1
|
González Del Portillo E, Couñago F, López-Campos F. Neoadjuvant treatment of rectal cancer: Where we are and where we are going. World J Clin Oncol 2024; 15:790-795. [PMID: 39071468 PMCID: PMC11271721 DOI: 10.5306/wjco.v15.i7.790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 04/28/2024] [Accepted: 05/17/2024] [Indexed: 07/16/2024] Open
Abstract
Locally advanced rectal cancer requires a multidisciplinary approach based on total neoadjuvant treatment with radiotherapy (RT) and chemotherapy (ChT), followed by deferred surgery. Currently, alternatives to the standard total neoadjuvant therapy (TNT) are being explored, such as new ChT regimens or the introduction of immunotherapy. With standard TNT, up to a third of patients may achieve a complete pathological response (CPR), potentially avoiding surgery. However, as of now, we lack predictive markers of response that would allow us to define criteria for a conservative organ strategy. The presence of mutations, genes, or new imaging tests is helping to define these criteria. An example of this is the diffusion coefficient in the diffusion-weighted sequence of magnetic resonance imaging and the integration of this imaging technique into RT treatment. This allows for the monitoring of the evolution of this coefficient over successive RT sessions, helping to determine which patients will achieve CPR or those who may require intensification of neoadjuvant therapy.
Collapse
Affiliation(s)
| | - Felipe Couñago
- Department of Radiation Oncology, GenesisCare Madrid, Madrid 28010, Spain
| | - Fernando López-Campos
- Department of Radiation Oncology, Hospital Universitario Ramón Y Cajal, Madrid 28034, Spain
| |
Collapse
|
2
|
Pollom EL, Sheth VR, Dawes AJ, Holden T. Nonoperative Management for Rectal Cancer. Cancer J 2024; 30:238-244. [PMID: 39042774 DOI: 10.1097/ppo.0000000000000727] [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] [Indexed: 07/25/2024]
Abstract
ABSTRACT The treatment paradigm for rectal cancer has been shifting toward de-escalated approaches to preserve patient quality of life. Historically, the standard treatment in the United States for locally advanced rectal cancer has standardly comprised preoperative chemoradiotherapy coupled with total mesorectal excision. Recent data challenge this "one-size-fits-all" strategy, supporting the possibility of omitting surgery for certain patients who achieve a clinical complete response to neoadjuvant therapy. Consequently, patients and their physicians must navigate diverse neoadjuvant options, often in the context of pursuing organ preservation. Total neoadjuvant therapy, involving the administration of all chemotherapy and radiation before total mesorectal excision, is associated with the highest rates of clinical complete response. However, questions persist regarding the optimal sequencing of radiation and chemotherapy and the choice between short-course and long-course radiation. Additionally, meticulous response assessment and surveillance are critical for selecting patients for nonoperative management without compromising the excellent cure rates associated with trimodality therapy. As nonoperative management becomes increasingly recognized as a standard-of-care treatment option for patients with rectal cancer, ongoing research in patient selection and monitoring as well as patient-reported outcomes is critical to guide personalized rectal cancer management within a patient-centered framework.
Collapse
Affiliation(s)
| | | | | | - Thomas Holden
- Department of Medicine, Stanford University School of Medicine, Stanford, CA
| |
Collapse
|
3
|
Shen Y, Wu Q, Meng W, Wei M, Deng X, Wang Z. Neoadjuvant chemotherapy (CAPOX) alone for low- and intermediate-risk stage II/III rectal cancer: Long-term follow-up of a prospective single-arm study. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:107115. [PMID: 37839296 DOI: 10.1016/j.ejso.2023.107115] [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: 07/21/2023] [Revised: 09/09/2023] [Accepted: 10/10/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND Stratified treatment has been recommended for rectal cancer. Our previous multicenter randomized trial showed that low-/intermediate-risk rectal cancer patients did not benefit much from neoadjuvant chemoradiotherapy. In our phase II study, we found that stage II/III rectal cancer patients with low-/intermediate risks can be managed by neoadjuvant chemotherapy alone and achieve a good response. The current study aimed to report the long-term survival outcomes in the expanded phase II trial. METHOD Consecutive patients diagnosed with mid-low stage II/III rectal cancer with low/intermediate risk factors were included. Four cycles of neoadjuvant chemotherapy (CAPOX) were given, and MRI was used for tumour response detection. The primary endpoint was disease-free survival. The secondary endpoints were tumour response to NCT, tumour-related death, and overall survival. RESULTS This study enrolled 121 eligible patients. The good tumour response rate based on MRI was 82.6 %, with a pathological complete response (pCR) rate of 18.3 %. The disease-free survival rate was 82.6 %, and the overall survival rate was 96.7 % after a median follow-up time of 40 months. Two patients (1.7 %) suffered local recurrence, and 15 patients (12.4 %) suffered distant metastasis. The median disease-free survival and overall survival were 37 (9-60) and 40 (16-60) months, respectively. Tumour longitudinal length reduction and tumour regression grade on MRI were identified as predictors for poor tumour response to neoadjuvant chemotherapy. CONCLUSION In stage II/III rectal cancer patients with low-/intermediate risks, neoadjuvant chemotherapy alone may result in an acceptable tumour response and disease-free survival. Tumour response might be predicted early.
Collapse
Affiliation(s)
- Yu Shen
- Colorectal Cancer Center, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Qingbin Wu
- Colorectal Cancer Center, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Wenjian Meng
- Colorectal Cancer Center, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Mingtian Wei
- Colorectal Cancer Center, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China.
| | - Xiangbing Deng
- Colorectal Cancer Center, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China.
| | - Ziqiang Wang
- Colorectal Cancer Center, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China.
| |
Collapse
|
4
|
Patel S, Ankathi S, Haria P, Kazi M, Desouza AL, Saklani A. Impact of consolidation chemotherapy in poor responders to neoadjuvant radiation therapy: magnetic resonance imaging-based clinical-radiological correlation in high-risk rectal cancers. Ann Coloproctol 2023; 39:474-483. [PMID: 38124365 PMCID: PMC10781604 DOI: 10.3393/ac.2023.00080.0011] [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] [Received: 01/26/2023] [Revised: 04/06/2023] [Accepted: 04/15/2023] [Indexed: 12/23/2023] Open
Abstract
PURPOSE The current study was conducted to examine the role of consolidation chemotherapy after neoadjuvant radiation therapy (NART) in decreasing the involvement of the mesorectal fascia (MRF) in high-risk locally advanced rectal cancers (LARCs). METHODS In total, 46 patients who received consolidation chemotherapy after NART due to persistent MRF involvement were identified from a database. A team of 2 radiologists, blinded to the clinical data, studied sequential magnetic resonance imaging (MRI) scans to assess the tumor response and then predict a surgical plan. This prediction was then correlated with the actual procedure conducted as well as histopathological details to assess the impact of consolidation chemotherapy. RESULTS The comparison of MRI-based parameters of sequential images showed significant downstaging of T2 signal intensity, tumor height, MRF involvement, diffusion restriction, and N category between sequential MRIs (P < 0.05). However, clinically relevant downstaging (standardized mean difference, > 0.3) was observed for only T2 signal intensity and diffusion restriction on diffusion-weighted imaging. No clinically relevant changes occurred in the remaining parameters; thus, no change was noted in the extent of surgery predicted by MRI. Weak agreement (Cohen κ coefficient, 0.375) and correlation (Spearman rank coefficient, 0.231) were found between MRI-predicted surgery and the actual procedure performed. The comparison of MRI-based and pathological tumor response grading also showed a poor correlation. CONCLUSION Evidence is lacking regarding the use of consolidation chemotherapy in reducing MRF involvement in LARCs. The benefit of additional chemotherapy after NART in decreasing the extent of planned surgery by reducing margin involvement requires prospective research.
Collapse
Affiliation(s)
- Swapnil Patel
- Department of Surgical Oncology, MPMMCC & HBCH, Tata Memorial Centre, Varanasi, India
| | - Suman Ankathi
- Department of Radiodiagnosis, Tata Memorial Centre, Mumbai, India
| | - Purvi Haria
- Department of Radiodiagnosis, Tata Memorial Centre, Mumbai, India
| | - Mufaddal Kazi
- Colorectal Division, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India
| | - Ashwin L. Desouza
- Colorectal Division, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India
| | - Avanish Saklani
- Colorectal Division, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India
| |
Collapse
|
5
|
Hodges N, Battersby N, Rao S, Brown G. Relationship Between Baseline Rectal Tumor Length and Magnetic Resonance Tumor Regression Grade Response to Chemoradiotherapy: A Subanalysis of the TRIGGER Feasibility Study. Ann Surg Oncol 2023; 30:4729-4735. [PMID: 35771366 PMCID: PMC10319655 DOI: 10.1245/s10434-022-11914-5] [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: 03/01/2022] [Accepted: 05/03/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND It is widely believed that small rectal tumors are more likely to have a good response to neoadjuvant treatment, which may influence the selection of patients for a 'watch and wait' strategy. OBJECTIVE The aim of this study was to investigate whether there is a relationship between baseline tumor length on magnetic resonance imaging (MRI) and response to chemoradiotherapy. METHOD The 96 patients with locally advanced rectal cancer randomised (2:1-intervention:control) in the TRIGGER feasibility study where eligible. Baseline tumor length was defined as the maximal cranio-caudal length on baseline MRI (mm) and was recorded prospectively at study registration. Magnetic resonance tumor regression grade (mrTRG) assessment was performed on the post-chemoradiotherapy (CRT) MRI 4-6 weeks (no later than 10 weeks) post completion of CRT. This was routinely reported for patients in the intervention (mrTRG-directed management) arm and reported for the purposes of this study by the central radiologist in the control arm patients. Those with an mrTRG I/II response were defined as 'good responders' and those with an mrTRG III-V response were defined as 'poor responders'. RESULTS Overall, 94 patients had a post-CRT MRI performed and were included. Forty-three (46%) patients had a good response (mrTRG I/II) and 51 (54%) patients had a poor response (mrTRG III/IV). The median tumor length of good responders was 43 mm versus 50 mm (p < 0.001), with considerable overlap in tumor lengths between groups. CONCLUSION Baseline tumor length on MRI is not a clinically useful biomarker to predict mrTRG tumor response to CRT and therefore patient suitability for a deferral of surgery trial.
Collapse
Affiliation(s)
- Nicola Hodges
- The Royal Marsden NHS Foundation Trust and Imperial College London, Sutton, UK
- Imperial College, London, UK
| | | | - Sheela Rao
- The Royal Marsden NHS Foundation Trust and Imperial College London, Sutton, UK
| | - Gina Brown
- The Royal Marsden NHS Foundation Trust and Imperial College London, Sutton, UK.
| |
Collapse
|
6
|
Mohan H, Rabie M, Walsh C, Harji D, Sutton P, Geh I, Jackson I, Helbren E, Evans M, Jenkins JT. Patient and multidisciplinary team perspectives on watch and wait in rectal cancer. Colorectal Dis 2023; 25:1489-1497. [PMID: 37477408 DOI: 10.1111/codi.16592] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 03/21/2023] [Accepted: 03/25/2023] [Indexed: 07/22/2023]
Abstract
This article adopts a multidisciplinary approach, including surgery, oncology, radiology and patient perspectives, to discuss the key points of debate surrounding a watch and wait approach. In an era of shared decision-making, discussion of watch and wait as an option in the context of complete clinical response is appropriate, although it is not the gold standard treatment. Key challenges are the difficulty in assessing for a complete clinical response, prediction of recurrence and access to timely diagnostics for surveillance. Salvage surgery has good results if regrowth is detected early but does have imperfect outcomes, with only a 90% salvage rate. Good communication with patients about the risks and alternatives is essential. Patients undergoing watch and wait should ideally be enrolled in prospective registries or clinical trials.
Collapse
Affiliation(s)
- Helen Mohan
- ACPGBI Advanced Malignancy Subcommittee, London, UK
- The Dukes Club, London, UK
- Department of Surgery, University of Melbourne, Melbourne, Australia
| | | | - Ciaran Walsh
- ACPGBI Multidisciplinary Clinical Committee, London, UK
| | | | | | - Ian Geh
- ACPGBI Multidisciplinary Clinical Committee, London, UK
| | | | - Emma Helbren
- British Society of Gastrointestinal Abdominal Radiology (BSGAR), London, UK
| | - Martyn Evans
- ACPGBI Multidisciplinary Clinical Committee, London, UK
| | - John T Jenkins
- ACPGBI Advanced Malignancy Subcommittee, London, UK
- ACPGBI Multidisciplinary Clinical Committee, London, UK
| |
Collapse
|
7
|
Shen Y, Shi W, Huang C, Gong X, Wei M, Meng W, Deng X, Wang Z. Comparison of the pathological response to 2 or 4 cycles of neoadjuvant CAPOX in II/III rectal cancer patients with low/intermediate risks: study protocol for a prospective, non-inferior, randomized control trial (COPEC trial). Trials 2023; 24:397. [PMID: 37312165 DOI: 10.1186/s13063-023-07405-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 05/23/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND For patients with low- and intermediate-risk stage II/III rectal cancer, current studies have reached a consensus that preoperative radiotherapy may be dispensed with, and neoadjuvant chemotherapy (NCT) alone might achieve an accepted local control. Our previous phase II study has evidenced that the morphological response of NCT could be better judged at a relatively early stage. Low- and intermediate-risk stage II/III rectal cancer patients could achieve a high rate of tumor shrinkage and downgrade after only 4 cycles of NCT and obvious tumor morphological changes could be observed after 2 cycles of NCT. However, there is still a lack of more detailed stratification and evidence for pathological criteria. The aim of the present study (comparison of the pathological response to 2 or 4 cycles of neoadjuvant CAPOX in II/III rectal cancer patients with low/intermediate risks, COPEC trial) is to determine the pathological tumor regression grade (pTRG) rate of 2 or 4 cycles of NCT in low- and intermediate-risk stage II/III rectal cancer and verify the feasibility of early identification of chemotherapy-insensitive population. METHODS/DESIGN This is a multicenter, prospective, non-inferior, randomized controlled trial (RCT) initiated by West China Hospital of Sichuan University and designed to be conducted in fourteen hospitals around China. Eligible patients will be centrally randomized into 2 or 4 cycles of CAPOX in a 1:1 ratio using the central automated randomization system offered by the O-trial online system ( https://plus.o-trial.com/ ) and accept total mesorectal excision after 2 or 4 cycles of CAPOX (oxaliplatin 130 mg/m2, once daily on day 1, every 21 days and capecitabine 1000 mg/m2, twice daily on days 1 to 14, every 21 days). The primary endpoint is the proportion of patients with pathological no-tumor regression (pTRG 3), which is determined postoperatively by each sub-center and verified by the primary center. DISCUSSION COPEC trial is designed to verify that the preoperative CAPOX chemotherapy for low- and intermediate-risk stage II/III rectal cancer could achieve a good response judgment after 2 cycles and obtain the tumor pathological response rate after 2 cycles of CAPOX. We hope the COPEC trial could help in establishing a consensus standard of low- and intermediate-risk rectal cancer and the early identification of stage II/III rectal patients with low- and intermediate-risk who are poorly responding to NCT. TRIAL REGISTRATION Clinicaltrial.gov NCT04922853. Registered on June 4, 2021.
