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Williams H, Thompson HM, Lee C, Rangnekar A, Gomez JT, Widmar M, Wei IH, Pappou EP, Nash GM, Weiser MR, Paty PB, Smith JJ, Veeraraghavan H, Garcia-Aguilar J. Assessing Endoscopic Response in Locally Advanced Rectal Cancer Treated with Total Neoadjuvant Therapy: Development and Validation of a Highly Accurate Convolutional Neural Network. Ann Surg Oncol 2024; 31:6443-6451. [PMID: 38700799 DOI: 10.1245/s10434-024-15311-y] [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: 01/18/2024] [Accepted: 04/01/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Rectal tumors display varying degrees of response to total neoadjuvant therapy (TNT). We evaluated the performance of a convolutional neural network (CNN) in interpreting endoscopic images of either a non-complete response to TNT or local regrowth during watch-and-wait surveillance. METHODS Endoscopic images from stage II/III rectal cancers treated with TNT from 2012 to 2020 at a single institution were retrospectively reviewed. Images were labelled as Tumor or No Tumor based on endoscopy timing (before, during, or after treatment) and the tumor's endoluminal response. A CNN was trained using ResNet-50 architecture. The area under the curve (AUC) was analyzed during training and for two test sets. The main test set included images of tumors treated with TNT. The other contained images of local regrowth. The model's performance was compared to sixteen surgeons and surgical trainees who evaluated 119 images for evidence of tumor. Fleiss' kappa was calculated by respondent experience level. RESULTS A total of 2717 images from 288 patients were included; 1407 (51.8%) contained tumor. The AUC was 0.99, 0.98, and 0.92 for training, main test, and local regrowth test sets. The model performed on par with surgeons of all experience levels for the main test set. Interobserver agreement was good ( k = 0.71-0.81). All groups outperformed the model in identifying tumor from images of local regrowth. Interobserver agreement was fair to moderate ( k = 0.24-0.52). CONCLUSIONS A highly accurate CNN matched the performance of colorectal surgeons in identifying a noncomplete response to TNT. However, the model demonstrated suboptimal accuracy when analyzing images of local regrowth.
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Affiliation(s)
- Hannah Williams
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hannah M Thompson
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Christina Lee
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Aneesh Rangnekar
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Jorge T Gomez
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Maria Widmar
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Iris H Wei
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Emmanouil P Pappou
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Garrett M Nash
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Martin R Weiser
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Philip B Paty
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - J Joshua Smith
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Harini Veeraraghavan
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Julio Garcia-Aguilar
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Dossa F, Weiser MR. Watch and wait for rectal cancer: towards data-informed surveillance. Lancet Gastroenterol Hepatol 2024; 9:781-784. [PMID: 39127068 DOI: 10.1016/s2468-1253(24)00158-4] [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] [Received: 04/06/2024] [Revised: 05/12/2024] [Accepted: 05/13/2024] [Indexed: 08/12/2024]
Affiliation(s)
- Fahima Dossa
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Martin R Weiser
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA.
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Socha J, Glynne-Jones R, Bujko K. Oncological risks associated with the planned watch-and-wait strategy using total neoadjuvant treatment for rectal cancer: A narrative review. Cancer Treat Rev 2024; 129:102796. [PMID: 38968742 DOI: 10.1016/j.ctrv.2024.102796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 06/27/2024] [Accepted: 06/28/2024] [Indexed: 07/07/2024]
Abstract
Overall survival benefit of total neoadjuvant treatment (TNT) remains unconfirmed. Thus, in our opinion, the main rationale for using TNT is a planned watch-and-wait (w&w) strategy to improve patients' long-term quality of life through organ preservation. The OPRA randomized trial, which examined a planned w&w strategy using TNT, showed a higher organ preservation rate but also a higher regrowth rate compared to studies on the opportunistic w&w strategy. Higher rates of complete clinical response with TNT did not improve disease-free survival compared to historical controls. Therefore, the gain in organ-sparing capability might not be balanced by the increased oncological risk. The ultimate local failure rate in the intention-to-treat analysis of the OPRA trial was 13% for induction chemotherapy and 16% for consolidation chemotherapy, which seems higher than expected compared to 8% in a meta-analysis of w&w studies or 12% after TNT and surgery in the PRODIGE-23 and RAPIDO trials, which enrolled patients with more advanced cancers than the OPRA trial. Other studies also suggest worse local control when surgery is delayed for radio-chemoresistant cancers. Our review questions the safety of the planned w&w strategy using TNT in unselected patients. To reduce the oncological risk while maintaining high organ preservation rates, we suggest that the planned w&w strategy using TNT requires a two-tier patient selection process: before treatment and after tumor response assessment at the midpoint of consolidation chemotherapy. These robust selections should identify patients who are unlikely to achieve organ preservation with TNT and would be better managed by preoperative chemoradiotherapy (without consolidation chemotherapy) and surgery, or by discontinuing consolidation chemotherapy and proceeding directly to surgery.
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Affiliation(s)
- Joanna Socha
- Department of Radiotherapy, Regional Oncology Centre, Bialska 104/118, 42-200 Częstochowa, Poland.
| | - Robert Glynne-Jones
- Radiotherapy Department, Mount Vernon Centre for Cancer Treatment, Rickmansworth Rd, Northwood HA6 2RN, UK.
| | - Krzysztof Bujko
- Department of Radiotherapy I, Maria Skłodowska-Curie National Research Institute of Oncology, Roentgena 5, 02-781 Warsaw, Poland.
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Mahmood AS, Jalal Fakhir O, Ahmed HA, Abdulelah Alnaqqash M, Alrubaei T, Abdulfattah Saleh W, Alkadir AA, Zuhair Alsammarraie A, Yahya Mohsin F, Shakir AA, Jamal Albadri Y, Ismail M. Outcomes of Watch-and-Wait Versus Abdominoperineal Resection in Lower Rectal Adenocarcinoma Post Neoadjuvant Therapy: An Iraqi Cohort Study. Cureus 2024; 16:e67955. [PMID: 39328707 PMCID: PMC11426549 DOI: 10.7759/cureus.67955] [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] [Accepted: 08/27/2024] [Indexed: 09/28/2024] Open
Abstract
BACKGROUND Rectal malignancy ranks among the most prevalent malignancies in humans. Neoadjuvant chemoradiotherapy (nCRT) is advocated as the standard treatment for locally advanced rectal cancer. In patients who achieve complete clinical response (cCR), successive surgical intervention may result in favorable immediate and long-lasting results; however, it may be associated with decreased quality of life. This study aims to evaluate the incidence of local recurrence in rectal adenocarcinoma between patients who underwent a watch-and-wait approach and those who underwent abdominoperineal resection following the achievement of a cCR after nCRT. METHODS This is an analytic cohort study that included 68 patients and was conducted in Baghdad Teaching Hospital/Medical City, Baghdad. The data were collected from the 1st of April 2021 to the 1st of October 2023. All patients with stage II and III rectal adenocarcinoma who achieved cCR after receiving nCRT were included in the study. RESULTS There was no statistically significant difference between the two study groups regarding non-regrowth disease-free survival (p-value = 0.708). Cox-regression multivariate analysis revealed that baseline T stage and serum carcinoembryonic antigen (CEA) were significantly associated with locoregional failure. CONCLUSION The present study reveals that implementing the watch-and-wait strategy had the benefit of avoiding major surgery, stoma, and their complications without coming at the cost of reduced locoregional recurrence.
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Affiliation(s)
| | - Osama Jalal Fakhir
- Department of Surgical Oncology, Oncology Teaching Hospital, Baghdad, IRQ
| | - Haider A Ahmed
- Department of Surgery, Iraqi Board for Medical Specializations, Baghdad, IRQ
| | | | - Tahseen Alrubaei
- Department of Surgical Oncology, Oncology Teaching Hospital, Baghdad, IRQ
| | | | - Ahmed A Alkadir
- Department of Surgical Oncology, Oncology Teaching Hospital, Baghdad, IRQ
| | | | - Forat Yahya Mohsin
- Department of Surgical Oncology, Oncology Teaching Hospital, Baghdad, IRQ
| | - Ahmed A Shakir
- Department of Surgery, Baghdad Teaching Hospital, Baghdad, IRQ
| | | | - Mustafa Ismail
- Department of Surgery, College of Medicine, University of Baghdad, Baghdad, IRQ
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5
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Park S, Park HS, Jang S, Cho J, Kim JH, Yu MH, Jung SI, Kim YJ, Hwang DY. Utility of abbreviated MRI in the post-treatment evaluation of rectal cancer. Acta Radiol 2024; 65:689-699. [PMID: 38778748 DOI: 10.1177/02841851241253936] [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: 05/25/2024]
Abstract
BACKGROUND Post-treatment evaluation of patients with rectal cancer (RC) using magnetic resonance imaging (MRI) burdens medical resources, necessitating an exploration of abbreviated protocols. PURPOSE To evaluate the diagnostic performance of abbreviated MRI (A-MRI) for the post-treatment evaluation of RC patients. MATERIAL AND METHODS This retrospective study included RC patients who underwent non-contrast rectal MRI and standard liver MRI, as well as abdominal contrast-enhanced computed tomography (CECT) for post-treatment evaluation. A-MRI comprised diffusion-weighted imaging (DWI) and T2-weighted imaging of the upper abdomen and the pelvic cavity. Three radiologists independently reviewed A-MRI, CECT, and standard liver MRI in the detection of viable disease. The diagnostic performances were compared using a reference standard considering all available information, including pathology, FDG-PET, endoscopic results, and clinical follow-up. RESULTS We included 78 patients (50 men, 28 women; mean age=60.9 ± 10.2 years) and observed viable disease in 34 (43.6%). On a per-patient-basis analysis, A-MRI showed significantly higher sensitivity (95% vs. 81%, P = 0.04) and higher accuracy (93% vs. 82%, P < 0.01), compared to those of CECT, while A-MRI showed comparable sensitivity (91% vs. 91%, P = 0.42) and accuracy (97% vs. 98%, P = 0.06) to that of standard liver MRI. On a per-lesion-based analysis, A-MRI exhibited significantly superior lesion detectability than that of CECT (figure of merit 0.91 vs. 0.77, P < 0.01) and comparable to that of standard liver MRI (figure of merit 0.91 vs. 0.92, P = 0.75). CONCLUSION A-MRI exhibited higher sensitivity and diagnostic accuracy than those of CECT in the post-treatment evaluation of RC, while it showed comparable performances with standard liver MRI. A-MRI provides diagnostic added value in the follow-up of RC patients.
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Affiliation(s)
- Sungeun Park
- Department of Radiology, Konkuk University Medical Center, Seoul, Republic of Korea
| | - Hee Sun Park
- Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Siwon Jang
- Department of Radiology, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - Jungheum Cho
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jae Hyun Kim
- Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Mi Hye Yu
- Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Sung Il Jung
- Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Young Jun Kim
- Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Dae-Yong Hwang
- Department of Surgery, Colorectal Cancer Center, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Republic of Korea
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Cerdan-Santacruz C, São Julião GP, Vailati BB, Perez RO. Chemoradiation, Consolidation Chemotherapy, and Watch and Wait for Early Rectal Cancer. Clin Colon Rectal Surg 2024; 37:216-221. [PMID: 38882934 PMCID: PMC11178383 DOI: 10.1055/s-0043-1770710] [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
As watch and wait has become an attractive management alternative among patients with rectal cancer who achieve a clinical complete response to neoadjuvant chemoradiation, the focus of organ preservation has now shifted toward the use of this approach in patients with early rectal cancer. These patients would otherwise be treated without the use of neoadjuvant therapy for oncological reasons. The sole purpose of any neoadjuvant treatment here would be the achievement of a complete clinical response in an attempt to avoid total mesorectal excision. This has become particularly interesting after the incorporation of total neoadjuvant therapy regimens. These regimens have resulted in significantly higher rates of complete tumor regression and therefore become an interesting alternative among early rectal cancer patients where organ preservation is desired. The present review provides an overview of the currently available evidence and the preliminary experience with this rather controversial approach.
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Affiliation(s)
| | | | - Bruna Borba Vailati
- Division of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Rodrigo Oliva Perez
- Division of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil
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7
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Fazio R, Audisio A, Daprà V, Conti C, Benhima N, Abbassi FZ, Assaf I, Hendlisz A, Sclafani F. Non-operative management after immune checkpoint inhibitors for early-stage, dMMR/MSI-H gastrointestinal cancers. Cancer Treat Rev 2024; 128:102752. [PMID: 38772170 DOI: 10.1016/j.ctrv.2024.102752] [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: 02/15/2024] [Revised: 05/10/2024] [Accepted: 05/11/2024] [Indexed: 05/23/2024]
Abstract
Surgery is a standard treatment for early-stage gastrointestinal cancers, often preceded by neoadjuvant chemo(radio)therapy or followed by adjuvant therapy. While leading to cure in a proportion of patients, it has some drawbacks such as intra/post-operative complications, mutilation and life-long functional sequelae. Further to the unprecedented efficacy data from studies of immune checkpoint inhibitors for advanced mismatch repair deficient/microsatellite instable (dMMR/MSI-H) tumours, a strong interest has recently emerged for the investigation of such agents in the neoadjuvant setting. Although limited by the exploratory design and small sample size, trials of neoadjuvant immune checkpoint inhibitors for early-stage dMMR/MSI-H gastrointestinal cancers have consistently reported complete response rates ranging from 70 % to 100 %. As a result, the question has arisen as to whether surgery is still needed or organ-preserving strategies should be offered to this especially immuno-sensitive population. In this article, we discuss the available evidence for neoadjuvant immune checkpoint inhibitors in dMMR/MSI-H gastrointestinal cancers and analyse opportunities and challenges to the implementation of non-operative management approaches in this setting.
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Affiliation(s)
- Roberta Fazio
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Brussels, Belgium
| | - Alessandro Audisio
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Brussels, Belgium
| | - Valentina Daprà
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Brussels, Belgium
| | - Chiara Conti
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Brussels, Belgium
| | - Nada Benhima
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Brussels, Belgium
| | - Fatima-Zahara Abbassi
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Brussels, Belgium
| | - Irene Assaf
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Brussels, Belgium
| | - Alain Hendlisz
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Brussels, Belgium
| | - Francesco Sclafani
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Brussels, Belgium.
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8
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Emile SH, Wignakumar A. Non-operative management of rectal cancer: Highlighting the controversies. World J Gastrointest Surg 2024; 16:1501-1506. [PMID: 38983314 PMCID: PMC11230012 DOI: 10.4240/wjgs.v16.i6.1501] [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: 02/21/2024] [Revised: 04/18/2024] [Accepted: 04/23/2024] [Indexed: 06/27/2024] Open
Abstract
There remains much ambiguity on what non-operative management (NOM) of rectal cancer truly entails in terms of the methods to be adopted and the best algorithm to follow. This is clearly shown by the discordance between various national and international guidelines on NOM of rectal cancer. The main aim of the NOM strategy is organ preservation and avoiding unnecessary surgical intervention, which carries its own risk of morbidity. A highly specific and sensitive surveillance program must be devised to avoid patients undergoing unnecessary surgical interventions. In many studies, NOM, often interchangeably called the Watch and Wait strategy, has been shown as a promising treatment option when undertaken in the appropriate patient population, where a clinical complete response is achieved. However, there are no clear guidelines on patient selection for NOM along with the optimal method of surveillance.
