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Socha J, Glynne-Jones R, Bujko K. Oncological risks associated with the planned watch-and-wait strategy using total neoadjuvant treatment for rectal cancer: A narrative review. Cancer Treat Rev 2024; 129:102796. [PMID: 38968742 DOI: 10.1016/j.ctrv.2024.102796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 06/27/2024] [Accepted: 06/28/2024] [Indexed: 07/07/2024]
Abstract
Overall survival benefit of total neoadjuvant treatment (TNT) remains unconfirmed. Thus, in our opinion, the main rationale for using TNT is a planned watch-and-wait (w&w) strategy to improve patients' long-term quality of life through organ preservation. The OPRA randomized trial, which examined a planned w&w strategy using TNT, showed a higher organ preservation rate but also a higher regrowth rate compared to studies on the opportunistic w&w strategy. Higher rates of complete clinical response with TNT did not improve disease-free survival compared to historical controls. Therefore, the gain in organ-sparing capability might not be balanced by the increased oncological risk. The ultimate local failure rate in the intention-to-treat analysis of the OPRA trial was 13% for induction chemotherapy and 16% for consolidation chemotherapy, which seems higher than expected compared to 8% in a meta-analysis of w&w studies or 12% after TNT and surgery in the PRODIGE-23 and RAPIDO trials, which enrolled patients with more advanced cancers than the OPRA trial. Other studies also suggest worse local control when surgery is delayed for radio-chemoresistant cancers. Our review questions the safety of the planned w&w strategy using TNT in unselected patients. To reduce the oncological risk while maintaining high organ preservation rates, we suggest that the planned w&w strategy using TNT requires a two-tier patient selection process: before treatment and after tumor response assessment at the midpoint of consolidation chemotherapy. These robust selections should identify patients who are unlikely to achieve organ preservation with TNT and would be better managed by preoperative chemoradiotherapy (without consolidation chemotherapy) and surgery, or by discontinuing consolidation chemotherapy and proceeding directly to surgery.
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Affiliation(s)
- Joanna Socha
- Department of Radiotherapy, Regional Oncology Centre, Bialska 104/118, 42-200 Częstochowa, Poland.
| | - Robert Glynne-Jones
- Radiotherapy Department, Mount Vernon Centre for Cancer Treatment, Rickmansworth Rd, Northwood HA6 2RN, UK.
| | - Krzysztof Bujko
- Department of Radiotherapy I, Maria Skłodowska-Curie National Research Institute of Oncology, Roentgena 5, 02-781 Warsaw, Poland.
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2
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Li Z, Yuan Y, Liu M, Bo T, Ma X, Wang H, Chen C, Shi X, Wang H, Bai C, Ni X, Shao C, Lu Y, Lu J, Shen F. Rectal adenocarcinoma: Ex vivo 9.4T MRI-correlation with histopathologic treatment response to neoadjuvant chemoradiotherapy. Cancer Med 2024; 13:e70075. [PMID: 39087899 PMCID: PMC11293138 DOI: 10.1002/cam4.70075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 04/24/2024] [Accepted: 07/23/2024] [Indexed: 08/02/2024] Open
Abstract
OBJECTIVES To determine the imaging details and diagnostic information of the treatment response to neoadjuvant chemoradiotherapy (nCRT) of rectal adenocarcinoma at 9.4T magnetic resonance imaging (MRI) by ex vivo. METHODS Fifteen cases with locally advanced rectal cancer (LARC) followed by radical surgery after nCRT between September 2022 and February 2023 were recruited. Resected specimens were fixed in a perfluoropolyether-filled test tube and scanned with a 3.0T and 9.4T MRI system ex vivo. The residual tumor depth and MRI-based tumor regression grade (TRG) were subjectively assessed and then compared with the pathological findings. RESULTS The ex vivo 9.4T T2WI without fat suppression clearly differentiated tumor tissue, fibrosis and normal rectal wall, which clearly corresponded to the pathologic tissues of the rectal specimens. The TRG could be accurately assessed on ex vivo 9.4T images in 13/15 specimens (86.7%), while in 11/15 specimens (73.3%) on ex vivo 3.0T images. CONCLUSION Ex vivo 9.4T MR imaging clearly displayed the components of rectal wall and proved excellent diagnostic performance for evaluating the treatment response to nCRT, which allow radiologists to understand and then assess more accurately the TRG of LARC after nCRT.
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Affiliation(s)
- Zhihui Li
- Department of Radiology, Ruijin Hospital Luwan BranchShanghai Jiaotong University School of MedicineShanghaiChina
| | - Yuan Yuan
- Department of Radiology, Changhai HospitalThe Navy Medical UniversityShanghaiChina
| | - Minglu Liu
- Department of Radiology, Changhai HospitalThe Navy Medical UniversityShanghaiChina
| | - Tingting Bo
- Department of Radiology, Ruijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
- Department of Endocrine and Metabolic DiseasesShanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of MedicineShanghaiChina
- Clinical Neuroscience Center, Ruijin Hospital Luwan BranchShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Xiaolu Ma
- Department of Radiology, Changhai HospitalThe Navy Medical UniversityShanghaiChina
| | - Hanqi Wang
- Department of Radiology, Ruijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Chen Chen
- United Imaging HealthcareShanghaiChina
| | - Xiaohui Shi
- Department of Colorectal Surgery, Changhai HospitalThe Navy Medical UniversityShanghaiChina
| | - Hao Wang
- Department of Colorectal Surgery, Changhai HospitalThe Navy Medical UniversityShanghaiChina
| | - Chenguang Bai
- Department of Pathology, Changhai HospitalThe Navy Medical UniversityShanghaiChina
| | - Xiang Ni
- Department of Pathology, Changhai HospitalThe Navy Medical UniversityShanghaiChina
| | - Chengwei Shao
- Department of Radiology, Changhai HospitalThe Navy Medical UniversityShanghaiChina
| | - Yong Lu
- Department of Radiology, Ruijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Jianping Lu
- Department of Radiology, Changhai HospitalThe Navy Medical UniversityShanghaiChina
| | - Fu Shen
- Department of Radiology, Changhai HospitalThe Navy Medical UniversityShanghaiChina
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3
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Labadie KP, Olson KA, Sun SH, Ituarte PHG, Hanna M, Zerhouni Y, Lai LL, Sentovich SM, Kaiser AM, Melstrom KA. Outcomes of rectal cancer patients who refuse surgery after incomplete clinical response to neoadjuvant therapy. J Surg Oncol 2024; 129:1131-1138. [PMID: 38396372 DOI: 10.1002/jso.27604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 01/28/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND AND OBJECTIVES Total mesorectal excision (TME) remains the standard of care for patients with rectal cancer who have an incomplete response to total neoadjuvant therapy (TNT). A minority of patients will refuse curative intent resection. The aim of this study is to examine the outcomes for these patients. METHODS A retrospective cohort study of stage 1-3 rectal adenocarcinoma patients who underwent neoadjuvant chemoradiation therapy or TNT at a single institution. Patients either underwent TME, watch-and-wait protocol, or if they refused TME, were counseled and watched (RCW). Clinical outcomes and resource utilization were examined in each group. RESULTS One hundred seventy-one patients (Male 59%) were included with a median surveillance of 43 months. Twenty-nine patients (17%) refused TME and had shortened overall survival (OS). Twelve patients who refused TME converted to a complete clinical response (cCR) on subsequent staging with a prolonged OS. 92% of these patients had a near cCR at initial staging endoscopy. Increased physician visits and testing was utilized in RCW and WW groups. CONCLUSION A significant portion of patients convert to cCR and have prolonged OS. Lengthening the time to declare cCR may be considered in select patients, such as those with a near cCR at initial endoscopic staging.