Collapse
Affiliation(s)
- Yu Shen
- Colorectal Cancer Center, Department of General Surgery, West China Hospital, Sichuan UniversitySichuan Province, Chengdu, China
| | - Wanyue Shi
- Colorectal Cancer Center, Department of General Surgery, West China Hospital, Sichuan UniversitySichuan Province, Chengdu, China
| | - Cui Huang
- Colorectal Cancer Center, Department of General Surgery, West China Hospital, Sichuan UniversitySichuan Province, Chengdu, China
| | - Xiaoling Gong
- Department of Radiology, West China Hospital, Sichuan University, Sichuan Province, Guo Xue Xiang 37#, Chengdu, China
| | - Mingtian Wei
- Colorectal Cancer Center, Department of General Surgery, West China Hospital, Sichuan UniversitySichuan Province, Chengdu, China
| | - Wenjian Meng
- Colorectal Cancer Center, Department of General Surgery, West China Hospital, Sichuan UniversitySichuan Province, Chengdu, China.
| | - Xiangbing Deng
- Colorectal Cancer Center, Department of General Surgery, West China Hospital, Sichuan UniversitySichuan Province, Chengdu, China.
| | - Ziqiang Wang
- Colorectal Cancer Center, Department of General Surgery, West China Hospital, Sichuan UniversitySichuan Province, Chengdu, China.
| |
Collapse
|
8
|
Tissera NS, Freile B, Waisberg F, Esteso F, Galli M, Loria FS, Luca R, Pedraza II, Enrico DH, Chacón C, Huertas E, Chacón MR, O’Connor JM. Short-course radiotherapy for rectal cancer: real-world evidence in Argentina. Ecancermedicalscience 2023; 17:1555. [PMID: 37396101 PMCID: PMC10310334 DOI: 10.3332/ecancer.2023.1555] [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: 04/12/2023] [Indexed: 07/04/2023] Open
Abstract
Background Short-course radiotherapy (SCRT) of 25 Gy in five daily fractions is a recommended strategy in the neoadjuvant setting for resectable locally advanced rectal cancer (LARC), as well as in cases of metastatic disease for local control. There is scarce information regarding the use of SCRT for patients who have received nonoperative management. Objectives To describe the characteristics of patients who received treatment with SCRT for LARC and metastatic rectal cancer, toxicity, and the approach after radiation treatment. Methods This is a retrospective analysis of all patients who underwent SCRT for rectal cancer at the Alexander Fleming Institute from March 2014 to June 2022. Results In total, 44 patients were treated with SCRT. The majority were male (29, 66%), with a median age of 59 years (interquartile range 46-73). Most patients had stage IV disease (26, 59.1%), followed by LARC (18, 40.9%). Most lesions were located in the middle rectum (30, 68%). The majority of LARC patients underwent SCRT followed by consolidation chemotherapy (ChT) (16/18, 89%), while most patients with metastatic disease underwent SCRT followed by consolidation ChT (14/26, 53.8%). A clinical complete response (cCR) was documented in 8/44, 18.2% of patients. Most patients with LARC and cCR were managed by a watch and wait approach (5/18, 27.7%). Local recurrence was observed in LARC cases (2/18, 11.1%). Patients who underwent SCRT following consolidation ChT were more likely to have adverse events (AEs) than those undergoing induction ChT following SCRT (11/30, 36.7% versus 3/12, 25%, p = 0.02). Conclusion In a subgroup of patients diagnosed with LARC and treated with SCRT followed by ChT, surgical treatment could be omitted after they achieved a cCR. Local recurrence was similar to that reported in a previous study. SCRT is a reasonable option for local disease control in stage IV disease, yielding low toxicity rates. Therefore, decisions must be made by a multidisciplinary team. Prospective studies are necessary to reach further conclusions.
Collapse
Affiliation(s)
- Natalia S Tissera
- Upper Gastrointestinal Cancer Translational Research Group, Vall´d Hebron Institute of Oncology (VHIO), 08035 Barcelona, Spain
- https://orcid.org/0000-0002-3396-6878
| | - Berenice Freile
- Department of Oncology, Alexander Fleming Institute, CABA C1426, Argentina
- https://orcid.org/0000-0003-3192-126X
| | - Federico Waisberg
- Department of Oncology, Alexander Fleming Institute, CABA C1426, Argentina
- https://orcid.org/0000-0003-4435-5068
| | - Federico Esteso
- Department of Oncology, Alexander Fleming Institute, CABA C1426, Argentina
- https://orcid.org/0000-0003-1977-9846
| | - Mariana Galli
- Department of Radiotherapy, Alexander Fleming Institute, CABA C1426, Argentina
- https://orcid.org/0000-0003-0147-2192
| | - Fernando Sanchez Loria
- Department of Surgery, Alexander Fleming Institute, CABA C1426, Argentina
- https://orcid.org/0000-0001-9708-0649
| | - Romina Luca
- Department of Oncology, Alexander Fleming Institute, CABA C1426, Argentina
- https://orcid.org/0000-0001-8564-905X
| | - Ivana Inés Pedraza
- Department of Surgery, Alexander Fleming Institute, CABA C1426, Argentina
- https://orcid.org/0000-0001-9679-8368
| | - Diego Hernán Enrico
- Department of Oncology, Alexander Fleming Institute, CABA C1426, Argentina
- https://orcid.org/0000-0003-4121-6855
| | - Carolina Chacón
- Department of Radiotherapy, Alexander Fleming Institute, CABA C1426, Argentina
- https://orcid.org/0009-0004-8556-6325
| | - Eduardo Huertas
- Department of Surgery, Alexander Fleming Institute, CABA C1426, Argentina
- https://orcid.org/0000-0003-3473-0928
| | - Matías Rodrigo Chacón
- Department of Oncology, Alexander Fleming Institute, CABA C1426, Argentina
- https://orcid.org/0000-0001-6872-4185
| | - Juan Manuel O’Connor
- Department of Oncology, Alexander Fleming Institute, CABA C1426, Argentina
- https://orcid.org/0000-0002-6975-5466
| |
Collapse
|
9
|
Seo N, Lim JS. [Interpretation of Rectal MRI after Neoadjuvant Treatment in Patients with Rectal Cancer]. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2023; 84:550-564. [PMID: 37325000 PMCID: PMC10265231 DOI: 10.3348/jksr.2023.0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 02/28/2023] [Accepted: 03/14/2023] [Indexed: 06/17/2023]
Abstract
MRI is currently the imaging modality of choice to evaluate rectal cancer after neoadjuvant treatment. The purposes of restaging MRI are to assess the resectability of rectal cancer and to decide whether organ preservation strategies can be applied in patients with a complete clinical response. This review article indicates the key MRI features needed to evaluate rectal cancer after neoadjuvant treatment using a systematic approach. Assessment of primary tumor response including MRI findings to predict a complete response is discussed. Additionally, MRI evaluation of the relationship between the primary tumor and adjacent structures, lymph node response, extramural venous invasion, and tumor deposits after neoadjuvant treatment is presented. Knowledge of these imaging features and their clinical relevance may help radiologists provide an accurate and clinically valuable interpretation of restaging rectal MRI.
Collapse
|
10
|
Jayaprakasam VS, Alvarez J, Omer DM, Gollub MJ, Smith JJ, Petkovska I. Watch-and-Wait Approach to Rectal Cancer: The Role of Imaging. Radiology 2023; 307:e221529. [PMID: 36880951 PMCID: PMC10068893 DOI: 10.1148/radiol.221529] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 11/09/2022] [Accepted: 11/14/2022] [Indexed: 03/08/2023]
Abstract
The diagnosis and treatment of rectal cancer have evolved dramatically over the past several decades. At the same time, its incidence has increased in younger populations. This review will inform the reader of advances in both diagnosis and treatment. These advances have led to the watch-and-wait approach, otherwise known as nonsurgical management. This review briefly outlines changes in medical and surgical treatment, advances in MRI technology and interpretation, and landmark studies or trials that have led to this exciting juncture. Herein, the authors delve into current state-of-the-art methods to assess response to treatment with MRI and endoscopy. Currently, these methods for avoiding surgery can be used to detect a complete clinical response in as many as 50% of patients with rectal cancer. Finally, the limitations of imaging and endoscopy and future challenges will be discussed.
Collapse
Affiliation(s)
- Vetri Sudar Jayaprakasam
- From the Departments of Radiology (V.S.J., M.J.G., I.P.) and Surgery
(J.A., D.M.O., J.J.S.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave,
Box 29, New York, NY 10065
| | - Janet Alvarez
- From the Departments of Radiology (V.S.J., M.J.G., I.P.) and Surgery
(J.A., D.M.O., J.J.S.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave,
Box 29, New York, NY 10065
| | - Dana M. Omer
- From the Departments of Radiology (V.S.J., M.J.G., I.P.) and Surgery
(J.A., D.M.O., J.J.S.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave,
Box 29, New York, NY 10065
| | - Marc J. Gollub
- From the Departments of Radiology (V.S.J., M.J.G., I.P.) and Surgery
(J.A., D.M.O., J.J.S.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave,
Box 29, New York, NY 10065
| | - J. Joshua Smith
- From the Departments of Radiology (V.S.J., M.J.G., I.P.) and Surgery
(J.A., D.M.O., J.J.S.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave,
Box 29, New York, NY 10065
| | - Iva Petkovska
- From the Departments of Radiology (V.S.J., M.J.G., I.P.) and Surgery
(J.A., D.M.O., J.J.S.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave,
Box 29, New York, NY 10065
| |
Collapse
|
11
|
Awiwi MO, Kaur H, Ernst R, Rauch GM, Morani AC, Stanietzky N, Palmquist SM, Salem UI. Restaging MRI of Rectal Adenocarcinoma after Neoadjuvant Chemoradiotherapy: Imaging Findings and Potential Pitfalls. Radiographics 2023; 43:e220135. [PMID: 36927125 DOI: 10.1148/rg.220135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
Rectal adenocarcinoma constitutes about one-third of all colorectal adenocarcinoma cases. Rectal MRI has become mandatory for evaluation of patients newly diagnosed with rectal cancer because it can help accurately stage the disease, impact the choice to give neoadjuvant therapy or proceed with up-front surgery, and even direct surgical dissection planes. Better understanding of neoadjuvant chemoradiotherapy effects on rectal tumors and recognition that up to 30% of patients can have a pathologic complete response have opened the door for the nonsurgical "watch-and-wait" management approach for rectal adenocarcinoma. Candidates for this organ-preserving approach should have no evidence of malignancy on all three components of response assessment after neoadjuvant therapy (ie, digital rectal examination, endoscopy, and rectal MRI). Hence, rectal MRI again has a major role in directing patient management and possibly sparing patients from unnecessary surgical morbidity. In this article, the authors discuss the indications for neoadjuvant therapy in management of patients with rectal adenocarcinoma, describe expected imaging appearances of rectal adenocarcinoma after completion of neoadjuvant therapy, and outline the MRI tumor regression grading system. Since pelvic sidewall lymph node dissection is associated with a high risk of permanent genitourinary dysfunction, it is performed for only selected patients who have radiologic evidence of sidewall lymph node involvement. Therefore, the authors review the relevant lymphatic compartments of the pelvis and describe lymph node criteria for determining locoregional nodal spread. Finally, the authors discuss limitations of rectal MRI, describe several potential interpretation pitfalls after neoadjuvant therapy, and emphasize how these pitfalls may be avoided. © RSNA, 2023 Quiz questions for this article are available in the supplemental material.
