Postoperative adjuvant chemotherapy or radiation therapy for rectal cancer: results from NSABP protocol R-01

Journey through the Decades: The Evolution in Treatment and Shared Decision Making for Locally Advanced Rectal Cancer

The management of locally advanced rectal cancer has undergone significant transformations over the decades and optimal treatment approaches continue to evolve. There have been numerous advances in surgery, chemotherapy, and radiation therapy from the first description of the abdominoperineal resection in 1908, timing of chemotherapy and radiation therapy in the late 20th and early 21st century, and most recently, the introduction of organ preservation or nonoperative management in 2004. Alongside these advancements, the concept of shared decision making in medicine has evolved, prompting a focus on patient-centered care. This evolution in practice has been fueled by a growing recognition of the importance of patient autonomy and the alignment of treatment options with patients' values and preferences. With the growing number of possible treatment options, variability in patient counseling exists, highlighting the need for a standardized approach to shared decision making in locally advanced rectal cancer. This narrative review will describe the evolution of treatment options of locally advanced rectal cancer as well as the concept of shared decision making and decision aids, and will introduce a decision aid for patients with locally advanced rectal cancer who have achieved a complete clinical response and are eligible for watch and wait.

T3N0 Rectal Cancer: Radiation for All, None, or Some?

ABSTRACT

The optimal management of T3N0 rectal cancer is an area of active debate that has withstood multiple decades of research. In this comprehensive review, we delve into the many nuances that come with treating T3N0 rectal cancer, particularly examining the role and evolution of radiation therapy. We review both the historical paradigms and latest advances in treatment and highlight the significance of precise preoperative staging. As the field continues to evolve, this review highlights a shift toward more tailored treatments, considering both patient goals and the desire for optimal oncologic outcomes. In the current era, clinical decision-making for T3N0 rectal cancer requires a patient-centric approach that balances effective therapy while minimizing undue side effects.

Total Neoadjuvant Therapy for Rectal Cancer

The treatment of locally advanced rectal cancer has traditionally included sequenced multimodal therapy including radiation, chemotherapy, and surgery. The relative contribution of each and the order of treatments have evolved over the years. By the early twenty-first century, there was widespread use of the German Rectal Cancer Trial approach: preoperative chemoradiation, followed by standardized surgery including total mesorectal excision, and finally adjuvant chemotherapy. Recent advances have defined the superiority of moving the chemotherapy into the preoperative setting. This approach, termed total neoadjuvant therapy promises better systemic control and overall survival and expaned options for omitting surgery in selected patients.

Contemporary management of rectal cancer

The management of rectal cancer has undergone significant changes over the past 50 years, and this has been associated with major improvements in overall outcomes and quality of life. From standardization of total mesorectal excision to refinements in radiation delivery and shifting of chemoradiotherapy treatment to favor a neoadjuvant approach, as well as the development of targeted chemotherapeutics, these management strategies have continually aimed to achieve locoregional and systemic control while limiting adverse effects and enhance overall survival. This article highlights evolving aspects of rectal cancer therapy including improved staging modalities, total neoadjuvant therapy, the role of short-course and more selective radiotherapy strategies, as well as organ preservation. We also discuss the evolving role of minimally invasive surgery and comment on lateral pelvic lymph node dissection.

Key message

Rectal cancer management is constantly evolving through refinements in radiation timing and delivery, modification of chemoradiotherapy treatment schedules, and increasing utilization of minimally invasive surgical techniques and organ preservation strategies. This manuscript aims to provide a synopsis of recent changes in the management of rectal cancer, highlighting contemporary modifications in neoadjuvant approaches and surgical management to enhance the knowledge of surgeons who care for this challenging population.

Adoption of Total Neoadjuvant Therapy in the Treatment of Locally Advanced Rectal Cancer

Local and metastatic recurrence are primary concerns following the treatment of locally advanced rectal cancer (LARC). Chemoradiation (CRT) can reduce the local recurrence rates and has subsequently moved to the neoadjuvant setting from the adjuvant setting. Pathological complete response (pCR) rates have also been noted to be greater in patients treated with neoadjuvant CRT prior to surgery. The standard approach to treating LARC would often involve CRT followed by surgery and optional adjuvant chemotherapy and remained the treatment paradigm for almost two decades. However, patients were often unable to complete adjuvant chemotherapy due to a decreased tolerance of chemotherapy following surgery, which led to upfront treatment with both CRT and chemotherapy, and total neoadjuvant therapy, or TNT, was created. The efficacy outcomes of local recurrence, disease-free survival, and pCR have improved in patients receiving TNT compared to the standard approach. Additionally, more recent data suggest a possible improvement in overall survival as well. Patients with a complete clinical response following TNT have the opportunity for watch-and-wait surveillance, allowing some patients to undergo organ preservation. Here, we discuss the clinical trials and studies that led to the adoption of TNT as the standard of care for LARC, with the possibility of watch-and-wait surveillance for patients achieving complete responses. We also review the possibility of overtreating some patients with LARC.

Quality of Surgical Outcome Reporting in Randomised Clinical Trials of Multimodal Rectal Cancer Treatment: A Systematic Review

INTRODUCTION

Randomised controlled trials (RCTs) continue to provide the best evidence for treatment options, but the quality of reporting in RCTs and the completeness rate of reporting of surgical outcomes and complication data vary widely. The aim of this study was to measure the quality of reporting of the surgical outcome and complication data in RCTs of rectal cancer treatment and whether this quality has changed over time.

METHODS

Eligible articles with the keywords ("rectal cancer" OR "rectal carcinoma") AND ("radiation" OR "radiotherapy") that were RCTs and published in the English, German, Polish, or Italian language were identified by reviewing all abstracts published from 1982 through 2022. Two authors independently screened and analysed all studies. The quality of the surgical outcome and complication data was assessed based on fourteen criteria, and the quality of RCTs was evaluated based on a modified Jadad scale. The primary outcome was the quality of reporting in RCTs and the completeness rate of reporting of surgical results and complication data.

RESULTS

A total of 340 articles reporting multimodal therapy outcomes for 143,576 rectal cancer patients were analysed. A total of 7 articles (2%) met all 14 reporting criteria, 13 met 13 criteria, 27 met from 11 to 12 criteria, 36 met from 9 to 10 criteria, 76 met from 7 to 8 criteria, and most articles met fewer than 7 criteria (mean 5.5 criteria). Commonly underreported criteria included complication severity (15% of articles), macroscopic integrity of mesorectal excision (17% of articles), length of stay (18% of articles), number of lymph nodes (21% of articles), distance between the tumour and circumferential resection margin (CRM) (26% of articles), surgical radicality according to the site of the primary tumour (R0 vs. R1 + R2) (29% of articles), and CRM status (38% of articles).

CONCLUSION

Inconsistent surgical outcome and complication data reporting in multimodal rectal cancer treatment RCTs is standard. Standardised reporting of clinical and oncological outcomes should be established to facilitate comparing studies and results of related research topics.

The impact of intensity-modulated radiotherapy in conjunction with chemotherapy on proximal pT3N0 rectal cancer patients after total mesorectum excision

BACKGROUND

This study aimed to ascertain if the incorporation of intensity-modulated radiotherapy (IMRT) with chemotherapy (CTx) offered any advantages for patients diagnosed with stage pT3N0 rectal cancer located in the proximal (upper) region following a complete total mesorectum excision (TME).

METHODS

We retrospectively examined medical records of stage II/III rectal cancer patients who had undergone CTx or concurrent chemoradiation (CCRT) with IMRT after a successful TME. We juxtaposed a variety of survival outcomes across two patient cohorts. Each outcome was further classified according to Gunderson's risk stratification between proximal and distal (middle and low) rectal cancer patients, and we evaluated the factors associated with each outcome.

RESULTS

The median follow-up duration was 4.9 years. Our research comprised 236 rectal adenocarcinoma patients treated at our institution between 2007 and 2019. They received either the CTx (n = 135) or the CCRT (n = 101) with 10-year locoregional recurrence-free survival (LRRFS) of 90.1% and 96.1%, respectively (p = 0.163). However, after performing multivariate adjustments, a pattern emerged hinting at a better LRRFS for the CCRT group (p = 0.052). Perforation had a strong correlation with locoregional recurrence. No significant differences were observed in other survival between the two treatment arms and their respective subgroups. The CCRT group witnessed significantly higher immediate and chronic complications with p = 0.007 and 0.009, respectively. The CCRT group had two secondary cancer-related fatalities (2%, one attributed to IMRT), and another reported by the CTx group (1%). The sole classified locoregional recurrence within the cohort of 37 individuals treated with CTx for proximal pT3N0 rectal cancer was, in fact, the development of sigmoid colon cancer.