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Affiliation(s)
| | | | - Steven H Sun
- Division of Colorectal Surgery, Duarte, California, USA
| | | | - Mark Hanna
- Division of Colorectal Surgery, Duarte, California, USA
| | | | - Lily L Lai
- Division of Colorectal Surgery, Duarte, California, USA
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4
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Brewer J, Kamara M, Huebner M, Taxakis E, Grajewski K, Ramm C, Cleary RK. Operative trends following the adoption of nonoperative management of rectal cancer. J Surg Oncol 2024; 129:1139-1149. [PMID: 38406980 DOI: 10.1002/jso.27605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Accepted: 02/07/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND Differentiating clinical near-complete and complete responses (cCR) after neoadjuvant therapy (NT) is challenging in rectal cancer patients. We hypothesized that magnetic resonance imaging staging limitations for low rectal cancers may increase the proportion of abdominoperineal resection (APR) with permanent colostomy for those without a cCR. METHODS Single institution retrospective analysis of rectal cancer cases before and after adoption of nonoperative "watch and wait" (W&W) pathway. APR as a percentage of rectal resections was the primary outcome. RESULTS There were 76 total mesorectal excisions (TME) in the pre-W&W group and 98 in the post-W&W group. NT was significantly more common in the post-W&W group. There was no significant difference in the APR primary outcome (pre-W&W APR 33.3% vs. post-W&W APR 26.5%, p = 0.482). APR patients had fewer complete TME grades (69.2% vs. 46.2%) and more pathologic complete responses (0% vs. 26.9%) in the post-W&W period. The cCR rate for patients with nonoperative management was 51.4% (n = 37) and 13.5% (n = 5) had regrowths, all of whom underwent salvage surgery. CONCLUSION APR for those without a cCR to NT has not increased in the nonoperative management era. Balancing the pathologic complete response rate may require restaging some patients with clinical near-complete responses.
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Affiliation(s)
- Justin Brewer
- Department of Surgery, Trinity Health Ann Arbor, Ann Arbor, Michigan, USA
| | - Maseray Kamara
- Department of Surgery, Trinity Health Ann Arbor, Ann Arbor, Michigan, USA
| | - Marianne Huebner
- Center for Statistical Training and Consulting, Michigan State University, East Lansing, Michigan, USA
| | - Elias Taxakis
- Department of Radiology, Trinity Health Ann Arbor, Ann Arbor, Michigan, USA
| | - Karen Grajewski
- Department of Radiology, Trinity Health Ann Arbor, Ann Arbor, Michigan, USA
| | - Carole Ramm
- Department of Academic Research, Trinity Health Ann Arbor, Ann Arbor, Michigan, USA
| | - Robert K Cleary
- Department of Surgery, Trinity Health Ann Arbor, Ann Arbor, Michigan, USA
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5
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Obonyo D, Uslar V, Weyhe D, Tabriz N. Personalized medicine for locally advanced rectal cancer: five years of complete clinical response after neoadjuvant radiochemotherapy-a case report with a literature review. Front Surg 2024; 11:1385378. [PMID: 38590724 PMCID: PMC10999613 DOI: 10.3389/fsurg.2024.1385378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 03/11/2024] [Indexed: 04/10/2024] Open
Abstract
We present a case report of a 73-year-old male patient with a complete clinical response following neoadjuvant radiochemotherapy of mid-rectal adenocarcinoma. The patient was initially diagnosed with stage IIIB microsatellite stable mid-rectal adenocarcinoma in February 2017. During restaging in June 2017, which included rectoscopy, endosonography, computed tomography and magnetic resonance imaging, a complete clinical response was observed. After appropriate consultation, a watch-and-wait strategy was chosen. During stringent follow-up every 3 months for the first 3 years and thereafter every 6 months, no recurrence or regrowth was observed. After the fifth year of complete clinical response, we recommended an annual follow-up. As of November 2023, the patient has no signs of recurrence or late toxicity after radiochemotherapy. The omission of resection in patients with locally advanced rectal cancer and the establishment of a watch-and-wait strategy are currently under discussion as possible treatment courses in patients with complete clinical response. Long-term data on watch-and-wait strategies for patients with a complete clinical response in locally advanced rectal cancer are rare. A clear national and international accepted standardization of follow-up programs for patients managed by a watch-and-wait strategy in the long-term is missing. Here, we report the case of a patient who had undergone a follow-up program for more than five years and discuss the current literature. Our case report and literature review highlights that a watch-and-wait strategy does not seem to increase the risk of systemic disease or compromise survival outcomes in selected locally advanced rectal cancer patients. Thus, our case contributes to the growing body of knowledge on personalized and precision medicine for rectal cancer.
