Recurrence rates and prognostic factors in ypN0 rectal cancer after neoadjuvant chemoradiation and total mesorectal excision

Impact of adjuvant chemotherapy on survival after pathological complete response in rectal cancer: a meta-analysis of 31,558 patients

BACKGROUND

Locally advanced rectal cancer (LARC) typically involves neoadjuvant chemoradiotherapy (nCRT) followed by surgery (total mesorectal excision, TME). While achieving a complete pathological response (pCR) is a strong indicator of a positive prognosis, the specific benefits of adjuvant chemotherapy after pCR remain unclear. To address this knowledge gap, we conducted a systematic review and meta-analysis to assess the potential advantages of adjuvant therapy in patients who achieve pCR.

METHODS

In this study, we searched Medline, Embase, and Web of Science databases for relevant research. We focused on binary outcomes, analyzing them using odds ratios (ORs) with 95% confidence intervals (CIs). To account for potential variability between studies, all endpoints were analyzed with DerSimonian and Laird random-effects models. We assessed heterogeneity using the I2 statistic and employed the R statistical software (version 4.2.3) for all analyses.

RESULTS

Thirty-four studies, comprising 31,558 patients, were included. The outcomes demonstrated a significant difference favoring the AC group in terms of overall survival (OS) (HR 0.75; 95% CI 0.60-0.94; p = 0.015; I2 = 0%), and OS in 5 years (OR 1.65; 95% CI 1.21-2.24; p = 0.001; I2 = 39%). There was no significant difference between the groups for disease-free survival (DFS) (HR 0.94; 95% CI 0.76-1.17; p = 0.61; I2 = 17%), DFS in 5 years (OR 1.19; 95% CI 0.82-1.74; p = 0.36; I2 = 43%), recurrence-free survival (RFS) (HR 1.10; 95% CI 0.87-1.40; p = 0.39; I2 = 0%), and relapse-free survival (OR 1.08; 95% CI 0.78-1.51; p = 0.62; I2 = 0%).

CONCLUSION

This systematic review and meta-analysis found a significant difference in favor of the ACT group in terms of survival after pCR. Therefore, the administration of this treatment as adjuvant therapy should be encouraged in clinical practice.

The role of adjuvant chemotherapy in rectal cancer patients with ypT0-2N0 after neoadjuvant chemoradiotherapy

Background

Neoadjuvant chemoradiotherapy has emerged as the established treatment for locally advanced rectal cancer. Nevertheless, there remains a debate regarding the necessity of adjuvant chemotherapy for patients with locally advanced rectal cancer who exhibit a favorable tumor response (ypT0-2N0) after neoadjuvant chemoradiotherapy and surgery. Thus, the objective of this study is to investigate the impact of adjuvant chemotherapy on the oncological prognosis of rectal cancer patients who have a good response to neoadjuvant chemoradiotherapy.

Materials and methods

The study was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol. Articles were searched in the Web of Science, PubMed, and Cochrane Library databases. The primary outcomes assessed were 5-year overall survival, disease-free survival, cancer-specific survival, recurrence-free survival, local recurrence, and distant metastasis. The data was summarized using a random effects model.

Results

A meta-analysis was conducted using 18 retrospective studies published between 2009 and 2023. The studies included 9 from China and 5 from Korea, involving a total of 6566 patients with ypT0-2N0 rectal cancer after neoadjuvant chemoradiotherapy. The pooled data revealed that adjuvant chemotherapy significantly improved 5-year overall survival (OR=1.75, 95% CI: 1.15-2.65, P=0.008), recurrence-free survival (OR=1.73, 95% CI: 1.20-2.48, P=0.003), and reduced distant metastasis (OR=0.68, 95% CI: 0.51-0.92, P=0.011). However, adjuvant chemotherapy did not have a significant effect on disease-free survival, cancer-specific survival, and local recurrence in ypT0-2N0 rectal cancer. Subgroup analysis indicated that adjuvant chemotherapy was beneficial in improving overall survival for ypT1-2N0 rectal cancer (OR=1.89, 95% CI: 1.13-3.19, P=0.003).

Conclusion

The findings of the meta-analysis suggest that adjuvant chemotherapy may provide benefits in terms of oncological outcomes for rectal cancer patients with ypT0-2N0 after neoadjuvant chemoradiotherapy and radical surgery. However, further prospective clinical studies are needed to confirm these findings.

Effect of adjuvant chemotherapy on the oncological outcome of rectal cancer patients with pathological complete response

BACKGROUND

Locally advanced rectal cancer is typically treated using a combination of neoadjuvant chemoradiotherapy and total mesorectal resection. While achieving pathological complete response following neoadjuvant chemoradiotherapy has been recognized as a positive prognostic factor in oncology, the necessity of adjuvant chemotherapy for locally advanced rectal cancer patients with pathological complete response after surgery remains uncertain. The objective of this meta-analysis was to examine the impact of adjuvant chemotherapy on the oncological outcomes of rectal cancer patients who attain pathological complete response after neoadjuvant chemoradiotherapy.

METHODS

This meta-analysis followed the guidelines outlined in the preferred reporting items for systematic review and meta-analysis (PRISMA). The Web of Science, PubMed, and Cochrane Library databases were systematically searched to identify relevant literature.