CONCLUSION

The results suggest that for patients with proximal pT3N0 rectal cancer post-TME, IMRT is better when not combined with CTx, except in highly perilous scenarios or those involving perforation.

International Society of University Colon and Rectal Surgeons survey of surgeons' preference on rectal cancer treatment

PURPOSE

Rectal cancer treatment has a wide range of possible approaches from radical extirpative surgery to nonoperative watchful waiting following chemoradiotherapy, with or without, additional chemotherapy. Our goal was to assess the personal opinion of active practicing surgeons on rectal cancer treatment if he/she was the patient.

METHODS

A panel of the International Society of University Colon and Rectal Surgeons (ISUCRS) selected 10 questions that were included in a questionnaire that included other items including demographics. The questionnaire was distributed electronically to ISUCRS fellows and other surgeons included in our database and remained open from April 16 to 28, 2020.

RESULTS

One hundred sixty-three specialists completed the survey. The majority of surgeons (n=65, 39.9%) chose the minimally invasive (laparoscopic) surgery for their personal treatment of rectal cancer. For low-lying rectal cancer T1 and T2, the treatment choice was standard chemoradiation+local excision (n=60, 36.8%) followed by local excision±chemoradiotherapy if needed (n=55, 33.7%). In regards to locally advanced low rectal cancer T3 or greater, the preference of the responders was for laparoscopic surgery (n=65, 39.9%). We found a statistically significant relationship between surgeons' age and their preference for minimally invasive techniques demonstrating an age-based bias on senior surgeons' inclination toward open approach.

CONCLUSION

Our survey reveals an age-based preference by surgeons for minimally invasive surgical techniques as well as organ-preserving techniques for personal treatment of treating rectal cancer. Only 1/4 of specialists do adhere to the international guidelines for treating early rectal cancer.

The use of adjuvant chemotherapy is not associated with recurrence or cancer-specific death following curative resection for stage III rectal cancer: a competing risks analysis

BACKGROUND

The role of adjuvant chemotherapy (AC) in stage III rectal cancer (RC) has been argued based on evidence from its use in colon cancer. Previous trials have analysed disease-free and overall survivals as endpoints, rather than disease recurrence. This study compares the competing risks incidences of recurrence and cancer-specific death between patients who did and did not receive AC for stage III RC.

METHODS

Consecutive patients who underwent a potentially curative resection for stage III RC (1995-2019) at Concord Hospital, Sydney, Australia, were studied. AC was considered following multidisciplinary discussion. Primary outcome measures were the competing risks incidences of disease recurrence and cancer-specific death. Associations between these outcomes and use of AC (and other variables) were tested by regression modelling.

RESULTS

Some 338 patients (213 male, mean age 64.4 years [SD12.7]) were included. Of these, 208 received AC. The use of AC was associated with resection year (adjusted OR [aOR] 1.74, 95%CI 1.27-2.38); age ≥75 years (aOR0.04, 95%CI 0.02-0.12); peripheral vascular disease (aOR0.08, 95%CI 0.01-0.74); and postoperative abdomino-pelvic abscess (aOR0.23, 95%CI 0.07-0.81). One hundred fifty-seven patients (46.5%) were diagnosed with recurrence; death due to RC occurred in 119 (35.2%). After adjustment for the competing risk of non-cancer death, neither recurrence nor RC-specific death was associated with AC (HR0.97, 95%CI 0.70-1.33 and HR0.72, 95%CI 0.50-1.03, respectively).

CONCLUSION

This study found no significant difference in either recurrence or cancer-specific death between patients who did and did not receive AC following curative resection for stage III RC.

Intraoperative Radiation Therapy for Gastrointestinal Malignancies

Despite improvements in definitive therapy, many patients with gastrointestinal malignancies experience local recurrences or have unresectable disease making subsequent management often challenging and morbid. Although higher doses of radiation may offer improved local control, the ability for dose escalation of external beam radiation therapy is often limited by adjacent radiosensitive structures. Intraoperative radiation therapy allows for additional radiotherapy to be delivered directly to the tumor or areas at highest risk for local recurrence while minimizing toxicity to adjacent structures, offering potentially improved outcomes for patients with unresectable disease or those with a high risk of local recurrence.

Watch-and-Wait Approach to Rectal Cancer: The Role of Imaging

The diagnosis and treatment of rectal cancer have evolved dramatically over the past several decades. At the same time, its incidence has increased in younger populations. This review will inform the reader of advances in both diagnosis and treatment. These advances have led to the watch-and-wait approach, otherwise known as nonsurgical management. This review briefly outlines changes in medical and surgical treatment, advances in MRI technology and interpretation, and landmark studies or trials that have led to this exciting juncture. Herein, the authors delve into current state-of-the-art methods to assess response to treatment with MRI and endoscopy. Currently, these methods for avoiding surgery can be used to detect a complete clinical response in as many as 50% of patients with rectal cancer. Finally, the limitations of imaging and endoscopy and future challenges will be discussed.

Determining the survival benefit of postoperative radiotherapy in patients with pT1-3N1M0 rectal cancer undergoing total mesorectal excision: a retrospective analysis

BACKGROUND

The National Comprehensive Cancer Network guidelines recommend routine postoperative adjuvant radiotherapy and chemotherapy for patients with stage III rectal cancer who do not receive neoadjuvant therapy before surgery. The present study aimed to evaluate the value of postoperative radiotherapy in patients with low-risk disease (pT1-3N1M0) who did not receive neoadjuvant therapy prior to total mesorectal excision.

METHODS

We used the Surveillance, Epidemiology, and End Results database (2004-2016) to retrospectively recruit patients with pT1-3N1M0 rectal cancer whose initial treatment was radical surgery with postoperative adjuvant chemotherapy. A propensity score model was used to balance the baseline covariates.

RESULTS

Of the 2012 patients included in the present study, 1384 received adjuvant chemoradiotherapy (radio group), whereas the remaining 718 received chemotherapy alone (no-radio group). There was no significant difference in cancer-specific survival rate between the two groups (log-rank test χ² = 2.372, P = 0.124) in the overall sample. Additionally, in the propensity score-matched cohort, adjuvant radiotherapy did not improve cancer-specific survival. Subgroup analysis showed that having three positive lymph nodes and a tumor > 50 mm, combined with postoperative adjuvant chemotherapy, could lead to an improved tumor-specific survival rate, while other cases did not benefit from postoperative radiotherapy.

CONCLUSIONS

For patients with pT1-3N1M0 rectal cancer who did not receive neoadjuvant therapy before surgery, postoperative radiotherapy in addition to adjuvant chemotherapy did not significantly improve survival rates. The number of positive nodes (n = 3) and tumor size (> 50 mm) were found to be potential screening indicators for postoperative adjuvant radiotherapy.

A systematic review and network meta-analysis of randomised controlled trials comparing neoadjuvant treatment strategies for stage II and III rectal cancer

AIM

Multiple neoadjuvant therapy strategies have been used and compared for rectal cancer and there has been no true consensus as to the optimal neoadjuvant therapy regimen. The aim is to identify and compare the neoadjuvant therapies available for stage II and III rectal cancer.

DESIGN

A systematic literature review was performed, from inception to August 2022, of the following databases: MEDLINE, EMBASE, Science Citation Index Expanded, Cochrane Library. Only randomized controlled trials comparing neoadjuvant therapies for stage II and III rectal cancer were considered. Stata was used to draw network plots, and a Bayesian network meta-analysis was conducted through models utilizing the Markov Chain Monte Carlo method in WinBUGS.