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Affiliation(s)
- Dennis Obonyo
- Carl von Ossietzky University Oldenburg, University Clinic for Visceral Surgery, Pius-Hospital Oldenburg, Oldenburg, Germany
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6
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Verheij FS, Omer DM, Williams H, Lin ST, Qin LX, Buckley JT, Thompson HM, Yuval JB, Kim JK, Dunne RF, Marcet J, Cataldo P, Polite B, Herzig DO, Liska D, Oommen S, Friel CM, Ternent C, Coveler AL, Hunt S, Gregory A, Varma MG, Bello BL, Carmichael JC, Krauss J, Gleisner A, Guillem JG, Temple L, Goodman KA, Segal NH, Cercek A, Yaeger R, Nash GM, Widmar M, Wei IH, Pappou EP, Weiser MR, Paty PB, Smith JJ, Wu AJ, Gollub MJ, Saltz LB, Garcia-Aguilar J. Long-Term Results of Organ Preservation in Patients With Rectal Adenocarcinoma Treated With Total Neoadjuvant Therapy: The Randomized Phase II OPRA Trial. J Clin Oncol 2024; 42:500-506. [PMID: 37883738 DOI: 10.1200/jco.23.01208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 07/29/2023] [Accepted: 09/07/2023] [Indexed: 10/28/2023] Open
Abstract
Clinical trials frequently include multiple end points that mature at different times. The initial report, typically based on the primary end point, may be published when key planned co-primary or secondary analyses are not yet available. Clinical Trial Updates provide an opportunity to disseminate additional results from studies, published in JCO or elsewhere, for which the primary end point has already been reported.To assess long-term risk of local tumor regrowth, we report updated organ preservation rate and oncologic outcomes of the OPRA trial (ClinicalTrials.gov identifier: NCT02008656). Patients with stage II/III rectal cancer were randomly assigned to receive induction chemotherapy followed by chemoradiation (INCT-CRT) or chemoradiation followed by consolidation chemotherapy (CRT-CNCT). Patients who achieved a complete or near-complete response after finishing treatment were offered watch-and-wait (WW). Total mesorectal excision (TME) was recommended for those who achieved an incomplete response. The primary end point was disease-free survival (DFS). The secondary end point was TME-free survival. In total, 324 patients were randomly assigned (INCT-CRT, n = 158; CRT-CNCT, n = 166). Median follow-up was 5.1 years. The 5-year DFS rates were 71% (95% CI, 64 to 79) and 69% (95% CI, 62 to 77) for INCT-CRT and CRT-CNCT, respectively (P = .68). TME-free survival was 39% (95% CI, 32 to 48) in the INCT-CRT group and 54% (95% CI, 46 to 62) in the CRT-CNCT group (P = .012). Of 81 patients with regrowth, 94% occurred within 2 years and 99% occurred within 3 years. DFS was similar for patients who underwent TME after restaging (64% [95% CI, 53 to 78]) and patients in WW who underwent TME after regrowth (64% [95% CI, 53 to 78]; P = .94). Updated analysis continues to show long-term organ preservation in half of the patients with rectal cancer treated with total neoadjuvant therapy. In patients who enter WW, most cases of tumor regrowth occur in the first 2 years.
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Affiliation(s)
- Floris S Verheij
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Dana M Omer
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Hannah Williams
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Sabrina T Lin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Li-Xuan Qin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - James T Buckley
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Hannah M Thompson
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jonathan B Yuval
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jin K Kim
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Richard F Dunne
- Department of Medicine, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY
| | - Jorge Marcet
- Division of Colon and Rectal Surgery, Department of Surgery, University of South Florida, Tampa, FL
| | - Peter Cataldo
- Division of General Surgery, Department of Surgery, University of Vermont, Burlington, VT
| | - Blase Polite
- Department of Medicine, Comprehensive Cancer Center, University of Chicago, Chicago, IL
| | - Daniel O Herzig
- Division of Gastrointestinal and General Surgery, Oregon Health and Science University, Portland, OR
| | - David Liska
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH
| | - Samuel Oommen
- Division of Gastrointestinal Oncology, John Muir Cancer Institute, John Muir Health, Walnut Creek, CA
| | - Charles M Friel
- Division of General Surgery, Department of Surgery, University of Virginia, Charlottesville, VA
| | - Charles Ternent
- Methodist Hospital Physicians Clinic Colon and Rectal Surgery and The Creighton University Clinical Research Center, Omaha, NE
| | - Andrew L Coveler
- Department of Medicine, Fred Hutch Cancer Center, University of Washington, Seattle, WA
| | - Steven Hunt
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Anita Gregory
- Department of Surgery, St Joseph Hospital Orange County, Orange, CA
| | - Madhulika G Varma
- Section of Colon and Rectal Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Brian L Bello
- Division of Colorectal Surgery, Department of Surgery, Medstar Washington Hospital Center, Washington, DC
| | - Joseph C Carmichael
- Division of Colon and Rectal Surgery, Department of Surgery, University of California, Irvine, Irvine, CA
| | - John Krauss
- Department of Medicine, Rogel Cancer Center at the University of Michigan, Ann Arbor, MI
| | - Ana Gleisner
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Denver, CO
| | - José G Guillem
- Division of Gastrointestinal Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Larissa Temple
- Division of Colorectal Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Karyn A Goodman
- Department of Radiation Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Neil H Segal
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andrea Cercek
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Rona Yaeger
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Garrett M Nash
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Maria Widmar
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Iris H Wei
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Emmanouil P Pappou
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Martin R Weiser
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Philip B Paty
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - J Joshua Smith
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Marc J Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Leonard B Saltz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Julio Garcia-Aguilar
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY
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7
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Hołdakowska A, Kurkowska K, Pietrzak L, Michalski W, Rutkowski A, Olesiński T, Cencelewicz A, Rydziński M, Socha J, Bujko K. Which tumour factors preclude organ preservation in patients with rectal cancer? Radiother Oncol 2024; 191:110054. [PMID: 38104780 DOI: 10.1016/j.radonc.2023.110054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 12/06/2023] [Accepted: 12/11/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND cT3cdT4, cN2, mesorectal nodes > 8 mm, clinically positive lateral nodes, extramural vascular invasion (EMVI) and mesorectal fascia threatening (MRF+) have been utilized as exclusion criteria in several studies on the watch-and-wait (w&w) strategy. Here, our aim was to validate these criteria through a post hoc analysis of two pooled prospective studies on w&w following routine radio(chemo)therapy. METHODS A review of baseline magnetic resonance imaging was performed in a subgroup of 223 patients treated at a single institution. Of these, 17.9 % started w&w, 12.6 % achieved clinical complete response (cCR) and 9.0 % sustained cCR during median follow-up of 54 months. RESULTS The multivariable logistic analysis showed that the proportion of circumferential bowel involvement and EMVI significantly influenced the chance of sustained cCR; odds ratios were 0.063 (95 % confidence interval [CI] 0.008-0.489, p = 0.008), and 0.109 (95 % CI 0.014-0.850, p = 0.034), respectively. Sustained cCR was observed in none of the 57 patients with 90 %-100 % circumferential bowel involvement and in only one of the 89 patients with EMVI. In contrast, cT3cdT4, cN2, mesorectal nodes > 8 mm, clinically positive lateral nodes or MRF+ were not independently associated with sustained cCR. Among the subgroups of patients with these features but without (near-)circular tumour or EMVI+, sustained cCR was observed in 12 %-25 % of patients. CONCLUSION Sustained cCR after routine preoperative radio(chemo)therapy is unlikely in patients with (near-)circular tumour or EMVI, whereas patients with cT3cdT4, cN2, mesorectal nodes > 8 mm, clinically positive lateral nodes and MRF+ should not be denied w&w.
