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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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Bedrikovetski S, Traeger L, Seow W, Dudi-Venkata NN, Selva-Nayagam S, Penniment M, Sammour T. Oncological Outcomes and Response Rate After Total Neoadjuvant Therapy for Locally Advanced Rectal Cancer: A Network Meta-Analysis Comparing Induction vs. Consolidation Chemotherapy vs. Standard Chemoradiation. Clin Colorectal Cancer 2024:S1533-0028(24)00056-2. [PMID: 38945765 DOI: 10.1016/j.clcc.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Revised: 06/04/2024] [Accepted: 06/06/2024] [Indexed: 07/02/2024]
Abstract
TNT is now considered the preferred option for stage II-III locally advanced rectal cancer (LARC). However, the prognostic benefit and optimal sequence of TNT remains unclear. This network meta-analysis (NMA) compared short- and long-term outcomes amongst patients with LARC receiving total neoadjuvant therapy (TNT) as induction (iTNT) or consolidation chemotherapy (cTNT) with those receiving neoadjuvant chemoradiation (nCRT) alone. A systematic literature search was performed between 2012 and 2023. A Bayesian NMA was conducted using a Markov Chain Monte Carlo method with a random-effects model and vague prior distribution to calculate odds ratios (OR) with 95% credible intervals (CrI). The surface under the cumulative ranking (SUCRA) curves were used to rank treatment(s) for each outcome. In total, 11 cohorts involving 8360 patients with LARC were included. There was no significant difference in disease-free survival (DFS) and overall survival (OS) amongst the 3 treatments. Compared with nCRT, both cTNT (OR 2.36; 95% CrI, 1.57-3.66) and iTNT (OR 1.99; 95% CrI, 1.44-2.95) significantly improved complete response (CR) rate. Notably, cTNT ranked as the best treatment for CR (SUCRA 0.90) and iTNT as the best treatment for 3-year DFS and OS (SUCRA 0.72 and 0.87, respectively). Both iTNT and cTNT strategies significantly improved CR rates compared with nCRT. cTNT was ranked highest for CR rates, while iTNT was ranked highest for 3-year survival outcomes. However, no other significant differences in DFS, OS, sphincter-saving surgery, R0 resection and postoperative complications were found amongst the treatment groups.
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Affiliation(s)
- Sergei Bedrikovetski
- Department of Surgery, Colorectal Unit, Royal Adelaide Hospital, Adelaide, Australia; Department of Surgical Specialties, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia.
| | - Luke Traeger
- Department of Surgery, Colorectal Unit, Royal Adelaide Hospital, Adelaide, Australia; Department of Surgical Specialties, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | - Warren Seow
- Department of Surgery, Colorectal Unit, Royal Adelaide Hospital, Adelaide, Australia
| | | | | | - Michael Penniment
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, Australia
| | - Tarik Sammour
- Department of Surgery, Colorectal Unit, Royal Adelaide Hospital, Adelaide, Australia; Department of Surgical Specialties, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
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3
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Lin W, Li C, Clement EA, Brown CJ, Raval MJ, Karimuddin AA, Ghuman A, Phang PT. Surgical Outcomes in Total Neoadjuvant Therapy for Rectal Cancer Versus Standard Long-course Chemoradiation: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Ann Surg 2024; 279:620-630. [PMID: 38009646 DOI: 10.1097/sla.0000000000006161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
OBJECTIVE This systematic review and meta-analysis seeks to evaluate the impact of total neoadjuvant therapy (TNT) for rectal cancers on surgical complications and surgical pathology when compared with standard long-course chemoradiotherapy (LCRT). BACKGROUND The oncological benefits of TNT are well published in previous meta-analyses, but there is little synthesized information on how it affects surgical outcomes. A recent study has suggested an increase in local recurrence and higher rates of breached total mesorectal excision (TME) plane in TNT patients. METHODS This study conformed to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A search was performed in Medline (via PubMed), Cochrane databases, EMBASE and CINAHL to identify relevant randomized