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Cheng X, Zhang H, Hamad A, Huang H, Tsung A. Surgery-mediated tumor-promoting effects on the immune microenvironment. Semin Cancer Biol 2022; 86:408-419. [PMID: 35066156 DOI: 10.1016/j.semcancer.2022.01.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/18/2022] [Accepted: 01/19/2022] [Indexed: 02/07/2023]
Abstract
Surgical resection continues to be the mainstay treatment for solid cancers even though chemotherapy and immunotherapy have significantly improved patient overall survival and progression-free survival. Numerous studies have shown that surgery induces the dissemination of circulating tumor cells (CTCs) and that the resultant inflammatory response promotes occult tumor growth and the metastatic process by forming a supportive tumor microenvironment (TME). Surgery-induced platelet activation is one of the initial responses to a wound and the formation of fibrin clots can provide the scaffold for recruited inflammatory cells. Activated platelets can also shield CTCs to protect them from blood shear forces and promote CTCs evasion of immune destruction. Similarly, neutrophils are recruited to the fibrin clot and enhance cancer metastatic dissemination and progression by forming neutrophil extracellular traps (NETs). Activated macrophages are also recruited to surgical sites to facilitate the metastatic spread. More importantly, the body's response to surgical insult results in the recruitment and expansion of immunosuppressive cell populations (i.e. myeloid-derived suppressor cells and regulatory T cells) and in the suppression of natural killer (NK) cells that contribute to postoperative cancer recurrence and metastasis. In this review, we seek to provide an overview of the pro-tumorigenic mechanisms resulting from surgery's impact on these cells in the TME. Further understanding of these events will allow for the development of perioperative therapeutic strategies to prevent surgery-associated metastasis.
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Affiliation(s)
- Xiang Cheng
- Division of Surgical Oncology, Department of Surgery, The Ohio State University James Comprehensive Cancer Center, Columbus, OH, 43210, USA
| | - Hongji Zhang
- Division of Surgical Oncology, Department of Surgery, The Ohio State University James Comprehensive Cancer Center, Columbus, OH, 43210, USA
| | - Ahmad Hamad
- Division of Surgical Oncology, Department of Surgery, The Ohio State University James Comprehensive Cancer Center, Columbus, OH, 43210, USA
| | - Hai Huang
- Division of Surgical Oncology, Department of Surgery, The Ohio State University James Comprehensive Cancer Center, Columbus, OH, 43210, USA
| | - Allan Tsung
- Division of Surgical Oncology, Department of Surgery, The Ohio State University James Comprehensive Cancer Center, Columbus, OH, 43210, USA.
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Koo K, Ward R, Smith RL, Ruben J, Carne PWG, Elsaleh H. Temporal determinants of tumour response to neoadjuvant rectal radiotherapy. PLoS One 2021; 16:e0254018. [PMID: 34191861 PMCID: PMC8244879 DOI: 10.1371/journal.pone.0254018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 06/17/2021] [Indexed: 02/01/2023] Open
Abstract
Introduction In locally advanced rectal cancer, longer delay to surgery after neoadjuvant radiotherapy increases the likelihood of histopathological tumour response. Chronomodulated radiotherapy in rectal cancer has recently been reported as a factor increasing tumour response to neoadjuvant treatment in patients having earlier surgery, with patients receiving a larger proportion of afternoon treatments showing improved response. This paper aims to replicate this work by exploring the impact of these two temporal factors, independently and in combination, on histopathological tumour response in rectal cancer patients. Methods A retrospective review of all patients with rectal adenocarcinoma who received long course (≥24 fractions) neoadjuvant radiotherapy with or without chemotherapy at a tertiary referral centre was conducted. Delay to surgery and radiotherapy treatment time were correlated to clinicopathologic characteristics with a particular focus on tumour regression grade. A review of the literature and meta-analysis were also conducted to ascertain the impact of time to surgery from preoperative radiotherapy on tumour regression. Results From a cohort of 367 patients, 197 patients met the inclusion criteria. Complete pathologic response (AJCC regression grade 0) was seen in 46 (23%) patients with a further 44 patients (22%) having at most small groups of residual cells (AJCC regression grade 1). Median time to surgery was 63 days, and no statistically significant difference was seen in tumour regression between patients having early or late surgery. There was a non-significant trend towards a larger proportion of morning treatments in patients with grade 0 or 1 regression (p = 0.077). There was no difference in tumour regression when composite groups of the two temporal variables were analysed. Visualisation of data from 39 reviewed papers (describing 27379 patients) demonstrated a plateau of response to neoadjuvant radiotherapy after approximately 60 days, and a meta-analysis found improved complete pathologic response in patients having later surgery. Conclusions There was no observed benefit of chronomodulated radiotherapy in our cohort of rectal cancer patients. Review of the literature and meta-analysis confirms the benefit of delayed surgery, with a plateau in complete response rates at approximately 60-days between completion of radiotherapy and surgery. In our cohort, time to surgery for the majority of our patients lay along this plateau and this may be a more dominant factor in determining response to neoadjuvant therapy, obscuring any effects of chronomodulation on tumour response. We would recommend surgery be performed between 8 and 11 weeks after completion of neoadjuvant radiotherapy in patients with locally advanced rectal cancer.
