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Boublikova L, Novakova A, Simsa J, Lohynska R. Total neoadjuvant therapy in rectal cancer: the evidence and expectations. Crit Rev Oncol Hematol 2023; 192:104196. [PMID: 37926376 DOI: 10.1016/j.critrevonc.2023.104196] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 10/14/2023] [Accepted: 11/01/2023] [Indexed: 11/07/2023] Open
Abstract
Current management of locally advanced rectal cancer achieves high cure rates, distant metastatic spread being the main cause of patients' death. Total neoadjuvant therapy (TNT) employs (chemo)radiotherapy and combined chemotherapy prior to surgery to improve the treatment outcomes. TNT has been shown to reduce significantly distant metastases, increase disease-free survival by 5 - 10% in 3 years, and finally also overall survival (≈ 5% in 7 years). It proved to double the rate of pathologic complete responses, making it an attractive strategy for non-operative management to avoid permanent colostomy in patients with distal tumors. In addition, it endorses adherence to the therapy due to better tolerance and, potentially, shortens its overall duration. A number of questions related to TNT remain currently unresolved including the indications, preferred radiotherapy and chemotherapy regimens, their sequence, timing of surgery, and role of adjuvant therapy. A stratified approach may be the optimal way to go.
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Affiliation(s)
- Ludmila Boublikova
- Department of Oncology, 1st Faculty of Medicine, Charles University and Thomayer University Hospital, Prague, Czech Republic; CLIP - Department of Pediatric Hematology and Oncology, 2nd Faculty of Medicine, Charles University and University Hospital in Motol, Prague, Czech Republic.
| | - Alena Novakova
- Department of Oncology, 1st Faculty of Medicine, Charles University and Thomayer University Hospital, Prague, Czech Republic
| | - Jaromir Simsa
- Department of Surgery, 1st Faculty of Medicine, Charles University and Thomayer University Hospital, Prague, Czech Republic
| | - Radka Lohynska
- Department of Oncology, 1st Faculty of Medicine, Charles University and Thomayer University Hospital, Prague, Czech Republic
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2
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Prata I, Eriksson M, Krdzalic J, Kranenbarg EMK, Roodvoets AGH, Beets-Tan R, van de Velde CJH, van Etten B, Hospers GAP, Glimelius B, Nilsson PJ, Marijnen CAM, Peeters KCMJ, Blomqvist LK. Results of a diagnostic imaging audit in a randomised clinical trial in rectal cancer highlight the importance of careful planning and quality control. Insights Imaging 2023; 14:206. [PMID: 38001376 PMCID: PMC10673763 DOI: 10.1186/s13244-023-01552-0] [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: 09/04/2023] [Accepted: 10/27/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Magnetic resonance (MR) imaging is the modality used for baseline assessment of locally advanced rectal cancer (LARC) and restaging after neoadjuvant treatment. The overall audited quality of MR imaging in large multicentre trials on rectal cancer is so far not routinely reported. MATERIALS AND METHODS We collected MR images obtained within the Rectal Cancer And Pre-operative Induction Therapy Followed by Dedicated Operation (RAPIDO) trial and performed an audit of the technical features of image acquisition. The required MR sequences and slice thickness stated in the RAPIDO protocol were used as a reference. RESULTS Out of 920 participants of the RAPIDO study, MR investigations of 668 and 623 patients in the baseline and restaging setting, respectively, were collected. Of these, 304/668 (45.5%) and 328/623 (52.6%) MR images, respectively, fulfilled the technical quality criteria. The main reason for non-compliance was exceeding slice thickness 238/668, 35.6% in the baseline setting and 162/623, 26.0% in the restaging setting. In 166/668, 24.9% and 168/623, 27.0% MR images in the baseline and restaging setting, respectively, one or more of the required pulse sequences were missing. CONCLUSION Altogether, 49.0% of the MR images obtained within the RAPIDO trial fulfilled the image acquisition criteria required in the study protocol. High-quality MR imaging should be expected for the appropriate initial treatment and response evaluation of patients with LARC, and efforts should be made to maximise the quality of imaging in clinical trials and in clinical practice. CRITICAL RELEVANCE STATEMENT This audit highlights the importance of adherence to MR image acquisition criteria for rectal cancer, both in multicentre trials and in daily clinical practice. High-resolution images allow correct staging, treatment stratification and evaluation of response to neoadjuvant treatment. KEY POINTS - Complying to MR acquisition guidelines in multicentre trials is challenging. - Neglection on MR acquisition criteria leads to poor staging and treatment. - MR acquisition guidelines should be followed in trials and clinical practice. - Researchers should consider mandatory audits prior to study initiation.
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Affiliation(s)
- Ilaria Prata
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands.
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands.
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands.
| | - Martina Eriksson
- Department of Radiology, Capio S:T Göran Hospital, Stockholm, Sweden
| | - Jasenko Krdzalic
- Department of Radiology, Zuyderland Medical Center, Geleen, the Netherlands
| | | | - Annet G H Roodvoets
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Regina Beets-Tan
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | | | - Boudewijn van Etten
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Geke A P Hospers
- Department of Medical Oncology, University Medical Center Groningen, Groningen, the Netherlands
| | - Bengt Glimelius
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Per J Nilsson
- Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Corrie A M Marijnen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Koen C M J Peeters
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Lennart K Blomqvist
- Department of Radiation Physics/Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
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3
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Kato S, Miyoshi N, Fujino S, Minami S, Nagae A, Hayashi R, Sekido Y, Hata T, Hamabe A, Ogino T, Tei M, Kagawa Y, Takahashi H, Uemura M, Yamamoto H, Doki Y, Eguchi H. Treatment response prediction of neoadjuvant chemotherapy for rectal cancer by deep learning of colonoscopy images. Oncol Lett 2023; 26:474. [PMID: 37809043 PMCID: PMC10551859 DOI: 10.3892/ol.2023.14062] [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: 01/11/2023] [Accepted: 08/04/2023] [Indexed: 10/10/2023] Open
Abstract
In current clinical practice, several treatment methods, including neoadjuvant therapy, are being developed to improve overall survival or local recurrence rates for locally advanced rectal cancer. The response to neoadjuvant therapy is usually evaluated using imaging data collected before and after preoperative treatment or postsurgical pathological diagnosis. However, there is a need to accurately predict the response to preoperative treatment before treatment is administered. The present study used a deep learning network to examine colonoscopy images and construct a model to predict the response of rectal cancer to neoadjuvant chemotherapy. A total of 53 patients who underwent preoperative chemotherapy followed by radical resection for advanced rectal cancer at the Osaka University Hospital between January 2011 and August 2019 were retrospectively analyzed. A convolutional neural network model was constructed using 403 images from 43 patients as the learning set. The diagnostic accuracy of the deep learning model was evaluated using 84 images from 10 patients as the validation set. The model demonstrated a sensitivity, specificity, accuracy, positive predictive value and area under the curve of 77.6% (38/49), 62.9% (22/33), 71.4% (60/84), 74.5% (38/51) and 0.713, respectively, in predicting a poor response to neoadjuvant therapy. Overall, deep learning of colonoscopy images may contribute to an accurate prediction of the response of rectal cancer to neoadjuvant chemotherapy.