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Affiliation(s)
- Anna Hołdakowska
- Department of Radiology, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Kamila Kurkowska
- Department of Radiology, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Lucyna Pietrzak
- Department of Radiotherapy I, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Wojciech Michalski
- Department of Computational Oncology, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Andrzej Rutkowski
- Department of Surgery of Gastrointestinal Cancers and Neuroendocrine Tumors, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Tomasz Olesiński
- Department of Surgery of Gastrointestinal Cancers and Neuroendocrine Tumors, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Anna Cencelewicz
- Department of Gastroenterological Oncology, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Martin Rydziński
- Department of Radiotherapy I, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Joanna Socha
- Department of Radiotherapy, Military Institute of Medicine - National Research Institute, Warsaw, Poland; Department of Radiotherapy, Regional Oncology Center, Czestochowa, Poland
| | - Krzysztof Bujko
- Department of Radiotherapy I, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland.
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8
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Flom E, Schultz KS, Pantel HJ, Leeds IL. The Predictors of Complete Pathologic Response in Rectal Cancer during the Total Neoadjuvant Therapy Era: A Systematic Review. Cancers (Basel) 2023; 15:5853. [PMID: 38136397 PMCID: PMC10742121 DOI: 10.3390/cancers15245853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/11/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023] Open
Abstract
The modern rectal cancer treatment paradigm offers additional opportunities for organ preservation, most notably via total neoadjuvant therapy (TNT) and consideration for a watch-and-wait (WW) surveillance-only approach. A major barrier to widespread implementation of a WW approach to rectal cancer is the potential discordance between a clinical complete response (cCR) and a pathologic complete response (pCR). In the pre-TNT era, the identification of predictors of pCR after neoadjuvant therapy had been previously studied. However, the last meta-analysis to assess the summative evidence on this important treatment decision point predates the acceptance and dissemination of TNT strategies. The purpose of this systematic review was to assess preoperative predictors of pCR after TNT to guide the ideal selection criteria for WW in the current era. An exhaustive literature review was performed and the electronic databases Embase, Ovid, MEDLINE, PubMed, and Cochrane were comprehensively searched up to 27 June 2023. Search terms and their combinations included "rectal neoplasms", "total neoadjuvant therapy", and "pathologic complete response". Only studies in English were included. Randomized clinical trials or prospective/retrospective cohort studies of patients with clinical stage 2 or 3 rectal adenocarcinoma who underwent at least 8 weeks of neoadjuvant chemotherapy in addition to chemoradiotherapy with pCR as a measured study outcome were included. In this systematic review, nine studies were reviewed for characteristics positively or negatively associated with pCR or tumor response after TNT. The results were qualitatively grouped into four categories: (1) biochemical factors; (2) clinical factors; (3) patient demographics; and (4) treatment sequence for TNT. The heterogeneity of studies precluded meta-analysis. The level of evidence was low to very low. There is minimal data to support any clinicopathologic factors that either have a negative or positive relationship to pCR and tumor response after TNT. Additional data from long-term trials using TNT is critical to better inform those considering WW approaches following a cCR.
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Affiliation(s)
- Emily Flom
- Division of Colon and Rectal Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT 06520, USA
| | - Kurt S Schultz
- Division of Colon and Rectal Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT 06520, USA
| | - Haddon J Pantel
- Division of Colon and Rectal Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT 06520, USA
| | - Ira L Leeds
- Division of Colon and Rectal Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT 06520, USA
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9
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Takano Y, Yogosawa S, Imaizumi Y, Kamioka H, Kanegae Y, Eto K, Yoshida K. DYRK2 promotes chemosensitivity via p53-mediated apoptosis after DNA damage in colorectal cancer. Cancer Sci 2023; 114:4558-4570. [PMID: 37776195 PMCID: PMC10728020 DOI: 10.1111/cas.15973] [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: 06/02/2023] [Revised: 08/29/2023] [Accepted: 09/06/2023] [Indexed: 10/02/2023] Open
Abstract
Dual-specificity tyrosine-regulated kinase 2 (DYRK2) is a protein kinase that phosphorylates p53-Ser46 and induces apoptosis in response to DNA damage. However, the relationship between DYRK2 expression and chemosensitivity after DNA damage in colorectal cancer has not been well investigated. The aim of the present study was to examine whether DYRK2 could be a novel marker for predicting chemosensitivity after 5-fluorouracil- and oxaliplatin-induced DNA damage in colorectal cancer. Here we showed that DYRK2 knockout decreased the chemosensitivity to 5-fluorouracil and oxaliplatin in p53 wild-type colorectal cancer cells, whereas the chemosensitivity remained unchanged in p53-deficient/mutated colorectal cancer cells. In addition, no significant differences in chemosensitivity to 5-fluorouracil and oxaliplatin between scramble and siDYRK2 p53(-/-) colorectal cancer cells were observed. Conversely, the combination of adenovirus-mediated overexpression of DYRK2 with 5-fluorouracil or oxaliplatin enhanced apoptosis and chemosensitivity through p53-Ser46 phosphorylation in p53 wild-type colorectal cancer cells. Furthermore, DYRK2 knockout decreased chemosensitivity to 5-fluorouracil and oxaliplatin in p53 wild-type xenograft mouse models. Taken together, these findings demonstrated that DYRK2 expression was associated with chemosensitivity to 5-fluorouracil and oxaliplatin in p53 wild-type colorectal cancer, suggesting the importance of evaluating the p53 status and DYRK2 expression as a novel marker in therapeutic strategies for colorectal cancer.