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Affiliation(s)
- Kendrick Koo
- Radiation Oncology, Alfred Health, Melbourne, Victoria, Australia
| | - Rachel Ward
- Radiation Oncology, Alfred Health, Melbourne, Victoria, Australia
| | - Ryan L. Smith
- Radiation Oncology, Alfred Health, Melbourne, Victoria, Australia
| | - Jeremy Ruben
- Radiation Oncology, Alfred Health, Melbourne, Victoria, Australia
| | - Peter W. G. Carne
- Colorectal Surgery Unit, Alfred Health, Melbourne, Victoria, Australia
- Cabrini Monash University Department of Surgery, Melbourne, Victoria, Australia
| | - Hany Elsaleh
- Radiation Oncology, Alfred Health, Melbourne, Victoria, Australia
- * E-mail:
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Detering R, Borstlap WAA, Broeders L, Hermus L, Marijnen CAM, Beets-Tan RGH, Bemelman WA, van Westreenen HL, Tanis PJ. Cross-Sectional Study on MRI Restaging After Chemoradiotherapy and Interval to Surgery in Rectal Cancer: Influence on Short- and Long-Term Outcomes. Ann Surg Oncol 2018; 26:437-448. [PMID: 30547330 PMCID: PMC6341052 DOI: 10.1245/s10434-018-07097-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Indexed: 02/01/2023]
Abstract
Background The time interval between CRT and surgery in rectal cancer patients is still the subject of debate. The aim of this study was to first evaluate the nationwide use of restaging magnetic resonance imaging (MRI) and its impact on timing of surgery, and, second, to evaluate the impact of timing of surgery after chemoradiotherapy (CRT) on short- and long-term outcomes. Methods Patients were selected from a collaborative rectal cancer research project including 71 Dutch centres, and were subdivided into two groups according to time interval from the start of preoperative CRT to surgery (< 14 and ≥ 14 weeks). Results From 2095 registered patients, 475 patients received preoperative CRT. MRI restaging was performed in 79.4% of patients, with a median CRT–MRI interval of 10 weeks (interquartile range [IQR] 8–11) and a median MRI–surgery interval of 4 weeks (IQR 2–5). The CRT–surgery interval groups consisted of 224 (< 14 weeks) and 251 patients (≥ 14 weeks), and the long-interval group included a higher proportion of cT4 stage and multivisceral resection patients. Pathological complete response rate (n = 34 [15.2%] vs. n = 47 [18.7%], p = 0.305) and CRM involvement (9.7% vs. 15.9%, p = 0.145) did not significantly differ. Thirty-day surgical complications were similar (20.1% vs. 23.1%, p = 0.943), however no significant differences were found for local and distant recurrence rates, disease-free survival, and overall survival. Conclusions These real-life data, reflecting routine daily practice in The Netherlands, showed substantial variability in the use and timing of restaging MRI after preoperative CRT for rectal cancer, as well as time interval to surgery. Surgery before or after 14 weeks from the start of CRT resulted in similar short- and long-term outcomes. Electronic supplementary material The online version of this article (10.1245/s10434-018-07097-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Robin Detering
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - Wernard A A Borstlap
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Lisa Broeders
- Scientific Bureau of the Dutch Institute of Clinical Auditing, Leiden, The Netherlands
| | - Linda Hermus
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Corrie A M Marijnen
- Department of Radiotherapy, Leiden University Medical Center, Leiden, The Netherlands
| | - Regina G H Beets-Tan
- Department of Radiology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Willem A Bemelman
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Pieter J Tanis
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Kim MJ, Cho JS, Kim EM, Ko WA, Oh JH. Optimal Time Interval for Surgery After Neoadjuvant Chemoradiotherapy in Patients With Locally Advanced Rectal Cancer: Analysis of Health Insurance Review and Assessment Service Data. Ann Coloproctol 2018; 34:241-247. [PMID: 30419721 PMCID: PMC6238805 DOI: 10.3393/ac.2018.01.01] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Accepted: 01/01/2018] [Indexed: 02/07/2023] Open
Abstract
Purpose Pathologic downstaging of rectal cancer has been suggested to be associated with the time interval from chemoradiotherapy (CRT) completion to surgery. We aimed to evaluate the effect of this time interval for patients with rectal cancer on the pathologic response. Methods All patients with rectal cancer undergoing neoadjuvant CRT with evaluable data were selected from among the Health Insurance Review and Assessment Service data. Patients were divided into groups according to the time between CRT and surgery. CRT responses were analyzed. Results Two hundred forty-nine patients were included, of whom 86 (34.5%) were in the 5- to 7-week interval, 113 (45.4%) in the 7- to 9-week interval, 38 (15.3%) in the 9- to 11-week interval, and 12 (4.8%) in the >11-week interval. The median time interval between CRT completion and surgery was 7.4 weeks (range: 5–22.7 weeks; interquartile range, 6.7–8.7 weeks). Surgery 9–11 weeks after CRT completion resulted in the highest, but not statistically significant, pathologic complete response (pCR) rate (3 patients, 8.6%; P = 0.886), no pCR was noted in the >11-week interval group. Results for downstaging in the 9- to 11-week interval group were as follows: T downstaging, 38.2% (P = 0.735); N downstaging, 50.0% (P = 0.439); and TN downstaging, 52.9% (P = 0.087). The 3-year overall survival rates for the 5- to 7-week, 7- to 9-week, 9- to 11-week, and >11-week interval groups were 93.0%, 85.0%, 81.6%, and 91.7%, respectively (P = 0.326). Conclusion Delaying surgery by 9 to 11 weeks may increase TN downstaging, but delaying for over 11 weeks may not increase additional tumor downstaging from long-course CRT.