RESULTS

A total of 34 retrospective studies, including 9 studies from the NCBD database, involving 31,558 patients with pathological complete response rectal cancer, were included in the meta-analysis. The included studies were published between 2008 and 2023. The pooled analysis demonstrated that adjuvant chemotherapy significantly improved overall survival (HR = 0.803, 95% CI 0.678-0.952, P = 0.011), and no heterogeneity was observed (I2 = 0%). Locally advanced rectal cancer patients with pathological complete response who underwent adjuvant chemotherapy exhibited a higher 5-year overall survival rate compared to those who did not receive adjuvant chemotherapy (OR = 1.605, 95% CI 1.183-2.177, P = 0.002). However, the analysis also revealed that postoperative ACT did not lead to improvements in disease-free survival and recurrence-free survival within the same patient population. Subgroup analysis indicated that pathological complete response patients with clinical stage T3/T4, lymph node positivity, and younger than 70 years of age may benefit from adjuvant chemotherapy in terms of overall survival.

CONCLUSIONS

The findings of this meta-analysis suggest that adjuvant chemotherapy has a beneficial effect on improving overall survival among rectal cancer patients with pathological complete response. However, no such association was observed in terms of disease-free survival and recurrence-free survival.

Examined lymph node numbers influence prognosis in rectal cancer treated with neoadjuvant therapy

Background

The number of lymph nodes examined (LNe) is often insufficient in patients with rectal cancer (RC) treated with neoadjuvant therapy; however, its prognostic value remains controversial. Thus, we retrospectively explored whether LNe had an influence on staging and prognosis and investigated whether there was a cut-off value for better prognosis in patients with RC treated with neoadjuvant therapy.

Methods

Data were collected from seven prospective hospital databases in China from July 2002 to May 2018. Binary logistic regression models were used to predict lymph node metastasis. The cut-off value for LNe was determined using X-tile 3.6.1. Survival outcomes and risk factors were analyzed using the log-rank test and Cox regression model.

Results

A total of 482 patients were included, of whom 459 had complete overall survival (OS) information. Using the percentile method, the total number of lymph nodes examined (TLNe) was 14-16 (40th-60th percentile), and the proportion of patients with lymph node metastasis reached a maximum of 48.1%. Cox multivariate analysis showed that the odds ratio (OR) remained the highest when TLNe was 14-16 (OR = 3.379, P = 0.003). The 3-year and 5-year OS were 85.4% and 77.8%, respectively. Negative lymph nodes examined (NLNe) of ≤6 was an independent risk factor for 3-year and 5-year OS (3-year OS 71.1% vs. 85.9%, P = 0.004; 5-year OS 66.3% vs. 74.3%, P = 0.035). Subgroup analysis for patients with ypN + showed that higher 3-year and 5-year OS were achieved when the TLNe was >10, 78.8% vs. 54.0% (P = 0.005), and 60.8% vs. 36.0% (P = 0.012), respectively. Patients with ypN0M0 had a higher 5-year OS when the TLNe was >19 (P = 0.055).

Conclusion

The TLNe and NLNe influenced the staging accuracy and demonstrated prognostic value in patients with RC treated with neoadjuvant therapy.

Chemotherapy Duration for Various Indications in Colorectal Cancer: a Review

PURPOSE OF REVIEW

The treatment of colorectal cancer (CRC) has evolved and become more personalized during the past several years. For example, depotentiation/reduced duration of systemic therapies has proven to be beneficial in both advanced and early stages of the disease.

RECENT FINDINGS

In particular, recent randomized studies of stage III and high-risk stage II CRC showed that a shorter duration (3 months), when compared to the historical 6-month comparator, provides nearly similar overall survival (OS) and disease-free survival (DFS). In the setting of advanced, inoperable CRC, a relatively short induction phase (six to eight cycles) followed by biological agents is the current standard of care in RAS wild-type (wt). versus RAS mutated cases. With regard to potentially operable stage IV disease (with the aim of converting liver metastases to operability), a relatively short number of cycles (four to six cycles) should be offered with re-staging and re-evaluation for surgery as soon as possible in most cases. For inoperable liver metastases, a relatively intensive triplet or doublet plus targeted therapy may attain conversion in some cases and may even result in cure. Rectal cancer treatment continues to be a complex disease in terms of treatment and oncological results. Recent data seem to showcase the benefits of more prolonged sequential strategies (total neoadjuvant therapy, all treatment delivered before surgery, to reduce the risk of distant metastases and local control). In recent years, different strategies regarding treatment intensity have been employed in CRC in adjuvant and metastatic setting. Introduction of triplets as first-line therapy for colon cancer and as induction phase for rectal cancer are now therapeutic options. Conversely in stage II disease or low-risk stage III resected CRC, a reduced chemotherapy length is a new standard of care.

Prognostic value of final pathological stage in colon adenocarcinoma after neoadjuvant chemotherapy: A propensity score-matched study

Background

Neoadjuvant chemotherapy (NAC) could improve local tumor control of locally advanced colon cancer (LACC), but the prognostic value of yp stage in colon cancer remains unknown. Here, we aimed to ascertain yp stage as an indicator for LACC prognosis after NAC.

Methods

The data of patients diagnosed with colon adenocarcinoma between 2004 and 2015 were extracted from the Surveillance, Epidemiology, and End Results database. After 1:2 propensity score matching, cancer-specific survival (CSS) and overall survival (OS) were compared between the NAC and Non-NAC groups of different stage classifications. The correlation between clinical and pathological factors and CSS was identified.

Results

A total of 49, 149, and 81 matched pairs of stage 0-I, II, and III patients, respectively, were generated for analysis. For stage 0-I (p = 0.011) and III (p = 0.015), only CSS in the NAC groups were inferior. Receiving NAC was an independent prognostic risk factor for patients with stage 0-I (hazard ratio, 7.70; 95% confidence interval, 1.820-32.5; p = 0.006) and stage III (hazard ratio, 1.73; 95% confidence interval, 1.11-2.68; p = 0.015).

