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Aherne S, Donnelly M, Ryan ÉJ, Davey MG, Creavin B, McGrath E, McCarthy A, Geraghty R, Gibbons D, Nagtegaal I, Lugli A, Kirsch R, Martin ST, Winter DC, Sheahan K. Tumour budding as a prognostic biomarker in biopsies and resections of neoadjuvant-treated rectal adenocarcinoma. Histopathology 2024; 85:224-243. [PMID: 38629323 DOI: 10.1111/his.15192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 03/02/2024] [Accepted: 03/30/2024] [Indexed: 07/16/2024]
Abstract
BACKGROUND Tumour budding (TB) is a marker of tumour aggressiveness which, when measured in rectal cancer resection specimens, predicts worse outcomes and response to neoadjuvant therapy. We investigated the utility of TB assessment in the setting of neoadjuvant treatment. METHODS AND RESULTS A single-centre, retrospective cohort study was conducted. TB was assessed using the hot-spot International Tumour Budding Consortium (ITBCC) method and classified by the revised ITBCC criteria. Haematoxylin and eosin (H&E) and AE1/AE3 cytokeratin (CK) stains for ITB (intratumoural budding) in biopsies with PTB (peritumoural budding) and ITB (intratumoural budding) in resection specimens were compared. Logistic regression assessed budding as predictors of lymph node metastasis (LNM). Cox regression and Kaplan-Meier analyses investigated their utility as a predictor of disease-free (DFS) and overall (OS) survival. A total of 146 patients were included; 91 were male (62.3%). Thirty-seven cases (25.3%) had ITB on H&E and 79 (54.1%) had ITB on CK assessment of biopsy tissue. In univariable analysis, H&E ITB [odds (OR) = 2.709, 95% confidence interval (CI) = 1.261-5.822, P = 0.011] and CK ITB (OR = 2.165, 95% CI = 1.076-4.357, P = 0.030) predicted LNM. Biopsy-assessed H&E ITB (OR = 2.749, 95% CI = 1.258-6.528, P = 0.022) was an independent predictor of LNM. In Kaplan-Meier analysis, ITB identified on biopsy was associated with worse OS (H&E, P = 0.003, CK: P = 0.009) and DFS (H&E, P = 0.012; CK, P = 0.045). In resection specimens, CK PTB was associated with worse OS (P = 0.047), and both CK PTB and ITB with worse DFS (PTB, P = 0.014; ITB: P = 0.019). In multivariable analysis H&E ITB predicted OS (HR = 2.930, 95% CI = 1.261-6.809) and DFS (HR = 2.072, 95% CI = 1.031-4.164). CK PTB grading on resection also independently predicted OS (HR = 3.417, 95% CI = 1.45-8.053, P = 0.005). CONCLUSION Assessment of TB using H&E and CK may be feasible in rectal cancer biopsy and post-neoadjuvant therapy-treated resection specimens and is associated with LNM and worse survival outcomes. Future management strategies for rectal cancer might be tailored to incorporate these findings.
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Affiliation(s)
- Susan Aherne
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
- School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
- International Tumour Budding Consortium Funded by the Dutch Cancer Society, Amsterdam, The Netherlands
| | - Mark Donnelly
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
- School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
| | - Éanna J Ryan
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
- School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
| | - Matthew G Davey
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - Ben Creavin
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
- School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
| | - Erinn McGrath
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
- School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
| | - Aoife McCarthy
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - Robert Geraghty
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - David Gibbons
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
- School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
- International Tumour Budding Consortium Funded by the Dutch Cancer Society, Amsterdam, The Netherlands
| | - Iris Nagtegaal
- International Tumour Budding Consortium Funded by the Dutch Cancer Society, Amsterdam, The Netherlands
| | - Alessandro Lugli
- International Tumour Budding Consortium Funded by the Dutch Cancer Society, Amsterdam, The Netherlands
| | - Richard Kirsch
- International Tumour Budding Consortium Funded by the Dutch Cancer Society, Amsterdam, The Netherlands
| | - Sean T Martin
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
- School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
| | - Desmond C Winter
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
- School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
| | - Kieran Sheahan
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
- School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
- International Tumour Budding Consortium Funded by the Dutch Cancer Society, Amsterdam, The Netherlands
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2
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Anker CJ, Tchelebi L, 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 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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3
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Obonyo D, Uslar V, Weyhe D, Tabriz N. Personalized medicine for locally advanced rectal cancer: five years of complete clinical response after neoadjuvant radiochemotherapy-a case report with a literature review. Front Surg 2024; 11:1385378. [PMID: 38590724 PMCID: PMC10999613 DOI: 10.3389/fsurg.2024.1385378] [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: 02/12/2024] [Accepted: 03/11/2024] [Indexed: 04/10/2024] Open
Abstract
We present a case report of a 73-year-old male patient with a complete clinical response following neoadjuvant radiochemotherapy of mid-rectal adenocarcinoma. The patient was initially diagnosed with stage IIIB microsatellite stable mid-rectal adenocarcinoma in February 2017. During restaging in June 2017, which included rectoscopy, endosonography, computed tomography and magnetic resonance imaging, a complete clinical response was observed. After appropriate consultation, a watch-and-wait strategy was chosen. During stringent follow-up every 3 months for the first 3 years and thereafter every 6 months, no recurrence or regrowth was observed. After the fifth year of complete clinical response, we recommended an annual follow-up. As of November 2023, the patient has no signs of recurrence or late toxicity after radiochemotherapy. The omission of resection in patients with locally advanced rectal cancer and the establishment of a watch-and-wait strategy are currently under discussion as possible treatment courses in patients with complete clinical response. Long-term data on watch-and-wait strategies for patients with a complete clinical response in locally advanced rectal cancer are rare. A clear national and international accepted standardization of follow-up programs for patients managed by a watch-and-wait strategy in the long-term is missing. Here, we report the case of a patient who had undergone a follow-up program for more than five years and discuss the current literature. Our case report and literature review highlights that a watch-and-wait strategy does not seem to increase the risk of systemic disease or compromise survival outcomes in selected locally advanced rectal cancer patients. Thus, our case contributes to the growing body of knowledge on personalized and precision medicine for rectal cancer.
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Affiliation(s)
- Dennis Obonyo
- Carl von Ossietzky University Oldenburg, University Clinic for Visceral Surgery, Pius-Hospital Oldenburg, Oldenburg, Germany
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4
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Du R, Chang Y, Zhang J, Cheng Y, Li Y, Zhang C, Zhang J, Xu L, Liu Y. Whether the watch-and-wait strategy has application value for rectal cancer with clinical complete response after neoadjuvant chemoradiotherapy? A network meta-analysis. Asian J Surg 2024; 47:853-863. [PMID: 38042663 DOI: 10.1016/j.asjsur.2023.11.047] [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: 08/03/2023] [Revised: 10/29/2023] [Accepted: 11/10/2023] [Indexed: 12/04/2023] Open
Abstract
The aim was to evaluate the efficacy and safety between the watch-and-wait strategy (WW), radical surgery (RS), and local excision (LE) for rectal cancer with clinical complete response (cCR) after neoadjuvant radiotherapy (nCRT). We searched MEDLINE, EMBASE, the Cochrane Library, and clinical trials to compare WW with RS and LE for patients with cCR until March 2023 and collected the following data: local recurrence (LR), distant metastasis (DM), cancer-related death (CRD), overall survival (OS), and disease-free survival (DFS). In total, 2240 patients from 21 studies were included. Pairwise meta-analysis revealed no statistically significant differences between the three groups in terms of CRD and 2-, 3-, and 5-year OS (P < 0.05). The RS group was significantly better than the WW group in terms of the LR rate (odds ratio [OR] = 0.12, 95 % confidence interval [CI]: 0.06-0.21, P < 0.001, I2 = 0 %], 3-year DFS (OR = 1.56, 95 % CI: 1.10-2.21, P = 0.01, I2 = 38 %), and 5-year DFS (OR = 2.30, 95 % CI: 1.53-3.46, P < 0.001, I2 = 34 %). The results of network meta-analysis were also similar. After sensitivity analysis, the 5-year OS of the RS group was significantly better than that of the WW group (OR = 2.77, 95 % CI: 1.28-6.00, P = 0.009, I2 = 33 %). Nevertheless, neither regression analysis nor subgroup analysis provided meaningful results. However, the cumulative meta-analysis of LR, DM, and 3- and 5-year DFS revealed significant turning points (P < 0.05). Our meta-analysis recommends using the WW strategy for patients with cCR having poor underlying conditions and high surgical risk; however, there is a risk of higher LR and worse survival after 3 years.
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Affiliation(s)
- Rui Du
- Department of Anorectal Surgery, The Third Affiliated Hospital of Anhui Medical University, Hefei First People's Hospital, Hefei, 230000, China
| | - Yue Chang
- Cancer Comprehensive Treatment Center, Hefei Cancer Hospital, Chinese Academy of Sciences, Hefei, 230000, China
| | - Juan Zhang
- Department of Anorectal Surgery, The Third Affiliated Hospital of Anhui Medical University, Hefei First People's Hospital, Hefei, 230000, China
| | - Yuanguang Cheng
- Department of Anorectal Surgery, The Third Affiliated Hospital of Anhui Medical University, Hefei First People's Hospital, Hefei, 230000, China
| | - Yonghai Li
- Department of Anorectal Surgery, The Third Affiliated Hospital of Anhui Medical University, Hefei First People's Hospital, Hefei, 230000, China
| | - Chengyue Zhang
- Department of Anorectal Surgery, The Third Affiliated Hospital of Anhui Medical University, Hefei First People's Hospital, Hefei, 230000, China
| | - Jinyuan Zhang
- Department of Anorectal Surgery, The Third Affiliated Hospital of Anhui Medical University, Hefei First People's Hospital, Hefei, 230000, China
| | - Liejuan Xu
- Department of Anorectal Surgery, The Third Affiliated Hospital of Anhui Medical University, Hefei First People's Hospital, Hefei, 230000, China
| | - Yuancheng Liu
- Department of Anorectal Surgery, The Third Affiliated Hospital of Anhui Medical University, Hefei First People's Hospital, Hefei, 230000, China.
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Langenfeld SJ, Davis BR, Vogel JD, Davids JS, Temple LKF, Cologne KG, Hendren S, Hunt S, Garcia Aguilar J, Feingold DL, Lightner AL, Paquette IM. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Rectal Cancer 2023 Supplement. Dis Colon Rectum 2024; 67:18-31. [PMID: 37647138 DOI: 10.1097/dcr.0000000000003057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Affiliation(s)
- Sean J Langenfeld
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska
| | - Bradley R Davis
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Jon D Vogel
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | | | - Larissa K F Temple
- Colorectal Surgery Division, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Kyle G Cologne
- Department of Surgery, Division of Colorectal Surgery, University of Southern California, Los Angeles, California
| | - Samantha Hendren
- Division of Colon and Rectal Surgery, Department of Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan
| | - Steven Hunt
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Julio Garcia Aguilar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel L Feingold
- Department of Surgery, Rutgers University, New Brunswick, New Jersey
| | - Amy L Lightner
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ian M Paquette
- Department of Surgery, Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
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6
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Lynch P, Ryan OK, Donnelly M, Ryan ÉJ, Davey MG, Reynolds IS, Creavin B, Hanly A, Kennelly R, Martin ST, Winter DC. Comparing neoadjuvant therapy followed by local excision to total mesorectal excision in the treatment of early stage rectal cancer: a systematic review and meta-analysis of randomised clinical trials. Int J Colorectal Dis 2023; 38:263. [PMID: 37924372 DOI: 10.1007/s00384-023-04558-8] [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: 10/26/2023] [Indexed: 11/06/2023]
Abstract
INTRODUCTION Total mesorectal excision (TME) is the standard-of-care in early, clinical stage (cT2-3 N0 M0) rectal cancer. Local excision (LE) may be an alternative after adequate response to neoadjuvant therapy (NAT), with either long-course chemoradiotherapy (nCRT) or short-course radiotherapy (SCRT), as a means of preserving the rectum and potentially obviating the morbidity of TME. METHODS A systematic review was performed according to PRISMA guidelines for studies that randomly assigned patients with cT2-3 N0 M0 rectal cancer to either NAT + LE or TME that reported radiologic, oncologic, surgical, and morbidity outcomes. RESULTS A total of 4 RCTs comprise 462 patients (232 patients receiving NAT + LE; nCRT n = 205; SCRT n = 27) and 230 undergoing TME, respectively. NAT compliance was 98.86%. The rate of early completion TME in the NAT + LE group was 22.3%, while the proportion of patients achieving durable organ preservation was 75.4% at mean follow-up of 5.6 years. There was no difference in disease-free survival (DFS) (HR [hazard ratio] 1.19; 95% CI 0.95, 1.49; p = 0.13) or overall survival (OS) (HR 0.94; 95% CI 0.72, 1.23; p = 0.63]) according to the assigned treatment arm. The local recurrence rate (LRR) (HR 1.22; 95% CI 0.5-3.02; p = 0.66) and distant metastases (HR 0.92; 95% CI 0.45, 1.90; p = 0.82) were also comparable between the groups. There was a significant reduction in major (OR 0.45; 95% CI 0.21, 0.95; p = 0.04) and minor morbidity (OR 0.45; 95% CI 0.24, 0.85; p = 0.01) for patients undergoing NAT + LE. Overall stoma formation was decreased in the NAT + LE group (OR 0.03; 95% CI 0.0, 0.23; p ≤ 0.00001). CONCLUSION NAT + LE reduces adverse effects of TME, without any compromise in oncological outcomes, and the potential for an organ preserving strategy should be discussed with patients with T2-3N0 rectal cancers prior to treatment.