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Affiliation(s)
- Min Jung Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Jin Suk Cho
- Health Insurance Review and Assessment Service, Seoul, Korea
| | - Eun Mi Kim
- Health Insurance Review and Assessment Service, Seoul, Korea
| | - Woo Ah Ko
- Health Insurance Review and Assessment Service, Seoul, Korea
| | - Jae Hwan Oh
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
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Gural Z, Saglam S, Yucel S, Kaytan-Saglam E, Asoglu O, Ordu C, Acun H, Sharifov R, Onder S, Kizir A, Oral EN. Neoadjuvant hyperfractionated accelerated radiotherapy plus concomitant 5-fluorouracil infusion in locally advanced rectal cancer: A phase II study. World J Gastrointest Oncol 2018; 10:40-47. [PMID: 29375747 PMCID: PMC5767792 DOI: 10.4251/wjgo.v10.i1.40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 11/26/2017] [Accepted: 12/04/2017] [Indexed: 02/05/2023] Open
Abstract
AIM To evaluate the efficacy and tolerability of neoadjuvant hyperfractionated accelerated radiotherapy (HART) and concurrent chemotherapy in patients with locally advanced infraperitoneal rectal cancer. METHODS A total of 30 patients with histopathologically confirmed T2-3/N0+ infraperitoneal adenocarcinoma of rectum cancer patients received preoperative 42 Gy/1.5 Gy/18 days/bid radiotherapy and continuous infusion of 5-fluorouracil (325 mg/m2). All patients were operated 4-8 wk after neoadjuvant concomitant therapy. RESULTS In the early phase of treatment, 6 patients had grade III-IV gastrointestinal toxicity, 2 patients had grade III-IV hematologic toxicity, and 1 patient had grade V toxicity due to postoperative sepsis during chemotherapy. Only 1 patient had radiotherapy-related late side effects, i.e., grade IV tenesmus. Complete pathological response was achieved in 6 patients (21%), while near-complete pathological response was obtained in 9 (31%). After a median follow-up period of 60 mo, the local tumor control rate was 96.6%. In 13 patients, distant metastasis occurred. Disease-free survival rates at 2 and 5 years were 63.3% and 53%, and corresponding overall survival rates were 70% and 53.1%, respectively. CONCLUSION Although it has excellent local control and complete pathological response rates, neoadjuvant HART concurrent chemotherapy appears to not be a feasible treatment regimen in locally advanced rectal cancer, having high perioperative complication and intolerable side effects. Effects of reduced 5-fluorouracil dose or omission of chemotherapy with the aim of reducing toxicity may be examined in further studies.
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Affiliation(s)
- Zeynep Gural
- Department of Radiation Oncology, Acibadem University Medical Faculty, Istanbul 34303, Turkey
| | - Sezer Saglam
- Department of Medical Oncology, Istanbul Bilim University, Istanbul 34349, Turkey
| | - Serap Yucel
- Department of Radiation Oncology, Acibadem University Medical Faculty, Istanbul 34303, Turkey
| | - Esra Kaytan-Saglam
- Department of Radiation Oncology, Istanbul Medical Faculty, Istanbul University, Istanbul 34093, Turkey
| | - Oktar Asoglu
- Department of General Surgery, Academia of Clinical Science of Bogazici, Istanbul 34357, Turkey
| | - Cetin Ordu
- Department of Medical Oncology, Istanbul Bilim University, Istanbul 34349, Turkey
| | - Hediye Acun
- Department of Medical Biophysics, Harran University Medical Faculty, Şanlıurfa 60300, Turkey
| | - Rasul Sharifov
- Department of Radiology, Bezm-i Alem University, Istanbul 34093, Turkey
| | - Semen Onder
- Department of Pathology, Istanbul Medical Faculty, Istanbul University, Istanbul 34093, Turkey
| | - Ahmet Kizir
- Department of Radiation Oncology, Istanbul Medical Faculty, Istanbul University, Istanbul 34093, Turkey
| | - Ethem N Oral
- Department of Radiation Oncology, Istanbul Medical Faculty, Istanbul University, Istanbul 34093, Turkey
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Lee SW, Lee JH, Lee IK, Oh ST, Kim DY, Kim TH, Oh JH, Baek JY, Chang HJ, Park HC, Kim HC, Chie EK, Nam TK, Jang HS. The Impact of Surgical Timing on Pathologic Tumor Response after Short Course and Long Course Preoperative Chemoradiation for Locally Advanced Rectal Adenocarcinoma. Cancer Res Treat 2017; 50:1039-1050. [PMID: 29161802 PMCID: PMC6056970 DOI: 10.4143/crt.2017.252] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 11/07/2017] [Indexed: 12/14/2022] Open
Abstract
Purpose A pooled analysis of multi-institutional trials was performed to analyze the effect of surgical timing on tumor response by comparing short course concurrent chemoradiotherapy (CCRT) with long course CCRT followed by delayed surgery in locally advanced rectal cancer. Materials and Methods Three hundred patients with cT3-4N0-2 rectal adenocarcinoma were included. Long course patients from KROG 14-12 (n=150) were matched 1:1 to 150 short course patients from KROG 10-01 (NCT01129700) and KROG 11-02 (NCT01431599) according to stage, age, and other risk factors. The primary endpoint was to determine the interval between surgery and the last day of neoadjuvant CCRT which yields the best tumor response after the short course and long course CCRT. Downstaging was defined as ypT0-2N0M0 and pathologic complete response (ypCR) was defined as ypT0N0M0, respectively. Results Both the long and short course groups achieved lowest downstaging rates at < 6 weeks (long 20% vs. short 8%) and highest downstaging rates at 6-7 weeks (long 44% vs. short 40%). The ypCR rates were lowest at < 6 weeks (both long and short 0%) and highest at 6-7 weeks (long 21% vs. short 11%) in both the short and long course arms. The downstaging and ypCR rates of long course group gradually declined after the peak at 6-7 weeks and those of the short course group trend to constantly increase afterwards. Conclusion It is optimal to perform surgery at least 6 weeks after both the short course and long course CCRT to obtain maximal tumor regression in locally advanced rectal adenocarcinoma.