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Affiliation(s)
- Sameh Hany Emile
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL 33331, United States
| | - Anjelli Wignakumar
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL 33331, United States
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9
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Crean R, Glyn T, McCombie A, Frizelle F. Comparing outcomes and cost in surgery versus watch & wait surveillance of patients with rectal cancer post neoadjuvant long course chemoradiotherapy. ANZ J Surg 2024; 94:1151-1160. [PMID: 38486505 DOI: 10.1111/ans.18916] [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: 07/25/2023] [Revised: 02/07/2024] [Accepted: 02/12/2024] [Indexed: 06/19/2024]
Abstract
BACKGROUND Watch and wait (W&W) in complete clinical responders after neoadjuvant chemoradiotherapy has increasingly robust data supporting its oncological safety. Recently, studies have assessed the real-world costs of this strategy compared to surgical resection. Our aim was to compare our oncological safety and costs associated with operative and surveillance strategies to international literature. METHODS Data were retrospectively collected and analysed via electronic health records from March 2014 to March 2021 in Christchurch, New Zealand. Two cohorts were created based on intention to treat. All hospital events were recorded and costed, as well as oncologic outcomes. Our primary endpoints were the cumulative cost of both strategies, 3-year survival rate, and disease-free survival. RESULTS Forty-eight patients were identified who had rectal cancers resected (OT) with a yPT0N0 pathology, and 42 who were on the wait-and-watch (W&W) audit after having a clinical complete response. After exclusions, we identified 38 OT and 23 W&W patients; the W&W group were more co-morbid (P = 0.05), had worse functional status (P = 0.008), higher BMI (P = 0.34) and more favourable clinical tumour staging (P = 0.01). The operative treatment (OT) group (n = 38) had more acute admissions (34% versus 13% in W&W, P = 0.08, OR 0.29). There was a 35.7% (n = 8 of 23) local recurrence in W&W and none in the OT group (P ≤ 0.001), with successful salvage in the W&W with local recurrence in 71.5% (n = 5 of 7). Three-year distant metastasis-free rate was 97.3% in the OT group and 90.9% in W&W (p = 0.05). Overall survival was 100% (W&W) and 94.7% (OT); (P = 0.019). Care in the OT group cost more than W&W, accounting for local regrowth management; $NZ70,759.56 versus $NZ47,905.52 (P = 0.014). CONCLUSION This study found better oncological outcomes in the OT group, whilst the W&W group had reduced morbidity and acute bed days. The cost of wait and watch was approximately two-thirds that of operative treatment, even accounting for salvage procedures for local regrowth.
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Affiliation(s)
- Rory Crean
- Department of Surgery, Christchurch Hospital, Health New Zealand, Canterbury, New Zealand
| | - Tamara Glyn
- Department of Surgery, Christchurch Hospital, Health New Zealand, Canterbury, New Zealand
| | - Andrew McCombie
- Department of Surgery, Christchurch Hospital, Health New Zealand, Canterbury, New Zealand
| | - Frank Frizelle
- Department of Surgery, Christchurch Hospital, Health New Zealand, Canterbury, New Zealand
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10
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El Homsi M, Bercz A, Chahwan S, Fernandes MC, Javed-Tayyab S, Golia Pernicka JS, Nincevic J, Paroder V, Ruby L, Smith JJ, Petkovska I. Watch & wait - Post neoadjuvant imaging for rectal cancer. Clin Imaging 2024; 110:110166. [PMID: 38669916 PMCID: PMC11090716 DOI: 10.1016/j.clinimag.2024.110166] [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: 03/06/2024] [Revised: 04/15/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024]
Abstract
Rectal cancer management has evolved over the past decade with the emergence of total neoadjuvant therapy (TNT). For select patients who achieve a clinical complete response following TNT, organ preservation by means of the watch-and-wait (WW) strategy is an increasingly adopted alternative that preserves rectal function and quality of life without compromising oncologic outcomes. Recently, published 5-year results from the OPRA trial demonstrated that organ preservation can be achieved in approximately half of patients managed with the WW strategy, with most local regrowth events occurring within two years. Considering the potential for local regrowth, the implementation of the WW strategy mandates rigorous clinical and radiographic surveillance. Magnetic resonance imaging (MRI) serves as the conventional imaging modality for local staging and surveillance of rectal cancer given its excellent soft-tissue resolution. This review will discuss the current evidence for the WW strategy and the role of restaging rectal MRI in determining patient eligibility for this strategy. Restaging rectal MRI acquisition parameters and treatment response assessment, including important factors to assess, pitfalls, and classification systems, will be discussed in the context of the WW strategy.
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Affiliation(s)
- Maria El Homsi
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Aron Bercz
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Stephanie Chahwan
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Maria Clara Fernandes
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Sidra Javed-Tayyab
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Jennifer S Golia Pernicka
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Josip Nincevic
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Viktoriya Paroder
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Lisa Ruby
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - J Joshua Smith
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Iva Petkovska
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
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11
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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.
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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
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12
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Smith HG, Nilsson PJ, Shogan BD, Harji D, Gambacorta MA, Romano A, Brandl A, Qvortrup C. Neoadjuvant treatment of colorectal cancer: comprehensive review. BJS Open 2024; 8:zrae038. [PMID: 38747103 PMCID: PMC11094476 DOI: 10.1093/bjsopen/zrae038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 03/12/2024] [Accepted: 03/21/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND Neoadjuvant therapy has an established role in the treatment of patients with colorectal cancer. However, its role continues to evolve due to both advances in the available treatment modalities, and refinements in the indications for neoadjuvant treatment and subsequent surgery. METHODS A narrative review of the most recent relevant literature was conducted. RESULTS Short-course radiotherapy and long-course chemoradiotherapy have an established role in improving local but not systemic disease control in patients with rectal cancer. Total neoadjuvant therapy offers advantages over short-course radiotherapy and long-course chemoradiotherapy, not only in terms of increased local response but also in reducing the risk of systemic relapses. Non-operative management is increasingly preferred to surgery in patients with rectal cancer and clinical complete responses but is still associated with some negative impacts on functional outcomes. Neoadjuvant chemotherapy may be of some benefit in patients with locally advanced colon cancer with proficient mismatch repair, although patient selection is a major challenge. Neoadjuvant immunotherapy in patients with deficient mismatch repair cancers in the colon or rectum is altering the treatment paradigm for these patients. CONCLUSION Neoadjuvant treatments for patients with colon or rectal cancers continue to evolve, increasing the complexity of decision-making for patients and clinicians alike. This review describes the current guidance and most recent developments.
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Affiliation(s)
- Henry G Smith
- Abdominalcenter K, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Per J Nilsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Dept. of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Benjamin D Shogan
- Department of Surgery, The University of Chicago Medicine, Chicago, Illinois, USA
| | - Deena Harji
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, UK
| | - Maria Antonietta Gambacorta
- Dipartimento di Diagnostica per Immagini, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
- Dipartimento di Scienze Radiologiche ed Ematologiche, Universita Cattolica del Sacro Cuore, Rome, Italy
| | - Angela Romano
- Dipartimento di Diagnostica per Immagini, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
| | - Andreas Brandl
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Camilla Qvortrup
- Department of Oncology, Rigshospital, University of Copenhagen, Copenhagen, Denmark
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13
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Yu G, Chi H, Zhao G, Wang Y. Tumor regression and safe distance of distal margin after neoadjuvant therapy for rectal cancer. Front Oncol 2024; 14:1375334. [PMID: 38638858 PMCID: PMC11024319 DOI: 10.3389/fonc.2024.1375334] [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: 01/23/2024] [Accepted: 03/15/2024] [Indexed: 04/20/2024] Open
Abstract
Neoadjuvant therapy has been widely employed in the treatment of rectal cancer, demonstrating its utility in reducing tumor volume, downstaging tumors, and improving patient prognosis. It has become the standard preoperative treatment modality for locally advanced rectal cancer. However, the efficacy of neoadjuvant therapy varies significantly among patients, with notable differences in tumor regression outcomes. In some cases, patients exhibit substantial tumor regression, even achieving pathological complete response. The assessment of tumor regression outcomes holds crucial significance for determining surgical approaches and establishing safe margins. Nonetheless, current research on tumor regression patterns remains limited, and there is considerable controversy surrounding the determination of a safe margin after neoadjuvant therapy. In light of these factors, this study aims to summarize the primary patterns of tumor regression observed following neoadjuvant therapy for rectal cancer, categorizing them into three types: tumor shrinkage, tumor fragmentation, and mucinous lake formation. Furthermore, a comparison will be made between gross and microscopic tumor regression, highlighting the asynchronous nature of regression in the two contexts. Additionally, this study will analyze the safety of non-surgical treatment in patients who achieve complete clinical response, elucidating the necessity of surgical intervention. Lastly, the study will investigate the optimal range for safe surgical resection margins and explore the concept of a safe margin distance post-neoadjuvant therapy.
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Affiliation(s)
- Guilin Yu
- Department of General Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, China
| | - Huanyu Chi
- Department of General Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, China
- The Second Clinical College, Dalian Medical University, Dalian, China
| | - Guohua Zhao
- Department of General Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, China
| | - Yue Wang
- Department of General Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, China
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14
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Klimkowski R, Krzyzkowiak J, Pilonis ND, Bujko K, Kaminski MF. Endoscopic resection of residual rectal neoplasia after definitive chemoradiotherapy for rectal cancer. Best Pract Res Clin Gastroenterol 2024; 68:101896. [PMID: 38522889 DOI: 10.1016/j.bpg.2024.101896] [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: 08/31/2023] [Revised: 02/21/2024] [Accepted: 02/25/2024] [Indexed: 03/26/2024]
Abstract
The conventional approach to treating locally advanced rectal cancer, commonly defined as cT3 or cT4 primary tumors or with nodal metastases, involves chemoradiation (CRT) followed by surgical resection. There is a growing recognition of the potential for nonsurgical management following CRT or total neoadjuvant therapy (TNT), which allows for organ preservation. "Watch and wait" strategy may be considered if complete clinical response is achieved. In cases when adenoma or superficial cancer is present, a novel approach known as "salvage endoscopic resection of the residual disease" is emerging as a viable nonsurgical option for carefully selected patients. This review discusses available evidence and future potential for endoscopic management of residual neoplasia after oncological treatment of rectal cancer.
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Affiliation(s)
- Robert Klimkowski
- Department of Gastroenterological Oncology, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland; Department of Gastroenterology, Hepatology and Oncology, Medical Center for Postgraduate Education, Warsaw, Poland.
| | - Jakub Krzyzkowiak
- Department of Gastroenterological Oncology, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Nastazja Dagny Pilonis
- Department of Gastroenterological Oncology, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland; Department of Gastroenterology, Hepatology and Oncology, Medical Center for Postgraduate Education, Warsaw, Poland; Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway; Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, Gdansk, Poland
| | - Krzysztof Bujko
- Department of Radiotherapy I, National Research Institute of Oncology, Warsaw, Poland
| | - Michal F Kaminski
- Department of Gastroenterological Oncology, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland; Department of Gastroenterology, Hepatology and Oncology, Medical Center for Postgraduate Education, Warsaw, Poland; Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway; Department of Surgical Oncology Medical University of Gdansk, Gdansk, Poland
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15
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Hołdakowska A, Kurkowska K, Pietrzak L, Michalski W, Rutkowski A, Olesiński T, Cencelewicz A, Rydziński M, Socha J, Bujko K. Which tumour factors preclude organ preservation in patients with rectal cancer? Radiother Oncol 2024; 191:110054. [PMID: 38104780 DOI: 10.1016/j.radonc.2023.110054] [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: 07/31/2023] [Revised: 12/06/2023] [Accepted: 12/11/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND cT3cdT4, cN2, mesorectal nodes > 8 mm, clinically positive lateral nodes, extramural vascular invasion (EMVI) and mesorectal fascia threatening (MRF+) have been utilized as exclusion criteria in several studies on the watch-and-wait (w&w) strategy. Here, our aim was to validate these criteria through a post hoc analysis of two pooled prospective studies on w&w following routine radio(chemo)therapy. METHODS A review of baseline magnetic resonance imaging was performed in a subgroup of 223 patients treated at a single institution. Of these, 17.9 % started w&w, 12.6 % achieved clinical complete response (cCR) and 9.0 % sustained cCR during median follow-up of 54 months. RESULTS The multivariable logistic analysis showed that the proportion of circumferential bowel involvement and EMVI significantly influenced the chance of sustained cCR; odds ratios were 0.063 (95 % confidence interval [CI] 0.008-0.489, p = 0.008), and 0.109 (95 % CI 0.014-0.850, p = 0.034), respectively. Sustained cCR was observed in none of the 57 patients with 90 %-100 % circumferential bowel involvement and in only one of the 89 patients with EMVI. In contrast, cT3cdT4, cN2, mesorectal nodes > 8 mm, clinically positive lateral nodes or MRF+ were not independently associated with sustained cCR. Among the subgroups of patients with these features but without (near-)circular tumour or EMVI+, sustained cCR was observed in 12 %-25 % of patients. CONCLUSION Sustained cCR after routine preoperative radio(chemo)therapy is unlikely in patients with (near-)circular tumour or EMVI, whereas patients with cT3cdT4, cN2, mesorectal nodes > 8 mm, clinically positive lateral nodes and MRF+ should not be denied w&w.
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Affiliation(s)
- Anna Hołdakowska
- Department of Radiology, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Kamila Kurkowska
- Department of Radiology, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Lucyna Pietrzak
- Department of Radiotherapy I, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Wojciech Michalski
- Department of Computational Oncology, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Andrzej Rutkowski
- Department of Surgery of Gastrointestinal Cancers and Neuroendocrine Tumors, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Tomasz Olesiński
- Department of Surgery of Gastrointestinal Cancers and Neuroendocrine Tumors, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Anna Cencelewicz
- Department of Gastroenterological Oncology, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Martin Rydziński
- Department of Radiotherapy I, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Joanna Socha
- Department of Radiotherapy, Military Institute of Medicine - National Research Institute, Warsaw, Poland; Department of Radiotherapy, Regional Oncology Center, Czestochowa, Poland
| | - Krzysztof Bujko
- Department of Radiotherapy I, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland.
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16
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Thompson HM, Omer DM, Lin S, Kim JK, Yuval JB, Veheij FS, Qin LX, Gollub MJ, Wu AJC, Lee M, Patil S, Hezel AF, Marcet JE, Cataldo PA, Polite BN, Herzig DO, Liska D, Oommen S, Friel CM, Ternent CA, Coveler AL, Hunt SR, Garcia-Aguilar J. Organ Preservation and Survival by Clinical Response Grade in Patients With Rectal Cancer Treated With Total Neoadjuvant Therapy: A Secondary Analysis of the OPRA Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2350903. [PMID: 38194231 PMCID: PMC10777257 DOI: 10.1001/jamanetworkopen.2023.50903] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/20/2023] [Indexed: 01/10/2024] Open
Abstract
Importance Assessing clinical tumor response following completion of total neoadjuvant therapy (TNT) in patients with locally advanced rectal cancer is paramount to select patients for watch-and-wait treatment. Objective To assess organ preservation (OP) and oncologic outcomes according to clinical tumor response grade. Design, Setting, and Participants This was secondary analysis of the Organ Preservation in Patients with Rectal Adenocarcinoma trial, a phase 2, nonblinded, multicenter, randomized clinical trial. Randomization occurred between April 2014 and March 2020. Eligible participants included patients with stage II or III rectal adenocarcinoma. Data analysis occurred from March 2022 to July 2023. Intervention Patients were randomized to induction chemotherapy followed by chemoradiation or chemoradiation followed by consolidation chemotherapy. Tumor response was assessed 8 (±4) weeks after TNT by digital rectal examination and endoscopy and categorized by clinical tumor response grade. A 3-tier grading schema that stratifies clinical tumor response into clinical complete response (CCR), near complete response (NCR), and incomplete clinical response (ICR) was devised to maximize patient eligibility for OP. Main Outcomes and Measures OP and survival rates by clinical tumor response grade were analyzed using the Kaplan-Meier method and log-rank test. Results There were 304 eligible patients, including 125 patients with a CCR (median [IQR] age, 60.6 [50.4-68.0] years; 76 male [60.8%]), 114 with an NCR (median [IQR] age, 57.6 [49.1-67.9] years; 80 male [70.2%]), and 65 with an ICR (median [IQR] age, 55.5 [47.7-64.2] years; 41 male [63.1%]) based on endoscopic imaging. Age, sex, tumor distance from the anal verge, pathological tumor classification, and clinical nodal classification were similar among the clinical tumor response grades. Median (IQR) follow-up for patients with OP was 4.09 (2.99-4.93) years. The 3-year probability of OP was 77% (95% CI, 70%-85%) for patients with a CCR and 40% (95% CI, 32%-51%) for patients with an NCR (P < .001). Clinical tumor response grade was associated with disease-free survival, local recurrence-free survival, distant metastasis-free survival, and overall survival. Conclusions and Relevance In this secondary analysis of a randomized clinical trial, most patients with a CCR after TNT achieved OP, with few developing tumor regrowth. Although the probability of tumor regrowth was higher for patients with an NCR compared with patients with a CCR, a significant proportion of patients achieved OP. These findings suggest the 3-tier grading schema can be used to estimate recurrence and survival outcomes in patients with locally advanced rectal cancer who receive TNT. Trial Registration ClinicalTrials.gov Identifier: NCT02008656.