Collapse
Affiliation(s)
- Muhammad O Awiwi
- From the Division of Diagnostic Imaging, Department of Abdominal Imaging, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030
| | - Harmeet Kaur
- From the Division of Diagnostic Imaging, Department of Abdominal Imaging, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030
| | - Randy Ernst
- From the Division of Diagnostic Imaging, Department of Abdominal Imaging, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030
| | - Gaiane M Rauch
- From the Division of Diagnostic Imaging, Department of Abdominal Imaging, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030
| | - Ajaykumar C Morani
- From the Division of Diagnostic Imaging, Department of Abdominal Imaging, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030
| | - Nir Stanietzky
- From the Division of Diagnostic Imaging, Department of Abdominal Imaging, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030
| | - Sarah M Palmquist
- From the Division of Diagnostic Imaging, Department of Abdominal Imaging, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030
| | - Usama I Salem
- From the Division of Diagnostic Imaging, Department of Abdominal Imaging, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030
| |
Collapse
|
12
|
Kim B, Lee CM, Jang JK, Kim J, Lim SB, Kim AY. Deep learning-based imaging reconstruction for MRI after neoadjuvant chemoradiotherapy for rectal cancer: effects on image quality and assessment of treatment response. ABDOMINAL RADIOLOGY (NEW YORK) 2023; 48:201-210. [PMID: 36261505 DOI: 10.1007/s00261-022-03701-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 10/01/2022] [Accepted: 10/03/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE To investigate the effects of deep learning-based imaging reconstruction (DLR) on the image quality of MRI of rectal cancer after chemoradiotherapy (CRT), and its accuracy in diagnosing pathological complete responses (pCR). METHODS We included 39 patients (men: women, 21:18; mean age ± standard deviation, 59.1 ± 9.7 years) with mid-to-lower rectal cancer who underwent a long-course of CRT and high-resolution rectal MRIs between January 2020 and April 2021. Axial T2WI was reconstructed using the conventional method (MRIconv) and DLR with two different noise reduction factors (MRIDLR30 and MRIDLR50). The signal-to-noise ratio (SNR) of the tumor was measured. Two experienced radiologists independently made a blind assessment of the complete response on MRI. The sensitivity and specificity for pCR were analyzed using a multivariable logistic regression analysis with generalized estimating equations. RESULTS Thirty-four patients did not have a pCR whereas five (12.8%) had pCR. Compared with the SNR of MRIconv (mean ± SD, 7.94 ± 1.92), MRIDLR30 and MRIDLR50 showed higher SNR (9.44 ± 2.31 and 11.83 ± 3.07, respectively) (p < 0.001). Compared to MRIconv, MRIDLR30 and MRIDLR50 showed significantly higher specificity values (p < 0.036) while the sensitivity values were not significantly different (p > 0.301). The sensitivity and specificity for pCR were 48.9% and 80.8% for MRIconv; 48.9% and 88.2% for MRIDLR30; and 38.8% and 86.7% for MRIDLR50, respectively. CONCLUSION DLR produced MR images with higher resolution and SNR. The specificity of MRI for identification of pCR was significantly higher with DLR than with conventional MRI.
Collapse
Affiliation(s)
- Bona Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Chul-Min Lee
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.,Department of Radiology, Hanyang University Medical Center, 222-1, Wangsimni-ro, Seongdong-gu, Seoul, 04763, Republic of Korea
| | - Jong Keon Jang
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
| | - Jihun Kim
- Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Seok-Byung Lim
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Ah Young Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| |
Collapse
|
13
|
Hui C, Vitzthum LK, Chang DT, Pollom EL. Neoadjuvant Therapy in the Post-German Rectal Trial Era: Making Sense in the Absence of Consensus. Pract Radiat Oncol 2023; 13:e54-e60. [PMID: 35803535 DOI: 10.1016/j.prro.2022.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 06/16/2022] [Accepted: 06/23/2022] [Indexed: 01/10/2023]
Abstract
Trimodality therapy per the German Rectal Trial has led to excellent locoregional outcomes for locally advanced rectal cancer. Recent efforts have shifted toward improving distant control and health-related quality of life in this disease. To this end, total neoadjuvant therapy has become an increasingly used approach in which most, if not all, chemotherapy is delivered before surgery to improve compliance and to address micrometastases early. To avoid surgical morbidity, a "watch-and-wait" approach, in which total mesorectal excision is deferred, has also been studied for patients who achieve a clinical complete response after chemoradiation. These 2 concurrent treatment trends have raised many points of uncertainty in what used to be a relatively straightforward neoadjuvant treatment paradigm. We discuss here our approach to neoadjuvant therapy for locally advanced rectal cancer, based on the data we currently have and through shared decision-making with patients to help them select the treatment that best aligns with their preferences and values.
Collapse
Affiliation(s)
- Caressa Hui
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Lucas K Vitzthum
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Daniel T Chang
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Erqi L Pollom
- Department of Radiation Oncology, Stanford University, Stanford, California.
| |
Collapse
|
14
|
Boubaddi M, Fleming C, Vendrely V, Frulio N, Salut C, Rullier E, Denost Q. Feasibility study of a Response Surveillance Program in locally advanced mid and low rectal cancer to increase organ preservation. Eur J Surg Oncol 2023; 49:237-243. [PMID: 36114048 DOI: 10.1016/j.ejso.2022.08.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/02/2022] [Accepted: 08/25/2022] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Assessment of tumor response in rectal cancer after neoadjuvant treatment by MRI (Tumour Regression Grade, TRG 1-5) is well standardized. The overall timing and method of defining complete response (cCR) remain controversial. The aim of this work was to evaluate the feasibility of a defined Response Surveillance Program (RSP) to increase organ preservation for locally advanced rectal cancer after neoadjuvant treatment. METHODS A standardized program of clinical (CR), radiological (RR) and metabolic (MR) assessment of tumor response is defined over a 6 month period from completion of NACRT with formal assessment performed every 2 months (M). Patients with TRG1-3 at M2 and TRG1-2 at M4 continue in the program up to M6 assessment. Patients managed with this protocol from 2016 to 2020 were analyzed. The primary endpoint was rectal preservation rate. Secondary endpoints included disease-free survival and overall survival at 3 years. RESULT 314 potentially suitable patients were enrolled in the RSP and 50 patients completed the six month program and were successfully enrolled into watch and wait. Fourteen (28%) were T2 tumor stage, 27 (54%) T3 and nine (18%) were T4. During watch and wait, patients with locoregional recurrence (n = 11) were treated with local excision (n = 3), endocavitary radiotherapy (n = 1), TME (n = 5) and APR (n = 2). With a median follow-up of 32 months, the rectal preservation rate was 88%, with a 3-year disease-free survival of 67% and an overall survival of 98%. CONCLUSION This study validates the feasibility of the practical implementation of a Response Surveillance Program to increase organ preservation rates without compromising oncological outcomes in rectal cancer.
Collapse
Affiliation(s)
| | | | | | - Nora Frulio
- Department of Radiology, CHU, Bordeaux, France
| | | | - Eric Rullier
- Department of Colorectal Surgery, CHU, Bordeaux, France
| | - Quentin Denost
- Department of Colorectal Surgery, CHU, Bordeaux, France.
| |
Collapse
|
15
|
Jameson MB, Stevenson ARL, Ngan SY. TNT: Raising more questions than answers? Asia Pac J Clin Oncol 2022; 18:489-492. [PMID: 35322550 DOI: 10.1111/ajco.13760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 01/16/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Michael B Jameson
- Waikato Clinical Campus, University of Auckland, Hamilton, New Zealand.,Oncology Department, Waikato District Health Board, Hamilton, New Zealand
| | - Andrew R L Stevenson
- Department of Surgery, University of Queensland, Brisbane, Queensland, Australia
| | - Samuel Y Ngan
- Division of Radiation Oncology, Sir Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
16
|
Robinson P, Bacon CM, Lim SJ, Shaaban AM, Brierley D, Lewis I, Harrison DJ, Kendall TJ, Robinson M. Assessment of clinical trial protocols for pathology content using the SPIRIT-Path guidelines highlights areas for improvement. J Pathol Clin Res 2022; 8:411-421. [PMID: 35638866 PMCID: PMC9353656 DOI: 10.1002/cjp2.274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/24/2022] [Accepted: 04/26/2022] [Indexed: 11/30/2022]
Abstract
The SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) 2013 Statement provides evidence-based recommendations for the minimum content of clinical trial protocols. The Cellular Molecular Pathology Initiative, hosted by the UK National Cancer Research Institute, developed an extension, SPIRIT-Path, describing how to effectively incorporate pathology support into clinical trial protocols. The current study assessed the inclusion of SPIRIT-Path items in protocols of active clinical trials. Publicly available clinical trial protocols were identified for assessment against the new guidelines using a single UK hospital as the 'test site'. One hundred and ninety interventional clinical trials were identified as receiving support from the pathology department. However, only 38 had publicly available full trial protocols (20%) and following application of the inclusion/exclusion criteria, 19 were assessed against the SPIRIT-Path guidelines. The reviewed clinical trial protocols showed some areas of compliance and highlighted other items that were inadequately described. The latter lacked information about the individuals responsible for the pathology content of the trial protocol, how pathology activities and roles were organised in the trial, where the laboratory work would be carried out, and the accreditation status of the laboratory. Only one trial had information specific to digital pathology, a technology certain to become more prevalent in the future. Adoption of the SPIRIT-Path checklist will facilitate comprehensive trial protocols that address all the key cellular and molecular pathology aspects of interventional clinical trials. This study highlights once again the lack of public availability of trial protocols. Full trial protocols should be available for scrutiny by the scientific community and the public who participate in the studies, increasing the transparency of clinical trial activity and improving quality.
Collapse
Affiliation(s)
- Peter Robinson
- School of Medical EducationNewcastle UniversityNewcastle upon TyneUK
| | - Chris M Bacon
- Translational and Clinical Research InstituteNewcastle UniversityNewcastle upon TyneUK
- Department of Cellular PathologyNewcastle upon Tyne Hospitals NHS Foundation TrustNewcastle upon TyneUK
| | - Shujing J Lim
- Department of Cellular PathologyNewcastle upon Tyne Hospitals NHS Foundation TrustNewcastle upon TyneUK
| | - Abeer M Shaaban
- Department of HistopathologyQueen Elizabeth HospitalBirminghamUK
- Institute of Cancer and Genomic SciencesUniversity of BirminghamBirminghamUK
| | - Daniel Brierley
- Unit of Oral and Maxillofacial PathologyUniversity of SheffieldSheffieldUK
| | - Ian Lewis
- National Cancer Research InstituteLondonUK
| | | | | | - Max Robinson
- Department of Cellular PathologyNewcastle upon Tyne Hospitals NHS Foundation TrustNewcastle upon TyneUK
| |
Collapse
|
17
|
Fletcher T, Thompson AJ, Ashrafian H, Darzi A. The measurement and modification of hypoxia in colorectal cancer: overlooked but not forgotten. Gastroenterol Rep (Oxf) 2022; 10:goac042. [PMID: 36032656 PMCID: PMC9406947 DOI: 10.1093/gastro/goac042] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 05/18/2022] [Accepted: 07/21/2022] [Indexed: 11/14/2022] Open
Abstract
Tumour hypoxia is the inevitable consequence of a tumour's rapid growth and disorganized, inefficient vasculature. The compensatory mechanisms employed by tumours, and indeed the absence of oxygen itself, hinder the ability of all treatment modalities. The clinical consequence is poorer overall survival, disease-free survival, and locoregional control. Recognizing this, clinicians have been attenuating the effect of hypoxia, primarily with hypoxic modification or with hypoxia-activated pro-drugs, and notable success has been demonstrated. However, in the case of colorectal cancer (CRC), there is a general paucity of knowledge and evidence surrounding the measurement and modification of hypoxia, and this is possibly due to the comparative inaccessibility of such tumours. We specifically review the role of hypoxia in CRC and focus on the current evidence for the existence of hypoxia in CRC, the majority of which originates from indirect positron emission topography imaging with hypoxia selective radiotracers; the evidence correlating CRC hypoxia with poorer oncological outcome, which is largely based on the measurement of hypoxia inducible factor in correlation with clinical outcome; the evidence of hypoxic modification in CRC, of which no direct evidence exists, but is reflected in a number of indirect markers; the prognostic and monitoring implications of accurate CRC hypoxia quantification and its potential in the field of precision oncology; and the present and future imaging tools and technologies being developed for the measurement of CRC hypoxia, including the use of blood-oxygen-level-dependent magnetic resonance imaging and diffuse reflectance spectroscopy.