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Affiliation(s)
- Yasuhiro Takano
- Department of BiochemistryThe Jikei University School of MedicineTokyoJapan
- Department of SurgeryThe Jikei University School of MedicineTokyoJapan
| | - Satomi Yogosawa
- Department of BiochemistryThe Jikei University School of MedicineTokyoJapan
| | - Yuta Imaizumi
- Department of SurgeryThe Jikei University School of MedicineTokyoJapan
| | - Hiroshi Kamioka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of MedicineTokyoJapan
| | - Yumi Kanegae
- Core Research Facilities for Basic Science, Research Center for Medical ScienceThe Jikei University School of MedicineTokyoJapan
| | - Ken Eto
- Department of SurgeryThe Jikei University School of MedicineTokyoJapan
| | - Kiyotsugu Yoshida
- Department of BiochemistryThe Jikei University School of MedicineTokyoJapan
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10
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Tan S, Gao Q, Cui Y, Ou Y, Huang S, Feng W. Oncologic outcomes of watch-and-wait strategy or surgery for low to intermediate rectal cancer in clinical complete remission after adjuvant chemotherapy: a systematic review and meta-analysis. Int J Colorectal Dis 2023; 38:246. [PMID: 37787779 DOI: 10.1007/s00384-023-04534-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND A watch-and-wait (WW) strategy or surgery for low to intermediate rectal cancer that has reached clinical complete remission (cCR) after neoadjuvant chemotherapy (nCRT) or total neoadjuvant therapy (TNT) has been widely used in the clinic, but both treatment strategies are controversial. OBJECTIVE The aim of this study was to compare the oncologic outcomes of a watch-and-wait strategy or a surgical approach to treat rectal cancer in complete remission and to report the evidence-based clinical advantages of the two treatment strategies. METHODS Seven national and international databases were searched for clinical trials comparing the watch-and-wait strategy with surgical treatment for oncological outcomes in patients with rectal cancer in clinical complete remission. RESULTS In terms of oncological outcomes, there was no significant difference between the watch-and-wait strategy and surgical treatment in terms of overall survival (OS) (HR = 0.92, 95% CI (0.52, 1.64), P = 0.777), and subgroup analysis showed no significant difference in 5-year disease-free survival (5-year DFS) between WW and both local excision (LE) and radical surgery (RS) (HR = 1.76, 95% CI (0.97, 3.19), P = 0.279; HR = 1.98, 95% CI (0.95, 4.13), P = 0.164), in distant metastasis rate (RR = 1.12, 95% CI (0.73, 1.72), P = 0.593), mortality rate (RR = 1.62, 95% CI (0.93, 2.84), P = 0.09), and organ preservation rate (RR = 1.05, 95% CI (0.94, 1.17), P = 0.394) which were not statistically significant and on the outcome indicators of local recurrence rate (RR = 2.09, 95% CI (1.44, 3.03), P < 0.001) and stoma rate (RR = 0.35, 95% CI (0.20, 0.61), P < 0.001). There were significant differences between the WW group and the surgical treatment group. CONCLUSION There were no differences in OS, 5-year DFS, distant metastasis, and mortality between the WW strategy group and the surgical treatment group. The WW strategy did not increase the risk of local recurrence compared with local resection but may be at greater risk of local recurrence compared with radical surgery, and the WW group was significantly better than the surgical group in terms of stoma rate; the WW strategy was evidently superior in preserving organ integrity compared to radical excision. Consequently, for patients who exhibit a profound inclination towards organ preservation and the evasion of stoma formation in the scenario of clinically complete remission of rectal cancer, the WW strategy can be contemplated as a pragmatic alternative to surgical interventions. It is, however, paramount to emphasize that the deployment of such a strategy should be meticulously undertaken within the ambit of a multidisciplinary team's management and within specialized centers dedicated to rectal cancer management.
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Affiliation(s)
- Shufa Tan
- Shaanxi University of Chinese Medicine, Xianyang, Shaanxi, China
| | - Qiangqiang Gao
- Affiliated Hospital of Shaanxi University of Traditional Chinese Medicine, Deputy No. 2, West Weiyang Road, Xianyang City, Shaanxi Province, 712000, China
| | - Yaping Cui
- Affiliated Hospital of Shaanxi University of Traditional Chinese Medicine, Deputy No. 2, West Weiyang Road, Xianyang City, Shaanxi Province, 712000, China
| | - Yan Ou
- Affiliated Hospital of Shaanxi University of Traditional Chinese Medicine, Deputy No. 2, West Weiyang Road, Xianyang City, Shaanxi Province, 712000, China
| | - Shuilan Huang
- Shaanxi University of Chinese Medicine, Xianyang, Shaanxi, China
| | - Wenzhe Feng
- Affiliated Hospital of Shaanxi University of Traditional Chinese Medicine, Deputy No. 2, West Weiyang Road, Xianyang City, Shaanxi Province, 712000, China.
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11
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Quezada-Diaz FF, Smith JJ. Is Nonoperative Management of Rectal Cancer Feasible? Adv Surg 2023; 57:141-154. [PMID: 37536849 PMCID: PMC10926904 DOI: 10.1016/j.yasu.2023.05.001] [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] [Indexed: 08/05/2023]
Abstract
During the past decade, the treatment of locally advanced rectal cancer (LARC) has become more complex. Total neoadjuvant treatment (TNT) has increased the rates of both clinical and pathologic complete response, resulting in improved long-term oncological outcomes. The feasibility to implement nonoperative management (NOM) depends on solving current challenges such as how to correctly identify the best candidates for a NOM without compromising oncologic safety. NOM should be part of the treatment discussion of LARC, considering increasing rates of clinical complete response, potential quality of life gains, avoidance of surgical morbidity, and patient preferences.