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Affiliation(s)
- Shinya Kato
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka 565-0871, Japan
- Department of Innovative Oncology Research and Regenerative Medicine, Osaka International Cancer Institute, Osaka 541-8567, Japan
| | - Norikatsu Miyoshi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka 565-0871, Japan
- Department of Innovative Oncology Research and Regenerative Medicine, Osaka International Cancer Institute, Osaka 541-8567, Japan
| | - Shiki Fujino
- Department of Innovative Oncology Research and Regenerative Medicine, Osaka International Cancer Institute, Osaka 541-8567, Japan
| | - Soichiro Minami
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka 565-0871, Japan
- Department of Innovative Oncology Research and Regenerative Medicine, Osaka International Cancer Institute, Osaka 541-8567, Japan
| | - Ayumi Nagae
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka 565-0871, Japan
- Department of Innovative Oncology Research and Regenerative Medicine, Osaka International Cancer Institute, Osaka 541-8567, Japan
| | - Rie Hayashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka 565-0871, Japan
- Department of Innovative Oncology Research and Regenerative Medicine, Osaka International Cancer Institute, Osaka 541-8567, Japan
| | - Yuki Sekido
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka 565-0871, Japan
| | - Tsuyoshi Hata
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka 565-0871, Japan
| | - Atsushi Hamabe
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka 565-0871, Japan
| | - Takayuki Ogino
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka 565-0871, Japan
| | - Mitsuyoshi Tei
- Department of Surgery, Osaka Rosai Hospital, Sakai, Osaka 591-8025, Japan
| | - Yoshinori Kagawa
- Department of Gastroenterological Surgery, Osaka General Medical Center, Osaka 558-8588, Japan
| | - Hidekazu Takahashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka 565-0871, Japan
| | - Mamoru Uemura
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka 565-0871, Japan
| | - Hirofumi Yamamoto
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka 565-0871, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka 565-0871, Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka 565-0871, Japan
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Park H. Predictive factors for early distant metastasis after neoadjuvant chemoradiotherapy in locally advanced rectal cancer. World J Gastrointest Oncol 2021; 13:252-264. [PMID: 33889277 PMCID: PMC8040066 DOI: 10.4251/wjgo.v13.i4.252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 01/11/2021] [Accepted: 03/16/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Distant relapse is the leading cause of cancer-related death in locally advanced rectal cancer. Neoadjuvant chemoradiation (NACRT) followed by surgery inevitably delays delivery of systemic treatment. Some patients show early distant metastasis before systemic treatment.
AIM To identify the most effective treatments. We investigated prognostic factors for distant metastasis, especially early distant metastasis, using the standard treatment paradigm to identify the most effective treatments according to recurrence risk.
METHODS From January 2015 through December 2019, rectal cancer patients who underwent NACRT for having clinical T 3-4 or clinical N 1-2 disease according to the 8th American Joint Committee on Cancer staging system were included. Radiotherapy was delivered to the whole pelvis with concomitant chemotherapy. Patients received surgery 6-8 wk after completion of NACRT. Adjuvant chemotherapy was administered at the physician’s discretion.
RESULTS A total of 127 patients received NACRT. Ninety-three patients (73.2%) underwent surgery. The R0 resection rate was 89.2% in all patients. Pathologic tumor and node downstaging rates were 41.9% and 76.3%. Half the patients (n = 69) received adjuvant chemotherapy after surgery. The 3-year distant metastasis-free survival (DMFS) and overall survival (OS) rates were 81.7% and 83.5%. On univariate analyses, poorly differentiated tumors, > 5 cm, involvement of mesorectal fascia (MRF), or presence of extramural involvement (EMVI) were associated with worse DMFS and OS. Five patients showed distant metastasis at their first evaluation after NACRT. Patients with early distant metastasis were more likely to have poorly differentiated tumor (P = 0.025), tumors with involved MRF (P = 0.002), and EMVI (P = 0.012) than those who did not.
CONCLUSION EMVI, the involvement of MRF, and poor histologic grade were associated with early distant metastasis. In order to control distant metastasis and improve treatment outcome, selective use of neoadjuvant treatment according to individualized risk factors is necessary. Future studies are required to determine effective treatment strategies for patients at high risk for distant metastasis.
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Affiliation(s)
- Hyojung Park
- Departments of Radiation Oncology, Dankook University Hospital, Dankook University College of Medicine, Cheonan 46115, South Korea
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Nath J, Sarma G. Preoperative radiotherapy and total neoadjuvant therapy in locally advanced rectal cancer management: So far, so good. JOURNAL OF RADIATION AND CANCER RESEARCH 2021. [DOI: 10.4103/jrcr.jrcr_20_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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Ostwal V, Kapoor A, Engineer R, Saklani A, deSouza A, Patil P, Arya S, Ankathi SK, Chopra S, Patil M, Jain S, Ramaswamy A. Systemic chemotherapy and short-course radiation in metastatic rectal cancers: A feasible paradigm in unresectable and potentially resectable cancers. South Asian J Cancer 2020; 8:92-97. [PMID: 31069186 PMCID: PMC6498721 DOI: 10.4103/sajc.sajc_174_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background: The optimal use and sequencing of short-course radiotherapy (SCRT) in metastatic rectal cancers (mRCs) are not well established. Materials and Methods: We retrospectively reviewed the records of mRC patients receiving SCRT followed by palliative chemotherapy between January 1, 2013, and December 31, 2016, in Tata Memorial Hospital. Patients were classified as having “potentially resectable” disease (local and metastatic) or “unresectable” disease at baseline based on prespecified criteria. Results: A total of 105 consecutive patients were available for analysis. The median age of patients was 48 years (range: 16–62 years), and 57.1% were male patients. Signet ring histology was seen in 13.3% of patients. The most common site of metastases was liver limited (29.5%), nonloco-regional nodes (12.4%), and lung limited metastases (9.5%). Chemotherapeutic regimens administered were capecitabine-oxaliplatin (70.5%), modified 5 fluorouracil (5 FU)-leucovorin-irinotecan-oxaliplatin (10.5%), and modified 5 FU-leucovorin-irinotecan (8.6%). Targeted therapy accompanying chemotherapy was administered in 27.6% of patients. About 42.1% of patients with potentially resectable disease and 11.1% with the unresectable disease at baseline underwent curative-intent resection of the primary and address of metastatic sites. With a median follow-up 18.2 months, median overall survival (OS) was 15.7 months (95% confidence interval: 10.42–20.99). Patients classified as potentially resectable had a median OS of 32.62 months while patients initially classified as unresectable had a median OS of 13.04 months (P = 0.016). The presence of signet ring morphology predicted for inferior mOS (P = 0.021). Conclusions: SCRT followed by systemic therapy in mRC is a feasible, efficacious paradigm for maximizing palliation, and achieving objective responses. The classification of patients based on resectability was predictive of actual resection rates as well as outcomes. Signet ring mRC show inferior outcomes in this cohort of patients.