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Affiliation(s)
- Sea-Won Lee
- Department of Radiation Oncology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong Hoon Lee
- Department of Radiation Oncology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - In Kyu Lee
- Department of Colorectal Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seong Taek Oh
- Department of Colorectal Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dae Yong Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Tae Hyun Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Jae Hwan Oh
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Ji Yeon Baek
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Hee Jin Chang
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Hee Chul Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Cheol Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eui Kyu Chie
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
| | - Taek-Keun Nam
- Department of Radiation Oncology, Chonnam National University Medical School, Gwangju, Korea
| | - Hong Seok Jang
- Department of Radiation Oncology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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De La Maza L, Wu M, Wu L, Yun H, Zhao Y, Cattral M, McCart A, Cho BJ, de Perrot M. In Situ Vaccination after Accelerated Hypofractionated Radiation and Surgery in a Mesothelioma Mouse Model. Clin Cancer Res 2017; 23:5502-5513. [PMID: 28606922 DOI: 10.1158/1078-0432.ccr-17-0438] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 04/27/2017] [Accepted: 06/05/2017] [Indexed: 11/16/2022]
Abstract
Purpose: How best to sequence and integrate immunotherapy into standard of care is currently unknown. Clinical protocols with accelerated nonablative hypofractionated radiation followed by surgery could provide an opportunity to implement immune checkpoint blockade.Experimental Design: We therefore assessed the impact of nonablative hypofractionated radiation on the immune system in combination with surgery in a mouse mesothelioma model. Blunt surgery (R1 resection) was used to analyze the short-term effect, and radical surgery (R0 resection) was used to analyze the long-term effect of this radiation protocol before surgery.Results: Nonablative hypofractionated radiation led to a specific immune activation against the tumor associated with significant upregulation of CD8+ T cells, limiting the negative effect of an incomplete resection. The same radiation protocol performed 7 days before radical surgery led to a long-term antitumor immune protection that was primarily driven by CD4+ T cells. Radical surgery alone or with a short course of nonablative radiation completed 24 hours before radical surgery did not provide this vaccination effect. Combining this radiation protocol with CTLA-4 blockade provided better results than radiation alone. The effect of PD-1 or PD-L1 blockade with this radiation protocol was less effective than the combination with CTLA-4 blockade.Conclusions: A specific activation of the immune system against the tumor contributes to the benefit of accelerated, hypofractionated radiation before surgery. Nonablative hypofractionated radiation combined with surgery provides an opportunity to introduce immune checkpoint blockades in the clinical setting. Clin Cancer Res; 23(18); 5502-13. ©2017 AACR.
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Affiliation(s)
- Luis De La Maza
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Matthew Wu
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Licun Wu
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Hana Yun
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Yidan Zhao
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Mark Cattral
- Department of General Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Andrea McCart
- Department of General Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Bc John Cho
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Marc de Perrot
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute, University of Toronto, Toronto, Ontario, Canada. .,Division of Thoracic Surgery, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
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Leroi N, Sounni NE, Van Overmeire E, Blacher S, Marée R, Van Ginderachter J, Lallemand F, Lenaerts E, Coucke P, Noel A, Martinive P. The timing of surgery after neoadjuvant radiotherapy influences tumor dissemination in a preclinical model. Oncotarget 2017; 6:36825-37. [PMID: 26440148 PMCID: PMC4742213 DOI: 10.18632/oncotarget.5931] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Accepted: 09/15/2015] [Indexed: 12/18/2022] Open
Abstract
Neoadjuvant radiotherapy (neoRT) used in cancer treatments aims at improving local tumor control and patient overall survival. The neoRT schedule and the timing of the surgical treatment (ST) are empirically based and influenced by the clinician's experience. The current study examines how the sequencing of neoRT and ST affects metastatic dissemination. In a breast carcinoma model, tumors were exposed to different neoRT schedules (2x5Gy or 5x2Gy) followed by surgery at day 4 or 11 post-RT. The impact on the tumor microenvironment and lung metastases was evaluated through immunohistochemical and flow cytometry analyses. After 2x5Gy, early ST (at day 4 post-RT) led to increased size and number of lung metastases as compared to ST performed at day 11. Inversely, after 5x2Gy neoRT, early ST protected the mice against lung metastases. This intriguing relationship between tumor aggressiveness and ST timing could not be explained by differences in classical parameters studied such as hypoxia, vessel density and matrix remodeling. The study of tumor-related inflammation and immunity reveals an increased circulating NK cell percentage following neoRT as compared to non irradiated mice. Then, radiation treatment and surgery were applied to tumor-bearing NOD/SCID mice. In the absence of NK cells, neoRT appears to increase lung metastatic dissemination as compared to non irradiated tumor-bearing mice. Altogether our data demonstrate that the neoRT schedule and the ST timing affect metastasis formation in a pre-clinical model and points out the potential role of NK cells. These findings highlight the importance to cautiously tailor the optimal window for ST following RT.
