1
|
Li S, Song M, Tie J, Zhu X, Zhang Y, Wang H, Geng J, Liu Z, Sui X, Teng H, Cai Y, Li Y, Wang W. Outcomes and failure patterns after chemoradiotherapy for locally advanced rectal cancer with positive lateral pelvic lymph nodes: a propensity score-matched analysis. Radiat Oncol 2024; 19:132. [PMID: 39354612 PMCID: PMC11443637 DOI: 10.1186/s13014-024-02529-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 09/19/2024] [Indexed: 10/03/2024] Open
Abstract
PURPOSE This study aimed to use propensity score matching (PSM) to explore the long-term outcomes and failure patterns in locally advanced rectal cancer (LARC) patients with positive versus negative lateral pelvic lymph node (LPLN). MATERIALS AND METHODS Patients with LARC were retrospectively divided into LPLN-positive and LPLN-negative groups. Clinical characteristics were compared between the groups using the chi-square test. PSM was applied to balance these differences. Progression-free survival (PFS) and overall survival (OS), and local-regional recurrence (LRR) and distant metastasis (DM) rates were compared between the groups using the Kaplan-Meier method and log-rank tests. RESULTS A total of 651 LARC patients were included, 160 (24.6%) of whom had positive LPLN and 491 (75.4%) had negative LPLN. Before PSM, the LPLN-positive group had higher rates of lower location (53.1% vs. 43.0%, P = 0.025), T4 stage (37.5% vs. 23.2%, P = 0.002), mesorectal fascia (MRF)-positive (53.9% vs. 35.4%, P < 0.001) and extramural venous invasion (EMVI)-positive (51.2% vs. 27.2%, P < 0.001) disease than the LPLN-negative group. After PSM, there were 114 patients for each group along with the balanced clinical factors, and both groups had comparable surgery, pathologic complete response (pCR), and ypN stage rates. The median follow-up was 45.9 months, 3-year OS (88.3% vs. 92.1%, P = 0.276) and LRR (5.7% vs. 2.8%, P = 0.172) rates were comparable between LPLN-positive and LPLN-negative groups. Meanwhile, despite no statistical difference, 3-year PFS (78.8% vs. 85.9%, P = 0.065) and DM (20.4% vs. 13.3%, P = 0.061) rates slightly differed between the groups. 45 patients were diagnosed with DM, 11 (39.3%) LPLN-positive and 3 (17.6%) LPLN-negative patients were diagnosed with oligometastases (P = 0.109). CONCLUSIONS Our study indicates that for LPLN-positive patients, there is a tendency of worse PFS and DM than LPLN-negative patients, and for this group patients, large samples are needed to further confirm our conclusion.
Collapse
Affiliation(s)
- Shuai Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Maxiaowei Song
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Jian Tie
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Xianggao Zhu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Yangzi Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Hongzhi Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Jianhao Geng
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Zhiyan Liu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Xin Sui
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Huajing Teng
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Yong Cai
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Yongheng Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China.
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers, Beijing Key Laboratory of Carcinogenesis and Translational Research, Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing, 100142, China.
| | - Weihu Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China.
| |
Collapse
|
2
|
Williams B, Gupta A, Iype P, Woll S, Koller SE, Shin J, Cologne KG, Lee SW, Duldulao MP. Pathologic Outcomes of Short-Course and Long-Course Radiotherapy for Locally Advanced Rectal Cancers Treated With Total Neoadjuvant Therapy. Am Surg 2024; 90:2632-2639. [PMID: 38770756 DOI: 10.1177/00031348241256055] [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] [Indexed: 05/22/2024]
Abstract
INTRODUCTION Total neoadjuvant therapy (TNT) for patients with locally advanced rectal cancer (LARC) is now the standard of care. Randomized trials suggest the use of short-course radiotherapy (SCRT) and long-course radiotherapy (LCRT) are oncologically equivalent. OBJECTIVE To describe pathologic outcomes after surgical resections of patients receiving SCRT versus LCRT as part of TNT for LARC. PARTICIPANTS All patients with LARC treated at a single tertiary hospital who underwent proctectomy after completing TNT were included. Patients were excluded if adequate details of TNT were not available in the electronic medical record. RESULTS A total of 53 patients with LARC were included. Thirty-nine patients (73.5%) received LCRT and 14 (26.4%) received SCRT. Forty-nine patients (92.5%) were clinical stage III (cN1-2) prior to treatment. The average lymph node yield after proctectomy was 20.9 for SCRT and 17.0 for LCRT (P = .075). Of the 49 patients with clinically positive nodes before treatment, 76.9% of those who received SCRT and 72.2% of those who received LCRT achieved pN0 disease after TNT. Additionally, there were no significant differences in rates of pathologic complete response between patients who received SCRT and LCRT, 7.1% and 12.8%, respectively (P = .565). CONCLUSION Pathologic outcomes of patients with LARC treated with SCRT or LCRT, as part of TNT, may be similar. Further prospective trials are needed to assess long-term clinical outcomes and to determine best treatment protocols.
Collapse
Affiliation(s)
- Brian Williams
- Division of Colorectal Surgery, Keck Hospital of USC, Los Angeles, CA, USA
| | - Abhinav Gupta
- Division of Colorectal Surgery, Keck Hospital of USC, Los Angeles, CA, USA
| | - Priyanka Iype
- Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Sabrina Woll
- Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Sarah E Koller
- Division of Colorectal Surgery, Keck Hospital of USC, Los Angeles, CA, USA
| | - Joongho Shin
- Division of Colorectal Surgery, Keck Hospital of USC, Los Angeles, CA, USA
| | - Kyle G Cologne
- Division of Colorectal Surgery, Keck Hospital of USC, Los Angeles, CA, USA
| | - Sang W Lee
- Division of Colorectal Surgery, Keck Hospital of USC, Los Angeles, CA, USA
| | - Marjun P Duldulao
- Division of Colorectal Surgery, Keck Hospital of USC, Los Angeles, CA, USA
| |
Collapse
|
3
|
Wang H, Zhang X, Leng B, Zhu K, Jiang S, Feng R, Dou X, Shi F, Xu L, Yue J. Efficacy and safety of MR-guided adaptive simultaneous integrated boost radiotherapy to primary lesions and positive lymph nodes in the neoadjuvant treatment of locally advanced rectal cancer: a randomized controlled phase III trial. Radiat Oncol 2024; 19:118. [PMID: 39267085 PMCID: PMC11395642 DOI: 10.1186/s13014-024-02506-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 08/12/2024] [Indexed: 09/14/2024] Open
Abstract
BACKGROUND In locally advanced rectal cancer (LARC), optimizing neoadjuvant strategies, including the addition of concurrent chemotherapy and dose escalation of radiotherapy, is essential to improve tumor regression and subsequent implementation of anal preservation strategies. Currently, dose escalation studies in rectal cancer have focused on the primary lesions. However, a common source of recurrence in LARC is the metastasis of cancer cells to the proximal lymph nodes. In our trial, we implement simultaneous integrated boost (SIB) to both primary lesions and positive lymph nodes in the experimental group based on magnetic resonance-guided adaptive radiotherapy (MRgART), which allows for more precise (and consequently intense) targeting while sparing neighboring healthy tissue. The objective of this study is to evaluate the efficacy and safety of MRgART dose escalation to both primary lesions and positive lymph nodes, in comparison with the conventional radiotherapy of long-course concurrent chemoradiotherapy (LCCRT) group, in the neoadjuvant treatment of LARC. METHODS This is a multi-center, randomized, controlled phase III trial (NCT06246344). 128 patients with LARC (cT3-4/N+) will be enrolled. During LCCRT, patients will be randomized to receive either MRgART with SIB (60-65 Gy in 25-28 fractions to primary lesions and positive lymph nodes; 50-50.4 Gy in 25-28 fractions to the pelvis) or intensity-modulated radiotherapy (50-50.4 Gy in 25-28 fractions). Both groups will receive concurrent chemotherapy with capecitabine and consolidation chemotherapy of either two cycles of CAPEOX or three cycles of FOLFOX between radiotherapy and surgery. The primary endpoints are pathological complete response (pCR) rate and surgical difficulty, while the secondary endpoints are clinical complete response (cCR) rate, 3-year and 5-year disease-free survival (DFS) and overall survival (OS) rates, acute and late toxicity and quality of life. DISCUSSION Since dose escalation of both primary lesions and positive nodes in LARC is rare, we propose conducting a phase III trial to evaluate the efficacy and safety of SIB for both primary lesions and positive nodes in LARC based on MRgART. TRIAL REGISTRATION The study was registered at ClinicalTrials.gov with the Identifier: NCT06246344 (Registered 7th Feb 2024).
Collapse
Affiliation(s)
- Haohua Wang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, China
- Cheeloo College of Medicine, Shandong University Cancer Center, Shandong University, Jinan, Shandong, China
| | - Xiang Zhang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, China
| | - Boyu Leng
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, China
| | - Kunli Zhu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, China
| | - Shumei Jiang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, China
| | - Rui Feng
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, China
| | - Xue Dou
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, China
| | - Fang Shi
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, China
| | - Lei Xu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, China.
| | - Jinbo Yue
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, China.
| |
Collapse
|
4
|
Xiao WW, Chen G, Gao YH, Lin JZ, Wu XJ, Luo HL, Lu ZH, Wang QX, Sun R, Cai PQ, Zhu CM, Liu M, Li JB, Wang YR, Jin Y, Wang F, Luo HT, Li CL, Pan ZZ, Xu RH. Effect of neoadjuvant chemoradiotherapy with or without PD-1 antibody sintilimab in pMMR locally advanced rectal cancer: A randomized clinical trial. Cancer Cell 2024; 42:1570-1581.e4. [PMID: 39094560 DOI: 10.1016/j.ccell.2024.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 05/26/2024] [Accepted: 07/08/2024] [Indexed: 08/04/2024]
Abstract
Neoadjuvant chemoradiotherapy (NACRT) was the standard treatment for patients with locally advanced rectal cancer (LARC) with proficient mismatch repair (pMMR) proteins. In this randomized phase 2 trial (ClinicalTrial.gov: NCT04304209), 134 pMMR LARC patients were randomly (1:1) assigned to receive NACRT or NACRT and the programmed cell death protein 1 (PD-1) antibody sintilimab. As the primary endpoint, the total complete response (CR) rate is 26.9% (18/67, 95% confidence interval [CI] 16.0%-37.8%) and 44.8% (30/67, 95% CI 32.6%-57.0%) in the control and experimental arm, respectively, with significant difference (p = 0.031 for chi-squared test). Response ratio is 1.667 (95% CI 1.035-2.683). Immunohistochemistry shows PD-1 ligand 1 (PD-L1) combined positive score is associated with the synergistic effect. The safety profile is similar between the arms. Adding the PD-1 antibody sintilimab to NACRT significantly increases the CR rate in pMMR LARC, with a manageable safety profile. PD-L1 positivity may help identify patients who might benefit most from the combination therapy.
Collapse
Affiliation(s)
- Wei-Wei Xiao
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, The State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Guangzhou, China; United Laboratory of Frontier Radiotherapy Technology of Sun Yat-sen University & Chinese Academy of Sciences Ion Medical Technology Co., Ltd, Guangzhou, China
| | - Gong Chen
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, The State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Guangzhou, China
| | - Yuan-Hong Gao
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, The State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Guangzhou, China
| | - Jun-Zhong Lin
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, The State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Guangzhou, China
| | - Xiao-Jun Wu
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, The State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Guangzhou, China
| | - Hui-Long Luo
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, The State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Guangzhou, China
| | - Zhen-Hai Lu
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, The State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Guangzhou, China
| | - Qiao-Xuan Wang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, The State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Guangzhou, China
| | - Rui Sun
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, The State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Guangzhou, China
| | - Pei-Qiang Cai
- Department of Radiology, Sun Yat-sen University Cancer Center, The State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Guangzhou, China
| | - Chong-Mei Zhu
- Department of Pathology, Sun Yat-sen University Cancer Center, The State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Guangzhou, China
| | - Min Liu
- Department of Ultrasound, Sun Yat-sen University Cancer Center, The State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Guangzhou, China
| | - Ji-Bin Li
- Department of Statistics, Sun Yat-sen University Cancer Center, The State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Guangzhou, China
| | - Yi-Rui Wang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, The State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Guangzhou, China
| | - Ying Jin
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, The State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Research Unit of Precision Diagnosis and Treatment for Gastrointestinal Cancer, Chinese Academy of Medical Sciences, Guangzhou, China
| | - Feng Wang
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, The State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Research Unit of Precision Diagnosis and Treatment for Gastrointestinal Cancer, Chinese Academy of Medical Sciences, Guangzhou, China
| | - Hai-Tao Luo
- Shenzhen Engineering Center for Translational Medicine of Precision Cancer Immunodiagnosis and Therapy, YuceBio Technology Co., Ltd, Shenzhen, China
| | - Cai-Ling Li
- Shenzhen Engineering Center for Translational Medicine of Precision Cancer Immunodiagnosis and Therapy, YuceBio Technology Co., Ltd, Shenzhen, China
| | - Zhi-Zhong Pan
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, The State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Guangzhou, China
| | - Rui-Hua Xu
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, The State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Research Unit of Precision Diagnosis and Treatment for Gastrointestinal Cancer, Chinese Academy of Medical Sciences, Guangzhou, China.
| |
Collapse
|
5
|
Bugano DDG, Santos VM, Campos-Bragagnoli A, Melo JCM, Romagnolo LGC, Barbosa Neto O, Carvalho IT, Karassawa-Helito J, Ortega CD, Tridente CF, Gerbasi LS, Tustumi F, Giovani Blasi PB, Novaes Figueiredo de Araujo M, Pandini RV, Seid VE, Portilho AS, Buosso A, Rolla F, Schettino GDPP, Araujo SEA. Brazil-TNT: A Randomized Phase 2 Trial of Neoadjuvant Chemoradiation Followed by FOLFIRINOX Versus Chemoradiation for Stage II/III Rectal Cancer. Clin Colorectal Cancer 2024; 23:238-244. [PMID: 38851990 DOI: 10.1016/j.clcc.2024.03.003] [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: 12/30/2023] [Revised: 03/01/2024] [Accepted: 03/03/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND Neoadjuvant radiation and oxaliplatin-based systemic therapy (total neoadjuvant therapy-TNT) have been shown to increase response and organ-preservation rates in localized rectal cancer. However, trials have been heterogeneous regarding treatment protocols and few have used a watch-and-wait (WW) approach for complete responders. This trial evaluates if conventional long-term chemoradiation followed by consolidation of FOLFIRINOX increases complete response rates and the number of patients managed by WW. METHODS This was a pragmatic randomized phase II trial conducted in 2 Cancer Centers in Brazil that included patients with T3+ or N+ rectal adenocarcinoma. After completing a long-course 54 Gy chemoradiation with capecitabine patients were randomized 1:1 to 4 cycles of mFOLFIRINOX (Oxaliplatin 85, irinotecan 150, 5-FU 2400)-TNT-arm-or to the control arm, that did not include further neoadjuvant treatment. All patients were re-staged with dedicated pelvic magnetic resonance imaging and sigmoidoscopy 12 weeks after the end of radiation. Patients with a clinical complete response were followed using a WW protocol. The primary endpoint was complete response: clinical complete response (cCR) or pathological response (pCR). RESULTS Between April 2021 and June 2023, 55 patients were randomized to TNT and 53 to the control arm. Tumors were 74% stage 3, median distance from the anal verge was 6 cm, 63% had an at-risk circumferential margin, and 33% an involved sphincter. The rates of cCR + pCR were (31%) for TNT versus (17%) for controls (odds ratio 2.19, CI 95% 0.8-6.22 P = .091) and rates of WW were 16% and 9% (P = ns). Median follow-up was 8.1 months and recurrence rates were 16% versus 21% for TNT and controls (P = ns). CONCLUSIONS TNT with consolidation FOLFIRINOX is feasible and has high response rates, consistent with the current literature for TNT. This trial was supported by a grant from the Brazilian Government (PROADI-SUS - NUP 25000.164382/2020-81).