RESULTS

A total of 58 articles were included based on 41 randomised controlled trials, reporting on 12,404 participants that underwent 15 neoadjuvant treatment regimens. No significant difference was identified between treatments for major or total postoperative complications, anastomotic leak rates, or sphincter-saving surgery. Straight to surgery (STS) ranked as best treatment for preoperative toxicity but ranked worst treatment for positive resection margins and complete response. STS had significantly increased positive resection margins compared to long-course chemoradiotherapy with short-wait (LCCRT-SW) or long-wait (LCCRT-LW) to surgery, or short-course radiotherapy with short-wait (SCRT-SW) or immediate surgery (SCRT-IS). LCCRT-SW or LCCRT-LW resulted in significantly increased complete response rates compared to STS. LCCRT-LW significantly improved 2-year overall survival compared to STS, SCRT-IS, SCRT-SW. Total neoadjuvant therapy regimes with short-course radiotherapy followed by consolidation chemotherapy (SCRT-CT-SW), induction chemotherapy followed by long-course chemoradiotherapy (CT-LCCRT-S), long-course chemoradiotherapy followed by consolidation chemotherapy (LCCRT-CT-S), significantly improved positive resection margins, complete response, and disease-free survival compared to STS. Chemotherapy with monoclonal antibodies followed by long-course chemoradiotherapy (CT+MAB-LCCRT+MAB-S) significantly improved complete response and positive resection margins compared to STS, and 2-year disease-free survival compared to STS, SCRT-IS, SCRT-SW, SCRT-CT-SW, LCCRT-SW, LCCRT-LW. CT+MAB-LCCRT+MAB-S ranked as best treatment for disease-free survival and overall survival.

CONCLUSIONS

Conventional neoadjuvant therapies with short-course radiation or long-course chemoradiotherapy have oncological benefits compared to no neoadjuvant therapy without increasing perioperative complication rates. Prolonged wait to surgery may improve oncological outcomes. Total neoadjuvant therapies provide additional benefits in terms of complete response, positive resection margins, and disease-free survival. Monoclonal antibody therapy may further improve oncological outcomes but currently is only applicable to a small subgroup of patients and requires further validation.

Applying a neoscore in locally advanced rectal cancer is beneficial in predicting local recurrences after surgery

BACKGROUND AND AIM

The current study was undertaken to provide more detailed prognostic models for early prediction of local recurrences and local recurrence free survival (RFS) using different radiologic and pathologic features of locally advanced rectal carcinomas treated with neoadjuvant chemoradiation (CRT).

METHODS

One hundred patients with locally advanced rectal carcinomas decided to receive neoadjuvant CRT were retrospectively recruited, Hazard ratios (HR) were determined in the two cox regression models and only significant ratios were considered for pointing, Models were built to determine their important effects of different predictors including: pathologic T (T), pathologic N (N), grade (G), clinical stage (cTNM), site (S), perineural invasion (PNI), and response to CRT (R) on 3-year RFS, goodness of performance of each model was measured by Harrell's C index.

RESULTS

HR of 1st group of models: T+N, T+N+G, T+N+G+S, T+N+G+S+PNI, and T+N+G+S+PNI+R were summated and categorized into scores, these scores were significantly correlated with the risk of recurrence (Somer's D = 0.5, p<0.0001) & Harrell's C index = 0.751, (Somer's D = 0.6, p<0.0001) & its Harrell's C index = 0.794, (Somer's D = 0.7, p<0.0001) & C index = 0.826, Somer's D = 0.7, p<0.0001) & C index = 0.827, and (Somer's D = 0.7, p<0.0001) & C index = 0.843 respectively. The 2nd group of models including: cTNM stage, cTNM+G, cTNM+G+S, cTNM+G+S+PNI, cTNM+G+S+PNI+R scores which were significantly correlated with the HR of LRR (Somer's D = 0.2, 0.5, 0.6, 0.6, & 0.6 respectively), (p = 0.006, <0.0001, <0.0001, <0.0001, <0.0001 respectively), the corresponding Harrell's C indices were 0.595, 0.743, 0.782, 0.795, & 0.813 respectively.

CONCLUSION

We propose that the addition of biologic factors to staging of rectal cancer provide precise stratification and association with local recurrences in patients received preoperative CRT.

A practical framework for the targeted use of total neoadjuvant therapy for rectal cancer

Total neoadjuvant therapy (TNT) for rectal cancer is the preoperative delivery of radiation or chemoradiotherapy as well as systemic chemotherapy for the purpose of improving treatment completion rates and decreasing toxicity, maximizing the primary tumor response, and improving survival for patients with rectal cancer. This review summarizes the data surrounding TNT, including several recent randomized controlled trials. Moreover, it reviews the literature regarding high-quality surgery and the role of radiation and chemotherapy in the treatment of rectal cancer in the modern era. Finally, it presents an evidence-based protocol for the selective use of TNT in the treatment of patients with rectal cancer.

Postoperative hypofractionated-accelerated radiotherapy (HypoAR) for locally advanced rectal cancer

BACKGROUND

despite the advances in preoperative hypofractionated-accelerated radiotherapy for patients with locally advanced rectal cancer, postoperative radiotherapy delivered with standard fractionation (46-50 Gy in 5 weeks) remains a standard adjuvant schedule. The role of hypofractionated-accelerated radiotherapy in a postoperative setting remains largely unexplored.

METHODS

eighty-eight patients with rectal cancer infiltrating the rectal wall and/or having metastasis to the perirectal lymph nodes were treated with surgery followed by adjuvant chemotherapy and, subsequently, with hypofractionated-accelerated radiotherapy. Ten fractions of 3.4 Gy were delivered to the pelvis for 10 consecutive fractions, within 12 days. The follow-up of patients alive at the time of analysis ranges from 12-120 months (median 48).

RESULTS

mild abdominal discomfort and diarrhoea were frequent, but medical medication was demanded in 14/88 (15.9%) of patients. The incidence of late toxicities was low; 4/88 (3.5%) patients complained for intermittent intestinal urgency. Locoregional recurrence occurred in 8/88 patients (9%). The 5-year locoregional relapse-free survival was achieved in 89.7% of patients, and this dropped to 84% in node-positive patients (P = 0.45). The 5-year disease-specific overall survival was 72.4%. Nodal involvement showed a trend to negatively affect prognosis (5-year overall survival 68.2 vs. 79.6%; P = 0.23).

CONCLUSION

postoperative hypofractionated-accelerated radiotherapy has minimal early and late toxicity. The locoregional control and disease-specific survival rates are similar to the expected from conventional postoperative chemoradiotherapy. The 2.5-fold decrease of radiotherapy treatment time, reduction of waiting lists and the lower overall cost of radiotherapy are additional benefits associated with hypofractionated-accelerated radiotherapy.

Rectal cancer: Maximizing local control and minimizing toxicity

Adoption of multimodality treatment approach for rectal cancer has resulted in significant improvements in oncologic outcomes. The roles of chemotherapy, radiation, and surgery in rectal cancer treatment are continuously evolving with the goal of achieving the best possible oncologic and functional outcome while minimizing treatment toxicity. The aim of this review is to summarize the most recent trials focusing on organ-sparing treatment strategies and the optimal selection of patients for neoadjuvant radiation therapy.

Current State of Neoadjuvant Radiotherapy for Rectal Cancer

Colorectal cancer is the third most commonly diagnosed cancer, with rectal cancer accounting for 30% of cases. The current standard of care curative treatment for locally advanced rectal cancer is (chemo)radiotherapy followed by surgery and adjuvant chemotherapy. Although neoadjuvant radiotherapy has reduced the risk of local recurrence to less than 10%, the risk of distant metastasis remained high at 30% affecting patient survival. In addition, there is a recognition that there is heterogeneity in tumor biology and treatment response with good responders potentially suitable for treatment de-escalation. Therefore, new treatment sequencing and regimens were investigated. Here, we reviewed the evidence for current neoadjuvant treatment options in patients with locally advanced rectal adenocarcinoma, and highlight the new challenges in this new treatment landscape.

Preoperative versus postoperative chemoradiotherapy for locally advanced rectal cancer: Outcomes of survival, toxicity, sphincter preserving and prognostic factors

BACKGROUND

This study aimed to compare preoperative chemoradiotherapy (CRT) with postoperative CRT regarding survival, local control, disease control, sphincter preservation, toxicity and also prognostic factors for the treatment of locally advanced rectal cancer.

METHODS

Records of 140 patients with locally advanced rectal cancer who received preoperative or postoperative CRT were analyzed retrospectively. We compared the treatment groups (preoperative vs postoperative) according to baseline characteristics (demographic and rectal cancer disease characteristics), and also carried out the survival analyses.