controlled trials (RCTs) comparing outcomes between TNT and LCRT. Meta-analyses of pooled proportions between TNT and LCRT were performed, comparing primary outcomes of surgical mortality, morbidity and all reported complications; surgical-pathology differences, namely mesorectal quality, R0 resection rates, circumferential resection margin positive rates, and sphincter preservation rates. Death and progression of disease during neoadjuvant treatment period was also compared. Risk of bias of RCTs was performed using the Cochrane risk-of-bias tool by 2 independent reviewers. RESULTS A total of 3185 patients with rectal cancer from 11 RCTs were included in the analysis: 1607 received TNT and 1578 received LCRT, of which 1422 (TNT arm) and 1391 (LCRT arm) underwent surgical resection with curative intent. There was no significant difference in mortality [risk ratio (RR)=0.86, 95% CI: 0.13-5.52, P =0.88, I2 =52%] or major complications (RR=1.04, 95% CI: 0.86-1.26, P =0.70, I2 =0%) between TNT and LCRT. There was a significantly higher risk of breached TME in TNT group on pooled analysis (RR=1.49, 95% CI: 1.03-12.16, P =0.03, I2 =0%), and on subgroup analysis there is higher risk of breached TME in those receiving extended duration of neoadjuvant treatment (>17 weeks from start of treatment to surgery) when compared with LCRT (RR=1.61, 95% CI: 1.06-2.44, P =0.03). No difference in R0 resection rates (RR=0.85, 95% CI: 0.66-1.10, P =0.21, I2 =15%), circumferential resection margin positive rates (RR=0.87, 95% CI: 0.65-1.16, P =0.35, I2 =10%) or sphincter preservation rates (RR=1.02, 95% CI: 0.83-1.25, P =0.88, I2 =57%) were observed. There was a significantly lower risk of progression of disease to an unresectable stage during the neoadjuvant treatment period in TNT patients (RR=0.60, 95% CI: 0.39-0.92, P =0.03, I2 =18%). On subgroup analysis, it appears to favor those receiving extended duration of neoadjuvant treatment (RR=0.44, 95% CI: 0.26-0.80, P =0.002), and those receiving induction-type chemotherapy in TNT (RR=0.25, 95% CI: 0.07-0.88, P =0.03). CONCLUSIONS TNT increases rates of breached TME which can contribute to higher local recurrence rates. TNT, however, improves systemic control by reducing early progression of disease during neoadjuvant treatment period. Further research is warranted to identify patients that will benefit from this strategy.
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Affiliation(s)
- Wenjie Lin
- Department of Surgery, Colorectal Surgery Division, St. Paul's Hospital, Vancouver, BC, Canada
- Department of Colorectal Surgery, Singapore General Hospital, Singapore
| | - Christine Li
- Department of Surgery, Colorectal Surgery Division, St. Paul's Hospital, Vancouver, BC, Canada
| | - Elizabeth A Clement
- Department of Surgery, Colorectal Surgery Division, St. Paul's Hospital, Vancouver, BC, Canada
| | - Carl J Brown
- Department of Surgery, Colorectal Surgery Division, St. Paul's Hospital, Vancouver, BC, Canada
| | - Manoj J Raval
- Department of Surgery, Colorectal Surgery Division, St. Paul's Hospital, Vancouver, BC, Canada
| | - Ahmer A Karimuddin
- Department of Surgery, Colorectal Surgery Division, St. Paul's Hospital, Vancouver, BC, Canada
| | - Amandeep Ghuman
- Department of Surgery, Colorectal Surgery Division, St. Paul's Hospital, Vancouver, BC, Canada
| | - Paul T Phang
- Department of Surgery, Colorectal Surgery Division, St. Paul's Hospital, Vancouver, BC, Canada
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Daamen L, Westerhoff J, Couwenberg A, Braam P, Rütten H, den Hartogh M, Christodouleas J, Hall W, Verkooijen H, Intven M. Quality of life and clinical outcomes in rectal cancer patients treated on a 1.5T MR-Linac within the MOMENTUM study. Clin Transl Radiat Oncol 2024; 45:100721. [PMID: 38274389 PMCID: PMC10808928 DOI: 10.1016/j.ctro.2023.100721] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 11/10/2023] [Accepted: 12/30/2023] [Indexed: 01/27/2024] Open
Abstract