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Affiliation(s)
- Hannah M. Thompson
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Dana M. Omer
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sabrina Lin
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jin K. Kim
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonathan B. Yuval
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Floris S. Veheij
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Li-Xuan Qin
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marc J. Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Abraham Jing-Ching Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Meghan Lee
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sujata Patil
- Department of Quantitative Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Aram F. Hezel
- James P. Wilmot Cancer Center, University of Rochester, Rochester, New York
| | | | | | - Blase N. Polite
- Department of Surgery, University of Chicago, Chicago, Illinois
| | - Daniel O. Herzig
- Department of Surgery, Oregon Health & Science University, Portland
| | - David Liska
- Department of Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Samuel Oommen
- Department of Surgery, John Muir Health, Walnut Creek, California
| | - Charles M. Friel
- Department of Surgery, University Hospital, University of Virginia Health System, Charlottesville
| | - Charles A. Ternent
- Department of Surgery, Creighton University Medical Center, Omaha, Nebraska
| | | | - Steven R. Hunt
- Department of Surgery, Washington University, St Louis, Missouri
| | - Julio Garcia-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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17
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El Sissy C, Kirilovsky A, Lagorce Pagès C, Marliot F, Custers PA, Dizdarevic E, Sroussi M, Castillo-Martin M, Haicheur N, Dermani M, Loche N, Buttard B, Musina AM, Anitei MG, van den Berg JG, Broeks A, Iseas S, Coraglio M, Loria FS, Romero A, Laurent-Puig P, de Reyniès A, Fernandez LM, Karoui M, Tougeron D, Vaccaro CA, Santino JP, Poulsen LØ, Lindebjerg J, O'Connor JM, Scripcariu V, Dimofte MG, Gérard JP, Chalabi M, Figueiredo N, Perez RO, Habr-Gama A, Galon J, Hansen TF, Jensen LH, Beets G, Zeitoun G, Pagès F. International Validation of the Immunoscore Biopsy in Patients With Rectal Cancer Managed by a Watch-and-Wait Strategy. J Clin Oncol 2024; 42:70-80. [PMID: 37788410 PMCID: PMC10730081 DOI: 10.1200/jco.23.00586] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 07/06/2023] [Accepted: 07/24/2023] [Indexed: 10/05/2023] Open
Abstract
PURPOSE No biomarker capable of improving selection and monitoring of patients with rectal cancer managed by watch-and-wait (W&W) strategy is currently available. Prognostic performance of the Immunoscore biopsy (ISB) was recently suggested in a preliminary study. METHODS This international validation study included 249 patients with clinical complete response (cCR) managed by W&W strategy. Intratumoral CD3+ and CD8+ T cells were quantified on pretreatment rectal biopsies by digital pathology and converted to ISB. The primary end point was time to recurrence (TTR; the time from the end of neoadjuvant treatment to the date of local regrowth or distant metastasis). Associations between ISB and outcomes were analyzed by stratified Cox regression adjusted for confounders. Immune status of tumor-draining lymph nodes (n = 161) of 17 additional patients treated by neoadjuvant chemoradiotherapy and surgery was investigated by 3'RNA-Seq and immunofluorescence. RESULTS Recurrence-free rates at 5 years were 91.3% (82.4%-100.0%), 62.5% (53.2%-73.3%), and 53.1% (42.4%-66.5%) with ISB High, ISB Intermediate, and ISB Low, respectively (hazard ratio [HR; Low v High], 6.51; 95% CI, 1.99 to 21.28; log-rank P = .0004). ISB was also significantly associated with disease-free survival (log-rank P = .0002), and predicted both local regrowth and distant metastasis. In multivariate analysis, ISB was independent of patient age, sex, tumor location, cT stage (T, primary tumor; c, clinical), cN stage (N, regional lymph node; c, clinical), and was the strongest predictor for TTR (HR [ISB High v Low], 6.93; 95% CI, 2.08 to 23.15; P = .0017). The addition of ISB to a clinical-based model significantly improved the prediction of recurrence. Finally, B-cell proliferation and memory in draining lymph nodes was evidenced in the draining lymph nodes of patients with cCR. CONCLUSION The ISB is validated as a biomarker to predict both local regrowth and distant metastasis, with a gradual scaling of the risk of pejorative outcome.
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Affiliation(s)
- Carine El Sissy
- INSERM, Laboratory of Integrative Cancer Immunology, Paris, France
- Equipe Labellisée Ligue Contre le Cancer, Paris, France
- Cordeliers Research Center, Sorbonne University, University Paris Cité, Paris, France
- Immunomonitoring Platform, Laboratory of Immunology, Assistance Publique-Hôpitaux de Paris (AP-HP), Georges Pompidou European Hospital, Paris, France
| | - Amos Kirilovsky
- INSERM, Laboratory of Integrative Cancer Immunology, Paris, France
- Equipe Labellisée Ligue Contre le Cancer, Paris, France
- Cordeliers Research Center, Sorbonne University, University Paris Cité, Paris, France
- Immunomonitoring Platform, Laboratory of Immunology, Assistance Publique-Hôpitaux de Paris (AP-HP), Georges Pompidou European Hospital, Paris, France
| | - Christine Lagorce Pagès
- INSERM, Laboratory of Integrative Cancer Immunology, Paris, France
- Equipe Labellisée Ligue Contre le Cancer, Paris, France
- Cordeliers Research Center, Sorbonne University, University Paris Cité, Paris, France
- Immunomonitoring Platform, Laboratory of Immunology, Assistance Publique-Hôpitaux de Paris (AP-HP), Georges Pompidou European Hospital, Paris, France
- Department of Pathology, AP-HP, Georges Pompidou European Hospital, Paris, France
| | - Florence Marliot
- INSERM, Laboratory of Integrative Cancer Immunology, Paris, France
- Equipe Labellisée Ligue Contre le Cancer, Paris, France
- Cordeliers Research Center, Sorbonne University, University Paris Cité, Paris, France
- Immunomonitoring Platform, Laboratory of Immunology, Assistance Publique-Hôpitaux de Paris (AP-HP), Georges Pompidou European Hospital, Paris, France
| | - Petra A. Custers
- Department of Surgery, Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, the Netherlands
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
| | - Edina Dizdarevic
- Department of Oncology, Danish Colorectal Cancer Center South, University Hospital of Southern Denmark, Vejle, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Marine Sroussi
- Cordeliers Research Center, Sorbonne University, INSERM, University Paris Cité, SIRIC CARPEM, Paris, France
- Chemistry Biology Innovation Institute, BioChimie Laboratory, ESPCI, UMR8231 CNRS, University PSL, Paris, France
| | | | - Nacilla Haicheur
- INSERM, Laboratory of Integrative Cancer Immunology, Paris, France
- Equipe Labellisée Ligue Contre le Cancer, Paris, France
- Cordeliers Research Center, Sorbonne University, University Paris Cité, Paris, France
- Immunomonitoring Platform, Laboratory of Immunology, Assistance Publique-Hôpitaux de Paris (AP-HP), Georges Pompidou European Hospital, Paris, France
| | - Mohamed Dermani
- INSERM, Laboratory of Integrative Cancer Immunology, Paris, France
- Equipe Labellisée Ligue Contre le Cancer, Paris, France
- Cordeliers Research Center, Sorbonne University, University Paris Cité, Paris, France
- Immunomonitoring Platform, Laboratory of Immunology, Assistance Publique-Hôpitaux de Paris (AP-HP), Georges Pompidou European Hospital, Paris, France
| | - Nicolas Loche
- INSERM, Laboratory of Integrative Cancer Immunology, Paris, France
- Equipe Labellisée Ligue Contre le Cancer, Paris, France
- Cordeliers Research Center, Sorbonne University, University Paris Cité, Paris, France
- Immunomonitoring Platform, Laboratory of Immunology, Assistance Publique-Hôpitaux de Paris (AP-HP), Georges Pompidou European Hospital, Paris, France
| | - Bénedicte Buttard
- INSERM, Laboratory of Integrative Cancer Immunology, Paris, France
- Equipe Labellisée Ligue Contre le Cancer, Paris, France
- Cordeliers Research Center, Sorbonne University, University Paris Cité, Paris, France
| | - Ana Maria Musina
- Department of Surgical Oncology, Regional Institute of Oncology (IRO), Iasi, Romania
- “Grigore T. Popa” University of Medicine and Pharmacy, Iasi, Romania
| | - Maria Gabriela Anitei
- “Grigore T. Popa” University of Medicine and Pharmacy, Iasi, Romania
- Surgical Oncology Unit, Regional Institute of Oncology, Iasi, Romania
| | - José G. van den Berg
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Annegien Broeks
- Core Facility Molecular Pathology and Biobanking, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Soledad Iseas
- Oncology Unit, Gastroenterology Hospital Carlos Bonorino Udaondo, Buenos Aires, Argentina
| | - Mariana Coraglio
- Oncology Unit, Gastroenterology Hospital Carlos Bonorino Udaondo, Buenos Aires, Argentina
| | - Fernando Sanchez Loria
- GI Clinical Oncology and GI Surgical Oncology, Instituto Alexander Fleming, Buenos Aires, Argentina
| | - Alfredo Romero
- Department of Clinical Oncology, British Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Pierre Laurent-Puig
- Cordeliers Research Center, Sorbonne University, University Paris Cité, INSERM UMR1138, Paris, France
- Department of Biology, Cancer Institute Paris CARPEM, AP-HP, Georges Pompidou European Hospital, Paris, France
| | - Aurélien de Reyniès
- Cordeliers Research Center, University Paris Cité, INSERM UMRS1138, Paris, France
- AP-HP, SeqOIA Genomic Medicine Laboratory—IT Platform, Paris, France
| | - Laura M. Fernandez
- Colorectal Surgery, Digestive Department, Champalimaud Foundation, Lisbon, Portugal
| | - Mehdi Karoui
- Department of Digestive and Oncologic Surgery, AP-HP, Georges Pompidou European Hospital, Paris, France
| | - David Tougeron
- Department of Hepato-Gastro-Enterology and Nutritional Assistance, University Hospital of Poitiers, Poitiers, France
| | - Carlos A. Vaccaro
- Department of General Surgery, Hospital Italiano, Buenos Aires, Argentina
| | - Juan P. Santino
- Department of General Surgery, Hospital Italiano, Buenos Aires, Argentina
| | - Laurids Østergaard Poulsen
- Department of Oncology, Danish Colorectal Cancer Center South, University Hospital of Southern Denmark, Vejle, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Jan Lindebjerg
- Department of Oncology, Danish Colorectal Cancer Center South, University Hospital of Southern Denmark, Vejle, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Juan Manuel O'Connor
- GI Clinical Oncology and GI Surgical Oncology, Instituto Alexander Fleming, Buenos Aires, Argentina
| | - Viorel Scripcariu
- “Grigore T. Popa” University of Medicine and Pharmacy, Iasi, Romania
- Surgical Oncology Unit, Regional Institute of Oncology, Iasi, Romania
| | - Mihail-Gabriel Dimofte
- Department of Surgical Oncology, Regional Institute of Oncology (IRO), Iasi, Romania
- “Grigore T. Popa” University of Medicine and Pharmacy, Iasi, Romania
| | | | - Myriam Chalabi
- Department of Gastrointestinal Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Nuno Figueiredo
- Colorectal Surgery, Digestive Department, Champalimaud Foundation, Lisbon, Portugal
| | - Rodrigo O. Perez
- Division of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
- Department of Surgical Oncology, Beneficencia Portuguesa Hospital, São Paulo, Brazil
- Angelita and Joaquim Gama Institute, São Paulo, Brazil
| | - Angelita Habr-Gama
- Division of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
- Department of Surgical Oncology, Beneficencia Portuguesa Hospital, São Paulo, Brazil
- Angelita and Joaquim Gama Institute, São Paulo, Brazil
| | - Jérôme Galon
- INSERM, Laboratory of Integrative Cancer Immunology, Paris, France
- Equipe Labellisée Ligue Contre le Cancer, Paris, France
- Cordeliers Research Center, Sorbonne University, University Paris Cité, Paris, France
| | - Torben Frøstrup Hansen
- Department of Oncology, Danish Colorectal Cancer Center South, University Hospital of Southern Denmark, Vejle, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Lars Henrik Jensen
- Department of Oncology, Danish Colorectal Cancer Center South, University Hospital of Southern Denmark, Vejle, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Geerard Beets
- Department of Surgery, Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, the Netherlands
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
| | - Guy Zeitoun
- INSERM, Laboratory of Integrative Cancer Immunology, Paris, France
- Equipe Labellisée Ligue Contre le Cancer, Paris, France
- Cordeliers Research Center, Sorbonne University, University Paris Cité, Paris, France
- Immunomonitoring Platform, Laboratory of Immunology, Assistance Publique-Hôpitaux de Paris (AP-HP), Georges Pompidou European Hospital, Paris, France
| | - Franck Pagès
- INSERM, Laboratory of Integrative Cancer Immunology, Paris, France
- Equipe Labellisée Ligue Contre le Cancer, Paris, France
- Cordeliers Research Center, Sorbonne University, University Paris Cité, Paris, France
- Immunomonitoring Platform, Laboratory of Immunology, Assistance Publique-Hôpitaux de Paris (AP-HP), Georges Pompidou European Hospital, Paris, France
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Datta D, Engineer R, Saklani A, D'souza A, Baheti A, Kumar S, Krishnatry R, Ostwal V, Ramaswamy A, Patil P. Non-operative management in low-lying rectal cancers undergoing chemoradiation. J Cancer Res Ther 2024; 20:417-422. [PMID: 38554355 DOI: 10.4103/jcrt.jcrt_189_23] [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: 01/29/2023] [Accepted: 04/04/2023] [Indexed: 04/01/2024]
Abstract
PURPOSE To evaluate the outcomes of post-neoadjuvant chemoradiation (NACTRT) wait-and-watch Strategy (WWS) in distal rectal cancers. MATERIALS AND METHODS All consecutive patients from December 2012 to 2019 diagnosed with distal rectal tumors (T2-T4 N0-N+) having a complete or near-complete response (cCR or nCR, respectively) post-NACTRT and wishing for the non-surgical treatment option of WWS were included in this study. Patients were observed with 3 monthly magnetic resonance imaging (MRIs), sigmoidoscopies, and digital rectal examination for 2 years and 6 monthly thereafter. Organ preservation rate (OPR), local regrowth rate (LRR), non-regrowth recurrence-free survival (NR-RFS) and overall survival (OAS) were estimated using the Kaplan-Meier method, and factors associated with LRR were identified on univariate and multivariate analysis using the log-rank test (P < 0.05 significant). RESULTS Sixty-one consecutive patients post-NACTRT achieving cCR[44 (72%)] and nCR[17 (28%)], respectively, were identified. All patients received pelvic radiotherapy at a dose of 45-50Gy conventional fractionation and concurrent capecitabine. An additional boost dose with either an external beam or brachytherapy was given to 39 patients. At a median follow-up of 39 months, 11 (18%) patients had local regrowth, of which seven were salvaged with surgery and the rest are alive with the disease, as they refused surgery. The overall OPR, NR-RFS, and OS were 83%, 95%, and 98%, respectively. Seven (11%) patients developed distant metastasis, of which six underwent metastatectomy and are alive and well. LRR was higher in patients with nCR versus cCR (P = 0.05). CONCLUSION The WWS is a safe non-operative alternative management for selected patients attaining cCR/nCR after NACTRT with excellent outcomes.