RESULTS

From January 2010 to December 2019, 140 patients were included in the analysis, 65 received preoperative treatment and 75 postoperative treatment. There was no difference in survival, recurrence or distant metastasis rate in both treatment groups. The ratios of the failure to complete adjuvant chemotherapy (32% vs 4.6%) and acute grade 3-4 toxicity (32% vs 6.2%) were higher in the postoperative group (p < 0.001). In lower located tumors (≤5 cm from anal verge) the ratio of the sphincter preserving in the preoperative group was 60.7% (n = 17/28), and was 16.6% (n = 3/18) in the postoperative group (Yates χ2 = 5.829, p = 0.005).

CONCLUSION

This study showed no difference in recurrence and survival rate. Preoperative CRT is the preferred treatment for patients with locally advanced rectal cancer, given that it is associated with a superior overall treatment compliance rate, reduced toxicity, and an increased rate of sphincter preservation in low-lying tumors, but not for overall survival.

Clinical outcome of neoadjuvant chemoradiation in rectal cancer treatment

To determine the clinical and pathological outcome of locally advanced rectal cancer patients treated with neoadjuvant chemoradiation (chemoradiotherapy [CRT]) followed by curative surgery and to identify predictive factors of pathological complete response (pCR).Locally advanced rectal cancer patients undergoing CRT followed by curative surgery from January 2012 to December 2017 were included. Patient's demographic data, pretreatment tumor characteristics, type of CRT regimens, type of surgery, postoperative complications, pathological reports and follow up records were analyzed. Univariate and multivariate analyses were applied to identify predictive factors for pCR. Five-year disease free and overall survival were estimated by Kaplan-Meier method and compared between pCR and non-pCR groups.A total of 85 patients were analyzed. Eighteen patients (21.1%) achieved pCR. The sphincter-saving surgery rate was 57.6%. After univariate analyses, tumor length >4 cm (P = .007) and positive lymph nodes (P = .040) were significantly associated with decreased rate of pCR. Complete clinical response was significantly associated with higher rate of pCR (P = .015). Multivariate analyses demonstrated that tumor length >4 cm (P = .010) was significantly associated with decreased rate of pCR. After a median follow-up of 65 months (IQR 34-79), the calculated 5-year overall survival and disease-free survival rates were 81.4% and 69.7%, respectively. Patients who achieved pCR tend to had longer 5-year disease-free survival (P = .355) and overall survival (P = .361) than those who did not.Tumor length >4 cm was associated with decreased rate of pCR in locally advanced rectal cancer who had CRT followed by surgery. Longer waiting time or more intense adjuvant treatment may be considered to improved pCR and oncological outcomes.

Omission of or Poor Response to Preoperative Chemoradiotherapy Impacts Radial Margin Positivity Rates in Locally Advanced Rectal Cancer

BACKGROUND

In the setting of multidisciplinary standardized care of locally advanced rectal cancer, preoperative chemoradiotherapy and total mesorectal excision have become the mainstay treatment.

OBJECTIVE

This study aimed to evaluate whether the lack of preoperative chemoradiotherapy or poor response to it is associated with higher radial margin disease involvement in patients with locally advanced rectal cancer.

DESIGN

This is a retrospective cohort study using a publicly available database.

SETTING

Data were collected from the proctectomy-targeted National Surgical Quality Improvement Project file from 2016 to 2017.

PATIENTS

A total of 1161 patients were analyzed. They were categorized into 3 groups: patients who did not receive any preoperative chemoradiotherapy (28.6%), patients who received and responded to preoperative chemoradiotherapy (41.2%), and patients who received but did not respond to preoperative chemoradiotherapy (30.2%).

MAIN OUTCOME MEASURES

Response to treatment was determined by using the American Joint Committee on Cancer pretreatment and final pathological staging. Circumferential radial margin was extracted from the targeted proctectomy file.

RESULTS

Disease-involved positive circumferential radial margin was found in 86 (7.4%) cases. Positive radial margin was noted in 11 of 479 patients (2.3%) who underwent preoperative chemoradiotherapy and responded to treatment, 30 of 350 patients (8.6%) who did not respond or had a poor response to preoperative chemoradiotherapy, and 45 of 332 patients (13.6%) who did not receive preoperative chemoradiotherapy (p < 0.001). Regression analysis demonstrated that patients who do not receive preoperative chemoradiotherapy or have poor response to it have 6.6 and 4 times higher chances of having a positive radial margin.

LIMITATIONS

There is a risk of selection bias, unidentified confounders, and missing data despite the use of a nationwide cohort.

CONCLUSIONS

Omission of indicated preoperative chemoradiotherapy or poor response to it is associated with increased risk of radial margin positivity. More efforts are needed for standardized rectal cancer care with the appropriate use of preoperative chemoradiotherapy. See Video Abstract at http://links.lww.com/DCR/B467.

LA OMISIN O LA ESCASA RESPUESTA A QUIMIORADIOTERAPIA PREOPERATORIA, AFECTA LAS TASAS DE POSITIVIDAD DEL MARGEN RADIAL, EN EL CNCER RECTAL LOCALMENTE AVANZADO

ANTECEDENTES:En el contexto de la atención multidisciplinaria estandarizada del cáncer rectal localmente avanzado, la quimioradioterapia preoperatoria y la escisión mesorrectal total, se han convertido en el tratamiento principal.OBJETIVO:Evaluar si la omisión de quimioradioterapia preoperatoria o la escasa respuesta, se asocia con mayor enfermedad del margen radial, en pacientes con cáncer rectal localmente avanzado.DISEÑO:Estudio de cohorte retrospectivo utilizando una base de datos disponible públicamente.AJUSTE:Se recopilaron datos del archivo del Proyecto Nacional de Mejora de la Calidad Quirúrgica dirigido a la proctectomía de 2016-2017.PACIENTES:Se analizaron un total de 1161 pacientes. Clasificados en tres grupos: pacientes que no recibieron quimioradioterapia preoperatoria (28,6%), pacientes que recibieron y respondieron a quimioradioterapia preoperatoria (41,2%) y pacientes que recibieron pero no respondieron a la quimioradioterapia preoperatoria (30,2%).PRINCIPALES MEDIDAS DE RESULTADO:La respuesta al tratamiento se determinó utilizando el pre tratamiento y la estatificación patológica final, del American Joint Committee on Cancer. El margen radial circunferencial se extrajo del archivo de proctectomía dirigida.RESULTADOS:Se encontró enfermedad que abarcaba el margen radial circunferencial +, en el 86 (7,4%) casos. Se observó el margen radial +, en 11 de 479 pacientes (2,3%) que se sometieron a quimioradioterapia preoperatoria y respondieron al tratamiento, 30 de 350 pacientes (8,6%) que no respondieron o tuvieron una mala respuesta con quimioradioterapia preoperatoria y en 45 de 332 pacientes (13,6%) que no recibieron quimioradioterapia preoperatoria (p <0,001). El análisis de regresión demostró que los pacientes que no reciben quimioradioterapia preoperatoria o que tienen escasa respuesta, presentan respectivamente, 6,6 y 4 veces más probabilidades de tener un margen radial +.LIMITACIONES:Existe el riesgo de sesgo de selección, factores de confusión no identificados y datos faltantes a pesar del uso de una cohorte nacional.CONCLUSIONES:La omisión de la quimioradioterapia preoperatoria indicada o la escasa respuesta, se asocian a un mayor riesgo de positividad del margen radial. Se necesitan mayores esfuerzos en la atención estandarizada del cáncer rectal, con el uso adecuado de quimioradioterapia preoperatoria. Consulte Video Resumen en http://links.lww.com/DCR/B467.

Immune Checkpoint Inhibition as a Strategy in the Neoadjuvant Treatment of Locally Advanced Rectal Cancer

The treatment of locally advanced rectal cancer (LARC) has seen major advances over the past 3 decades, with multimodality treatment now standard of care. Combining surgical resection with radiotherapy and/or chemotherapy can reduce local recurrence from around 20% to approximately 5%. Despite improvements in local control, distant recurrence and subsequent survival rates have not changed. Immune checkpoint inhibitors have improved patient outcomes in several solid tumor types in the neoadjuvant, adjuvant, and advanced disease setting; however, in colorectal cancer, most clinical trials have been performed in the metastatic setting and the benefits confined to microsatellite instability-high tumors. In this article, we review the current preclinical and clinical evidence for using immune checkpoint inhibition in the treatment of LARC and discuss the rationale for specifically exploring the use of this therapy in the neoadjuvant setting. We summarize and discuss relevant clinical trials that are currently in setup and recruiting to test this treatment strategy and reflect on unanswered questions that still need to be addressed within future research efforts.