Conclusions

The CSS was poorer among LACC patients who underwent NAC than among those who did not. The yp stage of colon cancer after NAC has distinctive significance, which may contribute to predicting the prognosis and guiding the treatment of LACC patients after NAC.

Collagen Score in the Tumor Microenvironment Predicts the Prognosis of Rectal Cancer Patients after Neoadjuvant Chemoradiotherapy

BACKGROUND AND PURPOSE

Little is known about the relationship between collagen and the prognosis of patients with locally advanced rectal cancer (LARC) after neoadjuvant chemoradiotherapy (nCRT). This study aimed to quantitatively analyze collagen alterations, establish a collagen score (CS) in the tumor microenvironment, and evaluate and validate the relationship of the CS with prognosis in these patients.

MATERIALS AND METHODS

A total of 365 primary patients diagnosed with LARC after nCRT between 2011 and 2018 were retrospectively reviewed (training cohort: 210; independent validation cohort: 155). Multiple collagen features of two fields in the tumor microenvironment, the core of the tumor (CT) and the invasive margin (IM), were derived from multiphoton imaging, and the CS_IM-CT was generated using least absolute shrinkage and selection operator (LASSO) Cox regression analysis.

RESULTS

The CS_IM-CT was created based on 3 features: collagen area, number of collagen fibers and a Gabor textural feature. In the training cohort, the CS_IM-CT predicted 3-year disease-free survival (DFS) with an area under the receiver operating characteristic curve (AUROC) of 0.765 (0.675-0.854) and an overall survival (OS) with AUROC of 0.822 (0.734-0.909). Additionally, the CS_IM-CT was significantly associated with DFS and OS in the two cohorts. A nomogram with the CS_IM-CT was developed and showed good prognostic value predicting a 3-year DFS with an AUROC of 0.826 (0.748-0.905) and an OS with AUROC of 0.882 (0.803-0.960).

CONCLUSIONS

The CS_IM-CT is an effective prognostic marker in patients with LARC after nCRT, and the nomogram with the CS_IM-CT can be used to accurately predict the individual prognosis of these patients.

Stratified Prognostic Value of Pathological Response to Preoperative Treatment in yp II/III Rectal Cancer

AIM

Accumulated studies have verified that tumor regression is associated with the prognosis of rectal cancer. However, stratified analysis within a certain stage is still unknown. The purpose of our study was to assess the impact of pathologic response on the survival of stageII and III rectal cancer patients after neoadjuvant chemoradiotherapy (nCRT).

METHODS

Clinicopathologic characteristics and tumor regression scores (TRS) were assessed in 236 rectal cancer patients who treated with nCRT followed by surgery. Survival analysis was performed using Cox proportional hazards models.

RESULTS

Among these patients, the stage of 88 patients was ypII, and 91 patients were with the stage of ypIII. The median follow-up time was 59.8 months. TRS was not an independent prognostic factor in ypII patients while it was significantly associated with the prognosis of ypIII patients (5-year survival rate 67.2% vs. 42.5%, P < 0.001). Furthermore, ypIII patients with the response to nCRT had similar survival to that of ypII patients (5-year survival rate 67.2% vs. 70.5%, P = 0.56). For ypIII patients, multivariable analysis showed that well differentiation, negative surgical margin, and the administration of adjuvant chemotherapy were associated with better survival. The surgical margin and differentiation were prognostic factors for ypII patients.

CONCLUSIONS

ypIII rectal cancer patients with poor response to preoperative treatment are at high risk of worse oncological outcomes.

Current evidence regarding the role of adjuvant chemotherapy in rectal cancer patients with pathologic complete response after neoadjuvant chemoradiotherapy: a systematic review and meta-analysis

PURPOSE

The aim of this meta-analysis was to investigate the role of adjuvant chemotherapy (AC) in rectal cancer patients with pathologic complete response (pCR) after neoadjuvant chemoradiotherapy (nCRT) and curative resection.

METHODS

This study was completed in accordance to the PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. The electronic scholar databases (Medline, Web of Science, Scopus) were screened for eligible articles. The level of evidence (LoE) was assessed using the GRADE methodology.

RESULTS

Overall, 23 non-randomized studies and 17,406 patients were included in the present meta-analysis. Pooled comparisons confirmed that AC improved overall survival (HR: 0.68, p=0.0003), but not disease-free (p=0.22) and recurrence-free survival (p=0.39). However, the LoE for all outcomes was characterized as "very low," due to the absence of RCTs.

CONCLUSIONS

Considering the study limitations and the lack of randomized studies, further high-quality RCTs are required to confirm the findings of our study.

Associations between clinical characteristics and tumor response to neoadjuvant chemoradiotherapy in rectal cancer

Following standard neoadjuvant chemoradiotherapy and total mesorectal excision, some patients with locally advanced rectal cancer achieve good response (pathological T0-2N0), while others show nonresponse (pathological T3-4N0 or node-positive). To date, the clinicopathological predictors of good response and the necessity of adjuvant chemotherapy treatment (ACT) in good responders remain unclear. In this retrospective study, clinicopathological characteristics were surveyed to investigate the correlation with good response; furthermore, a propensity score matching (PSM) model was designed to balance the confounding factors between good responders treated with ACT or observation. A total of 2255 patients were enrolled, including 1069 good responders and 1186 nonresponders. The results of the survival analysis showed a good response predicted a better 3-year prognosis (p < 0.001). The logistic regression analysis showed less advanced T and N stages (T3 vs. T4; N0 vs. N1-2), more neoadjuvant chemotherapy (nCT) cycles (≥4 vs. 1-3), and delayed surgery (≥8 weeks vs. <8 weeks) were independent predictors of a good response (p < 0.05). Especially, patients treated with both more nCT cycles and a delay in surgery included the greatest number of good responders (p < 0.001). For good responders, after PSM (1:3), 235 observation cases were matched to 705 ACT cases. As compared with observation, ACT had no greater impact on prognosis analysis (p > 0.05). In conclusion, more cycles of nCT and a delay in surgery predicted a better response, and the delivery of ACT might be omitted in good responders.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Prognostic Potential of Lymphocyte-C-Reactive Protein Ratio in Patients with Rectal Cancer Receiving Preoperative Chemoradiotherapy