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Affiliation(s)
- Natacha Leroi
- Laboratory of Tumor and Development Biology, Groupe Interdisciplinaire de Génoprotéomique Appliquée-Cancer (GIGA-Cancer), University of Liège, Belgium.,Department of Radiotherapy-Oncology, Centre Hospitalier Universitaire (CHU) de Liège, Belgium
| | - Nor Eddine Sounni
- Laboratory of Tumor and Development Biology, Groupe Interdisciplinaire de Génoprotéomique Appliquée-Cancer (GIGA-Cancer), University of Liège, Belgium
| | - Eva Van Overmeire
- Laboratory of Myeloid Cell Immunology, VIB, Brussels, Belgium.,Laboratory of Cellular and Molecular Immunology, Vrije Universiteit Brussel, Brussels, Belgium
| | - Silvia Blacher
- Laboratory of Tumor and Development Biology, Groupe Interdisciplinaire de Génoprotéomique Appliquée-Cancer (GIGA-Cancer), University of Liège, Belgium
| | - Raphael Marée
- Systems and Modeling (GIGA-Systems Biology and Chemical Biology), University of Liège, Belgium.,GIGA Bioinformatics Platform, University of Liège, Belgium
| | - Jo Van Ginderachter
- Laboratory of Myeloid Cell Immunology, VIB, Brussels, Belgium.,Laboratory of Cellular and Molecular Immunology, Vrije Universiteit Brussel, Brussels, Belgium
| | - François Lallemand
- Laboratory of Tumor and Development Biology, Groupe Interdisciplinaire de Génoprotéomique Appliquée-Cancer (GIGA-Cancer), University of Liège, Belgium
| | - Eric Lenaerts
- Department of Radiotherapy-Oncology, Centre Hospitalier Universitaire (CHU) de Liège, Belgium
| | - Philippe Coucke
- Department of Radiotherapy-Oncology, Centre Hospitalier Universitaire (CHU) de Liège, Belgium
| | - Agnès Noel
- Laboratory of Tumor and Development Biology, Groupe Interdisciplinaire de Génoprotéomique Appliquée-Cancer (GIGA-Cancer), University of Liège, Belgium
| | - Philippe Martinive
- Laboratory of Tumor and Development Biology, Groupe Interdisciplinaire de Génoprotéomique Appliquée-Cancer (GIGA-Cancer), University of Liège, Belgium.,Department of Radiotherapy-Oncology, Centre Hospitalier Universitaire (CHU) de Liège, Belgium
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9
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Leroi N, Lallemand F, Coucke P, Noel A, Martinive P. Impacts of Ionizing Radiation on the Different Compartments of the Tumor Microenvironment. Front Pharmacol 2016; 7:78. [PMID: 27064581 PMCID: PMC4811953 DOI: 10.3389/fphar.2016.00078] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 03/14/2016] [Indexed: 01/13/2023] Open
Abstract
Radiotherapy (RT) is one of the most important modalities for cancer treatment. For many years, the impact of RT on cancer cells has been extensively studied. Recently, the tumor microenvironment (TME) emerged as one of the key factors in therapy resistance. RT is known to influence and modify diverse components of the TME. Hence, we intent to review data from the literature on the impact of low and high single dose, as well as fractionated RT on host cells (endothelial cells, fibroblasts, immune and inflammatory cells) and the extracellular matrix. Optimizing the schedule of RT (i.e., dose per fraction) and other treatment modalities is a current challenge. A better understanding of the cascade of events and TME remodeling following RT would be helpful to design optimal treatment combination.
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Affiliation(s)
- Natacha Leroi
- Laboratory of Tumor and Development Biology, Groupe Interdisciplinaire de Génoprotéomique Appliquée-Cancer, University of Liège Liège, Belgium
| | - François Lallemand
- Laboratory of Tumor and Development Biology, Groupe Interdisciplinaire de Génoprotéomique Appliquée-Cancer, University of LiègeLiège, Belgium; Cyclotron Research Center, University of LiègeLiège, Belgium
| | - Philippe Coucke
- Radiotherapy-Oncology Department, Centre Hospitalier Universitaire de Liège Liège, Belgium
| | - Agnès Noel
- Laboratory of Tumor and Development Biology, Groupe Interdisciplinaire de Génoprotéomique Appliquée-Cancer, University of Liège Liège, Belgium
| | - Philippe Martinive
- Laboratory of Tumor and Development Biology, Groupe Interdisciplinaire de Génoprotéomique Appliquée-Cancer, University of LiègeLiège, Belgium; Radiotherapy-Oncology Department, Centre Hospitalier Universitaire de LiègeLiège, Belgium
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10
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Akbar A, Bhatti ABH, Niazi SK, Syed AA, Khattak S, Raza SH, Kazmi AS. Impact of Time Interval Between Chemoradiation and Surgery on Pathological Complete Response and Survival in Rectal Cancer. Asian Pac J Cancer Prev 2016; 17:89-93. [PMID: 26838260 DOI: 10.7314/apjcp.2016.17.1.89] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Ali Akbar
- Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital Research Centre, Lahore, Pakistan E-mail :
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Wasserberg N. Interval to surgery after neoadjuvant treatment for colorectal cancer. World J Gastroenterol 2014; 20:4256-62. [PMID: 24764663 PMCID: PMC3989961 DOI: 10.3748/wjg.v20.i15.4256] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Revised: 11/11/2013] [Accepted: 01/14/2014] [Indexed: 02/06/2023] Open
Abstract
The current standard treatment of low-lying locally advanced rectal cancer consists of chemoradiation followed by radical surgery. The interval between chemoradiation and surgery varied for many years until the 1999 Lyon R90-01 trial which compared the effects of a short (2-wk) and long (6-wk) interval. Results showed a better clinical tumor response (71.7% vs 53.1%) and higher rate of positive and pathologic tumor regression (26% vs 10.3%) after the longer interval. Accordingly, a 6-wk interval between chemoradiation and surgery was set to balance the oncological results with the surgical complexity. However, several recent retrospective studies reported that prolonging the interval beyond 8 or even 12 wk may lead to significantly higher rates of tumor downstaging and pathologic complete response. This in turn, according to some reports, may improve overall and disease-free survival, without increasing the surgical difficulty or complications. This work reviews the data on the effect of different intervals, derived mostly from retrospective analyses using a wide variation of treatment protocols. Prospective randomized trials are currently ongoing.