Collapse
Affiliation(s)
- Teddy Fletcher
- Department of Surgery and Cancer, Queen Elizabeth the Queen Mother Wing, St Mary’s Hospital, Imperial College London, London, UK
| | - Alex J Thompson
- The Hamlyn Centre, Institute of Global Health Innovation, Imperial College London, London, UK
| | - Hutan Ashrafian
- Department of Surgery and Cancer, Queen Elizabeth the Queen Mother Wing, St Mary’s Hospital, Imperial College London, London, UK
| | - Ara Darzi
- Department of Surgery and Cancer, Queen Elizabeth the Queen Mother Wing, St Mary’s Hospital, Imperial College London, London, UK
| |
Collapse
|
18
|
Domínguez Tristancho JL. Organ preservation in rectal cancer, the desire of a new paradigm. Cir Esp 2022; 100:389-391. [PMID: 35525484 DOI: 10.1016/j.cireng.2021.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 07/31/2021] [Indexed: 06/14/2023]
Affiliation(s)
- José Luis Domínguez Tristancho
- Unidad de Coloproctología y Terapia Celular, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Fundación, Jiménez Díaz, Madrid, Spain.
| |
Collapse
|
19
|
Neoadjuvant and Adjuvant Therapy for Local Excision of Rectal Cancer. SEMINARS IN COLON AND RECTAL SURGERY 2022. [DOI: 10.1016/j.scrs.2022.100900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
20
|
A new magnetic resonance imaging tumour response grading scheme for locally advanced rectal cancer. Br J Cancer 2022; 127:268-277. [PMID: 35388140 PMCID: PMC9296509 DOI: 10.1038/s41416-022-01801-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 03/14/2022] [Accepted: 03/21/2022] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND The potential of using magnetic resonance image tumour-regression grading (MRI-TRG) system to predict pathological TRG is debatable for locally advanced rectal cancer treated by neoadjuvant radiochemotherapy. METHODS Referring to the American Joint Committee on Cancer/College of American Pathologists (AJCC/CAP) TRG classification scheme, a new four-category MRI-TRG system based on the volumetric analysis of the residual tumour and radiochemotherapy induced anorectal fibrosis was established. The agreement between them was evaluated by Kendall's tau-b test, while Kaplan-Meier analysis was used to calculate survival outcomes. RESULTS In total, 1033 patients were included. Good agreement between MRI-TRG and AJCC/CAP TRG classifications was observed (k = 0.671). Particularly, as compared with other pairs, MRI-TRG 0 displayed the highest sensitivity [90.1% (95% CI: 84.3-93.9)] and specificity [92.8% (95% CI: 90.4-94.7)] in identifying AJCC/CAP TRG 0 category patients. Except for the survival ratios that were comparable between the MRI-TRG 0 and MRI-TRG 1 categories, any two of the four categories had distinguished 3-year prognosis (all P < 0.05). Cox regression analysis further proved that the MRI-TRG system was an independent prognostic factor (all P < 0.05). CONCLUSION The new MRI-TRG system might be a surrogate for AJCC/CAP TRG classification scheme. Importantly, the system is a reliable and non-invasive way to identify patients with complete pathological responses.
Collapse
|
21
|
Fernandes MC, Gollub MJ, Brown G. The importance of MRI for rectal cancer evaluation. Surg Oncol 2022; 43:101739. [PMID: 35339339 PMCID: PMC9464708 DOI: 10.1016/j.suronc.2022.101739] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 02/20/2022] [Indexed: 12/19/2022]
Abstract
Magnetic resonance imaging (MRI) has gained increasing importance in the management of rectal cancer over the last two decades. The role of MRI in patients with rectal cancer has expanded beyond the tumor-node-metastasis (TNM) system in both staging and restaging scenarios and has contributed to identifying "high" and "low" risk features that can be used to tailor and personalize patient treatment; for instance, selecting the patients for neoadjuvant chemoradiation (NCRT) before the total mesorectal excision (TME) surgery based on risk of recurrence. Among those features, the status of the circumferential resection margin (CRM), extramural vascular invasion (EMVI), and tumor deposits (TD) have stood out. Moreover, MRI also has played a role in surgical planning, especially when the tumor is located in the low rectum, when the relationship between tumor and the anal canal is important to choose the best surgical approach, and in cases of locally advanced or recurrent tumors invading adjacent pelvic organs that may require more complex surgeries such as pelvic exenteration. As approaches using organ preservation emerge, including transanal local excision and "watch-and-wait", MRI may help in the patient selection for those treatments, follow up, and detection of tumor regrowth. Additionally, potential MRI-based prognostic and predictive biomarkers, such as quantitative and semi-quantitative metrics derived from functional sequences like diffusion-weighted imaging (DWI) and dynamic contrast-enhanced (DCE), and radiomics, are under investigation. This review provides an overview of the current role of MRI in rectal cancer in staging and restaging and highlights the main areas under investigation and future perspectives.
Collapse
|
22
|
Raj P, Patel S, Prem A. Comment on Timing of Surgery For Patients With Rectal Cancers Not Responding to Preoperative Chemoradiation. JAMA Surg 2022; 157:548. [PMID: 35195721 DOI: 10.1001/jamasurg.2021.7589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Prudvi Raj
- Department of Surgical Oncology, Tata Memorial Centre, Mahamana Pandit Madan Mohan Malaviya Cancer Center (MPMMCC) & Homi Bhabha Cancer Hospital, Varanasi, India
| | - Swapnil Patel
- Department of Surgical Oncology, Tata Memorial Centre, Mahamana Pandit Madan Mohan Malaviya Cancer Center (MPMMCC) & Homi Bhabha Cancer Hospital, Varanasi, India
| | - Amar Prem
- Department of Surgical Oncology, Tata Memorial Centre, Mahamana Pandit Madan Mohan Malaviya Cancer Center (MPMMCC) & Homi Bhabha Cancer Hospital, Varanasi, India
| |
Collapse
|
23
|
Whelan S, Burneikis D, Kalady MF. Rectal cancer: Maximizing local control and minimizing toxicity. J Surg Oncol 2021; 125:46-54. [PMID: 34897711 DOI: 10.1002/jso.26743] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 10/11/2021] [Indexed: 12/31/2022]
Abstract
Adoption of multimodality treatment approach for rectal cancer has resulted in significant improvements in oncologic outcomes. The roles of chemotherapy, radiation, and surgery in rectal cancer treatment are continuously evolving with the goal of achieving the best possible oncologic and functional outcome while minimizing treatment toxicity. The aim of this review is to summarize the most recent trials focusing on organ-sparing treatment strategies and the optimal selection of patients for neoadjuvant radiation therapy.
Collapse
Affiliation(s)
- Sean Whelan
- Department of Surgery, Division of Colon and Rectal Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Dominykas Burneikis
- Department of Surgery, Division of Colon and Rectal Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Matthew F Kalady
- Department of Surgery, Division of Colon and Rectal Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| |
Collapse
|
24
|
Kastner C, Petritsch B, Reibetanz J, Germer CT, Wiegering A. [Complete response after neoadjuvant therapy of rectal cancer: implications for surgery]. Chirurg 2021; 93:144-151. [PMID: 34878582 DOI: 10.1007/s00104-021-01540-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2021] [Indexed: 12/17/2022]
Abstract
For (locally advanced) rectal cancer, a multimodal therapy concept comprising neoadjuvant radiotherapy/chemoradiotherapy, radical surgical resection with partial/complete mesorectal excision and subsequent adjuvant chemotherapy represents the current international standard of care. Further developments in neoadjuvant therapy concepts, such as the principle of total neoadjuvant therapy, lead to an increasing number of patients who show a complete clinical response in restaging after neoadjuvant therapy without clinically detectable residual tumor. In view of the risk associated with radical surgical resection in terms of perioperative morbidity and a potentially non-continence-preserving procedure, the question of the oncological justifiability of an organ-preserving procedure in the case of a complete clinical response under neoadjuvant therapy is increasingly being raised. The therapeutic principle of watch and wait, defined by refraining from immediate radical surgical resection and inclusion in a close-meshed, structured follow-up program, currently appears to be oncologically justifiable based on the current study situation; however, for the initial evaluation of the extent of the clinical response and for the structuring of the close-meshed follow-up program, further optimization and standardization based on broadly designed studies appear necessary in order to be able to provide this concept to a clearly defined patient collective as an oncologically equivalent therapy principle also outside specialized centers.
Collapse
Affiliation(s)
- Carolin Kastner
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Zentrum für operative Medizin, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
- Institut für Biochemie und molekulare Biologie, Julius-Maximilians-Universität Würzburg, Würzburg, Deutschland
| | - Bernhard Petritsch
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Joachim Reibetanz
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Zentrum für operative Medizin, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Christoph-Thomas Germer
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Zentrum für operative Medizin, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
- Comprehensive Cancer Center Mainfranken, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Armin Wiegering
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Zentrum für operative Medizin, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland.
- Institut für Biochemie und molekulare Biologie, Julius-Maximilians-Universität Würzburg, Würzburg, Deutschland.
- Comprehensive Cancer Center Mainfranken, Universitätsklinikum Würzburg, Würzburg, Deutschland.
| |
Collapse
|
25
|
Fokas E, Appelt A, Glynne-Jones R, Beets G, Perez R, Garcia-Aguilar J, Rullier E, Smith JJ, Marijnen C, Peters FP, van der Valk M, Beets-Tan R, Myint AS, Gerard JP, Bach SP, Ghadimi M, Hofheinz RD, Bujko K, Gani C, Haustermans K, Minsky BD, Ludmir E, West NP, Gambacorta MA, Valentini V, Buyse M, Renehan AG, Gilbert A, Sebag-Montefiore D, Rödel C. International consensus recommendations on key outcome measures for organ preservation after (chemo)radiotherapy in patients with rectal cancer. Nat Rev Clin Oncol 2021; 18:805-816. [PMID: 34349247 DOI: 10.1038/s41571-021-00538-5] [Citation(s) in RCA: 78] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2021] [Indexed: 02/07/2023]
Abstract
Multimodal treatment strategies for patients with rectal cancer are increasingly including the possibility of organ preservation, through nonoperative management or local excision. Organ preservation strategies can enable patients with a complete response or near-complete clinical responses after radiotherapy with or without concomitant chemotherapy to safely avoid the morbidities associated with radical surgery, and thus to maintain anorectal function and quality of life. However, standardization of the key outcome measures of organ preservation strategies is currently lacking; this includes a lack of consensus of the optimal definitions and selection of primary end points according to the trial phase and design; the optimal time points for response assessment; response-based decision-making; follow-up schedules; use of specific anorectal function tests; and quality of life and patient-reported outcomes. Thus, a consensus statement on outcome measures is necessary to ensure consistency and facilitate more accurate comparisons of data from ongoing and future trials. Here, we have convened an international group of experts with extensive experience in the management of patients with rectal cancer, including organ preservation approaches, and used a Delphi process to establish the first international consensus recommendations for key outcome measures of organ preservation, in an attempt to standardize the reporting of data from both trials and routine practice in this emerging area.
Collapse
Affiliation(s)
- Emmanouil Fokas
- Department of Radiotherapy of Oncology, University of Frankfurt, Frankfurt, Germany.
- German Cancer Research Center (DKFZ), Heidelberg, Germany.
- German Cancer Consortium (DKTK), Frankfurt, Germany.
- Frankfurt Cancer Institute (FCI), Frankfurt, Germany.
| | - Ane Appelt
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - Robert Glynne-Jones
- Department of Radiotherapy, Mount Vernon Centre for Cancer Treatment, Northwood, UK
| | - Geerard Beets
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, Netherlands
- Department of Surgery, Netherlands Cancer Institute Amsterdam, Amsterdam, Netherlands
| | - Rodrigo Perez
- Department of Surgery, Angelita & Joaquim Institute, São Paulo, Brazil
| | - Julio Garcia-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Eric Rullier
- Department of Colorectal Surgery, Haut-Lévèque Hospital, Centre Hospitalier Universitaire (CHU) Bordeaux, Bordeaux, France
| | - J Joshua Smith
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Corrie Marijnen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Femke P Peters
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Maxine van der Valk
- Department of Surgery, Netherlands Cancer Institute Amsterdam, Amsterdam, Netherlands
| | - Regina Beets-Tan
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, Netherlands
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Arthur S Myint
- The Clatterbridge Cancer Centre, Royal Liverpool University Hospital, Liverpool, UK
| | | | - Simon P Bach
- Academic Department of Surgery, University of Birmingham, Birmingham, UK
| | - Michael Ghadimi
- Department of General, Visceral, and Paediatric Surgery, University Medical Center, Göttingen, Germany
| | - Ralf D Hofheinz
- Department of Medical Oncology, University Hospital Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Krzysztof Bujko
- Department of Radiotherapy, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Cihan Gani
- Department of Radiation Oncology, University Hospital and Medical Faculty Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
- German Cancer Research Center (DKFZ) Heidelberg and German Consortium for Translational Cancer Research (DKTK) Partner Site Tübingen, Tübingen, Germany
| | - Karin Haustermans
- Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Bruce D Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ethan Ludmir
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nicholas P West
- Division of Pathology and Data Analytics, Leeds Institute of Medical Research at St. James's, School of Medicine, University of Leeds, Leeds, UK
| | - Maria A Gambacorta
- Department of Radiation Oncology and Medical Oncology, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Vincenzo Valentini
- Department of Radiation Oncology and Medical Oncology, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marc Buyse
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics, Hasselt University, Diepenbeek, Belgium
- International Drug Development Institute, San Francisco, CA, USA
| | - Andrew G Renehan
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Colorectal and Peritoneal Oncology Centre, Christie NHS Foundation Trust, Manchester, UK
| | - Alexandra Gilbert
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | | | - Claus Rödel
- Department of Radiotherapy of Oncology, University of Frankfurt, Frankfurt, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- German Cancer Consortium (DKTK), Frankfurt, Germany
- Frankfurt Cancer Institute (FCI), Frankfurt, Germany
| |
Collapse
|
26
|
Domínguez Tristancho JL. Organ preservation in rectal cancer, the desire of a new paradigm. Cir Esp 2021; 100:S0009-739X(21)00261-X. [PMID: 34544563 DOI: 10.1016/j.ciresp.2021.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/28/2021] [Accepted: 07/31/2021] [Indexed: 10/20/2022]
Affiliation(s)
- José Luis Domínguez Tristancho
- Unidad de Coloproctología y Terapia Celular, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Fundación Jiménez Díaz, Madrid, España.
| |
Collapse
|
27
|
Teneva T, Zlatarov A, Grigorov R. Role of Magnetic Resonance Imaging in Patients with Rectal Cancer. COLORECTAL CANCER 2021. [DOI: 10.5772/intechopen.94868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In a chapter about rectal cancer there is content about rectal anatomy in relation to magnet-resonanse imaging and TME- surgery (total mesorectal excision). Secondly there is content about imaging methods used in diagnosis and follow-up of rectal cancer. Very important topic is concerning the novel imaging strategies in surgical and radiotherapy planning in the era of individual oncologic approach to the patient. At last there is detailed desctiption and metaanalysis of imaging strategies concerning neoadjuvant and adjuvant radiotherapy and chemotherapy for rectal cancer patients. All imaging markers correspond to substantial oncologic parameters such as survival rates. The connecting bridge is magnet-resonance imaging.