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Affiliation(s)
- Paul Lynch
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Odhrán K Ryan
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Mark Donnelly
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Éanna J Ryan
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland.
| | - Matthew G Davey
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Ian S Reynolds
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Ben Creavin
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Ann Hanly
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Rory Kennelly
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Seán T Martin
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Des C Winter
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
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Sun Myint A, Rao C, Barbet N, Thamphya B, Pace-Loscos T, Schiappa R, Magné N, Martel-Lafay I, Mineur L, Deberne M, Zilli T, Dhadda A, Gerard JP. The safety and efficacy of total mesorectal excision (TME) surgery following dose-escalation: Surgical outcomes from the organ preservation in early rectal adenocarcinoma (OPERA) trial, a European multicentre phase 3 randomised trial (NCT02505750). Colorectal Dis 2023; 25:2160-2169. [PMID: 37837240 DOI: 10.1111/codi.16773] [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: 04/30/2023] [Revised: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 10/15/2023]
Abstract
AIM Nonsurgical treatment with chemoradiotherapy for rectal cancer is gaining interest as it avoids total mesorectal excision (TME) surgery and stoma. The OPERA trial aims to evaluate whether dose escalation with contact X-ray brachytherapy (CXB) boost improves organ preservation compared to external beam radiotherapy (EBRT) boost. It has been suggested that dose escalation adversely affects surgical outcomes and therefore we report outcomes following TME in OPERA at 36 months. METHODS OPERA is a European multicentre phase 3 trial (NCT02505750) which randomises patients with cT2-3a-b, cN0-1, M0 to EBCRT (45 Gy in 25 fractions over 5 weeks with oral capecitabine 825 mg/m2 ) followed by EBRT boost (9 Gy in 5 fractions over 5 days) versus EBCRT followed by CXB boost (90 Gy in 3 fractions over 4 weeks). Patients were assessed at 14, 20 and 24 weeks from the start of treatment. Watch and wait management was adopted for patients who achieved a clinical complete response (cCR) at 24 weeks following treatment. Either local excision (LE) or TME surgery was offered for residual disease or local regrowth, according to patient and surgeon preference. Surgical morbidity and mortality were recorded prospectively. RESULTS Between July 2015 and June 2020, 148 patients were randomised of which 141 were evaluable in March 2022. At median follow-up of 38.2 months (range: 34.2-42.5), surgery was performed for 66 (47%) patients. A total of 27 (20%) patients had local excision and 39 (29%) had TME surgery, 22/39 (56%) underwent anterior resection and 17/39 (44%) underwent abdominoperineal excision of the rectum. The R0 resection rate was 87%. There were no deaths, and six patients (15%) had Clavien-Dindo IIIb complications. Whilst there was a statistically significant decrease in the TME rate following CXB boost (HR 0.38, 95% CI: 0.19-0.74, p = 0.00419) there was no difference in surgical outcomes between patients who received EBRT and CXB boost. CONCLUSION Dose escalation can facilitate nonsurgical treatment for cT2-3 rectal cancer patients who are fit but wish to avoid TME surgery and stoma. If TME surgery is required, then it can be performed safely and effectively.
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Affiliation(s)
| | - Christopher Rao
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Colorectal Surgery, The Cumberland Infirmary, Carlisle, UK
| | | | - Brice Thamphya
- Departement of Epidemiology, Biostatistic, and Health Data, Centre Antoine Lacassagne, Université Côte d'Azur, Nice, France
| | - Tanguy Pace-Loscos
- Departement of Epidemiology, Biostatistic, and Health Data, Centre Antoine Lacassagne, Université Côte d'Azur, Nice, France
| | - Renaud Schiappa
- Departement of Epidemiology, Biostatistic, and Health Data, Centre Antoine Lacassagne, Université Côte d'Azur, Nice, France
| | - Nicolas Magné
- Department of Radiation Oncology, Saint-Priest-en-Jarez, France
| | | | - Laurent Mineur
- Department of Radiation Oncology, Institute Sainte Catherine, Avignon, France
| | | | - Thomas Zilli
- Department of Oncology, University of Genève, Genève, Switzerland
| | | | - Jean Pierre Gerard
- Departement of Epidemiology, Biostatistic, and Health Data, Centre Antoine Lacassagne, Université Côte d'Azur, Nice, France
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Hashimoto T, Tsukamoto S, Murofushi K, Ito Y, Hirano H, Tsukada Y, Sasaki K, Mizusawa J, Fukuda H, Takashima A, Kanemitsu Y. Total neoadjuvant therapy followed by a watch-and-wait strategy for patients with rectal cancer (TOWARd): protocol for single-arm phase II/III confirmatory trial (JCOG2010). BJS Open 2023; 7:zrad110. [PMID: 37931233 PMCID: PMC10627521 DOI: 10.1093/bjsopen/zrad110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/31/2023] [Accepted: 09/05/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Radical surgery is the standard treatment for rectal cancer, but can impact quality of life. Recently, the concept of total neoadjuvant therapy with a watch-and-wait strategy has been proposed in which patients with a cCR after total neoadjuvant therapy do not proceed to surgery. However, most investigations of a watch-and-wait strategy have reported cases where cCR was achieved coincidentally via total neoadjuvant therapy. The aim is to assess whether total neoadjuvant therapy is effective in early-stage rectal cancer in patients that achieve cCR and are offered a watch-and-wait strategy. METHODS JCOG2010 (TOWARd) is a multi-institutional, single-arm phase II/III confirmatory investigation of the safety and efficacy of total neoadjuvant therapy followed by a watch-and-wait strategy for rectal cancer. Key eligibility criteria include cT2-3 N0 M0 rectal adenocarcinoma, tumour diameter less than or equal to 5 cm, age 18-75 years, performance status 0-1, and no history of pelvic irradiation or rectal surgery. Total neoadjuvant therapy involves neoadjuvant chemoradiotherapy (capecitabine and radiotherapy: 45 Gy/25 fractions to the whole pelvis plus boost of 5.4 Gy/3 fractions to the primary tumour) followed by consolidation chemotherapy (four cycles of capecitabine/oxaliplatin). Patients will be re-staged every 8 weeks after total neoadjuvant therapy, and those who achieve cCR will undergo a watch-and-wait strategy, those with near complete response will undergo a watch-and-wait strategy or local resection, and those with an incomplete response will undergo radical surgery. The primary endpoint is the cCR rate in phase II and 5-year overall survival in phase III. Secondary endpoints include postoperative anal, urinary, and sexual function. A total of 105 patients (phase II, 40 patients; phase III, 65 patients) will be enrolled over 3.5 years. CONCLUSION This trial will determine whether total neoadjuvant therapy and a watch-and-wait strategy is an effective alternative to radical surgery for early-stage rectal cancer in patients with cT2-3 N0 M0 and tumour size less than or equal to 5 cm. REGISTRATION NUMBER jRCTs031220288 (https://jrct.niph.go.jp/en-latest-detail/jRCTs031220288).
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Affiliation(s)
- Tadayoshi Hashimoto
- Japan Clinical Oncology Group Data Centre/Operations Office, National Cancer Centre Hospital, Tokyo, Japan
- Translational Research Support Section, National Cancer Centre Hospital East, Kashiwa, Japan
- Department of Gastroenterology and Gastrointestinal Oncology, National Cancer Centre Hospital East, Kashiwa, Japan
| | - Shunsuke Tsukamoto
- Department of Colorectal Surgery, National Cancer Centre Hospital, Tokyo, Japan
| | - Keiko Murofushi
- Division of Radiation Oncology, Tokyo Metropolitan Cancer and Infectious Disease Centre Komagome Hospital, Tokyo, Japan
| | - Yoshinori Ito
- Department of Radiation Oncology, Showa University School of Medicine, Tokyo, Japan
| | - Hidekazu Hirano
- Department of Gastrointestinal Medical Oncology, National Cancer Centre Hospital, Tokyo, Japan
| | - Yuichiro Tsukada
- Department of Colorectal Surgery, National Cancer Centre Hospital East, Kashiwa, Japan
| | - Keita Sasaki
- Japan Clinical Oncology Group Data Centre/Operations Office, National Cancer Centre Hospital, Tokyo, Japan
| | - Junki Mizusawa
- Japan Clinical Oncology Group Data Centre/Operations Office, National Cancer Centre Hospital, Tokyo, Japan
| | - Haruhiko Fukuda
- Japan Clinical Oncology Group Data Centre/Operations Office, National Cancer Centre Hospital, Tokyo, Japan
| | - Atsuo Takashima
- Department of Gastrointestinal Medical Oncology, National Cancer Centre Hospital, Tokyo, Japan
| | - Yukihide Kanemitsu
- Department of Colorectal Surgery, National Cancer Centre Hospital, Tokyo, Japan
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9
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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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10
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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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11
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Quantitative synthetic MRI for predicting locally advanced rectal cancer response to neoadjuvant chemoradiotherapy. Eur Radiol 2023; 33:1737-1745. [PMID: 36380196 DOI: 10.1007/s00330-022-09191-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 08/08/2022] [Accepted: 09/20/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To investigate the value of pre-treatment quantitative synthetic MRI (SyMRI) for predicting a good response to neoadjuvant chemoradiotherapy (nCRT) in patients with locally advanced rectal cancer. METHODS This prospective study enrolled 63 patients with locally advanced rectal cancer scheduled to undergo preoperative chemoradiotherapy from January 2019 to June 2021. T1 relaxation time (T1), T2 relaxation time (T2), proton density (PD) from synthetic MRI, and apparent diffusion coefficient (ADC) from diffusion-weighted imaging (DWI) were measured. Independent-sample t-test, the Mann-Whitney U test, the Delong test, and receiver operating characteristic curve (ROC) analyses were used to predict the pathologic complete response (pCR) and T-downstaging. RESULTS Among the 63 patients, 19 (30%) achieved pCR and 44 (70%) did not, and 24 (38%) achieved T-downstaging, while 44 (62%) did not. The mean T1 and T2 values were significantly lower in the pCR group compared with those in the non-pCR group and in the T-downstage group compared with those in the non-T-downstage group (all p < 0.05). There were no significant differences in the PD and ADC values between the two groups. There were no significant differences between the mean values of T1 and T2 for predicting pCR after CRT (AUC, 0.767 vs. 0.831, p = 0.37). There were no significant differences between the AUC values of T1 and T2 values for the assessment of post-CRT T-downstaging (AUC, 0.746 vs. 0.820, p = 0.506). CONCLUSIONS In patients with locally advanced rectal cancer, the synthetic MRI-derived T1 relaxation time and T2 relaxation time values are promising imaging markers for predicting a good response to neoadjuvant chemoradiotherapy. KEY POINTS • Mean T1 and T2 values were significantly lower in the pathologic complete response group and the T-downstage group. • There were no significant differences in the proton density and apparent diffusion coefficient values between the two groups.
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12
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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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13
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Bao QR, Ferrari S, Capelli G, Ruffolo C, Scarpa M, Agnes A, Chiloiro G, Palazzari E, Urso EDL, Pucciarelli S, Spolverato G. Rectal Sparing Approaches after Neoadjuvant Treatment for Rectal Cancer: A Systematic Review and Meta-Analysis Comparing Local Excision and Watch and Wait. Cancers (Basel) 2023; 15:cancers15020465. [PMID: 36672414 PMCID: PMC9856629 DOI: 10.3390/cancers15020465] [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: 12/02/2022] [Revised: 01/04/2023] [Accepted: 01/06/2023] [Indexed: 01/15/2023] Open
Abstract
Local Excision (LE) or Watch and Wait (WW) for patients with complete clinical response or near-complete clinical response after neoadjuvant chemoradiotherapy (nCRT) were proposed to avoid morbidity and impairment of quality of life after rectal resection. The aim of this study is to perform a systematic review of the literature, and to compare rectal-sparing approaches, in terms of rectum-preservation rate, local control, and distant recurrences. A systematic review and meta-analysis were performed of studies published until July 2022 (PROSPERO, registration CRD42022341480), and the quality of evidence was assessed using a GRADE approach. Seven retrospective studies and one prospective trial were included. In six studies, patients were treated with standard long-course nCRT, and in two with Total Neoadjuvant Therapy (TNT). Overall, there were 213 and 188 patients in WW and LE group, respectively, and no difference was found between WW and LE when considering rectum-preservation rate (OR 0.80 95%CI 0.31-2.01, p = 0.63), local disease (OR 1.60 95%CI 0.75-3.42, p = 0.22), locoregional failure (OR 0.85 95%CI 0.20-3.66, p = 0.83) and distant recurrence (OR 0.76 95%CI 0.37-1.55, p = 0.45). Studies directly comparing WW and LE are still lacking, even though no differences between WW and LE in terms of rectum-preservation, local control, and distant recurrences have been found.