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Glimelius B. Optimal Time Intervals between Pre-Operative Radiotherapy or Chemoradiotherapy and Surgery in Rectal Cancer? Front Oncol 2014; 4:50. [PMID: 24778990 PMCID: PMC3985002 DOI: 10.3389/fonc.2014.00050] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 03/02/2014] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND In rectal cancer therapy, radiotherapy or chemoradiotherapy (RT/CRT) is extensively used pre-operatively to (i) decrease local recurrence risks, (ii) allow radical surgery in non-resectable tumors, and (iii) increase the chances of sphincter-saving surgery or (iv) organ-preservation. There is a growing interest among clinicians and scientists to prolong the interval from the RT/CRT to surgery to achieve maximal tumor regression and to diminish complications during surgery. METHODS The pros and cons of delaying surgery depending upon the aim of the pre-operative RT/CRT are critically evaluated. RESULTS Depending upon the clinical situation, the need for a time interval prior to surgery to allow tumor regression varies. In the first and most common situation (i), no regression is needed and any delay beyond what is needed for the acute radiation reaction in surrounding tissues to wash out can potentially only be deleterious. After short-course RT (5Gyx5) with immediate surgery, the ideal time between the last radiation fraction is 2-5 days, since a slightly longer interval appears to increase surgical complications. A delay beyond 4 weeks appears safe; it results in tumor regression including pathologic complete responses, but is not yet fully evaluated concerning oncologic outcome. Surgical complications do not appear to be influenced by the CRT-surgery interval within reasonable limits (about 4-12 weeks), but this has not been sufficiently explored. Maximum tumor regression may not be seen in rectal adenocarcinomas until after several months; thus, a longer than usual delay may be of benefit in well responding tumors if limited or no surgery is planned, as in (iii) or (iv), otherwise not. CONCLUSION A longer time interval after CRT is undoubtedly of benefit in some clinical situations but may be counterproductive in most situations. After short-course RT, long-term results from the clinical trials are not yet available to routinely recommend an interval longer than 2-5 days, unless the tumor is non-resectable at diagnosis.
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Affiliation(s)
- Bengt Glimelius
- Department of Radiology, Oncology and Radiation Science, Uppsala University , Uppsala , Sweden
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Doi H, Beppu N, Odawara S, Tanooka M, Takada Y, Niwa Y, Fujiwara M, Kimura F, Yanagi H, Yamanaka N, Kamikonya N, Hirota S. Neoadjuvant short-course hyperfractionated accelerated radiotherapy (SC-HART) combined with S-1 for locally advanced rectal cancer. JOURNAL OF RADIATION RESEARCH 2013; 54:1118-24. [PMID: 23658415 PMCID: PMC3823779 DOI: 10.1093/jrr/rrt058] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
The purpose of this study was to examine the safety and feasibility of a novel protocol of neoadjuvant short-course hyperfractionated accelerated radiotherapy (SC-HART) combined with S-1 for locally advanced rectal cancer. A total of 56 patients with lower rectal cancer of cT3N1M0 (Stage III b) was treated with SC-HART followed by radical surgery, and were analyzed in the present study. SC-HART was performed with a dose of 2.5 Gy twice daily, with an interval of at least 6 hours between fractions, up to a total dose of 25 Gy (25 Gy in 10 fractions for 5 days) combined with S-1 for 10 days. Radical surgery was performed within three weeks following the end of the SC-HART. The median age was 64.6 (range, 39-85) years. The median follow-up term was 16.3 (range, 2-53) months. Of the 56 patients, 53 (94.4%) had no apparent adverse events before surgery; 55 (98.2%) completed the full course of neoadjuvant therapy, while one patient stopped chemotherapy because of Grade 3 gastrointestinal toxicity (CTCAE v.3). The sphincter preservation rate was 94.6%. Downstaging was observed in 45 patients (80.4%). Adjuvant chemotherapy was administered to 43 patients (76.8%). The local control rate, disease-free survival rate and disease-specific survival rate were 100%, 91.1% and 100%, respectively. To conclude, SC-HART combined with S-1 for locally advanced rectal cancer was well tolerated and produced good short-term outcomes. SC-HART therefore appeared to have a good feasibility for use in further clinical trials.