Evolution and Current Status of the Multidisciplinary Management of Locally Advanced Rectal Cancer

The management of locally advanced rectal cancer has grown in both complexity and quality since the first proctectomy. What once was a malignancy with a fairly consistent treatment algorithm for decades, a recent paradigm shift in the care of these patients has led to a more personalized, multidisciplinary approach with variations in timing, sequence, duration, and potential exclusion of multimodality therapies. This review summarizes the most important evidence behind these developing overarching concepts to provide a context for this paradigm shift.

Downstaged ypT0-2N0 rectal cancer after neoadjuvant chemoradiation therapy may not need adjuvant chemotherapy: a retrospective cohort study

PURPOSE

Current guidelines suggest that adjuvant chemotherapy (AC) be administered to all locally advanced (clinically T3-4 or N-positivity) rectal cancer patients undergoing neoadjuvant chemoradiotherapy (nCRT) and radical surgical resection regardless of the final pathological staging (yp staging). This study aimed to evaluate the necessity of AC for ypT0-2N0 rectal cancer.

METHODS

Patients with ypT0-2N0 rectal cancer, who received nCRT and radical surgical resection, were recruited retrospectively at a university hospital. The main outcome was to evaluate the 5-year overall survival (OS) and disease-free survival (DFS) between ypT0-2N0 rectal cancer patients with AC and those without AC. We also identified potential independent prognostic factors associated with poor outcomes.

RESULTS

One hundred and ten ypT0-2N0 rectal cancer patients (ypT0: n = 6; ypT1: n = 44; ypT2: n = 60) were followed up for a median of 60 months. No significant difference was observed in DFS and 5-year OS between patients with AC and those without AC. The risk of recurrence was associated with the postoperative pathological staging (0% with ypT0, 2.4% with ypT1, and 10% with ypT2). In the multivariate analysis, retrieval of < 12 lymph nodes was an independent favorable prognostic factor, which correlated with a higher OS (HR: 2.263; 95% CI: 1.093-4.687, P = 0.028). Intra-tumor lymphovascular and perineural invasion were poor prognostic markers for shorter DFS (HR: 5.940; 95% CI: 1.150-30.696, P = 0.033).

CONCLUSION

Postoperative AC is not required for patients with ypT0-2N0 rectal cancer downstaged by nCRT, especially in those without poor prognostic factors.

Survival Advantage With Adjuvant Chemotherapy for Locoregionally Advanced Rectal Cancer: A Veterans Health Administration Analysis

BACKGROUND

Adjuvant chemotherapy (AC) after chemoradiation (CRT) and surgery for locoregionally advanced rectal cancer (LARC) is a standard of care in the United States. This study examined the role, optimal regimen, and duration of AC using data from the largest integrated health system in the United States.

PATIENTS AND METHODS

Using the Veterans Affairs Central Cancer Registry, patients with stage II-III rectal cancer diagnosed in 2001 through 2011 who received neoadjuvant CRT and surgery with or without AC were identified. Kaplan-Meier analysis, log-rank tests, and propensity score (PS) adjustment analysis were used to assess survival.

RESULTS

A total of 866 patients were identified; 417 received AC and 449 did not (observation [OBS] group). Median follow-up was 109 months. Median disease-specific survival (DSS) was not reached. Six-year DSS was 73.7%; 79.5% for the AC group versus 68.0% for the OBS group. PS-matched analysis for DSS favored AC (P=.0002). Median overall survival (OS) was 90.8 months. Six-year OS was 56.7%; 64.3% for AC versus 49.6% for OBS. In PS-matched analysis, median OS was 117.4 months for AC and 74.3 months for OBS (P<.0001). A DSS advantage was seen when comparing ≥4 months with <4 months of AC (P=.023). No difference in DSS or OS was seen with single-agent versus multiagent AC.

CONCLUSIONS

In this population of patients with LARC treated with neoadjuvant CRT and surgery, OS and DSS were improved among those treated with AC versus OBS. DSS benefits were seen with ≥4 months of AC. No additional benefit was observed with multiagent therapy. In the absence of phase III data, these findings support the use of AC for LARC.

Curative therapy for rectal cancer

Introduction: A comprehensive trimodality approach has become the standard of care for patients with locally advanced rectal cancer. However, the sequencing and duration of chemotherapy and chemoradiotherapy around surgery varies between clinical studies and geographical regions. Growing evidence is also mounting for strategies such as total neoadjuvant therapy and non-operative management for carefully selected patients.Areas covered: We provide a perspective review of the current evidence and controversies in the treatment of locally advanced rectal cancer including the recent updates from the 2020 ASCO annual conference.Expert opinion: With ongoing advances in the management of locally advanced rectal cancer, a multidisciplinary team approach is necessary as treatments could involve multiple approaches. Chemoradiotherapy whether short or long course followed by at least 3 months of systemic chemotherapy may be the preferred option to balance local and distant disease control. Albeit the choice of doublet or triplet chemotherapy is still controversial. As total neoadjuvant treatment becomes part of the standard of care in rectal cancer, modification of the surveillance schedule is needed to detect early recurrences which may be limited by resources and availability of services.

Trans-anal total mesorectal excision in low rectal cancers: Preliminary oncological results of a comparative study

OBJECTIVE

The management of lower rectal cancers is a therapeutic challenge both from the oncological and functional viewpoints. The aim of this study is to assess the oncological results and postoperative morbidity after transanal total mesorectal excision (TaTME) for low rectal cancer.

MATERIAL AND METHODS

In this monocentric retrospective study, we compared the quality of carcinologic resection and the morbidity-mortality between a group of 20 patients undergoing TaTME and 21 patients treated by abdomino-perineal resection (APR) between 2016 to 2019.

RESULTS

More patients had a positive circumferential resection margin (CRM) (≤1mm) in the APR group (47.6% vs. 5%; P<0.0036). The difference in the rates of grades I-II and III-IV complications (Clavien-Dindo classification) between the two groups was not statistically significant (50% vs. 57.1% and 5% vs. 9.5% in TaTME and APR, respectively; P=0.7579, P=1.00). The median follow-up was longer in the TaTME group (20 months vs. 11 months; P=0.58). The local recurrence rate did not differ between the two groups (5% vs. 4.8%; P=1.00) CONCLUSION: TaTME provides a reliable total mesorectal resection with an acceptable CRM. However, like any new technique, it requires experience and the learning curve is long.

Light-controlled calcium signalling in prostate cancer and benign prostatic hyperplasia

Background

Identifying ways to reduce the burden of prostate cancer (Pca) or benign prostatic hyperplasia (BPH) is a top research priority. It is a typical entanglement seen in men which is portrayed by trouble in micturition. It stands as a significant problem in our society. Different molecular biomarker has high potential to treat Pca or BPH but also causes serious side effects during treatment.

Main text

The role of calcium signalling in the alteration of different biomarkers of Pca or BPH is important. Therefore, the photoswitch drugs may hold the potential to rebalance the altered calcium signaling cascade and the biomarker levels. Thereby play a significant role in the management of Pca and BPH. Online literature searches such as PubMed, Web of Science, Scopus, and Google Scholar were carried out. The search terms used for this review were photo-pharmacology, photo-switch drug, photodynamic therapy, calcium signalling, etc. Present treatment of Pca or BPH shows absence of selectivity and explicitness which may additionally result in side effects. The new condition of the calcium flagging may offer promising outcomes in restoring the present issues related with prostate malignancy and BPH treatment.

Conclusion

The light-switching calcium channel blockers aim to solve this issue by incorporating photo-switchable calcium channel blockers that may control the signalling pathway related to proliferation and metastasis in prostate cancer without any side effects.