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Affiliation(s)
- Felipe F Quezada-Diaz
- Colorectal Unit, Department of Surgery, Complejo Asistencial Doctor Sótero del Río, Santiago, Región Metropolitana, Chile. https://twitter.com/ffquezad
| | - Jesse Joshua Smith
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue | SR-201, New York, NY 10065, USA.
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12
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Liscu HD, Liscu BR, Mitre R, Anghel IV, Antone-Iordache IL, Balan A, Coniac S, Miron AI, Halcu G. The Conditioning of Adjuvant Chemotherapy for Stage II and III Rectal Cancer Determined by Postoperative Pathological Characteristics in Romania. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1224. [PMID: 37512037 PMCID: PMC10384917 DOI: 10.3390/medicina59071224] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 06/17/2023] [Accepted: 06/28/2023] [Indexed: 07/30/2023]
Abstract
The management of locally advanced rectal cancer (LARC) suffered changes thanks to the development of improved surgical procedures, radiation delivery, and chemotherapy. Although treatment options improved individually, the optimal order is still debated. Neoadjuvant chemo-radiotherapy followed by total mesorectal excision (TME) has been the "golden standard" for locally advanced rectal cancer. There is no common ground in international guidelines on the indications of adjuvant chemotherapy (ADJCHT), with differences between the American, European, and Japanese guidelines. This paper studies the preferences of Romanian oncologists in prescribing ADJCHT. We conducted a single-institution, retrospective study of all nonmetastatic, ECOG 0-1 LARC patients staged II-III who underwent TME and were admitted to the Oncology or Radiotherapy Department of Colțea Clinical Hospital, Bucharest between January 2017 and March 2021. A total of 186 patients were included in the study. A positive correlation was found between ADJCHT and each of the following: (y)pT > 2, (y)pN > 0, and the presence of perineural invasion (PNI+). A strong positive correlation was found between ADJCHT and the presence of at least one risk factor: (y)pT > 2, (y)pN > 0, PNI+, lymphovascular invasion, positive margins, or tumor grade > 1. Tumor downstaging decreased the risk of metastases in the first 2 years and was associated with the use of neoadjuvant radiotherapy, while adding neoadjuvant chemotherapy increased the chance of nodal downstaging. ADJCHT practice for LARC in Romania follows either NCCN or ESMO guidelines, at the discretion of the oncologist, due to the lack of national guideline.
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Affiliation(s)
- Horia-Dan Liscu
- Discipline of Oncological Radiotherapy and Medical Imaging, University of Medicine and Pharmacy "Carol Davila", 020021 Bucharest, Romania
- Radiotherapy Department, Colțea Clinical Hospital, 030167 Bucharest, Romania
| | - Bogdan-Radu Liscu
- Radiotherapy Department, Colțea Clinical Hospital, 030167 Bucharest, Romania
| | - Ruxandra Mitre
- Medical Oncology Department, Colțea Clinical Hospital, 030167 Bucharest, Romania
| | - Ioana-Valentina Anghel
- Discipline of Oncological Radiotherapy and Medical Imaging, University of Medicine and Pharmacy "Carol Davila", 020021 Bucharest, Romania
| | - Ionut-Lucian Antone-Iordache
- Discipline of Oncological Radiotherapy and Medical Imaging, University of Medicine and Pharmacy "Carol Davila", 020021 Bucharest, Romania
| | - Andrei Balan
- Discipline of Oncological Radiotherapy and Medical Imaging, University of Medicine and Pharmacy "Carol Davila", 020021 Bucharest, Romania
| | - Simona Coniac
- Medical Oncology Department, Colțea Clinical Hospital, 030167 Bucharest, Romania
| | - Andreea-Iuliana Miron
- Discipline of Oncological Radiotherapy and Medical Imaging, University of Medicine and Pharmacy "Carol Davila", 020021 Bucharest, Romania
- Medical Oncology Department, Colțea Clinical Hospital, 030167 Bucharest, Romania
| | - Georgian Halcu
- Discipline of Pathological Anatomy, University of Medicine and Pharmacy "Carol Davila", 020021 Bucharest, Romania
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13
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Predictive value of modified MRI-based split scar sign (mrSSS) score for pathological complete response after neoadjuvant chemoradiotherapy for patients with rectal cancer. Int J Colorectal Dis 2023; 38:40. [PMID: 36790595 DOI: 10.1007/s00384-023-04330-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/04/2023] [Indexed: 02/16/2023]
Abstract
PURPOSE To measure the diagnostic performance of modified MRI-based split scar sign (mrSSS) score for the prediction of pathological complete response (pCR) after neoadjuvant chemoradiotherapy (nCRT) for patients with rectal cancer. METHODS The modified MRI-based split scar sign (mrSSS) score, which consists of T2-weighted images (T2WI)-based score and diffusion-weighted images (DWI)-based score. The sensitivity, specificity, and accuracy of modified mrSSS score, endoscopic gross type, and MRI-based tumor regression grading (mrTRG) score, in the prediction of pCR, were compared. The prognostic value of the modified mrSSS score was also studied. RESULTS A total of 189 patients were included in the study. The Kendall's coefficient of interobserver concordance of modified mrSSS score, T2WI -based score, and DWI-based score were 0.899, 0.890, and 0.789 respectively. And the maximum and minimum k value of the modified mrSSS score was 0.797 (0.742-0.853) and 0.562 (0.490-0.634). The sensitivity, specificity, and accuracy of prediction of pCR were 0.66, 0.97, and 0.90 for modified mrSSS score; 0.37, 0.89, and 0.78 for endoscopic gross type (scar); and 0.24, 0.92, and 0.77 for mrTRG score (mrTRG = 1). The modified mrSSS score had significantly higher sensitivity than the endoscopic gross type and the mrTRG score in predicting pCR. Patients with lower modified mrSSS scores had significantly longer disease-free survival (P < 0.05). CONCLUSION The modified mrSSS score showed satisfactory interobserver agreement and higher sensitivity in predicting pCR after nCRT in patients with rectal cancer. The modified mrSSS score is also a predictor of disease-free survival.