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Affiliation(s)
- Debanjali Datta
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Reena Engineer
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Avanish Saklani
- Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Ashwin D'souza
- Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Akshay Baheti
- Department of Radiodiagnosis, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Suman Kumar
- Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Rahul Krishnatry
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Vikas Ostwal
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Anant Ramaswamy
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Prachi Patil
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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Rubens ME, Mayo TP, Smith RK, Glasgow SC, Politi MC. A Qualitative Exploration of Stakeholders' Preferences for Early-Stage Rectal Cancer Treatment. ANNALS OF SURGERY OPEN 2023; 4:e364. [PMID: 38144488 PMCID: PMC10735060 DOI: 10.1097/as9.0000000000000364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 10/28/2023] [Indexed: 12/26/2023] Open
Abstract
As treatment options for patients with rectal cancer evolve, patients with early-stage rectal cancer may have a treatment choice between surgery and a trial of nonoperative management. Patients must consider the treatments' clinical tradeoffs alongside their personal goals and preferences. Shared decision-making (SDM) between patients and clinicians can improve decision quality when patients are faced with preference-sensitive care options. We interviewed 28 stakeholders (13 clinicians and 15 patients) to understand their perspectives on early-stage rectal cancer treatment decision-making. Clinicians included surgeons, medical oncologists, and radiation oncologists who treat rectal cancer. Adult patients included those diagnosed with early-stage rectal cancer in the past 5 years, recruited from an institutional database. A semi-structured interview guide was developed based on a well-established decision support framework and reviewed by the research team and stakeholders. Interviews were conducted between January 2022 and January 2023. Transcripts were coded by 2 raters and analyzed using thematic analysis. Both clinicians and patients recognized the importance of SDM to support high-quality decisions about the treatment of early-stage rectal cancer. Barriers to SDM included variable clinician motivation due to lack of training or perception of patients' desires or abilities to engage, as well as time-constrained encounters. A decision aid could help facilitate SDM for early-stage rectal cancer by providing standardized, evidence-based information about treatment options that align with clinicians' and patients' decision needs.
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Affiliation(s)
| | | | | | | | - Mary C. Politi
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine in St. Louis, MO
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20
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Boublikova L, Novakova A, Simsa J, Lohynska R. Total neoadjuvant therapy in rectal cancer: the evidence and expectations. Crit Rev Oncol Hematol 2023; 192:104196. [PMID: 37926376 DOI: 10.1016/j.critrevonc.2023.104196] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 10/14/2023] [Accepted: 11/01/2023] [Indexed: 11/07/2023] Open
Abstract
Current management of locally advanced rectal cancer achieves high cure rates, distant metastatic spread being the main cause of patients' death. Total neoadjuvant therapy (TNT) employs (chemo)radiotherapy and combined chemotherapy prior to surgery to improve the treatment outcomes. TNT has been shown to reduce significantly distant metastases, increase disease-free survival by 5 - 10% in 3 years, and finally also overall survival (≈ 5% in 7 years). It proved to double the rate of pathologic complete responses, making it an attractive strategy for non-operative management to avoid permanent colostomy in patients with distal tumors. In addition, it endorses adherence to the therapy due to better tolerance and, potentially, shortens its overall duration. A number of questions related to TNT remain currently unresolved including the indications, preferred radiotherapy and chemotherapy regimens, their sequence, timing of surgery, and role of adjuvant therapy. A stratified approach may be the optimal way to go.
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Affiliation(s)
- Ludmila Boublikova
- Department of Oncology, 1st Faculty of Medicine, Charles University and Thomayer University Hospital, Prague, Czech Republic; CLIP - Department of Pediatric Hematology and Oncology, 2nd Faculty of Medicine, Charles University and University Hospital in Motol, Prague, Czech Republic.
| | - Alena Novakova
- Department of Oncology, 1st Faculty of Medicine, Charles University and Thomayer University Hospital, Prague, Czech Republic
| | - Jaromir Simsa
- Department of Surgery, 1st Faculty of Medicine, Charles University and Thomayer University Hospital, Prague, Czech Republic
| | - Radka Lohynska
- Department of Oncology, 1st Faculty of Medicine, Charles University and Thomayer University Hospital, Prague, Czech Republic
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21
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Stefanou AJ, Dessureault S, Sanchez J, Felder S. Clinical Tools for Rectal Cancer Response Assessment following Neoadjuvant Treatment in the Era of Organ Preservation. Cancers (Basel) 2023; 15:5535. [PMID: 38067239 PMCID: PMC10705332 DOI: 10.3390/cancers15235535] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 11/04/2023] [Accepted: 11/10/2023] [Indexed: 09/16/2024] Open
Abstract
Local tumor response evaluation following neoadjuvant treatment(s) in rectal adenocarcinoma requires a multi-modality approach including physical and endoscopic evaluations, rectal protocoled MRI, and cross-sectional imaging. Clinical tumor response exists on a spectrum from complete clinical response (cCR), defined as the absence of clinical evidence of residual tumor, to near-complete response (nCR), which assumes a significant reduction in tumor burden but with increased uncertainty of residual microscopic disease, to incomplete clinical response (iCR), which incorporates all responses less than nCR that is not progressive disease. This article aims to review the clinical tools currently routinely available to evaluate treatment response and offers a potential management approach based on the extent of local tumor response.
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Affiliation(s)
| | | | | | - Seth Felder
- Clinical and Pathologic Response to Therapy in Gastrointestinal Oncology, Moffitt Cancer Center, 12902 Magnolia Dr., Tampa, FL 33612, USA; (A.J.S.); (S.D.); (J.S.)
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22
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Amintas S, Giraud N, Fernandez B, Dupin C, Denost Q, Garant A, Frulio N, Smith D, Rullier A, Rullier E, Vuong T, Dabernat S, Vendrely V. The Crying Need for a Better Response Assessment in Rectal Cancer. Curr Treat Options Oncol 2023; 24:1507-1523. [PMID: 37702885 PMCID: PMC10643426 DOI: 10.1007/s11864-023-01125-9] [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: 07/09/2023] [Indexed: 09/14/2023]
Abstract
OPINION STATEMENT Since total neoadjuvant treatment achieves almost 30% pathologic complete response, organ preservation has been increasingly debated for good responders after neoadjuvant treatment for patients diagnosed with rectal cancer. Two organ preservation strategies are available: a watch and wait strategy and a local excision strategy including patients with a near clinical complete response. A major issue is the selection of patients according to the initial tumor staging or the response assessment. Despite modern imaging improvement, identifying complete response remains challenging. A better selection could be possible by radiomics analyses, exploiting numerous image features to feed data characterization algorithms. The subsequent step is to include baseline and/or pre-therapeutic MRI, PET-CT, and CT radiomics added to the patients' clinicopathological data, inside machine learning (ML) prediction models, with predictive or prognostic purposes. These models could be further improved by the addition of new biomarkers such as circulating tumor biomarkers, molecular profiling, or pathological immune biomarkers.
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Affiliation(s)
- Samuel Amintas
- Tumor Biology and Tumor Bank Laboratory, CHU Bordeaux, F-33600, Pessac, France.
- BRIC (BoRdeaux Institute of onCology), UMR1312, INSERM, University of Bordeaux, F-33000, Bordeaux, France.
| | - Nicolas Giraud
- Department of Radiation Oncology, CHU Bordeaux, F-33000, Bordeaux, France
| | | | - Charles Dupin
- BRIC (BoRdeaux Institute of onCology), UMR1312, INSERM, University of Bordeaux, F-33000, Bordeaux, France
- Department of Radiation Oncology, CHU Bordeaux, F-33000, Bordeaux, France
| | - Quentin Denost
- Bordeaux Colorectal Institute, F-33000, Bordeaux, France
| | - Aurelie Garant
- UT Southwestern Department of Radiation Oncology, Dallas, USA
| | - Nora Frulio
- Radiology Department, CHU Bordeaux, F-33600, Pessac, France
| | - Denis Smith
- Department of Digestive Oncology, CHU Bordeaux, F-33600, Pessac, France
| | - Anne Rullier
- Histology Department, CHU Bordeaux, F-33000, Bordeaux, France
| | - Eric Rullier
- BRIC (BoRdeaux Institute of onCology), UMR1312, INSERM, University of Bordeaux, F-33000, Bordeaux, France
- Surgery Department, CHU Bordeaux, F-33600, Pessac, France
| | - Te Vuong
- Department of Radiation Oncology, McGill University, Jewish General Hospital, Montreal, Canada
| | - Sandrine Dabernat
- BRIC (BoRdeaux Institute of onCology), UMR1312, INSERM, University of Bordeaux, F-33000, Bordeaux, France
- Biochemistry Department, CHU Bordeaux, F-33000, Bordeaux, France
| | - Véronique Vendrely
- BRIC (BoRdeaux Institute of onCology), UMR1312, INSERM, University of Bordeaux, F-33000, Bordeaux, France
- Department of Radiation Oncology, CHU Bordeaux, F-33000, Bordeaux, France
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23
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Tan S, Gao Q, Cui Y, Ou Y, Huang S, Feng W. Oncologic outcomes of watch-and-wait strategy or surgery for low to intermediate rectal cancer in clinical complete remission after adjuvant chemotherapy: a systematic review and meta-analysis. Int J Colorectal Dis 2023; 38:246. [PMID: 37787779 DOI: 10.1007/s00384-023-04534-2] [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: 09/18/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND A watch-and-wait (WW) strategy or surgery for low to intermediate rectal cancer that has reached clinical complete remission (cCR) after neoadjuvant chemotherapy (nCRT) or total neoadjuvant therapy (TNT) has been widely used in the clinic, but both treatment strategies are controversial. OBJECTIVE The aim of this study was to compare the oncologic outcomes of a watch-and-wait strategy or a surgical approach to treat rectal cancer in complete remission and to report the evidence-based clinical advantages of the two treatment strategies. METHODS Seven national and international databases were searched for clinical trials comparing the watch-and-wait strategy with surgical treatment for oncological outcomes in patients with rectal cancer in clinical complete remission. RESULTS In terms of oncological outcomes, there was no significant difference between the watch-and-wait strategy and surgical treatment in terms of overall survival (OS) (HR = 0.92, 95% CI (0.52, 1.64), P = 0.777), and subgroup analysis showed no significant difference in 5-year disease-free survival (5-year DFS) between WW and both local excision (LE) and radical surgery (RS) (HR = 1.76, 95% CI (0.97, 3.19), P = 0.279; HR = 1.98, 95% CI (0.95, 4.13), P = 0.164), in distant metastasis rate (RR = 1.12, 95% CI (0.73, 1.72), P = 0.593), mortality rate (RR = 1.62, 95% CI (0.93, 2.84), P = 0.09), and organ preservation rate (RR = 1.05, 95% CI (0.94, 1.17), P = 0.394) which were not statistically significant and on the outcome indicators of local recurrence rate (RR = 2.09, 95% CI (1.44, 3.03), P < 0.001) and stoma rate (RR = 0.35, 95% CI (0.20, 0.61), P < 0.001). There were significant differences between the WW group and the surgical treatment group. CONCLUSION There were no differences in OS, 5-year DFS, distant metastasis, and mortality between the WW strategy group and the surgical treatment group. The WW strategy did not increase the risk of local recurrence compared with local resection but may be at greater risk of local recurrence compared with radical surgery, and the WW group was significantly better than the surgical group in terms of stoma rate; the WW strategy was evidently superior in preserving organ integrity compared to radical excision. Consequently, for patients who exhibit a profound inclination towards organ preservation and the evasion of stoma formation in the scenario of clinically complete remission of rectal cancer, the WW strategy can be contemplated as a pragmatic alternative to surgical interventions. It is, however, paramount to emphasize that the deployment of such a strategy should be meticulously undertaken within the ambit of a multidisciplinary team's management and within specialized centers dedicated to rectal cancer management.
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Affiliation(s)
- Shufa Tan
- Shaanxi University of Chinese Medicine, Xianyang, Shaanxi, China
| | - Qiangqiang Gao
- Affiliated Hospital of Shaanxi University of Traditional Chinese Medicine, Deputy No. 2, West Weiyang Road, Xianyang City, Shaanxi Province, 712000, China
| | - Yaping Cui
- Affiliated Hospital of Shaanxi University of Traditional Chinese Medicine, Deputy No. 2, West Weiyang Road, Xianyang City, Shaanxi Province, 712000, China
| | - Yan Ou
- Affiliated Hospital of Shaanxi University of Traditional Chinese Medicine, Deputy No. 2, West Weiyang Road, Xianyang City, Shaanxi Province, 712000, China
| | - Shuilan Huang
- Shaanxi University of Chinese Medicine, Xianyang, Shaanxi, China
| | - Wenzhe Feng
- Affiliated Hospital of Shaanxi University of Traditional Chinese Medicine, Deputy No. 2, West Weiyang Road, Xianyang City, Shaanxi Province, 712000, China.
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24
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Özoran E, Özata İH, Uymaz DS, Omarov N, Bozkurt E, Tüfekçi T, Karahan SN, Gürbüz B, Selçukbiricik F, Bölükbaşı Y, Taşkın OÇ, Gürses B, Rencüzoğulları A, Buğra D, Balık E. Multimodal assessment after total neoadjuvant therapy versus standard neoadjuvant chemoradiotherapy in locally advanced rectal cancer accurately predicts complete responders. Int J Colorectal Dis 2023; 38:229. [PMID: 37707664 DOI: 10.1007/s00384-023-04526-2] [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: 09/08/2023] [Indexed: 09/15/2023]
Abstract
PURPOSE This study aimed to compare local regrowth rates after total neoadjuvant therapy (TNT) versus standard neoadjuvant chemoradiotherapy (SNCRT) in locally advanced rectal cancer (LARC) patients that were strictly selected and assessed with a multimodal approach. Secondary outcomes were 4-year disease-free (DFS) and overall survival (OS) rates. METHODS Locally advanced rectal cancer patients without distant metastases treated at Koç Healthcare Group between January 2014 and January 2021 were included. Patients were assessed for complete response with a combination of digital rectal exam, endoscopy, and magnetic resonance imaging with a dedicated rectum protocol. The systemic evaluation was performed with an upper abdomen MRI using intravenous hepatobiliary contrast agent and a thorax CT. RESULTS Of the 270 patients with LARC, 182 fulfilled the inclusion criteria. Ninety-seven (53.3%) underwent TNT, while 85 (46.7%) underwent SNCRT. A cumulative combination of pathological and sustained clinical complete response was significantly higher in the TNT group than in the SNCRT (45.4% vs. 20.0%, p < 0.0001). After a median follow-up of 48 months, seven patients in the W&W group had regrowth [TNT: 4 (10.8%) vs. SNCRT: 3 (23.1%), p = 0.357]. Based on pathological examination, complete/near complete mesorectum rates (p = 1.000) and circumferential resection margin positivity rates (p = 1.000) were similar between the groups. The 4-year DFS and OS rates were comparable. The patients with clinical or pathological complete response had significantly longer overall survival (p = 0.017) regardless of the type of neoadjuvant treatment. CONCLUSIONS Multimodal assessment after TNT effectively detects complete responders, resulting in low local recurrence and increased cumulative complete response rates. However, these outcomes did not translate into a survival advantage.