Graphical abstract

Schematic diagram explaining the proposed role of photo-switch therapy in curbing the side effects of active drugs in Pca (prostate cancer) and BPH (benign prostatic hyperplasia). a) Delivery of medication by ordinary strategies and irreversible phototherapy causes side effects during treatment. Utilization of photo-switch drug to control the dynamic and inert condition of the medication can cause the medication impacts as we required in prostate cancer and BPH. b) Support of harmony between the calcium signaling is essential to guarantee ordinary physiology. Increment or abatement in the dimensions of calcium signaling can result in changed physiology. c) Major factors involved in the pathogenesis of BPH; downregulation of vitamin D receptor (VDR) and histone deacetylase (HDAC) can prevent BPH. Similarly, downregulation of α-1 adrenoceptor can reduce muscle contraction, while overexpression of β-3 adrenoceptor in BPH can promote further muscle relaxation in BPH treatment therapy. Inhibition of overexpressed biomarkers in BPH TRPM2-1: transient receptor potential cation channel subfamily M member 1; TRPM2-2: transient receptor potential cation channel subfamily M member 2; Androgens; CXCL5: C-X-C motif chemokine ligand 5; TGFβ-1: transforming growth factor β-1; TXA2; thromboxane-2; NMDA: N-methyl-d-aspartate can be the potential target in BPH therapy.

Estimating Population-Based Recurrence Rates of Colorectal Cancer over Time in the United States

BACKGROUND

Population-based metastatic recurrence rates for patients diagnosed with nonmetastatic colorectal cancer cannot be estimated directly from population-based cancer registries because recurrence information is not reported. We derived population-based colorectal cancer recurrence rates using disease-specific survival data based on our understanding of the colorectal cancer recurrence-death process.

METHODS

We used a statistical continuous-time multistate survival model to derive population-based annual colorectal cancer recurrence rates from 6 months to 10 years after colorectal cancer diagnosis using relative survival data from the Surveillance, Epidemiology, and End Results Program. The model was based on the assumption that, after 6 months of diagnosis, all colorectal cancer-related deaths occur only in patients who experience a metastatic recurrence first, and that the annual colorectal cancer-specific death rate among patients with recurrence was the same as in those diagnosed with de novo metastatic disease. We allowed recurrence rates to vary by post-diagnosis time, age, stage, and location for two diagnostic time periods.

RESULTS

In patients diagnosed in 1975-1984, annual recurrence rates 6 months to 5 years after diagnosis ranged from 0.054 to 0.060 in stage II colon cancer, 0.094 to 0.105 in stage II rectal cancer, and 0.146 to 0.177 in stage III colorectal cancer, depending on age. We found a statistically significant decrease in colorectal cancer recurrence among patients diagnosed in 1994-2003 compared with those diagnosed in 1975-1984 for 6 months to 5 years after diagnosis (hazard ratios between 0.43 and 0.70).

CONCLUSIONS

We derived population-based annual recurrence rates for up to 10 years after diagnosis using relative survival data.

IMPACT

Our estimates can be used in decision-analytic models to facilitate analyses of colorectal cancer interventions that are more generalizable.

Phase II randomized trial of capecitabine with bevacizumab and external beam radiation therapy as preoperative treatment for patients with resectable locally advanced rectal adenocarcinoma: long term results

Background

Preoperative chemoradiotherapy with capecitabine is considered as a standard of care for locally advanced rectal cancer. The “Tratamiento de Tumores Digestivos” group (TTD) previously reported in a randomized Ph II study that the addition of Bevacizumab to capecitabine-RT conferred no differences in the pre-defined efficacy endpoint (pathological complete response).

We present the follow-up results of progression-free survival, distant relapse-free survival, and overall survival data at 3 and 5 years.

Methods

Patients (pts) were randomized to receive 5 weeks of radiotherapy (45 Gy/25 fractions) with concurrent Capecitabine 825 mg/m2 twice daily, 5 days per week with (arm A) or without (arm b) bevacizumab (5 mg/kg once every 2 weeks).

Results

In our study, the addition of bevacizumab to capecitabine and radiotherapy in the neoadjuvant setting shows no differences in pathological complete response (15.9% vs 10.9%), distant relapse-free survival (81.0 vs 80.4 and 76.2% vs 78.2% at 3 and 5 years respectively), disease-free survival (75% vs 71.7 and 68.1% vs 69.57% at 3 and 5 years respectively) nor overall survival at 5-years of follow-up (81.8% vs 86.9%).

Conclusions

the addition of bevacizumab to capecitabine plus radiotherapy does not confer statistically significant advantages neither in distant relapse-free survival nor in disease-free survival nor in Overall Survival in the short or long term.

Trial registration

EudraCT number: 2009–010192-24.

Clinicaltrials.gov number: NCT01043484.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-020-07661-z.

Recurrence Risk after Radical Colorectal Cancer Surgery-Less Than before, But How High Is It?

Simple Summary

Evidence indicates that recurrence risk after colon cancer today is less than it was when trials performed decades ago showed that adjuvant chemotherapy reduces the risk and prolong disease-free and overall survival. After rectal cancer surgery, local recurrence rates have decreased but it is unclear if systemic recurrences have. After a systematic review of available literature reporting recurrence risks after curative colorectal cancer surgery we report that the risks are lower today than they were in the past and that this risk reduction is not solely ascribed to the use of adjuvant therapy. Adjuvant therapy always means overtreatment of many patients, already cured by the surgery. Fewer recurrences mean that progress in the care of these patients has happened but also that the present guidelines giving recommendations based upon old data must be adjusted. The relative gains from adding chemotherapy are not altered, but the absolute number of patients gaining is less.

Abstract

Adjuvant chemotherapy aims at eradicating tumour cells sometimes present after radical surgery for a colorectal cancer (CRC) and thereby diminish the recurrence rate and prolong time to recurrence (TTR). Remaining tumour cells will lead to recurrent disease that is usually fatal. Adjuvant therapy is administered based upon the estimated recurrence risk, which in turn defines the need for this treatment. This systematic overview aims at describing whether the need has decreased since trials showing that adjuvant chemotherapy provides benefits in colon cancer were performed decades ago. Thanks to other improvements than the administration of adjuvant chemotherapy, such as better staging, improved surgery, the use of radiotherapy and more careful pathology, recurrence risks have decreased. Methodological difficulties including intertrial comparisons decades apart and the present selective use of adjuvant therapy prevent an accurate estimate of the magnitude of the decreased need. Furthermore, most trials do not report recurrence rates or TTR, only disease-free and overall survival (DFS/OS). Fewer colon cancer patients, particularly in stage II but also in stage III, today display a sufficient need for adjuvant treatment considering the burden of treatment, especially when oxaliplatin is added. In rectal cancer, neo-adjuvant treatment will be increasingly used, diminishing the need for adjuvant treatment.

Improving Rectal Cancer Outcomes with the National Accreditation Program for Rectal Cancer

Background  The treatment of rectal cancer has undergone dramatic changes over the past 50 years. It has evolved from a rather morbid disease usually requiring a permanent stoma, almost exclusively managed by surgeons, to one that involves experts across numerous disciplines to provide the best care for the patient. With significant improvements in surgical techniques, the use of chemotherapy and radiotherapy, advanced imaging, and standardization of pathological assessment, the perioperative morbidity and permanent colostomy rates have significantly decreased. We have seen improvements in the quality of the specimen and rates of recurrence as well as disease-free survival. Rectal cancer, as demonstrated in European trials, has now been recognized as a disease best managed by a multidisciplinary team. Objective  The aim of this article is to evaluate the main body of literature leading to the advances made possible by the new American College of Surgeons Commission on Cancer National Accreditation Program for Rectal Cancer. Results  Following the launch of the American College of Surgeons Commission on Cancer National Accreditation Program for Rectal Cancer, we expect dramatic increases in membership and accreditation, with associated improvement in center performance and, ultimately, in patient outcomes. Limitations  The National Accreditation Program for Rectal Cancer began in 2017. To date, the only data that have been analyzed are from the preintervention phase. Conclusions  Based on the results of studies within the United States and on the successes demonstrated in Europe, it remains our hope and expectation that the management of rectal cancer in the United States will rapidly improve.

MRI for Rectal Cancer Primary Staging and Restaging After Neoadjuvant Chemoradiation Therapy: How to Do It During Daily Clinical Practice

PURPOSE

To provide a practical overview regarding the state-of-the-art of the magnetic resonance imaging (MRI) protocol for rectal cancer imaging and interpretation during primary staging and restaging after neoadjuvant chemoradiation therapy (CRT), pointing out technical skills and findings that radiologists should consider for their reports during everyday clinical activity.