PURPOSE

The systemic inflammatory response is attracting increasing attention as a predictive biomarker for oncological outcome in patients with colorectal cancer. This study is aimed at verifying if the lymphocyte-C-reactive protein (CRP) ratio (LCR) could be used as a predictor of oncological outcome in patients with rectal cancer (RC) receiving preoperative chemoradiotherapy (CRT).

METHODS

We analyzed data for 86 patients with RC who received preoperative CRT followed by total mesorectal excision at our institution. A ratio of 6000 was used as the cut-off value for LCR for further analysis.

RESULTS

The post-CRT LCR was significantly lower than the pre-CRT LCR in patients with RC. Although post-CRT LCR status was not significantly correlated with overall survival (OS), low pre-CRT LCR was significantly associated with shorter recurrence-free survival (RFS: p = 0.02) and OS (p = 0.017) in this population and was an independent prognostic factor for both RFS and OS (hazard ratio (HR) 3.19, 95% confidence interval (CI) 1.33-7.66, p = 0.009; HR 2.83, 95%CI 1.14-7.01, p = 0.025, respectively). Furthermore, low pre-CRT LCR was a stronger indicator of early recurrence (p = 0.001) and poor prognosis (p = 0.025) in RC patients without pathological lymph node metastasis compared with patients with pathological lymph node metastasis, and prognostic potential of pre-CRT LCR was clearly revealed especially RC patients receiving long-course CRT.

CONCLUSIONS

Assessment of pretreatment LCR status might aid decision-making regarding postoperative treatment strategies in patients with RC receiving CRT followed by potentially curative resection.

Oncologic effects of adjuvant chemotherapy in patients with ypT0-2N0 rectal cancer after neoadjuvant chemoradiotherapy and curative surgery: a meta-analysis

Purpose

The role of adjuvant chemotherapy for patients with ypT0–2N0 rectal cancer following neoadjuvant chemoradiotherapy (nCRT) and curative surgery is uncertain. We performed a meta-analysis using selected studies to compare adjuvant chemotherapy with observation for this cohort of patients.

Methods

PubMed, Embase, and the Cochrane Library were searched. Data were pooled, and overall effect size was calculated using random effect models. Outcome measures were 5-year overall survival (OS), disease-free survival (DFS), local, and distant recurrence.

Results

We included 17 nonrandomized studies for qualitative analysis and 16 nonrandomized studies that examined 4,747 patients for the meta-analysis. In analysis of patients with ypT0N0 rectal cancer, adjuvant chemotherapy had no significant effect on OS (odds ratio [OR], 1.53; 95% confidence interval [CI], 0.86–2.72; I² = 27%), DFS (OR, 1.22; 95% CI, 0.61–2.42; I² = 5%), local recurrence (OR, 0.78; 95% CI, 0.08–7.37; I² = 0%), and distant recurrence (OR, 1.04; 95% CI, 0.41–2.62; I² = 0%). In analysis of patients with ypT1–2N0 rectal cancer, adjuvant chemotherapy also had no significant effect on OS (OR, 2.15; 95% CI, 0.59–7.80; I² = 26%), DFS (OR, 1.66; 95% CI, 0.35–7.85; I² = 44%), local recurrence (OR, 2.56; 95% CI, 0.72–9.13; I² = 0%), and distant recurrence (OR, 1.15; 95% CI, 0.23–5.87; I² = 0%).

Conclusion

Adjuvant chemotherapy may have no oncologic benefits in patients with ypT0–2N0 rectal cancer after nCRT and radical surgery. Routine use of adjuvant chemotherapy for those patients may be avoided.

Pathological nodal staging score for rectal cancer patients treated with radical surgery with or without neoadjuvant therapy: a postoperative decision tool

Background

Lymph node status can predict the prognosis of patients with rectal cancer treated with surgery. Thus, we sought to establish a standard for the minimum number of lymph nodes (LNs) examined in patients with rectal cancer by evaluating the probability that pathologically negative LNs prove positive during surgery.

Patients and methods

We extracted information of 31,853 patients with stage I–III rectal carcinoma registered between 2004 and 2013 from the Surveillance, Epidemiology, and End Results database and divided them into two groups: the first group was SURG, including patients receiving surgery directly and the other group was NEO, encompassing those underwent neo-adjuvant therapy. Using a beta-binomial model, we developed nodal staging score (NSS) based on pT/ypT stage and the number of LNs retrieved.

Results

In both cohorts, the false-negative rate was estimated to be 16% when 12 LNs were examined, but it dropped to 10% when 20 LNs were evaluated. In the SURG cohort, to rule out 90% possibility of false staging, 3, 7, 28, and 32 LNs would be necessarily examined in patients with pT1–4 disease, respectively. While in the NEO cohort, 4, 7, 12, and 16 LNs would be included for examination in patients with ypT1–4 disease to guarantee an NSS of 90%.

Conclusion

By determining whether a rectal cancer patient with negative LNs was appropriately staged, the NSS model we developed in this study may assist in tailoring postoperative management.