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Affiliation(s)
- Quoc Riccardo Bao
- General Surgery 3, Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padova, 35128 Padova, Italy
| | - Stefania Ferrari
- General Surgery 3, Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padova, 35128 Padova, Italy
| | - Giulia Capelli
- General Surgery 3, Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padova, 35128 Padova, Italy
- Department of Surgery, ASST Bergamo Est, 24068 Bergamo, Italy
| | - Cesare Ruffolo
- General Surgery 3, Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padova, 35128 Padova, Italy
| | - Marco Scarpa
- General Surgery 3, Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padova, 35128 Padova, Italy
- Correspondence:
| | - Amedea Agnes
- Department of Surgery, Fondazione Policlinico Universitario A. Gemelli—IRCCS, 00168 Roma, Italy
| | - Giuditta Chiloiro
- Department of Radiation Oncology, Fondazione Policlinico Universitario A. Gemelli—IRCCS, 00168 Roma, Italy
| | - Elisa Palazzari
- Department of Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO)—IRCCS, 33081 Aviano, Italy
| | - Emanuele Damiano Luca Urso
- General Surgery 3, Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padova, 35128 Padova, Italy
| | - Salvatore Pucciarelli
- General Surgery 3, Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padova, 35128 Padova, Italy
| | - Gaya Spolverato
- General Surgery 3, Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padova, 35128 Padova, Italy
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14
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MRI-based radiomics to predict neoadjuvant chemoradiotherapy outcomes in locally advanced rectal cancer: A multicenter study. Clin Transl Radiat Oncol 2022; 38:175-182. [DOI: 10.1016/j.ctro.2022.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/12/2022] [Accepted: 11/14/2022] [Indexed: 11/18/2022] Open
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15
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Crafa F, Vanella S, Catalano OA, Pomykala KL, Baiamonte M. Role of one-step nucleic acid amplification in colorectal cancer lymph node metastases detection. World J Gastroenterol 2022; 28:4019-4043. [PMID: 36157105 PMCID: PMC9403438 DOI: 10.3748/wjg.v28.i30.4019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 06/03/2022] [Accepted: 07/22/2022] [Indexed: 02/06/2023] Open
Abstract
Current histopathological staging procedures in colorectal cancer (CRC) depend on midline division of the lymph nodes (LNs) with one section of hematoxylin and eosin staining. Cancer cells outside this transection line may be missed, which could lead to understaging of Union for International Cancer Control Stage II high-risk patients. The one-step nucleic acid amplification (OSNA) assay has emerged as a rapid molecular diagnostic tool for LN metastases detection. It is a molecular technique that can analyze the entire LN tissue using a reverse-transcriptase loop-mediated isothermal amplification reaction to detect tumor-specific cytokeratin 19 mRNA. Our findings suggest that the OSNA assay has a high diagnostic accuracy in detecting metastatic LNs in CRC and a high negative predictive value. OSNA is a standardized, observer-independent technique, which may lead to more accurate staging. It has been suggested that in stage II CRC, the upstaging can reach 25% and these patients can access postoperative adjuvant chemotherapy. Moreover, intraoperative OSNA sentinel node evaluation may allow early CRC to be treated with organ-preserving surgery, while in more advanced-stage disease, a tailored lymphadenectomy can be performed considering the presence of aberrant lymphatic drainage and skip metastases.
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Affiliation(s)
- Francesco Crafa
- Division of General and Surgical Oncology, St. Giuseppe Moscati Hospital, Center of National Excellence and High Specialty, Avellino 83100, Italy
| | - Serafino Vanella
- Division of General and Surgical Oncology, St. Giuseppe Moscati Hospital, Center of National Excellence and High Specialty, Avellino 83100, Italy
| | - Onofrio A Catalano
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | - Kelsey L Pomykala
- Department of Nuclear Medicine, Department of Radiological Sciences, David Geffen School of Medicine at University of California, Los Angeles, University Hospital Essen, University of Duisburg-Essen, Essen 45141, Germany
| | - Mario Baiamonte
- Division of General and Surgical Oncology, St. Giuseppe Moscati Hospital, Center of National Excellence and High Specialty, Avellino 83100, Italy
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16
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A multicentre cohort study assessing the utility of routine blood tests as adjuncts to identify complete responders in rectal cancer following neoadjuvant chemoradiotherapy. Int J Colorectal Dis 2022; 37:957-965. [PMID: 35325271 PMCID: PMC8976819 DOI: 10.1007/s00384-022-04103-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/30/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Management of rectal cancer with a complete clinical response (cCR) to neoadjuvant chemoradiotherapy (NACRT) is controversial. Some advocate "watch and wait" programmes and organ-preserving surgery. Central to these strategies is the ability to accurately preoperatively distinguish cCR from residual disease (RD). We sought to identify if post-NACRT (preoperative) inflammatory markers act as an adjunct to MRI and endoscopy findings for distinguishing cCR from RD in rectal cancer. METHODS Patients from three specialist rectal cancer centres were screened for inclusion (2010-2015). For inclusion, patients were required to have completed NACRT, had a post-NACRT MRI (to assess mrTRG) and proceeded to total mesorectal excision (TME). Endoluminal response was assessed on endoscopy at 6-8 weeks post-NACRT. Pathological response to therapy was calculated using a three-point tumour regression grade system (TRG1-3). Neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), serum albumin (SAL), CEA and CA19-9 levels post-NACRT (preoperatively) were recorded. Variables were compared between those who had RD on post-operative pathology and those with ypCR. Statistical analysis was performed using SPSS (version 21). RESULTS Six hundred forty-six patients were screened, of which 422 were suitable for inclusion. A cCR rate of 25.5% (n = 123) was observed. Sixty patients who achieved cCR were excluded from final analysis as they underwent organ-preserving surgery (local excision) leaving 63 ypCR patients compared to 359 with RD. On multivariate analysis, combining cCR on MRI and endoscopy with NLR < 5 demonstrated the greatest odds of ypCR on final histological assessment [OR 6.503 (1.594-11.652]) p < 0.001]. This method had the best diagnostic accuracy (AUC = 0.962 95% CI 0.936-0.987), compared to MRI (AUC = 0.711 95% CI 0.650-0.773) or endoscopy (AUC = 0.857 95% CI 0.811-0.902) alone or used together (AUC = 0.926 95% CI 0.892-0.961). CONCLUSION Combining post-NACRT inflammatory markers with restaging MRI and endoscopy findings adds another avenue to aid distinguishing RD from cCR in rectal cancer.
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17
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Kastner C, Petritsch B, Reibetanz J, Germer CT, Wiegering A. [Complete response after neoadjuvant therapy of rectal cancer: implications for surgery]. Chirurg 2021; 93:144-151. [PMID: 34878582 DOI: 10.1007/s00104-021-01540-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2021] [Indexed: 12/17/2022]
Abstract
For (locally advanced) rectal cancer, a multimodal therapy concept comprising neoadjuvant radiotherapy/chemoradiotherapy, radical surgical resection with partial/complete mesorectal excision and subsequent adjuvant chemotherapy represents the current international standard of care. Further developments in neoadjuvant therapy concepts, such as the principle of total neoadjuvant therapy, lead to an increasing number of patients who show a complete clinical response in restaging after neoadjuvant therapy without clinically detectable residual tumor. In view of the risk associated with radical surgical resection in terms of perioperative morbidity and a potentially non-continence-preserving procedure, the question of the oncological justifiability of an organ-preserving procedure in the case of a complete clinical response under neoadjuvant therapy is increasingly being raised. The therapeutic principle of watch and wait, defined by refraining from immediate radical surgical resection and inclusion in a close-meshed, structured follow-up program, currently appears to be oncologically justifiable based on the current study situation; however, for the initial evaluation of the extent of the clinical response and for the structuring of the close-meshed follow-up program, further optimization and standardization based on broadly designed studies appear necessary in order to be able to provide this concept to a clearly defined patient collective as an oncologically equivalent therapy principle also outside specialized centers.
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Affiliation(s)
- Carolin Kastner
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Zentrum für operative Medizin, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
- Institut für Biochemie und molekulare Biologie, Julius-Maximilians-Universität Würzburg, Würzburg, Deutschland
| | - Bernhard Petritsch
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Joachim Reibetanz
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Zentrum für operative Medizin, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Christoph-Thomas Germer
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Zentrum für operative Medizin, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
- Comprehensive Cancer Center Mainfranken, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Armin Wiegering
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Zentrum für operative Medizin, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland.
- Institut für Biochemie und molekulare Biologie, Julius-Maximilians-Universität Würzburg, Würzburg, Deutschland.
- Comprehensive Cancer Center Mainfranken, Universitätsklinikum Würzburg, Würzburg, Deutschland.
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18
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Yu G, Lu W, Jiao Z, Qiao J, Ma S, Liu X. A meta-analysis of the watch-and-wait strategy versus total mesorectal excision for rectal cancer exhibiting complete clinical response after neoadjuvant chemoradiotherapy. World J Surg Oncol 2021; 19:305. [PMID: 34663341 PMCID: PMC8522111 DOI: 10.1186/s12957-021-02415-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 09/30/2021] [Indexed: 01/04/2023] Open
Abstract
Background Some clinical researchers have reported that patients with cCR (clinical complete response) status after neoadjuvant chemoradiotherapy (nCRT) could adopt the watch-and-wait (W&W) strategy. Compared with total mesorectal excision (TME) surgery, the W&W strategy could achieve a similar overall survival. Could the W&W strategy replace TME surgery as the main treatment option for the cCR patients? By using the meta-analysis method, we evaluated the safety and efficacy of the W&W strategy and TME surgery for rectal cancer exhibiting cCR after nCRT. Methods We evaluated two treatment strategies for rectal cancer with cCR after nCRT up to July 2021 by searching the Cochrane Library, PubMed, Wanfang, and China National Knowledge Infrastructure (CNKI) databases. Clinical data for primary outcomes (local recurrence, cancer-related death and distant metastasis), and secondary outcomes (disease-free survival (DFS) and overall survival (OS)) were collected to evaluate the efficacy and safety in the two groups. Results We included nine studies with 818 patients in the meta-analysis, and there were five moderate-quality studies and four high-quality studies. A total of 339 patients were in the W&W group and 479 patients were in the TME group. The local recurrence rate in the W&W group was greater than that in the TME group in the fixed-effects model (OR 8.54, 95% CI 3.52 to 20.71, P < 0.001). The results of other outcomes were similar in the two groups. Conclusion The local recurrence rate of the W&W group was greater than that in the TME group, but other results were similar in the two groups. With the help of physical examination and salvage therapy, the W&W strategy could achieve similar treatment effects with the TME approach. Trial registration Protocol registration number: CRD42021244032. Supplementary Information The online version contains supplementary material available at 10.1186/s12957-021-02415-y.
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Affiliation(s)
- Guilin Yu
- Department of General Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, No. 44 Xiaoheyan Road, Dadong District, Shenyang, 110042, Liaoning Province, People's Republic of China
| | - Wenqing Lu
- School of Life Sciences, Hebei University, Baoding, 071002, Hebei Province, People's Republic of China
| | - Zhouguang Jiao
- Institute of Process Engineering, Chinese Academy of Science, Beijing, 100190, People's Republic of China
| | - Jun Qiao
- Department of Colorectal Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, No. 44 Xiaoheyan Road, Dadong District, Shenyang, 110042, Liaoning Province, People's Republic of China
| | - Shiyang Ma
- Department of Colorectal Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, No. 44 Xiaoheyan Road, Dadong District, Shenyang, 110042, Liaoning Province, People's Republic of China
| | - Xin Liu
- Department of Colorectal Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, No. 44 Xiaoheyan Road, Dadong District, Shenyang, 110042, Liaoning Province, People's Republic of China.
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19
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Ahmad NZ, Abbas MH, Abunada MH, Parvaiz A. A Meta-analysis of Transanal Endoscopic Microsurgery versus Total Mesorectal Excision in the Treatment of Rectal Cancer. Surg J (N Y) 2021; 7:e241-e250. [PMID: 34541316 PMCID: PMC8440057 DOI: 10.1055/s-0041-1735587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 07/22/2021] [Indexed: 11/23/2022] Open
Abstract
Background
Transanal endoscopic microsurgery (TEMS) has been suggested as an alternative to total mesorectal excision (TME) in the treatment of early rectal cancers. The extended role of TEMS for higher stage rectal cancers after neoadjuvant therapy is also experimented. The aim of this meta-analysis was to compare the oncological outcomes and report on the evidence-based clinical supremacy of either technique.
Methods
Medline, Embase, and Cochrane databases were searched for the randomized controlled trials comparing the oncological and perioperative outcomes of TEMS and a radical TME. A local recurrence and postoperative complications were analyzed as primary end points. Intraoperative blood loss, operation time, and duration of hospital stay were compared as secondary end points.
Results
There was no statistical difference in the local recurrence or postoperative complications with a risk ratio of 1.898 and 0.753 and
p
-values of 0.296 and 0.306, respectively, for TEMS and TME. A marked statistical significance in favor of TEMS was observed for secondary end points. There was standard difference in means of −4.697, −6.940, and −5.685 with
p
-values of 0.001, 0.005, and 0.001 for blood loss, operation time, and hospital stay, respectively.
Conclusion
TEMS procedure is a viable alternative to TME in the treatment of early rectal cancers. An extended role of TEMS after neoadjuvant therapy may also be offered to a selected group of patients. TME surgery remains the standard of care in more advanced rectal cancers.
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Affiliation(s)
- Nasir Zaheer Ahmad
- Department of Surgery, University Hospital Limerick, Limerick, Republic of Ireland
| | - Muhammad Hasan Abbas
- Department of Surgery, Russells Hall Hospital, NHS Trust, West Midlands, Dudley, United Kingdom
| | | | - Amjad Parvaiz
- Faculty of Health Sciences, University of Portsmouth, Portsmouth, England.,Department of Colorectal Surgery, Poole NHS Trust, Poole, United Kingdom
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20
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Kaul S, Rao C, Mane R, Tan KL, Khan AHA, Hussain MS, Shafi MA, Buettner F, Banerjee S, Boulton R, Bhargava A, Huang J, Hanson M, Raouf S, Ball S, Rajendran N. Is the Management of Rectal Cancer Using a Watch and Wait Approach Feasible, Safe and Effective in a Publicly Funded General Hospital? CLINICAL ONCOLOGY (ROYAL COLLEGE OF RADIOLOGISTS (GREAT BRITAIN)) 2021; 34:e25-e34. [PMID: 34454807 DOI: 10.1016/j.clon.2021.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 07/03/2021] [Accepted: 08/09/2021] [Indexed: 11/29/2022]
Abstract
AIMS Although there is emerging evidence to suggest equivalent oncological outcomes using a watch and wait approach compared with primary total mesorectal excision surgery, there is a paucity of evidence about the safety and efficacy of this approach in routine clinical practice. Here we report the long-term outcomes and quality of life from patients managed with watch and wait following a clinical complete response (cCR) to neoadjuvant therapy. MATERIALS AND METHODS Patients with adenocarcinoma of the rectum with cCR following neoadjuvant therapy managed using watch and wait were retrospectively identified. Demographic data, performance status, pretreatment staging information, oncological and surgical outcomes were obtained from routinely collected clinical data. Quality of life was measured by trained clinicians during telephone interviews. RESULTS Over a 7-year period, 506 patients were treated for rectal cancer, 276 had neoadjuvant therapy and 72 had a cCR (26.1%). Sixty-three were managed with watch and wait. Thirteen patients had mucosal regrowth. There was no significant difference in the incidence of metastatic disease between the surgical and watch and wait cohorts (P = 0.38). The 13 patients with mucosal regrowth underwent salvage surgery. Eleven of the patients who underwent surgical resection had R0 resections. There was also a statistically and clinically significant improvement in the Functional Assessment of Cancer Therapy - Colorectal (FACT-C) trial outcome index (P = 0.022). CONCLUSION This study shows that watch and wait is safe and effective outside of tertiary referral centres. It suggests that an opportunistic cCR is durable and when mucosal regrowth occurs it can be salvaged. Finally, we have shown that quality of life is probably improved if a watch and wait approach is adopted.