Collapse
Affiliation(s)
- Diogo Diniz Gomes Bugano
- Hospital Israelita Albert Einstein, São Paulo, Brazil; Hospital Municipal Vila Santa Catarina, São Paulo, Brazil.
| | - Vanessa Montes Santos
- Hospital Israelita Albert Einstein, São Paulo, Brazil; Hospital Municipal Vila Santa Catarina, São Paulo, Brazil
| | | | | | | | | | | | | | | | | | - Lucas Soares Gerbasi
- Hospital Israelita Albert Einstein, São Paulo, Brazil; Hospital Municipal Vila Santa Catarina, São Paulo, Brazil
| | - Francisco Tustumi
- Hospital Israelita Albert Einstein, São Paulo, Brazil; Hospital Municipal Vila Santa Catarina, São Paulo, Brazil
| | | | | | - Rafael Vaz Pandini
- Hospital Israelita Albert Einstein, São Paulo, Brazil; Hospital Municipal Vila Santa Catarina, São Paulo, Brazil
| | - Victor Edmond Seid
- Hospital Israelita Albert Einstein, São Paulo, Brazil; Hospital Municipal Vila Santa Catarina, São Paulo, Brazil
| | - Ana Sarah Portilho
- Hospital Israelita Albert Einstein, São Paulo, Brazil; Hospital Municipal Vila Santa Catarina, São Paulo, Brazil
| | - Albert Buosso
- Hospital Municipal Vila Santa Catarina, São Paulo, Brazil
| | - Fabiana Rolla
- Hospital Municipal Vila Santa Catarina, São Paulo, Brazil
| | | | - Sergio Eduardo Alonso Araujo
- Hospital Israelita Albert Einstein, São Paulo, Brazil; Hospital Municipal Vila Santa Catarina, São Paulo, Brazil
| |
Collapse
|
6
|
Slavu IM, Munteanu O, Filipoiu F, Tulin R, Macovei Oprescu AM, Dima I, Dogaru IA, Tulin A. A Review of Neoadjuvant Therapy and the Watch-and-Wait Protocol in Rectal Cancer: Current Evidence and Future Directions. Cureus 2024; 16:e68461. [PMID: 39360080 PMCID: PMC11446489 DOI: 10.7759/cureus.68461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2024] [Indexed: 10/04/2024] Open
Abstract
The treatment of rectal cancer underwent a significant change with the introduction of total mesorectal excision (TME), which substantially improved recurrence rates. However, TME is associated with complications such as fecal incontinence and poor bladder control, especially in tumors located near the anal verge. The watch-and-wait (WW) protocol has emerged as an alternative for patients achieving a clinical complete response (cCR) following neoadjuvant radiochemotherapy. This narrative review, developed according to the Scale for the Assessment of Narrative Review Articles guidelines, evaluates neoadjuvant treatments and the WW protocol for rectal cancer. Literature was sourced from the PubMed database using specific search terms related to neoadjuvant therapy and the WW protocol, resulting in 63 articles selected for discussion. Neoadjuvant treatment, including chemoradiation and short-course radiotherapy, is indicated for T3 and T4 rectal adenocarcinomas. Studies like the German Rectal Cancer Study Group and the PRODIGE 23 trial have shown the benefits of preoperative treatment, including improved disease-free survival and reduced local recurrence rates. However, challenges in adopting the WW protocol include the risk of local regrowth and distant metastasis. Immune checkpoint inhibitors have shown promise in mismatch repair-deficient patients, yet the data are insufficient to fully endorse WW for these cases. The WW protocol is viable for selected rectal cancer patients, with ongoing debates regarding criteria for inclusion. Key challenges include accurately identifying cCR and managing patients with near-complete responses. MRI and endoscopic evaluation are crucial for assessing treatment response, although achieving a pathological complete response remains uncertain. The WW strategy offers a potential organ-preserving approach in rectal cancer management but requires careful patient selection and comprehensive risk-benefit discussions. Further research is needed to refine criteria for inclusion and optimize treatment protocols, enhancing outcomes while minimizing invasive interventions.
Collapse
Affiliation(s)
- Iulian M Slavu
- Anatomy, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | - Octavian Munteanu
- Anatomy, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | - Florin Filipoiu
- Anatomy, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | - Raluca Tulin
- Embryology, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
- Endocrinology, Agrippa Ionescu Emergency Clinical Hospital, Bucharest, ROU
| | | | - Ileana Dima
- General Surgery, Agrippa Ionescu Emergency Clinical Hospital, Bucharest, ROU
| | - Iulian A Dogaru
- General Surgery, Agrippa Ionescu Emergency Clinical Hospital, Bucharest, ROU
- Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | - Adrian Tulin
- General Surgery, Agrippa Ionescu Emergency Clinical Hospital, Bucharest, ROU
| |
Collapse
|
7
|
Williams H, Yuval JB, Verheij FS, Miranda J, Lin ST, Omer DM, Qin LX, Gollub MJ, Kim TH, Garcia-Aguilar J. Baseline MRI predictors of successful organ preservation in the Organ Preservation in Rectal Adenocarcinoma (OPRA) trial. Br J Surg 2024; 111:znae246. [PMID: 39319400 PMCID: PMC11422670 DOI: 10.1093/bjs/znae246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 07/12/2024] [Accepted: 08/29/2024] [Indexed: 09/26/2024]
Abstract
BACKGROUND Prospective randomized trials have not yet identified baseline features predictive of organ preservation in locally advanced rectal cancers treated with total neoadjuvant therapy and a selective watch-and-wait strategy. METHODS This was a secondary analysis of the OPRA trial, which randomized patients with stage II-III rectal adenocarcinoma to receive either induction or consolidation total neoadjuvant therapy. Patients were recommended for total mesorectal excision, or watch and wait based on clinical response at 8 ± 4 weeks after completing treatment. Standardized baseline clinical and radiological variables were collected prospectively. Survival outcomes, including total mesorectal excision-free survival, disease-free survival, and overall survival, were assessed by intention-to-treat analysis. Cox proportional hazards models were used to evaluate associations between baseline variables and survival outcomes. RESULTS Of the 324 patients randomized for the OPRA trial, 38 (11.7%) had cT4 tumours, 230 (71.0%) cN-positive disease, 101 (32.5%) mesorectal fascia involvement, and 64 (19.8%) extramural venous invasion. Several baseline features were independently associated with recommendation for total mesorectal excision on multivariable analysis: nodal disease (HR 1.66, 95% c.i. 1.12 to 2.48), extramural venous invasion (HR 1.57, 1.07 to 2.29), mesorectal fascia involvement (HR 1.45, 1.01 to 2.09), and tumour length (HR 1.11, 1.00 to 1.22). Of these, nodal disease (HR 2.02, 1.15 to 3.53) and mesorectal fascia involvement (HR 2.02, 1.26 to 3.26) also predicted worse disease-free survival. Age (HR 1.03, 1.00 to 1.06) was associated with overall survival. CONCLUSION Baseline MRI features, including nodal disease, extramural venous invasion, mesorectal fascia involvement, and tumour length, independently predict the likelihood of organ preservation after completion of total neoadjuvant therapy. Mesorectal fascia involvement and nodal disease are associated with disease-free survival.
Collapse
Affiliation(s)
- Hannah Williams
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jonathan B Yuval
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Floris S Verheij
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Joao Miranda
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Sabrina T Lin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Dana M Omer
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Li-Xuan Qin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Marc J Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Tae-Hyung Kim
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Julio Garcia-Aguilar
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| |
Collapse
|
8
|
Tan X, Zhang Y, Wu X, Fang Q, Xu Y, Li S, Yuan J, Peng X, Fu K, Xiao S. Mucinous histology is a negative predictor of neoadjuvant chemoradiotherapy for locally advanced rectal adenocarcinoma. BMC Gastroenterol 2024; 24:263. [PMID: 39138423 PMCID: PMC11323364 DOI: 10.1186/s12876-024-03359-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 08/06/2024] [Indexed: 08/15/2024] Open
Abstract
BACKGROUND Neoadjuvant chemoradiotherapy (NCRT) followed by total mesorectal excision (TME) is the standard treatment for locally advanced rectal cancer (LARC). Mucinous adenocarcinoma (MAC) is a potential poor prognosis subgroup of rectal cancer. However, the predictive value of MAC in NCRT treatment of LARC is controversial. METHODS A comprehensive literature search of PubMed, Embase, and the Cochrane Library was performed. All studies examining the effect of MAC on CRT response in LARC were included. Outcomes of MAC were compared with non-specific adenocarcinoma (AC) by using random-effects methods. Data were presented as odds ratios (ORs) with 95% confidence intervals (CIs). The main outcomes were the rates of pathological complete response (pCR), tumor and nodal down-staging, positive resection margin rate, local recurrence, and overall mortality. RESULTS Fifteen studies containing comparative data on outcomes in a total of 9,238 patients receiving NCRT for LARC were eligible for inclusion. MAC had a reduced rate of pCR (OR, 0.38; 95% CI, 0.18-0.78) and tumor down-staging (OR, 0.31; 95% CI, 0.22-0.44) following NCRT compared with AC. MAC did not significantly affect nodal down-staging (OR, 0.42; 95% CI, 0.16-1.12) after NCRT. CONCLUSION MAC of LARC was found to be a negative predictor of response to NCRT with lower rates of pCR and tumor down-staging for LARC. The nodal down-staging of MAC was relatively lower than that of AC, although the differences were not statistically significant.
Collapse
Affiliation(s)
- Xiangwen Tan
- The Second Affiliated Hospital, Department of Hepatobiliary Surgery, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, China
| | - Yiwei Zhang
- The First Affiliated Hospital, Institute of Oncology, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, China
| | - Xiaofeng Wu
- The First Affiliated Hospital, Institute of Oncology, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, China
| | - Qing Fang
- The First Affiliated Hospital, Institute of Oncology, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, China
| | - Yunhua Xu
- The First Affiliated Hospital, Institute of Oncology, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, China
| | - Shuxiang Li
- The First Affiliated Hospital, Department of Gastrointestinal surgery, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, China
| | - Jinyi Yuan
- The First Affiliated Hospital, Department of Gastrointestinal surgery, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, China
| | - Xiuda Peng
- The Second Affiliated Hospital, Department of Hepatobiliary Surgery, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, China.
| | - Kai Fu
- Institute of Molecular Precision Medicine and Hunan Key Laboratory of Molecular Precision Medicine, Department of General Surgery, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China.
| | - Shuai Xiao
- The First Affiliated Hospital, Institute of Oncology, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, China.
- The First Affiliated Hospital, Department of Gastrointestinal surgery, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, China.
| |
Collapse
|
9
|
Gaetani RS, Ladin K, Abelson JS. Journey through the Decades: The Evolution in Treatment and Shared Decision Making for Locally Advanced Rectal Cancer. Cancers (Basel) 2024; 16:2807. [PMID: 39199579 PMCID: PMC11353159 DOI: 10.3390/cancers16162807] [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: 07/12/2024] [Revised: 08/03/2024] [Accepted: 08/06/2024] [Indexed: 09/01/2024] Open
Abstract
The management of locally advanced rectal cancer has undergone significant transformations over the decades and optimal treatment approaches continue to evolve. There have been numerous advances in surgery, chemotherapy, and radiation therapy from the first description of the abdominoperineal resection in 1908, timing of chemotherapy and radiation therapy in the late 20th and early 21st century, and most recently, the introduction of organ preservation or nonoperative management in 2004. Alongside these advancements, the concept of shared decision making in medicine has evolved, prompting a focus on patient-centered care. This evolution in practice has been fueled by a growing recognition of the importance of patient autonomy and the alignment of treatment options with patients' values and preferences. With the growing number of possible treatment options, variability in patient counseling exists, highlighting the need for a standardized approach to shared decision making in locally advanced rectal cancer. This narrative review will describe the evolution of treatment options of locally advanced rectal cancer as well as the concept of shared decision making and decision aids, and will introduce a decision aid for patients with locally advanced rectal cancer who have achieved a complete clinical response and are eligible for watch and wait.
Collapse
Affiliation(s)
- Racquel S. Gaetani
- Department of Colon and Rectal Surgery, Lahey Hospital and Medical Center, Burlington, MA 01805, USA;
| | - Keren Ladin
- Department of Community Health, Tufts University, Medford, MA 02155, USA
| | - Jonathan S. Abelson
- Department of Colon and Rectal Surgery, Lahey Hospital and Medical Center, Burlington, MA 01805, USA;
| |
Collapse
|
10
|
Li Y, Liu X, Gu M, Xu T, Ge C, Chang P. Significance of MRI-based radiomics in predicting pathological complete response to neoadjuvant chemoradiotherapy of locally advanced rectal cancer: A narrative review. Cancer Radiother 2024; 28:390-401. [PMID: 39174361 DOI: 10.1016/j.canrad.2024.04.003] [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: 03/27/2024] [Revised: 04/24/2024] [Accepted: 04/25/2024] [Indexed: 08/24/2024]
Abstract
Neoadjuvant chemoradiotherapy is the standard treatment for patients with locally advanced rectal cancers owing to its ability to downstage primary tumours. Some patients can achieve pathological complete response after neoadjuvant therapy, and can adopt a "watch and wait" treatment strategy to avoid overtreatment. Therefore, it is essential to develop strategies for predicting responses to neoadjuvant therapy. Radiomics has shown great potential in extracting tumour features from high-throughput medical images for the construction of mathematics models for predicting the effects of anticancerous therapies. Herein, we explored MRI-based radiomics and found that it can predict responses of locally advanced rectal cancers to chemoradiation. Efficient radiomics model allow early-stage prediction of the effect of neoadjuvant chemoradiotherapy on locally advanced rectal cancers. It helps clinicians to make informed therapeutic decisions. In this review, we discuss the workflow of radiomics, and summarize the clinical application of MRI-based radiomics in predicting pathological complete response to neoadjuvant chemoradiotherapy of locally advanced rectal cancer.
Collapse
Affiliation(s)
- Y Li
- Department of Radiation Oncology and Therapy, The First Hospital of Jilin University, Changchun, China
| | - X Liu
- Department of Radiation Oncology and Therapy, The First Hospital of Jilin University, Changchun, China
| | - M Gu
- Department of Radiation Oncology and Therapy, The First Hospital of Jilin University, Changchun, China
| | - T Xu
- Department of Radiation Oncology and Therapy, The First Hospital of Jilin University, Changchun, China
| | - C Ge
- Department of Radiation Oncology and Therapy, The First Hospital of Jilin University, Changchun, China
| | - P Chang
- Department of Radiation Oncology and Therapy, The First Hospital of Jilin University, Changchun, China.
| |
Collapse
|
11
|
Haussmann J, Budach W, Nestle-Krämling C, Wollandt S, Jazmati D, Tamaskovics B, Corradini S, Bölke E, Haussmann A, Audretsch W, Matuschek C. Factors influencing pathological complete response and tumor regression in neoadjuvant radiotherapy and chemotherapy for high-risk breast cancer. Radiat Oncol 2024; 19:99. [PMID: 39085866 PMCID: PMC11293047 DOI: 10.1186/s13014-024-02450-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 05/09/2024] [Indexed: 08/02/2024] Open
Abstract
BACKGROUND Pathological complete response (pCR) is a well-established prognostic factor in breast cancer treated with neoadjuvant systemic therapy (naST). The determining factors of pCR are known to be intrinsic subtype, proliferation index, grading, clinical tumor and nodal stage as well as type of systemic therapy. The addition of neoadjuvant radiotherapy (naRT) to this paradigm might improve response, freedom from disease, toxicity and cosmetic outcome compared to adjuvant radiotherapy. The factors for pCR and primary tumor regression when neoadjuvant radiation therapy is added to chemotherapy have not been thoroughly described. METHODS We performed a retrospective analysis of 341 patients (cT1-cT4/cN0-N+) treated with naRT and naST between 1990 and 2003. Patients underwent naRT to the breast and mostly to the supra-/infraclavicular lymph nodes combined with an electron or brachytherapy boost. NaST was given either sequentially or simultaneously to naRT using different regimens. We used the univariate and multivariate regression analysis to estimate the effect of different subgroups and treatment modalities on pCR (ypT0/Tis and ypN0) as well as complete primary tumor response (ypT0/Tis; bpCR) in our cohort. Receiver operating characteristic (ROC) analysis was performed to evaluate the interval between radiotherapy (RT) and resection (Rx) as well as radiotherapy dose. RESULTS Out of 341 patients, pCR and pbCR were achieved in 31% and 39%, respectively. pCR rate was influenced by resection type, breast cancer subtype, primary tumor stage and interval from radiation to surgery in the multivariate analysis. Univariate analysis of bpCR showed age, resection type, breast cancer subtype, clinical tumor stage and grading as significant factors. Resection type, subtype and clinical tumor stage remained significant in multivariate analysis. Radiation dose to the tumor and interval from radiation to surgery were not significant factors for pCR. However, when treatment factors were added to the model, a longer interval from radiotherapy to resection was a significant predictor for pCR. CONCLUSIONS The factors associated with pCR following naST and naRT are similar to known factors after naST alone. Longer interval to surgery might to be associated with higher pCR rates. Dose escalation beyond 60 Gy did not result in higher response rates.
Collapse
Affiliation(s)
- Jan Haussmann
- Department of Radiation Oncology, Center for Integrated Oncology, Medical Faculty and University Hospital Düsseldorf , Heinrich Heine University, Aachen Bonn Cologne Düsseldorf (CIO ABCD), Dusseldorf, Germany
| | - Wilfried Budach
- Department of Radiation Oncology, Center for Integrated Oncology, Medical Faculty and University Hospital Düsseldorf , Heinrich Heine University, Aachen Bonn Cologne Düsseldorf (CIO ABCD), Dusseldorf, Germany
| | | | - Sylvia Wollandt
- Department of Senology, Sana-Kliniken Düsseldorf-Gerresheim, 40625, Dusseldorf, Germany
- Department of Gynecological Oncological Rehabilitation, Asklepios Nordseesklinik, Sylt, Germany
| | - Danny Jazmati
- Department of Radiation Oncology, Center for Integrated Oncology, Medical Faculty and University Hospital Düsseldorf , Heinrich Heine University, Aachen Bonn Cologne Düsseldorf (CIO ABCD), Dusseldorf, Germany
| | - Bálint Tamaskovics
- Department of Radiation Oncology, Center for Integrated Oncology, Medical Faculty and University Hospital Düsseldorf , Heinrich Heine University, Aachen Bonn Cologne Düsseldorf (CIO ABCD), Dusseldorf, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Edwin Bölke
- Department of Radiation Oncology, Center for Integrated Oncology, Medical Faculty and University Hospital Düsseldorf , Heinrich Heine University, Aachen Bonn Cologne Düsseldorf (CIO ABCD), Dusseldorf, Germany.
| | - Alexander Haussmann
- Division of Physical Activity, Prevention and Cancer, German Cancer Research Center (DKFZ), 69120, Heidelberg, Germany
| | - Werner Audretsch
- Department of Senology and Breast Surgery, Breast Center at Marien Hospital Cancer Center, 40479, Dusseldorf, Germany
| | - Christiane Matuschek
- Department of Radiation Oncology, University Hospital OWL, Campus Bielefeld, Bielefeld, Germany
| |
Collapse
|
12
|
Asare E, Venner E, Batchelor H, Sanders J, Kunk P, Hedrick T, Hoang S, Reilley M, Le T, Friel C, Janowski EM. Outcomes associated with total neoadjuvant therapy with non-operative intent for rectal adenocarcinoma. Front Oncol 2024; 14:1374360. [PMID: 39156701 PMCID: PMC11328831 DOI: 10.3389/fonc.2024.1374360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 07/15/2024] [Indexed: 08/20/2024] Open
Abstract
Purpose/objectives To evaluate rates of clinical complete response (cCR), surgery-free survival, permanent ostomy-free survival, and factors associated with these outcomes in patients treated with total neoadjuvant therapy (TNT) with intent for non-operative management of rectal adenocarcinoma. Methods A retrospective review was conducted of patients treated with TNT for stage II-IV rectal adenocarcinoma (n=45) at our institution between 2013 - 2022 with curative intent. All patients received radiation with concurrent capecitabine and additional chemotherapy, either prior to or following chemoradiation (CRT), with intent for non-operative management. Response rates were determined based on post-treatment MRI and endoscopy. Kaplan-Meier method was utilized to estimate the 1- and 2-year surgery- and permanent ostomy-free survivals. Cox regression was used to evaluate associations between surgery- and permanent ostomy-free survivals and various factors of interest, including patient and tumor characteristics and clinical response. Chi-squared analysis compared rates of cCR and surgery by sequence of TNT modality and cell count ratios. Results Of the 45 patients treated with TNT, most patients had low-lying rectal tumors with a median distance of 4.1 cm from the anal verge (range, 0.0 - 12.0). Overall, 64.4% (n=29) achieved cCR after TNT. 13 patients (28.9%) underwent surgical resection following TNT, 12 of whom had incomplete response and one who elected to undergo surgery after reaching cCR. At median follow up of 32.0 months (range, 7.1 - 86.1), 22.2% (n=10) of patients had a permanent colostomy, with only 2 of these completed for tumor regrowth after cCR. At one and two years, respectively, surgery-free survival was 77.3% and 66.2%, and permanent ostomy-free survival was 90.9% and 78.2%. Rates of cCR were higher in patients who received CRT first compared to those who received chemotherapy first (72.2% vs. 33.3%, p=0.029) and rates of surgery were also lower in patients who received CRT first compared to those who received chemotherapy first (19.4% vs. 66.7%, p=0.005). On Cox regression model, cCR on 6 month post-CRT endoscopy was associated with surgery-free survival (p=0.006) and permanent ostomy-free survival (p=0.033). Clinical response at earlier follow up points did not predict surgery- nor permanent ostomy-free survival. Conclusion These results support evidence that TNT may be a non-surgical option for select patients with rectal adenocarcinoma who desire organ preservation. In this investigation at a single institution, the treatment response on 6-month post-CRT endoscopy was the best predictor of surgery- and permanent ostomy-free survival, which are outcomes that are important to patient quality of life. CRT followed by consolidation chemotherapy was associated with higher rates of cCR and lower rates of surgery compared to those treated with induction chemotherapy.