Background and purpose This study assessed quality of life (QoL) and clinical outcomes in rectal cancer patients treated with magnetic resonance (MR) guided short-course radiation therapy (SCRT) on a 1.5 Tesla (T) MR-Linac during the first 12 months after treatment. Materials and methods Rectal cancer patients treated with 25 Gy SCRT in five fractions with curative intent in the Netherlands (2019-2022) were identified in MOMENTUM (NCT04075305). Toxicity (CTCAE v5) and QoL (EORTC QLQ-C30 and -CR29) was primarily analyzed in patients without metastatic disease (M0) and no other therapies after SCRT. Patients who underwent tumor resection were censored from surgery. A generalized linear mixed-model was used to investigate clinically meaningful (≥10) and significant (P < 0.05) QoL changes. Clinical and pathological complete response (cCR and pCR) rates were calculated in patients in whom response was documented. Results A total of 172 patients were included, of whom 112 patients were primarily analyzed. Acute and late radiation-induced high-grade toxicity were reported in one patient, respectively. CCR was observed in 8/64 patients (13 %), 14/37 patients (38 %) and 13/16 patients (91 %) at three, six and twelve months; pCR was observed in 3/69 (4 %) patients. After 12 months, diarrhea (mean difference [MD] -17.4 [95 % confidence interval [CI] -31.2 to -3.7]), blood and mucus in stool (MD -31.1 [95 % CI -46.4 to -15.8]), and anxiety (MD -22.4 [95 % CI -34.0 to -10.9]) were improved. Conclusion High-field MR-guided SCRT for the treatment of patients with rectal cancer is associated with improved disease-related symptom management and functioning one year after treatment.
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Affiliation(s)
- L.A. Daamen
- University Medical Center Utrecht, Division of Imaging and Oncology, Utrecht, The Netherlands
| | - J.M. Westerhoff
- University Medical Center Utrecht, Division of Imaging and Oncology, Utrecht, The Netherlands
| | - A.M. Couwenberg
- The Netherlands Cancer Institute, Department of Radiation Oncology, Amsterdam, The Netherlands
| | - P.M. Braam
- Radboud University Medical Center, Department of Radiation Oncology, Nijmegen, The Netherlands
| | - H. Rütten
- Radboud University Medical Center, Department of Radiation Oncology, Nijmegen, The Netherlands
| | | | - J.P. Christodouleas
- Elekta AB, Stockholm, Sweden
- Hospital of the University of Pennsylvania, Department of Radiation Oncology, Philadelphia, PA, United States
| | - W.A. Hall
- Medical College of Wisconsin, Department of Radiation Oncology, Milwaukee, WI, United States
| | - H.M. Verkooijen
- University Medical Center Utrecht, Division of Imaging and Oncology, Utrecht, The Netherlands
| | - M.P.W. Intven
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands
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5
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Saklani A, Kazi M, Desouza A, Sharma A, Engineer R, Krishnatry R, Gudi S, Ostwal V, Ramaswamy A, Dhanwat A, Bhargava P, Mehta S, Sundaram S, Kale A, Goel M, Patkar S, Vartey G, Kulkarni S, Baheti A, Ankathi S, Haria P, Katdare A, Choudhari A, Ramadwar M, Menon M, Patil P. Tata Memorial Centre Evidence Based Management of Colorectal cancer. Indian J Cancer 2024; 61:S29-S51. [PMID: 38424681 DOI: 10.4103/ijc.ijc_66_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 02/01/2024] [Indexed: 03/02/2024]
Abstract
ABSTRACT This review article examines the evidence-based management of colorectal cancers, focusing on topics characterized by ongoing debates and evolving evidence. To contribute to the scientific discourse, we intentionally exclude subjects with established guidelines, concentrating instead on areas where the current understanding is dynamic. Our analysis encompasses a thorough exploration of critical themes, including the evidence surrounding complete mesocolic excision and D3 lymphadenectomy in colon cancers. Additionally, we delve into the evolving landscape of perioperative chemotherapy in both colon and rectal cancers, considering its nuanced role in the context of contemporary treatment strategies. Advancements in surgical techniques are a pivotal aspect of our discussion, with an emphasis on the utilization of minimally invasive approaches such as laparoscopy and robotic surgery in both colon and rectal cancers, including advanced rectal cases. Moving beyond conventional radical procedures, we scrutinize the feasibility and implications of endoscopic resections for small tumors, explore the paradigm of organ preservation in locally advanced rectal cancers, and assess the utility of total neoadjuvant therapy in the current treatment landscape. Our final segment reviews pivotal trials that have significantly influenced the management of colorectal liver and peritoneal metastasis.