Collapse
|
28
|
On J, Shim J, Mackay C, Murray G, Samuel L, Parnaby C, Ramsay G. Pathological response post neoadjuvant therapy for locally advanced rectal cancer is an independent predictor of survival. Colorectal Dis 2021; 23:1326-1333. [PMID: 33394572 DOI: 10.1111/codi.15512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 12/14/2020] [Accepted: 12/22/2020] [Indexed: 02/08/2023]
Abstract
AIM Neoadjuvant treatment (NaT) for locally advanced rectal cancer prior to surgery has led to improved outcomes. However, the relationship between pathological response to NaT and survival is not entirely clear. The aim of this study was to assess the degree of pathological response to NaT on survival outcomes. METHODS Clinical and pathological data were collected from a prospectively maintained pathology database between 2005 and 2017. The primary outcome was the overall survival based on pathological response categorized as complete, good partial, partial and minimal. Univariate and multivariate analyses were conducted to identify variables predictive of survival. Cox proportional hazard ratios were used for survival. RESULTS A total of 596 patients had surgery following NaT for locally advanced rectal cancer. The median follow-up was 4.57 years (interquartile range 2.21-8.15 years). The overall survival for complete pathological response was 75.6% vs. 37.3% for minimal response (P < 0.001). The overall survival at the end of the study in the good partial vs. partial response groups was 58.9% vs. 39% (P < 0.001). On multivariate analysis, the degree of pathological response remains an independent variable for overall and disease-specific survival across all categories. DISCUSSION In addition to other pathological variables, the degree of pathological response to NaT is an independent predictor for survival outcomes. Future verification of these findings elsewhere could support NaT response being used for adjuvant therapy decision making.
Collapse
Affiliation(s)
- Jason On
- Department of Colorectal Surgery, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - Joanna Shim
- Department of Epidemiology, University of Aberdeen, Aberdeen, UK
| | - Craig Mackay
- Department of Colorectal Surgery, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - Graeme Murray
- Pathology, Division of Applied Medicine, School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK
| | - Leslie Samuel
- Department of Clinical Oncology, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - Craig Parnaby
- Department of Colorectal Surgery, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - George Ramsay
- Department of Colorectal Surgery, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK.,Rowett Institute for Nutrition and Health, University of Aberdeen, Aberdeen, UK
| |
Collapse
|
29
|
Song SH, Park JS, Kang MK, Choi GS, Park SY, Kim HJ, Kim JG, Kang BW, Baek JH, Baek DW, Kim JC, Park SH, Cho SH, Seo AN. Initial experience of preoperative short-course radiotherapy followed by oxaliplatin-based consolidation chemotherapy for locally advanced rectal cancer. Int J Colorectal Dis 2021; 36:1279-1286. [PMID: 33547945 DOI: 10.1007/s00384-021-03875-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/28/2021] [Indexed: 02/08/2023]
Abstract
PURPOSE We analyzed the safety and feasibility of preoperative short-course radiotherapy (SCRT) followed by consolidation chemotherapy for patients with locally advanced rectal cancer (LARC). METHODS From April 2018 to May 2019, 19 patients with LARC were treated with SCRT followed by three cycles of consolidation chemotherapy with leucovorin, fluorouracil, and oxaliplatin (FOLFOX6) before surgery. Adjuvant chemotherapy relied on oxaliplatin. Tumor response, patient compliance, and toxicities were analyzed. RESULTS The median age was 60 years (range 44-71), and 16 of the patients were male. The median tumor height was 5 cm (range 0-9) from anal verge. All patients received a total dose of 25 Gy in five fractions. The number of cycles of FOLFOX6 before surgery was three in 17, four in one, five in one. Five patients required dose reductions in consolidation chemotherapy. The median interval between initiation of SCRT and surgery was 10.6 weeks (range 8.6-16.4). A pathologic complete response was seen in two patients (11%). Grade III toxicities to the preoperative treatment were seen in five patients (26%): diarrhea in two, a decreased white blood cell count in one, and anemia in two. Postoperative complications arising within 30 days developed in five patients (26%). During the median follow-up period of 20.4 months, there was no tumor recurrence. CONCLUSION Preoperative SCRT followed by oxaliplatin-based consolidation chemotherapy showed acceptable toxicity and feasibility in patients with LARC. Prospective randomized trials are warranted to verify the efficacy and safety of this treatment strategy compared with conventional long-course concurrent chemoradiotherapy.
Collapse
Affiliation(s)
- Seung Ho Song
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Jun Seok Park
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Republic of Korea.
| | - Min Kyu Kang
- Department of Radiation Oncology, School of Medicine, Kyungpook National University, Daegu, Republic of Korea.
| | - Gyu-Seog Choi
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Soo Yeun Park
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Hye Jin Kim
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Jong Gwang Kim
- Department of Hematology/Oncology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Byung Woog Kang
- Department of Hematology/Oncology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Jin Ho Baek
- Department of Hematology/Oncology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Dong Won Baek
- Department of Hematology/Oncology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Jae-Chul Kim
- Department of Radiation Oncology, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Shin-Hyung Park
- Department of Radiation Oncology, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Seung Hyun Cho
- Department of Radiology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - An Na Seo
- Department of Pathology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| |
Collapse
|
30
|
Maslova M, Herden H, Schork K, Turewicz M, Eisenacher M, Schroers R, Baraniskin A, Mika T. Computertomography-Based Prediction of Complete Response Following Neoadjuvant Chemoradiotherapy of Locally Advanced Rectal Cancer. Front Oncol 2021; 11:623144. [PMID: 34136378 PMCID: PMC8202275 DOI: 10.3389/fonc.2021.623144] [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: 10/29/2020] [Accepted: 04/19/2021] [Indexed: 12/24/2022] Open
Abstract
Therapeutic strategies for patients with locally advanced rectal cancer (LARC) who are achieving a pathological complete response (pCR) after neoadjuvant radio-chemotherapy (neoCRT) are being increasingly investigated. Recent trials challenge the current standard therapy of total mesorectal excision (TME). For some patients, the treatment strategy of “watch-and-wait” seems a preferable procedure. The key factor in determining individual treatment strategies following neoCRT is the precise evaluation of the tumor response. Contrast-enhanced computer tomography (ceCT) has proven its ability to discriminate benign and malign lesions in multiple cancers. In this study, we retrospectively analyzed the ceCT based density of LARC in 30 patients, undergoing neoCRT followed by TME. We compared the tumors´ pre- and post-neoCRT density and correlated the results to the amount of residual vital tumor cells in the resected tissue. Overall, the density decreased after neoCRT, with the highest decrease in patients achieving pCR. Densitometry demonstrated a specificity of 88% and sensitivity of 68% in predicting pCR. Thus, we claim that ceCT based densitometry is a useful tool in identifying patients with LARC who may benefit from a “watch-and-wait” strategy and suggest further prospective studies.
Collapse
Affiliation(s)
- Marina Maslova
- Department of Radiology, Neuroradiology and Nuclear Medicine, Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
| | - Heinz Herden
- Department of Radiology, VAMED Clinic, Bad Berleburg, Germany
| | - Karin Schork
- Medizinisches Proteom-Center, Ruhr University Bochum, Bochum, Germany
| | - Michael Turewicz
- Medizinisches Proteom-Center, Ruhr University Bochum, Bochum, Germany
| | - Martin Eisenacher
- Medizinisches Proteom-Center, Ruhr University Bochum, Bochum, Germany
| | - Roland Schroers
- Department of Medicine, Hematology and Oncology, Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
| | - Alexander Baraniskin
- Department of Medicine, Hematology and Oncology, Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
| | - Thomas Mika
- Department of Medicine, Hematology and Oncology, Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
| |
Collapse
|
31
|
Foley KG, Pearson B, Riddell Z, Taylor SA. Opportunities in cancer imaging: a review of oesophageal, gastric and colorectal malignancies. Clin Radiol 2021; 76:748-762. [PMID: 33579518 DOI: 10.1016/j.crad.2021.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 01/13/2021] [Indexed: 02/07/2023]
Abstract
The incidence of gastrointestinal (GI) malignancy is increasing worldwide. In particular, there is a concerning rise in incidence of GI cancer in younger adults. Direct endoscopic visualisation of luminal tumour sites requires invasive procedures, which are associated with certain risks, but remain necessary because of limitations in current imaging techniques and the continuing need to obtain tissue for diagnosis and genetic analysis; however, management of GI cancer is increasingly reliant on non-invasive, radiological imaging to diagnose, stage, and treat these malignancies. Oesophageal, gastric, and colorectal malignancies require specialist investigation and treatment due to the complex nature of the anatomy, biology, and subsequent treatment strategies. As cancer imaging techniques develop, many opportunities to improve tumour detection, diagnostic accuracy and treatment monitoring present themselves. This review article aims to report current imaging practice, advances in various radiological modalities in relation to GI luminal tumour sites and describes opportunities for GI radiologists to improve patient outcomes.
Collapse
Affiliation(s)
- K G Foley
- Department of Clinical Radiology, Royal Glamorgan Hospital, Llantrisant, UK.
| | - B Pearson
- National Imaging Academy Wales (NIAW), Pencoed, UK
| | - Z Riddell
- National Imaging Academy Wales (NIAW), Pencoed, UK
| | - S A Taylor
- Centre for Medical Imaging, UCL, London, UK
| |
Collapse
|
32
|
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
|
33
|
Park SH, Cho SH, Choi SH, Jang JK, Kim MJ, Kim SH, Lim JS, Moon SK, Park JH, Seo N. MRI Assessment of Complete Response to Preoperative Chemoradiation Therapy for Rectal Cancer: 2020 Guide for Practice from the Korean Society of Abdominal Radiology. Korean J Radiol 2020; 21:812-828. [PMID: 32524782 PMCID: PMC7289703 DOI: 10.3348/kjr.2020.0483] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 04/18/2020] [Accepted: 04/19/2020] [Indexed: 12/23/2022] Open
Abstract
Objective To provide an evidence-based guide for the MRI interpretation of complete tumor response after neoadjuvant chemoradiation therapy (CRT) for rectal cancer using visual assessment on T2-weighted imaging (T2) and diffusion-weighted imaging (DWI). Materials and Methods PubMed MEDLINE, EMBASE, and Cochrane Library were searched on November 28, 2019 to identify articles on the following issues: 1) sensitivity and specificity of T2 or DWI for diagnosing pathologic complete response (pCR) and the criteria for MRI diagnosis; 2) MRI alone vs. MRI combined with other test(s) in sensitivity and specificity for pCR; and 3) tests to select patients for the watch-and-wait management. Eligible articles were selected according to meticulous criteria and were synthesized. Results Of 1615 article candidates, 55 eligible articles (for all three issues combined) were identified. Combined T2 and DWI performed better than T2 alone, with a meta-analytic summary sensitivity of 0.62 (95% confidence interval [CI], 0.43–0.77; I2 = 80.60) and summary specificity of 0.89 (95% CI, 0.80–0.94; I2 = 92.61) for diagnosing pCR. The criteria for the complete response on T2 in most studies had the commonality of remarkable tumor decrease to the absence of mass-like or nodular intermediate signal, although somewhat varied, as follows: (near) normalization of the wall; regular, thin, hypointense scar in the luminal side with (near) normal-appearance or homogeneous intermediate signal in the underlying wall; and hypointense thickening of the wall. The criteria on DWI were the absence of a hyperintense signal at high b-value (≥ 800 sec/mm2) in most studies. The specific algorithm to combine T2 and DWI was obscure in half of the studies. MRI combined with endoscopy was the most utilized means to select patients for the watch-and-wait management despite a lack of strong evidence to guide and support a multi-test approach. Conclusion This systematic review and meta-analysis provide an evidence-based practical guide for MRI assessment of complete tumor response after CRT for rectal cancer.
Collapse
Affiliation(s)
- Seong Ho Park
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
| | - Seung Hyun Cho
- Department of Radiology, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sang Hyun Choi
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jong Keon Jang
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Min Ju Kim
- Department of Radiology, Ewha Womans University Seoul Hospital, Seoul, Korea
| | - Seung Ho Kim
- Department of Radiology, Inje University College of Medicine, Haeundae Paik Hospital, Busan, Korea
| | - Joon Seok Lim
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Kyoung Moon
- Department of Radiology, Kyung Hee University Hospital, Seoul, Korea
| | - Ji Hoon Park
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Nieun Seo
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | | |
Collapse
|
34
|
Haak HE, Maas M, Trebeschi S, Beets-Tan RGH. Modern MR Imaging Technology in Rectal Cancer; There Is More Than Meets the Eye. Front Oncol 2020; 10:537532. [PMID: 33117678 PMCID: PMC7578261 DOI: 10.3389/fonc.2020.537532] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 09/02/2020] [Indexed: 12/29/2022] Open
Abstract
MR imaging (MRI) is now part of the standard work up of patients with rectal cancer. Restaging MRI has been traditionally used to plan the surgical approach. Its role has recently increased and been adopted as a valuable tool to assist the clinical selection of clinical (near) complete responders for organ preserving treatment. Recently several studies have addressed new imaging biomarkers that combined with morphological provides a comprehensive picture of the tumor. Diffusion-weighted MRI (DWI) has entered the clinics and proven useful for response assessment after chemoradiotherapy. Other functional (quantitative) MRI technologies are on the horizon including artificial intelligence modeling. This narrative review provides an overview of recent advances in rectal cancer (re)staging by imaging with a specific focus on response prediction and evaluation of neoadjuvant treatment response. Furthermore, directions are given for future research.