Collapse
Affiliation(s)
- Ebenezer Asare
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, United States
| | - Emily Venner
- University of Virginia School of Medicine, Charlottesville, VA, United States
| | - Hanna Batchelor
- University of Virginia School of Medicine, Charlottesville, VA, United States
| | - Jason Sanders
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, United States
| | - Paul Kunk
- Department of Hematology/Oncology, University of Virginia, Charlottesville, VA, United States
| | - Traci Hedrick
- Department of Colorectal Surgery, University of Virginia, Charlottesville, VA, United States
| | - Sook Hoang
- Department of Colorectal Surgery, University of Virginia, Charlottesville, VA, United States
| | - Matthew Reilley
- Department of Hematology/Oncology, University of Virginia, Charlottesville, VA, United States
| | - Tri Le
- Department of Hematology/Oncology, University of Virginia, Charlottesville, VA, United States
| | - Charles Friel
- Department of Colorectal Surgery, University of Virginia, Charlottesville, VA, United States
| | - Einsley-Marie Janowski
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, United States
| |
Collapse
|
13
|
Alvarez JA, Shi Q, Dasari A, Garcia-Aguilar J, Sanoff H, George TJ, Hong T, Yothers G, Philip P, Nelson G, Al Baghdadi T, Alese OB, Zambare W, Omer D, Verheij FS, Bercz A, Kim MJ, Buckley J, Williams H, George M, Garcia R, Gallagher P, O'Reilly EM, Meyerhardt JA, Crawley J, Shergill A, Horvat N, Romesser PB, Hall W, Smith JJ. Alliance A022104/NRG-GI010: The Janus Rectal Cancer Trial: a randomized phase II/III trial testing the efficacy of triplet versus doublet chemotherapy regarding clinical complete response and disease-free survival in patients with locally advanced rectal cancer. BMC Cancer 2024; 24:901. [PMID: 39060961 PMCID: PMC11282593 DOI: 10.1186/s12885-024-12529-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Accepted: 06/17/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND Recent data have demonstrated that in locally advanced rectal cancer (LARC), a total neoadjuvant therapy (TNT) approach improves compliance with chemotherapy and increases rates of tumor response compared to neoadjuvant chemoradiation (CRT) alone. They further indicate that the optimal sequencing of TNT involves consolidation (rather than induction) chemotherapy to optimize complete response rates. Data, largely from retrospective studies, have also shown that patients with clinical complete response (cCR) after TNT may be managed safely with the watch and wait approach (WW) instead of preemptive total mesorectal resection (TME). However, the optimal consolidation chemotherapy regimen to achieve cCR has not been established, and a randomized clinical trial has not robustly evaluated cCR as a primary endpoint. Collaborating with a multidisciplinary oncology team and patient groups, we designed this NCI-sponsored study of chemotherapy intensification to address these issues and to drive up cCR rates, to provide opportunity for organ preservation, improve quality of life for patients and improve survival outcomes. METHODS In this NCI-sponsored multi-group randomized, seamless phase II/III trial (1:1), up to 760 patients with LARC, T4N0, any T with node positive disease (any T, N +) or T3N0 requiring abdominoperineal resection or coloanal anastomosis and distal margin within 12 cm of anal verge will be enrolled. Stratification factors include tumor stage (T4 vs T1-3), nodal stage (N + vs N0) and distance from anal verge (0-4; 4-8; 8-12 cm). Patients will be randomized to receive neoadjuvant long-course chemoradiation (LCRT) followed by consolidation doublet (mFOLFOX6 or CAPOX) or triplet chemotherapy (mFOLFIRINOX) for 3-4 months. LCRT in both arms involves 4500 cGy in 25 fractions over 5 weeks + 900 cGy boost in 5 fractions with a fluoropyrimidine (capecitabine preferred). Patients will undergo assessment 8-12 (± 4) weeks post-TNT completion. The primary endpoint for the phase II portion will compare cCR between treatment arms. A total number of 312 evaluable patients (156 per arm) will provide statistical power of 90.5% to detect a 17% increase in cCR rate, at a one-sided alpha = 0.048. The primary endpoint for the phase III portion will compare disease-free survival (DFS) between treatment arms. A total of 285 DFS events will provide 85% power to detect an effect size of hazard ratio 0.70 at a one-sided alpha of 0.025, requiring enrollment of 760 patients (380 per arm). Secondary objectives include time-to event outcomes (overall survival, organ preservation time and time to distant metastasis) and adverse event rates. Biospecimens including archival tumor tissue, plasma and buffy coat, and serial rectal MRIs will be collected for exploratory correlative research. This study, activated in late 2022, is open across the NCTN and had accrued 330 patients as of May 2024. Study support: U10CA180821, U10CA180882, U24 CA196171; https://acknowledgments.alliancefound.org . DISCUSSION Building on data from modern day rectal cancer trials and patient input from national advocacy groups, we have designed The Janus Rectal Cancer Trial studying chemotherapy intensification via a consolidation chemotherapy approach with the intent to enhance cCR and DFS rates, increase organ preservation rates, and improve quality of life for patients with rectal cancer. TRIAL REGISTRATION Clinicaltrials.gov ID: NCT05610163; Support includes U10CA180868 (NRG) and U10CA180888 (SWOG).
Collapse
Affiliation(s)
- Janet A Alvarez
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-201, New York, NY, 10065, USA
| | | | - Arvind Dasari
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Julio Garcia-Aguilar
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-201, New York, NY, 10065, USA
| | - Hanna Sanoff
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Thomas J George
- University of Florida Health Cancer Center, University of Florida, Gainesville, FL, USA
| | | | | | | | | | | | | | - Wini Zambare
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-201, New York, NY, 10065, USA
| | - Dana Omer
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-201, New York, NY, 10065, USA
| | - Floris S Verheij
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-201, New York, NY, 10065, USA
| | - Aron Bercz
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-201, New York, NY, 10065, USA
| | - Min Jung Kim
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-201, New York, NY, 10065, USA
| | - James Buckley
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-201, New York, NY, 10065, USA
| | - Hannah Williams
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-201, New York, NY, 10065, USA
| | - Manju George
- COLONTOWN/Paltown Development Foundation, Crownsville, MD, USA
| | | | | | - Eileen M O'Reilly
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-201, New York, NY, 10065, USA
| | | | | | | | - Natally Horvat
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-201, New York, NY, 10065, USA
| | - Paul B Romesser
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-201, New York, NY, 10065, USA
| | - William Hall
- Medical College of Wisconsin, Milwaukee, WI, USA
| | - J Joshua Smith
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-201, New York, NY, 10065, USA.
| |
Collapse
|
14
|
Erozkan K, Elamin D, Tasci ME, Liska D, Valente MA, Alipouriani A, Schabl L, Lavryk O, Catalano B, Krishnamurthi S, Miller JA, Purysko AS, Steele SR, Gorgun E. Evaluating complete response rates and predictors in total neoadjuvant therapy for rectal cancer. J Gastrointest Surg 2024:S1091-255X(24)00544-4. [PMID: 39067745 DOI: 10.1016/j.gassur.2024.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 07/18/2024] [Accepted: 07/23/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND There is a paradigm shift in the management of locally advanced rectal cancer (LARC) from conventional neoadjuvant treatment to total neoadjuvant therapy (TNT). Despite its growing acceptance, there are limited studies that have examined its effects on disease presentation. In addition, it is important to determine the factors that play a role in complete response (CR). Our previous data from 119 patients revealed that the CR rate was 37%, and low rectal tumors and the absence of extramural vascular invasion (EMVI) were predictors of CR. Unfortunately, there continues to be a lack of data, and reliable markers are still needed to consistently identify the best respondents. Therefore, this study aimed to determine the factors associated with CR. Moreover, this study hypothesized that both predictive factors and the CR ratio might evolve over time because of the growing patient population. METHODS This retrospective study included patients who completed TNT for LARC at our tertiary care center between 2015 and 2022. The primary outcome was to determine the predictors of CR. The secondary outcomes were the 2-year disease-free survival (DFS) rate and overall survival (OS) rate. CR consists of patients who sustained clinical CR (cCR) for at least 12 months under watch and wait or had pathologic CR (pCR) after surgery. RESULTS Of 339 patients with LARC, 208 (61.3%) successfully completed TNT. Among 208 patients, 57 (27.4%) achieved cCR, and 166 (80.0%) sustained cCR without tumor regrowth after 1 year. The remaining 151 patients (72.6%) underwent surgery, and 42 patients had pCR. The final CR rate was 42.3%. The median age of the patients was 56 years (IQR, 49-66). Moreover, 132 participants (63.5%) were male, whereas 76 participants (36.5%) were female. The median tumor size was 4.95 cm (IQR, 3.60-6.43), with most tumors in the low rectum (119 [57.2%]). Based on the MRI findings, the mesorectal facia (MRF) involvement rate was 25.0% (n = 52), and EMVI was observed in 43 patients (20.7%). Low rectal tumors, the absence of MRF involvement, and the absence of EMVI were predictors of CR. With a median follow-up of 24.7 months, 2-year DFS and OS were significantly higher among patients with CR than among patients with incomplete response (91.3% vs 71.0% [P < .01] and 98.8% vs 90.2% [P = .03], respectively). CONCLUSION An increasing CR rate was observed in our updated dataset compared with that in our previous study. In addition to previously identified predictors, low tumor location, and the absence of EMVI, the absence of MRF involvement was determined as a predictor of CR. Our findings offer valuable insights into clinical practice and help clinicians set clear expectations when counseling patients.
Collapse
Affiliation(s)
- Kamil Erozkan
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Doua Elamin
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Muhammed Enes Tasci
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, United States
| | - David Liska
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Michael A Valente
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Ali Alipouriani
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Lukas Schabl
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Olga Lavryk
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Brogan Catalano
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Smitha Krishnamurthi
- Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH, United States
| | - Jacob A Miller
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH, United States
| | - Andrei S Purysko
- Section of Abdominal Imaging and Nuclear Radiology Department, Imaging Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Emre Gorgun
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, United States.
| |
Collapse
|
15
|
Crippa J, Luberto A, Magistro C, Carvello M, Carnevali P, Maroli A, Ferrari GC, Spinelli A. Implementing a no-drain policy for extraperitoneal colorectal anastomosis in a real-life setting: analysis of outcomes and surgeons' adherence. Int J Colorectal Dis 2024; 39:109. [PMID: 39008120 PMCID: PMC11249572 DOI: 10.1007/s00384-024-04681-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/04/2024] [Indexed: 07/16/2024]
Abstract
AIM Recent evidence has questioned the usefulness of anastomotic drain (AD) after low anterior resection (LAR). However, the implementation and adoption of a no-drain policy are still poor. This study aims to assess the clinical outcomes of the implementation of a no-drain policy for rectal cancer surgery into a real-life setting and the adherence of the surgeons to such policy. METHOD A retrospective analysis was conducted on patients who underwent elective minimally invasive LAR between January 2015 and December 2019 at two tertiary referral centers. In 2017, both centers implemented a policy aimed at reducing the use of AD. Patients were retrospectively categorized into two groups: the drain policy (DP) group, comprising patients treated before 2017, and the no-drain policy (NDP) group, consisting of patients treated from 2017 onwards. The endpoints were the rate of anastomotic leak (AL) and of related interventions. RESULTS Among the 272 patients included, 188 (69.1%) were in the NDP group, and 84 (30.9%) were in the DP group. Baseline characteristics were similar between the two groups. AL rate was 11.2% in the NDP group compared to 10.7% in the DP group (p = 1.000), and the AL grade distribution (grade A, 19.1% (4/21) vs 28.6% (2/9); grade B, 28.6% (6/21) vs 11.1% (1/9); grade C, 52.4% (11/21) vs 66.7% (6/9), p = 0.759) did not significantly differ between the groups. All patients with symptomatic AL and AD underwent surgical treatment for the leak, while those with symptomatic AL in the NPD group were managed with surgery (66.7%), endoscopic (19.0%), or percutaneous (14.3%) interventions. Postoperative outcomes were similar between the groups. Three years after implementing the no-drain policy, AD was utilized in only 16.5% of cases, compared to 76.2% at the study's outset. CONCLUSION The introduction of a no-drain policy received a good adoption rate and did not affect negatively the surgical outcomes.
Collapse
Affiliation(s)
- Jacopo Crippa
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Via Alessandro Manzoni 56 Rozzano, 20089, Milan, Italy
| | - Antonio Luberto
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4 Pieve Emanuele, 20072, Milan, Italy
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Via Alessandro Manzoni 56 Rozzano, 20089, Milan, Italy
| | - Carmelo Magistro
- Division of Minimally Invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - Michele Carvello
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4 Pieve Emanuele, 20072, Milan, Italy
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Via Alessandro Manzoni 56 Rozzano, 20089, Milan, Italy
| | - Pietro Carnevali
- Division of Minimally Invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - Annalisa Maroli
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Via Alessandro Manzoni 56 Rozzano, 20089, Milan, Italy
| | - Giovanni Carlo Ferrari
- Division of Minimally Invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4 Pieve Emanuele, 20072, Milan, Italy.
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Via Alessandro Manzoni 56 Rozzano, 20089, Milan, Italy.
| |
Collapse
|
16
|
Friedman G. Surveillance after Total Neoadjuvant Therapy: What to do for Near-Complete Responders. Clin Colon Rectal Surg 2024; 37:229-232. [PMID: 38882942 PMCID: PMC11178382 DOI: 10.1055/s-0043-1770716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
A proportion of patients who undergo total neoadjuvant therapy for rectal cancer will achieve what is classified as a near-complete response. Significant debate exists as to the optimal management strategy for these patients with large heterogeneity in management. This article will examine the therapeutic and surveillance options for these patients as well as the relevant outcomes data.
Collapse
|
17
|
Chapman WC, Hunt SR, Henke LE. Radiotherapy for Rectal Cancer: How Much is Enough? Clin Colon Rectal Surg 2024; 37:207-215. [PMID: 38882937 PMCID: PMC11178390 DOI: 10.1055/s-0043-1770709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
Though resection has been the mainstay of treatment for nonmetastatic rectal cancer over the past century, radiation has become an increasingly integral component of care for locally advanced disease. Today, two predominant radiotherapy approaches-hyperfractionated chemoradiotherapy and "short-course" radiation-are widely utilized to reduce local recurrence and, in some cases, cure disease. Both have been incorporated into total neoadjuvant therapy (TNT) regimens and achieved excellent local control and superior complete response rates compared to chemoradiation alone. Additionally, initial results of "watch and wait" protocols utilizing either radiation modality have been promising. Yet, differences do exist; though short course is cheaper and more convenient for patients, recently published data may show superior complete response and local recurrence rates with chemoradiation. Ultimately, direct comparisons of short-course radiotherapy against chemoradiation within the TNT framework are needed to identify optimal radiation regimens in the treatment of locally advanced rectal cancer.