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Affiliation(s)
- Emre Özoran
- Department of General Surgery, Koç University School of Medicine, Istanbul, Turkey.
| | - İbrahim Halil Özata
- Department of General Surgery, Koç University School of Medicine, Istanbul, Turkey
| | - Derya Salim Uymaz
- Department of General Surgery, Koç University School of Medicine, Istanbul, Turkey
| | - Nail Omarov
- Department of General Surgery, Koç University School of Medicine, Istanbul, Turkey
| | - Emre Bozkurt
- Department of General Surgery, Koç University School of Medicine, Istanbul, Turkey
| | - Tutku Tüfekçi
- Department of General Surgery, Koç University School of Medicine, Istanbul, Turkey
| | - Salih Nafiz Karahan
- Department of General Surgery, Koç University School of Medicine, Istanbul, Turkey
| | - Bülent Gürbüz
- Department of General Surgery, VKV American Hospital, Istanbul, Turkey
| | - Fatih Selçukbiricik
- Department of Medical Oncology, Koç University School of Medicine, Istanbul, Turkey
| | - Yasemin Bölükbaşı
- Department of Radiation Oncology, Koç University School of Medicine, Istanbul, Turkey
| | - Orhun Çığ Taşkın
- Department of Pathology, Koç University School of Medicine, Istanbul, Turkey
| | - Bengi Gürses
- Department of Radiology, Koç University School of Medicine, Istanbul, Turkey
| | - Ahmet Rencüzoğulları
- Department of General Surgery, Koç University School of Medicine, Istanbul, Turkey
| | - Dursun Buğra
- Department of General Surgery, Koç University School of Medicine, Istanbul, Turkey
- Department of General Surgery, VKV American Hospital, Istanbul, Turkey
| | - Emre Balık
- Department of General Surgery, Koç University School of Medicine, Istanbul, Turkey
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25
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Safatle-Ribeiro AV, Ribeiro U, Lata J, Baba ER, Lenz L, da Costa Martins B, Kawaguti F, Moura RN, Pennacchi C, Gusmon C, de Lima MS, de Paulo GA, Nahas CS, Marques CF, Imperiale AR, Cotti GC, Maluf-Filho F, Nahas SC. The Role of Probe-Based Confocal Laser Endomicroscopy (pCLE) in the Diagnosis of Sustained Clinical Complete Response Under Watch-and-Wait Strategy After Neoadjuvant Chemoradiotherapy for Locally Advanced Rectal Adenocarcinoma: a Score Validation. J Gastrointest Surg 2023; 27:1903-1912. [PMID: 37291428 DOI: 10.1007/s11605-023-05732-7] [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: 01/16/2023] [Accepted: 05/01/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Watch-and-wait strategy has been increasingly accepted for patients with clinical complete response (cCR) after multimodal treatment for locally advanced rectal adenocarcinoma. Close follow-up is essential to the early detection of local regrowth. It was previously demonstrated that probe-based confocal laser endomicroscopy (pCLE) scoring using the combination of epithelial and vascular features might improve the diagnostic accuracy of cCR. AIM To validate the pCLE scoring system in the assessment of patients with cCR after neoadjuvant chemoradiotherapy (nCRxt) for advanced rectal adenocarcinoma. METHODS Digital rectal examination, pelvic magnetic resonance imaging (MRI), and pCLE were performed in 43 patients with cCR, who presented either a scar (N = 33; 76.7%) or a small ulcer with no signs of tumor, and/or biopsy negative for malignancy (N = 10; 23.3%). RESULTS Twenty-five (58.1%) patients were men, and the mean age was 58.4 years. During the follow-up, 12/43 (27.9%) patients presented local regrowth and underwent salvage surgery. There was an association between pCLE diagnostic scoring and final histological report (for patients who underwent surgical resection) or final diagnosis at the latest follow-up (p = 0.0001), while this association was not observed with MRI (p = 0.49). pCLE sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 66.7%, 93.5%, 80%, 88.9%, and 86%, respectively. MRI sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 66.7%, 48.4%, 66.7%, 78.9%, and 53.5%, respectively. CONCLUSIONS pCLE scoring system based on epithelial and vascular features improved the diagnosis of sustained cCR and might be recommended during follow-up. pCLE might add some valuable contribution for identifying local regrowth. Trial Registration This protocol was registered at the Clinical Trials (ClinicalTrials.gov identifier NCT02284802).
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Affiliation(s)
- Adriana Vaz Safatle-Ribeiro
- Endoscopy Unit, Department of Gastroenterology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Universidade de São Paulo (ICESP-HCFMUSP), São Paulo, Brazil.
| | - Ulysses Ribeiro
- Digestive Surgery and Colorectal Division, Department of Gastroenterology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Universidade de São Paulo (ICESP-HCFMUSP), São Paulo, Brazil
| | - John Lata
- Endoscopy Unit, Department of Gastroenterology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Universidade de São Paulo (ICESP-HCFMUSP), São Paulo, Brazil
| | - Elisa Ryoka Baba
- Endoscopy Unit, Department of Gastroenterology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Universidade de São Paulo (ICESP-HCFMUSP), São Paulo, Brazil
| | - Luciano Lenz
- Endoscopy Unit, Department of Gastroenterology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Universidade de São Paulo (ICESP-HCFMUSP), São Paulo, Brazil
| | - Bruno da Costa Martins
- Endoscopy Unit, Department of Gastroenterology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Universidade de São Paulo (ICESP-HCFMUSP), São Paulo, Brazil
| | - Fábio Kawaguti
- Endoscopy Unit, Department of Gastroenterology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Universidade de São Paulo (ICESP-HCFMUSP), São Paulo, Brazil
| | - Renata Nobre Moura
- Endoscopy Unit, Department of Gastroenterology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Universidade de São Paulo (ICESP-HCFMUSP), São Paulo, Brazil
| | - Caterina Pennacchi
- Endoscopy Unit, Department of Gastroenterology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Universidade de São Paulo (ICESP-HCFMUSP), São Paulo, Brazil
| | - Carla Gusmon
- Endoscopy Unit, Department of Gastroenterology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Universidade de São Paulo (ICESP-HCFMUSP), São Paulo, Brazil
| | - Marcelo Simas de Lima
- Endoscopy Unit, Department of Gastroenterology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Universidade de São Paulo (ICESP-HCFMUSP), São Paulo, Brazil
| | - Gustavo Andrade de Paulo
- Endoscopy Unit, Department of Gastroenterology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Universidade de São Paulo (ICESP-HCFMUSP), São Paulo, Brazil
| | - Caio Sérgio Nahas
- Digestive Surgery and Colorectal Division, Department of Gastroenterology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Universidade de São Paulo (ICESP-HCFMUSP), São Paulo, Brazil
| | - Carlos Frederico Marques
- Digestive Surgery and Colorectal Division, Department of Gastroenterology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Universidade de São Paulo (ICESP-HCFMUSP), São Paulo, Brazil
| | - Antônio Rocco Imperiale
- Digestive Surgery and Colorectal Division, Department of Gastroenterology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Universidade de São Paulo (ICESP-HCFMUSP), São Paulo, Brazil
| | - Guilherme C Cotti
- Digestive Surgery and Colorectal Division, Department of Gastroenterology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Universidade de São Paulo (ICESP-HCFMUSP), São Paulo, Brazil
| | - Fauze Maluf-Filho
- Endoscopy Unit, Department of Gastroenterology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Universidade de São Paulo (ICESP-HCFMUSP), São Paulo, Brazil
| | - Sérgio Carlos Nahas
- Digestive Surgery and Colorectal Division, Department of Gastroenterology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Universidade de São Paulo (ICESP-HCFMUSP), São Paulo, Brazil
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Horváth ÖP, Bellyei S, Pozsgai É, Vereczkei A. Changes in Oncological Surgical Principles Driven by Advances in Preoperative Treatments. Ther Clin Risk Manag 2023; 19:667-674. [PMID: 37575686 PMCID: PMC10422972 DOI: 10.2147/tcrm.s415860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 06/25/2023] [Indexed: 08/15/2023] Open
Abstract
From a surgical point of view, the development of preoperative oncological treatment has had a profound effect on the surgical treatment trends of cancer as well as on the outcomes of cancer patients. Consequently, these changes have challenged formerly entrenched oncological surgical principles. In our short report, we aimed to summarize the main shifts regarding the surgical principles of cancer treatment due to the development of preoperative oncological therapy in recent years. As a result of successful preoperative treatment, surgeons may perform less radical surgeries, the required free resection margin has been narrowed down to a few millimeters in dimension and preoperative treatment is justified in both definitely resectable tumors and in oligometastatic tumors as well. For prognosis assessment, the post-preoperative oncological treatment stage is now considered decisive, rather than the pretreatment stage as previously thought. Other changes include the introduction of the watch and wait strategy and the reverse order of treatment of the primary tumor and metastasis. Observing the continuously improving outcomes of cancer patients and the developments in oncological treatment modalities, a further expansion of the indication of preoperative treatments is to be expected.
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Affiliation(s)
- Örs Péter Horváth
- Department of Surgery, University of Pécs Clinical Center, Pécs, 7624, Hungary
| | - Szabolcs Bellyei
- Department of Oncotherapy, University of Pécs Clinical Center, Pécs, 7624, Hungary
| | - Éva Pozsgai
- Department of Public Health, University of Pécs Medical School, Pécs, 7624, Hungary
- Department of Primary Health Care, University of Pécs Medical School, Pécs, 7623, Hungary
| | - András Vereczkei
- Department of Surgery, University of Pécs Clinical Center, Pécs, 7624, Hungary
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27
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Habr-Gama A, São Julião GP, Ortega CD, Vailati BB, Araujo S, Jorge T, Sabbaga J, Rossi GL, D'Alpino R, Kater FR, Aguilar PB, Mattacheo A, Perez RO. A multi-centre randomized controlled trial investigating Consolidation Chemotherapy with and without oxaliplatin in distal rectal cancer and Watch & Wait. BMC Cancer 2023; 23:546. [PMID: 37316784 DOI: 10.1186/s12885-023-10984-2] [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: 06/09/2022] [Accepted: 05/19/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Neoadjuvant chemoradiation(nCRT) has been considered the preferred initial treatment strategy for distal rectal cancer. Advantages of this approach include improved local control after radical surgery but also the opportunity for organ preserving strategies (Watch and Wait-WW). Consolidation chemotherapy(cCT) regimens using fluoropyrimidine-based with or without oxalipatin following nCRT have demonstrated to increase complete response and organ preservation rates among these patients. However, the benefit of adding oxaliplatin to cCT compared to fluoropirimidine alone regimens in terms of primary tumor response remains unclear. Since oxalipatin-treatment may be associated with considerable toxicity, it becomes imperative to understand the benefit of its incorporation into standard cCT regimens in terms of primary tumor response. The aim of the present trial is to compare the outcomes of 2 different cCT regimens following nCRT (fluoropyrimidine-alone versus fluoropyrimidine + oxaliplatin) for patients with distal rectal cancer. METHODS In this multi-centre study, patients with magnetic resonance-defined distal rectal tumors will be randomized on a 1:1 ratio to receive long-course chemoradiation (54 Gy) followed by cCT with fluoropyrimidine alone versus fluoropyrimidine + oxaliplatin. Magnetic resonance(MR) will be analyzed centrally prior to patient inclusion and randomization. mrT2-3N0-1 tumor located no more than 1 cm above the anorectal ring determined by sagittal views on MR will be eligible for the study. Tumor response will be assessed after 12 weeks from radiotherapy(RT) completion. Patients with clinical complete response (clinical, endoscopic and radiological) may be enrolled in an organ-preservation program(WW). The primary endpoint of this trial is decision to organ-preservation surveillance (WW) at 18 weeks from RT completion. Secondary endpoints are 3-year surgery-free survival, TME-free survival, distant metastases-free survival, local regrowth-free survival and colostomy-free survival. DISCUSSION Long-course nCRT with cCT is associated with improved complete response rates and may be a very attractive alternative to increase the chances for organ-preservation strategies. Fluoropyrimidine-based cCT with or without oxaliplatin has never been investigated in the setting of a randomized trial to compare clinical response rates and the possibility of organ-preservation. The outcomes of this study may significantly impact clinical practice of patients with distal rectal cancer interested in organ-preservation. TRIAL REGISTRATION www. CLINICALTRIALS gov NCT05000697; registered on August 11th, 2021.
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Affiliation(s)
- Angelita Habr-Gama
- University of São Paulo School of Medicine, São Paulo, Brazil
- Angelita and Joaquim Gama Institute, Praça Amadeu Amaral, 47 - conj.111, São Paulo, 01327-904, Brazil
- Department of Coloproctology, Hospital Alemão Oswaldo Cruz, Praça Amadeu Amaral, 47 - conj.111, São Paulo, 01327-904, Brazil
| | - Guilherme Pagin São Julião
- Angelita and Joaquim Gama Institute, Praça Amadeu Amaral, 47 - conj.111, São Paulo, 01327-904, Brazil
- Department of Coloproctology, Hospital Alemão Oswaldo Cruz, Praça Amadeu Amaral, 47 - conj.111, São Paulo, 01327-904, Brazil
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, Praça Amadeu Amaral, 47 - conj.111, São Paulo, 01327-904, Brazil
| | - Cinthia D Ortega
- Department of Radiology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
- Department of Radiology and Diagnostic Imaging, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Bruna Borba Vailati
- Angelita and Joaquim Gama Institute, Praça Amadeu Amaral, 47 - conj.111, São Paulo, 01327-904, Brazil
- Department of Coloproctology, Hospital Alemão Oswaldo Cruz, Praça Amadeu Amaral, 47 - conj.111, São Paulo, 01327-904, Brazil
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, Praça Amadeu Amaral, 47 - conj.111, São Paulo, 01327-904, Brazil
| | - Sergio Araujo
- Department of Radiology and Diagnostic Imaging, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Thiago Jorge
- Department of Medical Oncology, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Jorge Sabbaga
- Department of Medical Oncology, Hospital Sírio Libanês, São Paulo, Brazil
| | - Gustavo L Rossi
- Servicio Cirugia General, Hospital Italiano de Buenos Aires, Sector de Coloproctologia, Buenos Aires, Argentina
| | | | - Fabio Roberto Kater
- Department of Medical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil
| | | | | | - Rodrigo Oliva Perez
- Angelita and Joaquim Gama Institute, Praça Amadeu Amaral, 47 - conj.111, São Paulo, 01327-904, Brazil.
- Department of Coloproctology, Hospital Alemão Oswaldo Cruz, Praça Amadeu Amaral, 47 - conj.111, São Paulo, 01327-904, Brazil.
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, Praça Amadeu Amaral, 47 - conj.111, São Paulo, 01327-904, Brazil.
- Ludwig Institute for Cancer Research, Praça Amadeu Amaral, 47 - conj.111, São Paulo, 01327-904, Brazil.
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Couwenberg AM, Varvoglis DN, Grieb BC, Marijnen CA, Ciombor KK, Guillem JG. New Opportunities for Minimizing Toxicity in Rectal Cancer Management. Am Soc Clin Oncol Educ Book 2023; 43:e389558. [PMID: 37307515 PMCID: PMC10450577 DOI: 10.1200/edbk_389558] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Advances in multimodal management of locally advanced rectal cancer (LARC), consisting of preoperative chemotherapy and/or radiotherapy followed by surgery with or without adjuvant chemotherapy, have improved local disease control and patient survival but are associated with significant risk for acute and long-term morbidity. Recently published trials, evaluating treatment dose intensification via the addition of preoperative induction or consolidation chemotherapy (total neoadjuvant therapy [TNT]), have demonstrated improved tumor response rates while maintaining acceptable toxicity. In addition, TNT has led to an increased number of patients achieving a clinical complete response and thus eligible to pursue a nonoperative, organ-preserving, watch and wait approach, thereby avoiding toxicities associated with surgery, such as bowel dysfunction and stoma-related complications. Ongoing trials using immune checkpoint inhibitors in patients with mismatch repair-deficient tumors suggest that this subgroup of patients with LARC could potentially be treated with immunotherapy alone, sparing them the toxicity associated with preoperative treatment and surgery. However, the majority of rectal cancers are mismatch repair-proficient and less responsive to immune checkpoint inhibitors and require multimodal management. The synergy noted in preclinical studies between immunotherapy and radiotherapy on immunogenic tumor cell death has led to the design of ongoing clinical trials that explore the benefit of combining radiotherapy, chemotherapy, and immunotherapy (mainly of immune checkpoint inhibitors) and aim to increase the number of patients eligible for organ preservation.
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Affiliation(s)
- Alice M. Couwenberg
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Brian C. Grieb
- Vanderbilt University Medical Center/Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Corrie A.M. Marijnen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Kristen K. Ciombor
- Vanderbilt University Medical Center/Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Jose G. Guillem
- Department of Surgery, Lineberger Comprehensive Cancer Center, University of North Carolina-Chapel Hill, Chapel Hill, NC
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29
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Cuicchi D, Castagna G, Cardelli S, Larotonda C, Petrello B, Poggioli G. Restaging rectal cancer following neoadjuvant chemoradiotherapy. World J Gastrointest Oncol 2023; 15:700-712. [PMID: 37275455 PMCID: PMC10237020 DOI: 10.4251/wjgo.v15.i5.700] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/01/2023] [Accepted: 03/29/2023] [Indexed: 05/12/2023] Open
Abstract
Correct tumour restaging is pivotal for identifying the most personalised surgical treatment for patients with locally advanced rectal cancer undergoing neoadjuvant therapy, and works to avoid both poor oncological outcome and overtreatment. Digital rectal examination, endoscopy, and pelvic magnetic resonance imaging are the recommended modalities for local tumour restaging, while chest and abdominal computed tomography are utilised for the assessment of distant disease. The optimal length of time between neoadjuvant treatment and restaging, in terms of both oncological safety and clinical effectiveness of treatment, remains unclear, especially for patients receiving prolonged total neoadjuvant therapy. The timely identification of patients who are radioresistant and at risk of disease progression remains challenging.