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14
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Bibi S, Edilbe MW, Rao C. The Cost-effectiveness of Watch and Wait for Rectal Cancer. Clin Oncol (R Coll Radiol) 2023; 35:132-137. [PMID: 36266161 DOI: 10.1016/j.clon.2022.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 08/25/2022] [Accepted: 10/03/2022] [Indexed: 01/18/2023]
Abstract
The existing literature suggests with a high degree of certainty that watch and wait is more cost-effective than initial total mesorectal excision. However, it is heavily reliant on poor-quality health-related quality of life data. Furthermore, the cost-effectiveness of organ preservation from a broader societal perspective has not been studied. Finally, the cost-effectiveness of emerging adjuncts to watch and wait for organ preservation, such as contact X-ray brachytherapy, local excision and total neoadjuvant therapy, need to be characterised.
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Affiliation(s)
- S Bibi
- The Department of Colorectal Surgery, North Cumbria Integrated Care NHS Foundation Trust, Carlisle, UK
| | - M W Edilbe
- The Department of Colorectal Surgery, North Cumbria Integrated Care NHS Foundation Trust, Carlisle, UK; The Academic Surgical Unit, North Cumbria Integrated Care NHS Foundation Trust, Carlisle, UK
| | - C Rao
- The Academic Surgical Unit, North Cumbria Integrated Care NHS Foundation Trust, Carlisle, UK; The Department of Surgery and Cancer, Imperial College, London, UK.
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15
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Ulusoy C, Kamalı GH, Nikolovski A. Analysis of Survival in Complete Pathological Response after Long-Course Chemoradiotherapy in Patients with Advanced Rectal Cancer. Curr Oncol 2023; 30:1054-1064. [PMID: 36661730 PMCID: PMC9857960 DOI: 10.3390/curroncol30010081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/02/2023] [Accepted: 01/07/2023] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Neoadjuvant chemoradiotherapy prior to surgery is the standard treatment for locally advanced rectal cancer. This consists in the patient's complete pathological response being achieved with no residual tumor presence in the resected specimen, which results in survival improvement. METHODS This retrospective study aimed to examine the rate of complete pathological response in patients with advanced rectal cancer treated with neoadjuvant long-course chemoradiotherapy and to examine the survival differences between the different tumor regression grade (TRG) scores. RESULTS A total of 154 patients were operated prior to long-course chemoradiotherapy with a total of 50 Gy plus FOLFOX protocol. Complete pathologic response was achieved in 29 (18.8%) patients. There was no statistical difference for the different pathologic responses according to gender, type of surgery, and number of harvested lymph nodes. Mean survival for all the groups was 37.2 months. Survival within a different TRG score exhibited statistical significance (p = 0.006). Overall, the survival rate during the follow-up period was of 81.8%. CONCLUSIONS The complete pathological response rate in this study was of 18.8%. High tumor regression grade scores (TRG0 and TRG1) had a survival rate of over 90% during follow-up. Multivariate analysis identified perineural invasion and tumor regression grade as independent factors that affect survival.
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Affiliation(s)
- Cemal Ulusoy
- Department of General Surgery, Prof. Dr. Cemil Taşçıoğlu Şehir Hastanesi, Istanbul 34384, Turkey
| | - Gülçin Harman Kamalı
- Department of Pathology, Prof. Dr. Cemil Taşçıoğlu Şehir Hastanesi, Istanbul 34384, Turkey
| | - Andrej Nikolovski
- Department of Visceral Surgery, University Surgical Clinic “Sv. Naum Ohridski”, Ss. Cyril and Methodius University in Skopje, 1000 Skopje, North Macedonia
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16
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Development of a method for digital assessment of tumor regression grade in patients with rectal cancer following neoadjuvant therapy. J Pathol Inform 2022; 13:100152. [PMID: 36605115 PMCID: PMC9808016 DOI: 10.1016/j.jpi.2022.100152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/07/2022] [Accepted: 11/02/2022] [Indexed: 11/09/2022] Open
Abstract
Neoadjuvant chemo-radiotherapy (nCRT) followed by surgical resection is the standard treatment strategy in patients with locally advanced rectal cancer (RC). The pathological effect of nCRT is assessed by determining the tumor regression grade (TRG) of the resected tumor. Various methods exist for assessing TRG and all are performed manually by the pathologist with an accompanying risk of interobserver variation. Automated digital image analysis could be a more objective and reproducible approach to evaluate TRG. This study aimed at developing a digital method to assess TRG in RC following nCRT, and correlate the results to the currently used Mandard method. A deep learning-based semi-automatic Epithelium-Tumor area Percentage (ETP) algorithm enabling quantification of tumor regression by determining the percentage of residual tumor epithelium out of the total tumor area was developed. The ETP was quantified in 50 cases treated with nCRT and 25 cases with no prior nCRT served as controls. Median ETP was 39.25% in untreated compared with 6.64% in patients who received nCRT (P < .001). The ETP of the resected tumors treated with nCRT increased along with increasing Mandard grade (P < .001). As new treatment strategies in RC are emerging, performing an accurate and reproducible evaluation of TRG is important in the assessment of treatment response and prognosis. TRG is often used as an outcome point in clinical trials. The ETP algorithm is capable of performing a precise and objective value of tumor regression.
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17
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Hołdakowska A, Gerard JP, Bujko K. The importance of measuring baseline tumour volume (or alternatively tumour length along with its rectal circumferential extent) in the watch-and-wait strategy in rectal cancer: a review. Acta Oncol 2022; 61:1084-1092. [DOI: 10.1080/0284186x.2022.2122866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Anna Hołdakowska
- Department of Radiology I, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | | | - Krzysztof Bujko
- Department of Radiotherapy I, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
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18
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Goffredo P, Quezada-Diaz FF, Garcia-Aguilar J, Smith JJ. Non-Operative Management of Patients with Rectal Cancer: Lessons Learnt from the OPRA Trial. Cancers (Basel) 2022; 14:3204. [PMID: 35804975 PMCID: PMC9264788 DOI: 10.3390/cancers14133204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/28/2022] [Accepted: 06/28/2022] [Indexed: 11/17/2022] Open
Abstract
Over the past decade, the management of locally advanced rectal cancer (LARC) has progressively become more complex. The introduction of total neoadjuvant treatment (TNT) has increased the rates of both clinical and pathological complete response, resulting in excellent long-term oncological outcomes. As a result, non-operative management (NOM) of LARC patients with a clinical complete response (cCR) after neoadjuvant therapy has gained acceptance as a potential treatment option in selected cases. NOM is based on replacement of surgical resection with safe and active surveillance. However, the identification of appropriate candidates for a NOM strategy without compromising oncologic safety is currently challenging due to the lack of an objective standardization. NOM should be part of the treatment plan discussion with LARC patients, considering the increasing rates of cCR, patient preference, quality of life, expectations, and the potential avoidance of surgical morbidity. The recently published OPRA trial showed that organ preservation is achievable in half of rectal cancer patients treated with TNT, and that chemoradiotherapy followed by consolidation chemotherapy may an appropriate strategy to maximize cCR rates. Ongoing trials are investigating optimal algorithms of TNT delivery to further expand the pool of patients who may benefit from NOM of LARC.