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Affiliation(s)
- S Kaul
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK
| | - C Rao
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK; Department of Surgery and Cancer, Imperial College London, London, UK; North Cumbria Integrated Care NHS Foundation Trust, UK.
| | - R Mane
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK
| | - K L Tan
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK
| | - A H A Khan
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK
| | - M S Hussain
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK
| | - M A Shafi
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK
| | - F Buettner
- German Cancer Consortium (DKTK), Heidelberg, Germany; German Cancer Research Centre (DKFZ), Heidelberg, Germany; Department of Medicine, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - S Banerjee
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK
| | - R Boulton
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK
| | - A Bhargava
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK; Institute of Health, Barts and London Medical School, Queen Mary University of London (QMUL), London, UK
| | - J Huang
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK
| | - M Hanson
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK
| | - S Raouf
- Barts Health NHS Trust, London, UK
| | - S Ball
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK
| | - N Rajendran
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK.
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21
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Cho E, Jung SW, Park IJ, Jang JK, Park SH, Hong SM, Lee JL, Kim CW, Yoon YS, Lim SB, Yu CS, Kim JC. Improvement in the Assessment of Response to Preoperative Chemoradiotherapy for Rectal Cancer Using Magnetic Resonance Imaging and a Multigene Biomarker. Cancers (Basel) 2021; 13:cancers13143480. [PMID: 34298695 PMCID: PMC8305437 DOI: 10.3390/cancers13143480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 07/09/2021] [Accepted: 07/09/2021] [Indexed: 11/16/2022] Open
Abstract
The response to preoperative chemoradiotherapy (PCRT) is correlated with oncologic outcomes in patients with locally advanced rectal cancer. Accurate prediction of PCRT response before surgery can provide crucial information to aid clinicians in further treatment planning. This study aimed to develop an evaluation tool incorporating a genetic biomarker and magnetic resonance imaging (MRI) to improve the assessment of response in post-CRT patients with locally advanced rectal cancer. A total of 198 patients who underwent PCRT followed by surgical resection for locally advanced rectal cancer between 2010 and 2016 were included in this study. Each patient's response prediction index (RPI) score, a multigene biomarker developed in our previous study, and magnetic resonance tumor regression grade (mrTRG) score were added to create a new predictive value for pathologic response after PCRT, called the combined radiation prediction value (cRPV). Based on the new value, 121 and 77 patients were predicted to be good and poor responders, respectively, showing significantly different cRPV values (p = 0.001). With an overall predictive accuracy of 84.8%, cRPV was superior to mrTRG and RPI for the prediction of pathologic chemoradiotherapy response (mrTRG, 69.2%; RPI, 77.3%). In multivariate analysis, cRPV was found to be the sole predictor of tumor response (odds ratio, 32.211; 95% confidence interval, 14.408-72.011; p = 0.001). With its good predictive value for final pathologic regression, cRPV may be a valuable tool for assessing the response to PCRT before surgery.
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Affiliation(s)
- Eunhae Cho
- Asan Medical Center, Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Seoul 05505, Korea; (E.C.); (J.L.L.); (C.W.K.); (Y.S.Y.); (S.-B.L.); (C.S.Y.); (J.C.K.)
| | - Sung Woo Jung
- Department of General Surgery, Good Morning Hospital, Pyeongtaek-si 17874, Korea;
| | - In Ja Park
- Asan Medical Center, Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Seoul 05505, Korea; (E.C.); (J.L.L.); (C.W.K.); (Y.S.Y.); (S.-B.L.); (C.S.Y.); (J.C.K.)
- Correspondence: ; Tel.: +82-2-3010-3937
| | - Jong Keon Jang
- Asan Medical Center, Department of Radiology, University of Ulsan College of Medicine, Seoul 05505, Korea; (J.K.J.); (S.H.P.)
| | - Seong Ho Park
- Asan Medical Center, Department of Radiology, University of Ulsan College of Medicine, Seoul 05505, Korea; (J.K.J.); (S.H.P.)
| | - Seung-Mo Hong
- Asan Medical Center, Department of Pathology, University of Ulsan College of Medicine, Seoul 05505, Korea;
| | - Jong Lyul Lee
- Asan Medical Center, Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Seoul 05505, Korea; (E.C.); (J.L.L.); (C.W.K.); (Y.S.Y.); (S.-B.L.); (C.S.Y.); (J.C.K.)
| | - Chan Wook Kim
- Asan Medical Center, Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Seoul 05505, Korea; (E.C.); (J.L.L.); (C.W.K.); (Y.S.Y.); (S.-B.L.); (C.S.Y.); (J.C.K.)
| | - Yong Sik Yoon
- Asan Medical Center, Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Seoul 05505, Korea; (E.C.); (J.L.L.); (C.W.K.); (Y.S.Y.); (S.-B.L.); (C.S.Y.); (J.C.K.)
| | - Seok-Byung Lim
- Asan Medical Center, Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Seoul 05505, Korea; (E.C.); (J.L.L.); (C.W.K.); (Y.S.Y.); (S.-B.L.); (C.S.Y.); (J.C.K.)
| | - Chang Sik Yu
- Asan Medical Center, Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Seoul 05505, Korea; (E.C.); (J.L.L.); (C.W.K.); (Y.S.Y.); (S.-B.L.); (C.S.Y.); (J.C.K.)
| | - Jin Cheon Kim
- Asan Medical Center, Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Seoul 05505, Korea; (E.C.); (J.L.L.); (C.W.K.); (Y.S.Y.); (S.-B.L.); (C.S.Y.); (J.C.K.)
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22
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Long-term outcomes of transanal endoscopic microsurgery for clinical complete response after neoadjuvant treatment in T2-3 rectal cancer. Surg Endosc 2021; 36:2906-2913. [PMID: 34231071 DOI: 10.1007/s00464-021-08583-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 06/02/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Organ sparing by the transanal endoscopic microsurgery (TEM) procedure is a treatment for patients with locally advanced rectal cancer after chemoradiotherapy (CRT) and complete clinical response (cCR). AIMS To assess the surgical and long-term oncological outcomes of TEM for the treatment in T2-3 rectal cancer after CRT and cCR. METHODS This study was a retrospective review of a prospective database of patients with rectal cancer who underwent TEM after CRT and cCR from April 2011 to March 2020. RESULTS 52 patients underwent TEM during a period of 9 years. This group of patients included 27 females and 25 males. The median age was 62 (32-86) years, lesion size was 2.5 (1-4) cm, and lesion distance from the anal verge 7.3 (4-10) cm. Median operative time was 79.5 (25-120) min and hospital stay was 1 day (14 h-4 days). Morbidity rate was 13.5% and reoperation rate due to major complications was 3.8%. Final histological findings confirmed 34 (65.4%) patients with ypT0, 7 (13.5%), 6 (11.5%), and 5 (9.6%) patients with carcinoma ypT1, ypT2, and ypT3, respectively. After a median follow-up period of 86 (5-107) months, 1 (2.4%) patient had local recurrences and 3 (7.3%) distant metastases. The 5-year disease-free survival was 91.7% and 5-year overall survival 89.5%. CONCLUSION Our experience has shown significant rates of ypT0 and ypT1 associated with excellent long-term results. Performing TEM to treat T2-3N0 rectal cancer after CRT and cCR appears to be an oncologically safe and effective procedure.
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23
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Anker CJ, Akselrod D, Ades S, Bianchi NA, Lester-Coll NH, Cataldo PA. Non-operative Management (NOM) of Rectal Cancer: Literature Review and Translation of Evidence into Practice. CURRENT COLORECTAL CANCER REPORTS 2021. [DOI: 10.1007/s11888-020-00463-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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24
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Wo JY, Anker CJ, Ashman JB, Bhadkamkar NA, Bradfield L, Chang DT, Dorth J, Garcia-Aguilar J, Goff D, Jacqmin D, Kelly P, Newman NB, Olsen J, Raldow AC, Ruiz-Garcia E, Stitzenberg KB, Thomas CR, Wu QJ, Das P. Radiation Therapy for Rectal Cancer: Executive Summary of an ASTRO Clinical Practice Guideline. Pract Radiat Oncol 2021; 11:13-25. [PMID: 33097436 DOI: 10.1016/j.prro.2020.08.004] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 08/12/2020] [Accepted: 08/12/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE This guideline reviews the evidence and provides recommendations for the indications and appropriate technique and dose of neoadjuvant radiation therapy (RT) in the treatment of localized rectal cancer. METHODS The American Society for Radiation Oncology convened a task force to address 4 key questions focused on the use of RT in preoperative management of operable rectal cancer. These questions included the indications for neoadjuvant RT, identification of appropriate neoadjuvant regimens, indications for consideration of a nonoperative or local excision approach after chemoradiation, and appropriate treatment volumes and techniques. Recommendations were based on a systematic literature review and created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength. RESULTS Neoadjuvant RT is recommended for patients with stage II-III rectal cancer, with either conventional fractionation with concurrent 5-FU or capecitabine or short-course RT. RT should be performed preoperatively rather than postoperatively. Omission of preoperative RT is conditionally recommended in selected patients with lower risk of locoregional recurrence. Addition of chemotherapy before or after chemoradiation or after short-course RT is conditionally recommended. Nonoperative management is conditionally recommended if a clinical complete response is achieved after neoadjuvant treatment in selected patients. Inclusion of the rectum and mesorectal, presacral, internal iliac, and obturator nodes in the clinical treatment volume is recommended. In addition, inclusion of external iliac nodes is conditionally recommended in patients with tumors invading an anterior organ or structure, and inclusion of inguinal and external iliac nodes is conditionally recommended in patients with tumors involving the anal canal. CONCLUSIONS Based on currently published data, the American Society for Radiation Oncology task force has proposed evidence-based recommendations regarding the use of RT for rectal cancer. Future studies will look to further personalize treatment recommendations to optimize treatment outcomes and quality of life.
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Affiliation(s)
- Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Christopher J Anker
- Division of Radiation Oncology, University of Vermont Cancer Center, Burlington, Vermont
| | | | | | - Lisa Bradfield
- American Society for Radiation Oncology, Arlington, Virginia
| | - Daniel T Chang
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Jennifer Dorth
- Department of Radiation Oncology, Seidman Cancer Center, University Hospitals, Cleveland, Ohio
| | - Julio Garcia-Aguilar
- Department of Colorectal Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - David Goff
- Patient Representative, Las Cruces, New Mexico
| | - Dustin Jacqmin
- Department of Human Oncology, University of Wisconsin, Madison, Wisconsin
| | - Patrick Kelly
- Department of Radiation Oncology, Orlando Health, Orlando, Florida
| | - Neil B Newman
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jeffrey Olsen
- Department of Radiation Oncology, University of Colorado, Aurora, Colorado
| | - Ann C Raldow
- Department of Radiation Oncology, University of California, Los Angeles, California
| | - Erika Ruiz-Garcia
- Department of Medical Oncology, Instituto Nacional de Cancerologia, Mexico City, Mexico
| | - Karyn B Stitzenberg
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Charles R Thomas
- Department of Radiation Oncology, Oregon Health & Science University, Portland, Oregon
| | - Q Jackie Wu
- Department of Radiation Oncology, Duke University, Durham, North Carolina
| | - Prajnan Das
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas.
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25
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Cong Y, Fan Z, Dai Y, Zhang Z, Yan K. Application Value of Shear Wave Elastography in the Evaluation of Tumor Downstaging for Locally Advanced Rectal Cancer After Neoadjuvant Chemoradiotherapy. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:81-89. [PMID: 32648968 DOI: 10.1002/jum.15378] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 05/14/2020] [Accepted: 05/26/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES The aim of this study was to assess the application value of shear wave elastography in the evaluation of tumor downstaging for locally advanced rectal cancer after neoadjuvant chemoradiotherapy. METHODS A retrospective analysis was conducted using data from patients with locally advanced rectal cancer treated in our hospital who received endorectal ultrasound (ERUS) and shear wave elastographic examinations before and after chemoradiotherapy. The cases were grouped according to the postoperative pathologic tumor-staging scores. The lesions were divided into 2 groups: 1 showing and the other not showing tumor downstaging. The efficacy of ERUS in diagnosis of tumor downstaging was calculated. The differences in the mean and maximum values of the Young modulus of the lesions before and after chemoradiotherapy between the groups were calculated and compared. Receiver operating characteristic curves were constructed by using the differences in the 2 kinds of values of the Young modulus. RESULTS The mean and maximum values of the Young modulus before and after chemoradiotherapy were significantly different (P < .05). The differences in the mean and maximum values of the Young modulus of rectal lesions between groups were statistically significant (P < .05). The results of the receiver operating characteristic curve showed that a difference in the mean value at 34.7 kPa was the optimal diagnostic threshold. Compared with ERUS, this standard showed a significant difference in diagnosis of tumor downstaging (P < .05). CONCLUSIONS Shear wave elastography is an effective ultrasound elastographic technique to assist ERUS in evaluating lesions after chemoradiotherapy in rectal cancer. It can improve the diagnostic efficacy of tumor downstaging and provide effective imaging conclusions for clinical decision making.