Collapse
Affiliation(s)
- Hester E Haak
- Department of Radiology, Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, Netherlands.,Department of Surgery, Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, Netherlands.,GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, Netherlands
| | - Monique Maas
- Department of Radiology, Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, Netherlands
| | - Stefano Trebeschi
- Department of Radiology, Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, Netherlands.,GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, Netherlands
| | - Regina G H Beets-Tan
- Department of Radiology, Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, Netherlands.,GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, Netherlands.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
35
|
Guevara Jabiles A, Berrospi Espinoza F, Chávez Passiuri IK, Payet Meza E, Luque-Vásquez CE, Ruiz Figueroa E. TransAnal Total Mesorectal Excision (TaTME) in Peru: Case series. Int J Surg Case Rep 2020; 76:425-430. [PMID: 33099247 PMCID: PMC7585049 DOI: 10.1016/j.ijscr.2020.09.204] [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: 09/03/2020] [Revised: 09/22/2020] [Accepted: 09/30/2020] [Indexed: 11/25/2022] Open
Abstract
Transanal total mesorectum excision is feasible for mid and low rectal cancer. Good quality of the mesorectum specimen is obtain after TaTME surgery. TaTME with intersphincteric resection is a feasible option for selected cases of very low rectal cancer. Surgical complication rates after intersphincteric TaTME with hand-sewn coloanal anastomosis could be higher.
Introduction Describe and demonstrate the feasibility and safety of TaTME in short term outcomes in the Instituto Nacional de Enfermedades Neoplásicas (INEN) in Peru. Materials and methods Case series with retrospective and prospective data collection of patients with middle and inferior rectal cancer who underwent TaTME between January 2015 and March 2020. Patients and tumor characteristics, operative details, postoperative complications and pathological results were analyzed. Results Nineteen patients were included. The median age was 56 years old (range 40–69). Ten were female. The median distance from the anal verge was 4 cm (range 3–6) and 17 cases were located in the inferior rectum. Eleven patients with clinical stage III. Thirteen (68.4%) patients received neoadjuvant treatment. There was no conversion to open surgery reported. Ten (52.6%) cases had intersphincteric resection and 18 (94.7%) had primary coloanal anastomosis, 13 (72.2%) of them with hand-sewn. All patients had a diversion with ileostomy. The median operative time was 330 min (range 270–480). Median postoperative hospital stay of 5 days (range 3–18). The overall rate of postoperative complication was 21.1%, two cases (10.5%) had anastomotic leakage and mortality was present in one (5.3%) patient. 94.5% had an optimal TME specimen, only one case (5.3%) had positive circumferential resection margin and positive distal margin. The median tumor size in the specimen was 4 cm (range 2–11) and nine (47.4%) patients had ypT3 on pathology. Conclusion TaTME is a safe and feasible technique with good pathological results.
Collapse
Affiliation(s)
- Andrés Guevara Jabiles
- Department of Abdominal Surgery, INEN, Angamos Este 2520 Ave, Surquillo, 15038 Lima, Peru.
| | | | | | - Eduardo Payet Meza
- Department of Abdominal Surgery, INEN, Angamos Este 2520 Ave, Surquillo, 15038 Lima, Peru
| | | | - Eloy Ruiz Figueroa
- Department of Abdominal Surgery, INEN, Angamos Este 2520 Ave, Surquillo, 15038 Lima, Peru
| |
Collapse
|
36
|
Non-surgical “Watch and Wait” Approach to Rectal Cancer. CURRENT COLORECTAL CANCER REPORTS 2020. [DOI: 10.1007/s11888-020-00460-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
37
|
Nonoperative Management Versus Radical Surgery of Rectal Cancer After Neoadjuvant Therapy-Induced Clinical Complete Response: A Markov Decision Analysis. Dis Colon Rectum 2020; 63:1080-1089. [PMID: 32398412 DOI: 10.1097/dcr.0000000000001665] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Nonoperative management of rectal cancer was introduced for patients with clinical complete response after neoadjuvant chemoradiotherapy to avoid short- and long-term surgical morbidity related to radical resection. OBJECTIVE The purpose of this study was to determine the expected life-years and quality-adjusted life-years for nonoperative management and radical resection of locally advanced rectal cancer after clinical complete response following neoadjuvant chemoradiotherapy. DESIGN Markov modeling was used to simulate nonoperative management and radical surgery for a base case scenario over a 10-year time horizon. Estimates for various clinical variables were obtained after extensive literature search. Outcome was expressed in both life-years and quality-adjusted life-years. Deterministic sensitivity analyses were completed to assess the impact of variation in key parameters. SETTING A decision model using a Markov model was designed. PATIENTS The base case was a 65-year-old man with a distal rectal tumor who had achieved clinical complete response after neoadjuvant chemoradiotherapy. MAIN OUTCOME MEASURES Life-years and quality-adjusted life-years were measured. RESULTS Quality-adjusted life-years (5.79 for nonoperative management vs 5.62 for radical surgery) and life-years (6.92 for nonoperative management vs 6.96 for radical surgery) were similar between nonoperative management and radical surgery. The preferred treatment strategy changed with variations in the probability of local regrowth in nonoperative management, the probability of salvage surgery for regrowth in nonoperative management, utilities associated with nonoperative management and low anterior resection, and the utility of low anterior resection syndrome. The model was not sensitive to (dis)utilities associated with stoma, chemotherapy, or postoperative morbidity and mortality. LIMITATIONS The study was limited by assumptions inherent to modeling studies. CONCLUSIONS Nonoperative management and radical surgery resulted in similar (quality-adjusted) life-years. Nonoperative management should therefore be considered as a reasonable treatment option. See Video Abstract at http://links.lww.com/DCR/B246. MANEJO NO-QUIRÚRGICO VERSUS CIRUGÍA RADICAL DEL CÁNCER RECTAL DESPUÉS DE LA RESPUESTA CLÍNICA COMPLETA INDUCIDA POR TERAPIA NEOADYUVANTE: UN ANÁLISIS DE DECISIÓN DE MARKOV: Se introdujo el tratamiento no quirúrgico del cáncer rectal para pacientes con respuesta clínica completa después de la quimiorradioterapia neoadyuvante para evitar la morbilidad quirúrgica a corto y largo plazo relacionada con la resección radical.Determinar los años de vida esperados y los años de vida ajustados por calidad para el tratamiento no-quirúrgico y la resección radical del cáncer rectal localmente avanzado, después de la respuesta clínica completa siguiente de la quimiorradioterapia neoadyuvante.El modelo de Markov se usó para simular el manejo no-quirúrgico y la cirugía radical para un escenario de caso base en un horizonte temporal de 10 años. Se obtuvieron estimaciones para diversas variables clínicas después de una extensa búsqueda bibliográfica. El resultado se expresó tanto en años de vida como en años de vida ajustados por calidad. Se completaron análisis determinísticos de sensibilidad para evaluar el impacto de la variación en los parámetros clave.Se diseñó un modelo de decisión utilizando un modelo de Markov.El caso base fue un hombre de 65 años con un tumor rectal distal que había logrado una respuesta clínica completa después de la quimiorradioterapia neoadyuvante.Años de vida y años de vida ajustados por calidad.Los años de vida ajustados por calidad (5.79 para el tratamiento no-quirúrgico frente a 5.62 para la cirugía radical) y los años de vida (6.92 para el tratamiento no-quirúrgico frente a 6.96 para la cirugía radical) fueron similares entre el tratamiento no-quirúrgico y la cirugía radical. La estrategia de tratamiento preferida cambió con las variaciones en la probabilidad de nuevo crecimiento local en el manejo no-operatorio, la probabilidad de cirugía de rescate para el rebrote en el manejo no-operatorio, las utilidades asociadas con el manejo no-operatorio, y la resección anterior baja y la utilidad de el syndrome de resección anterior baja. El modelo no era sensible a las (des) utilidades asociadas con el estoma, la quimioterapia o la morbilidad y mortalidad postoperatorias.El estudio estuvo limitado por suposiciones inherentes a los estudios de modelado.El manejo no-quirúrgico y la cirugía radical resultaron en años de vida similares (ajustados por calidad). Por lo tanto, el tratamiento no-quirúrgico debe considerarse como una opción de tratamiento razonable. Consulte Video Resumen en http://links.lww.com/DCR/B246.
Collapse
|
38
|
Hearn N, Atwell D, Cahill K, Elks J, Vignarajah D, Lagopoulos J, Min M. Neoadjuvant Radiotherapy Dose Escalation in Locally Advanced Rectal Cancer: a Systematic Review and Meta-analysis of Modern Treatment Approaches and Outcomes. Clin Oncol (R Coll Radiol) 2020; 33:e1-e14. [PMID: 32669228 DOI: 10.1016/j.clon.2020.06.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 05/15/2020] [Accepted: 06/05/2020] [Indexed: 01/10/2023]
Abstract
AIMS Improving pathological complete response (pCR) rates after neoadjuvant chemoradiotherapy for locally advanced rectal cancer may facilitate surgery-sparing treatment paradigms. Radiotherapy boost has been linked to higher rates of pCR; however, outcomes in moderately escalated inverse-planning studies have not been systematically evaluated. We therefore carried out a systematic review and meta-analysis of radiation dose-escalation studies in the context of neoadjuvant therapy for locally advanced rectal cancer. MATERIALS AND METHODS A systematic search of Pubmed, EMBASE and Cochrane databases for synonyms of 'rectal cancer', 'radiotherapy' and 'boost' was carried out. Studies were screened for radiotherapy prescription >54 Gy. Prespecified quality assessment was carried out for meta-analysis inclusion suitability. Pooled estimates of pCR, acute toxicity (grade ≥3) and R0 resection rates were determined with random-effects restricted maximum-likelihood estimation. Heterogeneity was assessed with Higgins I2 and Cochran Q statistic. Subset analysis examined outcomes in modern inverse-planning studies. Meta-regression with permutation correction was carried out for each outcome against radiation dose, radiotherapy technique, boost technique, chemotherapy intensification and other patient- and treatment-related cofactors. RESULTS Forty-nine primary and three follow-up publications were included in the systematic review. Pooled estimates of pCR, toxicity and R0 resection across 37 eligible publications (n = 1817 patients) were 24.1% (95% confidence interval 21.2-27.4%), 11.2% (95% confidence interval 7.2-17.0%) and 90.7% (95% confidence interval 87.9-93.8%). Within inverse-planning studies (17 publications, n = 959 patients), these rates were 25.7% (95% confidence interval 21.0-31.1%), 9.8% (95% confidence interval 4.6-19.7%) and 95.3% (95% confidence interval 91.6-97.4%). Regression analysis did not identify any significant predictor of pCR (P > 0.05). CONCLUSIONS Radiotherapy dose escalation above 54 Gy is associated with high rates of pCR and does not seem to increase the risk of acute grade ≥3 toxicity events. pCR rates approaching 25% may be achievable utilising moderate escalation (54-60 Gy) with modern inverse-planning techniques; however, a clear dose-response relationship was not identified in regression analysis and additional evidence is awaited given the prevalence of heterogenous single-arm studies to date.
Collapse
Affiliation(s)
- N Hearn
- Department of Radiation Oncology, Sunshine Coast University Hospital, Birtinya, Queensland, Australia; ICON Cancer Centre, Maroochydore, Queensland, Australia; University of the Sunshine Coast, Sippy Downs, Queensland, Australia.
| | - D Atwell
- Department of Radiation Oncology, Sunshine Coast University Hospital, Birtinya, Queensland, Australia; ICON Cancer Centre, Maroochydore, Queensland, Australia; University of the Sunshine Coast, Sippy Downs, Queensland, Australia
| | - K Cahill
- Department of Radiation Oncology, Sunshine Coast University Hospital, Birtinya, Queensland, Australia; University of the Sunshine Coast, Sippy Downs, Queensland, Australia
| | - J Elks
- University of the Sunshine Coast, Sippy Downs, Queensland, Australia
| | - D Vignarajah
- Department of Radiation Oncology, Sunshine Coast University Hospital, Birtinya, Queensland, Australia; ICON Cancer Centre, Maroochydore, Queensland, Australia
| | - J Lagopoulos
- University of the Sunshine Coast, Sippy Downs, Queensland, Australia; Sunshine Coast Mind and Neuroscience - Thompson Institute, University of the Sunshine Coast, Birtinya, Queensland, Australia
| | - M Min
- Department of Radiation Oncology, Sunshine Coast University Hospital, Birtinya, Queensland, Australia; ICON Cancer Centre, Maroochydore, Queensland, Australia; University of the Sunshine Coast, Sippy Downs, Queensland, Australia
| |
Collapse
|
39
|
|
40
|
Seo N, Kim H, Cho MS, Lim JS. Response Assessment with MRI after Chemoradiotherapy in Rectal Cancer: Current Evidences. Korean J Radiol 2020; 20:1003-1018. [PMID: 31270972 PMCID: PMC6609432 DOI: 10.3348/kjr.2018.0611] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 04/07/2019] [Indexed: 12/20/2022] Open
Abstract
Baseline magnetic resonance imaging (MRI) has become the primary staging modality for surgical plans and stratification of patient populations for more efficient neoadjuvant treatment. Patients who exhibit a complete response to chemoradiotherapy (CRT) may achieve excellent local tumor control and better quality of life with organ-preserving treatments such as local excision or even watch-and-wait management. Therefore, the evaluation of tumor response is a key factor for determining the appropriate treatment following CRT. Although post-CRT MRI is generally accepted as the first-choice method for evaluating treatment response after CRT, its application in the clinical decision process is not fully validated. In this review, we will discuss various oncologic treatment options from radical surgical technique to organ-preservation strategies for achieving better cancer control and improved quality of life following CRT. In addition, the current status of post-CRT MRI in restaging rectal cancer as well as the main imaging features that should be evaluated for treatment planning will also be described for the tailored treatment.
