patients were 12.5%, 32.9%, 36.4% and 76.8%, respectively. Local control was inferior among patients who received no adjuvant therapy. Patients could be divided into three risk subsets: Low-risk, T1N1; Intermediate-risk, T2N1 and T1N2; and High-risk, T2N2. The 5-year LR rates were 5.3%, 9.8% and 26.4%, respectively (p = 0.005). In High-risk patients, addition of radiotherapy achieved a 5-year LR rate of 9.1%, compared 34.8% without radiotherapy.

Conclusions

In our study, we provide the detailed outcomes and preliminary survival analysis in a relatively infrequent subset of rectal cancer. Three risk subsets could be identified based on local control for pT1-2 node positive rectal cancer. Postoperative treatment needs to be individualized for patients with pT1-2 node-positive rectal cancer.

Preoperative chemoradiotherapy in elderly patients with locally advanced rectal cancer

PURPOSE

To evaluate the treatment tolerance and clinical outcomes in patients aged 70 and older with locally advanced rectal carcinoma treated with multimodality approach.

METHODS AND MATERIALS

We retrospectively analysed 20 consecutive elderly patients, with histologically proven rectal adenocarcinoma, staged T3-4, and/or node-positive tumour, who received chemoradiotherapy and proceeded to surgical approach. Performance status score and adult comorbidity evaluation-27 score were calculated, and their influence on treatment tolerance and clinical outcomes was analysed.

RESULTS

All patients completed programmed chemoradiotherapy treatment. Gastrointestinal toxicity was the most common acute side effects: proctitis in 70% of patients and diarrhoea in 55%, classified as Grade 3 in 3 patients only. Radiation dermatitis was reported in 7 patients (35%) and it was graded G3 in one patient. There was no haematological toxicity. Eighteen patients out of 20 underwent surgery. Sphincter preservation was assured in 13 patients. Comorbidity index was related to higher severe acute toxicity (P = 0.015) but no influenced treatment outcomes.

CONCLUSION

Treatment tolerance with combined modality is good in elderly patients. Due to age, no dose reduction for radiation therapy and chemotherapy should be considered.

Current controversies in neoadjuvant chemoradiation of rectal cancer

Total mesorectal excision with preoperative radiation and chemotherapy provide the lowest local recurrence rates for rectal cancer. Timing of surgery after preoperative chemoradiation is being increased to optimize tumor downstaging. In cases of complete clinical response from chemoradiation, permissive observation without resection is being investigated. Significant anorectal dysfunction results from low anterior resection and radiation. Good prognostic tumor characteristics are being investigated with the aim of selecting cases for whom preoperative radiation may be avoided. Preoperative and postoperative radiation provides improved local cancer control for superficial cancers removed by local excision.

The location of locoregional recurrence in pathologic T3N0, non-irradiated lower rectal cancer

PURPOSE

To investigate the patterns of locoregional recurrence of pathologic T3N0 (pT3N0) lower rectal cancer omitting postoperative radiotherapy (RT) and explore the potential of modification of a RT field.

MATERIALS AND METHODS

From Jan 2003 to Nov 2011, 35 patients omitting preoperative or postoperative RT for pT3N0 lower rectal cancer were included. We defined the lower rectal cancer as the tumor with the inferior margin located below the virtual line-a convergent level between rectal wall and levator ani muscle. All patients had radiologic examinations for recurrence evaluation during the follow-up duration.

RESULTS

The median follow-up duration was 66.4 months (range, 1.4 to 126.1 months). Eight (22.9%) of the 35 patients had recurrence. Three (8.6%) was local recurrence (LR) only, 3 (8.6%) was distant metastasis (DM) only, and 2 (5.7%) was LR with DM. All LR were located at primary tumor sites. The overall survival rate, LR-free survival rate, and DM-free survival rate at 5 years was 79.8%, 83%, and 87%, respectively. All LR developed from tumors over 5 cm. However, there was no statistical significance (p = 0.065). There was no other risk factor for LR.