Collapse
Affiliation(s)
- William C. Chapman
- Department of Surgery, Section of Colon Rectal Surgery, Washington University School of Medicine, St. Louis, Missouri
- Department of Colon and Rectal Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Steven R. Hunt
- Department of Surgery, Section of Colon Rectal Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Lauren E. Henke
- Department of Radiation Oncology, University Hospitals, Cleveland, Ohio
| |
Collapse
|
18
|
Pollom EL, Sheth VR, Dawes AJ, Holden T. Nonoperative Management for Rectal Cancer. Cancer J 2024; 30:238-244. [PMID: 39042774 DOI: 10.1097/ppo.0000000000000727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2024]
Abstract
ABSTRACT The treatment paradigm for rectal cancer has been shifting toward de-escalated approaches to preserve patient quality of life. Historically, the standard treatment in the United States for locally advanced rectal cancer has standardly comprised preoperative chemoradiotherapy coupled with total mesorectal excision. Recent data challenge this "one-size-fits-all" strategy, supporting the possibility of omitting surgery for certain patients who achieve a clinical complete response to neoadjuvant therapy. Consequently, patients and their physicians must navigate diverse neoadjuvant options, often in the context of pursuing organ preservation. Total neoadjuvant therapy, involving the administration of all chemotherapy and radiation before total mesorectal excision, is associated with the highest rates of clinical complete response. However, questions persist regarding the optimal sequencing of radiation and chemotherapy and the choice between short-course and long-course radiation. Additionally, meticulous response assessment and surveillance are critical for selecting patients for nonoperative management without compromising the excellent cure rates associated with trimodality therapy. As nonoperative management becomes increasingly recognized as a standard-of-care treatment option for patients with rectal cancer, ongoing research in patient selection and monitoring as well as patient-reported outcomes is critical to guide personalized rectal cancer management within a patient-centered framework.
Collapse
Affiliation(s)
| | | | | | - Thomas Holden
- Department of Medicine, Stanford University School of Medicine, Stanford, CA
| |
Collapse
|
19
|
Kohrman NM, Wlodarczyk JR, Ding L, McAndrew NP, Algaze SD, Cologne KG, Lee SW, Koller SE. Rectal Cancer Survival for Residual Carcinoma In Situ Versus Pathologic Complete Response After Neoadjuvant Therapy. Dis Colon Rectum 2024; 67:920-928. [PMID: 38498775 DOI: 10.1097/dcr.0000000000003261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
BACKGROUND Pathologic complete response after neoadjuvant chemoradiotherapy for rectal cancer is associated with improved survival. It is unclear whether residual carcinoma in situ portends a similar outcome. OBJECTIVE To compare the survival of patients with locally advanced rectal cancer who received neoadjuvant therapy and achieved pathologic carcinoma in situ versus pathologic complete response. DESIGN Retrospective cohort study. SETTING National public database. PATIENTS A total of 4594 patients in the National Cancer Database from 2006 to 2016 with locally advanced rectal cancer who received neoadjuvant therapy, underwent surgery, and had node-negative ypTis or ypT0 on final pathology were included. Of these, 4321 patients (94.1%) had ypT0 and 273 (5.9%) had ypTis on final pathology. MAIN OUTCOME MEASURE Overall survival. RESULTS The median age was 60 years, and 1822 patients (39.7%) were women. On initial staging, 54.5% (n = 2503) had stage II disease and 45.5% (n = 2091) had stage III disease. The ypTis group had decreased overall survival compared to the ypT0 group (HR 1.42; 95% CI, 1.04-1.95; p = 0.028). Other factors associated with decreased overall survival were older age at diagnosis, increasing Charlson-Deyo score, and poorly differentiated tumor grade. Variables associated with improved survival were female sex, private insurance, and receipt of both neoadjuvant and adjuvant chemotherapy. For the total cohort, there was no difference in survival between clinical stage II and stage III. LIMITATIONS Standard therapy versus total neoadjuvant therapy could not be abstracted. Overall survival was defined as the time from surgery to death from any cause or last contact, allowing for some erroneously misclassified deaths. CONCLUSIONS ypTis is associated with worse overall survival than ypT0 for patients with locally advanced rectal cancer who receive neoadjuvant chemoradiotherapy followed by surgery. For this cohort, clinical stage was not a significant predictor of survival. Prospective trials comparing survival for these pathologic outcomes are needed. See Video Abstract . SUPERVIVENCIA DEL CNCER DE RECTO PARA EL CARCINOMA RESIDUAL IN SITU VS RESPUESTA PATOLGICA COMPLETA DESPUS DE LA TERAPIA NEOADYUVANTE ANTECEDENTESLa respuesta patológica completa después de la quimiorradioterapia neoadyuvante para el cáncer de recto se asocia con una mayor supervivencia. No está claro si el carcinoma residual in situ presagia un resultado similar.OBJETIVOComparar la supervivencia de pacientes con cáncer de recto localmente avanzado que recibieron terapia neoadyuvante y lograron un carcinoma patológico in situ versus una respuesta patológica completa.DISEÑOEstudio de cohorte retrospectivo.ESCENARIOBase de datos pública nacional.PACIENTESSe incluyeron 4,594 pacientes de la Base de Datos Nacional de Cáncer de 2006 a 2016 con cáncer de recto localmente avanzado que recibieron terapia neoadyuvante, fueron sometidos a cirugía y tuvieron ganglios negativos, ypTis o ypT0 en el reporte patológico final. 4.321 (94,1%) tuvieron ypT0 y 273 (5,9%) tuvieron ypTis en el reporte final.PRINCIPALES MEDIDAS DE RESULTADOSupervivencia general.RESULTADOSLa mediana de edad fue de 60 años. 1.822 pacientes (39,7%) fueron mujeres. El 54,5% (n = 2.503) tuvo la enfermedad en estadio II y el 45,5% (n = 2.091) tuvo la enfermedad en estadio III según la estadificación inicial. El grupo ypTis tuvo una supervivencia general reducida en comparación con el grupo ypT0 (HR 1,42, IC 95 % 1,04-1,95, p = 0,028). Otros factores asociados con una menor supervivencia general fueron una edad más avanzada al momento del diagnóstico, un aumento de la puntuación de Charlson-Deyo y un grado tumoral poco diferenciado. Las variables asociadas con una mejor supervivencia fueron el sexo femenino, el seguro privado y la recepción de quimioterapia neoadyuvante y adyuvante. Para la cohorte total, no hubo diferencias en la supervivencia entre el estadio clínico 2 y el estadio 3.LIMITACIONESNo se pudo resumir el tratamiento estándar versus el tratamiento neoadyuvante total. La supervivencia general se definió como el tiempo transcurrido desde la cirugía hasta la muerte por cualquier causa o último contacto, lo que permite algunas muertes erróneamente clasificadas.CONCLUSIONESypTis se asocia con una peor supervivencia general que ypT0 en pacientes con cáncer de recto localmente avanzado que reciben quimiorradioterapia neoadyuvante seguida de cirugía. Para esta cohorte, el estadio clínico no fue un predictor significativo de supervivencia. Se necesitan ensayos prospectivos que comparen la supervivencia de estos resultados patológicos. ( Traducción-Dr Osvaldo Gauto ).
Collapse
Affiliation(s)
- Nathan M Kohrman
- University of Southern California Keck School of Medicine, Los Angeles, California
| | - Jordan R Wlodarczyk
- Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Li Ding
- Department of Population and Public Health Sciences, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Nicholas P McAndrew
- Division of Hematology/Oncology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California
| | - Sandra D Algaze
- Division of Medical Oncology, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Kyle G Cologne
- Division of Colorectal Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Sang W Lee
- Division of Colorectal Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Sarah E Koller
- Division of Colorectal Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| |
Collapse
|
20
|
Rajeev-Kumar G, Katipally RR, Li S, Shogan BD, Olortegui KS, Chin J, Polite BN, Liauw SL. Point/Counterpoint #2: Current Clinical Considerations With Nonoperative Management of Rectal Cancer. Cancer J 2024; 30:256-263. [PMID: 39042777 DOI: 10.1097/ppo.0000000000000732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2024]
Abstract
ABSTRACT Locally advanced rectal cancer has historically been treated with multimodal therapy consisting of radiation therapy, chemotherapy, and total mesorectal excision. However, recent prospective trials and registry studies have demonstrated similar disease outcomes with nonoperative management for patients who experience an excellent clinical response to radiation and chemotherapy. This article reviews data regarding nonoperative management for rectal cancer, and highlights current challenges and limitations in a point-counterpoint format, in the context of two clinical cases.
Collapse
Affiliation(s)
| | | | - Shen Li
- Sections of Surgical Oncology
| | | | | | - Janet Chin
- Department of Hematology/Oncology, University of Chicago Medical Center, Chicago, IL
| | - Blase N Polite
- Department of Hematology/Oncology, University of Chicago Medical Center, Chicago, IL
| | | |
Collapse
|
21
|
Panni RZ, D'Angelica M. Stage IV Rectal Cancer and Timing of Surgical Approach. Clin Colon Rectal Surg 2024; 37:248-255. [PMID: 38882938 PMCID: PMC11178389 DOI: 10.1055/s-0043-1770719] [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] [Indexed: 06/18/2024]
Abstract
Liver metastases are seen in at least 60% of patients with colorectal cancer at some point during the course of their disease. The management of both primary and liver disease is uniquely challenging in rectal cancer due to competing treatments and complex sequence of treatments depending on the clinical presentation of disease. Recently, several novel concepts are shaping new treatment paradigms, including changes in timing, sequence, and duration of therapies combined with potential deescalation of treatment components. Overall, the treatment of this clinical scenario mandates multidisciplinary evaluation and personalization of care; however, there is still considerable debate regarding the timing of liver metastasectomy in the context of the overall treatment plan. Herein, we will discuss the current literature on management of rectal cancer with synchronous liver metastasis, current treatment approaches with respect to chemotherapy, and role of hepatic artery infusion therapy.
Collapse
Affiliation(s)
- Roheena Z. Panni
- Complex General Surgical Oncology, Hepatopancreatobiliary Surgery, Memorial Sloan Kettering Cancer Center, New York
| | - Michael D'Angelica
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, Cornell University, New York
| |
Collapse
|
22
|
Wang Y, Yang Y, Liu QQ, Wang SZ. Compare clinical efficacy and safety of neoadjuvant therapy and neoadjuvant chemoradiotherapy for locally advanced rectal cancer: Meta-analysis. World J Gastrointest Surg 2024; 16:1845-1856. [PMID: 38983334 PMCID: PMC11230002 DOI: 10.4240/wjgs.v16.i6.1845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 04/01/2024] [Accepted: 04/28/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND To compare the efficacy and safety of total neoadjuvant therapy (TNT) and neoadjuvant chemoradiotherapy (nCRT) in the treatment of middle and low locally advanced rectal cancer. Our study will systematically collect and integrate studies to evaluate the ability of these two treatments to improve tumor shrinkage rates, surgical resection rates, tumor-free survival, and severe adverse events. AIM To provide clinicians and patients with more reliable treatment options to optimize treatment outcomes and quality of life for patients with locally advanced rectal cancer by comparing the advantages and disadvantages of the two treatment options. METHODS A full search of all clinical studies on the effectiveness and safety of TNT and nCRT for treating locally advanced rectal cancer identified in Chinese (CNKI, Wanfang, China Biomedical Literature Database) and English (PubMed, Embase) databases was performed. Two system assessors independently screened the studies according to the inclusion and exclusion criteria. Quality evaluation and data extraction were performed for the included literature. We used RevMan 5.3 software to perform a meta-analysis of the pathologic complete response (pCR) rate, T stage degradation rate, resection 0 (R0) rate, anal grade 3/4 acute toxicity rate, perioperative complications, overall survival (OS), and disease-free survival (DFS) in the TNT and nCRT groups. RESULTS Finally, 14 studies were included, six of which were randomized controlled studies. A total of 3797 patients were included, including 1865 in the TNT group and 1932 in the nCRT group. The two sets of baseline data were comparable. The results of the meta-analysis showed that the pCR rate [odds ratio (OR) = 1.57, 95% confidence interval (CI): 1.30-1.90, P < 0.00001], T stage degradation rate (OR = 2.16, 95%CI: 1.63-2.57, P < 0.00001), and R0 resection rate (OR = 1.42, 95%CI: 1.09-1.85, P = 0.009) were significantly greater in the nCRT group than in the nCRT group. There was no significant difference in the incidence of grade 3/4 acute toxicity or perioperative complications between the two groups. The 5-year OS [hazard ratio (HR) = 0.84, 95%CI: 0.69-1.02, P = 0.08] and DFS (HR = 0.94, 95%CI: 0.03-1.39, P = 0.74) of the TNT group were similar to those of the nCRT group. CONCLUSION TNT has greater clinical efficacy and safety than nCRT in the treatment of locally advanced rectal cancer.
Collapse
Affiliation(s)
- Ying Wang
- Department of Anus Intestinal Surgery, Feicheng People’s Hospital, Feicheng 271600, Shandong Province, China
| | - Yan Yang
- Department of Gastroenterology, Qingdao Hospital of University of Health and Rehabilitation Sciences (Qingdao Municipal Hospital), Qingdao 266011, Shandong Province, China
| | - Qi-Qi Liu
- Department of Gastrointestinal Surgery, Peking University Shenzhen Hospital, Shenzhen 518036, Guangdong Province, China
| | - Shao-Zhao Wang
- Department of Anorectal Words, Central Hospital Affiliated Shandong First Medical University, Jinan 250013, Shandong Province, China
| |
Collapse
|
23
|
Bedrikovetski S, Traeger L, Seow W, Dudi-Venkata NN, Selva-Nayagam S, Penniment M, Sammour T. Oncological Outcomes and Response Rate After Total Neoadjuvant Therapy for Locally Advanced Rectal Cancer: A Network Meta-Analysis Comparing Induction vs. Consolidation Chemotherapy vs. Standard Chemoradiation. Clin Colorectal Cancer 2024:S1533-0028(24)00056-2. [PMID: 38945765 DOI: 10.1016/j.clcc.2024.06.001] [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: 05/05/2024] [Revised: 06/04/2024] [Accepted: 06/06/2024] [Indexed: 07/02/2024]
Abstract
TNT is now considered the preferred option for stage II-III locally advanced rectal cancer (LARC). However, the prognostic benefit and optimal sequence of TNT remains unclear. This network meta-analysis (NMA) compared short- and long-term outcomes amongst patients with LARC receiving total neoadjuvant therapy (TNT) as induction (iTNT) or consolidation chemotherapy (cTNT) with those receiving neoadjuvant chemoradiation (nCRT) alone. A systematic literature search was performed between 2012 and 2023. A Bayesian NMA was conducted using a Markov Chain Monte Carlo method with a random-effects model and vague prior distribution to calculate odds ratios (OR) with 95% credible intervals (CrI). The surface under the cumulative ranking (SUCRA) curves were used to rank treatment(s) for each outcome. In total, 11 cohorts involving 8360 patients with LARC were included. There was no significant difference in disease-free survival (DFS) and overall survival (OS) amongst the 3 treatments. Compared with nCRT, both cTNT (OR 2.36; 95% CrI, 1.57-3.66) and iTNT (OR 1.99; 95% CrI, 1.44-2.95) significantly improved complete response (CR) rate. Notably, cTNT ranked as the best treatment for CR (SUCRA 0.90) and iTNT as the best treatment for 3-year DFS and OS (SUCRA 0.72 and 0.87, respectively). Both iTNT and cTNT strategies significantly improved CR rates compared with nCRT. cTNT was ranked highest for CR rates, while iTNT was ranked highest for 3-year survival outcomes. However, no other significant differences in DFS, OS, sphincter-saving surgery, R0 resection and postoperative complications were found amongst the treatment groups.
Collapse
Affiliation(s)
- Sergei Bedrikovetski
- Department of Surgery, Colorectal Unit, Royal Adelaide Hospital, Adelaide, Australia; Department of Surgical Specialties, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia.
| | - Luke Traeger
- Department of Surgery, Colorectal Unit, Royal Adelaide Hospital, Adelaide, Australia; Department of Surgical Specialties, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | - Warren Seow
- Department of Surgery, Colorectal Unit, Royal Adelaide Hospital, Adelaide, Australia
| | | | | | - Michael Penniment
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, Australia
| | - Tarik Sammour
- Department of Surgery, Colorectal Unit, Royal Adelaide Hospital, Adelaide, Australia; Department of Surgical Specialties, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| |
Collapse
|
24
|
Turri G, Ostuzzi G, Vita G, Barresi V, Scarpa A, Milella M, Mazzarotto R, Ruzzenente A, Barbui C, Pedrazzani C. Treatment of Locally Advanced Rectal Cancer in the Era of Total Neoadjuvant Therapy: A Systematic Review and Network Meta-Analysis. JAMA Netw Open 2024; 7:e2414702. [PMID: 38833249 PMCID: PMC11151159 DOI: 10.1001/jamanetworkopen.2024.14702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 03/30/2024] [Indexed: 06/06/2024] Open
Abstract
Importance Treatment of locally advanced rectal cancer (LARC) involves neoadjuvant chemoradiotherapy plus total mesorectal excision and adjuvant chemotherapy. However, total neoadjuvant therapy (TNT) protocols (ie, preoperative chemotherapy in addition to radiotherapy) may allow better adherence and early treatment of distant micrometastases and may increase pathological complete response (pCR) rates. Objective To assess the efficacy and tolerability of TNT protocols for LARC. Data Sources MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science Core Collection electronic databases and ClinicalTrials.gov for unpublished studies were searched from inception to March 2, 2024. Study Selection Randomized clinical trials including adults with LARC who underwent rectal resection as a final treatment were included. Studies including nonoperative treatment (watch-and-wait strategy), treatments other than rectal resection, immunotherapy, or antiangiogenic agents were excluded. Among the initially identified studies, 2.9% met the selection criteria. Data Extraction and Synthesis Two authors independently screened the records and extracted data. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA)-compliant pairwise and network meta-analyses with a random-effects model were performed in a frequentist framework, and the certainty of evidence was assessed according to the confidence in network meta-analysis approach. Main Outcomes and Measures The primary outcome was pCR, defined as the absence of residual tumor at pathological assessment after surgery. Secondary outcomes included tolerability, toxic effects, perioperative outcomes, and long-term survival. Results Of 925 records identified, 27 randomized clinical trials, including 13 413 adults aged 18 years or older (median age, 60.0 years [range, 42.0-63.5 years]; 67.2% male) contributed to the primary network meta-analysis. With regard to pCR, long-course chemoradiotherapy (L-CRT) plus consolidation chemotherapy (relative risk [RR], 1.96; 95% CI, 1.25-3.06), short-course radiotherapy (S-RT) plus consolidation chemotherapy (RR, 1.76; 95% CI, 1.34-2.30), and induction chemotherapy plus L-CRT (RR, 1.57; 95% CI, 1.09-2.25) outperformed standard L-CRT with single-agent fluoropyrimidine-based chemotherapy. Considering 3-year disease-free survival, S-RT plus consolidation chemotherapy (RR, 1.08; 95% CI, 1.01-1.14) and induction chemotherapy plus L-CRT (RR, 1.12; 95% CI, 1.01-1.24) outperformed L-CRT, in spite of an increased 5-year locoregional recurrence rate of S-RT plus consolidation chemotherapy (RR, 1.65; 95% CI, 1.03-2.63). Conclusions and Relevance In this systematic review and network meta-analysis, 3 TNT protocols were identified to outperform the current standard of care in terms of pCR rates, with good tolerability and optimal postoperative outcomes, suggesting they should be recognized as first-line treatments.