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Affiliation(s)
- Yue Cong
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Ultrasound, Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Zhihui Fan
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Ultrasound, Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Ying Dai
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Ultrasound, Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Zhongyi Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Ultrasound, Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Kun Yan
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Ultrasound, Peking University Cancer Hospital & Institute, Beijing, 100142, China
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26
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Coraglio MF, Eleta MA, Kujaruk MR, Oviedo JH, Roca EL, Masciangioli GA, Mendez G, Iseas IS. Analysis of long-term oncological results of clinical versus pathological responses after neoadjuvant treatment in locally advanced rectal cancer. World J Surg Oncol 2020; 18:313. [PMID: 33256819 PMCID: PMC7706260 DOI: 10.1186/s12957-020-02094-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 11/24/2020] [Indexed: 12/13/2022] Open
Abstract
Background Nonoperative management after neoadjuvant treatment in low rectal cancer enables organ preservation and avoids surgical morbidity. Our aim is to compare oncological outcomes in patients with clinical complete response in watch and wait strategy with those who received neoadjuvant therapy followed by surgery with a pathological complete response. Methods Patients with non-metastatic rectal cancer after neoadjuvant treatment with clinical complete response in watch and wait approach (group 1, n = 26) and complete pathological responders (ypT0N0) after chemoradiotherapy and surgery (group 2, n = 22), between January 2011 and October 2018, were included retrospectively, and all of them evaluated and followed in a multidisciplinary team. A comparative analysis of local and distant recurrence rates and disease-free and overall survival between both groups was carried out. Statistical analysis was performed using log-rank test, Cox proportional hazards regression model, and Kaplan-Meier curves. Results No differences were found between patient’s demographic characteristics in both groups. Group 1: distance from the anal verge mean 5 cm (r = 1–12), 10 (38%) stage III, and 7 (27%) circumferential resection margin involved. The median follow-up of 47 months (r = 6, a 108). Group 2: distance from the anal verge mean 7 cm (r = 2–12), 16 (72%) stage III, and 13 (59%) circumferential resection margin involved. The median follow-up 49.5 months (r = 3, a 112). Local recurrence: 2 patients in group 1 (8.3%) and 1 in group 2 (4.8%) (p = 0.6235). Distant recurrence: 1 patient in group 1 (3.8%) and 3 in group 2 (19.2%) (p = 0.2237). Disease-free survival: 87.9% in group 1, 80% in group 2 (p = 0.7546). Overall survival: 86% in group 1 and 85% in group 2 (p = 0.5367). Conclusion Oncological results in operated patients with pathological complete response were similar to those in patients under a watch and wait strategy mediating a systematic and personalized evaluation. Surgery can safely be deferred in clinical complete responders.
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Affiliation(s)
- Mariana F Coraglio
- Colorectal Surgery Unit, Gastroenterology Hospital, Dr. Carlos Bonorino Udaondo, Av. Caseros 2061, 1264, Ciudad Autónoma de Buenos Aires (CABA), Argentina.
| | - Martin A Eleta
- Imaxe Image Diagnosis Center, Ciudad Autónoma de Buenos Aires (CABA), Argentina
| | - Mirta R Kujaruk
- Pathology Unit, Gastroenterology Hospital, Dr. Carlos Bonorino Udaondo, Ciudad Autónoma de Buenos Aires (CABA), Argentina
| | - Javier H Oviedo
- Coloproctology Fellowship National Health Cancer Institute, Gastroenterology Hospital, Dr. Carlos Bonorino Udaondo, Ciudad Autónoma de Buenos Aires (CABA), Argentina
| | - Enrique L Roca
- Oncology Unit, Gastroenterology Hospital, Dr. Carlos Bonorino Udaondo, Ciudad Autónoma de Buenos Aires, Argentina
| | - Guillermo A Masciangioli
- Colorectal Surgery Unit, Gastroenterology Hospital, Dr. Carlos Bonorino Udaondo, Av. Caseros 2061, 1264, Ciudad Autónoma de Buenos Aires (CABA), Argentina
| | - Guillermo Mendez
- Oncology Unit, Gastroenterology Hospital, Dr. Carlos Bonorino Udaondo, Ciudad Autónoma de Buenos Aires, Argentina
| | - Ilma S Iseas
- Oncology Unit, Gastroenterology Hospital, Dr. Carlos Bonorino Udaondo, Ciudad Autónoma de Buenos Aires, Argentina
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Beard BW, Rettig RL, Ryoo JJ, Parker RA, McLemore EC, Attaluri V. Watch-and-Wait Compared to Operation for Patients with Complete Response to Neoadjuvant Therapy for Rectal Cancer. J Am Coll Surg 2020; 231:681-692. [PMID: 33121903 DOI: 10.1016/j.jamcollsurg.2020.08.775] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/24/2020] [Accepted: 08/24/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Trimodality therapy with neoadjuvant chemoradiation (nCRT), surgery, and adjuvant chemotherapy is the standard treatment for locally advanced rectal cancer. There is evidence that surgery can be deferred in patients with complete response (CR) to nCRT, a strategy termed "watch-and-wait" (WW). We compare WW to surgery in patients with CR to nCRT. STUDY DESIGN We reviewed records of patients treated with nCRT for nonmetastatic rectal cancer at our institution. Complete endoscopic response (CER) was defined as negative digital rectal exam and negative endoscopy at the end of neoadjuvant therapy (NAT). Clinical complete response (cCR) was defined as CER with negative rectal MRI. Patients with CER refusing surgery were offered WW, which included strict surveillance with digital rectal exam and endoscopy. RESULTS From January 2015 through February 2019, 465 patients completed nCRT; 406 patients had response assessment, of which 95 (23%) had CER. Of these patients, 53 patients underwent WW and 42 patients had surgery. Median follow-up was 35 months. In the WW group, 3-year freedom from local regrowth was 85%. In the surgical and WW groups, 3-year overall survival, rectal cancer-specific survival, and freedom from nonregrowth recurrence were 100% vs 88% (p = 0.03), 100% vs 95% (p = 0.16), and 92% vs 85% (p = 0.36), respectively. Of the 6 WW patients with local regrowth, 5 (83%) eventually developed distant recurrence. CONCLUSIONS WW in lieu of surgery appears to be a safe and feasible treatment approach for patients achieving CR to nCRT. Careful evaluation to confirm cCR after nCRT is valuable in selecting patients for WW.
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Affiliation(s)
- Bryce W Beard
- Departments of Radiation Oncology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA.
| | - Robert L Rettig
- Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Joan J Ryoo
- Departments of Radiation Oncology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Rex A Parker
- Radiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | | | - Vikram Attaluri
- Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA; Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
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Bae H, Seo N, Han K, Koom WS, Kim MJ, Kim NK, Lim JS. MR prediction of pathologic complete response and early-stage rectal cancer after neoadjuvant chemoradiation in patients with clinical T1/T2 rectal cancer for organ saving strategy. Medicine (Baltimore) 2020; 99:e22746. [PMID: 33080736 PMCID: PMC7571887 DOI: 10.1097/md.0000000000022746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
To evaluate the ability of magnetic resonance imaging (MRI) to predict pathologic complete response (pCR) after neoadjuvant chemoradiation therapy (CRT) in patients with clinical T1/T2 rectal cancer to indicate candidates for organ-saving strategies.Between 2012 and 2016, 38 patients with clinical T1/T2 rectal cancer received neoadjuvant CRT. Radiologic complete response (rCR) was assigned when dense fibrotic tissue without tumor signal intensity was observed on post-CRT MRI. Surgical pathologic assessment was used to evaluate tumor regression. The association between rCR and the mural extent of the primary tumor, pCR, and pathologic T stage were analyzed.In rCR patients, the pCR rate was higher; the odds of achieving pCR were 8.00 times higher than for non-rCR patients (P = .02). rCR patients were also more likely to have early-stage cancer than non-rCR patients (P = 0.01). Patients with partial extent of the primary tumor on post-CRT MRI were more likely to be diagnosed with early-stage cancer than those with transmural extent (P = .01).rCR indicated by post-CRT MRI can be used as a supportive factor to predict pCR after neoadjuvant CRT in patients with clinical T1/T2 rectal cancer and can guide management decisions around organ-saving treatments.
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Affiliation(s)
- Heejin Bae
- Department of Radiology and Research Institute of Radiological Science
| | - Nieun Seo
- Department of Radiology and Research Institute of Radiological Science
| | - Kyunghwa Han
- Department of Radiology and Research Institute of Radiological Science
| | | | - Myeong-Jin Kim
- Department of Radiology and Research Institute of Radiological Science
| | - Nam Kyu Kim
- Division of Colorectal Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joon Seok Lim
- Department of Radiology and Research Institute of Radiological Science
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29
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Jeon SH, Song C, Chie EK, Kim B, Kim YH, Chang W, Lee YJ, Chung JH, Chung JB, Lee KW, Kang SB, Kim JS. Combining Radiomics and Blood Test Biomarkers to Predict the Response of Locally Advanced Rectal Cancer to Chemoradiation. In Vivo 2020; 34:2955-2965. [PMID: 32871838 DOI: 10.21873/invivo.12126] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 07/06/2020] [Accepted: 07/08/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND/AIM A noninvasive method for predicting a patient's response to neoadjuvant chemoradiotherapy (nCRT) for locally advanced rectal cancer would be useful because this would help determine the subsequent treatment strategy. Two types of noninvasive biomarkers have previously been studied, based on radiomics and based on blood test parameters. We hypothesized that a combination of both types would provide a better predictive power, and this has not previously been investigated. PATIENTS AND METHODS Data from 135 patients with locally advanced rectal cancer who underwent nCRT were retrospectively allocated into training and validation cohorts in a 2:1 ratio. Sixty-five radiomics features were extracted from tumors segmented on T2-weighted magnetic resonance images. An elastic net was applied to generate four models for discerning the patients with good responses to nCRT based on radiomics features (model R), blood biomarkers (model B), both (model RB), and a linear combination of models R and B (model R+B). RESULTS Among 65 radiomics features, 17 were selected as robust features for model development. The AUC values of model R, model B, model RB, and model R+B achieved 0.751, 0.627, 0.785, and 0.711 in the training cohort (n=90), and 0.705, 0.603, 0.679, and 0.705 in validation cohort (n=45), respectively. In the entire cohort, models RB and R+B demonstrated a significantly better performance than model B but not R. There was no correlation between the scores of models R and B (p=0.76). Radiomics features had a greater influence than blood biomarkers on models RB and R+B. CONCLUSION A non-redundancy between radiomics features and blood-based biomarkers was observed. Furthermore, radiomics features are more valuable in terms of predicting response to nCRT. The importance of combining non-invasive biomarkers in future investigations is highlighted.
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Affiliation(s)
- Seung Hyuck Jeon
- Laboratory of Translational Immunology and Vaccinology, Graduate School of Medical Science and Engineering, KAIST, Daejeon, Republic of Korea
| | - Changhoon Song
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Eui Kyu Chie
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Bohyoung Kim
- Division of Biomedical Engineering, Hankuk University of Foreign Studies, Yongin, Republic of Korea
| | - Young Hoon Kim
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Won Chang
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Yoon Jin Lee
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Joo-Hyun Chung
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jin Beom Chung
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Keun-Wook Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Sung-Bum Kang
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jae-Sung Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
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López-Campos F, Martín-Martín M, Fornell-Pérez R, García-Pérez JC, Die-Trill J, Fuentes-Mateos R, López-Durán S, Domínguez-Rullán J, Ferreiro R, Riquelme-Oliveira A, Hervás-Morón A, Couñago F. Watch and wait approach in rectal cancer: Current controversies and future directions. World J Gastroenterol 2020; 26:4218-4239. [PMID: 32848330 PMCID: PMC7422545 DOI: 10.3748/wjg.v26.i29.4218] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/25/2020] [Accepted: 07/21/2020] [Indexed: 02/06/2023] Open
Abstract
According to the main international clinical guidelines, the recommended treatment for locally-advanced rectal cancer is neoadjuvant chemoradiotherapy followed by surgery. However, doubts have been raised about the appropriate definition of clinical complete response (cCR) after neoadjuvant therapy and the role of surgery in patients who achieve a cCR. Surgical resection is associated with significant morbidity and decreased quality of life (QoL), which is especially relevant given the favourable prognosis in this patient subset. Accordingly, there has been a growing interest in alternative approaches with less morbidity, including the organ-preserving watch and wait strategy, in which surgery is omitted in patients who have achieved a cCR. These patients are managed with a specific follow-up protocol to ensure adequate cancer control, including the early identification of recurrent disease. However, there are several open questions about this strategy, including patient selection, the clinical and radiological criteria to accurately determine cCR, the duration of neoadjuvant treatment, the role of dose intensification (chemotherapy and/or radiotherapy), optimal follow-up protocols, and the future perspectives of this approach. In the present review, we summarize the available evidence on the watch and wait strategy in this clinical scenario, including ongoing clinical trials, QoL in these patients, and the controversies surrounding this treatment approach.