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Affiliation(s)
- Vikas Ostwal
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Akhil Kapoor
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Reena Engineer
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Avanish Saklani
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Ashwin deSouza
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Prachi Patil
- Department of Medical Gastroenterology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Supreeta Arya
- Department of Radiology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | | | - Supriya Chopra
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Mangesh Patil
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Shanu Jain
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Anant Ramaswamy
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
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Papamichael D, Hernandez P, Mistry R, Xenophontos E, Kakani C. Adjuvant chemotherapy in patients with colorectal cancer. Is there a role in the older adult? Eur J Surg Oncol 2020; 46:363-368. [PMID: 31973924 DOI: 10.1016/j.ejso.2020.01.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 12/06/2019] [Accepted: 01/02/2020] [Indexed: 01/13/2023] Open
Abstract
As global life expectancy has increased in most countries, there is a rising percentage of patients over 65 years old being diagnosed with colorectal cancer. Despite an increase in the incidence and prevalence of colorectal cancer in older adults, this cohort receives adjuvant therapy at a decreased rate due to anticipated intolerance. The presumed limitations seem to be based on chronologic age, competing life limiting diagnoses, and the paucity of data studying this population in major clinical trials. This review explores the data regarding disparities in the treatment of older patients with colorectal cancer, safety and efficacy of adjuvant therapy, and newer tools to make decisions based on the biologic age, rather than chronologic age, of the patient.
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Affiliation(s)
| | - Paul Hernandez
- Division of Colorectal Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ronak Mistry
- Department of Internal Medicine, Pennsylvania Hospital, University of Pennsylvania, Philadelphia, PA, USA
| | - Eleni Xenophontos
- Division of Medical Oncology, Bank Of Cyprus Oncology Centre, Nicosia, Cyprus
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Optimized Parameters of Diffusion-Weighted MRI for Prediction of the Response to Neoadjuvant Chemoradiotherapy for Locally Advanced Rectal Cancer. BIOMED RESEARCH INTERNATIONAL 2019; 2019:9392747. [PMID: 31737679 PMCID: PMC6815634 DOI: 10.1155/2019/9392747] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 08/14/2019] [Accepted: 09/17/2019] [Indexed: 12/11/2022]
Abstract
Aim To identify the optimal diffusion-weighted MRI-derived parameters for predicting the response to neoadjuvant chemoradiotherapy in locally advanced rectal cancer. Methods This prospective study enrolled 92 patients who underwent neoadjuvant chemoradiotherapy. Diffusion-weighted MRI sequences with two b-value combinations of b (0, 800) and b (0, 1000) were acquired before the start of neoadjuvant chemoradiotherapy and surgery. The pathological tumor regression grade was obtained according to the Mandard criteria, recommended by the seventh edition of the American Joint Committee on Cancer, to act as the reference standard. Pathological good responders (pathological tumor regression grade 1-2) were compared with poor responders (pathological tumor regression grade 3–5). Results The good responder group contained 37 (40.2%) patients and the poor responder group 55 (59.8%) patients. Both before and after neoadjuvant chemoradiotherapy, the mean ADC value for b = 1000 was significantly higher than that for b = 800. In the two patient groups, the post-ADC value and ΔADC for b = 800 were significantly lower than those for b = 1000, but percentages of ADC increase for b = 800 and b = 1000 showed no significant difference. Conclusions The percentage of ADC increase, as an optimized predictor unaffected by different b-values, may have a significant role in differentiating those patients with a good response to N-CRT from those with a poor response.
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Yoo RN, Kim HJ. Total neoadjuvant therapy in locally advanced rectal cancer: Role of systemic chemotherapy. Ann Gastroenterol Surg 2019; 3:356-367. [PMID: 31346574 PMCID: PMC6635691 DOI: 10.1002/ags3.12253] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 04/01/2019] [Indexed: 12/12/2022] Open
Abstract
For the past several decades, disease-related outcomes, particularly local recurrence rate, in patients with locally advanced rectal cancer have significantly improved as a result of advancement of surgical technique and implementation of neoadjuvant chemoradiation. However, distant metastasis remains unresolved, being a significant cause of cancer death. To focus on micrometastases early in the course of multimodal treatment, delivering systemic chemotherapy in the neoadjuvant setting is emerging. Also, driven by patient demand and interest in preserving quality of life, upfront chemotherapy prior to surgery serves as a strategy for organ preservation in the management of rectal cancer. Herein, currently available literature on different methods and strategies of the multimodal approach is critically appraised.