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Affiliation(s)
- Hiroshi Doi
- Department of Radiology, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya City, Hyogo, 663-8501 Japan
- Corresponding author. Department of Radiology, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya City, Hyogo, 663-8501, Japan. Tel: +89-798-45-6362; Fax: +89-798-45-6361;
| | - Naohito Beppu
- Department of Surgery, Meiwa Hospital, 4-31 Agenaruo, Nishinomiya, Hyogo 663-8186, Japan
| | - Soichi Odawara
- Department of Radiology, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya City, Hyogo, 663-8501 Japan
| | - Masao Tanooka
- Department of Radiology, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya City, Hyogo, 663-8501 Japan
| | - Yasuhiro Takada
- Department of Radiology, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya City, Hyogo, 663-8501 Japan
| | - Yasue Niwa
- Department of Radiology, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya City, Hyogo, 663-8501 Japan
| | - Masayuki Fujiwara
- Department of Radiology, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya City, Hyogo, 663-8501 Japan
| | - Fumihiko Kimura
- Department of Surgery, Meiwa Hospital, 4-31 Agenaruo, Nishinomiya, Hyogo 663-8186, Japan
| | - Hidenori Yanagi
- Department of Surgery, Meiwa Hospital, 4-31 Agenaruo, Nishinomiya, Hyogo 663-8186, Japan
| | - Naoki Yamanaka
- Department of Surgery, Meiwa Hospital, 4-31 Agenaruo, Nishinomiya, Hyogo 663-8186, Japan
| | - Norihiko Kamikonya
- Department of Radiology, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya City, Hyogo, 663-8501 Japan
| | - Shozo Hirota
- Department of Radiology, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya City, Hyogo, 663-8501 Japan
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Fang CB, Gomes CMCDN, Formiga FB, Fonseca VA, Carvalho MP, Klug WA. Existem benefícios com a cirurgia retardada após radioterapia e quimioterapia neoadjuvante no câncer de reto localmente avançado? ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2013; 26:31-5. [DOI: 10.1590/s0102-67202013000100007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Accepted: 12/11/2012] [Indexed: 12/15/2022]
Abstract
RACIONAL: Tratamento neoadjuvante com radioterapia e quimioterapia é o esquema preferencial para câncer de reto localmente avançado, tendo por objetivo aumentar a ressecabilidade e diminuir a recidiva local. OBJETIVO: Avaliar os benefícios da operação tardia após radioterapia e quimioterapia neoadjuvante em câncer de reto localmente avançado quanto à resposta da regressão tumoral, sobrevida e efeitos adversos. MÉTODOS: Foram tratados consecutivamente 106 pacientes, portadores de adenocarcinoma do reto localmente avançado no período pré-operatório com radioterapia na dose de 50,4 Gy (28 frações) e quimioterapia com 5-fluoracil e leucovorin. A operação foi programada entre cinco e seis semanas. Pacientes que retornaram após seis semanas por motivos diversos foram agrupados em grupo de operação tardia. Variáveis como diminuição do estádio, remissão tumoral completa, tempo cirúrgico, transfusão sanguínea, recidiva local, metástase e sobrevida foram correlacionadas com o restante dos pacientes a fim de verificar os seus benefícios. RESULTADOS: Remissão completa do tumor foi encontrada em 15 pacientes (T0=15/106 - 14,2%). Resposta parcial em 38 (34,9%); entretanto em um paciente a resposta foi pT0N2. O seguimento médio foi 35,6 semanas e 32,2 semanas para grupo de operação em seis semanas e grupo de cirurgia tardia. Não houve diferença entre os dois grupos quanto à diminuição de estádio, remissão tumoral completa, tempo cirúrgico, transfusão sanguínea e complicações cirúrgicas precoces. Embora a operação tardia não apresentasse diferença significante quanto à recidiva local (p=0,1468), ela mostrou tendência em menor risco de metástase à distância (p=0,0520). CONCLUSÃO: Operação tardia após tratamento neoadjuvante não oferece benefícios evidentes em termos de remissão completa ou diminuição do estádio tumoral. Fatores moleculares preditivos devem ser investigados no futuro para melhor seleção de doentes que poderão beneficiar-se com o tratamento neoadjuvante.
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Glynne-Jones R, Kronfli M. Locally advanced rectal cancer: a comparison of management strategies. Drugs 2011; 71:1153-77. [PMID: 21711061 DOI: 10.2165/11591330-000000000-00000] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Traditionally, there has been a high local recurrence rate in rectal cancer and 10-40% of patients require a permanent stoma. Both short-course preoperative radiotherapy (SCPRT) and long-course preoperative chemoradiation (CRT) are used to reduce the risk of local recurrence and enable a curative resection. Total mesorectal excision has reduced the rate of local recurrence (even without radiotherapy) to below 10%, but has highlighted a high risk of metastatic disease in 30-40% of patients. Current trials suggest that in resectable cancers, where the preoperative magnetic resonance imaging (MRI) suggests the circumferential resection margin (CRM) is not potentially involved, then SCPRT and CRT are equivalent in terms of outcomes such as local recurrence, disease-free survival (DFS) and overall survival (OS). For patients with more advanced disease, where the CRM is breached or threatened according to the MRI, the integration of more active chemotherapy and biological agents into chemoradiation is an attractive strategy because of the high risk of metastases. However, in none of the trials published in the last decade has chemoradiation impacted on DFS or OS. We examine the strategies of neoadjuvant, concurrent, consolidation (after chemoradiation and before surgery) and postoperative adjuvant chemotherapy with cytotoxic agents, and the integration of biological agents for future potential strategies of treatment. We also compare the trials and compare the different strategies of long-course preoperative radiotherapy and SCPRT; the intensification of preoperative radiation and chemoradiation with dose escalation of external beam radiotherapy, using brachytherapy, intra-operative radiotherapy, hyperfractionation, and various available techniques such as intensity-modulated radiotherapy. We recommend examining dose escalation of radiotherapy to the primary tumour where MRI predicts a threatened CRM. Of the potential treatment strategies involving cytotoxic agents, such as neoadjuvant, concurrent, consolidation and postoperative adjuvant chemotherapy, the most promising would appear to be consolidation chemotherapy following chemoradiation in locally advanced disease, and neoadjuvant chemotherapy in MRI-selected patients who do not require radiation. Improvement in the quality of surgery is also an important future goal.