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Affiliation(s)
- Fernando López-Campos
- Department of Radiation Oncology, Hospital Universitario Ramón y Cajal, Madrid 28034, Spain
| | | | - Roberto Fornell-Pérez
- Department of Radiology, Hospital Universitario de Basurto, Bilbao 48013, Vizcaya, Spain
| | | | - Javier Die-Trill
- Department of Surgery, Hospital Universitario Ramón y Cajal, Madrid 28034, Spain
| | - Raquel Fuentes-Mateos
- Department of Medical Oncology, Hospital Universitario Ramón y Cajal, Madrid 28034, Spain
| | - Sergio López-Durán
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Madrid 28034, Spain
| | - José Domínguez-Rullán
- Department of Radiation Oncology, Hospital Universitario Ramón y Cajal, Madrid 28034, Spain
| | - Reyes Ferreiro
- Department of Medical Oncology, Hospital Universitario Ramón y Cajal, Madrid 28034, Spain
| | | | - Asunción Hervás-Morón
- Department of Radiation Oncology, Hospital Universitario Ramón y Cajal, Madrid 28034, Spain
| | - Felipe Couñago
- Department of Radiation Oncology, Hospital Universitario Quirónsalud, Madrid 28003, Spain
- Department of Radiation Oncology, Hospital La Luz, Madrid 28003, Spain
- Universidad Europea de Madrid (UEM), Madrid 28223, Spain
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Shao L, Liu Z, Feng L, Lou X, Li Z, Zhang XY, Wan X, Zhou X, Sun K, Zhang DF, Wu L, Yang G, Sun YS, Xu R, Fan X, Tian J. Multiparametric MRI and Whole Slide Image-Based Pretreatment Prediction of Pathological Response to Neoadjuvant Chemoradiotherapy in Rectal Cancer: A Multicenter Radiopathomic Study. Ann Surg Oncol 2020; 27:4296-4306. [PMID: 32729045 PMCID: PMC7497677 DOI: 10.1245/s10434-020-08659-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Indexed: 01/01/2023]
Abstract
Background The aim of this work is to combine radiological and pathological information of tumor to develop a signature for pretreatment prediction of discrepancies of pathological response at several centers and restage patients with locally advanced rectal cancer (LARC) for individualized treatment planning. Patients and Methods A total of 981 consecutive patients with evaluation of response according to tumor regression grade (TRG) who received nCRT were retrospectively recruited from four hospitals (primary cohort and external validation cohort 1–3); both pretreatment multiparametric MRI (mp-MRI) and whole slide image (WSI) of biopsy specimens were available for each patient. Quantitative image features were extracted from mp-MRI and WSI and used to construct a radiopathomics signature (RPS) powered by an artificial-intelligence model. Models based on mp-MRI or WSI alone were also constructed for comparison. Results The RPS showed overall accuracy of 79.66–87.66% in validation cohorts. The areas under the curve of RPS at specific response grades were 0.98 (TRG0), 0.93 (≤ TRG1), and 0.84 (≤ TRG2). RPS at each grade of pathological response revealed significant improvement compared with both signatures constructed without combining multiscale tumor information (P < 0.01). Moreover, RPS showed relevance to distinct probabilities of overall survival and disease-free survival in patients with LARC who underwent nCRT (P < 0.05). Conclusions The results of this study suggest that radiopathomics, combining both radiological information of the whole tumor and pathological information of local lesions from biopsy, could potentially predict discrepancies of pathological response prior to nCRT for better treatment planning. Electronic supplementary material The online version of this article (10.1245/s10434-020-08659-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lizhi Shao
- School of Computer Science and Engineering, Southeast University, Nanjing, China.,CAS Key Laboratory of Molecular Imaging, Institute of Automation, Beijing, China
| | - Zhenyu Liu
- CAS Key Laboratory of Molecular Imaging, Institute of Automation, Beijing, China.,School of Artificial Intelligence, University of Chinese Academy of Sciences, Beijing, China
| | - Lili Feng
- Department of Radiation Oncology, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiaoying Lou
- Department of Pathology, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhenhui Li
- Department of Radiology, Yunnan Cancer Center, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Xiao-Yan Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiology, Peking University Cancer Hospital & Institute, Beijing, China
| | - Xiangbo Wan
- Department of Radiation Oncology, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xuezhi Zhou
- CAS Key Laboratory of Molecular Imaging, Institute of Automation, Beijing, China.,Engineering Research Center of Molecular and Neuro Imaging of Ministry of Education, School of Life Science and Technology, Xidian University, Xi'an, China
| | - Kai Sun
- CAS Key Laboratory of Molecular Imaging, Institute of Automation, Beijing, China.,Engineering Research Center of Molecular and Neuro Imaging of Ministry of Education, School of Life Science and Technology, Xidian University, Xi'an, China
| | - Da-Fu Zhang
- Department of Radiology, Yunnan Cancer Center, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Lin Wu
- Department of Pathology, Yunnan Cancer Center, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Guanyu Yang
- School of Computer Science and Engineering, Southeast University, Nanjing, China.,LIST, Key Laboratory of Computer Network and Information Integration, Southeast University, Ministry of Education, Nanjing, China
| | - Ying-Shi Sun
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiology, Peking University Cancer Hospital & Institute, Beijing, China
| | - Ruihua Xu
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China.
| | - Xinjuan Fan
- Department of Pathology, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
| | - Jie Tian
- CAS Key Laboratory of Molecular Imaging, Institute of Automation, Beijing, China. .,School of Artificial Intelligence, University of Chinese Academy of Sciences, Beijing, China. .,Engineering Research Center of Molecular and Neuro Imaging of Ministry of Education, School of Life Science and Technology, Xidian University, Xi'an, China. .,Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, School of Medicine, Beihang University, Beijing, China.
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32
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Sun Y, Zhang Y, Wu X, Chi P. A Four Gene-Based Risk Score System Associated with Chemoradiotherapy Response and Tumor Recurrence in Rectal Cancer by Co-Expression Network Analysis. Onco Targets Ther 2020; 13:6721-6733. [PMID: 32753901 PMCID: PMC7354918 DOI: 10.2147/ott.s256696] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 05/26/2020] [Indexed: 12/14/2022] Open
Abstract
Aim Resistance to neoadjuvant chemoradiotherapy (NCRT) and tumor recurrence presents a major clinical problem in locally advanced rectal cancer (LARC) patients. This study aimed to explore a genetic risk score related to NCRT response and tumor recurrence in rectal cancer after NCRT. Materials and Methods Weighted gene co-expression network analysis was employed to identify hub genes associated with NCRT response from the GSE93375 dataset. Prognostic hub genes were determined using Cox regression analysis and associated with disease-free survival (DFS). A risk score system was constructed and the prognostic significance of the risk score was validated in our patient cohort. A predictive nomogram for DFS was developed and validated internally. Results The Tan module had the highest correlations with NCRT response. Ten hub genes (COL15A1, THBS2, ITGB1, MMP2, CD34, SPARC, NOTCH3, PDGFRB, DCN, and SERPINH1) were associated with NCRT response. Immunostaining expression of four genes (NOTCH3, SPARC, DCN, and ITGB1) was found to be significantly associated with both NCRT response and DFS in our patient cohort and was selected to build a prognostic risk score for DFS as follows: risk score= (0.6188×Exp NOTCH3 ) + (0.6511×Exp SPARC ) + (-0.2976×Exp DCN ) + (1.0035×Exp ITGB1 ). Using this risk score, patients could be separated into high- and low-risk groups for tumor recurrence. A nomogram that incorporated the risk score, ypTNM stage, and tumor regression grade (TRG) was constructed and utilized to predict DFS in LARC patients. Conclusion The four-gene expression-based risk score system presented here could be potentially used for predicting tumor recurrence in LARC patients after NCRT.
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Affiliation(s)
- Yanwu Sun
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, People's Republic of China
| | - Yiyi Zhang
- Fujian Medical University, Fuzhou, Fujian Province, People's Republic of China
| | - Xuejing Wu
- Department of Pathology, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, People's Republic of China
| | - Pan Chi
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, People's Republic of China
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33
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Olson CH. Current Status of the Management of Stage I Rectal Cancer. Curr Oncol Rep 2020; 22:40. [PMID: 32240411 DOI: 10.1007/s11912-020-00905-y] [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: 10/24/2022]
Abstract
PURPOSE OF REVIEW To summarize the current available treatments for stage I rectal cancer and the evidence that supports them. RECENT FINDINGS Radical surgery, or total mesorectal excision (TME) without neoadjuvant therapy, reports excellent oncologic outcomes, with 5-year disease-free survival of approximately 95%. Alternative therapies include local excision, which has acceptable long-term outcomes in some low-risk T1 tumors; but overall local excision, with or without additional chemotherapy or radiation, generally reports 5-year disease-free survival less than TME alone. New research is showing complete clinical response rates of 67% with chemoradiation combined with additional consolidation chemotherapy in T2 lesions, making watch and wait a potential strategy for stage I tumors. Owing to its superior oncologic outcomes, radical surgery remains the mainstay of treatment for stage I tumors. Both local excision and watch and wait have advantages that may make them useful in individual patients and should be considered under the right circumstances.
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Affiliation(s)
- Craig Howard Olson
- Division of Colon and Rectal Surgery, University of Texas Southwestern, 1801 Inwood Blvd WA3.316, Dallas, TX, 75390, USA.
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Tjalma JJJ, Koller M, Linssen MD, Hartmans E, de Jongh SJ, Jorritsma-Smit A, Karrenbeld A, de Vries EG, Kleibeuker JH, Pennings JP, Havenga K, Hemmer PH, Hospers GA, van Etten B, Ntziachristos V, van Dam GM, Robinson DJ, Nagengast WB. Quantitative fluorescence endoscopy: an innovative endoscopy approach to evaluate neoadjuvant treatment response in locally advanced rectal cancer. Gut 2020; 69:406-410. [PMID: 31533965 PMCID: PMC7034345 DOI: 10.1136/gutjnl-2019-319755] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 08/31/2019] [Indexed: 12/08/2022]
Affiliation(s)
- Jolien J J Tjalma
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marjory Koller
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Matthijs D Linssen
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Elmire Hartmans
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Steven J de Jongh
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Annelies Jorritsma-Smit
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Arend Karrenbeld
- Department of Pathology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Elisabeth G de Vries
- Department of Medical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan H Kleibeuker
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan Pieter Pennings
- Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Klaas Havenga
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Patrick Hjh Hemmer
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Geke Ap Hospers
- Department of Medical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Boudewijn van Etten
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Vasilis Ntziachristos
- Institute for Biological and Medical Imaging, Helmholtz Zentrum München, Munich, Germany
| | - Gooitzen M van Dam
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Dominic J Robinson
- Otolaryngology and Head and Neck Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Wouter B Nagengast
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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The risk of distant metastases in rectal cancer managed by a watch-and-wait strategy – A systematic review and meta-analysis. Radiother Oncol 2020; 144:1-6. [DOI: 10.1016/j.radonc.2019.10.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 10/12/2019] [Accepted: 10/15/2019] [Indexed: 12/18/2022]
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36
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Cosimelli M, Ursi P, Mancini R, Pattaro G, Perri P, Parrino C, De Peppo V, Diodoro MG, Balla A, Grazi GL. Organ-saving surgery for rectal cancer after neoadjuvant chemoradiation: Analysis of failures and long-term results. J Surg Oncol 2020; 121:375-381. [PMID: 31788805 DOI: 10.1002/jso.25794] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 11/25/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND To analyze long-term results and risk of relapse in the clinical TNM stages II and III, mid-low rectal cancer patients (RC pts), treated with transanal local excision (LE) after major response to neoadjuvant chemoradiation (n-CRT). METHODS Thirty-two out of 345 extraperitoneal cT3-4 or N+ RC pts (9.3%) underwent LE. INCLUSION CRITERIA extraperitoneal RC, adenocarcinoma, ECOG Performance Status ≤2. Pts with distant metastases were excluded. RESULTS All pts showed histologically clear margins of resection and 81.2% were restaged ypT0/mic/1. Nine out of 32 (28.1%) pts relapsed: 7 (21.8%) showed a local recurrence, of which 5 (15.6%) at the endorectal suture, 1 (3.1%) pelvic and 1 (3.1%) mesorectal. Two pts (6.2%) relapsed distantly. Among the pT0/1, 11.5% relapsed vs 100% of the pT2 and pT4 ones. The six pts relapsing locally or in the mesorectal fat underwent a salvage total mesorectal excision surgery. The old patient with pelvic recurrence relapsed after 108 months and underwent a re-irradiation; the two pts with distant metastases were treated with chemotherapy followed by radical surgery. CONCLUSIONS Presently combined approach seems a valid option in major responders, confirming its potential curative impact in the ypT0/mic/1 pts. A strict selection of pts is basic to obtain favourable results.
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Affiliation(s)
- Maurizio Cosimelli
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Pietro Ursi
- Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Rome, Italy
| | - Raffaello Mancini
- Robotic General Surgery Unit, San Giovanni Addolorata Hospital, Rome, Italy
| | - Giada Pattaro
- Department of General Surgery, S.M. Goretti Hospital, Latina, Italy
| | - Pasquale Perri
- Division of General and HepatoPancreatoBiliary Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Chiara Parrino
- Division of General and HepatoPancreatoBiliary Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Valerio De Peppo
- Division of General and HepatoPancreatoBiliary Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Maria Grazia Diodoro
- Department of Pathology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Andrea Balla
- Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Rome, Italy
| | - Gian Luca Grazi
- Division of General and HepatoPancreatoBiliary Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy
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MR tumor regression grade for pathological complete response in rectal cancer post neoadjuvant chemoradiotherapy: a systematic review and meta-analysis for accuracy. Eur Radiol 2020; 30:2312-2323. [PMID: 31953656 DOI: 10.1007/s00330-019-06565-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 10/25/2019] [Accepted: 10/30/2019] [Indexed: 01/07/2023]
Abstract
OBJECTIVES To determine the diagnostic accuracy of magnetic resonance tumor regression grade (mrTRG) for pathological complete response (pCR) and its correlation with pathological findings. METHODS Original studies that investigated the correlation of mrTRG with pathological tumor regression grade and pathological T stage were identified in MEDLINE and EMBASE up until August 31, 2018, according to PRISMA guidelines. The search terms included colorectal cancer, chemoradiation therapy, magnetic resonance imaging, and response or regression. Meta-analytic summary sensitivity and specificity for pathologic complete response (pCR) and pathologic T1 or lower than T1 stage (≤ypT1) were calculated using a bivariate random-effects model. The sensitivity and specificity were calculated in both mrTRG 1 and mrTRG 1 or 2, respectively. RESULTS Six studies with 916 patients were included. The meta-analytic summary sensitivity and specificity of mrTRG 1 for pCR were 32.3% (95% CI, 18.2-50.6%) and 93.5% (95% CI, 91.5-95.1%), while for ≤ypT1 they were 31.8% (95% CI, 16.2-53.0%) and 94.7% (95% CI, 91.9-96.5%). On the contrary, sensitivity and specificity of mrTRG 1 or 2 for pCR were 69.9% (95% CI, 60.2-78.1%) and 62.2% (95% CI, 56.2-67.8%), while those for ≤ypT1 were 71.4% (95% CI, 61.6-79.6%) and 67.7% (95% CI, 59.8-74.7%). CONCLUSIONS mrTRG 1 showed high specificity for pCR and ≤ypT1, but suboptimal sensitivity. mrTRG 1 or 2 showed higher sensitivity for pCR and ≤ypT1, but lower specificity. Because of the suboptimal sensitivity of mrTRG 1, it might be limited as a criterion for less aggressive treatment after neoadjuvant chemoradiotherapy. KEY POINTS • Magnetic resonance tumor regression grade 1 shows high specificity for pCR and ≤ypT1, but suboptimal sensitivity. • Magnetic resonance tumor regression grade 1 or 2 shows higher sensitivity for pCR and ≤ypT1, but lower specificity than magnetic resonance tumor regression grade 1 alone.