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Affiliation(s)
- Ri Na Yoo
- Division of Colorectal SurgeryDepartment of SurgerySt. Vincent's HospitalCollege of MedicineThe Catholic University of KoreaSuwonGyeonggi‐doKorea
| | - Hyung Jin Kim
- Division of Colorectal SurgeryDepartment of SurgerySt. Vincent's HospitalCollege of MedicineThe Catholic University of KoreaSuwonGyeonggi‐doKorea
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10
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Yoo RN, Kim HJ. Organ Preservation Strategies After Neoadjuvant Chemoradiotherapy for Locally Advanced Rectal Cancer. Ann Coloproctol 2019; 35:53-64. [PMID: 31113170 PMCID: PMC6529751 DOI: 10.3393/ac.2019.04.15.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 04/15/2019] [Indexed: 02/06/2023] Open
Abstract
Standard use of neoadjuvant chemoradiotherapy, total mesorectal excision, and postoperative adjuvant chemotherapy in locally advanced rectal cancer has tremendously improved oncologic outcomes over the past several decades. However, these improvements come with costs of significant morbidity and poor quality of life. Along with developments in imaging techniques, clinical experience and evidence have identified a certain subgroup of patients that have exceptionally good clinical outcomes while preserving quality of life. Driven by patient demand and interest in preserving quality of life, numerous organ preservation treatment strategies for managing rectal cancer are rapidly evolving. Herein, the flow of research in organ preservation strategies and counter arguments are discussed.
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Affiliation(s)
- Ri Na Yoo
- Division of Colorectal Surgery, Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Hyung Jin Kim
- Division of Colorectal Surgery, Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
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11
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Chen M, Chen LZ, Xu L, Zhang JS, Song X. Neoadjuvant chemoradiation for locally advanced rectal cancer: a systematic review of the literature with network meta-analysis. Cancer Manag Res 2019; 11:741-758. [PMID: 30697067 PMCID: PMC6339644 DOI: 10.2147/cmar.s189445] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Neoadjuvant chemoradiotherapy (CRT) prior to surgery is a standard therapy for locally advanced rectal cancer, but the optimum regime is not conclusive. This meta-analysis evaluated various CRT regimens with regard to the rate of pathologic complete response (pCR) and toxic effects of grade ≥3. Methods The databases PubMed, Cochrane Library, and Embase were searched for randomized controlled trials (RCTs) that compared neoadjuvant CRT regimes for treating patients with locally advanced rectal cancer, published before 28 December 2017. The primary end points were pCR and toxic effects. A network meta-analysis was applied. Results Fourteen RCTs (with 5,599 participants) involving the following eight regimens were included: fluorouracil (5FU) alone, or 5FU with oxaliplatin (OXA), cisplatin, or irinotecan (CPT-11); capecitabine (CAP) alone, or CAP with OXA or CPT-11; and CPT-11 with combined tegafur, 5-chloro-2,4-dihydroxypyridine, and potassium oxonate. The rate of pCR associated with CAP + OXA was significantly higher compared with 5FU alone; there were no significant differences among the other regimens. The toxicity of 5FU + OXA or CAP + OXA was significantly worse than that of 5FU alone or CAP alone. CAP + OXA and CAP were ranked, respectively, the most and second most effective regimens in terms of pCR rate. 5FU alone and CAP alone likely had the lowest and second lowest toxicity, respectively. Conclusion Among the currently available CRT regimens for locally advanced rectal cancer, this meta-analysis indicated that CAP + OXA provides the superior clinical results. Adding OXA to 5FU or CAP significantly increases toxicity.
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Affiliation(s)
- Min Chen
- Department of General Surgery, Xiamen Hospital of Traditional Chinese Medicine, Fujian University of Traditional Chinese Medicine, Xiamen 361009, China,
| | - Liang-Zhou Chen
- Department of General Surgery, Xiamen Hospital of Traditional Chinese Medicine, Fujian University of Traditional Chinese Medicine, Xiamen 361009, China,
| | - Lin Xu
- Department of General Surgery, Xiamen Hospital of Traditional Chinese Medicine, Fujian University of Traditional Chinese Medicine, Xiamen 361009, China,
| | - Jin-Song Zhang
- Department of General Surgery, Xiamen Hospital of Traditional Chinese Medicine, Fujian University of Traditional Chinese Medicine, Xiamen 361009, China,
| | - Xue Song
- Department of General Surgery, Xiamen Hospital of Traditional Chinese Medicine, Fujian University of Traditional Chinese Medicine, Xiamen 361009, China,
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12
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Total Neoadjuvant Therapy (TNT) in Rectal Cancer. CURRENT COLORECTAL CANCER REPORTS 2018. [DOI: 10.1007/s11888-018-0415-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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13
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Goldenberg BA, Holliday EB, Helewa RM, Singh H. Rectal Cancer in 2018: A Primer for the Gastroenterologist. Am J Gastroenterol 2018; 113:1763-1771. [PMID: 30008472 PMCID: PMC6768608 DOI: 10.1038/s41395-018-0180-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The rectum has distinctive anatomic and physiologic features, which increase the risk of local spread and recurrence among rectal cancers as compared to colon cancers. Essential to the management of rectal cancers is accurate endoscopic localization as well as preoperative imaging assessment of local and distant disease. Successful oncologic care is multidisciplinary including input from Gastroenterologists, Surgeons, Medical and Radiation Oncologists, Radiologists, and Pathologists. Extensive planning of curative intent is mandatory as failures of upfront treatment present great long‐term difficulty for patients and caregivers. Local recurrences are frequently associated with major morbidity including bowel and urinary obstruction, severe pain, and significantly diminished quality of life. Distant recurrence is associated with lower survival. Over the last two decades, there have been many advances in diagnostic imaging techniques as well as surgical techniques including transanal endoscopic microsurgery for very early stage cancers. Progress in curative management paradigms includes shorter courses of preoperative radiotherapy and chemotherapy doublet paradigms for perioperative treatment. This review describes the diagnosis, workup, and multimodality curative intent treatment of rectal cancers. It is emphasized that success begins in the hands and eyes of the gastroenterologist.
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Affiliation(s)
- Benjamin A. Goldenberg
- 1Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada.,2Department of Hematology and Oncology, CancerCare Manitoba, Winnipeg, MB, Canada
| | - Emma B. Holliday
- 3Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ramzi M. Helewa
- 4Department of Surgery, University of Manitoba, Winnipeg, MB, Canada
| | - Harminder Singh
- 1Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada.,2Department of Hematology and Oncology, CancerCare Manitoba, Winnipeg, MB, Canada.,5Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
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14
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Imaging predictors of treatment outcomes in rectal cancer: An overview. Crit Rev Oncol Hematol 2018; 129:153-162. [DOI: 10.1016/j.critrevonc.2018.06.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 04/26/2018] [Accepted: 06/13/2018] [Indexed: 12/14/2022] Open
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15
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Lin XL, Xiao XY. Progress in neoadjuvant drug therapy of rectal cancer. Shijie Huaren Xiaohua Zazhi 2018; 26:1340-1347. [DOI: 10.11569/wcjd.v26.i22.1340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Rectal cancer is one of the most common malignant tumors of the digestive system. A portion of patients have had locally advanced disease at the time of diagnosis and have lost the chance of radical surgery. How to increase the R0 resection rate has always been a major difficulty in clinical practice. Some studies have shown that for some patients, neoadjuvant drug therapy can achieve reduction of clinical stage, increase the R0 resection rate and anus-preserving rate, reduce the local recurrence and micro-metastasis, and prolong the survival time of patients. This article mainly reviews the progress in neoadjuvant drug therapy of rectal cancer.