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Affiliation(s)
- Dajana Cuicchi
- Department of Medical and Surgical Sciences, Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna 40138, Italy
| | - Giovanni Castagna
- Department of Medical and Surgical Sciences, Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna 40138, Italy
| | - Stefano Cardelli
- Department of Medical and Surgical Sciences, Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna 40138, Italy
| | - Cristina Larotonda
- Department of Medical and Surgical Sciences, Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna 40138, Italy
| | - Benedetta Petrello
- Department of Medical and Surgical Sciences, Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna 40138, Italy
| | - Gilberto Poggioli
- Department of Medical and Surgical Sciences, Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna 40138, Italy
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30
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Cerdan-Santacruz C, São Julião GP, Vailati BB, Corbi L, Habr-Gama A, Perez RO. Watch and Wait Approach for Rectal Cancer. J Clin Med 2023; 12:jcm12082873. [PMID: 37109210 PMCID: PMC10143332 DOI: 10.3390/jcm12082873] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/10/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
The administration of neoadjuvant chemoradiotherapy (nCRT) followed by total mesorrectal excision (TME) and selective use of adjuvant chemotherapy can still be considered the standard of care in locally advanced rectal cancer (LARC). However, avoiding sequelae of TME and entering a narrow follow-up program of watch and wait (W&W), in select cases that achieve a comparable clinical complete response (cCR) to nCRT, is now very attractive to both patients and clinicians. Many advances based on well-designed studies and long-term data coming from big multicenter cohorts have drawn some important conclusions and warnings regarding this strategy. In order to safely implement W&W, it is important consider proper selection of cases, best treatment options, surveillance strategy and the attitudes towards near complete responses or even tumor regrowth. The present review offers a comprehensive overview of W&W strategy from its origins to the most current literature, from a practical point of view focused on daily clinical practice, without losing sight of the most important future prospects in this area.
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Affiliation(s)
- Carlos Cerdan-Santacruz
- Department of Coloproctology, Hospital Universitario de la Princesa, 28006 Madrid, Spain
- Department of Coloproctology, Clínica Santa Elena, 28003 Madrid, Spain
| | - Guilherme Pagin São Julião
- Angelita and Joaquim Gama Institute, São Paulo 01329-020, Brazil
- Department of Coloproctology, Hospital Alemão Oswaldo Cruz, São Paulo 01323-020, Brazil
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo 01323-001, Brazil
| | - Bruna Borba Vailati
- Angelita and Joaquim Gama Institute, São Paulo 01329-020, Brazil
- Department of Coloproctology, Hospital Alemão Oswaldo Cruz, São Paulo 01323-020, Brazil
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo 01323-001, Brazil
| | - Leonardo Corbi
- Angelita and Joaquim Gama Institute, São Paulo 01329-020, Brazil
- Department of Coloproctology, Hospital Alemão Oswaldo Cruz, São Paulo 01323-020, Brazil
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo 01323-001, Brazil
| | - Angelita Habr-Gama
- Angelita and Joaquim Gama Institute, São Paulo 01329-020, Brazil
- Department of Coloproctology, Hospital Alemão Oswaldo Cruz, São Paulo 01323-020, Brazil
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo 01323-001, Brazil
| | - Rodrigo Oliva Perez
- Angelita and Joaquim Gama Institute, São Paulo 01329-020, Brazil
- Department of Coloproctology, Hospital Alemão Oswaldo Cruz, São Paulo 01323-020, Brazil
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo 01323-001, Brazil
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31
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Borelli B, Germani MM, Carullo M, Mattioni R, Manfredi B, Sainato A, Rossi P, Vagli P, Balestri R, Buccianti P, Morelli L, Antoniotti C, Cremolini C, Masi G, Moretto R. Total neoadjuvant treatment and organ preservation strategies in the management of localized rectal cancer: a narrative review and evidence-based algorithm. Crit Rev Oncol Hematol 2023; 186:103985. [PMID: 37059274 DOI: 10.1016/j.critrevonc.2023.103985] [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: 01/15/2023] [Revised: 03/26/2023] [Accepted: 04/11/2023] [Indexed: 04/16/2023] Open
Abstract
The multimodal approach with total mesorectal excision preceded by neoadjuvant (chemo)radiotherapy represented the mainstay treatment for locally advanced rectal cancer (LARC) for a long time. However, the benefit of adjuvant chemotherapy in terms of distant relapse reduction is limited. Recently, chemotherapy regimens administered before surgery and incorporated with (chemo)radiotherapy in total neoadjuvant treatment protocols have been established as new options in the management of LARC. Meanwhile, patients with clinical complete response to neoadjuvant treatment can benefit from organ preservation strategies, aimed at sparing surgery and long-term post-operative morbidities, while preserving an adequate disease control. However, the introduction of a non-operative management in clinical practice is a matter of debate with some concerns regarding the risk of local recurrence and long-term outcomes. In this review, we discuss how these recent advances are reshaping the multimodal management of localized rectal cancer and propose an algorithm to place them in the clinical practice.
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Affiliation(s)
- Beatrice Borelli
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy; Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Marco Maria Germani
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Martina Carullo
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy; Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Roberto Mattioni
- Radiation Oncology Unit, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Bruno Manfredi
- Radiation Oncology Unit, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Aldo Sainato
- Radiation Oncology Unit, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Piercarlo Rossi
- Diagnostic and Interventional Radiology Unit, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Paola Vagli
- Diagnostic and Interventional Radiology Unit, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Riccardo Balestri
- General Surgery, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Piero Buccianti
- General Surgery, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Luca Morelli
- General Surgery, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Carlotta Antoniotti
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Chiara Cremolini
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy; Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Gianluca Masi
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy; Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Roberto Moretto
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy.
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Wang L, Zhang XY, Zhao YM, Li SJ, Li ZW, Sun YS, Wang WH, Wu AW. Intentional Watch and Wait or Organ Preservation Surgery Following Neoadjuvant Chemoradiotherapy Plus Consolidation CAPEOX for MRI-defined Low-risk Rectal Cancer: Findings From a Prospective Phase 2 Trial (PKUCH-R01 Trial, NCT02860234). Ann Surg 2023; 277:647-654. [PMID: 35766394 PMCID: PMC9994840 DOI: 10.1097/sla.0000000000005507] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the efficacy and safety of intentional watch and wait (W&W) and organ preservation surgery following neoadjuvant chemoradiotherapy plus consolidation CAPEOX in magnetic resonance imaging (MRI)-defined low-risk rectal cancer. BACKGROUND Clinical T2/early T3 rectal cancers can achieve high yield pathological complete response (ypCR) rates after chemoradiotherapy; thus, an intentional W&W or organ preservation strategy for good clinical responders in these subgroups can be further tested. METHODS This prospective, single-arm, phase 2 trial enrolled patients with low-risk MRI prestaged rectal cancers, who concurrently received chemoradiation, followed by four 3-weekly cycles of CAPEOX regimen. Following reassessment, clinical complete response (cCR) or near-cCR patients underwent W&W/organ preservation surgery; the primary endpoint was a 3-year organ preservation rate. RESULTS Of the 64 participants, 58 completed treatment, with 6.4% and 33.9% grade 3 to 4 toxicities in the radiotherapy and consolidation CAPEOX phases, respectively, during a median 39.5-month follow-up. Initial cCR, and non-cCR occurred in 33, 13, and 18 patients, respectively. Of the 31 cCR and 7 near-cCR cases managed by W&W, local regrowth occurred in 7; of these, 6 received salvage surgery. The estimated 2-year local regrowth rates were 12.9% [95% confidence interval (CI): 1.1%-24.7%] in cCR and 42.9% (95% CI: 6.2%-79.6%) in near-cCR cases, respectively. Eight patients received local excision, including 2 with regrowth salvage. Lung metastases occurred in 3 patients and multiple metastasis occurred in 1 patient; no local recurrence occurred. The estimated 3-year organ preservation rate was 67.2% (95% CI: 55.6%-78.8%). The estimated 3-year cancer-specific survival, non-regrowth disease-free survival, and stoma-free survival were 96.6% (95% CI: 92.1%-100%), 92.2% (95% CI: 85.5%-98.9%), and 82.7% (95% CI: 73.5%-91.9%), respectively. CONCLUSIONS Chemoradiotherapy plus consolidation CAPEOX for MRI-defined low-risk rectal cancer can lead to high rates of organ preservation through intentional W&W or local excision. The oncologic safety of this strategy should be further tested.
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Affiliation(s)
- Lin Wang
- Department of Gastrointestinal Surgery, Peking University Cancer Hospital, Beijing, PR China
| | - Xiao-Yan Zhang
- Department of Radiology, Peking University Cancer Hospital, Beijing, PR China
| | - Yi-Ming Zhao
- Department of Gastrointestinal Surgery, Peking University Cancer Hospital, Beijing, PR China
| | - Shi-Jie Li
- Department of Endoscopy Center, Peking University Cancer Hospital, Beijing, PR China
| | - Zhong-Wu Li
- Department of Pathology, Peking University Cancer Hospital, Beijing, PR China
| | - Ying-Shi Sun
- Department of Radiology, Peking University Cancer Hospital, Beijing, PR China
| | - Wei-Hu Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing, PR China
| | - Ai-Wen Wu
- Department of Gastrointestinal Surgery, Peking University Cancer Hospital, Beijing, PR China
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Li J, Ma Y, Wen L, Zhang G, Yao X. Outcomes after the watch-and-wait strategy and local excision treatment for rectal cancer: a meta-analysis. Expert Rev Anticancer Ther 2023; 23:555-564. [PMID: 36795784 DOI: 10.1080/14737140.2023.2181796] [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: 02/17/2023]
Abstract
BACKGROUND The watch-and-wait (W&W) strategy and local excision (LE) have been used in patients with clinical complete response (cCR) for rectal cancer, but the comparative outcomes of the two strategies are controversial. We compared the efficacy of the W&W strategy with LE for rectal cancer patients after neoadjuvant chemoradiotherapy (nCRT) or total neoadjuvant therapy (TNT). RESEARCH DESIGN AND METHODS Several domestic and foreign databases were searched for the relevant literature on comparative trials of the W&W strategy and LE surgery for rectal cancer after neoadjuvant therapy with the following outcomes; differences in local recurrence (LR), distant metastasis (DM/DM+LR), 3-year disease-free survival (DFS), 3-year local recurrence-free survival (LRFS) and 3-year overall survival (OS). RESULTS Nine articles, were analyzed. Overall, 442 patients were included, with 267 and 175 patients in the W&W and LE groups, respectively. Meta-analysis results showed no significant differences the between W&W and LE groups with respect to LR, DM/DM+LR, 3-year DFS, 3-year LRFS, and 3-year OS. This study has been registered in PROSPERO (registration number: CRD42022331208). CONCLUSION The W&W strategy may be preferred for some rectal cancer patients who select LE and reach cCR or near cCR after nCRT or TNT.
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Affiliation(s)
- Jinghui Li
- Gannan Medical university, Ganzhou, Jiangxi, China.,Ganzhou Hospital of Guangdong Provincial People's Hospital, Ganzhou Municipal Hospital, Ganzhou, Jiangxi, China.,Department of Gastrointestinal Surgery, Department of General Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, PR, China
| | - Yongli Ma
- Gannan Medical university, Ganzhou, Jiangxi, China.,Ganzhou Hospital of Guangdong Provincial People's Hospital, Ganzhou Municipal Hospital, Ganzhou, Jiangxi, China
| | - Liang Wen
- Gannan Medical university, Ganzhou, Jiangxi, China.,Ganzhou Hospital of Guangdong Provincial People's Hospital, Ganzhou Municipal Hospital, Ganzhou, Jiangxi, China.,Department of Gastrointestinal Surgery, Department of General Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, PR, China
| | - Guosheng Zhang
- Gannan Medical university, Ganzhou, Jiangxi, China.,Ganzhou Hospital of Guangdong Provincial People's Hospital, Ganzhou Municipal Hospital, Ganzhou, Jiangxi, China
| | - Xueqing Yao
- Gannan Medical university, Ganzhou, Jiangxi, China.,Ganzhou Hospital of Guangdong Provincial People's Hospital, Ganzhou Municipal Hospital, Ganzhou, Jiangxi, China.,Department of Gastrointestinal Surgery, Department of General Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, PR, China
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Post-Surgical Imaging Assessment in Rectal Cancer: Normal Findings and Complications. J Clin Med 2023; 12:jcm12041489. [PMID: 36836024 PMCID: PMC9966470 DOI: 10.3390/jcm12041489] [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: 11/17/2022] [Revised: 12/30/2022] [Accepted: 02/09/2023] [Indexed: 02/16/2023] Open
Abstract
Rectal cancer (RC) is one of the deadliest malignancies worldwide. Surgery is the most common treatment for RC, performed in 63.2% of patients. The type of surgical approach chosen aims to achieve maximum residual function with the lowest risk of recurrence. The selection is made by a multidisciplinary team that assesses the characteristics of the patient and the tumor. Total mesorectal excision (TME), including both low anterior resection (LAR) and abdominoperineal resection (APR), is still the standard of care for RC. Radical surgery is burdened by a 31% rate of major complications (Clavien-Dindo grade 3-4), such as anastomotic leaks and a risk of a permanent stoma. In recent years, less-invasive techniques, such as local excision, have been tested. These additional procedures could mitigate the morbidity of rectal resection, while providing acceptable oncologic results. The "watch and wait" approach is not a globally accepted model of care but encouraging results on selected groups of patients make it a promising strategy. In this plethora of treatments, the radiologist is called upon to distinguish a physiological from a pathological postoperative finding. The aim of this narrative review is to identify the main post-surgical complications and the most effective imaging techniques.
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Grotenhuis BA, Beets GL. Watch-and-Wait is an Option in Rectal Cancer Patients: From Controversy to Common Clinical Practice. Clin Oncol (R Coll Radiol) 2023; 35:124-129. [PMID: 36481218 DOI: 10.1016/j.clon.2022.11.011] [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: 04/26/2022] [Revised: 10/26/2022] [Accepted: 11/14/2022] [Indexed: 12/12/2022]
Abstract
Overview of the introduction of organ preservation in rectal cancer patients and future challenges.
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Affiliation(s)
- B A Grotenhuis
- Department of Surgical Oncology, Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - G L Beets
- GROW - School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands.
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Kim B, Lee CM, Jang JK, Kim J, Lim SB, Kim AY. Deep learning-based imaging reconstruction for MRI after neoadjuvant chemoradiotherapy for rectal cancer: effects on image quality and assessment of treatment response. ABDOMINAL RADIOLOGY (NEW YORK) 2023; 48:201-210. [PMID: 36261505 DOI: 10.1007/s00261-022-03701-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 10/01/2022] [Accepted: 10/03/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE To investigate the effects of deep learning-based imaging reconstruction (DLR) on the image quality of MRI of rectal cancer after chemoradiotherapy (CRT), and its accuracy in diagnosing pathological complete responses (pCR). METHODS We included 39 patients (men: women, 21:18; mean age ± standard deviation, 59.1 ± 9.7 years) with mid-to-lower rectal cancer who underwent a long-course of CRT and high-resolution rectal MRIs between January 2020 and April 2021. Axial T2WI was reconstructed using the conventional method (MRIconv) and DLR with two different noise reduction factors (MRIDLR30 and MRIDLR50). The signal-to-noise ratio (SNR) of the tumor was measured. Two experienced radiologists independently made a blind assessment of the complete response on MRI. The sensitivity and specificity for pCR were analyzed using a multivariable logistic regression analysis with generalized estimating equations. RESULTS Thirty-four patients did not have a pCR whereas five (12.8%) had pCR. Compared with the SNR of MRIconv (mean ± SD, 7.94 ± 1.92), MRIDLR30 and MRIDLR50 showed higher SNR (9.44 ± 2.31 and 11.83 ± 3.07, respectively) (p < 0.001). Compared to MRIconv, MRIDLR30 and MRIDLR50 showed significantly higher specificity values (p < 0.036) while the sensitivity values were not significantly different (p > 0.301). The sensitivity and specificity for pCR were 48.9% and 80.8% for MRIconv; 48.9% and 88.2% for MRIDLR30; and 38.8% and 86.7% for MRIDLR50, respectively. CONCLUSION DLR produced MR images with higher resolution and SNR. The specificity of MRI for identification of pCR was significantly higher with DLR than with conventional MRI.