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Abstract
Purpose of Review With advances in radiation therapy (RT) techniques for rectal and anal cancers allowing for the modulation of critical normal tissues, there has been an increased emphasis on improving the quality of life (QOL) of cancer survivors. Herein, we review the literature to examine the impact of RT on QOL and patient reported outcomes (PROs) to better inform providers about the challenges of survivorship. Recent Findings Large systematic reviews, recent studies and long-term follow-up of pivotal clinical trials have shown that RT impacts QOL, particularly fecal continence and sexual function. Modern preoperative RT techniques allow for decreased dose to organs-at-risk will likely improve QOL. Summary RT, though critical in the treatment of rectal and anal cancer, has a profound impact on QOL for some patients. Recent studies have included PROs and validated QOL metrics to better inform providers and patients.
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Russo S, Anker CJ, Abdel-Wahab M, Azad N, Das P, Dragovic J, Goodman KA, Herman JM, Jones W, Kennedy T, Konski A, Kumar R, Lee P, Patel NM, Sharma N, Small W, Suh WW, Jabbour SK. Executive Summary of the American Radium Society Appropriate Use Criteria for Local Excision in Rectal Cancer. Int J Radiat Oncol Biol Phys 2019; 105:977-993. [PMID: 31445109 PMCID: PMC11101014 DOI: 10.1016/j.ijrobp.2019.08.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 08/02/2019] [Accepted: 08/11/2019] [Indexed: 02/07/2023]
Abstract
The goal of treatment for early stage rectal cancer is to optimize oncologic outcome while minimizing effect of treatment on quality of life. The standard of care treatment for most early rectal cancers is radical surgery alone. Given the morbidity associated with radical surgery, local excision for early rectal cancers has been explored as an alternative approach associated with lower rates of morbidity. The American Radium Society Appropriate Use Criteria presented in this manuscript are evidence-based guidelines for the use of local excision in early stage rectal cancer that include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) used by a multidisciplinary expert panel to rate the appropriateness of imaging and treatment procedures. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. These guidelines are intended for the use of all practitioners and patients who desire information regarding the use of local excision in rectal cancer.
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Affiliation(s)
- Suzanne Russo
- Case Western Reserve University School of Medicine and University Hospitals, Cleveland, Ohio.
| | | | - May Abdel-Wahab
- International Atomic Energy Agency, Division of Human Health, New York, New York
| | - Nilofer Azad
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Prajnan Das
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | | | - Joseph M Herman
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - William Jones
- UT Health Cancer Center, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | | | - Andre Konski
- University of Pennsylvania Perelman School of Medicine, Chester County Hospital, West Chester, Pennsylvania
| | - Rachit Kumar
- Banner MD Anderson Cancer Center, Gilbert, Arizona
| | - Percy Lee
- University of California, Los Angeles, Jonsson Comprehensive Cancer Center, Los Angeles, California
| | | | - Navesh Sharma
- Milton S. Hershey Cancer Institute, Hershey, Pennsylvania
| | | | - W Warren Suh
- Ridley-Tree Cancer Center Santa Barbara @ Sansum Clinic, Santa Barbara California
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Bushati M, Pucciarelli S, Gennaro N, Maretto I, Toppan P, Perin A, Urso EDL, Bagatella A, Spolverato G. Local excision in rectal cancer patients with major or complete clinical response after neoadjuvant therapy: a case-matched study. Int J Colorectal Dis 2019; 34:2129-2136. [PMID: 31724079 DOI: 10.1007/s00384-019-03420-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE To assess the long-term oncological outcomes in patients with locally advanced rectal cancer who underwent neoadjuvant therapy followed by local or total mesorectal excision. METHODS Patients with locally advanced rectal adenocarcinoma who received neoadjuvant therapy from 2005 to 2017 were evaluated. Those with major or complete clinical response underwent a full-thickness local excision. Kaplan-Meier estimates were used to evaluate overall, disease-free, and local recurrence-free survival of patients who underwent local excision (LE group) and were compared with a matched cohort of patients who underwent total mesorectal excision (TME group). RESULTS Among 252 patients who received neoadjuvant therapy for rectal cancer, 51 (20.2%) underwent a local excision. At a median follow-up of 61 months, patients who underwent local excision were stoma-free in 88.2% of cases and with rectum preserved in 78.5% of cases, respectively. The estimated 5-year local, disease-free, and overall survival was 91.8% vs 97.6% (95% CI: 79.5-96.8 vs 84.6-99.6), 86.7% vs 86.4% (95% CI: 72.5-93.9 vs 70.1-94.1), and 85% vs 90% (95% CI: 69.0-93.0% vs 75.3-96.2), in the study and matched control group, respectively. None of the differences was statistically significant. CONCLUSIONS One-fifth of patients with locally advanced rectal cancer are manageable with a rectum-sparing approach after neoadjuvant therapy. With this strategy, about 80% patients will have their rectum preserved and 90% will be without stoma at long term.
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Affiliation(s)
- M Bushati
- 1st Surgical Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - S Pucciarelli
- 1st Surgical Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padua, Via Giustiniani 2, 35128, Padua, Italy.
| | - N Gennaro
- Regional Health Service, Epidemiology Unit, Veneto Region, Padua, Italy
| | - I Maretto
- 1st Surgical Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - P Toppan
- 1st Surgical Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - A Perin
- 1st Surgical Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - E D L Urso
- 1st Surgical Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - A Bagatella
- 1st Surgical Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - G Spolverato
- 1st Surgical Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
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Stijns RCH, de Graaf EJR, Punt CJA, Nagtegaal ID, Nuyttens JJME, van Meerten E, Tanis PJ, de Hingh IHJT, van der Schelling GP, Acherman Y, Leijtens JWA, Bremers AJA, Beets GL, Hoff C, Verhoef C, Marijnen CAM, de Wilt JHW. Long-term Oncological and Functional Outcomes of Chemoradiotherapy Followed by Organ-Sparing Transanal Endoscopic Microsurgery for Distal Rectal Cancer: The CARTS Study. JAMA Surg 2019; 154:47-54. [PMID: 30304338 DOI: 10.1001/jamasurg.2018.3752] [Citation(s) in RCA: 142] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Importance Treatment of rectal cancer is shifting toward organ preservation aiming to reduce surgery-related morbidity. Short-term outcomes of organ-preserving strategies are promising, but long-term outcomes are scarce in the literature. Objective To explore long-term oncological outcomes and health-related quality of life (HRQL) in patients with cT1-3N0M0 rectal cancer who underwent neoadjuvant chemoradiotherapy (CRT) followed by transanal endoscopic microsurgery (TEM). Design, Setting, and Participants In this multicenter phase II feasibility study, patients with cT1-3N0M0 rectal cancer admitted to referral centers for rectal cancer throughout the Netherlands between February 2011 and September 2012 were prospectively included. These patients were to be treated with neoadjuvant CRT followed by TEM in case of good response. An intensive follow-up scheme was used to detect local recurrences and/or distant metastases. Data from validated HRQL questionnaires and low anterior resection syndrome questionnaires were collected. Data were analyzed from February 2011 to April 2017. Main Outcomes and Measures The primary study outcome of the study was the number of ypT0-1 specimens by performing TEM. Secondary outcome parameters were locoregional recurrences and HRQL. Results Of the 55 included patients, 30 (55%) were male, and the mean (SD) age was 64 (39-82) years. Patients were followed up for a median (interquartile range) period of 53 (39-57) months. Two patients (4%) died during CRT, 1 (2%) stopped CRT, and 1 (2%) was lost to follow-up. Following CRT, 47 patients (85%) underwent TEM, of whom 35 (74%) were successfully treated with local excision alone. Total mesorectal excision was performed in 16 patients (4 with inadequate responses, 8 with completion after TEM, and 4 with salvage for local recurrence). The actuarial 5-year local recurrence rate was 7.7%, with 5-year disease-free and overall survival rates of 81.6% and 82.8%, respectively. Health-related quality of life during follow-up was equal to baseline, with improved emotional well-being in patients treated with local excision (mean score at baseline, 72.0; 95% CI, 67.1-80.1; mean score at follow-up, 86.9; 95% CI, 79.2-94.7; P = .001). Major, minor, and no low anterior resection syndrome was experienced in 50%, 28%, and 22%, respectively, of patients with successful organ preservation. Conclusions and Relevance In early-stage rectal cancer (cT1-3N0M0), CRT enables organ preservation with additional TEM surgery in approximately two-thirds of patients with good long-term oncological outcome and HRQL. This multimodality treatment triggers a certain degree of bowel dysfunction, and one-third of patients still undergo radical surgery and are overtreated by CRT.
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Affiliation(s)
- Rutger C H Stijns
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Eelco J R de Graaf
- Department of Surgery, IJsselland Hospital, Capelle aan de Ijssel, the Netherlands
| | - Cornelis J A Punt
- Department of Medical Oncology, Academic Medical Centre, Amsterdam, the Netherlands
| | - Iris D Nagtegaal
- Department of Pathology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Joost J M E Nuyttens
- Department of Radiation Oncology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Esther van Meerten
- Department of Oncology, Erasmus Medical Centre Cancer Institute, Rotterdam, the Netherlands
| | - Pieter J Tanis
- Department of Surgery, Academic Medical Centre, Amsterdam, the Netherlands
| | | | | | - Yair Acherman
- Department of Surgery, Medical Centre Slotervaart, Amsterdam, the Netherlands
| | | | - Andreas J A Bremers
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Geerard L Beets
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Christiaan Hoff
- Department of Surgery, Medical Centre Leeuwarden, Leeuwarden, the Netherlands
| | - Cornelis Verhoef
- Department of Surgical Oncology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Corrie A M Marijnen
- Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands
| | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
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van der Sluis FJ, Couwenberg AM, de Bock GH, Intven MPW, Reerink O, van Leeuwen BL, van Westreenen HL. Population-based study of morbidity risk associated with pathological complete response after chemoradiotherapy for rectal cancer. Br J Surg 2019; 107:131-139. [DOI: 10.1002/bjs.11324] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 07/03/2019] [Accepted: 07/04/2019] [Indexed: 12/31/2022]
Abstract
Abstract
Background
Neoadjuvant chemoradiotherapy (nCRT) for locally advanced rectal cancer may induce a pathological complete response (pCR) but increase surgical morbidity due to radiation-induced fibrosis. In this study the association between pCR and postoperative surgical morbidity was investigated.
Methods
Patients in the Netherlands with rectal cancer who underwent nCRT followed by total mesorectal excision between 2009 and 2017 were included. Data were stratified into patients who underwent resection with creation of a primary anastomosis and those who had a permanent stoma procedure. The association between pCR and postoperative morbidity was investigated in univariable and multivariable logistic regression analyses.
Results
pCR was observed in 976 (12·2 per cent) of 8003 patients. In 3472 patients who had a primary anastomosis, the presence of pCR was significantly associated with surgical complications (122 of 443 (27·5 per cent) versus 598 of 3029 (19·7 per cent) in those without pCR) and anastomotic leak (35 of 443 (7·9 per cent) versus 173 of 3029 (5·7 per cent) respectively). Multivariable analysis also showed associations between pCR and surgical complications (adjusted odds ratio (OR) 1·53, 95 per cent c.i. 1·22 to 1·92) and pCR and anastomotic leak (adjusted OR 1·41, 1·03 to 2·05). Of 4531 patients with a permanent stoma, surgical complications were observed in 120 (22·5 per cent) of 533 patients with a pCR, compared with 798 (20·0 per cent) of 3998 patients with no pCR (adjusted OR 1·17, 0·94 to 1·46).
Conclusion
Patients with a pCR in whom an anastomosis was created were at increased risk of developing an anastomotic leak.
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Affiliation(s)
| | - A M Couwenberg
- Department of Radiation Oncology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - G H de Bock
- Department of Epidemiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - M P W Intven
- Department of Radiation Oncology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - O Reerink
- Department of Radiation Oncology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - B L van Leeuwen
- Department of Surgical Oncology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
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Esposito F, Noviello A, Moles N, Coppola Bottazzi E, Baiamonte M, Macaione I, Ferbo U, Lepore M, Miro A, Crafa F. Sentinel Lymph Node Analysis in Colorectal Cancer Patients Using One-Step Nucleic Acid Amplification in Combination With Fluorescence and Indocyanine Green. Ann Coloproctol 2019; 35:174-180. [PMID: 31487764 PMCID: PMC6732328 DOI: 10.3393/ac.2018.07.21.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 07/21/2018] [Indexed: 02/06/2023] Open
Abstract
PURPOSE Analysis of the sentinel lymph node (SLN) in colorectal cancer (CRC) patients was proposed for more accurate staging and tailored lymphadenectomy. The aim of this study was to assess the ability to predict lymph node (LN) involvement through analysis of the SLN with a one-step nucleic acid (OSNA) technique in combination with peritumoral injection of indocyanine green (ICG) and near-infrared (NIR) lymphangiography in CRC patients. METHODS A total of 34 patients were enrolled. Overall, 51 LNs were analyzed with OSNA. LNs of 17 patients (50%) were examined simultaneously with hematoxylin and eosin (H&E) and OSNA. RESULTS SLN analysis of 17 patients examined with H&E and OSNA revealed that OSNA had a higher sensitivity (1 vs. 0.55), higher negative predictive value (1 vs. 0.66) and higher accuracy (100% vs. 76.4%) in predicting LN involvement. Overall, OSNA showed a sensitivity of 0.69, specificity of 1, accuracy of 88.2%, and stage migration of 8.8%. Compared to those who were OSNA (-), OSNA (+) patients had a greater number of LN metastases (4.8 vs. 0.16, P = 0.04), higher G3 rate (44.4% vs. 4%, P = 0.01), more advanced stage of disease (stage III: 77.8% vs. 16%; P = 0.00) and were more rapidly subjected to adjuvant chemotherapy (39.1 days vs. 50.2 days, P = 0.01). CONCLUSION SLN analysis with OSNA in combination with ICG-NIR lymphangiography is feasible and can detect LN involvement in CRC patients. Furthermore, it allows for more accurate staging reducing the delay between surgery and adjuvant chemotherapy.