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Affiliation(s)
- Xiao-Lin Lin
- Department of Oncology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Xiu-Ying Xiao
- Department of Oncology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
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16
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Phase II trial of capecitabine plus oxaliplatin (CAPOX) as perioperative therapy for locally advanced rectal cancer. Cancer Chemother Pharmacol 2018; 82:707-716. [PMID: 30078098 DOI: 10.1007/s00280-018-3663-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 08/02/2018] [Indexed: 12/23/2022]
Abstract
PURPOSE The standard strategy for locally advanced lower rectal cancer is chemoradiotherapy followed by total mesorectal excision (TME) in Western countries and TME followed by adjuvant chemotherapy without preoperative treatment in Japan. METHODS This phase II trial evaluated the efficacy of a preoperative CAPOX chemotherapy regimen without radiation therapy for patients with locally advanced rectal cancer. The primary endpoint was 2-year disease-free survival. RESULTS The trial enrolled 45 patients from 9 institutions between 2012 and 2014. The mean age was 63.5 (29-74) years; 31 patients were male. Most patients (n = 41) received preoperative chemotherapy (CTx), and the preoperative CTx completion rate was 95.2%. R0 resection after CTx was performed in 41 patients. The pathological complete response rate was 7.3% (3/41). After surgery, 35 patients (85.3%) received adjuvant CTx, and 22 of 35 completed the protocol treatment. The follow-up period ranged from 0.71 to 4.68 years (median 2.86 years). There was recurrence in 13 of 40 patients who underwent R0 resection, and the 2-year disease-free survival rate and overall survival rate were 71.6 and 92.7%, respectively. CONCLUSIONS Here we report the completion rates for neoadjuvant CTx and adjuvant CTx, the pathological complete response rate, and the mid-term prognosis. The results indicate that CAPOX followed by TME may be a safe treatment strategy for locally advanced rectal cancer.
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Okuyama T, Sameshima S, Takeshita E, Yoshioka R, Yamagata Y, Ono Y, Tagaya N, Noie T, Oya M. Therapeutic effects of oxaliplatin-based neoadjuvant chemotherapy and chemoradiotherapy in patients with locally advanced rectal cancer: a single-center, retrospective cohort study. World J Surg Oncol 2018; 16:105. [PMID: 29871650 PMCID: PMC5989356 DOI: 10.1186/s12957-018-1403-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 05/22/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Neoadjuvant chemoradiotherapy (NACRT) has now become the standard treatment for locally advanced rectal cancer (LARC). NACRT has decreased local relapse (LR) rate in patients with LARC; however, distant relapse has recently attracted much attention. This study aimed to assess the feasibility and efficiency of neoadjuvant chemotherapy (NAC) for LARC. METHODS Data on patients with cT3/4 and N+ rectal cancer who were treated in our institution from April 2010 to February 2016 were reviewed retrospectively. Twenty-seven patients who received 2-9 cycles of oxaliplatin-based NAC and 28 patients who received NACRT (45 Gy delivered in 25 fractions and 5-fluorouracil-based oral chemotherapy) were analyzed. The primary and secondary endpoints of the present study were the 3-year relapse-free survival (RFS) and the local and distant relapse rates, respectively. RESULTS Regardless of the kind of neoadjuvant therapy, no patient experienced any grade 3-4 therapy-related adverse events. The frequent toxic events were grade 1 diarrhea in patients with NACRT and neutropenia in patients with NAC. A significantly higher proportion of patients with NAC underwent laparoscopic surgery and anterior resection (p = 0.037 and p = 0.003, respectively). The percentages of patients with lymph node yield less than 12 in the NAC group, and those in the NACRT group were 26 and 68%, respectively (p = 0.002). Comparing the NAC with the NACRT groups, the local relapse and distant relapse rates were 7.4 and 7.1% and 7.4 and 18%, respectively. There were no significant differences in 3-year RFS and 4-year overall survival (OS) between NAC and NACRT (3-year RFS 85.2 vs. 70.4%, p = 0.279; 4-year OS 96.3 vs. 89.1%, p = 0.145, respectively). With an analysis excluding patients who received postoperative adjuvant chemotherapy, no patients who received NAC had a distant relapse, and there was a significant difference in 3-year RFS compared with the NACRT groups (94.4 vs. 63.2%, p = 0.043). CONCLUSION These outcomes suggest that the therapeutic effect of oxaliplatin-based NAC is at least equal to that of NACRT and that NAC is a feasible and promising option for LARC.