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Affiliation(s)
- Avanish Saklani
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Mufaddal Kazi
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
- Department of Surgical Oncology, Advanced Centre of the Treatment, Research, and Education in Cancer, Kharghar, Navi Mumbai, India
| | - Ashwin Desouza
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Ankit Sharma
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
- Department of Surgical Oncology, Advanced Centre of the Treatment, Research, and Education in Cancer, Kharghar, Navi Mumbai, India
| | - Reena Engineer
- Homi Bhabha National Institute, Mumbai, India
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, India
| | - Rahul Krishnatry
- Homi Bhabha National Institute, Mumbai, India
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, India
| | - Shivkumar Gudi
- Homi Bhabha National Institute, Mumbai, India
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, India
| | - Vikas Ostwal
- Homi Bhabha National Institute, Mumbai, India
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Anant Ramaswamy
- Homi Bhabha National Institute, Mumbai, India
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Aditya Dhanwat
- Homi Bhabha National Institute, Mumbai, India
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Prabhat Bhargava
- Homi Bhabha National Institute, Mumbai, India
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Shaesta Mehta
- Homi Bhabha National Institute, Mumbai, India
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, India
| | - Sridhar Sundaram
- Homi Bhabha National Institute, Mumbai, India
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, India
| | - Aditya Kale
- Homi Bhabha National Institute, Mumbai, India
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, India
| | - Mahesh Goel
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Shraddha Patkar
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Gurudutt Vartey
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Suyash Kulkarni
- Homi Bhabha National Institute, Mumbai, India
- Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, India
| | - Akshay Baheti
- Homi Bhabha National Institute, Mumbai, India
- Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, India
| | - Suman Ankathi
- Homi Bhabha National Institute, Mumbai, India
- Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, India
| | - Purvi Haria
- Homi Bhabha National Institute, Mumbai, India
- Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, India
| | - Aparna Katdare
- Homi Bhabha National Institute, Mumbai, India
- Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, India
| | - Amit Choudhari
- Homi Bhabha National Institute, Mumbai, India
- Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, India
| | - Mukta Ramadwar
- Homi Bhabha National Institute, Mumbai, India
- Department of Pathology, Tata Memorial Hospital, Mumbai, India
| | - Munita Menon
- Homi Bhabha National Institute, Mumbai, India
- Department of Pathology, Tata Memorial Hospital, Mumbai, India
| | - Prachi Patil
- Homi Bhabha National Institute, Mumbai, India
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, India
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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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7
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Langheinrich M, Paasch C, Mantke R, Weber K, Benz S, Kersting S. A contemporary assessment of total neoadjuvant therapy (TNT) protocols for locally advanced rectal cancer: adoption and expert perspectives at German Cancer Society (DKG)-certified colorectal cancer centers. J Cancer Res Clin Oncol 2023; 149:12591-12596. [PMID: 37438538 PMCID: PMC10465655 DOI: 10.1007/s00432-023-05139-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 07/05/2023] [Indexed: 07/14/2023]
Abstract
PURPOSE The treatment paradigm for locally advanced rectal cancer (LARC) is shifting toward the total neoadjuvant therapy (TNT) concept, which administered systemic chemotherapy in the neoadjuvant setting, either before or after chemoradiotherapy (CRT) or short-course radiotherapy (SCRT). First results have shown higher pathologic complete response (pCR) rates and a favorable impact on disease-free survival (DFS). Our study aimed to evaluate the current clinical practice and expert opinion regarding TNT for locally advanced rectal cancer across DKG (German Cancer Society)-certified colorectal cancer centers. METHODS A comprehensive online questionnaire, constituted of 14 TNT-focused queries targeting patients with locally advanced rectal cancer, was conducted among DKG-certified colorectal cancer centers registered within the database of the Addz (Arbeitsgemeinschaft Deutscher Darmzentren) between December 2022 and January 2023. RESULTS A significant majority (68%) indicated that they treated between 0 and 10 patients using a TNT