Collapse
Affiliation(s)
- Nieun Seo
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Honsoul Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Min Soo Cho
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Joon Seok Lim
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
| |
Collapse
|
41
|
AlQudah M, Salmo E, Haboubi N. The effect of radiotherapy on rectal cancer: a histopathological appraisal and prognostic indicators. Radiat Oncol J 2020; 38:77-83. [PMID: 33012150 PMCID: PMC7533410 DOI: 10.3857/roj.2020.00010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 04/13/2020] [Indexed: 12/13/2022] Open
Abstract
The management of rectal cancer is a major undertaking. There are currently multiple treatment modalities with variable degrees of complications. Radiotherapy (RT) is one of the more frequently used modalities either on its own or more frequently with chemotherapy mostly before the definitive surgery. The outcome of RT is unpredictable. RT has its serious side effects and there are no guarantees of its usefulness in all patients. This article outlines the effect of RT on the tumor, reviews the various staging systems of responses to RT and present recent evidence of which case is less responsive to such treatments to avoid unnecessary complications.
Collapse
Affiliation(s)
- Mohammad AlQudah
- Department of Pathology and Microbiology, School of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Emil Salmo
- Department of Histopathology, The Pennine Acute Hospitals NHS Trust, The Royal Oldham Hospital, Oldham, UK
| | - Najib Haboubi
- Department of Histopathology, Spire Manchester Hospital, Manchester, UK
| |
Collapse
|
42
|
Pinto JC, Pereira AD, Pimenta A, Pedro C, Fernandez G, Marques I, Miguel I, Freire J, Maciel J, Venâncio J, D'Orey L, Mirones L, Limbert M, Labareda M, Chaves P, Fonseca R, Barroca R, Ferreira T, Marques T, Rosa I. Low rectal cancer treatment strategies: a cohort study assessing watch and wait. J Cancer Res Clin Oncol 2020; 146:2631-2638. [PMID: 32435893 DOI: 10.1007/s00432-020-03248-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 05/05/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE Treatment strategies for low rectal cancer have been evolving toward achieving less treatment morbidity with the same oncological success-we aimed to assess the results of the new watch and wait (W&W) strategy in our cohort. METHODS A tertiary care cohort study was conducted. New patients with rectal adenocarcinoma up to 6 cm from the anal margin, cM0, locally staged higher than cT1N0, evaluated between November 2014 and October 2018, were included. All 93 patients received neoadjuvant radiotherapy ± chemotherapy. Re-evaluation was planned 8-12 weeks after the end of treatment. Patients showing clinical complete response (cCR) were given the choice of either to proceed to surgery or to enter W&W. RESULTS Of the 93 patients, 82.8% were re-evaluated and 20.8% had cCR. Patients in clinical stages II/III were significantly less likely to achieve cCR than those in stage I (p = 0.017). After a mean follow-up of 17.44 months, there were 4 regrowths in the 16 patients under W&W, all submitted to R0 surgery, ypN0; there were no deaths or local recurrences; one patient with regrowth had distant recurrence. Sixty patients underwent direct surgery after a mean follow-up of 16.23 months; 3 patients had local and distant recurrences; 7 others had only distant recurrences; there were 8 deaths. There were no statistically significant differences between patients under W&W and patients who underwent direct surgery regarding local or distant recurrences, or death (p > 0.9; p = 0.44; p = 0.19, respectively). CONCLUSION The W&W strategy for low rectal cancer achieved the same oncological outcomes as the traditional strategy while sparing some patients from surgery.
Collapse
Affiliation(s)
- João Cortez Pinto
- Gastroenterology Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Serviço de Gastrenterologia, Rua Prof. Lima Basto, 1099-023, Lisboa, Portugal
| | - António Dias Pereira
- Gastroenterology Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Serviço de Gastrenterologia, Rua Prof. Lima Basto, 1099-023, Lisboa, Portugal
| | - Ana Pimenta
- Radiotherapy Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Lisboa, Portugal
| | - Cátia Pedro
- Radiotherapy Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Lisboa, Portugal
| | - Gonçalo Fernandez
- Radiotherapy Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Lisboa, Portugal
| | - Inês Marques
- Gastroenterology Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Serviço de Gastrenterologia, Rua Prof. Lima Basto, 1099-023, Lisboa, Portugal
| | - Isália Miguel
- Oncology Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Lisboa, Portugal
| | - João Freire
- Oncology Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Lisboa, Portugal
| | - João Maciel
- Surgery Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Lisboa, Portugal
| | - José Venâncio
- Radiology Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Lisboa, Portugal
| | - Luís D'Orey
- Surgery Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Lisboa, Portugal
| | - Luísa Mirones
- Radiotherapy Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Lisboa, Portugal
| | - Manuel Limbert
- Surgery Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Lisboa, Portugal
| | - Miguel Labareda
- Radiotherapy Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Lisboa, Portugal
| | - Paula Chaves
- Pathology Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Lisboa, Portugal
| | - Ricardo Fonseca
- Pathology Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Lisboa, Portugal
| | - Rita Barroca
- Surgery Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Lisboa, Portugal
| | - Teresa Ferreira
- Nuclear Medicine Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Lisboa, Portugal
| | - Teresa Marques
- Oncology Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Lisboa, Portugal
| | - Isadora Rosa
- Gastroenterology Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Serviço de Gastrenterologia, Rua Prof. Lima Basto, 1099-023, Lisboa, Portugal.
| |
Collapse
|
43
|
Koëter T, van Elderen SGC, van Tilborg GFAJB, de Wilt JHW, Wasowicz DK, Rozema T, Zimmerman DDE. MRI response rate after short-course radiotherapy on rectal cancer in the elderly comorbid patient: results from a retrospective cohort study. Radiat Oncol 2020; 15:53. [PMID: 32122381 PMCID: PMC7053128 DOI: 10.1186/s13014-020-01500-y] [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] [Received: 12/30/2019] [Accepted: 02/18/2020] [Indexed: 02/07/2023] Open
Abstract
Background The aim of the present study was to evaluate MRI response rate and clinical outcome of short-course radiotherapy (SCRT) on rectal cancer as an alternative to chemoradiotherapy in patients where downstaging is indicated. Methods A retrospective analysis was performed of a patient cohort with rectal carcinoma (cT1-4cN0-2 cM0–1) from a large teaching hospital receiving restaging MRI, deferred surgery or no surgery after SCRT between 2011 and 2017. Patients who received chemotherapy during the interval between SCRT and restaging MRI were excluded. The primary outcome measure was the magnetic resonance tumor regression grade (mrTRG) at restaging MRI after SCRT followed by a long interval. Secondary, pathological tumor stage, complete resection rate and 1-year overall survival were assessed. Results A total of 47 patients (M:F = 27:20, median age 80 (range 53–88) years), were included. In 33 patients MRI was performed for response assessment 10 weeks after SCRT. A moderate or good response (mrTRG≤3) was observed in 24 of 33 patients (73%). While most patients (85%; n = 28) showed cT3 or cT4 stage on baseline MRI, a ypT3 or ypT4 stage was found in only 20 patients (61%) after SCRT (p < 0.01). A complete radiologic response (mrTRG 1) was seen in 4 patients (12%). Clinical N+ stage was diagnosed in n = 23 (70%) before SCRT compared to n = 8 (30%) post-treatment (p = 0.03). After SCRT, 39 patients underwent deferred surgery (after a median of 14 weeks after start of SCRT) and a resection with complete margins was achieved in 35 (90%) patients. One-year overall survival after surgery was 82%. Complete pathological response was found in 2 patients (5%). Conclusions The use of SCRT followed by a long interval to restaging showed a moderate to good response in 73% and therefore can be considered as an alternative to chemoradiotherapy in elderly comorbid patients.
Collapse
Affiliation(s)
- T Koëter
- Department of Surgery, Elisabeth-TweeSteden Hospital Tilburg, Tilburg, The Netherlands. .,Department of Surgery, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands.
| | - S G C van Elderen
- Department of Radiology, Elisabeth-TweeSteden Hospital Tilburg, Tilburg, The Netherlands
| | - G F A J B van Tilborg
- Department of Radiology, Elisabeth-TweeSteden Hospital Tilburg, Tilburg, The Netherlands
| | - J H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - D K Wasowicz
- Department of Surgery, Elisabeth-TweeSteden Hospital Tilburg, Tilburg, The Netherlands
| | - T Rozema
- Department of Radiotherapy, Verbeeten Instituut Tilburg, Tilburg, The Netherlands
| | - D D E Zimmerman
- Department of Surgery, Elisabeth-TweeSteden Hospital Tilburg, Tilburg, The Netherlands
| |
Collapse
|
44
|
Peltrini R, Sacco M, Luglio G, Bucci L. Local excision following chemoradiotherapy in T2-T3 rectal cancer: current status and critical appraisal. Updates Surg 2020; 72:29-37. [PMID: 31621033 DOI: 10.1007/s13304-019-00689-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 10/10/2019] [Indexed: 12/18/2022]
Abstract
Local excision following chemoradiotherapy in rectal cancer is an organ-preserving procedure which aims at reducing morbidity and functional disorders associated with total mesorectal excision (TME) in selected patients. Although TME after chemoradiotherapy remains the gold standard for locally advanced mid and low rectal cancer, in the last years multicenter research trials have offered encouraging oncologic results which have allowed to preserve the rectum in patients with a pathologic complete response after chemoradiotherapy. A review of the available literature on this topic was conducted to define the state of the art of this conservative approach and to focus on the most controversial aspects concerning local excision performed after chemoradiotherapy, in particular tumor scatter and lymph node status, completion and salvage surgery, morbidity and quality of life. The analysis of these topics should be considered, in trial setting or in current practice, for their clinical implications. Oncologic outcomes of recent trials are encouraging for part of the patients presenting T2 rectal cancer; however, TME still remains the standard treatment in clinical practice. In such cases, local excision should include a surgical safety margin of at least 1 cm from the resection margin to achieve a true negative margin from residual tumor cells. The selection of the patients should be carefully performed and their consensus extremely detailed because TME is necessary in about 30% of cases. Failing that, morbidity and quality of life are negatively affected. However, about half of these patients refuse radical surgery (45%), thus undergoing only palliative care.
Collapse
Affiliation(s)
- Roberto Peltrini
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy.
| | - Michele Sacco
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Gaetano Luglio
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Luigi Bucci
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy
| |
Collapse
|
45
|
Arya S, Sen S, Engineer R, Saklani A, Pandey T. Imaging and Management of Rectal Cancer. Semin Ultrasound CT MR 2020; 41:183-206. [PMID: 32446431 DOI: 10.1053/j.sult.2020.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
High-resolution phased array external magnetic resonance imaging (MRI) is the first investigation of choice in rectal cancer for local staging, both in the primary and restaging situations. Use of MRI helps differentiate between those with good prognosis, which can be offered upfront surgery and the poor prognostic cases where treatment intensification is needed. MRI identified poor prognostic factors are threatened or involved mesorectal fascia, T3 tumors with >5 mm extramural spread, those with extramural vascular invasion, pelvic sidewall nodes and mucinous tumors. At restaging, use of MRI helps evaluate response and an MR tumor regression grading system is being evaluated. Complete response seen on clinical examination and endoscopy, needs confirmation on MRI using both T2-weighted and diffusion-weighted sequences to justify a "watch and wait" approach. In this subset of patients, MRI also plays a role in monitoring and detecting early regrowth. In those with partial response, MRI helps define surgical margins and can be used as a roadmap to decide between sphincter preserving surgeries and radical sphincter sacrificing surgeries; pelvic exenteration and pelvic sidewall lymph node dissection. Poor responders on MRI may benefit from adjuvant chemotherapy. Use of MRI thus helps in individualizing treatment in rectal cancer.