CONCLUSION

Even though the patients included in this study had pathologically favorable pT3N0 rectal cancer, LR developed in 14.3% of patients. Most of the LR was located at primary tumor sites prior to surgery. Based on these findings, it might seem reasonable to consider postoperative RT with a smaller radiation field to the primary tumor site rather than the conventional whole pelvic irradiation.

Modern rectal cancer multidisciplinary treatment: the role of radiation and surgery

INTRODUCTION

Treatment of rectal cancer has evolved during the last few decades due to more in-depth knowledge of rectal cancer biology and major advances in the field of preoperative staging, medical management and surgical techniques. Consequently, treatment strategies are shifting moving towards a more personalized approach based on the response to treatment. Currently topics of controversy are centered around the indication for neoadjuvant radiation therapy in locally advanced rectal cancer and the role of surgery in patients with complete clinical response after neoadjuvant combined modality therapy. This manuscript aims to critically evaluate the evolution of treatment of rectal cancer during the last three decades and future directions.

METHODS

A review of the literature has been performed in PubMed/Medline electronic databases.

RESULTS

Treatment modalities are moving towards a tailored approach to rectal cancer patients based on the response to chemoradiation. A "wait-and-see" approach and local excision by Transanal Endoscopic Microsurgery (TEM) are strategies recently proposed in case of complete clinical response.

CONCLUSIONS

The standard of care still requires that locally advanced rectal cancer should be treated by neoadjuvant chemoradiation therapy followed by total mesorectal excision, including patients with a clinical complete response. Further evidence is needed to endorse a "wait-and-see" strategy and to define the role of TEM.

Is the standardized uptake value of FDG-PET/CT predictive of pathological complete response in locally advanced rectal cancer treated with capecitabine-based neoadjuvant chemoradiation?

OBJECTIVES

Our aim was to assess FDG-PET/CT as a surrogate biomarker of the pathological complete response in locally advanced rectal cancer treated with neoadjuvant chemoradiation.

METHODS

T3-4 and/or N+ rectal cancer patients were treated prospectively with capecitabine-based chemoradiation and total mesorectal excision 7-8 weeks later. FDG-PET/CT uptake was obtained at baseline, after 2 weeks, and 6 weeks following treatment completion, calculating the maximum standardized uptake value (SUV) and percentage difference to identify the early and late metabolic 'response index'.

RESULTS

Thirty-one patients were treated from January 2009 to January 2012 at the Istituto Nazionale dei Tumori of Milan. One patient was excluded due to surgery refusal. The pathological complete response rate was 30%. Early FDG-PET/CT was performed in 24 consenting patients and failed to show predictive utility. On the contrary, significant differences in late SUV value and response index were observed between complete and noncomplete pathological responders (p = 0.0006 and 0.03). In multivariate analysis including most relevant SUV parameters, none of them was independently associated with a pathological complete response. With receiver operating characteristic curve analysis, a late SUV threshold <5.4 had 81% sensitivity and 100% specificity, with 90% overall accuracy.

CONCLUSIONS

We evidenced a possible predictive role of late FDG-PET/CT for the assessment of pathological response in locally advanced rectal cancer following neoadjuvant chemoradiation.

Outcomes of unselected patients with pathologic T3N0 rectal cancer

BACKGROUND AND PURPOSE

This study compares the outcomes of patients with pathological (p) T3N0 rectal cancer treated with surgery alone (S), surgery and radiation (SR) or surgery, radiation and chemotherapy (SRC), in a population based setting.

MATERIALS

Three hundred and seven patients with operable, macroscopically resected pT3N0 rectal cancer referred to the BC Cancer Agency between 2000 and 2004 were segregated by treatment type: S (n=65), SR (n=97) and SRC (n=145). Patient characteristics, 5-year locoregional recurrence (LRR) and disease-specific survival (DSS) were compared between treatment cohorts.

RESULTS

Median age differed significantly between S, SR and SRC patient cohorts: 76, 72 and 64 years respectively. Five-year LRR differed by treatment group, with 29% for S, 6.3% for SR and 3.84% for SRC patients. DSS was superior in SRC compared to S patients (hazard ratio=0.31 [0.17, 0.60]). Co-morbidities and patient preference were most common reasons for omission of radiation.