Collapse
Affiliation(s)
- Giulia Turri
- Division of General and Hepatobiliary Surgery, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Giovanni Ostuzzi
- World Health Organization Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Giovanni Vita
- World Health Organization Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Valeria Barresi
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, Italy
| | - Aldo Scarpa
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, Italy
| | - Michele Milella
- Section of Oncology, Department of Engineering for Innovation Medicine, University of Verona Hospital Trust, Verona, Italy
| | - Renzo Mazzarotto
- Section of Radiotherapy, Department of Medicine, University of Verona Hospital Trust, Verona, Italy
| | - Andrea Ruzzenente
- Division of General and Hepatobiliary Surgery, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Corrado Barbui
- World Health Organization Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Corrado Pedrazzani
- Division of General and Hepatobiliary Surgery, Department of Engineering for Innovation Medicine, University of Verona, Verona, Italy
| |
Collapse
|
25
|
Kagawa Y, Smith JJ, Fokas E, Watanabe J, Cercek A, Greten FR, Bando H, Shi Q, Garcia-Aguilar J, Romesser PB, Horvat N, Sanoff H, Hall W, Kato T, Rödel C, Dasari A, Yoshino T. Future direction of total neoadjuvant therapy for locally advanced rectal cancer. Nat Rev Gastroenterol Hepatol 2024; 21:444-455. [PMID: 38485756 DOI: 10.1038/s41575-024-00900-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/26/2024] [Indexed: 05/31/2024]
Abstract
Despite therapeutic advancements, disease-free survival and overall survival of patients with locally advanced rectal cancer have not improved in most trials as a result of distant metastases. For treatment decision-making, both long-term oncologic outcomes and impact on quality-of-life indices should be considered (for example, bowel function). Total neoadjuvant therapy (TNT), comprised of chemotherapy and radiotherapy or chemoradiotherapy, is now a standard treatment approach in patients with features of high-risk disease to prevent local recurrence and distant metastases. In selected patients who have a clinical complete response, subsequent surgery might be avoided through non-operative management, but patients who do not respond to TNT have a poor prognosis. Refined molecular characterization might help to predict which patients would benefit from TNT and non-operative management. Specifically, integrated analysis of spatiotemporal multi-omics using artificial intelligence and machine learning is promising. Three prospective trials of TNT and non-operative management in Japan, the USA and Germany are collaborating to better understand drivers of response to TNT. Here, we address the future direction for TNT.
Collapse
Affiliation(s)
- Yoshinori Kagawa
- Department of Gastroenterological Surgery, Osaka General Medical Center, Osaka, Japan
| | - J Joshua Smith
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Emmanouil Fokas
- Department of Radiotherapy and Oncology, University of Frankfurt, Frankfurt, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- Frankfurt Cancer Institute, Frankfurt, Germany
- Department of Radiation Oncology, CyberKnife and Radiation Therapy, Centre for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
- German Cancer Consortium (DKTK), Frankfurt, Germany
| | - Jun Watanabe
- Gastroenterological Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Andrea Cercek
- Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Florian R Greten
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- Frankfurt Cancer Institute, Frankfurt, Germany
- German Cancer Consortium (DKTK), Frankfurt, Germany
- Institute for Tumour Biology and Experimental Therapy, Georg-Speyer-Haus, Frankfurt, Germany
| | - Hideaki Bando
- Department of Gastroenterology and Gastrointestinal Oncology, National Cancer Center Hospital East, Chiba, Japan
| | - Qian Shi
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Julio Garcia-Aguilar
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Paul B Romesser
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Natally Horvat
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hanna Sanoff
- Department of Medicine, Division of Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - William Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Takeshi Kato
- Department of Surgery, NHO Osaka National Hospital, Osaka, Japan
| | - Claus Rödel
- Department of Radiotherapy and Oncology, University of Frankfurt, Frankfurt, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- Frankfurt Cancer Institute, Frankfurt, Germany
- German Cancer Consortium (DKTK), Frankfurt, Germany
| | - Arvind Dasari
- Department of GI Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Takayuki Yoshino
- Department of Gastroenterology and Gastrointestinal Oncology, National Cancer Center Hospital East, Chiba, Japan.
| |
Collapse
|
26
|
Wang G, Li J, Huang Y, Guo Y. A dynamic nomogram for predicting pathologic complete response to neoadjuvant chemotherapy in locally advanced rectal cancer. Cancer Med 2024; 13:e7251. [PMID: 38819440 PMCID: PMC11141331 DOI: 10.1002/cam4.7251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 03/19/2024] [Accepted: 04/28/2024] [Indexed: 06/01/2024] Open
Abstract
AIM To explore the clinical factors associated with pathologic complete response (pCR) for locally advanced rectal cancer (LARC) patients treated with neoadjuvant chemoradiotherapy (nCRT) and develop a web-based dynamic nomogram. METHODS Retrospective analysis of patients with examination confirmed LARC from 2011 to 2022. Patients from the Union Hospital of Fujian Medical University were included as the training cohort (n = 1579) and Zhangzhou Hospital of Fujian Medical University as the external validation cohort (n = 246). RESULTS In the training cohort, after nCRT, 350 (22.2%) patients achieved pCR. More stomas were avoided in pCR patients (73.9% vs. 69.7%, p = 0.043). After a median follow-up time of 47.7 months (IQR 2-145) shown OS (5-year: 93.7% vs. 81.0%, HR = 0.310, 95%CI: 0.189-0.510, p < 0.001) and DFS (5-year: 91.2% vs. 75.0%, HR = 0.204, 95%CI: 0.216-0.484, p < 0.001) were significantly better among patients with pCR than non-pCR. Multivariable Logistic analysis shown pCR was significantly associated with Pre-CRT CEA (HR = 0.944, 95%CI: 0.921-0.968; p < 0.001), histopathology (HR = 4.608, 95%CI: 2.625-8.089; p < 0.001), Pre-CRT T stage (HR = 0.793, 95%CI: 0.634-0.993; p = 0.043), Pre-CRT N stage (HR = 0.727, 95%CI: 0.606-0.873; p = 0.001), Pre-CRT MRI EMVI (HR = 0.352, 95%CI: 0.262-0.473; p < 0.001), total neoadjuvant therapy (HR = 2.264, 95%CI: 1.280-4.004; p = 0.005). Meanwhile, the online version of the nomogram established in this study was publicized on an open-access website (URL: https://pcrpredict.shinyapps.io/LARC2/). The model predicted accuracy with a C-index of 0.73 (95% CI: 0.70-0.75), with an average C-index of 0.73 for the internal cross validation and 0.78 (95% CI: 0.72-0.83) for the external validation cohort, showing excellent model accuracy. Delong test results showed the model has an important gain value for clinical characteristics to predict pCR in rectal cancer. CONCLUSIONS Patients with pCR had a better prognosis, including OS and DFS, and were independently associated with Pre-CRT CEA, histopathology, Pre-CRT T/N stage, Pre-CRT MRI EMVI, and TNT. A web-based dynamic nomogram was successfully established for clinical use at any time.
Collapse
Affiliation(s)
- Guancong Wang
- Department of Colorectal and Anal SurgeryZhangzhou Affiliated Hospital of Fujian Medical UniversityZhangzhouChina
| | - Jiasen Li
- Department of Interventional RadiologyZhangZhou Affiliated Hospital of Fujian Medical UniversityZhangzhouChina
| | - Ying Huang
- Department of Colorectal SurgeryFujian Medical University Union HospitalFuzhouChina
| | - Yincong Guo
- Department of Colorectal and Anal SurgeryZhangzhou Affiliated Hospital of Fujian Medical UniversityZhangzhouChina
| |
Collapse
|
27
|
Affleck AG, Herzig D. Total Neoadjuvant Therapy for Rectal Cancer. Surg Clin North Am 2024; 104:609-617. [PMID: 38677824 DOI: 10.1016/j.suc.2023.11.010] [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] [Indexed: 04/29/2024]
Abstract
The treatment of locally advanced rectal cancer has traditionally included sequenced multimodal therapy including radiation, chemotherapy, and surgery. The relative contribution of each and the order of treatments have evolved over the years. By the early twenty-first century, there was widespread use of the German Rectal Cancer Trial approach: preoperative chemoradiation, followed by standardized surgery including total mesorectal excision, and finally adjuvant chemotherapy. Recent advances have defined the superiority of moving the chemotherapy into the preoperative setting. This approach, termed total neoadjuvant therapy promises better systemic control and overall survival and expaned options for omitting surgery in selected patients.
Collapse
Affiliation(s)
- Arthur G Affleck
- Department of Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA. https://twitter.com/AffleckIv
| | - Daniel Herzig
- Division of General and Gastrointestinal Surgery, Department of Surgery, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Mail Code L-223A, Portland, OR 97239, USA.
| |
Collapse
|
28
|
Ochiai K, Bhutiani N, Ikeda A, Uppal A, White MG, Peacock O, Messick CA, Bednarski BK, You YQN, Skibber JM, Chang GJ, Konishi T. Total Neoadjuvant Therapy for Rectal Cancer: Which Regimens to Use? Cancers (Basel) 2024; 16:2093. [PMID: 38893212 PMCID: PMC11171181 DOI: 10.3390/cancers16112093] [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: 04/11/2024] [Revised: 05/21/2024] [Accepted: 05/28/2024] [Indexed: 06/21/2024] Open
Abstract
Total neoadjuvant therapy (TNT) is a novel strategy for rectal cancer that administers both (chemo)radiotherapy and systemic chemotherapy before surgery. TNT is expected to improve treatment compliance, tumor regression, organ preservation, and oncologic outcomes. Multiple TNT regimens are currently available with various combinations of the treatments including induction or consolidation chemotherapy, triplet or doublet chemotherapy, and long-course chemoradiotherapy or short-course radiotherapy. Evidence on TNT is rapidly evolving with new data on clinical trials, and no definitive consensus has been established on which regimens to use for improving outcomes. Clinicians need to understand the advantages and limitations of the available regimens for multidisciplinary decision making. This article reviews currently available evidence on TNT for rectal cancer. A decision making flow chart is provided for tailor-made use of TNT regimens based on tumor location and local and systemic risk.
Collapse
Affiliation(s)
- Kentaro Ochiai
- Department of Colon and Rectal Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA; (K.O.); (N.B.); (A.I.); (A.U.); (O.P.); (C.A.M.); (B.K.B.); (Y.-Q.N.Y.); (J.M.S.); (G.J.C.)
- Department of Colon and Rectal Surgery, The University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Neal Bhutiani
- Department of Colon and Rectal Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA; (K.O.); (N.B.); (A.I.); (A.U.); (O.P.); (C.A.M.); (B.K.B.); (Y.-Q.N.Y.); (J.M.S.); (G.J.C.)
| | - Atsushi Ikeda
- Department of Colon and Rectal Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA; (K.O.); (N.B.); (A.I.); (A.U.); (O.P.); (C.A.M.); (B.K.B.); (Y.-Q.N.Y.); (J.M.S.); (G.J.C.)
| | - Abhineet Uppal
- Department of Colon and Rectal Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA; (K.O.); (N.B.); (A.I.); (A.U.); (O.P.); (C.A.M.); (B.K.B.); (Y.-Q.N.Y.); (J.M.S.); (G.J.C.)
| | - Michael G. White
- Department of Colon and Rectal Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA; (K.O.); (N.B.); (A.I.); (A.U.); (O.P.); (C.A.M.); (B.K.B.); (Y.-Q.N.Y.); (J.M.S.); (G.J.C.)
| | - Oliver Peacock
- Department of Colon and Rectal Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA; (K.O.); (N.B.); (A.I.); (A.U.); (O.P.); (C.A.M.); (B.K.B.); (Y.-Q.N.Y.); (J.M.S.); (G.J.C.)
| | - Craig A. Messick
- Department of Colon and Rectal Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA; (K.O.); (N.B.); (A.I.); (A.U.); (O.P.); (C.A.M.); (B.K.B.); (Y.-Q.N.Y.); (J.M.S.); (G.J.C.)
| | - Brian K. Bednarski
- Department of Colon and Rectal Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA; (K.O.); (N.B.); (A.I.); (A.U.); (O.P.); (C.A.M.); (B.K.B.); (Y.-Q.N.Y.); (J.M.S.); (G.J.C.)
| | - Yi-Qian Nancy You
- Department of Colon and Rectal Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA; (K.O.); (N.B.); (A.I.); (A.U.); (O.P.); (C.A.M.); (B.K.B.); (Y.-Q.N.Y.); (J.M.S.); (G.J.C.)
| | - John M. Skibber
- Department of Colon and Rectal Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA; (K.O.); (N.B.); (A.I.); (A.U.); (O.P.); (C.A.M.); (B.K.B.); (Y.-Q.N.Y.); (J.M.S.); (G.J.C.)
| | - George J. Chang
- Department of Colon and Rectal Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA; (K.O.); (N.B.); (A.I.); (A.U.); (O.P.); (C.A.M.); (B.K.B.); (Y.-Q.N.Y.); (J.M.S.); (G.J.C.)
| | - Tsuyoshi Konishi
- Department of Colon and Rectal Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA; (K.O.); (N.B.); (A.I.); (A.U.); (O.P.); (C.A.M.); (B.K.B.); (Y.-Q.N.Y.); (J.M.S.); (G.J.C.)
| |
Collapse
|
29
|
Anker CJ, Tchelebi LT, Selfridge JE, Jabbour SK, Akselrod D, Cataldo P, Abood G, Berlin J, Hallemeier CL, Jethwa KR, Kim E, Kennedy T, Lee P, Sharma N, Small W, Williams VM, Russo S. Executive Summary of the American Radium Society on Appropriate Use Criteria for Nonoperative Management of Rectal Adenocarcinoma: Systematic Review and Guidelines. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00673-4. [PMID: 38797496 DOI: 10.1016/j.ijrobp.2024.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 04/15/2024] [Accepted: 05/17/2024] [Indexed: 05/29/2024]
Abstract
For patients with rectal cancer, the standard approach of chemotherapy, radiation therapy, and surgery (trimodality therapy) is associated with significant long-term toxicity and/or colostomy for most patients. Patient options focused on quality of life (QOL) have dramatically improved, but there remains limited guidance regarding comparative effectiveness. This systematic review and associated guidelines evaluate how various treatment strategies compare to each other in terms of oncologic outcomes and QOL. Cochrane and Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) methodology were used to search for prospective and retrospective trials and meta-analyses of adequate quality within the Ovid Medline database between January 1, 2012, and June 15, 2023. These studies informed the expert panel, which rated the appropriateness of various treatments in 6 clinical scenarios through a well-established consensus methodology (modified Delphi). The search process yielded 197 articles that advised voting. Increasing data have shown that nonoperative management (NOM) and primary surgery result in QOL benefits noted over trimodality therapy without detriment to oncologic outcomes. For patients with rectal cancer for whom total mesorectal excision would result in permanent colostomy or inadequate bowel continence, NOM was strongly recommended as usually appropriate. Restaging with tumor response assessment approximately 8 to 12 weeks after completion of radiation therapy/chemoradiation therapy was deemed a necessary component of NOM. The panel recommended active surveillance in the setting of a near-complete or complete response. In the setting of NOM, 54 to 56 Gy in 27 to 31 fractions concurrent with chemotherapy and followed by consolidation chemotherapy was recommended. The panel strongly recommends primary surgery as usually appropriate for a T3N0 high rectal tumor for which low anterior resection and adequate bowel function is possible, with adjuvant chemotherapy considered if N+. Recent data support NOM and primary surgery as important options that should be offered to eligible patients. Considering the complexity of multidisciplinary management, patients should be discussed in a multidisciplinary setting, and therapy should be tailored to individual patient goals/values.