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Affiliation(s)
- Paolo Goffredo
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; (P.G.); (J.G.-A.)
| | - Felipe F. Quezada-Diaz
- Colorectal Unit, Department of Surgery, Complejo Asistencial Doctor Sótero del Río, Santiago 8150215, Chile;
| | - Julio Garcia-Aguilar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; (P.G.); (J.G.-A.)
| | - J. Joshua Smith
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; (P.G.); (J.G.-A.)
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19
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Aref A, Abdalla A. Total Neoadjuvant Therapy for Locally Advanced Rectal Cancer: Induction or Consolidation Chemotherapy? J Clin Oncol 2022; 40:2515-2519. [PMID: 35724356 DOI: 10.1200/jco.22.00506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Affiliation(s)
- Amr Aref
- Rectal Cancer Group, Van Elslander Cancer Center, Ascension St John Hospital, Detroit, MI.,Radiation Oncology, Van Elslander Cancer Center, Ascension St John Hospital, Detroit, MI
| | - Ahmed Abdalla
- Interdisciplinary Oncology, Mitchell Cancer Center, University of South Alabama, Mobile, AL
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20
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Abstract
The treatment algorithm for locally advanced rectal cancer (LARC) has increased in complexity over the past 10 years. Nonoperative management (NOM) for rectal cancer in patients with clinical complete response (cCR) after neoadjuvant therapy has been gaining acceptance as a potential treatment option for selected LARC patients. The current challenge is to accurately select the patients with an apparent cCR, thereby correctly identifying those would-be appropriate candidates for a NOM strategy. NOM should be part of the treatment discussion of LARC, considering increasing rates of cCR, patient preference, potential quality of life gains, and the potential avoidance of surgical morbidity.
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Affiliation(s)
- Felipe F Quezada-Diaz
- Colorectal Unit, Department of Surgery, Complejo Asistencial Doctor Sótero del Río, Santiago, RM, Chile. https://twitter.com/ffquezad
| | - J Joshua Smith
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue
- SR-201, New York, NY 10065, USA.
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21
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The Evolving Neoadjuvant Treatment Paradigm for Patients with Locoregional mismatch Repair Proficient Rectal Cancer. Curr Treat Options Oncol 2022; 23:453-473. [PMID: 35312962 DOI: 10.1007/s11864-022-00961-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2022] [Indexed: 12/29/2022]
Abstract
OPINION STATEMENT The standard of care for locally advanced rectal cancer (LARC) has included preoperative chemoradiation, total mesorectal excision surgery and post operative adjuvant chemotherapy based on histopathology. The current therapeutic landscape in LARC has many different options with different directions of travel - depending on the goal of treatment. Enthusiasm for delivering total neoadjuvant therapy (TNT) for patients with locally advanced rectal cancer (LARC) is increasing in the light of recently published randomised phase III trials - RAPIDO and PRODIGE-23. There is a wide diversity of different potential schedules and a multitude of approaches, which include induction neoadjuvant chemotherapy (NACT) with a range of chemotherapy options (CAPEOX, FOLFOX, FOLFOXIRI) and a varying duration of 6-18 weeks, or consolidation NACT. These schedules either precede or follow short-course preoperative radiation therapy (SCPRT) using 5 × 5Gy or long-course chemoradiation (LCCRT) using 45-60Gy respectively. The different strategies of induction and consolidation neoadjuvant chemotherapy have been compared and have similar long-term outcomes, but consolidation chemotherapy may facilitate organ-sparing. The results are driving novel paradigms with both intensification and de-intensification treatment strategies. The ideal combination, sequence or duration of such a TNT approach remains undefined. As yet, there are no robust clinical, genetic, molecular, immune or imaging features (alone or integrated), which either direct or aid these choices. Currently, the selection of neoadjuvant treatment is driven by the impact on avoidance or feasibility of surgery or reducing the risk of metastases rather than prevention of local recurrence. Most believe that TNT will improve overall survival, despite the present lack of evidence. Both the inherent heterogeneity in LARC and the observed range of different responses underline the need for response biomarkers to individually tailor therapy rather than 'a one size fits all' approach.
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22
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Varela C, Kim NK. Surgical Treatment of Low-Lying Rectal Cancer: Updates. Ann Coloproctol 2021; 37:395-424. [PMID: 34961303 PMCID: PMC8717072 DOI: 10.3393/ac.2021.00927.0132] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 11/17/2021] [Indexed: 02/07/2023] Open
Abstract
Despite innovative advancements, distally located rectal cancer remains a critical disease of challenging management. The crucial location of the tumor predisposes it to a circumferential resection margin (CRM) that tends to involve the anal sphincter complex and surrounding organs, with a high incidence of delayed anastomotic complications and the risk of the pelvic sidewall or rarely inguinal lymph node metastases. In this regard, colorectal surgeons should be aware of other issues beyond total mesorectal excision (TME) performance. For decades, the concept of extralevator abdominoperineal resection to avoid compromised CRM has been introduced. However, the complexity of deep pelvic dissection with poor visualization in low-lying rectal cancer has led to transanal TME. In contrast, neoadjuvant chemoradiotherapy (NCRT) has allowed for the execution of more sphincter-saving procedures without oncologic compromise. Significant tumor regression after NCRT and complete pathologic response also permit applying the watch-and-wait protocol in some cases, now with more solid evidence. This review article will introduce the current surgical treatment options, their indication and technical details, and recent oncologic and functional outcomes. Lastly, the novel characteristics of distal rectal cancer, such as pelvic sidewall and inguinal lymph node metastases, will be discussed along with its tailored and individualized treatment approach.
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Affiliation(s)
- Cristopher Varela
- Coloproctology Unit, Department of General Surgery, Hospital Dr. Domingo Luciani, Caracas, Venezuela
| | - Nam Kyu Kim
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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