CONCLUSIONS

Unselected patients with pT3N0 rectal cancer not treated with peri-operative radiation experience a high rate of LRR and reduced DSS in comparison to patients treated with bimodality and trimodality therapies. Advanced age is significantly associated with omission of therapy in patients with early stage rectal cancer.

Impact and prognostic implications of colon cancers stage II sub-classification through the years

PURPOSE

According to the American Joint Committee on Cancer (AJCC) 7th edition, T4 colon cancers have been sub-divided into T4a and T4b, resulting in a stage II sub-classification (T3N0, T4aN0, and T4bN0). This study was aimed: (a) to investigate the impact of the AJCC 7th edition stage II sub-classification on the overall survival (OS), disease-free survival (DFS) and disease-specific survival (DSS) of colon cancer patients who underwent surgical resection and (b) to compare the last three AJCC editions for identifying stage II patients with high-risk of progression.

METHODS

One hundred seventy-eight stage II colon cancers out of 682 colorectal cancer patients who underwent surgical resection were selected. T4N0 were sub-divided in accordance with the AJCC 7th edition. Mean follow-up was 41.9 months. Kaplan-Meier method was employed to estimate the survival curves.

RESULTS

OS analysis documented a significant difference between stage-sub-groups using the 6th edition; conversely, this difference was not seen if the 7th edition was applied (p = 0.03 and 0.12, respectively). Stage II DFS analysis reported a significant difference using both the AJCC 6th and 7th editions (p = 0.03 and 0.02, respectively). A significant difference was reported on stage II DSS analysis using the AJCC 6th edition (p = 0.03); however, when the 7th edition was applied, a substantial discrepancy between survival curves was noted with T3N0 and T4aN0 displaying similar outcomes (p = 0.006).

CONCLUSIONS

The AJCC 7th edition is a reliable classification that might implement the identification of those stage II colon cancer patients with high-risk of progression, recurrence, and cancer mortality.

ACR appropriateness criteria® resectable rectal cancer

The management of resectable rectal cancer continues to be guided by clinical trials and advances in technique. Although surgical advances including total mesorectal excision continue to decrease rates of local recurrence, the management of locally advanced disease (T3-T4 or N+) benefits from a multimodality approach including neoadjuvant concomitant chemotherapy and radiation. Circumferential resection margin, which can be determined preoperatively via MRI, is prognostic. Toxicity associated with radiation therapy is decreased by placing the patient in the prone position on a belly board, however for patients who cannot tolerate prone positioning, IMRT decreases the volume of normal tissue irradiated. The use of IMRT requires knowledge of the patterns of spreads and anatomy. Clinical trials demonstrate high variability in target delineation without specific guidance demonstrating the need for peer review and the use of a consensus atlas. Concomitant with radiation, fluorouracil based chemotherapy remains the standard, and although toxicity is decreased with continuous infusion fluorouracil, oral capecitabine is non-inferior to the continuous infusion regimen. Additional chemotherapeutic agents, including oxaliplatin, continue to be investigated, however currently should only be utilized on clinical trials as increased toxicity and no definitive benefit has been demonstrated in clinical trials. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every two years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

The therapeutic and adverse effects of modified radiation fields for patients with rectal cancer

PURPOSE

To compare the therapeutic effect and complications of modified radiation fields (MRFs) with those of conventional pelvic radiation fields (CPRFs) for rectal cancer.

METHODS AND MATERIALS

From December 1996 to October 2009, a total of 160 patients with rectal carcinoma who received total mesorectal excision and postoperative radiotherapy were examined. Ninety-four patients were in the CPRFs group, and 66 were in the MRFs group. The dose was 50 Gy per 25 fractions in the initial plan.

RESULTS

The treatment volume and the volume of small bowel that received more than 15 Gy of the MRFs was smaller than that of the CPRFs (P < .001). The rates of local recurrence, overall survival, and disease-free survival were not statistically significant between the MRFs and CPRFs groups (P > .05). There was a statistical difference (P < .05) in the incidence of acute toxicity, which included serious complications in the lower digestive tract (grade ≥3). The completion rate for the initial radiotherapy plan was higher in the MRFs group than in the CPRFs group (P = .027).