Collapse
Affiliation(s)
- Supreeta Arya
- Ex-Professor, Radiodiagnosis, Tata Memorial Centre, Mumbai, India; Member Expert Committee, National Cancer Grid, India.
| | - Saugata Sen
- Department of Radiology and Imaging Sciences, Tata Medical Center, Kolkata, India
| | - Reena Engineer
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, India
| | - Avanish Saklani
- Department of Surgical Oncology, Robotic & Colorectal Surgery, Tata Memorial Hospital, Mumbai, India
| | - Tarun Pandey
- Department of Radiology and Orthopedics, University of Arkansas for Medical Sciences, Little Rock, AR
| |
Collapse
|
46
|
MR tumor regression grade for pathological complete response in rectal cancer post neoadjuvant chemoradiotherapy: a systematic review and meta-analysis for accuracy. Eur Radiol 2020; 30:2312-2323. [PMID: 31953656 DOI: 10.1007/s00330-019-06565-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 10/25/2019] [Accepted: 10/30/2019] [Indexed: 01/07/2023]
Abstract
OBJECTIVES To determine the diagnostic accuracy of magnetic resonance tumor regression grade (mrTRG) for pathological complete response (pCR) and its correlation with pathological findings. METHODS Original studies that investigated the correlation of mrTRG with pathological tumor regression grade and pathological T stage were identified in MEDLINE and EMBASE up until August 31, 2018, according to PRISMA guidelines. The search terms included colorectal cancer, chemoradiation therapy, magnetic resonance imaging, and response or regression. Meta-analytic summary sensitivity and specificity for pathologic complete response (pCR) and pathologic T1 or lower than T1 stage (≤ypT1) were calculated using a bivariate random-effects model. The sensitivity and specificity were calculated in both mrTRG 1 and mrTRG 1 or 2, respectively. RESULTS Six studies with 916 patients were included. The meta-analytic summary sensitivity and specificity of mrTRG 1 for pCR were 32.3% (95% CI, 18.2-50.6%) and 93.5% (95% CI, 91.5-95.1%), while for ≤ypT1 they were 31.8% (95% CI, 16.2-53.0%) and 94.7% (95% CI, 91.9-96.5%). On the contrary, sensitivity and specificity of mrTRG 1 or 2 for pCR were 69.9% (95% CI, 60.2-78.1%) and 62.2% (95% CI, 56.2-67.8%), while those for ≤ypT1 were 71.4% (95% CI, 61.6-79.6%) and 67.7% (95% CI, 59.8-74.7%). CONCLUSIONS mrTRG 1 showed high specificity for pCR and ≤ypT1, but suboptimal sensitivity. mrTRG 1 or 2 showed higher sensitivity for pCR and ≤ypT1, but lower specificity. Because of the suboptimal sensitivity of mrTRG 1, it might be limited as a criterion for less aggressive treatment after neoadjuvant chemoradiotherapy. KEY POINTS • Magnetic resonance tumor regression grade 1 shows high specificity for pCR and ≤ypT1, but suboptimal sensitivity. • Magnetic resonance tumor regression grade 1 or 2 shows higher sensitivity for pCR and ≤ypT1, but lower specificity than magnetic resonance tumor regression grade 1 alone.
Collapse
|
47
|
Tchelebi LT, Romesser PB, Feuerlein S, Hoffe S, Latifi K, Felder S, Chuong MD. Magnetic Resonance Guided Radiotherapy for Rectal Cancer: Expanding Opportunities for Non-Operative Management. Cancer Control 2020; 27:1073274820969449. [PMID: 33118384 PMCID: PMC7791447 DOI: 10.1177/1073274820969449] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Colorectal cancer is the third most common cancer in men and the second most common in women worldwide, and the incidence is increasing among younger patients. 30% of these malignancies arise in the rectum. Patients with rectal cancer have historically been managed with preoperative radiation, followed by radical surgery, and adjuvant chemotherapy, with permanent colostomies in up to 20% of patients. Beginning in the early 2000s, non-operative management (NOM) of rectal cancer emerged as a viable alternative to radical surgery in select patients. Efforts have been ongoing to optimize neoadjuvant therapy for rectal cancer, thereby increasing the number of patients potentially eligible to forgo radical surgery. Magnetic resonance guided radiotherapy (MRgRT) has recently emerged as a treatment modality capable of intensifying preoperative radiation therapy for rectal cancer patients. This technology may also predict which patients will achieve a complete response to preoperative therapy, thereby allowing for more appropriate selection of patients for NOM. The present work seeks to illustrate the potential role MRgRT could play in personalizing rectal cancer treatment thus expanding the role of NOM in rectal cancer.
Collapse
Affiliation(s)
- Leila T. Tchelebi
- Department of Radiation Oncology, Penn State College of Medicine,
Hershey, PA, USA
| | - Paul B. Romesser
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer
Center, New York, NY, USA
| | - Sebastian Feuerlein
- Department of Diagnostic Imaging and Interventional Radiology,
Moffitt Cancer Center, Tampa, FL, USA
| | - Sarah Hoffe
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL,
USA
| | - Kujtim Latifi
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL,
USA
| | - Seth Felder
- Department of Gastrointestinal Oncology, Moffitt Cancer Center,
Tampa, FL, USA
| | - Michael D. Chuong
- Department of Radiation Oncology, Miami Cancer Institute, Miami, FL,
USA
| |
Collapse
|
48
|
Khakoo S, Carter PD, Brown G, Valeri N, Picchia S, Bali MA, Shaikh R, Jones T, Begum R, Rana I, Wotherspoon A, Terlizzo M, von Loga K, Kalaitzaki E, Saffery C, Watkins D, Tait D, Chau I, Starling N, Hubank M, Cunningham D. MRI Tumor Regression Grade and Circulating Tumor DNA as Complementary Tools to Assess Response and Guide Therapy Adaptation in Rectal Cancer. Clin Cancer Res 2020; 26:183-192. [PMID: 31852830 DOI: 10.1158/1078-0432.ccr-19-1996] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 08/30/2019] [Accepted: 10/21/2019] [Indexed: 11/16/2022]
Abstract
PURPOSE Response to preoperative chemo-radiotherapy (CRT) varies. We assessed whether circulating tumor DNA (ctDNA) might be an early indicator of tumor response or progression to guide therapy adaptation in rectal cancer. EXPERIMENTAL DESIGN A total of 243 serial plasma samples were analyzed from 47 patients with localized rectal cancer undergoing CRT. Up to three somatic variants were tracked in plasma using droplet digital PCR. RECIST and MRI tumor regression grade (mrTRG) evaluated response. Survival analyses applied Kaplan-Meier method and Cox regression. RESULTS ctDNA detection rates were: 74% (n = 35/47) pretreatment, 21% (n = 10/47) mid CRT, 21% (n = 10/47) after completing CRT, and 13% (n = 3/23) after surgery. ctDNA status after CRT was associated with primary tumor response by mrTRG (P = 0.03). With a median follow-up of 26.4 months, metastases-free survival was shorter in patients with detectable ctDNA after completing CRT [HR 7.1; 95% confidence interval (CI), 2.4-21.5; P < 0.001], persistently detectable ctDNA pre and mid CRT (HR 3.8; 95% CI, 1.2-11.7; P = 0.02), and pre, mid, and after CRT (HR 11.5; 95% CI, 3.3-40.4; P < 0.001) compared with patients with undetectable or nonpersistent ctDNA. In patients with detectable ctDNA, a fractional abundance threshold of ≥0.07% mid CRT or ≥0.13% after completing CRT predicted for metastases with 100% sensitivity and 83.3% specificity for mid CRT and 66.7% for CRT completion. All 3 patients with detectable ctDNA post-surgery relapsed compared with none of the 20 patients with undetectable ctDNA (P = 0.001). CONCLUSIONS ctDNA identified patients at risk of developing metastases during the neoadjuvant period and post-surgery, and could be used to tailor treatment.
Collapse
Affiliation(s)
- Shelize Khakoo
- Department of Medicine, The Royal Marsden Hospital NHS Foundation Trust, London and Surrey, United Kingdom
| | - Paul David Carter
- Clinical Genomics, The Royal Marsden Hospital NHS Foundation Trust, Sutton, United Kingdom
| | - Gina Brown
- Department of Radiology, The Royal Marsden Hospital NHS Foundation Trust, London and Surrey, United Kingdom
| | - Nicola Valeri
- Molecular Pathology, The Institute of Cancer Research/The Royal Marsden NHS Foundation Trust, Sutton, United Kingdom
| | - Simona Picchia
- Department of Radiology, The Royal Marsden Hospital NHS Foundation Trust, London and Surrey, United Kingdom
| | - Maria Antonietta Bali
- Department of Radiology, The Royal Marsden Hospital NHS Foundation Trust, London and Surrey, United Kingdom
| | - Ridwan Shaikh
- Clinical Genomics, The Royal Marsden Hospital NHS Foundation Trust, Sutton, United Kingdom
| | - Thomas Jones
- Clinical Genomics, The Royal Marsden Hospital NHS Foundation Trust, Sutton, United Kingdom
| | - Ruwaida Begum
- Department of Medicine, The Royal Marsden Hospital NHS Foundation Trust, London and Surrey, United Kingdom
| | - Isma Rana
- Department of Medicine, The Royal Marsden Hospital NHS Foundation Trust, London and Surrey, United Kingdom
| | - Andrew Wotherspoon
- Department of Histopathology, The Royal Marsden Hospital NHS Foundation Trust, London and Surrey, United Kingdom
| | - Monica Terlizzo
- Department of Histopathology, The Royal Marsden Hospital NHS Foundation Trust, London and Surrey, United Kingdom
| | - Katharina von Loga
- Department of Histopathology, The Royal Marsden Hospital NHS Foundation Trust, London and Surrey, United Kingdom
| | - Eleftheria Kalaitzaki
- Clinical Research and Development, The Royal Marsden Hospital NHS Foundation Trust, London and Surrey, United Kingdom
| | - Claire Saffery
- Department of Medicine, The Royal Marsden Hospital NHS Foundation Trust, London and Surrey, United Kingdom
| | - David Watkins
- Department of Medicine, The Royal Marsden Hospital NHS Foundation Trust, London and Surrey, United Kingdom
| | - Diana Tait
- Department of Medicine, The Royal Marsden Hospital NHS Foundation Trust, London and Surrey, United Kingdom
| | - Ian Chau
- Department of Medicine, The Royal Marsden Hospital NHS Foundation Trust, London and Surrey, United Kingdom
| | - Naureen Starling
- Department of Medicine, The Royal Marsden Hospital NHS Foundation Trust, London and Surrey, United Kingdom
| | - Michael Hubank
- Clinical Genomics, The Royal Marsden Hospital NHS Foundation Trust, Sutton, United Kingdom
| | - David Cunningham
- Department of Medicine, The Royal Marsden Hospital NHS Foundation Trust, London and Surrey, United Kingdom.
| |
Collapse
|
49
|
Lorenzon L, Evrard S, Beets G, Gonzalez-Moreno S, Kovacs T, D'Ugo D, Polom K. Global variation in the long-term outcomes of ypT0 rectal cancers. Eur J Surg Oncol 2019; 46:420-428. [PMID: 31733929 DOI: 10.1016/j.ejso.2019.10.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 09/12/2019] [Accepted: 10/10/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Colorectal cancer mortality presents world-wide variation. In rectal cancers presenting a complete/nearly-complete tumor response (ypT0/ypTis) following neoadjuvant treatment, the features correlated to nodal metastases and relapses still need to be defined. METHODS An international cohort study enrolling ypT0/ypTis rectal cancers surgically treated from 2012 to 2017 was conducted. A propensity matching was used to balance nodal-positive and nodal-negative patients and statistical analyses were performed to investigate survivals, using a bootstrap model for internal validation. The features correlated with nodal metastasis were studied. Countries with participating centers were ranked using the World Bank (WBI), Human Development (HDI) and Global Gender Gap (GGG) indexes to compare survivals. RESULTS 680 ypT0/ypTis from 52 European, Australian, Indian and American Institutions were analyzed. Mean follow-up was of 30.4 months. 96.5% were treated with total mesorectal excision, 7.2% were nodal-positive and 8.8% relapsed. Distal cancers (HR 0.71 95%CI: 0.56-0.91) and nodal metastasis and nodal metastasis (HR 3.85 95%CI:1.12-13.19) correlated with worse DFS, whereas a younger age was of borderline significance (HR 0.95 95%CI:0.91-0.99). The bootstrap analysis validated the model on 5000 repetitions. A short-course radiotherapy (OR 0.18 95%CI:0.09-0.37) correlated with the occurrence of nodal metastasis. Those countries classified in the low/medium-WBI, medium-HDI and lower-GGG ranks documented worse DFS curves (respectively p < 0.0001, p < 0.0001 and p 0.0002). However, the clinical stages were similar and patients from medium-HDI countries received more adjuvant chemotherapy than the others (p < 0.0001). CONCLUSION Sub-groups at risk for relapses and nodal metastasis were identified. A global variation exists also when benchmarking a rectal cancer complete regression.
Collapse
Affiliation(s)
- Laura Lorenzon
- General Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy.
| | | | - Geerard Beets
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | - Tibor Kovacs
- Breast Surgery Unit, Guy's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Domenico D'Ugo
- General Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
| | - Karol Polom
- Department of Surgical Oncology, Medical University of Gdansk, 80-211, Gdańsk, Poland; General Surgery and Surgical Oncology Department, University of Siena, 53100, Siena, Italy
| |
Collapse
|
50
|
Gollub MJ, Lall C, Lalwani N, Rosenthal MH. Current controversy, confusion, and imprecision in the use and interpretation of rectal MRI. Abdom Radiol (NY) 2019; 44:3549-3558. [PMID: 31062058 DOI: 10.1007/s00261-019-01996-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
There has been a rapid increase in the utilization of MRI in rectal cancer staging in the USA essentially replacing endorectal ultrasound and mimicking the trend in Europe seen in the 1990s and 2000s. Accompanying this trend, there is a demand, and recognized need, for greater precision and clarification of confusing, misunderstood and poorly understood concepts, facts, statements and nomenclature regarding rectal cancer and the use of pelvic MRI for diagnosis. As such, this Review, part evidence-based and part expert opinion, will attempt to elucidate and clarify several concepts the authors have encountered in 25 years of imaging rectal cancer, focusing on MRI.
Collapse
Affiliation(s)
- Marc J Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
| | - Chandana Lall
- Division of Abdominal and Body Imaging, Department of Radiology, University of Florida, Jacksonville, 32209, FL, USA
| | - Neeraj Lalwani
- Department of Radiology, Section of Abdominal Imaging, Wake Forest University and Baptist Medical Center, Winston Salem, 27103, NC, USA
| | - Michael H Rosenthal
- Harvard Medical School, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston, 02215, MA, USA
| |
Collapse
|