Collapse
Affiliation(s)
- Christopher J Anker
- Division of Radiation Oncology, University of Vermont Cancer Center, Burlington, Vermont
| | - Leila T Tchelebi
- Northwell, New Hyde Park, New York; Department of Radiation Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York.
| | - J Eva Selfridge
- Division of Solid Tumor Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio
| | - Salma K Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute, New Brunswick, New Jersey
| | - Dmitriy Akselrod
- Department of Radiology, University of Vermont Larner College of Medicine, Burlington, Vermont
| | - Peter Cataldo
- Department of Surgery, University of Vermont Larner College of Medicine, Burlington, Vermont
| | - Gerard Abood
- Department of Surgery, Loyola University Stritch School of Medicine, Maywood, Illinois
| | - Jordan Berlin
- Division of Hematology Oncology, Department of Medicine Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | | | - Krishan R Jethwa
- Department of Radiation Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Ed Kim
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Timothy Kennedy
- Department of Surgery, Rutgers Cancer Institute, New Brunswick, New Jersey
| | - Percy Lee
- Department of Radiation Oncology, City of Hope National Medical Center, Los Angeles, California
| | - Navesh Sharma
- Department of Radiation Oncology, WellSpan Cancer Center, York, Pennsylvania
| | - William Small
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago, Maywood, Illinois
| | - Vonetta M Williams
- Department of Radiation Oncology, Memorial Sloan Kettering, New York, New York
| | - Suzanne Russo
- Department of Radiation Oncology, MetroHealth, Case Western Reserve University School of Medicine, Cleveland, Ohio
| |
Collapse
|
30
|
Valentini V, Alfieri S, Coco C, D'Ugo D, Crucitti A, Pacelli F, Persiani R, Sofo L, Picciocchi A, Doglietto GB, Barbaro B, Vecchio FM, Ricci R, Damiani A, Savino MC, Boldrini L, Cellini F, Meldolesi E, Romano A, Chiloiro G, Gambacorta MA. Four steps in the evolution of rectal cancer managements through 40 years of clinical practice: Pioneering, standardization, challenges and personalization. Radiother Oncol 2024; 194:110190. [PMID: 38438019 DOI: 10.1016/j.radonc.2024.110190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 02/26/2024] [Indexed: 03/06/2024]
Affiliation(s)
- Vincenzo Valentini
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Sergio Alfieri
- Chirurgia Digestiva, Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Claudio Coco
- U.O.C. Chirurgia Generale 2, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Domenico D'Ugo
- Unità di chirurgia generale, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | | | - Fabio Pacelli
- Unità chirurgica del peritoneo e del retroperitoneo, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Roberto Persiani
- Unità di chirurgia generale, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Luigi Sofo
- Divisione di Chirurgia Addominale, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Aurelio Picciocchi
- Dipartimento di Chirurgia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giovanni Battista Doglietto
- Chirurgia Digestiva, Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Brunella Barbaro
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Fabio Maria Vecchio
- Dipartimento di Patologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Riccardo Ricci
- Dipartimento di Patologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Andrea Damiani
- Gemelli Generator Real World Data Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Maria Chiara Savino
- Gemelli Generator Real World Data Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Luca Boldrini
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Francesco Cellini
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Elisa Meldolesi
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Angela Romano
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giuditta Chiloiro
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.
| | - Maria Antonietta Gambacorta
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| |
Collapse
|
31
|
Alvarez J, Shi Q, Dasari A, Garcia-Aguilar J, Sanoff H, George TJ, Hong TS, Yothers G, Philip PA, Nelson GD, Al Baghdadi T, Alese O, Zambare W, Omer DM, Verheij FS, Buckley J, Williams H, George M, Garcia R, O'Reilly EM, Meyerhardt JA, Shergill A, Horvat N, Romesser PB, Hall WA, Smith JJ. ALLIANCE A022104/NRG-GI010: The Janus Rectal Cancer Trial: a randomized phase II/III trial testing the efficacy of triplet versus doublet chemotherapy regarding clinical complete response and disease-free survival in patients with locally advanced rectal cancer. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.04.25.24306396. [PMID: 38712176 PMCID: PMC11071544 DOI: 10.1101/2024.04.25.24306396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
Background Recent data have demonstrated that in locally advanced rectal cancer (LARC), a total neoadjuvant therapy (TNT) approach improves compliance with chemotherapy and increases rates of tumor response compared to neoadjuvant chemoradiation (CRT) alone. They further indicate that the optimal sequencing of TNT involves consolidation (rather than induction) chemotherapy to optimize complete response rates. Data, largely from retrospective studies, have also shown that patients with clinical complete response (cCR) after neoadjuvant therapy may be managed safely with the watch and wait approach (WW) instead of preemptive total mesorectal resection (TME). However, the optimal consolidation chemotherapy regimen to achieve cCR has not been established, and a randomized clinical trial has not robustly evaluated cCR as a primary endpoint. Collaborating with a multidisciplinary oncology team and patient groups, we designed this NCI-sponsored study of chemotherapy intensification to address these issues and to drive up cCR rates, to provide opportunity for organ preservation, improve quality of life for patients and improve survival outcomes. Methods In this NCI-sponsored multi-group randomized, seamless phase II/III trial (1:1), up to 760 patients with LARC, T4N0, any T with node positive disease (any T, N+) or T3N0 requiring abdominoperineal resection or coloanal anastomosis and distal margin within 12 cm of anal verge will be enrolled. Stratification factors include tumor stage (T4 vs T1-3), nodal stage (N+ vs N0) and distance from anal verge (0-4; 4-8; 8-12 cm). Patients will be randomized to receive neoadjuvant long course chemoradiation (LCRT) followed by consolidation doublet (mFOLFOX6 or CAPOX) or triplet chemotherapy (mFOLFIRINOX) for 3-4 months. LCRT in both arms involves 4500 cGy in 25 fractions over 5 weeks + 900 cGy boost in 5 fractions with a fluoropyrimidine (capecitabine preferred). Patients will undergo assessment 8-12 (+/- 4) weeks post-TNT completion. The primary endpoint for the phase II portion will compare cCR between treatment arms. A total number of 296 evaluable patients (148 per arm) will provide statistical power of 90.5% to detect an 17% increase in cCR rate, at a one-sided alpha=0.048. The primary endpoint for the phase III portion will compare disease-free survival (DFS) between treatment arms. A total of 285 DFS events will provide 85% power to detect an effect size of hazard ratio 0.70 at a one-sided alpha of 0.025, requiring enrollment of 760 patients (380 per arm). Secondary objectives include time-to event outcomes (overall survival, organ preservation time and time to distant metastasis) and adverse effects. Biospecimens including archival tumor tissue, plasma and buffy coat in EDTA tubes, and serial rectal MRIs will be collected for exploratory correlative research. This study, activated in late 2022, is open across the NCTN and has a current accrual of 312. Support: U10CA180821, U10CA180882, U24 CA196171; https://acknowledgments.alliancefound.org . Discussion Building off of data from modern day rectal cancer trials and patient input from national advocacy groups, we have designed the current trial studying chemotherapy intensification via a consolidation chemotherapy approach with the intent to enhance cCR and DFS rates, increase organ preservation rates, and improve quality of life for patients with rectal cancer. Trial Registration Clinicaltrials.gov ID: NCT05610163 ; Support includes U10CA180868 (NRG) and U10CA180888 (SWOG).
Collapse
|
32
|
Liu M, Cui N, Sun C, Gong X, Wang B, Yang D, Wang Y. A prospective study on using shear wave elastography to predict the ypT0 stage of rectal cancer after neoadjuvant therapy: a new support for the watch-and-wait approach? Front Mol Biosci 2024; 11:1402498. [PMID: 38737335 PMCID: PMC11082269 DOI: 10.3389/fmolb.2024.1402498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 04/15/2024] [Indexed: 05/14/2024] Open
Abstract
Introduction The diagnostic accuracy of traditional imaging examination in predicting ypT stage of rectal cancer after neoadjuvant therapy is significantly reduced, which would affect patients' subsequent treatment choices. This study aimed to investigate the use of endorectal shear wave elastography (SWE) for diagnosing ypT0 stage of rectal cancer after neoadjuvant chemoradiotherapy (nCRT). Methods Sixty patients with rectal cancer were prospectively recruited in this study. Data on endorectal ultrasound (ERUS) and SWE parameters were collected before nCRT and 6-8 weeks after nCRT. Postoperative pathological results were the gold standard for evaluating the diagnostic accuracy of SWE and ERUS in predicting the ypT0 stage of rectal cancer after nCRT. Receiver operating characteristic (ROC) curve analysis was used to determine the cut-off values of the SWE parameters that best corresponded to the ypT0 stage and analyze the sensitivity, specificity, and accuracy. Results The diagnostic accuracies of using ERUS to predict the ypT and ypT0 stages of rectal cancer after nCRT were 58.1% (18/31) and 64.3% (9/14), respectively. The ROC curve was constructed with the lesion's Emean, Emean corrected (EC), Emean difference (ED), Emean corrected differencede (ECD), Emean descendding rate (EDR) and Emean corrected descendding rate (ECDR) values after nCRT, the cut-off values of diagnosing the ypT0 stage were 64.40 kPa, 55.45 kPa, 72.55 kPa, 73.75 kPa, 50.15%, and 55.93%, respectively; the area under the curve (AUC) for diagnosing the ypT0 stage was 0.924, 0.933, 0.748, 0.729, 0.857 and 0.861, respectively. The EC value showed the best diagnostic performance. Conclusion SWE could improve the accuracy of conventional ERUS in diagnosing the ypT0 stage of rectal cancer after nCRT. It is expected to become a new method to help predict pathological complete responses in clinical practice and provide new evidence for the watch-and-wait approach.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Yong Wang
- Department of Ultrasound, National Cancer Center, National Clinical Research Center for Cancer, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| |
Collapse
|
33
|
Bratu LD, Schenker M, Stovicek PO, Schenker RA, Mehedințeanu AM, Berisha TC, Donoiu A, Mogoantă SȘ. Retrospective Evaluation of the Efficacy of Total Neoadjuvant Therapy and Chemoradiotherapy Neoadjuvant Treatment in Relation to Surgery in Patients with Rectal Cancer. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:656. [PMID: 38674302 PMCID: PMC11052151 DOI: 10.3390/medicina60040656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 04/14/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024]
Abstract
Background and Objective: In the therapeutic strategy of rectal cancer, radiotherapy has consolidated its important position and frequent use in current practice due to its indications as neoadjuvant, adjuvant, definitive, or palliative treatment. In recent years, total neoadjuvant therapy (TNT) has been established as the preferred regimen compared to concurrent neoadjuvant chemoradiotherapy (CRT). In relation to better outcomes, the percentage of patients who achieved pathological complete response (pCR) after neoadjuvant treatment is higher in the case of TNT. This study aimed to analyze the response to TNT compared to neoadjuvant CRT regarding pCR rate and the change in staging after surgical intervention. Materials and Methods: We performed a retrospective study on 323 patients with rectal cancer and finally analyzed the data of 201 patients with neoadjuvant treatment, selected based on the inclusion and exclusion criteria. Patients received CRT neoadjuvant therapy or TNT neoadjuvant therapy with FOLFOX or CAPEOX. Results: Out of 157 patients who underwent TNT treatment, 19.74% had pathological complete response, whereas in the group with CRT (n = 44), those with pCR were 13.64%. After neoadjuvant treatment, the most frequent TNM classifications were ypT2 (40.30%) and ypN0 (79.10%). The statistical analysis of the postoperative disease stage, after neoadjuvant therapy, showed that the most frequent changes were downstaging (71.14%) and complete response (18.41%). Only four patients (1.99%) had an upstaging change. The majority of patients (88.56%) initially presented clinical evidence of nodal involvement whereas only 20.9% of the patients still presented regional disease at the time of surgical intervention. Conclusions: By using TNT, a higher rate of stage reduction is obtained compared to the neoadjuvant CRT treatment. The post-neoadjuvant-treatment imagistic evaluation fails to accurately evaluate the response. A better response to TNT was observed in young patients.
Collapse
Affiliation(s)
- Lucian Dragoș Bratu
- Doctoral School, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania (T.C.B.); (A.D.)
- Sf. Nectarie Oncology Center, 200347 Craiova, Romania; (R.A.S.); (A.M.M.)
| | - Michael Schenker
- Sf. Nectarie Oncology Center, 200347 Craiova, Romania; (R.A.S.); (A.M.M.)
- Department of Oncology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Puiu Olivian Stovicek
- Sf. Nectarie Oncology Center, 200347 Craiova, Romania; (R.A.S.); (A.M.M.)
- Department of Pharmacology, Faculty of Nursing, Târgu Jiu Subsidiary, Titu Maiorescu University, 040441 Bucharest, Romania
| | | | | | - Tradian Ciprian Berisha
- Doctoral School, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania (T.C.B.); (A.D.)
- Sf. Nectarie Oncology Center, 200347 Craiova, Romania; (R.A.S.); (A.M.M.)
| | - Andreas Donoiu
- Doctoral School, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania (T.C.B.); (A.D.)
- 3rd General Surgery Clinic, Emergency County Hospital, 200642 Craiova, Romania;
| | - Stelian Ștefăniță Mogoantă
- 3rd General Surgery Clinic, Emergency County Hospital, 200642 Craiova, Romania;
- Department of Surgery, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| |
Collapse
|
34
|
Willett CG, Acklin-Wehnert S. Neoadjuvant Short- Vs. Long-Course Radiation for Locally Advanced Rectal Cancer: How to Choose. Curr Treat Options Oncol 2024; 25:427-433. [PMID: 38386240 DOI: 10.1007/s11864-024-01185-5] [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] [Accepted: 01/17/2024] [Indexed: 02/23/2024]
Abstract
OPINION STATEMENT Over the past decades, the treatment of locally advanced rectal cancer has evolved dramatically due to improvements in diagnostic imaging, surgical technique, and the addition of radiotherapy and/or chemotherapy. Fractionation of neoadjuvant radiotherapy with or without concurrent chemotherapy remains the subject of discussion and the question multiple recent trials have aimed to answer. In light of recent data and concern for locoregional recurrence, our institution favors long-course chemoradiation in most cases, especially in low-lying primaries, threatened circumferential resection margin, consideration of non-operative management, or if the surgeon has concerns for resectability. Exceptions would include cases of oligometastatic disease planned for metastasectomy in which curative-intent treatment was pursued or if additional factors required a reduction in treatment time.
Collapse
Affiliation(s)
- Christopher G Willett
- Department of Radiation Oncology, Duke University Medical Center, Box 3085 Med Ctr, Durham, NC, 27710, USA
| | - Scarlett Acklin-Wehnert
- Department of Radiation Oncology, Duke University Medical Center, Box 3085 Med Ctr, Durham, NC, 27710, USA.
| |
Collapse
|
35
|
Jabbour SK, Kumar R, Anderson B, Chino JP, Jethwa KR, McDowell L, Lo AC, Owen D, Pollom EL, Tree AC, Tsang DS, Yom SS. Combinatorial Approaches for Chemotherapies and Targeted Therapies With Radiation: United Efforts to Innovate in Patient Care. Int J Radiat Oncol Biol Phys 2024; 118:1240-1261. [PMID: 38216094 DOI: 10.1016/j.ijrobp.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 01/05/2024] [Indexed: 01/14/2024]
Abstract
Combinatorial therapies consisting of radiation therapy (RT) with systemic therapies, particularly chemotherapy and targeted therapies, have moved the needle to augment disease control across nearly all disease sites for locally advanced disease. Evaluating these important combinations to incorporate more potent therapies with RT will aid our understanding of toxicity and efficacy for patients. This article discusses multiple disease sites and includes a compilation of contributions from expert Red Journal editors from each disease site. Leveraging improved systemic control with novel agents, we must continue efforts to study novel treatment combinations with RT.
Collapse
Affiliation(s)
- Salma K Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Jersey.
| | - Ritesh Kumar
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Jersey
| | - Bethany Anderson
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Junzo P Chino
- Department of Radiation Oncology, Duke University School of Medicine, Durham, North Carolina
| | - Krishan R Jethwa
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Lachlan McDowell
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Australia
| | - Andrea C Lo
- Department of Radiation Oncology, BC Cancer Vancouver Centre, Vancouver, British Columbia, Canada
| | - Dawn Owen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Erqi L Pollom
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Alison C Tree
- Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Derek S Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Sue S Yom
- Department of Radiation Oncology, University of California San Francisco, California
| |
Collapse
|
36
|
McFeetors C, O'Connell LV, Choy M, Dundon N, Regan M, Joyce M, Meshkat B, Hogan A, Nugent E. Influence of neoadjuvant treatment strategy on perioperative outcomes in locally advanced rectal cancer. Colorectal Dis 2024; 26:684-691. [PMID: 38424706 DOI: 10.1111/codi.16929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 11/20/2023] [Accepted: 12/28/2023] [Indexed: 03/02/2024]
Abstract
AIM Neoadjuvant chemoradiotherapy (nCRT) in locally advanced rectal cancer facilitates tumour downstaging and complete pathological response (pCR). The goal of neoadjuvant systemic chemotherapy (total neoadjuvant chemotherapy, TNT) is to further improve local and systemic control. While some patients forgo surgery, total mesorectal excision (TME) remains the standard of care. While TNT appears to be noninferior to nCRT with respect to short-term oncological outcomes few data exist on perioperative outcomes. Perioperative morbidity including anastomotic leaks is associated with a negative effect on oncological outcomes, probably due to a delay in proceeding to adjuvant therapy. Thus, we aimed to compare conversion rates, rates of sphincter-preserving surgery and anastomosis formation rates in patients undergoing rectal resection after either TNT or standard nCRT. METHODS An institutional colorectal oncology database was searched from January 2018 to July 2023. Inclusion criteria comprised patients with histologically confirmed rectal cancer who had undergone neoadjuvant therapy and TME. Exclusion criteria comprised patients with a noncolorectal primary, those operated on emergently or who had local excision only. Outcomes evaluated included rates of conversion to open, sphincter-preserving surgery, anastomosis formation and anastomotic leak. RESULTS A total of 119 patients were eligible for inclusion (60 with standard nCRT, 59 with TNT). There were no differences in rates of sphincter preservation or primary anastomosis formation between the groups. However, a significant increase in conversion to open (p = 0.03) and anastomotic leak (p = 0.03) was observed in the TNT cohort. CONCLUSION In this series TNT appears to be associated with higher rates of conversion to open surgery and higher anastomotic leak rates. While larger studies will be required to confirm these findings, these factors should be considered alongside oncological benefits when selecting treatment strategies.