Nadir/pre-chemoradiotherapy ratio of white blood-cell count can predict tumor response and recurrence-free survival in locally advanced rectal cancer: a multi-institutional analysis

PURPOSE

The objective of this study was to evaluate whether change of white blood-cell (WBC) count before and during chemoradiotherapy (CRT) might be associated with susceptibility to radiation and tumor response.

METHODS

Medical records of 641 patients with rectal cancer who received preoperative CRT followed by curative surgery were retrospectively reviewed in five tertiary centers. Complete blood cell with differential count was measured weekly during the period of CRT. We assessed nadir/pre-CRT ratio of WBC count as a predictor for tumor response to CRT and a prognostic factor for recurrence-free survival.

RESULTS

Enrolled patients were divided into low WBC ratio (LWR) and high WBC ratio (HWR) arms with cut-off value of 0.49 calculated by receiver operating characteristic curve. Of 641 patients, 490 (76.4%) and 151 (23.6%) were categorized into HWR (> 0.49) arm and LWR (≤ 0.49) arms, respectively. Complete pathologic response rate after CRT was significantly higher in LWR arm than that in HWR arm (23.8% vs. 12.2%, p = 0.001). In logistic regression analysis, carcinoembryonic antigen (CEA) level over 5 ng/ml [adjusted odds ratio (OR) 0.566, 95% confidence interval (CI) 0.351-0.912; p = 0.019) and HWR (adjusted OR 0.412, 95% CI 0.256-0.663; p = 0.001) were significantly negative factors of pathologic complete response. The 5-year recurrence-free survival rate was significantly higher in the LWR group than that in the HWR group (83.3% vs. 67.6%, p = 0.001).

CONCLUSION

Low nadir/pre-chemoradiotherapy ratio during preoperative CRT can predict good tumor response. It is significantly associated with improved recurrence-free survival in rectal cancer.

Is adjuvant chemotherapy necessary for patients with ypT0-2N0 rectal cancer treated with neoadjuvant chemoradiotherapy and curative surgery?

Background and objective

The benefit from adjuvant chemotherapy for patients treated with neoadjuvant chemoradiotherapy (NCRT) and curative surgery remains controversial, particularly among those responding well to NCRT. This retrospective study aimed to clarify the benefits of adjuvant chemotherapy in terms of the oncological outcomes of patients with ypT0–2N0 rectal cancer after NCRT and curative surgery.

Methods

All patients with ypT0–2N0 rectal cancer after NCRT and curative resection between 2005 and 2014 were examined. The oncological outcomes between patients treated with adjuvant chemotherapy and those without any chemotherapy were compared.

Results

The clinicopathological characteristics of 110 patients were reviewed in this study; one patient was excluded due to lack of follow-up. Of the 109 patients included, 58 (53.2%) underwent adjuvant chemotherapy (chemo group), whereas the remaining 51 (46.8%) did not receive any chemotherapy (non-chemo group). After a median follow-up of 50 months, there were no significant differences in the 5-year overall survival (OS) or recurrence-free survival (RFS) rates between the groups (OS: 92.1 vs 86.3%, P = 0.375; RFS: 80.9 vs 74.7%, P = 0.534). Subgroup analysis also demonstrated no significant differences in 5-year OS and RFS rates between patients with ypT0N0 rectal cancer (P = 0.712 and P = 0.599, respectively) and those with ypT1–2N0 disease (P = 0.255 and P = 0.278, respectively).

Conclusions

These results indicate that patients with ypT0–2N0 rectal cancer after NCRT followed by curative surgery may not derive significant benefit from adjuvant chemotherapy. However, further prospective randomized trials, with larger sample sizes, are warranted to confirm this conclusion.

Adjuvant Chemotherapy Seemed Not to Have Survival Benefit in Rectal Cancer Patients with ypTis-2N0 After Preoperative Radiotherapy and Surgery from a Population-Based Propensity Score Analysis

BACKGROUND

Adjuvant chemotherapy is currently offered routinely, as standard, after radical resection for patients with rectal cancer receiving neo-adjuvant chemoradiation. However, the efficacy of adjuvant chemotherapy in patients with ypTis-2N0M0 has not been documented to the same extent, and the survival benefit remained controversial. The purpose of this work was to determine the role of chemotherapy in patients with ypTis-2N0M0 classification.

MATERIALS AND METHODS

Data were obtained from the Surveillance, Epidemiology, and End Results database (n = 4,217). A propensity score model was utilized to balance baseline covariates.

RESULTS

Of the 4,217 included patients, 335 with ypTis-2N0M0 did not receive adjuvant chemotherapy. There were comparable cancer-specific survivals (CSS) between those undergoing adjuvant chemotherapy or not (log-rank test = 0.136, p = .712) in the overall sample. After propensity score matching, the cancer-specific survival did not differ between the chemotherapy and observation groups (log-rank test = 0.089, p = .765). Additionally, the Cox model did not demonstrate adjuvant chemotherapy as the prognostic factor, with hazard ratio = 0.95 (95% confidence interval 0.69-1.32) for CSS. Furthermore, the 10-year cumulative CSS was 78.7% and 79.4% between the chemotherapy and observation groups, indicating no significance, and no impact of adjuvant chemotherapy on survival was observed in different subgroups stratified by T stage, histological grade, histology, lymph nodes, and tumor size.

CONCLUSION

Patients with ypTis-2N0 rectal cancer did not benefit from adjuvant chemotherapy after preoperative radiology and radical surgery in this cohort study. These results provided new insight into the routine use of adjuvant chemotherapy for patients with rectal cancer with completed neo-adjuvant radiotherapy and curative surgery.