CONCLUSIONS

Compared with CPRFs, MRFs manifested a lower incidence of complications and the same therapeutic effects. This finding will facilitate the clinical application of MRFs for patients with rectal cancer.

Comparison of preoperative short-course radiotherapy and long-course radiochemotherapy for locally advanced rectal cancer

BACKGROUND

The purpose of this work was to perform a single institution comparison between preoperative short-course radiotherapy (SC-RT) and long-course radiochemotherapy (LC-RCHT) for locally advanced rectal cancer.

METHODS

A total of 225 patients with clinical stage UICC II-III rectal cancer were treated with SC-RT (29 Gy in 10 twice daily fractions followed by immediate surgery; n = 108) or LC-RCHT (54 Gy in 28 fractions with simultaneous 5-fluorouracil (5-FU) ± oxaliplatin chemotherapy followed by delayed surgery; n = 117). All patients in the LC-RCHT cohort and patients in the SC-RT with pathological UICC stage ≥ II received adjuvant chemotherapy. Before 2004, the standard of care was SC-RT with LC-RCHT reserved for patients where downstaging was considered as required for sphincter preservation or curative resection. In the later period, SC-RT was practiced only for patients unfit for radiochemotherapy.

RESULTS

Patients in the LC-RCHT cohort had a significantly higher proportion of cT4 tumors, clinical node positivity, and lower tumor location. The 5-year local control (LC) and overall survival (OS) were 91% and 66% without differences between the SC-RT and LC-RCHT groups. Acute toxicity was increased during LC-RCHT (grade ≥ II 1% vs. 33%) and there were no differences in postoperative complications. Severe late toxicity grade ≥ III was increased after SC-RT (12% vs. 3%). Of patients aged >  80 years, 7 of 7 patients and 4 of 9 patients received curative surgery after SC-RT and LC-RCHT, respectively.

CONCLUSION

Despite the fact that patients with worse prognostic factors were treated with LC-RCHT, there were no significant differences in LC and OS between the SC-RT and LC-RCHT group. Age > 80 years was identified as a significant risk factor for LC-RCHT and these patients could be treated preferably with SC-RT.

Neoadjuvant treatment in rectal cancer: actual status

Neoadjuvant (preoperative) concomitant chemoradiotherapy (CRT) has become a standard treatment of locally advanced rectal adenocarcinomas. The clinical stages II (cT3-4, N0, M0) and III (cT1-4, N+, M0) according to International Union Against Cancer (IUCC) are concerned. It can reduce tumor volume and subsequently lead to an increase in complete resections (R0 resections), shows less toxicity, and improves local control rate. The aim of this review is to summarize actual approaches, main problems, and discrepancies in the treatment of locally advanced rectal adenocarcinomas.

Role of radiation in intermediate-risk rectal cancer

The treatment of rectal cancer has greatly evolved during the last several decades as a result of the understanding of the pathways of cancer spread, natural history of the disease, stages prognosis and prognostic markers. The tendency is clearly to move toward a more personalized approach to these patients based on preoperative staging and response to therapy. Although in the past we have been adding more treatment modalities to surgery to the point that every stage II/III cancer was treated with neoadjuvant chemo and radiotherapy followed by radical surgery by total mesorectal excision with or without sphincter preservation and more chemotherapy to follow, more recently this algorithm has been under discussion and scrutiny. Two of the major topics of controversy are: the use of local excision or even a watch-and-wait approach after a clinical complete response and the need for radiotherapy in the intermediate risk group. In this manuscript we will present the historical perspective that has brought the treatment of rectal cancer to the current standard of care and present the evidence supporting further investigation in the intermediate risk group.

Pretherapy imaging of rectal cancers: ERUS or MRI?

ERUS and MRI should be seen more as complementary rather than competitive techniques. Each has its own strengths and weaknesses. ERUS is better in showing the tumor extent in small superficial tumors, whereas MRI is superior in imaging the more advanced tumors. The choice of imaging technique depends also on the amount of information that is required for choosing certain treatment strategies, like the distance to the mesorectal fascia for a short course of preoperative radiotherapy. For lymph node imaging, both techniques are at present only moderately accurate, although this could change with advances in new MR techniques.