Collapse
Affiliation(s)
- Carson McFeetors
- Department of Colorectal Surgery, University Hospital Galway, Co. Galway, Ireland
| | - Lauren V O'Connell
- Department of Colorectal Surgery, University Hospital Galway, Co. Galway, Ireland
| | - Megan Choy
- Department of Colorectal Surgery, University Hospital Galway, Co. Galway, Ireland
| | - Niamh Dundon
- Department of Colorectal Surgery, University Hospital Galway, Co. Galway, Ireland
| | - Mark Regan
- Department of Colorectal Surgery, University Hospital Galway, Co. Galway, Ireland
| | - Myles Joyce
- Department of Colorectal Surgery, University Hospital Galway, Co. Galway, Ireland
| | - Babak Meshkat
- Department of Colorectal Surgery, University Hospital Galway, Co. Galway, Ireland
| | - Aisling Hogan
- Department of Colorectal Surgery, University Hospital Galway, Co. Galway, Ireland
| | - Emmeline Nugent
- Department of Colorectal Surgery, University Hospital Galway, Co. Galway, Ireland
| |
Collapse
|
37
|
Mirinezhad SK, Akbarzadeh-Khiavi M, Seyednejad F, Somi MH. Rectal cancer survival and prognostic factors in Iranian population: A retrospective cohort study. Cancer Treat Res Commun 2024; 39:100810. [PMID: 38599152 DOI: 10.1016/j.ctarc.2024.100810] [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: 07/18/2023] [Revised: 03/12/2024] [Accepted: 03/26/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Rectal cancer (RC) poses a significant global health challenge, causing substantial morbidity and mortality. This study aims to investigate the survival rates of RC patients and identify the factors that influence their survival. The study considers demographic characteristics, tumor features, and treatment received as the factors under consideration. METHODS A retrospective analysis was conducted on the medical records of 593 RC patients. Data were collected through a comprehensive review of medical records and conducting telephone interviews. Survival rates were estimated using the life table method, and subgroup comparisons were performed using the log-rank test. Cox regression analysis was utilized to assess the independent associations between RC survival time and various covariates. RESULTS The study cohort comprised 593 RC patients, with a predominantly male representation. The mean age at diagnosis was 58.18 years, and the majority of patients (78.6 %) underwent surgical interventions. The median age at symptom onset and diagnosis were 58 and 59 years, respectively. Survival rates at 1st, 3rd, 5th, and 10th years were estimated to be 85 %, 59 %, 47 %, and 36 %, respectively. Statistical analysis revealed several significant prognostic factors, including age, education, symptoms, and cancer stage. In the multivariate Cox proportional-hazards analysis, advanced regional stage (HR = 1.54, 95 % CI, 1.13-2.08), presence of metastasis (HR = 3.73, 95 % CI, 2.49-5.58), and age over 70 (HR = 1.65) were associated with a higher risk of mortality. CONCLUSION Given the alarming prognosis of RC observed in the study area and the significant delay between symptom onset and diagnosis, it is crucial to address this issue and potentially improve the survival rates of RC patients.
Collapse
Affiliation(s)
- Seyed Kazem Mirinezhad
- Liver and Gastrointestinal Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - Mostafa Akbarzadeh-Khiavi
- Liver and Gastrointestinal Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Farshad Seyednejad
- Department of Radiology, School of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mohammad Hossein Somi
- Liver and Gastrointestinal Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| |
Collapse
|
38
|
Zhou J, Huang J, Zhou Z, Deng X, Wu Q, Wang Z. Total neoadjuvant therapy for locally advanced rectal cancer: a three-group propensity score matched study. Int J Colorectal Dis 2024; 39:38. [PMID: 38492080 PMCID: PMC10944449 DOI: 10.1007/s00384-024-04610-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/04/2024] [Indexed: 03/18/2024]
Abstract
PURPOSE Total neoadjuvant therapy (TNT) has emerged as a therapeutic approach for locally advanced rectal cancer (LARC). However, the optimal chemotherapy cycles within TNT remain uncertain. This study aimed to evaluate and compare the prognostic efficacy of varying cycles of chemotherapy during TNT for LARC. METHODS Patients diagnosed with LARC (T3-4N0M0/T1-4N1-2M0), who underwent TNT or chemoradiotherapy followed by total mesorectal excision (TME) between 2015 and 2020, were retrospective included. Patients were categorized into three groups based on their neoadjuvant strategy: CRT (long-course chemoradiotherapy), STNT (long-course CRT with one to three cycles of chemotherapy), and LTNT (long-course CRT with four or more cycles of chemotherapy). Propensity score matching (PSM) based on gender, age, body mass index, tumor distance from the anal verge, clinical T stage, clinical N stage, and mesorectal fascia status was employed to reduce confounding bias. Primary endpoints were disease-free survival (DFS) and metastasis-free survival (MFS). RESULTS The study comprised 372 patients, with 73 patients in each group after PSM. Compared with CRT, both STNT and LTNT demonstrated improved DFS (5-year rate: 59.7% vs. 77.8% vs. 76.5%, p = 0.027) and MFS (5-year rate: 65.1% vs. 81.3% vs. 81.4%, p = 0.030). There was no difference in DFS or MFS between STNT and LTNT. These favorable outcomes were consistent among subgroups defined by tumor distance from the anal verge ≥ 5 cm, clinical T3 stage, clinical N positive status, or involved mesorectal fascia. CONCLUSION Compared to CRT, both STNT and LTNT demonstrated improved DFS and MFS outcomes. Notably, survival outcomes were similar between STNT and LTNT, suggesting that chemotherapy cycles in TNT may not significantly impact survival.
Collapse
Affiliation(s)
- Jiahao Zhou
- Department of General Surgery, Colorectal Cancer Center, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, China
- West China School of Medicine, Sichuan University, Chengdu, 610041, China
| | - Jun Huang
- Department of General Surgery, Colorectal Cancer Center, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, China
- West China School of Medicine, Sichuan University, Chengdu, 610041, China
| | - Zikai Zhou
- Department of General Surgery, Colorectal Cancer Center, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, China
- West China School of Medicine, Sichuan University, Chengdu, 610041, China
| | - Xiangbing Deng
- Department of General Surgery, Colorectal Cancer Center, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, China
| | - Qingbin Wu
- Department of General Surgery, Colorectal Cancer Center, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, China.
| | - Ziqiang Wang
- Department of General Surgery, Colorectal Cancer Center, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, China.
| |
Collapse
|
39
|
Daamen L, Westerhoff J, Couwenberg A, Braam P, Rütten H, den Hartogh M, Christodouleas J, Hall W, Verkooijen H, Intven M. Quality of life and clinical outcomes in rectal cancer patients treated on a 1.5T MR-Linac within the MOMENTUM study. Clin Transl Radiat Oncol 2024; 45:100721. [PMID: 38274389 PMCID: PMC10808928 DOI: 10.1016/j.ctro.2023.100721] [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: 08/21/2023] [Revised: 11/10/2023] [Accepted: 12/30/2023] [Indexed: 01/27/2024] Open
Abstract
Background and purpose This study assessed quality of life (QoL) and clinical outcomes in rectal cancer patients treated with magnetic resonance (MR) guided short-course radiation therapy (SCRT) on a 1.5 Tesla (T) MR-Linac during the first 12 months after treatment. Materials and methods Rectal cancer patients treated with 25 Gy SCRT in five fractions with curative intent in the Netherlands (2019-2022) were identified in MOMENTUM (NCT04075305). Toxicity (CTCAE v5) and QoL (EORTC QLQ-C30 and -CR29) was primarily analyzed in patients without metastatic disease (M0) and no other therapies after SCRT. Patients who underwent tumor resection were censored from surgery. A generalized linear mixed-model was used to investigate clinically meaningful (≥10) and significant (P < 0.05) QoL changes. Clinical and pathological complete response (cCR and pCR) rates were calculated in patients in whom response was documented. Results A total of 172 patients were included, of whom 112 patients were primarily analyzed. Acute and late radiation-induced high-grade toxicity were reported in one patient, respectively. CCR was observed in 8/64 patients (13 %), 14/37 patients (38 %) and 13/16 patients (91 %) at three, six and twelve months; pCR was observed in 3/69 (4 %) patients. After 12 months, diarrhea (mean difference [MD] -17.4 [95 % confidence interval [CI] -31.2 to -3.7]), blood and mucus in stool (MD -31.1 [95 % CI -46.4 to -15.8]), and anxiety (MD -22.4 [95 % CI -34.0 to -10.9]) were improved. Conclusion High-field MR-guided SCRT for the treatment of patients with rectal cancer is associated with improved disease-related symptom management and functioning one year after treatment.
Collapse
Affiliation(s)
- L.A. Daamen
- University Medical Center Utrecht, Division of Imaging and Oncology, Utrecht, The Netherlands
| | - J.M. Westerhoff
- University Medical Center Utrecht, Division of Imaging and Oncology, Utrecht, The Netherlands
| | - A.M. Couwenberg
- The Netherlands Cancer Institute, Department of Radiation Oncology, Amsterdam, The Netherlands
| | - P.M. Braam
- Radboud University Medical Center, Department of Radiation Oncology, Nijmegen, The Netherlands
| | - H. Rütten
- Radboud University Medical Center, Department of Radiation Oncology, Nijmegen, The Netherlands
| | | | - J.P. Christodouleas
- Elekta AB, Stockholm, Sweden
- Hospital of the University of Pennsylvania, Department of Radiation Oncology, Philadelphia, PA, United States
| | - W.A. Hall
- Medical College of Wisconsin, Department of Radiation Oncology, Milwaukee, WI, United States
| | - H.M. Verkooijen
- University Medical Center Utrecht, Division of Imaging and Oncology, Utrecht, The Netherlands
| | - M.P.W. Intven
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands
| |
Collapse
|
40
|
Wu TC, Smith CP, Li JS, Burton J, Jackson NJ, Tao R, Ludmir EB, Raldow AC. A systematic review and meta-analysis of pathologic complete response rates for patients with cholangiocarcinoma treated on liver transplant protocols. J Surg Oncol 2024; 129:574-583. [PMID: 37986552 DOI: 10.1002/jso.27511] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/26/2023] [Accepted: 11/04/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND AND OBJECTIVES: Many heterogenous orthotopic liver transplant (OLT) protocols exist for patients with unresectable cholangiocarcinoma. Little is known about the incidence, predictors for, and the significance of achieving a pathologic complete response (pCR). METHODS We performed a systematic review through September 2022 of the PubMed, Embase, and Web of Science databases. A random-effect meta-analysis was conducted to pool data across studies with reported pCR rates. Heterogeneity between treatment protocols was assessed via subgroup analysis. The pCR and 1-, 3-, and 5-year recurrence-free survival (RFS) and overall survival (OS) rates were extracted as outcomes of interest. RESULTS A total of 15 studies reported pCR rates and were grouped by use of the Mayo protocol (4/15), stereotactic body radiation therapy (2/15), and an Other category (9/15). The pooled pCR rate among all studies was 32%. Both radiation technique and duration of CHT showed no significant association with pCR (p = 0.05 and 0.13, respectively). Pooled 1-year RFS and OS after any neoadjuvant therapy and OLT was 80% (95% confidence interval [CI], 0.61-0.91), and 91% (95% CI, 0.87-0.94), respectively. There was no 1-year OS difference detected among the three groups. pCR was not associated with OS in the meta-regression. Pooled 3- and 5-year OS among all studies was 72% and 61%, respectively. CONCLUSIONS The pooled incidence of pCR was 32%. Differences in radiation technique did not appear to influence pCR rates and upon meta-regression, pCR was not a surrogate marker for survival.
Collapse
Affiliation(s)
- Trudy C Wu
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California, USA
| | - Clayton P Smith
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California, USA
| | - Joshua S Li
- Department of Medicine Statistics Core, University of California Los Angeles, Los Angeles, California, USA
| | - Jason Burton
- Louise M. Darling Biomedical Library, University of California Los Angeles, Los Angeles, California, USA
| | - Nicholas J Jackson
- Department of Medicine Statistics Core, University of California Los Angeles, Los Angeles, California, USA
| | - Randa Tao
- Department of Radiation Oncology, University of Utah, Salt Lake City, Utah, USA
| | - Ethan B Ludmir
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ann C Raldow
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California, USA
| |
Collapse
|
41
|
Glimelius B. Recent advances in rectal cancer treatment - are we on the right track? Ups J Med Sci 2024; 129:10537. [PMID: 38449909 PMCID: PMC10916366 DOI: 10.48101/ujms.v129.10537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 01/25/2024] [Accepted: 01/25/2024] [Indexed: 03/08/2024] Open
Abstract
Background Staging and treatment of rectal cancer have evolved over several decades with considerably fewer locoregional recurrences but no marked improved survival since systemic recurrence risks remain virtually unchanged. This development will briefly be summarised followed by a thorough discussion of two recent developments. Methods A systematic approach towards the literature is aimed at focusing on organ preservation and the delivery of all non-surgical treatments prior to surgery or total neoadjuvant treatment (TNT). Results Organ preservation, that is to defer surgery if the tumour happens to disappear completely after any pre-treatment given to locally advanced tumours to decrease recurrence risks has increased in popularity and is, if not universally, widely accepted. To give neo-adjuvant treatment to intentionally obtain a clinically complete remission to avoid surgery is practised in some environments but is mostly still experimental. TNT, that is to provide both radiotherapy and chemotherapy aimed at killing microscopic disease in the pelvis or elsewhere has been subject to several trials. Collectively, they show that the chance of achieving a complete response, pathologically or clinically, has approximately doubled, increasing the chance for organ preservation, and the risk of distant metastasis has decreased at least in some trials. The best schedule remains to be established. Conclusions To obtain substantial progress and also improve survival, the systemic treatments need to be improved even if preoperative delivery is more effective and better tolerated than postoperative. The locoregional treatment may be further optimised through better risk prediction.
Collapse
Affiliation(s)
- Bengt Glimelius
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| |
Collapse
|
42
|
Verheij FS, Omer DM, Williams H, Lin ST, Qin LX, Buckley JT, Thompson HM, Yuval JB, Kim JK, Dunne RF, Marcet J, Cataldo P, Polite B, Herzig DO, Liska D, Oommen S, Friel CM, Ternent C, Coveler AL, Hunt S, Gregory A, Varma MG, Bello BL, Carmichael JC, Krauss J, Gleisner A, Guillem JG, Temple L, Goodman KA, Segal NH, Cercek A, Yaeger R, Nash GM, Widmar M, Wei IH, Pappou EP, Weiser MR, Paty PB, Smith JJ, Wu AJ, Gollub MJ, Saltz LB, Garcia-Aguilar J. Long-Term Results of Organ Preservation in Patients With Rectal Adenocarcinoma Treated With Total Neoadjuvant Therapy: The Randomized Phase II OPRA Trial. J Clin Oncol 2024; 42:500-506. [PMID: 37883738 DOI: 10.1200/jco.23.01208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 07/29/2023] [Accepted: 09/07/2023] [Indexed: 10/28/2023] Open
Abstract
Clinical trials frequently include multiple end points that mature at different times. The initial report, typically based on the primary end point, may be published when key planned co-primary or secondary analyses are not yet available. Clinical Trial Updates provide an opportunity to disseminate additional results from studies, published in JCO or elsewhere, for which the primary end point has already been reported.To assess long-term risk of local tumor regrowth, we report updated organ preservation rate and oncologic outcomes of the OPRA trial (ClinicalTrials.gov identifier: NCT02008656). Patients with stage II/III rectal cancer were randomly assigned to receive induction chemotherapy followed by chemoradiation (INCT-CRT) or chemoradiation followed by consolidation chemotherapy (CRT-CNCT). Patients who achieved a complete or near-complete response after finishing treatment were offered watch-and-wait (WW). Total mesorectal excision (TME) was recommended for those who achieved an incomplete response. The primary end point was disease-free survival (DFS). The secondary end point was TME-free survival. In total, 324 patients were randomly assigned (INCT-CRT, n = 158; CRT-CNCT, n = 166). Median follow-up was 5.1 years. The 5-year DFS rates were 71% (95% CI, 64 to 79) and 69% (95% CI, 62 to 77) for INCT-CRT and CRT-CNCT, respectively (P = .68). TME-free survival was 39% (95% CI, 32 to 48) in the INCT-CRT group and 54% (95% CI, 46 to 62) in the CRT-CNCT group (P = .012). Of 81 patients with regrowth, 94% occurred within 2 years and 99% occurred within 3 years. DFS was similar for patients who underwent TME after restaging (64% [95% CI, 53 to 78]) and patients in WW who underwent TME after regrowth (64% [95% CI, 53 to 78]; P = .94). Updated analysis continues to show long-term organ preservation in half of the patients with rectal cancer treated with total neoadjuvant therapy. In patients who enter WW, most cases of tumor regrowth occur in the first 2 years.