IMPLICATIONS FOR PRACTICE

Inconsistent recommendations for patients with rectal cancer receiving neo-adjuvant chemoradiation are offered by clinical guidelines. Adjuvant chemotherapy had no cancer-specific survival benefit, not only in the whole cohort, but also in the propensity score-matched cohort. A Cox model also confirmed adjuvant chemotherapy was not a significant prognostic factor in ypTis-2N0 rectal cancer. No survival benefit conferred by adjuvant chemotherapy was observed, regardless of whether T stage, histological type, grade, lymph nodes and tumor size varied.

The effect of adjuvant chemotherapy on survival and recurrence after curative rectal cancer surgery in patients who are histologically node negative after neoadjuvant chemoradiotherapy

AIM

The aim of this study was to evaluate whether adjuvant chemotherapy will affect recurrence rate or disease-free and overall survival in patients with rectal adenocarcinoma who were staged with MRI node-positive disease (mrN+) preoperatively. These patients underwent neoadjuvant chemoradiotherapy with curative rectal cancer surgery and their pathological staging was negative for nodal disease (ypN0). There is no consensus on the role of adjuvant chemotherapy in such patients.

METHOD

Patients who received neoadjuvant chemoradiotherapy and underwent curative rectal cancer surgery for rectal adenocarcinoma staged as [mrTxN+M0] on MRI staging and who on pathological staging were found to be [ypTxN0M0] were retrospectively identified from January 2008 December 2012 from two tertiary referral centres (Royal Marsden Hospital, London and Saint-Andre Hospital, Bordeaux).

RESULTS

One hundred and sixty-three patients were recruited and, after propensity matching at a ratio of 2:1, n = 80 patients were divided to receive adjuvant (n = 28) or no adjuvant treatment (n = 52). A comparison of adjuvant chemotherapy vs no adjuvant therapy showed that the mean overall survival was 2.67 vs 3.60 years (P = 0.42) and disease-free survival was 2.27 vs 3.32 years (P = 0.14).

CONCLUSION

This study found no significant difference in survival or disease recurrence between patients who received adjuvant chemotherapy and patients who did not. There is no clear evidence to support or dismiss the use of adjuvant chemotherapy for patients who were node positive on preoperative MRI and node negative on histopathological staging. Further multicentre prospective randomized trials are needed to identify the appropriate treatment regime for this group of patients.

Oncologic Outcome of ypT1-2N0 Rectal Cancer After Neoadjuvant Chemoradiotherapy Compared With pT1-2N0 Rectal Cancer

OBJECTIVE

To investigate the oncologic outcome of ypT1-2N0 mid and lower rectal cancer after chemoradiotherapy (CRT) compared with pT1-2N0 rectal cancer.

METHODS

We compared the oncologic outcome of patients with mid and lower rectal cancer who underwent preoperative CRT and who did not, between February 2005 and August 2012.

RESULTS

Compared with patients who did not receive preoperative CRT, patients who received preoperative CRT did not have significantly different clinicopathologic features except clinical stage and distal resection margin. The 5-year disease-free survival (DFS) rates were lower in patients who received preoperative CRT than those who did not (84.4% vs. 95.5%, P=0.029). Preoperative CRT was a prognostic factor affecting 5-year DFS in patients with pathologically proven stage T1N0 mid and lower rectal cancer (HR, 11.157; 95% CI, 1.735-71.762; P=0.011) CONCLUSIONS:: ypT2N0 rectal cancer after neoadjuvant CRT showed shorter DFS compared with pT2N0 rectal cancer.

Prognosis of locally advanced rectal cancer can be predicted more accurately using pre- and post-chemoradiotherapy neutrophil-lymphocyte ratios in patients who received preoperative chemoradiotherapy

Purpose

The neutrophil-lymphocyte ratio (NLR) has been suggested as an inflammation-related factor, but also as an indicator of systemic anti-tumor immunity. We aimed to evaluate the prognostic value of the NLR and to propose a proper cut-off value in patients with locally advanced rectal cancer who received preoperative chemoradiation (CRT) followed by curative total mesorectal excision (TME).

Methods

A total of 110 rectal cancer patients with clinical T3-4 or node-positive disease were retrospectively analyzed. The NLR value before preoperative CRT (pre-CRT NLR) and the NLR value between preoperative CRT and surgery (post-CRT NLR) were obtained. Using a maximally selected log-rank test, cut-off values were determined as 1.75 for the pre-CRT NLR and 5.14 for the post-CRT NLR.

Results

Patients were grouped as follows: group A, pre-CRT NLR ≤ 1.75 and post-CRT NLR ≤ 5.14 (n = 29); group B, pre-CRT NLR > 1.75 and post-CRT NLR ≤ 5.14, or pre-CRT NLR ≤ 1.75 and post-CRT NLR > 5.14 (n = 61); group C, pre-CRT NLR > 1.75 and post-CRT NLR > 5.14 (n = 20). The median follow-up time was 31.1 months. The 3-year disease-free survival (DFS) and overall survival (OS) rates showed significant differences between the NLR groups (3-year DFS rate: 92.7% vs. 73.0% vs. 47.3%, for group A, B, and C, respectively, p = 0.018; 3-year OS rate: 96.0% vs. 85.5% vs. 59.8%, p = 0.034). Multivariate analysis revealed that the NLR was an independent prognostic factor for DFS (p = 0.028).

Conclusion

Both the pre-CRT NLR and the post-CRT NLR have a predictive value for the prognosis of patients with locally advanced rectal cancer treated with preoperative CRT followed by curative TME and adjuvant chemotherapy. A persistently elevated post-CRT NLR may be an indicator of an increased risk of distant metastasis.