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Affiliation(s)
- Francesco Esposito
- Oncological and General Surgery Unit, St. Giuseppe Moscati Hospital of National Relevance and High Specialty, Avellino, Italy
| | - Adele Noviello
- Oncological and General Surgery Unit, St. Giuseppe Moscati Hospital of National Relevance and High Specialty, Avellino, Italy
| | - Nicola Moles
- Oncological and General Surgery Unit, St. Giuseppe Moscati Hospital of National Relevance and High Specialty, Avellino, Italy
| | - Enrico Coppola Bottazzi
- Oncological and General Surgery Unit, St. Giuseppe Moscati Hospital of National Relevance and High Specialty, Avellino, Italy
| | - Mario Baiamonte
- General and Emergency Surgery Unit, Civico Benfratelli Di Cristina Hospital, Palermo, Italy
| | - Ina Macaione
- Department of Surgical, Oncological and Stomatological Disciplines, University of Palermo, Palermo, Italy
| | - Umberto Ferbo
- Institute of Pathology, St. Giuseppe Moscati Hospital of National Relevance and High Specialty, Avellino, Italy
| | - Maria Lepore
- Institute of Pathology, St. Giuseppe Moscati Hospital of National Relevance and High Specialty, Avellino, Italy
| | - Antonio Miro
- Oncological and General Surgery Unit, St. Giuseppe Moscati Hospital of National Relevance and High Specialty, Avellino, Italy
| | - Francesco Crafa
- Oncological and General Surgery Unit, St. Giuseppe Moscati Hospital of National Relevance and High Specialty, Avellino, Italy
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Oncological and Survival Outcomes in Watch and Wait Patients With a Clinical Complete Response After Neoadjuvant Chemoradiotherapy for Rectal Cancer: A Systematic Review and Pooled Analysis. Ann Surg 2019; 268:955-967. [PMID: 29746338 DOI: 10.1097/sla.0000000000002761] [Citation(s) in RCA: 164] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the oncological and survival outcomes of a Watch and Wait policy in rectal cancer after a clinical complete response (cCR) following neoadjuvant chemoradiotherapy. BACKGROUND The detection of a cCR after neoadjuvant treatment may facilitate a nonoperative approach in selected patients. However, the long-term safety of this strategy remains to be validated. METHOD This is a systematic review of the literature to determine the oncological outcomes in Watch and Wait patients. The primary outcome was the cumulative rate of local regrowth, success of salvage surgery, and incidence of metastases. We also evaluated survival outcomes. A pooled analysis of manually extracted summary statistics from individual studies was carried out using inverse variance weighting. RESULTS Seventeen studies comprising 692 patients were identified; incidence of cCR was 22.4% [95% confidence interval (CI),14.3-31.8]. There were 153 (22.1%) local regrowths, of which 96% (n = 147/153) manifested in the first 3 years of surveillance. The 3-year cumulative risk of local regrowth was 21.6% (95% CI, 16.0-27.8). Salvage surgery was performed in 88% of patients, of which 121 (93%) had a complete (R0) resection. Fifty-seven metastases (8.2%) were detected, and 35 (60%) were isolated without evidence of synchronous regrowths; 3-year incidence was 6.8% (95% CI, 4.1-10.2). The 3-year overall survival was 93.5% (95% CI, 90.2-96.2). CONCLUSION In rectal cancer patients with a cCR following neoadjuvant chemoradiotherapy, a Watch and Wait policy appears feasible and safe. Robust surveillance with early detection of regrowths allows a high rate of successful salvage surgery, without an increase in the risk of systemic disease, or adverse survival outcomes.
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Arias F, Asín G, Flamarique S, Hernández I, Suarez J. In favor of total neoadjuvant therapy (TNT) for locally advanced rectal carcinoma. Clin Transl Oncol 2019; 22:793-794. [PMID: 31309436 DOI: 10.1007/s12094-019-02177-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 07/03/2019] [Indexed: 11/25/2022]
Affiliation(s)
- F Arias
- Services of Radiation Oncology, Multidisciplinary Colorectal Cancer Unit (UMDCR), Complejo Hospitalario de Navarra, Pamplona, Spain.
| | - G Asín
- Services of Radiation Oncology, Multidisciplinary Colorectal Cancer Unit (UMDCR), Complejo Hospitalario de Navarra, Pamplona, Spain
| | - S Flamarique
- Services of Radiation Oncology, Multidisciplinary Colorectal Cancer Unit (UMDCR), Complejo Hospitalario de Navarra, Pamplona, Spain
| | - I Hernández
- Services of Medical Oncology, Multidisciplinary Colorectal Cancer Unit (UMDCR), Complejo Hospitalario de Navarra, Pamplona, Spain
| | - J Suarez
- Services of Surgery, Multidisciplinary Colorectal Cancer Unit (UMDCR), Complejo Hospitalario de Navarra, Pamplona, Spain
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Akiyoshi T, Tanaka N, Kiyotani K, Gotoh O, Yamamoto N, Oba K, Fukunaga Y, Ueno M, Mori S. Immunogenomic profiles associated with response to neoadjuvant chemoradiotherapy in patients with rectal cancer. Br J Surg 2019; 106:1381-1392. [PMID: 31197828 DOI: 10.1002/bjs.11179] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 02/17/2019] [Accepted: 02/18/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Accumulating evidence suggests that radiotherapy success has an immune-associated component. The immunogenomic profiles associated with responses to chemoradiotherapy (CRT) were assessed in patients with locally advanced rectal cancer in this study. METHODS CD8+ tumour-infiltrating lymphocyte (TIL) and stromal lymphocyte densities were assessed by immunohistochemistry using pretreatment biopsies from patients with advanced rectal cancer who had preoperative CRT. Whole-exome sequencing and gene expression microarray analysis were conducted to investigate the genomic properties associated with the response to CRT and CD8+ TIL density. Response to CRT was determined based on Dworak tumour regression grade (TRG); tumours with complete (TRG 4) or near-complete (TRG 3) regression were grouped as good responders, and those with TRG 1 as non-responders. RESULTS Immunohistochemical examinations (275 patients) showed that pre-CRT CD8+ TIL density was associated with better response to CRT and improved recurrence-free survival, whereas pre-CRT stromal CD8+ cell density was not associated with either response to CRT or recurrence-free survival. Whole-exome sequencing (74 patients) showed that the numbers of single-nucleotide variations (SNVs) and neoantigens predicted from SNVs were higher in good responders than in non-responders, and these correlated positively with CD8+ TIL density (rS = 0·315 and rS = 0·334 respectively). Gene expression microarray (90 patients) showed that CD8A expression correlated positively with the expression of programmed cell death 1 (PDCD1) (rS = 0·264) and lymphocyte-activation gene 3 (LAG3) (rS = 0·507). CONCLUSION Pre-CRT neoantigen-specific CD8+ T cell priming may be a key event in CRT responses where immune checkpoint molecules could be useful targets to enhance tumour regression.
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Affiliation(s)
- T Akiyoshi
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Tokyo, Japan
| | - N Tanaka
- Cancer Precision Medicine Centre, Tokyo, Japan
| | - K Kiyotani
- Cancer Precision Medicine Centre, Tokyo, Japan
| | - O Gotoh
- Cancer Precision Medicine Centre, Tokyo, Japan
| | - N Yamamoto
- Division of Pathology, Cancer Institute, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - K Oba
- Department of Biostatistics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Y Fukunaga
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Tokyo, Japan
| | - M Ueno
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Tokyo, Japan
| | - S Mori
- Cancer Precision Medicine Centre, Tokyo, Japan
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Locally Advanced Rectal Cancer Evaluation by Magnetic Resonance Imaging after Neoadjuvant Therapy on Decision Making: Cancer Center Experience and Literature Review. J Gastrointest Cancer 2019; 51:254-259. [PMID: 31054106 DOI: 10.1007/s12029-019-00246-5] [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: 10/26/2022]
Abstract
PURPOSE An accurate clinical and radiological staging is the pyramid of treatment decisions in locally advanced rectal cancer (LARC). Guidelines recommended neoadjuvant chemoradiation therapy (CRT) followed by surgical resection for fit patients with LARC. Determining the aggressiveness of intervention while avoiding needless morbidity according to patient risk remains an unmet pre-operative decision-making need. With newer magnetic resonance imaging (MRI) techniques and image acquisition available at our Cancer Center, we seek to retrospectively review the correlation between pre- and post-CRT MRI response to the surgical pathological stage in order to aide multidisciplinary team decision making. METHODS Our Cancer Center Rectal Cancer Registry between 2011 and 2015 included 57 patients with LARC, 20 completed standard CRT with surgery, and of those 10 had repeated MRI after CRT. RESULTS Our retrospective case series revealed that 90% of the patients had a downstage tumor response on surgical specimen compared to radiological evaluation after CRT, and furthermore, all patients who were re-staged with MRI prior to surgery correlated with the gold standard pathological stage (p = 0.02). CONCLUSIONS Post-CRT MRI could potentially aide decision making to further avoid 20% of patients with a complete pathological response from a morbid surgery, whereas 10% of patients with an upstaged disease state may require a more aggressive neoadjuvant or planned surgical intervention. We concluded that future multidisciplinary oncology care treatment decision making would benefit from a repeat MRI after neoadjuvant CRT of LARC.
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Shah MF, Panteleimonitis S, Nasir IUI, Figueiredo N, Parvaiz A. Robotic resection for rectal regrowth in an obese patient - a video vignette. Colorectal Dis 2019; 21:606-607. [PMID: 30856688 DOI: 10.1111/codi.14607] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 03/05/2019] [Indexed: 01/19/2023]
Affiliation(s)
- M F Shah
- Poole Hospital NHS Trust, Poole, UK
| | | | | | | | - A Parvaiz
- Poole Hospital NHS Trust, Poole, UK.,Champalimaud Foundation, Lisbon, Portugal
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Lee JL, Lim SB, Yu CS, Park IJ, Yoon YS, Kim CW, Park SH, Lee JS, Hong YS, Kim SY, Kim JE, Kim JH, Park JH, Kim J, Han M. Local excision in mid-to-low rectal cancer patients who revealed clinically total or near-total regression after preoperative chemoradiotherapy; a proposed trial. BMC Cancer 2019; 19:404. [PMID: 31035949 PMCID: PMC6489182 DOI: 10.1186/s12885-019-5581-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 04/04/2019] [Indexed: 02/08/2023] Open
Abstract
Background Preoperative chemoradiotherapy (pre-CRT) followed by total mesorectal excision (TME) is currently a standard therapy for locally advanced mid-to-low rectal cancer. Less aggressive, organ-preserving option such as local excision (LE) or watchful wait can alternatively be used for patients who respond well to pre-CRT. High-resolution rectal magnetic resonance imaging (MRI) is one of the most useful methods to assess pre-CRT response, and the MERCURY group has shown that the MR tumor regression grade (mrTRG) correlated with the pathologic TRG. The aim of this study is to compare postoperative complication and oncologic outcomes between LE and TME in mid-to-low rectal cancer patients whose tumors are mrTRG grade 1 (radiological complete remission) or 2 (predominant fibrosis; near-complete remission) after pre-CRT. Methods A prospective, double-arm, randomized, open-labeled, single center, clinical trial will be conducted in patients with mid-to-low rectal cancer whose tumors are mrTRG 1/2 after pre-CRT at the Asan Medical Center, Seoul, Korea, after approval from the Institution Review Board. Patient medical records will be de-identified using a serial number to protect personal information. Inclusion criteria will include rectal adenocarcinoma with an inferior border < 8 cm from the anal verge, mrTRG 1/2, age > 20, and provision of informed consent. Postoperative complications will be assessed by Clavien-Dindo Classification Grade. Oncologic and functional outcomes will be collected and risk factors related to these outcomes will be investigated. Discussion We believed that the rate of postoperative complication of LE will be comparable to that of TME in mid-to-low advanced rectal cancer patients with a favorable response after pre-CRT. Trial registration KCT0002579 (https://cris.nih.go.kr) Dec-2017.
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Affiliation(s)
- Jong Lyul Lee
- 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, 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, Korea
| | - Chang Sik Yu
- 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, Korea.
| | - In Ja Park
- 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, Korea
| | - Yong Sik Yoon
- 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, Korea
| | - Chan Wook Kim
- 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, Korea
| | - Seong Ho Park
- Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Jong Seok Lee
- Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Yong Sang Hong
- Department of Medical Oncology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Sun Young Kim
- Department of Medical Oncology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Jeong Eun Kim
- Department of Medical Oncology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Jong Hoon Kim
- Department of Radiation Oncology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Jin-Hong Park
- Department of Radiation Oncology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Jihun Kim
- Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Minkyu Han
- Department of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
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50
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Tang Z, Zhang XY, Liu Z, Li XT, Shi YJ, Wang S, Fang M, Shen C, Dong E, Sun YS, Tian J. Quantitative analysis of diffusion weighted imaging to predict pathological good response to neoadjuvant chemoradiation for locally advanced rectal cancer. Radiother Oncol 2019; 132:100-108. [DOI: 10.1016/j.radonc.2018.11.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 10/16/2018] [Accepted: 11/13/2018] [Indexed: 12/14/2022]
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