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Affiliation(s)
- Takashi Okuyama
- Department of Surgery, Dokkyo Medical University, Koshigaya Hospital, 2-1-50, Minami Koshigaya, Koshigaya, Saitama 343-8555 Japan
| | - Shinichi Sameshima
- Department of Surgery, Dokkyo Medical University, Koshigaya Hospital, 2-1-50, Minami Koshigaya, Koshigaya, Saitama 343-8555 Japan
| | - Emiko Takeshita
- Department of Surgery, Dokkyo Medical University, Koshigaya Hospital, 2-1-50, Minami Koshigaya, Koshigaya, Saitama 343-8555 Japan
| | - Ryuji Yoshioka
- Department of Surgery, Dokkyo Medical University, Koshigaya Hospital, 2-1-50, Minami Koshigaya, Koshigaya, Saitama 343-8555 Japan
| | - Yukinori Yamagata
- Department of Surgery, Dokkyo Medical University, Koshigaya Hospital, 2-1-50, Minami Koshigaya, Koshigaya, Saitama 343-8555 Japan
| | - Yuko Ono
- Department of Pathology, Dokkyo Medical University, Koshigaya Hospital, 2-1-50, Minami Koshigaya, Koshigaya, Saitama 343-8555 Japan
| | - Nobumi Tagaya
- Department of Surgery, Dokkyo Medical University, Koshigaya Hospital, 2-1-50, Minami Koshigaya, Koshigaya, Saitama 343-8555 Japan
| | - Tamaki Noie
- Department of Surgery, Dokkyo Medical University, Koshigaya Hospital, 2-1-50, Minami Koshigaya, Koshigaya, Saitama 343-8555 Japan
| | - Masatoshi Oya
- Department of Surgery, Dokkyo Medical University, Koshigaya Hospital, 2-1-50, Minami Koshigaya, Koshigaya, Saitama 343-8555 Japan
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18
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Poulsen LØ, Yilmaz MK, Oddershede L, Bøgsted M, Holt G, Eld M, Ljungmann K, Falkmer UG. Is the accuracy of preoperative MRI stage in rectal adenocarcinoma influenced by tumour height? Acta Oncol 2018; 57:728-734. [PMID: 29383974 DOI: 10.1080/0284186x.2018.1433319] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
AIM To our knowledge, no prior studies have addressed the possible effects of tumour height on the accuracy of preoperative magnetic resonance imaging (MRI)-based staging relative to postoperative histopathological assessments in patients with adenocarcinoma of the rectum (RC). This study aimed to investigate whether the accuracy of preoperative MRI stage in RC is influenced by tumour height. METHODS A total of 489 consecutive RC patients scheduled for curative treatment between 2009 and 2013 were included. Of the 489 patients, 133 patients had preoperative chemoradiotherapy (CRT), and 356 patients underwent primary surgery. Low, mid and high RC were defined as a tumour <5 cm, 5-10 cm and >10 cm from the anal verge, respectively. Diagnostic MRI and, for patients with CRT, re-staging MRI features including tumour T-stage (mrT), distance between the tumour border and the distance to the mesorectal fascia (mrMRF), extramural tumour depth (mrEMD), extramural vascular invasion (mrEMVI) and nodal involvement (mrN) were correlated with the corresponding postoperative histopathological findings. RESULTS There were 115, 186 and 188 patients with low RC, mid RC and high RC, respectively. For all patients, the correlations between mrT and pT and between mrMRF and pCRM were not influenced by tumour height. None of the correlations between mrEMD, mrEMVI and mrN and the corresponding postoperative histopathological findings significantly differed for tumours of different heights. For patients with CRT, a remarkable proportion with low RC were overstaged as ymrT3 compared to ypT0-2. CONCLUSIONS The ability to preoperatively use MRI to accurately stage is not influenced by tumour height. For patients with preoperative CRT, low RC may be MRI overstaged due to post-radiation fibrosis. We found that mrEMD predicts pEMD reliably and should therefore be considered in treatment decisions. Although new MRI techniques are emerging, preoperative RC staging remains incompletely definitive in daily clinical practice.
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Affiliation(s)
| | | | | | - Martin Bøgsted
- Department of Clinical Science, Aalborg University, Aalborg, Denmark
| | - Gitte Holt
- Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
| | - Mikkel Eld
- Department of Pathology, Aalborg University Hospital, Aalborg, Denmark
| | - Ken Ljungmann
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
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Hoshino N, Hida K, Sakai Y, Osada S, Idani H, Sato T, Takii Y, Bando H, Shiomi A, Saito N. Nomogram for predicting anastomotic leakage after low anterior resection for rectal cancer. Int J Colorectal Dis 2018; 33:411-418. [PMID: 29411120 DOI: 10.1007/s00384-018-2970-5] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/29/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE Anastomotic leakage after low anterior resection for rectal cancer is a critical problem. Many risk factors have been suggested and surgical techniques have improved, but anastomotic leakage remains a major postoperative challenge. This study sought to create a nomogram for precise prediction of anastomotic leakage after low anterior resection for rectal cancer. METHODS We used data of 936 patients that had been prospectively collected by the Japanese Society for Colon and Rectal Cancer between June 2010 and February 2013. Risk factors for anastomotic leakage were identified by multivariate logistic regression analysis and used to create a nomogram. The performance of the nomogram was evaluated by using a bootstrapped-concordance index and calibration plots. RESULTS Sex, preoperative serum albumin, tumor location and diameter, and simultaneous resection of other organs were identified as significantly associated factors that could be combined for accurate prediction of anastomotic leakage. We created a nomogram for anastomotic leakage by using these risk factors. The area under the curve was 0.72 (95% confidence interval 0.67-0.76). The nomogram had a bootstrapped-concordance index of 0.72 and was well calibrated. CONCLUSIONS Our nomogram was a useful tool for precise prediction of anastomotic leakage after low anterior resection for rectal cancer.
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Affiliation(s)
- Nobuaki Hoshino
- Department of Surgery, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Koya Hida
- Department of Surgery, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - Yoshiharu Sakai
- Department of Surgery, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Shunichi Osada
- Division of Surgery, Yokohama City Minato Red Cross Hospital, Kanagawa, Japan
| | - Hitoshi Idani
- Division of Surgery, Fukuyama City Hospital, Fukuyama, Japan
| | - Toshihiko Sato
- Division of Surgery, Yamagata Prefectural Central Hospital, Yamagata, Japan
| | - Yasumasa Takii
- Division of Gastroenterological Surgery, Niigata Cancer Center Hospital, Niigata, Japan
| | - Hiroyuki Bando
- Division of Gastroenterological Surgery, Ishikawa Prefectural Central Hospital, Ishikawa, Japan
| | - Akio Shiomi
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Norio Saito
- Division of Colorectal Surgery, National Cancer Center Hospital East, Chiba, Japan
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20
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Oshiro T, Uehara K, Aiba T, Mukai T, Ebata T, Nagino M. Impact of RAS/BRAF mutation status in locally advanced rectal cancer treated with preoperative chemotherapy. Int J Clin Oncol 2018; 23:681-688. [PMID: 29478127 DOI: 10.1007/s10147-018-1253-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 02/17/2018] [Indexed: 12/15/2022]
Abstract
PURPOSE Our sincere hope is to establish the predictive factors of neoadjuvant chemotherapy (NAC) response and provide patients with greater certainty regarding treatment outcomes. The aim of this study was to assess the response to NAC and survival in patients with locally advanced rectal cancer (LARC) according to their RAS/BRAF mutation status. METHODS Data on 57 patients with LARC who received NAC between 2009 and 2016 were analyzed retrospectively. The patients were classified into two groups based on their mutation status: wild-type in both RAS and BRAF (WT) or mutant-type in either RAS or BRAF (MT). RESULTS Twenty-three patients were classified as WT, and the remaining 34 patients were MT. Histological response to NAC was similar in both groups. In responders, the 3-year relapse-free survival (RFS) was better compared with the non-responders (92 and 66%, respectively). In the WT group, the 3-year RFS was 95% which was significantly better than that in the MT group (59%, p = 0.011). The MT group was further subdivided into the following 2 groups by the pathological response; the MT responders (n = 10) and MT non-responders (n = 24). The 3-year RFS was 50% in the MT non-responders, which was significantly worse compared to that in the remaining patients (92%, p = 0.001). CONCLUSION RAS/BRAF mutations did not affect the response to NAC. However, the RFS was likely to be poor for those in the MT group who did not achieve favorable pathological response. In contrast, the RFS was favorable in the WT group regardless of the pathological response.