Pre- and post-surgery treatments in rectal cancer: a long-term single-centre experience

BACKGROUND

Our study evaluated long-term survival outcomes in rectal cancer patients treated with preoperative radiotherapy, and the impact on survival of concomitant and postoperative adjuvant chemotherapy (ctx), among other prognostic factors.

METHODS

The study included 196 patients [median age: 58 years (range: 20-86 years); 63.0% men] with locally advanced rectal carcinoma and, in some cases, resectable liver metastasis. Rates of distant metastasis and local recurrence and of 5-year distant metastasis-free survival (dmfs) and overall survival (os) were determined.

RESULTS

The 5-year os rate was 57.0%, with a median duration of 81.5 months (95% confidence interval: 73.7 months to 89.4 months), and the 5-year dmfs rate was 54.1%, with a median duration of 68.4 months (95% confidence interval: 40.4 months to 96.4 months). Prognostic factors for higher os and dmfs rates were downstaging (p = 0.013 and p = 0.005 respectively), radiotherapy dose (50 Gy vs. 56 Gy or 45-46 Gy, both p = 0.002), and concomitant ctx use (p = 0.004 and p = 0.001) and type (5-fluorouracil-leucovorin-folinic acid vs. tegafur-folinic acid, p = 0.034 and p = 0.043). Adjuvant ctx after neoadjuvant long-term concomitant chemoradiotherapy (ccrt) and surgery was associated with better 5-year os rates for postoperative T0-T3 disease (p = 0.003) and disease at all lymph node stages (p = 0.001).

CONCLUSIONS

Our findings revealed a favourable survival outcome with long-term fractionated irradiation and concomitant 5-fluorouracil-based ctx, achieving 5-year os and dmfs rates of 57.0% and 54.1% respectively. Preoperative administration of radiotherapy (50 Gy) and postoperative adjuvant ctx were associated with a significant survival benefit. Radiation doses above 50 Gy and the interval between ccrt and surgery had no significant effect on survival.

A nomogram to predict distant metastasis after neoadjuvant chemoradiotherapy and radical surgery in patients with locally advanced rectal cancer

PURPOSE

To compare distant metastasis (DM) in locally advanced rectal cancer (LARC) patients treated with neoadjuvant chemoradiotherapy (nCRT) and surgery alone, and to develop a predictive nomogram for DM following nCRT.

METHODS

Propensity-scoring match analysis was performed to compare DM in LARC treated with nCRT (n = 375) and surgery alone (n = 375). Cox regression was performed to identify predictors of DM following nCRT. A nomogram was developed and validated by internal (n = 425) and external validation (n = 97).

RESULTS

The 5-year local recurrence rate was significantly lower in the nCRT group (5.6% vs. 10.4%; P = 0.020). The 5-year DM rates (nCRT vs. surgery alone: 25.3% vs. 24.4%; P = 0.235) were similar between groups. Cox regression showed that the post-nCRT pathologic stage (ypTNM stage, OR = 2.022, P = 0.002), IMA nodal metastasis (OR = 2.171, P = 0.023), and CRM involvement (OR = 2.535, P = 0.016) were independently associated with DM following nCRT. A predictive nomogram was developed with a C-index of 0.70 on internal validation, and 0.71 on the external validation.

CONCLUSION

NCRT improved local control, but not distant metastasis. A nomogram to predict 3- and 5-year DM rates, using clinicopathological parameters, was successfully developed. This prognostic tool could support decision-making in clinical practice and follow-up strategies.

Is It Possible to Shorten the Duration of Adjuvant Chemotherapy for Locally Advanced Rectal Cancer?

The long duration of 4 months of postoperative adjuvant chemotherapy is currently recommended for locally advanced rectal cancer after preoperative chemoradiation and surgery. Whether a short duration could be applied in these patients is unknown. So, the purpose of this study is to evaluate the effects on prognosis based on different durations of adjuvant chemotherapy for rectal cancer. We performed a retrospective study of 200 rectal cancer patients who were treated with preoperative chemoradiation and were pathologically graded as ypII and ypIII stages between March 2003 and May 2012. All patients were divided into 2 groups according to the median duration of adjuvant chemotherapy of 2 months. Overall survival (OS) and disease-free survival (DFS) were compared between patients with duration shorter and longer than 2 months in the whole group and subgroups of ypII and ypIII. Recurrence patterns were also analyzed in all subgroups. Multivariate analysis was performed to explore clinical factors that were significantly associated with DFS, local recurrence-free survival, and distant metastasis-free survival. In subgroup of ypII stage, the 5-year OS and DFS were similar between patients in long and short durations of adjuvant chemotherapy. For patients of ypIII stage, although no significant difference was found in OS between patients in short and long durations, DFS was showed to be higher in the group of long duration. Further analysis showed that longer duration of adjuvant chemotherapy could lead to improved control of distant metastasis and no impact on local control. Multivariable analysis indicated that long duration of adjuvant chemotherapy is significantly associated with longer distant metastasis-free survival in patients with ypIII stage, but not in those with ypII stage. A long duration of at least 2 months of postoperative adjuvant chemotherapy is necessary for patients with ypIII stage, whereas it may not be absolutely appropriate for those with ypII stage. Therefore, we suggest a tailored selection of durations of adjuvant chemotherapy for locally advanced rectal cancer.

Prognostic significance of pathological response to preoperative chemoradiotherapy in patients with locally advanced rectal cancer

BACKGROUND

Preoperative chemoradiotherapy (CRT) is widely used in the treatment of locally advanced rectal cancer (LARC). Pathological response to CRT has been shown to be a potential prognostic predictor in rectal cancer patients. The aim of this study was to determine the prognostic significance of pathological response to preoperative CRT in LARC patients.