Collapse
Affiliation(s)
- Floris S Verheij
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Dana M Omer
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Hannah Williams
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Sabrina T Lin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Li-Xuan Qin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - James T Buckley
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Hannah M Thompson
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jonathan B Yuval
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jin K Kim
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Richard F Dunne
- Department of Medicine, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY
| | - Jorge Marcet
- Division of Colon and Rectal Surgery, Department of Surgery, University of South Florida, Tampa, FL
| | - Peter Cataldo
- Division of General Surgery, Department of Surgery, University of Vermont, Burlington, VT
| | - Blase Polite
- Department of Medicine, Comprehensive Cancer Center, University of Chicago, Chicago, IL
| | - Daniel O Herzig
- Division of Gastrointestinal and General Surgery, Oregon Health and Science University, Portland, OR
| | - David Liska
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH
| | - Samuel Oommen
- Division of Gastrointestinal Oncology, John Muir Cancer Institute, John Muir Health, Walnut Creek, CA
| | - Charles M Friel
- Division of General Surgery, Department of Surgery, University of Virginia, Charlottesville, VA
| | - Charles Ternent
- Methodist Hospital Physicians Clinic Colon and Rectal Surgery and The Creighton University Clinical Research Center, Omaha, NE
| | - Andrew L Coveler
- Department of Medicine, Fred Hutch Cancer Center, University of Washington, Seattle, WA
| | - Steven Hunt
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Anita Gregory
- Department of Surgery, St Joseph Hospital Orange County, Orange, CA
| | - Madhulika G Varma
- Section of Colon and Rectal Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Brian L Bello
- Division of Colorectal Surgery, Department of Surgery, Medstar Washington Hospital Center, Washington, DC
| | - Joseph C Carmichael
- Division of Colon and Rectal Surgery, Department of Surgery, University of California, Irvine, Irvine, CA
| | - John Krauss
- Department of Medicine, Rogel Cancer Center at the University of Michigan, Ann Arbor, MI
| | - Ana Gleisner
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Denver, CO
| | - José G Guillem
- Division of Gastrointestinal Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Larissa Temple
- Division of Colorectal Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Karyn A Goodman
- Department of Radiation Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Neil H Segal
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andrea Cercek
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Rona Yaeger
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Garrett M Nash
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Maria Widmar
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Iris H Wei
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Emmanouil P Pappou
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Martin R Weiser
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Philip B Paty
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - J Joshua Smith
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Marc J Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Leonard B Saltz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Julio Garcia-Aguilar
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY
| |
Collapse
|
43
|
Ng YY, Seow-En I, Chok AY, Lee TS, Palanisamy P, Tan EK. Surgical and short-term oncological safety of total neoadjuvant therapy in high-risk locally advanced rectal cancer. ANZ J Surg 2024; 94:175-180. [PMID: 37849414 DOI: 10.1111/ans.18739] [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: 06/20/2023] [Revised: 09/13/2023] [Accepted: 10/04/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND Management for locally advanced rectal cancer (LARC) conventionally comprises long-course chemoradiotherapy (LCCRT), total mesorectal excision (TME), and adjuvant chemotherapy. However, the RAPIDO study published in 2021 showed that total neoadjuvant therapy (TNT) led to better oncological outcomes without increased toxicity. We review the surgical and short-term oncological outcomes of patients with high-risk LARC who underwent TNT or LCCRT before TME. METHODS Patients with high-risk LARC who underwent TNT or LCCRT before TME between 2021 and 2022 were reviewed. RESULTS Thirty-five patients (66%) had TNT as per RAPIDO whilst 18 underwent LCCRT. Median follow-up was 16 months (range 5-25). Of the patients who had TNT, median age was 65 years old (range 44-79), 34 (97%) had clinical Stage 3 LARC and median height FAV was 5 cm (range 0.5-14). Nine (26%) required a dose delay/reduction due to treatment toxicity. Seven (50%) showed resolution of previously enlarged lateral nodes. Three (9%) had pathological complete response. Postoperative major morbidity was 23%, of which 4 patients required a reoperation. Six (17%) patients had disease-related treatment failure, with two having disease progression during TNT, two developed local recurrence, and two developed distal metastasis following surgery. Median duration to surgery following completion of chemotherapy was significantly shorter with TNT (36 days versus 74 days) (P < 0.001). There were no other significant differences in outcomes. CONCLUSION TNT is clinically safe in high-risk LARC patients with no significant difference to surgical and short-term oncological outcomes compared to LCCRT, although a higher incidence of early surgical morbidity was observed.
Collapse
Affiliation(s)
- Yvonne Y Ng
- Department of Colorectal Surgery, Singapore General Hospital, Singapore, Singapore
| | - Isaac Seow-En
- Department of Colorectal Surgery, Singapore General Hospital, Singapore, Singapore
| | - Aik Yong Chok
- Department of Colorectal Surgery, Singapore General Hospital, Singapore, Singapore
| | - Terence S Lee
- Department of Colorectal Surgery, Singapore General Hospital, Singapore, Singapore
| | - Prasad Palanisamy
- Department of Colorectal Surgery, Singapore General Hospital, Singapore, Singapore
| | - Emile K Tan
- Department of Colorectal Surgery, Singapore General Hospital, Singapore, Singapore
| |
Collapse
|
44
|
Bauer PS, Gamboa AC, Otegbeye EE, Chapman WC, Rivard S, Regenbogen S, Mohammed M, Holder-Murray J, Wiseman JT, Ejaz A, Edwards-Hollingsworth K, Hawkins AT, Hunt SR, Balch G, Silviera ML. Short-course radiation with consolidation chemotherapy does not increase operative morbidity compared to long-course chemoradiation: A retrospective study of the US rectal cancer consortium. J Surg Oncol 2024; 129:254-263. [PMID: 37792637 PMCID: PMC10872853 DOI: 10.1002/jso.27468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 09/19/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Neoadjuvant short-course radiation and consolidation chemotherapy (SC TNT) remains less widely used for rectal cancer in the United States than long-course chemoradiation (LCRT). SC TNT may improve compliance and downstaging; however, a longer radiation-to-surgery interval may worsen pelvic fibrosis and morbidity with total mesorectal excision (TME). A single, US-center retrospective analysis has shown comparable risk of morbidity after neoadjuvant short-course radiation with consolidation chemotherapy (SC TNT) and long-course chemoradiation (LCRT). Validation by a multi-institutional study is needed. METHODS The US Rectal Cancer Consortium database (2010-2018) was retrospectively reviewed for patients with nonmetastatic, rectal adenocarcinoma treated with neoadjuvant LCRT or SC TNT before TME. The primary endpoint was severe postoperative morbidity. Cohorts were compared by univariate analysis. Multivariable logistic regression modeled the odds of severe complication. RESULTS Of 788 included patients, 151 (19%) received SC TNT and 637 (81%) LCRT. The SC TNT group had fewer distal tumors (33.8% vs. 50.2%, p < 0.0001) and more clinical node-positive disease (74.2% vs. 47.6%, p < 0.0001). The intraoperative complication rate was similar (SC TNT 5.3% vs. 4.4%, p = 0.65). There was no difference in overall postoperative morbidity (38.4% vs. 46.3%, p = 0.08). Severe morbidity was similar with low anterior resection (9.1% vs. 15.3%, p = 0.10) and abdominoperineal resection (24.4% vs. 29.7%, p = 0.49). SC TNT did not increase the odds of severe morbidity relative to LCRT on multivariable analysis (OR 0.64, 95% CI 0.37-1.10). CONCLUSIONS SC TNT does not increase morbidity after TME for rectal cancer relative to LCRT. Concern for surgical complications should not discourage the use of SC TNT when aiming to increase the likelihood of complete clinical response.
Collapse
Affiliation(s)
- Philip S. Bauer
- Section of Colon & Rectal Surgery, Department of Surgery, Washington University School of Medicine
| | - Adriana C. Gamboa
- Division of Surgical Oncology, Winship Cancer Institute, Emory University
| | - Ebunoluwa E. Otegbeye
- Section of Colon & Rectal Surgery, Department of Surgery, Washington University School of Medicine
| | - William C. Chapman
- Section of Colon & Rectal Surgery, Department of Surgery, Washington University School of Medicine
| | - Samantha Rivard
- Division of Colorectal Surgery, Department of Surgery, University of Michigan
| | - Scott Regenbogen
- Division of Colorectal Surgery, Department of Surgery, University of Michigan
| | - Maryam Mohammed
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh Medical Center
| | - Jennifer Holder-Murray
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh Medical Center
| | - Jason T. Wiseman
- Division of Surgical Oncology, Department of Surgery, The Ohio State University
| | - Aslam Ejaz
- Division of Surgical Oncology, Department of Surgery, The Ohio State University
| | | | - Alexander T. Hawkins
- Section of Colon & Rectal Surgery, Division of General Surgery, Vanderbilt University Medical Center
| | - Steven R. Hunt
- Section of Colon & Rectal Surgery, Department of Surgery, Washington University School of Medicine
| | - Glen Balch
- Division of Colon & Rectal Surgery, Department of Surgery, Emory University
| | - Matthew L. Silviera
- Section of Colon & Rectal Surgery, Department of Surgery, Washington University School of Medicine
| |
Collapse
|
45
|
Kasheri E, Artinyan A, Oka K, Zhu R, Seiser N, Shirinian M, Barnajian M, Cohen J, Ellenhorn J, Nasseri Y. Downstaging after preoperative chemoradiation for locally advanced rectal cancer is associated with better survival than pathologic stage 0-1 disease treated with upfront surgery. Int J Colorectal Dis 2024; 39:16. [PMID: 38189849 PMCID: PMC10774158 DOI: 10.1007/s00384-023-04589-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/24/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND AND OBJECTIVES It is unknown how patients with locally advanced rectal cancer with significant response to preoperative radiotherapy/chemoradiotherapy fare relative to patients with true pathologic 0-1 disease undergoing upfront surgery. We aimed to determine whether survival is improved in locally advanced rectal cancer downstaged to pathologic stage 0-1 disease compared to true pathologic stage 0-1 tumors. METHODS A retrospective review of the National Cancer Database between 2004 and 2016 was conducted. Three groups were identified: (1) clinical stage 2-3 disease downstaged to pathologic stage 0-1 disease after radiotherapy, (2) clinical stage 2-3 disease not downstaged after radiotherapy, and (3) true pathologic 0-1 tumors undergoing upfront surgery. The primary endpoint was overall survival and was compared using Kaplan-Meier and multivariate Cox regression analyses. RESULTS The study population consisted of 59,884 patients. Of the 40,130 patients with locally advanced rectal cancer treated with preoperative radiation, 12,670 (31.5%) had significant downstaging (group 1), while 27,460 (68.4%) had no significant downstaging (group 2). A total of 19,754 had pathologic 0-1 disease treated with upfront resection (group 3). On Kaplan-Meier analysis, downstaged patients had significantly better overall survival compared to both non-downstaged and true pathologic stage 0-1 patients (median 156 vs. 99 and 136 months, respectively, p < 0.001). On multivariate analysis, downstaged patients had significantly better survival (HR 0.88, p < 0.001) compared to true pathologic 0-1 patients. CONCLUSIONS Locally advanced rectal cancer downstaged after preoperative radiotherapy has significantly better survival compared to true pathologic stage 0-1 disease treated with upfront surgery. Response to chemoradiotherapy likely identifies a subset of patients with a particularly good prognosis.
Collapse
Affiliation(s)
| | - Avo Artinyan
- Academic Surgical Associates, Glendale, USA
- Adventist Health Glendale, Glendale, USA
| | | | | | | | | | - Moshe Barnajian
- Surgery Group LA, Los Angeles, USA
- Cedars-Sinai Medical Center, Los Angeles, USA
| | - Jason Cohen
- Surgery Group LA, Los Angeles, USA
- Cedars-Sinai Medical Center, Los Angeles, USA
| | - Joshua Ellenhorn
- Surgery Group LA, Los Angeles, USA
- Cedars-Sinai Medical Center, Los Angeles, USA
| | - Yosef Nasseri
- Surgery Group LA, Los Angeles, USA
- Cedars-Sinai Medical Center, Los Angeles, USA
| |
Collapse
|
46
|
Verheij FS, Omer DM, Lin ST, Yuval JB, Thompson HM, Kim JK, Valdivieso SC, Qin LX, Wu AJ, Saltz LB, Garcia-Aguilar J. Compliance and Toxicity of Total Neoadjuvant Therapy for Rectal Cancer: A Secondary Analysis of the OPRA Trial. Int J Radiat Oncol Biol Phys 2024; 118:115-123. [PMID: 37544412 PMCID: PMC11027192 DOI: 10.1016/j.ijrobp.2023.07.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 06/29/2023] [Accepted: 07/29/2023] [Indexed: 08/08/2023]
Abstract
PURPOSE Patients with locally advanced rectal cancer treated with total neoadjuvant therapy (TNT) may achieve organ preservation without a compromise to oncologic outcomes. However, reports on patient compliance with TNT and with treatment-related toxicities are limited. METHODS AND MATERIALS The OPRA trial assessed organ preservation rates and oncologic outcomes in patients with clinical stage II/III rectal adenocarcinoma randomized to induction chemotherapy followed by chemoradiation (INCT-CRT) or chemoradiation followed by consolidation chemotherapy (CRT-CNCT). Systemic chemotherapy consisted of 8 cycles (16 weeks) of fluorouracil, leucovorin, and oxaliplatin (FOLFOX) or 5 cycles (15 weeks) of capecitabine and oxaliplatin (CAPEOX). Patients received >4500 cGy of radiation with sensitizing capecitabine or fluorouracil. In this report, we compare compliance and treatment-related toxicity in patients receiving INCT-CRT versus CRT-CNCT. Additionally, we evaluate the association of compliance to chemotherapy, compliance to chemoradiation, and toxicity with organ preservation and disease-free survival (DFS). RESULTS Of the 324 patients randomized, fewer patients started chemoradiation in the INCT-CRT group compared with the CRT-CNCT group (93% vs 98%, P = .03), and fewer patients started systemic chemotherapy in the CRT-CNCT group compared with the INCT-CRT group (94% vs 99%, P = .04). Order of TNT did not affect the ability to complete all intended cycles of FOLFOX (86% INCT-CRT vs 83% CRT-CNCT, P = .60) or CAPEOX (74% INCT-CRT vs 77% CRT-CNCT, P = .80). A total of 97% of INCT and 98% of CRT-CNCT patients received >4500 cGy radiation (P = .93). Sixty-four patients (41%) treated with INCT-CRT and 57 CRT-CNCT patients (34%) experienced a grade 3+ adverse event (P = .30). Compliance and toxicity were not associated with organ preservation or DFS. CONCLUSIONS We identified only minor differences in treatment compliance between patients treated with INCT-CRT and CRT-CNCT. No difference in adverse events was observed between groups. Treatment compliance and toxicity did not correlate with organ preservation rates or DFS.
Collapse
Affiliation(s)
- Floris S Verheij
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Dana M Omer
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sabrina T Lin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonathan B Yuval
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hannah M Thompson
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jin K Kim
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sebastian C Valdivieso
- Columbia University College of Physicians and Surgeons at Harlem Hospital, New York, New York
| | - Li-Xuan Qin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Leonard B Saltz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Julio Garcia-Aguilar
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York.
| |
Collapse
|
47
|
Wojcieszynski AP, Chuong MD, Hawkins M, Jethwa KR, Kim H, Raldow A, Sanford NN, Olsen JR. Rectal Cancer Update: Which Treatment Effects Are the Least "Brutal"? Int J Radiat Oncol Biol Phys 2024; 118:1-7. [PMID: 38049215 DOI: 10.1016/j.ijrobp.2023.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 08/04/2023] [Accepted: 08/06/2023] [Indexed: 12/06/2023]
Affiliation(s)
| | - Michael D Chuong
- Department of Radiation Oncology, Miami Cancer Institute, Miami, Florida
| | | | - Krishan R Jethwa
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Hyun Kim
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, Missouri
| | - Ann Raldow
- Department of Radiation Oncology, University of California, Los Angeles, California
| | - Nina N Sanford
- Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, Texas
| | - Jeffrey R Olsen
- Department of Radiation Oncology, University of Colorado, Denver, Colorado.
| |
Collapse
|
48
|
Langenfeld SJ, Davis BR, Vogel JD, Davids JS, Temple LKF, Cologne KG, Hendren S, Hunt S, Garcia Aguilar J, Feingold DL, Lightner AL, Paquette IM. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Rectal Cancer 2023 Supplement. Dis Colon Rectum 2024; 67:18-31. [PMID: 37647138 DOI: 10.1097/dcr.0000000000003057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Affiliation(s)
- Sean J Langenfeld
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska
| | - Bradley R Davis
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Jon D Vogel
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | | | - Larissa K F Temple
- Colorectal Surgery Division, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Kyle G Cologne
- Department of Surgery, Division of Colorectal Surgery, University of Southern California, Los Angeles, California
| | - Samantha Hendren
- Division of Colon and Rectal Surgery, Department of Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan
| | - Steven Hunt
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Julio Garcia Aguilar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel L Feingold
- Department of Surgery, Rutgers University, New Brunswick, New Jersey
| | - Amy L Lightner
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ian M Paquette
- Department of Surgery, Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| |
Collapse
|
49
|
Sawaf T, Gudipudi R, Ofshteyn A, Sarode AL, Bingmer K, Bliggenstorfer J, Stein SL, Steinhagen E. Disparities in Clinical Trial Enrollment and Reporting in Rectal Cancer: A Systematic Review and Demographic Comparison to the National Cancer Database. Am Surg 2024; 90:130-139. [PMID: 37670471 DOI: 10.1177/00031348231191175] [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] [Indexed: 09/07/2023]
Abstract
BACKGROUND Cancer care guidelines based on clinical trial data in homogenous populations may not be applicable to all rectal cancer patients. The aim of this study was to evaluate whether patients enrolled in rectal cancer clinical trials (CTs) are representative of United States (U.S.) rectal cancer patients. METHODS Prospective rectal cancer CTs from 2010 to 2019 in the United States were systematically reviewed. In trials with multiple arms reporting separate demographic variables, each arm was considered a separate CT group in the analysis. Demographic variables considered in the analysis were age, sex, race/ethnicity, facility location throughout the United States, rural vs urban geography, and facility type. Participant demographics from trial and the National Cancer Database (NCDB) participants were compared using chi-squared goodness of fit and one-sample t-test where applicable. RESULTS Of 50 CT groups identified, 42 (82%) studies reported mean or median age. Trial participants were younger compared to NCDB patients (P < .001 all studies). All but three trials had fewer female patients than NCDB (48.2% female, P < .001). Less than half the CT groups reported on race or ethnicity. Eighteen out of 22 trials (82%) had a smaller percentage of Black patients and 4 out of 8 (50%) trials had fewer Hispanic or Spanish origin patients than the NCDB. No CTs reported comorbidities, socioeconomic factors, or education. CT primary sites were largely at academic centers and in urban areas. CONCLUSION The present study supports the need for improved demographic representation and transparency in rectal cancer clinical trials.
Collapse
Affiliation(s)
- Tuleen Sawaf
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Rachana Gudipudi
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Asya Ofshteyn
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Anuja L Sarode
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Katherine Bingmer
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | | | - Sharon L Stein
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, OH, USA
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Emily Steinhagen
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, OH, USA
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| |
Collapse
|
50
|
Jabbour SK, Hochster HS. Evolving paradigms in locally advanced rectal cancer: the means justify the ends. J Natl Cancer Inst 2023; 115:1439-1441. [PMID: 37851864 DOI: 10.1093/jnci/djad196] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 09/11/2023] [Indexed: 10/20/2023] Open
Affiliation(s)
- Salma K Jabbour
- Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Howard S Hochster
- Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| |
Collapse
|