protocol. Only a third (36%) of these centers participated in patient enrollment for a TNT study. Despite this, 84% of centers reported treating patients in a manner analogous to a TNT study, with the RAPIDO regimen being the most prevalent approach, employed by 60% of the respondents. The decision to adopt a TNT approach was primarily influenced by factors, such as the lower third of the rectum (93% of centers), cT4 stage (86% of centers), and a positive circumferential resection margin (80% of centers). Regarding concerns, 65% of the survey respondents expressed no reservations about the TNT concept, while 35% had concerns. In particular, there appears to be disagreement and uncertainty in regard to a clinical complete response and the "Watch and Wait" approach. While some centers adopt the watch-and-wait approach (42%), others only utilize it when extirpation is otherwise necessary (39%), and a portion still proceeds with surgery as initially planned (19%). The survey also addressed unmet needs, which were elaborated in the free-text responses. Overall, there was high interest in participating in planned observational studies. CONCLUSIONS This study presents an overview of current clinical practice and unmet needs within DKG-certified German colorectal cancer centers. It is noteworthy that total neoadjuvant therapy (TNT) is predominantly performed outside of clinical trials. Moreover, across the centers, there is significant heterogeneity in handling clinical complete response and adopting the "watch and wait" approach. Further research is needed to establish standardization in the care of locally advanced rectal cancer.
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Affiliation(s)
- Melanie Langheinrich
- Department of Surgery, University Hospital Greifswald, 17475, Greifswald, Germany.
| | - Christoph Paasch
- Department of Surgery, Brandenburg Medical School, University Hospital Brandenburg/Havel, 14770, Brandenburg, Germany
| | - René Mantke
- Department of Surgery, Brandenburg Medical School, University Hospital Brandenburg/Havel, 14770, Brandenburg, Germany
| | - Klaus Weber
- Department of Surgery, University Hospital Erlangen, 91054, Erlangen, Germany
| | - Stefan Benz
- Department of Surgery, Hospital Böblingen, 71032, Böblingen, Germany
| | - Stephan Kersting
- Department of Surgery, University Hospital Greifswald, 17475, Greifswald, Germany
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8
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Sinnamon AJ, Mehta R, Saeed S, Lauwers GY, Palm RF, Frakes JM, Hoffe SE, Baldonado JJ, Fontaine JP, Pimiento JM. Induction Fluorouracil-Based Chemotherapy and PET-Adapted Consolidation Chemoradiation with Esophagectomy for High-Risk Gastroesophageal Adenocarcinoma. Cancers (Basel) 2023; 15:4375. [PMID: 37686650 PMCID: PMC10486661 DOI: 10.3390/cancers15174375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/11/2023] [Accepted: 08/21/2023] [Indexed: 09/10/2023] Open
Abstract
Background: Neoadjuvant chemoradiation with esophagectomy is standard management for locally advanced esophageal adenocarcinoma. Induction chemotherapy with a tailored approach to chemoradiation based on metabolic response to therapy on PET was explored as an alternative strategy in the CALGB 80803 trial. We sought to describe real-world institutional experience implementing this approach outside of a clinical trial. Methods: Patients who were treated with induction fluorouracil-leucovorin-oxaliplatin (FOLFOX) or fluorouracil-leucovorin-oxaliplatin-docetaxel (FLOT) with tailored chemoradiation based on PET response and subsequent esophagectomy were identified from a prospectively maintained database. Primary outcomes were pathologic complete response (pCR) and overall survival (OS) following completion of all therapy. Results: There were 35 patients who completed induction chemotherapy, chemoradiation, and esophagectomy. Thirty-three completed restaging PET following induction chemotherapy with metabolic response seen in 76% (n = 25/33). The pCR rate was 31% (n = 11/35) and the ypN0 rate was 71% (n = 25/35). Among the patients who demonstrated metabolic response to induction FOLFOX/FLOT and subsequently continued fluorouracil-based chemoradiation, the pCR rate was 39% (n = 9/23). The rate of pathologically negative lymph nodes in this group was high (n = 19/23, 83%) with 100% R0 resection rate (n = 23/23). With the median follow-up of 43 months, the median OS was not reached for this group and was significantly longer than the OS for the remainder of the cohort (p = 0.027, p = 0.046 adjusted for clinical stage). Conclusions: Induction FOLFOX/FLOT chemotherapy with evaluation of sensitivity via metabolic response and tailored chemoradiation seems to lead to high pCR and ypN0 rates in high-risk patients with adenocarcinoma of the esophagus and GE junction. This approach in clinical practice seems to recapitulate encouraging results in clinical trials.