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Affiliation(s)
- Robert Glynne-Jones
- Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, Middlesex, UK.
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Gollins S. Radiation, chemotherapy and biological therapy in the curative treatment of locally advanced rectal cancer. Colorectal Dis 2010; 12 Suppl 2:2-24. [PMID: 20618363 DOI: 10.1111/j.1463-1318.2010.02320.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To review the published evidence relating to the use of radiotherapy (RT), chemotherapy and biological therapy as adjuncts to surgery in the curative treatment of rectal cancer. METHODS Searches were carried out of the MEDLINE and CANCERLIT databases together with conference abstracts from key meetings including the American Society of Clinical Oncology Annual Meeting and Gastrointestinal Cancers Symposium and the ECCO/ESMO Multidisciplinary Congress. RESULTS RT reduces local pelvic recurrence when used as an adjunct to surgery, even when this is performed optimally by total mesorectal excision (TME). RT is usually given as short-course preoperative radiotherapy (SCPRT) followed by immediate surgery which produces no or very little downstaging or long-course concurrent chemoradiation (CRT) followed by a 6-8 week gap prior to surgery which produces significant downstaging. The prognostic importance of achieving a clear histological circumferential resection margin is now well recognised and pathological assessment of the quality of surgery can predict long-term outcomes. Internationally there is considerable heterogeneity in the staging modalities and criteria used in deciding which approach might be used, in the reporting of histological results and in RT parameters (time/dose/fractionation/volume). Attempts to increase the potency of CRT have included the addition of concurrent chemotherapeutic and biological agents to the standard fluoropyrimidine although there is little randomised data and none with regard to long-term survival outcomes. Neither SCPRT nor downstaging CRT have been shown to reduce the rate of subsequent distant metastatic relapse which remains a significant clinical problem. The potential additional benefit of neoadjuvant or adjuvant chemotherapy in addition to SCPRT or long-course CRT remains ill-defined. Late morbidity can include bowel and sexual dysfunction, pelvic fractures and second malignancies with considerably more being known in relation to SCPRT than long-course CRT. CONCLUSIONS Improvements in imaging, pathology and surgical technique combined with multimodality treatment using RT and chemotherapy are leading to continuing improvements in the long term outcome for patients with rectal cancer although much remains to be learnt regarding the optimum strategy for use of these in different clinical contexts and their relationship to long-term morbidity.
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Affiliation(s)
- S Gollins
- North Wales Cancer Treatment Centre, Glan Clwyd Hospital, Bodelwyddan, Denbighshire, UK.
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Kube R, Ptok H, Jacob D, Fahlke J, Mroczkowski P, Lippert H, Ziegenhardt G, Schmidt U, Gastinger I. Modified neoadjuvant short-course radiation therapy in uT3 rectal carcinoma: low local recurrence rate with unchanged overall survival and frequent morbidity. Int J Colorectal Dis 2010; 25:109-17. [PMID: 19876634 DOI: 10.1007/s00384-009-0823-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2009] [Indexed: 02/04/2023]
Abstract
PURPOSE The purpose of this study is to investigate the value of a modified neoadjuvant short-course radiation therapy (SCRT) in uT3 rectal carcinoma, which, despite local R0 resectability, carries a greater risk of local recurrence than less invasive carcinomas. METHODS Sixty-three patients with uT3 rectal carcinoma < or =10 cm above the anal verge received a modified 8 x 3 Gy pre-operative SCRT. Radiation-associated and peri-operative complications were recorded, and the patients were followed up for long-term oncological outcome and morbidity. RESULTS In the study group, there were no severe adverse radiation-associated effects; the rate of peri-operative morbidity was 54.0% and that of in-hospital mortality is 4.8%. The probability (Kaplan-Meier estimate) of local recurrence was 3.9% with a probability of metachronic distant metastases of 26.8% (5-year rates). We found the probability of 5-year disease-free survival to be 70.5% and that of 5-year overall survival, 59.5%. Long-term complications were reported for 31.7% of patients. CONCLUSIONS Compared to the literature-modified 8 x 3 Gy neoadjuvant SCRT and surgery in uT3, rectal carcinoma was associated with low local recurrence but frequent peri-operative complications. The decisive prognostic factor, distant metastasis, was unaffected. Difficulties included overestimation of tumour invasion depth by endosonography. Possible clinical consequences of the results are discussed.
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Affiliation(s)
- Rainer Kube
- An-Institut für Qualitätssicherung in der operativen Medizin an der Otto-von-Guericke Universität Magdeburg, Germany.
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