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Affiliation(s)
- Taihei Oshiro
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Keisuke Uehara
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
| | - Toshisada Aiba
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Toshiki Mukai
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Tomoki Ebata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Masato Nagino
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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Zhong X, Wu Z, Gao P, Shi J, Sun J, Guo Z, Wang Z, Song Y. The efficacy of adding targeted agents to neoadjuvant therapy for locally advanced rectal cancer patients: a meta-analysis. Cancer Med 2018; 7:565-582. [PMID: 29464874 PMCID: PMC5852374 DOI: 10.1002/cam4.1298] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 11/22/2017] [Accepted: 11/26/2017] [Indexed: 12/19/2022] Open
Abstract
Patients with locally advanced rectal cancer (LARC) are at tremendous risk of metastatic diseases. To improve the prognoses of LARC patients, the efficacy of adding targeted agents to neoadjuvant therapy has been investigated by many researchers but remains controversial. A literature search of relevant databases was conducted through December 2016, 804 studies were identified and 32 investigations were ultimately included. A total of 1196 patients from 31 cohorts of 29 studies were eligible for quantitative synthesis in this single‐arm setting meta‐analysis. As pathologic complete response (pCR) shows promise as a prognosis indicator, we focused on pCR rates to evaluate whether adding targeted agents to neoadjuvant therapies improves the outcome of LARC patients. In our study, we revealed pooled estimates of pCR of 27% (95%CI, 21–34%) and 14% (95%CI, 9–21%) for bevacizumab‐relevant cohorts and cetuximab‐relevant cohorts, respectively. The safety of adding targeted agents to neoadjuvant therapy was also evaluated by pooling the data of Grade 3/4 toxicity. In conclusion, our study revealed that adding bevacizumab to the neoadjuvant therapy regimens provides appreciable pCR for LARC patients. Meanwhile, the efficacy of cetuximab remains inconclusive, RCTs with larger scale and better study design that stress more on mutational status are needed.
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Affiliation(s)
- Xi Zhong
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang, 110001, China
| | - Zhonghua Wu
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang, 110001, China
| | - Peng Gao
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang, 110001, China
| | - Jinxin Shi
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang, 110001, China
| | - Jingxu Sun
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang, 110001, China
| | - Zhexu Guo
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang, 110001, China
| | - Zhenning Wang
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang, 110001, China
| | - Yongxi Song
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang, 110001, China
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22
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Nacion AJD, Park YY, Kim NK. Contemporary management of locally advanced rectal cancer: Resolving issues, controversies and shifting paradigms. Chin J Cancer Res 2018; 30:131-146. [PMID: 29545727 DOI: 10.21147/j.issn.1000-9604.2018.01.14] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Advancements in rectal cancer treatment have resulted in improvement only in locoregional control and have failed to address distant relapse, which is the predominant mode of treatment failure in rectal cancer. As the efficacy of conventional chemoradiotherapy (CRT) followed by total mesorectal excision (TME) reaches a plateau, the need for alternative strategies in locally advanced rectal cancer (LARC) has grown in relevance. Several novel strategies have been conceptualized to address this issue, including: 1) neoadjuvant induction and consolidation chemotherapy before CRT; 2) neoadjuvant chemotherapy alone to avoid the sequelae of radiation; and 3) nonoperative management for patients who achieved pathological or clinical complete response after CRT. This article explores the issues, recent advances and paradigm shifts in the management of LARC and emphasizes the need for a personalized treatment plan for each patient based on tumor stage, location, gene expression and quality of life.
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Affiliation(s)
- Aeris Jane D Nacion
- Department of Surgery, Eastern Visayas Regional Medical Center, Tacloban City 6500, Philippines
| | - Youn Young Park
- Department of Surgery, Eastern Visayas Regional Medical Center, Tacloban City 6500, Philippines
| | - Nam Kyu Kim
- Department of Surgery, Eastern Visayas Regional Medical Center, Tacloban City 6500, Philippines
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Miyake Y, Mizushima T, Hata T, Takahashi H, Hanada H, Shoji H, Nomura M, Haraguchi N, Nishimura J, Matsuda C, Takemasa I, Doki Y, Maeda I, Mori M, Yamamoto H. Inspection of Perirectal Lymph Nodes by One-Step Nucleic Acid Amplification Predicts Lateral Lymph Node Metastasis in Advanced Rectal Cancer. Ann Surg Oncol 2017; 24:3850-3856. [PMID: 28924845 DOI: 10.1245/s10434-017-6069-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Lateral lymph node dissection (LLND) is performed for advanced rectal cancers in Japan; however, it can cause sexual and urinary dysfunction. The incidence of lateral LN metastasis is estimated at 7-13.9%; therefore, excessive rectal surgery with LLND should be avoided, especially for prophylactic purposes. To identify the patients who require LLND, we examined metastases in perirectal LNs by using a one-step nucleic acid amplification (OSNA) assay to predict lateral LN metastases. METHODS Twenty-five patients who underwent surgery with bilateral LN dissection due to T3-T4 rectal cancers were prospectively included in this study. Twenty-two patients (88.0%) received preoperative chemotherapy. Among 1052 LNs from 25 patients (median 40 per case), 135 perirectal LNs (median 6 per patient) were divided into three pieces and analyzed by OSNA, reverse transcriptase-polymerase chain reaction for carcinoembryonic antigen mRNA, and pathological examination after surgery. These results were compared with the pathological diagnosis of lateral LNs. RESULTS Lateral LN metastases were present in 4 of 25 patients (16.0%). All of these patients were positive by OSNA for perirectal LN metastases. The OSNA assay had a sensitivity of 100%, specificity of 86%, positive predictive value of 57%, and negative predictive value (NPV) of 100% for predicting lateral LN metastases. CONCLUSIONS The findings from this prospective study suggest that the OSNA assay of perirectal LNs may be useful for determining when LLND is necessary because of its high NPV, even in patients treated with preoperative chemotherapy.