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Affiliation(s)
- Bona Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Chul-Min Lee
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.,Department of Radiology, Hanyang University Medical Center, 222-1, Wangsimni-ro, Seongdong-gu, Seoul, 04763, Republic of Korea
| | - Jong Keon Jang
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
| | - Jihun Kim
- Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Seok-Byung Lim
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Ah Young Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
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Cerdán-Santacruz C, Vailati BB, São Julião GP, Habr-Gama A, Perez RO. Local tumor regrowth after clinical complete response following neoadjuvant therapy for rectal cancer: what happens when organ preservation falls short. Tech Coloproctol 2023; 27:1-9. [PMID: 35986804 DOI: 10.1007/s10151-022-02654-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 06/09/2022] [Indexed: 01/12/2023]
Abstract
Organ preservation strategies, especially watch and wait, after neoadjuvant treatment in locally advanced rectal cancer, have become topics that generate significant interest, for both patients and clinicians. The obvious advantage of these strategies is the avoidance of surgery with its associated risks and functional consequences. Over time, it has become evident that these strategies offer acceptable safety in oncological terms and, in most patients, allows preservation of the rectum without harming patients in terms of distant metastasis or survival. However, there is a small group of patients in whom the tumor returns after an initially diagnosed clinical complete response; patients with local tumor regrowth. The main threat in these patients is not simply local disease, which can be successfully managed in most cases, but the possible effects it may have on distant metastases. The pathophysiology of the phenomenon of local tumor regrowth is not well known and, therefore, strategies to minimize possible impact on survival are not well defined. Our aim is to review key issues in this subgroup that pose a substantial threat to the safety and viability of organ-preserving and watch-and-wait strategies. We also explore possible pathophysiologic explanations and future directions and perspectives that may improve both local and systemic disease control.
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Affiliation(s)
- C Cerdán-Santacruz
- Colorectal Surgery, Hospital Universitario de la Princesa, Madrid, Spain
| | - B B Vailati
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil
- Division of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
- Angelita and Joaquim Gama Institute, Praça Amadeu Amaral 47, con. 111, São Paulo, 01327-904, Brazil
| | - G P São Julião
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil
- Division of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
- Angelita and Joaquim Gama Institute, Praça Amadeu Amaral 47, con. 111, São Paulo, 01327-904, Brazil
| | - A Habr-Gama
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil
- Division of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
- Angelita and Joaquim Gama Institute, Praça Amadeu Amaral 47, con. 111, São Paulo, 01327-904, Brazil
| | - R O Perez
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil.
- Division of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil.
- Angelita and Joaquim Gama Institute, Praça Amadeu Amaral 47, con. 111, São Paulo, 01327-904, Brazil.
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Fernandez LM, São Julião GP, Renehan AG, Beets GL, Papoila AL, Vailati BB, Bahadoer RR, Kranenbarg EMK, Roodvoets AGH, Figueiredo NL, Van De Velde CJH, Habr-Gama A, Perez RO. The Risk of Distant Metastases in Patients With Clinical Complete Response Managed by Watch and Wait After Neoadjuvant Therapy for Rectal Cancer: The Influence of Local Regrowth in the International Watch and Wait Database. Dis Colon Rectum 2023; 66:41-49. [PMID: 36515514 DOI: 10.1097/dcr.0000000000002494] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Nearly 30% of patients with rectal cancer develop local regrowth after initial clinical complete response managed by watch and wait. These patients might be at higher risk for distant metastases. OBJECTIVE This study aimed to investigate risk factors for distant metastases using time-dependent analyses. DESIGN Data from an international watch and wait database were retrospectively reviewed. Cox regression analysis was used to determine risk factors for worse distant metastases-free survival. Conditional survival modeling was used to investigate the impact of risk factors on the development of distant metastases. SETTING Retrospective, multicenter database. PATIENTS A total of 793 patients (47 institutions) with rectal cancer and clinical complete response to neoadjuvant treatment from the International Watch & Wait Database were included. MAIN OUTCOME MEASURES Distant metastases-free survival. RESULTS Of the 793 patients managed with watch and wait (median follow-up 55.2 mo)' 85 patients (10.7%) had distant metastases. Fifty-one of 85 patients (60%) had local regrowth at any time. Local regrowth was an independent factor associated with worse distant metastases-free survival in the multivariable model. Using conditional estimates, patients with local regrowth without distant metastases for 5 years (from decision to watch and wait) remained at higher risk for development of distant metastases for 1 subsequent year compared to patients without local regrowth (5-year conditional distant metastases-free survival 94.9% vs 98.4%). LIMITATIONS Lack of information on adjuvant chemotherapy, salvage surgery for local regrowth, and heterogeneity of individual surveillance/follow-up strategies used may have affected results. CONCLUSIONS In patients with clinical complete response managed by watch and wait, development of local regrowth at any time is a risk factor for distant metastases. The risk of distant metastases remains higher for 5 years after development of local regrowth. See Video Abstract at http://links.lww.com/DCR/C53. EL RIESGO DE METSTASIS A DISTANCIA EN PACIENTES CON RESPUESTA CLNICA COMPLETA MANEJADA POR WATCH AND WAIT DESPUS DE LA TERAPIA NEOADYUVANTE PARA EL CNCER DE RECTO LA INFLUENCIA DEL NUEVO CRECIMIENTO LOCAL EN LA BASE DE DATOS INTERNACIONAL WATCH AND WAIT ANTECEDENTES:Casi el 30 % de los pacientes con cáncer de recto desarrollan un nuevo crecimiento local después de la respuesta clínica completa inicial manejada por watch and wait. Estos pacientes podrían tener un mayor riesgo de metástasis a distancia.OBJETIVO:Investigar los factores de riesgo de metástasis a distancia mediante análisis dependientes del tiempo.DISEÑO:Se revisó retrospectivamente los datos de la base de datos internacional de Watch and Wait. Se utilizó el análisis de regresión de Cox para determinar los factores de riesgo de peor sobrevida libre de metástasis a distancia. Se utilizó un modelo de sobrevida condicional para investigar el impacto de los factores de riesgo en el desarrollo de metástasis a distancia. El tiempo transcurrido hasta el evento se calculó utilizando la fecha de decisión para watch and wait y la fecha del nuevo crecimiento local para el diagnóstico de metástasis a distancia.ESCENARIOBase de datos multicéntrica retrospectiva.PACIENTES:Se incluyeron un total de 793 pacientes (47 instituciones) con cáncer de recto y respuesta clínica completa al tratamiento neoadyuvante de la base de datos internacional de Watch and Wait.PRINCIPALES MEDIDAS DE RESULTADO:Desarrollo de metástasis a distancia.RESULTADOS:De los 793 pacientes tratados con watch and wait (mediana de seguimiento de 55,2 meses), 85 (10,7%) tenían metástasis a distancia. 51 de 85 (60%) tuvieron recrecimiento local en algún momento. El recrecimiento local fue un factor independiente asociado a una peor supervivencia libre de metástasis a distancia en el modelo multivariable. Además, al usar estimaciones condicionales, los pacientes con recrecimiento local sin metástasis a distancia durante 5 años (desde la decisión de watch and wait) permanecieron en mayor riesgo de desarrollar metástasis a distancia durante un año subsiguiente en comparación con los pacientes sin recrecimiento local (sobrevida libre de metástasis a distancia a 5 años: recrecimiento local 94,9% frente a no recrecimiento local 98,4%).LIMITACIONES:La falta de información relacionada con el uso de quimioterapia adyuvante, las características específicas de la cirugía de rescate para el nuevo crecimient o local y la heterogeneidad de las estrategias individuales de vigilancia/seguimiento utilizadas pueden haber afectado los resultados observados.CONCLUSIONES:En pacientes con respuesta clínica completa manejados por Watch and Wait, el desarrollo de recrecimiento local en cualquier momento es un factor de riesgo para metástasis a distancia. El riesgo de metástasis a distancia sigue siendo mayor durante 5 años después del desarrollo de un nuevo crecimiento local. Consulte Video Resumen en http://links.lww.com/DCR/C53. (Traducción-Dr. Felipe Bellolio).
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Affiliation(s)
- Laura M Fernandez
- Colorectal Surgery, Digestive Department, Champalimaud Foundation, Lisbon, Portugal
| | - Guilherme P São Julião
- Colorectal Surgery Division, Angelita and Joaquim Gama Institute, São Paulo, Brazil
- Department of Surgical Oncology, Colorectal Surgery Division, Hospital Beneficencia Portuguesa, São Paulo, Brazil
- Colorectal Surgery Division, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Andrew G Renehan
- Manchester Cancer Research Centre, National Institute of Health and Research Manchester Biomedical Research Centre, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, United Kingdom
- Colorectal and Peritoneal Oncology Centre, The Christie National Health Service Foundation Trust, Manchester, United Kingdom
| | - Geerard L Beets
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
- GROW School for Oncology and Developmental Biology, Maastricht University, the Netherlands
| | - Ana L Papoila
- NOVA Medical School, Faculdade de Ciências Médicas (NMS|FCM), Lisbon, Portugal
| | - Bruna B Vailati
- Colorectal Surgery Division, Angelita and Joaquim Gama Institute, São Paulo, Brazil
- Department of Surgical Oncology, Colorectal Surgery Division, Hospital Beneficencia Portuguesa, São Paulo, Brazil
- Colorectal Surgery Division, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Renu R Bahadoer
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Annet G H Roodvoets
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Nuno L Figueiredo
- Colorectal Surgery, Digestive Department, Champalimaud Foundation, Lisbon, Portugal
- Colorectal Surgery, Hospital Lusiadas, Lisbon, Portugal
| | - Cornelis J H Van De Velde
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Angelita Habr-Gama
- Colorectal Surgery Division, Angelita and Joaquim Gama Institute, São Paulo, Brazil
- Colorectal Surgery Division, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
- University of São Paulo School of Medicine, São Paulo, Brazil
| | - Rodrigo O Perez
- Colorectal Surgery Division, Angelita and Joaquim Gama Institute, São Paulo, Brazil
- Department of Surgical Oncology, Colorectal Surgery Division, Hospital Beneficencia Portuguesa, São Paulo, Brazil
- Colorectal Surgery Division, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
- Ludwig Institute for Cancer Research, São Paulo Branch, Brazil
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Wu F, Zhang X, Yang C, Wang K, Xiao L, Zhou C, Zhao X, Wang G. The reduction of 18F-FDG uptake ability of tumor tissue after neoadjuvant chemoradiotherapy in locally advanced rectal cancer can effectively reflect the degree of tumor regression. Front Oncol 2022; 12:1037783. [PMID: 36620536 PMCID: PMC9814115 DOI: 10.3389/fonc.2022.1037783] [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: 09/06/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction To evaluate the predictive value of 18F-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET-CT) imaging parameters for the response to neoadjuvant chemoradiotherapy (nCRT) in locally advanced rectal cancer (LARC). Methods From January 2016 to March 2020, 52 LARC patients who underwent 18F-FDG PET-CT scans within 1 week before and 8-9 weeks after nCRT, were enrolled in this study according to a pre-designed screening criteria. After total mesorectal excision (TME) surgery, we assessed tumor response to treatment and analyzed the correlation between imaging parameters obtained from two PET-CT scans and tumor regression status. Results Tumor response assessment showed that 13 of 52 patients received good response (GR), including 9 cases with pathological complete regression (pCR) and 4 cases with near-pathological complete regression (near-pCR). We also found that the maximum standard uptake value after nCRT (post-SUVmax), the response index (RI), the mean standard uptake values after nCRT (post-SUVmean), and the ratio of tumor SUVmean to liver SUVmean after nCRT (post-Ratio), were correlated with GR and pCR. Among these parameters, post-SUVmax and RI had a near-strong correlation with pCR (rs= -0.58 and 0.59, respectively), and also had a strong correlation with GR (rs = -0.7 and 0.63, respectively). Further ROC analysis showed that post-SUVmax and RI had higher values in predicting whether patients could achieve GR and pCR after nCRT, and the area under the curve (AUC) of both were greater than 0.9. The positive predictive values (PPVs) and negative predictive values (NPVs) of post-SUVmax for GR were 80.01% and 97.3%, and for pCR were 66.68% and 97.5%, respectively. The PPVs and NPVs of the RI values for GR were 84.61% and 94.87%, and for pCR were 69.24% and 100%, respectively. Conclusion For LARC patients, the analysis of imaging parameters such as post-SUVmax and RI, which can reflect the changes of 18F-FDG uptake capacity of tumor tissues before and after nCRT, is of great value for predicting the response of patients to neoadjuvant therapy and guiding the selection of subsequent treatment strategies.
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Affiliation(s)
- Fengpeng Wu
- Department of Radiation Oncology, Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xiaoxiao Zhang
- Department of Radiation Oncology, Fourth Hospital of Hebei Medical University, Shijiazhuang, China,Department of Radiation Oncology, Hebei Cancer Hospital Chinese Academy of Medical Sciences, Langfang, China
| | - Congrong Yang
- Department of Radiation Oncology, Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Kanghua Wang
- Department of Radiation Oncology, Fourth Hospital of Hebei Medical University, Shijiazhuang, China,Department of Medical Oncology, Affiliated Hospital Of Hebei University, Baoding, China
| | - Linlin Xiao
- Department of Radiation Oncology, Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Chaoxi Zhou
- Department of General Surgery, Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xinming Zhao
- Department of Nuclear Medicine, Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Guiying Wang
- Department of Radiation Oncology, Hebei Cancer Hospital Chinese Academy of Medical Sciences, Langfang, China,Department of General Surgery, Second Hospital of Hebei Medical University, Shijiazhuang, China,*Correspondence: Guiying Wang, ;
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Zhang SC, Atkins KM, Chung EM, Kamrava M. Emerging Role of Brachytherapy in the Non-operative Management of Rectal Cancer. CURRENT COLORECTAL CANCER REPORTS 2022. [DOI: 10.1007/s11888-022-00479-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Steinke J, Minnaar H, Franklin A, Yu J, Baird P, Halling-Brown M, Trumble M, Patel N, Jordan C, Rossides S, Wang L, Ratnakumaran R, Brooker C, Rockall T, Stewart A. Contact X-Ray Brachytherapy for Early Rectal Cancer: A Review of Outcomes From a Single UK Centre. Clin Oncol (R Coll Radiol) 2022. [DOI: 10.1016/j.clon.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Wyatt J, Powell S, Ahmed S. Watch and Wait in Rectal Cancer After a Complete Response to Chemoradiotherapy – Is It Safe and Are We Doing Enough? Clin Oncol (R Coll Radiol) 2022. [DOI: 10.1016/j.clon.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Sheng XQ, Wang HZ, Li S, Zhang YZ, Geng JH, Zhu XG, Quan JZ, Li YH, Cai Y, Wang WH. Consolidation chemotherapy with capecitabine after neoadjuvant chemoradiotherapy in high-risk patients with locally advanced rectal cancer: Propensity score study. World J Gastrointest Oncol 2022; 14:1711-1726. [PMID: 36187388 PMCID: PMC9516640 DOI: 10.4251/wjgo.v14.i9.1711] [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: 04/29/2022] [Revised: 07/20/2022] [Accepted: 08/10/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The effects of consolidation chemotherapy (CC) in neoadjuvant therapy in locally advanced rectal cancer (LARC) have been explored. However, the optimal neoadjuvant chemoradiotherapy (NCRT) and surgery interval, regimen, and cycles of chemotherapy remains unclear.
AIM To evaluate the effects of one to two cycles of CC with capecitabine on high-risk patients with LARC without extending NCRT and surgery interval.