METHOD

Both 1.5T and 3.0T scanners can be used for rectal cancer evaluation, using pelvic phased array external coils. The standard MR protocol includes T2-weighted imaging of the pelvis, high-resolution T2-weighted sequences focused on the tumor and diffusion-weighted imaging (DWI). The mnemonic DISTANCE is helpful for the interpretation of MR images: DIS, for distance from the inferior part of the tumor to the anorectal-junction; T, for T staging; A, for anal sphincter complex status; N, for nodal staging; C, for circumferential resection margin status; and E, for extramural venous invasion.

RESULTS

Primary staging with MRI is a cornerstone in the preoperative workup of patients with rectal cancer, because it provides clue information for decisions on the administration of CRT and surgical treatment. Restaging after CRT is crucial for treatment planning, and findings on post-CRT MRI correlate with the patient's prognosis and survival. It may be useful to remember the mnemonic word "DISTANCE" to check and describe all the relevant MRI findings necessary for an accurate radiological definition of tumor stage and response to CRT.

CONCLUSIONS

"DISTANCE" assessment for rectal cancer staging and treatment response estimation after CRT may be helpful as a checklist for a structured reporting.

Defining and predicting early recurrence in patients with locally advanced rectal cancer treated with neoadjuvant chemoradiotherapy

BACKGROUND

The definition of "early recurrence (ER)" after rectal cancer surgery is currently unclear.

OBJECTIVE

To determine an evidence-based cut-off to distinguish early and late recurrence (LR) for patients with rectal cancer and compare the clinicopathological factors between the two groups.

METHODS

Patients who underwent neoadjuvant chemoradiotherapy (nCRT) and radical resection for locally advanced rectal cancer were included. A minimum p-value approach was used to evaluate the optimal cut-off value of recurrence-free survival to divide the patients into ER and LR groups based on overall survival. A logistic regression model was used to assess risk factors for ER.

RESULTS

A total of 763 patients were included, of which 167 (21.9%) experienced recurrence. The optimal cut-off value of recurrence-free survival to differentiate between ER (n = 125, 74.9%) and LR (n = 42, 25.1%) was 24 months (P = 0.000001). The median postrecurrence survival of ER and LR was 12 months and 22 months, respectively (p = 0.028). The most common recurrent sites in patients with ER and LR were lung metastases, the incidence of liver metastases, however, differed considerably in ER and LR (27.2% vs 9.5%, P = 0.019). Risk factors including elevated preoperative carcinoembryonic antigen (CEA), higher ypTNM stage, positive circumferential resection margin (CRM), and perineural invasion were significantly associated with ER.

CONCLUSION

A recurrence-free interval of 24 months is the optimal cut-off value for defining ER versus LR. Elevated preoperative CEA, higher ypTNM staging, positive CRM, and perineural invasion were associated with ER of locally advanced rectal cancer.

Effect of understaging on local recurrence of rectal cancer

Background and Objectives

Magnetic resonance imaging of the pelvis has a limited accuracy to detect positive lymph nodes but does dictate neoadjuvant treatment in rectal cancer. This study aimed to investigate preoperative lymph node understaging and its effects on postoperative local recurrence rate.

Methods

Patients were selected from a retrospective cross‐sectional snapshot study. Patients with emergency surgery, cM1 disease, or unknown cN‐ or (y)pN category were excluded. Clinical and pathologic N‐categories were compared and the impact on local recurrence was determined by multivariable analysis.

Results

Out of 1548 included patients, 233 had preoperatively underestimated lymph node staging based on (y)pN category. Out of the 695 patients staged cN0, 168 (24%) had positive lymph nodes at pathology, and out of the 594 patients staged cN1, 65 (11%) were (y)pN2. Overall 3‐year local recurrence rate was 5%. Clinical N‐category was not associated with local recurrence when corrected for pT‐category, neoadjuvant therapy, and resection margin, neither in patients with (y)pN1 (hazard ratio [HR]: 1.67 (95% confidence interval [CI]: 0.68‐4.12) P = .263) nor (y)pN2‐category (HR: 1.91 95% CI: [0.75‐4.84], P = .175).

Conclusion

Preoperative understaging of nodal status in rectal cancer is not uncommon. No significant effect on local recurrence or overall survival rates were found in the present study.

Challenges of improving treatment outcomes for colorectal and anal cancers in Japan: the Colorectal Cancer Study Group (CCSG) of the Japan Clinical Oncology Group (JCOG)

Colorectal cancer is a major public health concern in Japan. While early-stage colorectal adenocarcinoma treatment entails radical resection of the primary tumor, the importance of perioperative treatment is growing as physicians seek to further improve treatment outcomes. For anal squamous cell carcinoma, definitive chemoradiotherapy is superior to radical surgery in terms of improved patient quality of life. The Colorectal Cancer Study Group of the Japanese Clinical Oncology Group was established in 2001 and has worked to provide answers to common clinical questions and improve treatment outcomes for colorectal and anal cancers through 15 large-scale prospective clinical trials. Here, we discuss the current state of perioperative treatment for early-stage colon, rectal and anal cancers in Japan and approaches taken by the Colorectal Cancer Study Group/the Japanese Clinical Oncology Group to improve treatment outcomes for these cancers.

Are Community Hospitals Meeting the Same Standards as Academic Hospitals for the Multimodal Management of Rectal Cancer?

Although multimodal treatment (surgery, chemotherapy ± radiation) has improved survival in patients with rectal cancer, there are inconsistent treatment patterns in hospitals in the United States. The objective of the study was to evaluate whether treatment paradigms have changed for patients with Stage II and III rectal cancer in community hospitals compared with academic research hospitals, i.e., teaching or comprehensive hospitals engaged in research. The National Cancer Database was queried to identify all patients diagnosed with Stage II or III rectal adenocarcinoma between 2000 and 2008. The first course of treatment and patient clinicodemographic factors were evaluated. Of 70,409 patients in the study cohort, 7,235 (62.9%) at community hospitals, 24,465 (66.9%) at comprehensive hospitals, and 14,868 (66.6%) at teaching hospitals received multimodal therapy. Community hospitals were more likely to treat individuals who were older, white, and with lower income compared with the other facility types. Teaching hospitals treated a higher proportion of uninsured patients. Despite differences in patient demographics, community hospitals have increased the use of multimodal treatment for rectal cancer but continue to remain below academic research hospital standards.

Preoperative chemoradiotherapy versus surgery alone for advanced low rectal cancer: a large multicenter cohort study in Japan

PURPOSE

To clarify the usefulness of chemoradiotherapy (CRT) for low rectal cancer, we investigated the current status of CRT in Japan and its short- and long-term outcomes versus surgery alone for low rectal cancer in a large multicenter cohort study.

METHODS

Between January 2010 and December 2011, data from 1608 patients with clinical Stage II-III rectal adenocarcinoma were collected from 69 specialized centers. Of these 1608 patients, 923 were diagnosed with clinical stage III low rectal cancer, 838 were enrolled in this study, divided into the surgery-alone group (n = 649) and preoperative CRT group (n = 189), and analyzed.

RESULTS

The following parameters were significantly lower in the CRT versus surgery-alone group: blood loss (210 vs. 431.5 mL), postoperative complications (27.5% vs 39.0%), and the incidence of anastomotic leakage (3.7% vs. 8.8%). The 3-year overall survival, relapse-free and local recurrence-free survival rates did not between the two groups to a statistically significant extent (91.2% vs. 87.4%, 68.8% vs. 66.4%, and 88.2% vs. 88.4%, respectively).

CONCLUSIONS

The present study revealed the current status of CRT for low rectal cancer in Japan. The results showed that CRT could be safely performed for advanced low rectal cancer in comparison to surgery alone.

Rectal cancer patients with downstaging after neoadjuvant chemoradiotherapy and radical resection do not benefit from adjuvant chemotherapy

BACKGROUND

Whether adjuvant chemotherapy is beneficial for rectal cancer patients who respond well to neoadjuvant chemoradiotherapy (NCRT) and undergo radical resection is controversial. This study aimed to assess the effect of adjuvant chemotherapy on the oncological outcomes of ypT0-2N0 rectal cancer patients after NCRT and radical resection, and identify the prognostic factors.