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Affiliation(s)
- Yuichiro Miyake
- Department of Surgery, Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita City, Osaka, Japan
| | - Tsunekazu Mizushima
- Department of Surgery, Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita City, Osaka, Japan
| | - Taishi Hata
- Department of Surgery, Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita City, Osaka, Japan
| | - Hidekazu Takahashi
- Department of Surgery, Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita City, Osaka, Japan
| | - Hiroyuki Hanada
- Laboratory for Clinical Investigation, Osaka University Hospital, Suita City, Osaka, Japan
| | - Hiroki Shoji
- Laboratory for Clinical Investigation, Osaka University Hospital, Suita City, Osaka, Japan
| | - Masatoshi Nomura
- Department of Surgery, Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita City, Osaka, Japan
| | - Naotsugu Haraguchi
- Department of Surgery, Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita City, Osaka, Japan
| | - Junichi Nishimura
- Department of Surgery, Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita City, Osaka, Japan
| | - Chu Matsuda
- Department of Surgery, Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita City, Osaka, Japan
| | - Ichiro Takemasa
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo City, Hokkaido, Japan
| | - Yuichiro Doki
- Department of Surgery, Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita City, Osaka, Japan
| | - Ikuhiro Maeda
- Laboratory for Clinical Investigation, Osaka University Hospital, Suita City, Osaka, Japan
| | - Masaki Mori
- Department of Surgery, Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita City, Osaka, Japan
| | - Hirofumi Yamamoto
- Department of Surgery, Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita City, Osaka, Japan. .,Department of Molecular Pathology, Division of Health Sciences, Graduate School of Medicine, Osaka University, Suita City, Osaka, Japan.
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Ludmir EB, Palta M, Willett CG, Czito BG. Total neoadjuvant therapy for rectal cancer: An emerging option. Cancer 2017; 123:1497-1506. [PMID: 28295220 DOI: 10.1002/cncr.30600] [Citation(s) in RCA: 124] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 01/02/2017] [Accepted: 01/10/2017] [Indexed: 12/13/2022]
Abstract
The treatment of locally advanced rectal cancer (LARC) has benefited from improved surgical techniques and from the implementation of neoadjuvant chemoradiotherapy (CRT), which have markedly decreased the rates of local recurrence. However, distant metastatic disease remains the most significant cause of death for these patients. Although adjuvant chemotherapy (ChT) after neoadjuvant CRT and definitive surgery is commonly recommended, the value of adjuvant systemic therapy remains less clear. Trials evaluating adjuvant ChT for rectal cancer have been handicapped by poor compliance rates and inconsistent survival results. Shifting systemic therapy delivery to the neoadjuvant setting has the promise to improve compliance rates, reduce toxicity, and decrease distant relapse rates. Recently, multiple prospective trials have reported on the use of total neoadjuvant therapy (TNT) for patients with LARC, incorporating both ChT and CRT in the neoadjuvant setting. Here, the authors review the promising results from those trials. Because the studies have largely focused on pathologic outcomes (primarily pathologic complete response rates), ongoing phase 2 and 3 trials are now underway assessing the long-term disease-related outcomes with TNT. In addition to improving survival, TNT has the potential to increase the pool of patients with LARC who are eligible for organ preservation, which is also being evaluated. Cancer 2017;123:1497-1506. © 2017 American Cancer Society.
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Affiliation(s)
- Ethan B Ludmir
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Manisha Palta
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Christopher G Willett
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Brian G Czito
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
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26
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Kamiya T, Uehara K, Nakayama G, Ishigure K, Kobayashi S, Hiramatsu K, Nakayama H, Yamashita K, Sakamoto E, Tojima Y, Kawai S, Kodera Y, Nagino M. Early results of multicenter phase II trial of perioperative oxaliplatin and capecitabine without radiotherapy for high-risk rectal cancer: CORONA I study. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2016; 42:829-35. [PMID: 26968228 DOI: 10.1016/j.ejso.2016.02.014] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Revised: 02/01/2016] [Accepted: 02/11/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUNDS Perioperative introduction of developed chemotherapy into the treatment strategy for locally advanced rectal cancer (LARC) may be a promising option. However, the most prevalent treatment for high-risk LARC remains preoperative chemoradiotherapy (CRT) in Western countries. PATIENTS AND METHODS A phase II trial was undertaken to evaluate safety and efficacy of perioperative XELOX without radiotherapy (RT) for patients with high-risk LARC. Patients received 4 cycles of XELOX before and after surgery, respectively. Primary endpoint was disease-free survival. RESULTS We enrolled 41 patients between June 2012 and April 2014. The completion rate of the preoperative XELOX was 90.3%. Twenty-nine patients (70.7%) could start postoperative XELOX, 15 of these patients (51.7%) completed 4 cycles. Allergic reaction to oxaliplatin was experienced by 5 patients (17.2%) during postoperative XELOX. One patient received additional RT after preoperative XELOX. Consequently, the remaining 40 patients underwent primary resection. Major complications occurred in 6 of 40 patients (15.0%). Pathological complete response (pCR) rate was 12.2%, and good tumor regression was exhibited in 31.7%. N down-staging (cN+ to ypN0) and T down-staging were detected in 56.7% and 52.5%, respectively. Clinical T4 tumor was a predictor of poor pathological response (p < 0.001). CONCLUSIONS We could show the favorable pCR rate after preoperative XELOX alone. However, the T and N down-staging rate was likely to be insufficient. When tumor regression is essential for curative resection, the use of preoperative CRT is likely to be recommended. For patients with massive LN metastasis, the additional Bev to NAC might be a promising option.
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Affiliation(s)
- T Kamiya
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - K Uehara
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - G Nakayama
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - K Ishigure
- Department of Surgery, Konan Kosei Hospital, Aichi, Japan
| | - S Kobayashi
- Department of Surgery, Toyota Kosei Hospital, Aichi, Japan
| | - K Hiramatsu
- Department of Surgery, Toyohashi Municipal Hospital, Aichi, Japan
| | - H Nakayama
- Department of Surgery, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - K Yamashita
- Department of Surgery, Toyohashi Medical Center, Aichi, Japan
| | - E Sakamoto
- Department of Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Y Tojima
- Department of Surgery, Chukyo Hospital, Nagoya, Japan
| | - S Kawai
- Department of Surgery, Tsushima City Hospital, Aichi, Japan
| | - Y Kodera
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - M Nagino
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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