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Affiliation(s)
- Andrew J Sinnamon
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612, USA
| | - Rutika Mehta
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612, USA
| | - Samir Saeed
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612, USA
| | - Gregory Y Lauwers
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612, USA
| | - Russell F Palm
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612, USA
| | - Jessica M Frakes
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612, USA
| | - Sarah E Hoffe
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612, USA
| | - Jobelle J Baldonado
- Department of Thoracic Oncology, H. Lee Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Jacques P Fontaine
- Department of Thoracic Oncology, H. Lee Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Jose M Pimiento
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612, USA
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9
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Tanaka MD, Geubels BM, Grotenhuis BA, Marijnen CAM, Peters FP, van der Mierden S, Maas M, Couwenberg AM. Validated Pretreatment Prediction Models for Response to Neoadjuvant Therapy in Patients with Rectal Cancer: A Systematic Review and Critical Appraisal. Cancers (Basel) 2023; 15:3945. [PMID: 37568760 PMCID: PMC10417363 DOI: 10.3390/cancers15153945] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/27/2023] [Accepted: 07/27/2023] [Indexed: 08/13/2023] Open
Abstract
Pretreatment response prediction is crucial to select those patients with rectal cancer who will benefit from organ preservation strategies following (intensified) neoadjuvant therapy and to avoid unnecessary toxicity in those who will not. The combination of individual predictors in multivariable prediction models might improve predictive accuracy. The aim of this systematic review was to summarize and critically appraise validated pretreatment prediction models (other than radiomics-based models or image-based deep learning models) for response to neoadjuvant therapy in patients with rectal cancer and provide evidence-based recommendations for future research. MEDLINE via Ovid, Embase.com, and Scopus were searched for eligible studies published up to November 2022. A total of 5006 studies were screened and 16 were included for data extraction and risk of bias assessment using Prediction model Risk Of Bias Assessment Tool (PROBAST). All selected models were unique and grouped into five predictor categories: clinical, combined, genetics, metabolites, and pathology. Studies generally included patients with intermediate or advanced tumor stages who were treated with neoadjuvant chemoradiotherapy. Evaluated outcomes were pathological complete response and pathological tumor response. All studies were considered to have a high risk of bias and none of the models were externally validated in an independent study. Discriminative performances, estimated with the area under the curve (AUC), ranged per predictor category from 0.60 to 0.70 (clinical), 0.78 to 0.81 (combined), 0.66 to 0.91 (genetics), 0.54 to 0.80 (metabolites), and 0.71 to 0.91 (pathology). Model calibration outcomes were reported in five studies. Two collagen feature-based models showed the best predictive performance (AUCs 0.83-0.91 and good calibration). In conclusion, some pretreatment models for response prediction in rectal cancer show encouraging predictive potential but, given the high risk of bias in these studies, their value should be evaluated in future, well-designed studies.
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Affiliation(s)
- Max D. Tanaka
- Department of Radiation Oncology, The Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands
| | - Barbara M. Geubels
- Department of Surgery, The Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands
- Department of Surgery, Catharina Hospital, 5602 ZA Eindhoven, The Netherlands
- GROW School for Oncology and Reproduction, Maastricht University, 6200 MD Maastricht, The Netherlands
| | - Brechtje A. Grotenhuis
- Department of Surgery, The Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands
| | - Corrie A. M. Marijnen
- Department of Radiation Oncology, The Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands
- Department of Radiation Oncology, Leiden University Medical Centre, 2333 ZA Leiden, The Netherlands
| | - Femke P. Peters
- Department of Radiation Oncology, The Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands
| | - Stevie van der Mierden
- Scientific Information Service, The Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands
| | - Monique Maas
- GROW School for Oncology and Reproduction, Maastricht University, 6200 MD Maastricht, The Netherlands
- Department of Radiology, The Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands
| | - Alice M. Couwenberg
- Department of Radiation Oncology, The Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands
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