METHODS We retrospectively evaluated high-risk patients with LARC, who were defined as having at least one of the following factors by magnetic resonance imaging: depth of invasion beyond the muscularis propria of more than 5 mm (cT3c-cT3d), T4, meso-rectal fascia or extramural vascular invasion positive, and treatment date between January 2015 and July 2019 in our center. Patients were divided into the CC and non-CC group according to whether they received CC (capecitabine 1000 mg/m2 twice daily from days 1 to 14 every 21 d) after NCRT. Propensity score matching (PSM) and inverse probability of treatment weight (IPTW) were used to balance the differences between the two groups. The main outcome was the complete response (CR) rate.
RESULTS A total of 265 patients were enrolled: 136 patients in the CC group and 129 patients in the non-CC group. The median interval was 70 d (range, 37-168). The CR rate was 24.3% and 16.3% (P = 0.107) in the CC and non-CC groups’ original samples, respectively. After PSM and IPTW, the CR rate in the CC group was higher than that in non-CC group (27.6% vs 16.2%, P = 0.045; 25.9% vs 16.3%, P = 0.045). The median follow-up was 39.8 mo (range, 2.9-74.8), and there were no differences in 3-year non-regrowth disease-free survival nor overall survival in the original samples (73.2% vs 71.9%, P = 0.913; 92.3% vs 86.7%, P = 0.294), PSM (73.2% vs 73.5%, P = 0.865; 92.5% vs 89.3%, P = 0.612), and IPTW (73.8% vs 72.1%, P = 0.913; 92.4% vs 87.4%, P = 0.294). There was also no difference in grade 2 or higher acute toxicity during neoadjuvant therapy in the two groups (49.3% vs 53.5%, P = 0.492).
CONCLUSION One to two cycles of CC with capecitabine after NCRT was safe and increased the CR rate in high-risk LARC but failed to improve the long-term outcomes.
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Affiliation(s)
- Xue-Qing Sheng
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital and Institute, Beijing 100142, China
- Department of Radiation Oncology, Peking University People's Hospital, Beijing 100044, China
| | - Hong-Zhi Wang
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Shuai Li
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Yang-Zi Zhang
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Jian-Hao Geng
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Xiang-Gao Zhu
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Ji-Zhong Quan
- Department of Radiation Oncology, Jilin Guowen Hospital, Gongzhuling 136199, Jilin Province, China
| | - Yong-Heng Li
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Yong Cai
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Wei-Hu Wang
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital and Institute, Beijing 100142, China
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Hołdakowska A, Gerard JP, Bujko K. The importance of measuring baseline tumour volume (or alternatively tumour length along with its rectal circumferential extent) in the watch-and-wait strategy in rectal cancer: a review. Acta Oncol 2022; 61:1084-1092. [DOI: 10.1080/0284186x.2022.2122866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Anna Hołdakowska
- Department of Radiology I, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | | | - Krzysztof Bujko
- Department of Radiotherapy I, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
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Peltrini R, Imperatore N, Di Nuzzo MM, Pellino G. Towards personalized treatment of T2N0 rectal cancer: A systematic review of long-term oncological outcomes of neoadjuvant therapy followed by local excision. J Gastroenterol Hepatol 2022; 37:1426-1433. [PMID: 35614027 PMCID: PMC9545053 DOI: 10.1111/jgh.15898] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 05/17/2022] [Accepted: 05/19/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIM Total mesorectal excision (TME) remains the treatment of choice in T2N0 tumors. However, evidence suggest that one-size-fits-all approach is not always beneficial for this group of patients. The aim of this study is to synthesize data on long-term outcomes after neoadjuvant therapy (NAT) followed by local excision (LE) in T2N0 rectal cancer patients in the perspective of a rectal-preserving strategy. METHODS A systematic search of PubMed/MEDLINE, SCOPUS, and Web of Science databases was conducted until October 2021 to identify studies comparing LE after NAT and TME or reporting oncologic outcomes after conservative approach. A pooled analysis was conducted using a fixed-effect model in the case of non-significant heterogeneity (P > 0.1), and a random effect model (DerSimonian-Laird method) when significant heterogeneity was present (P < 0.1) CRD42022300344. RESULTS Nine studies were included in the analysis. Three of them were comparative studies. The pooled 3-year DFS, 5-year DFS, 3-year OS, 5-year OS, local and distant recurrence rates were 92.8% (95% CI 81.6-99.5%), 91.3% (95% CI 88.3-94.3%), 96.1% (95% CI 90.5-100%), 72.6% (95% CI 57.5-87.7%), 4% (95% CI 18-63%), and 4.9% (95% CI 2-7.8%), respectively, in subjects treated with NAT followed by LE. No heterogeneity was found for all these analyses, except for the 5-year OS sub-analysis (I2 95.5%, P < 0.001). Complete pathological response (ypT0) rate after NAT and LE ranges from 26.7% to 59%. CONCLUSION LE following neoadjuvant CRT may provide comparable survival benefit to radical surgery for patients with clinical stage T2N0 in selected patients although the evidence is still limited to provide solid recommendations. A personalized therapeutic approach taking into account tumor and patient-related factors should be considered.
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Affiliation(s)
- Roberto Peltrini
- Department of Public Health, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Nicola Imperatore
- Gastroenterology and Endoscopy Unit, AORN Antonio Cardarelli, Naples, Italy
| | - Maria Michela Di Nuzzo
- Department of Public Health, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitell", Naples, Italy.,Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
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MORPHEUS Phase II–III Study: A Pre-Planned Interim Safety Analysis and Preliminary Results. Cancers (Basel) 2022; 14:cancers14153665. [PMID: 35954329 PMCID: PMC9367346 DOI: 10.3390/cancers14153665] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 07/21/2022] [Accepted: 07/22/2022] [Indexed: 02/04/2023] Open
Abstract
Background: We explored image-guided adaptive endorectal brachytherapy patients electing non-operative management for rectal cancer. We present the first pre-planned interim analysis. Methods: In this open-label phase II–III randomized study, patients with operable cT2-3ab N0 M0 rectal cancer received 45 Gy in 25 fractions of pelvic external beam radiotherapy (EBRT) with 5-FU/Capecitabine. They were randomized 1:1 to receive either an EBRT boost of 9 Gy in 5 fractions (Arm A) or three weekly adaptive brachytherapy (IGAEBT) boosts totaling 30 Gy (Arm B). Patient characteristics and toxicity are presented using descriptive analyses; TME-free survival between arms with the intention to treat the population is explored using the Kaplan–Meier method. Results: A total of 40 patients were in this analysis. Baseline characteristics were balanced; acute toxicities were similar. Complete clinical response (cCR) was 50% (n = 10/20) in Arm A and 90% in Arm B (n = 18/20). Median follow-up was 1.3 years; 2-year TME-free survival was 38.6% (95% CI: 16.5–60.6%) in the EBRT arm and 76.6% (95% CI: 56.1–97.1%) in the IGAEBT arm. Conclusions: Radiation intensification with IGAEBT is feasible. This interim analysis suggests an improvement in TME-free survival when comparing IGAEBT with EBRT, pending confirmation upon completion of this trial.
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Quality of life in a randomized trial comparing two neoadjuvant regimens for locally advanced rectal cancer-INCAGI004. Support Care Cancer 2022; 30:6557-6572. [PMID: 35486228 DOI: 10.1007/s00520-022-07059-6] [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: 09/29/2021] [Accepted: 04/11/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Neoadjuvant chemoradiotherapy (neoCRT) followed by surgery is the standard of care for locally advanced rectal cancer (LARC), but the emergence of different drug regimens may result in different response rates. Good clinical response translates into greater sphincter preservation, but quality of life (QOL) may be impaired after treatment due to chemoradiotherapy and surgical side effects. OBJECTIVE To prospectively evaluate the impact of clinical response and surgical resection on QOL in a randomized trial comparing two different neoCRT regimens. METHODS Stage II and III rectal cancer patients were randomized to receive neoCRT with either capecitabine (group 1) or 5-Fu and leucovorin (group 2) concomitant to long-course radiotherapy. Clinical downstaging was accessed using MRI 6-8 weeks after treatment. EORTCs QLQ-C30 and CR38 were applied before treatment (T0), after neoCRT (T1), after rectal resection (T2), early after adjuvant chemotherapy (T3), and 1 year after the end of treatment or stoma closure (T4). The Wexner scale was used for fecal incontinence evaluation at T4. A C30SummaryScore (Geisinger and cols.) was calculated to compare QOL results. RESULTS Thirty-two patients were assigned to group 1 and 31 to group 2. Clinical downstaging occurred in 70.0% of group 1 and 53.3% of group 2 (p = 0.288), and sphincter preservation was 83.3% in group 1 and 80.0% in group 2 (p = 0.111). No significant difference in QOL was detected when comparing the two treatment groups after neoCRT using QLQ-C30. However, the CR38 module detected differences in micturition problems (15.3 points), gastrointestinal problems (15.3 points), defecation problems (11.8 points), and sexual satisfaction (13.3 points) favoring the capecitabine group. C30SummaryScore detected significant improvement comparing T0 to T1 and deterioration comparing T1 to T2 (p = 0.025). The mean Wexner scale score was 9.2, and a high score correlated with symptoms of diarrhea and defecation problems at T4. CONCLUSIONS QOL was equivalent between groups after neoCRT except for micturition problems, gastrointestinal problems, defecation problems, and sexual satisfaction favoring the capecitabine arm after. The overall QOL using the C30SummaryScore was improved after neoCRT, but decreased following rectal resection, returning to basal levels at late evaluation. Fecal incontinence was high after sphincter preservation. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03428529.
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Paquette IM. Adding Versus Omitting: When New Clinical Information Appears After Updating Clinical Practice Guidelines. Dis Colon Rectum 2022; 65:464-465. [PMID: 35082231 DOI: 10.1097/dcr.0000000000002399] [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: 12/13/2022]
Affiliation(s)
- Ian M Paquette
- University of Cincinnati College of Medicine Surgery (Colon and Rectal), Cincinnati, Ohio
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Cerdán-Santacruz C, Vailati BB, São Julião GP, Habr-Gama A, Pérez RO. Watch and wait: Why, to whom and how. Surg Oncol 2022; 43:101774. [DOI: 10.1016/j.suronc.2022.101774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 04/12/2022] [Indexed: 12/26/2022]
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Cotti GC, Pandini RV, Braghiroli OFM, Nahas CSR, Bustamante-Lopez LA, Marques CFS, Imperiale AR, Ribeiro U, Salvajoli B, Hoff PM, Nahas SC. Outcomes of Patients With Local Regrowth After Nonoperative Management of Rectal Cancer After Neoadjuvant Chemoradiotherapy. Dis Colon Rectum 2022; 65:333-339. [PMID: 34775415 DOI: 10.1097/dcr.0000000000002197] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Clinical complete responders after chemoradiation for rectal cancer are increasingly being managed by a watch-and-wait strategy. Nonetheless, a significant proportion will experience a local regrowth, and the long-term oncological outcomes of these patients is not totally known. OBJECTIVE The purpose of this study was to analyze the outcomes of patients who submitted to a watch-and-wait strategy and developed a local regrowth, and to compare these results with sustained complete clinical responders. DESIGN This was a retrospective study. SETTING Single institution, tertiary cancer center involved in alternatives to organ preservation. PATIENTS Patients with a biopsy-proven rectal adenocarcinoma (stage II/III or low lying cT2N0M0 at risk for an abdominoperineal resection) treated with chemoradiation who were found at restage to have a clinical complete response. INTERVENTIONS Rectal cancer patients treated with chemoradiation who underwent a watch-and-wait strategy (without a full thickness local excision) and developed a local regrowth were compared to the remaining patients of the watch-and-wait strategy. MAIN OUTCOME MEASURES Overall survival between groups, incidence of regrowth' and results of salvage surgery. RESULTS There were 67 patients. Local regrowth occurred in 20 (29.9%) patients treated with a watch-and-wait strategy. Mean follow-up was 62.7 months. Regrowth occurred at mean 14.2 months after chemoradiation, half of them within the first 12 months. Patients presented with comparable initial staging, lateral pelvic lymph-node metastasis, and extramural venous invasion. The regrowth group had a statistically nonsignificant higher incidence of mesorectal fascia involvement (35.0% vs 13.3%, p = 0.089). All regrowths underwent salvage surgery, mostly (75%) a sphincter-sparing procedure. 5-year overall survival was 71.1% in patients with regrowth and 91.1% in patients with a sustained complete clinical response (p = 0.027). LIMITATIONS This study was limited by its retrospective evaluation of patient selection for a watch-and-wait strategy and outcomes, as well as its small sample size. CONCLUSIONS Local regrowth is a frequent event when following a watch-and-wait policy (29.9%); however, patients could undergo salvage surgical treatment with adequate pelvic control. In this series, overall survival showed a statistically significant difference from patients managed with a watch-and-wait strategy who experienced a local regrowth compared to those who did not. See Video Abstract at http://links.lww.com/DCR/B773.RESULTADOS DE LOS PACIENTES CON REBROTE LOCAL, DESPUÉS DEL MANEJO NO QUIRÚRGICO DEL CÁNCER DE RECTO, DESPUÉS DE LA QUIMIORRADIOTERAPIA NEOADYUVANTEANTECEDENTES:Los respondedores clínicos completos, después de la quimiorradiación para el cáncer de recto, se tratan cada vez más mediante una estrategia de observación y espera. No obstante, una proporción significativa experimentará un rebrote local y los resultados oncológicos a largo plazo de estos pacientes, no se conocen por completo.OBJETIVO:El propósito de este estudio, fue analizar los resultados de los pacientes sometidos a una estrategia de observación y espera, que desarrollaron un rebrote local, y comparar estos resultados con respondedores clínicos completos sostenidos.DISEÑO:Este fue un estudio retrospectivo.ENTORNO CLINICO.Institución única, centro oncológico terciario involucrado en alternativas a la preservación de órganos.PACIENTES:Pacientes con un adenocarcinoma de recto comprobado por biopsia (estadio II / III o posición baja cT2N0M0, en riesgo de resección abdominoperineal), tratados con quimiorradiación, y que durante un reestadiaje, presentaron una respuesta clínica completa.INTERVENCIONES:Los pacientes con cáncer de recto tratados con quimiorradiación, sometidos a una estrategia de observación y espera (sin una escisión local de espesor total) y que desarrollaron un rebrote local, se compararon con los pacientes restantes de la estrategia de observación y espera.PRINCIPALES MEDIDAS DE VALORACION:Supervivencia global entre los grupos, incidencia de rebrote y resultados de la cirugía de rescate.RESULTADOS:Fueron 67 pacientes. El rebrote local ocurrió en 20 (29,9%) pacientes tratados con una estrategia de observación y espera. El seguimiento medio fue de 62,7 meses. El rebrote se produjo a la media de 14,2 meses después de la quimiorradiación, la mitad de ellos dentro de los primeros 12 meses. Los pacientes se presentaron con una estadificación inicial comparable, metástasis en los ganglios linfáticos pélvicos laterales e invasión venosa extramural. El grupo de rebrote tuvo una mayor incidencia estadísticamente no significativa de afectación de la fascia mesorrectal (35,0 vs 13,3%, p = 0,089). Todos los rebrotes se sometieron a cirugía de rescate, en su mayoría (75%) con procedimiento de preservación del esfínter. La supervivencia global a 5 años fue del 71,1% en pacientes con rebrote y del 91,1% en pacientes con una respuesta clínica completa sostenida (p = 0,027).LIMITACIONES:Evaluación retrospectiva de la selección de pacientes para una estrategia y resultados de observar y esperar, tamaño de muestra pequeño.CONCLUSIONES:El rebrote local es un evento frecuente después de la política de observación y espera (29,9%), sin embargo los pacientes podrían someterse a un tratamiento quirúrgico de rescate con un adecuado control pélvico. En esta serie, la supervivencia global mostró una diferencia estadísticamente significativa de los pacientes manejados con una estrategia de observación y espera que experimentaron un rebrote local, en comparación con los que no lo hicieron. Consulte Video Resumen en http://links.lww.com/DCR/B773. (Traducción-Dr. Fidel Ruiz Healy).
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Affiliation(s)
- Guilherme Cutait Cotti
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
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