METHODS

The clinical and pathological data of rectal cancer patients with ypT0-2N0 who underwent NCRT and radical resection between January, 2010 and June, 2018 were collected and retrospectively analyzed. The oncological outcomes of the chemotherapy (chemo) group and the non-chemotherapy (non-chemo) group were compared. Multivariate analysis, using a Cox proportional hazard model, was performed to identify independent predictors of oncological outcome.

RESULTS

Of the 121 rectal cancer patients enrolled, 90 patients received postoperative adjuvant chemotherapy with no fewer than 3 cycles (the chemo group), and the other 31 patients with fewer than 3 cycles (the non-chemo group). There was no significant difference in the 5-year disease-free survival (DFS) or overall survival (OS) rates between the two groups (DFS: 79.1% vs. 82.9%, P=0.442; OS: 87.5% vs. 78.2%, P=0.667). cT4 is an independent risk factor for OS (HR =4.227, 95% CI: 1.128-15.838, P=0.02) and DFS (HR =4.878, 95% CI: 1.752-13.578). Preoperative consolidation chemotherapy with Capeox or FOLFOX after NCRT significantly improved the DFS rate (HR =0.212, 95% CI: 0.058-0.776, P=0.019).

CONCLUSIONS

Rectal cancer patients with ypT0-2N0 who underwent NCRT and radical resection did not benefit significantly from postoperative adjuvant chemotherapy. For these patients, cT4 was an independent risk factor for OS and DFS. Preoperative consolidation chemotherapy with Capeox or FOLFOX after NCRT can significantly improve DFS.

Controversies in Rectal Cancer Treatment and Management

Incorporation of new treatment modalities has significantly increased the complexity of the treatment and management of rectal cancer, including perioperative therapy for local advanced disease and organ preservation for those with response to the preoperative treatment. This review may help practitioners better understand the rationale and selection.

Local Irradiation Modulates the Pharmacokinetics of Metabolites in 5-Fluorouracil-Radiotherapy-Pharmacokinetics Phenomenon

Background

The effects of radiotherapy (RT) on the pharmacokinetics (PK) of 5-FU and 5-fluoro-5,6-dihydro-uracil (5-FDHU) were investigated by animal experiments.

Methods

Whole-pelvis RT with 0.5 and 2 Gy was delivered to Sprague–Dawley rats. 5-FU at 100 mg/kg was intravenously infused 24 h after radiation. The pharmacokinetics of 5-FU and 5-FDHU in the plasma and bile system were calculated.

Results

The areas under the concentration versus time curve (AUC) of 5-FU in the plasma were reduced by local irradiation by 23.7% at 0.5 Gy (P < 0.001) and 35.3% at 2 Gy (P < 0.001). The AUCs of 5-FDHU were also reduced by 21.4% at 0.5 Gy (P < 0.001) and 51.5% at 2 Gy (P < 0.001). Irradiation significantly increased the clearance values (CLs) of 5-FU by 30.6% at 0.5 Gy and 50.1% at 2 Gy, respectively. The CLs of 5-FDHU were increased by 27.2% at 0.5 Gy and 106% at 2 Gy. The AUCs of 5-FU in the bile were increased by 36.7% at 0.5 Gy (P < 0.001) and 68.6% at 2 Gy (P = 0.005). The AUCs of 5-FDHU in the bile were increased by 40.3% at 0.5 Gy (P < 0.001) and 248.1% at 2 Gy (P < 0.001). The CLs of 5-FU in the bile were increased by 31.8% at 0.5 Gy and 11.2% at 2 Gy. However, the CLs of 5-FDHU in the bile were decreased by 29.1% at 0.5 Gy and 71.0% at 2 Gy.

Conclusion

Both conventional and low-dose irradiation can affect the pharmacokinetics of 5-FU and its metabolite, 5-FDHU. RT plus 5-FU could cause more adverse events than 5-FU alone by increasing the AUC ratio of 5-FU/5-FDHU. Irradiation decreases the AUC of 5-FU in the plasma, which may cause poor clinical outcomes.

Neoadjuvant radiotherapy improves overall survival for T3/4N+M0 rectal cancer patients: a population-based study of 20300 patients

Background

Neoadjuvant radiotherapy (RT) has been shown to improve local control; however, whether it can improve overall survival (OS) in locally advanced rectal cancer (LARC) patients remains controversial. We therefore aimed to examine the benefits of surgery alone, neoadjuvant radiotherapy (RT), adjuvant RT, and surgery plus chemotherapy in stage II (T3/4N0M0) and III (any T and N + M0) on the OS of rectal cancer patients.

Methods

Date from the Surveillance, Epidemiology, and End Results (SEER) database diagnosed between 2004 and 2016 were used. Kaplan-Meier analyses were used to compare patient prognoses across different treatment modalities. Cox hazard regression analysis were used to identify independent predictors of OS.

Results

For stage T3/4N0M0 patients, neoadjuvant RT, adjuvant RT, and surgery plus chemotherapy resulted in similar OS (all p > 0.05; mean survival, 115.89 months (M), 111.97 M, and 117.22 M, respectively), with better OS observed in these patients than in patients who underwent surgery alone (all p < 0.001, mean survival, 88.96 M). For stage T1/2N + M0 patients, neoadjuvant RT, adjuvant RT, and surgery plus chemotherapy resulted in similar OS (all p > 0.05; mean survival, 121.50 M, 124.25 M, and 121.20 M, respectively), with better OS observed in these patients than in patients who underwent surgery alone (all p < 0.001, mean survival 83.81 M). For stage T3/4N + M0 patients, neoadjuvant RT (HR = 0.436; 95% CI, 0.396~0.478; p < 0.001) resulted in significantly longer OS than adjuvant RT and surgery plus chemotherapy (mean survival, 104.47 M, 93.94 M, and 93.62 M, respectively), with better OS observed in these patients than in patients who underwent surgery alone (all p < 0.001, mean survival 54.87 M). Older age (> 60 years), black race, unmarried status, high tumour grade, and tumour size > 5 cm were all associated with a poor prognosis (all p < 0.05).

Conclusions

Neoadjuvant RT, adjuvant RT, and surgery plus chemotherapy results in better OS than surgery alone in LARC patients. Neoadjuvant RT has the potential to be highly recommended over adjuvant RT and surgery plus chemotherapy for T3/4N + M0 patients; however, it showed no OS advantage over adjuvant RT or surgery plus chemotherapy for T3/4N0M0 and T1/2N + M0 patients.

Adjuvant chemotherapy for rectal cancer: Current evidence and recommendations for clinical practice

While adjuvant chemotherapy is an established treatment for pathological stage II and especially stage III colon cancer, its role in the multimodal management of rectal cancer remains controversial. As a result, there is substantial variation in the use of this treatment in clinical practice. Even among centres and physicians who consider adjuvant chemotherapy as a standard treatment, notable heterogeneity exists with regard to patient selection criteria and chemotherapy regimens. The controversy around this topic is confirmed by the lack of full consensus among national and international clinical guidelines. While most of the clinical trials do not support the contention that adjuvant chemotherapy may improve survival outcomes if pre-operative (chemo)radiotherapy is also given, these suffer from many limitations that preclude drawing definitive conclusions. Nevertheless, in the era of evidence-based medicine, physicians should be guided by the available data and refrain from extrapolating results of adjuvant colon cancer trials to inform treatment decisions for rectal cancer. Patients should be informed of the evidence gap, be given the opportunity to carefully discuss pros and cons of all the possible management options and be empowered in the decision making. In this article we review the available evidence on adjuvant chemotherapy for rectal cancer and propose a risk-adapted decisional algorithm that largely relies on informed patient preferences.

Short-course or long-course radiation therapy as a part of a neoadjuvant regimen for stage II & III rectal adenocarcinoma?

The aim of this mini-review is to compare and contrast the pros and cons of short-course and long-course neoadjuvant chemoradiation therapy regimens for stage II & III rectal adenocarcinoma. Multiple trials have demonstrated the equal efficacy and safety of short-course and long-course radiation therapy as a part of neoadjuvant regimens. Published data also shows that total neoadjuvant therapy could be more successful than neoadjuvant chemoradiation followed by adjuvant chemotherapy. This review points out future research directions for patients with locally advanced rectal adenocarcinoma such as comparing total neoadjuvant therapy that contains a short-course of radiation therapy to the standard of care, and evaluating how the sequence of short-course radiation therapy and chemotherapy in the total neoadjuvant therapy impacts the pathological complete response (pCR) rate, local control, and survival outcomes.