METHODS

Thirty-two patients with LARC were retrospectively analyzed to determine the relationships of pathological response and clinicopathological characteristics to survival outcomes. Patients received CRT with tegafur/uracil and leucovorin. Radiotherapy was administered in fractions of 1.8 Gy/day and 5 days per week. The total dose of radiation delivered was 45 Gy.

RESULTS

All patients underwent total mesorectal excision with lymph node dissections after CRT, and resected specimens were examined pathologically. Four patients showed pathological complete response, 14 showed good response, and 14 showed poor response. Pathological complete or good response was associated with longer survival (P = 0.041). Clinicopathological factors excluding gender were not correlated with outcome. No factor was associated with recurrence.

CONCLUSION

Pathological response to preoperative CRT may be a useful prognostic predictor in patients with LARC.

Prognostic significance of pathological response to preoperative chemoradiotherapy in patients with locally advanced rectal cancer

BACKGROUND

Preoperative chemoradiotherapy (CRT) is widely used in the treatment of locally advanced rectal cancer (LARC). Pathological response to CRT has been shown to be a potential prognostic predictor in rectal cancer patients. The aim of this study was to determine the prognostic significance of pathological response to preoperative CRT in LARC patients.

METHODS

Thirty-two patients with LARC were retrospectively analyzed to determine the relationships of pathological response and clinicopathological characteristics to survival outcomes. Patients received CRT with tegafur/uracil and leucovorin. Radiotherapy was administered in fractions of 1.8 Gy/day and 5 days per week. The total dose of radiation delivered was 45 Gy.

RESULTS

All patients underwent total mesorectal excision with lymph node dissections after CRT, and resected specimens were examined pathologically. Four patients showed pathological complete response, 14 showed good response, and 14 showed poor response. Pathological complete or good response was associated with longer survival (P = 0.041). Clinicopathological factors excluding gender were not correlated with outcome. No factor was associated with recurrence.

CONCLUSION

Pathological response to preoperative CRT may be a useful prognostic predictor in patients with LARC.

Oncologic results and prognostic predictors of patients with locally advanced rectal cancer showing ypN0 after radical surgery following neoadjuvant chemoradiotherapy

PURPOSE

Adjuvant chemotherapy is recommended for patients with locally advanced rectal cancer after radical surgery following neoadjuvant chemoradiotherapy (NCRT) regardless of the final pathologic stage. However, the efficacy of adjuvant chemotherapy in ypN0 patients remains controversial. The aim of this study was to evaluate the oncologic outcomes and analyze the prognostic factors for ypN0 patients in order to estimate prognosis and establish an effective adjuvant chemotherapy strategy for stage 0-II rectal cancers after radical surgery following NCRT.

METHODS

Between January 1999 and December 2009, the medical records of 202 patients who had been diagnosed with locally advanced rectal cancer, underwent radical surgery following NCRT, and showed ypN0 were retrospectively reviewed.

RESULTS

The median follow-up period was 60.5 months. The 5-year local recurrence rate was 3.1 %. The 5-year disease-free survival and 5-year overall survival were 86.3 and 86.9 %. Postirradiation T3-4 and abdominoperineal resection (APR) were the independent prognostic indicators for disease-free survival (p = 0.001, p = 0.003) and overall survival (p = 0.001, p = 0.002). Adjuvant chemotherapy improved local recurrence in the patient with ypT3-4 and patients who had undergone APR (p = 0.014, p = 0.002). APR affected local recurrence, disease-free survival, and overall survival of ypT3-4 patients (p = 0.013. 0.029, and 0.001) CONCLUSIONS: Postirradiation T3-4 and APR are the significant prognostic factors for ypN0. Further randomized prospective study is needed to evaluate the oncologic benefit of adjuvant chemotherapy in ypN0 patients, especially those with ypT3-4 and those having undergone APR, and to confirm which chemotherapeutic agent could improve the oncologic outcomes of patients poorly responding to NCRT.

Prognostic significance of clinical and pathological stages on locally advanced rectal carcinoma after neoadjuvant chemoradiotherapy

Objective

To investigate prognostic significance of clinical and pathological stages in patients with locally advanced rectal carcinoma treated with neoadjuvant chemoradiotherapy (neo-CRT) and total mesorectal excision.

Patients and methods

210 patients with locally advanced rectal carcinoma (cT3-4 or cN+) treated with neo-CRT followed by total mesorectal excision. Treatment outcomes were compared according to clinical and pathological stage. Overall survival (OS), disease free survival (DFS) among patients with different clinical stage and pathological stage after neo-CRT.

Results

The median follow-up time was 47 months (range, 14–98 months). Clinical T stage was associated with 5 year OS (p = 0.042) and 5 year DFS (p = 0.014) while clinical N stage was not associated with 5 year OS (p = 0.440), 5 year DFS (p = 0.711). Pathological T stage was associate with 5 year OS (p = 0.001) and 5 year DFS (p = 0.046); and N stage was associated with 5 year OS (p = 0.001), 5 year DFS (p = 0.002). The pathological stage was further classified into three groups: ypT0–2N0 in 91 patients (43.3 %), ypT3–4N0 in 69 patients (32.9 %) and ypT0–4N+ in 50 patients (23.8 %). While pathological stage (ypT0–2 vs ypT3–4N0 vs ypT0–4N+) was associated with 5 year OS (87.9 %, 75.5 %, 56.7 %, p = 0.000), 5 year DFS (74.5 %, 77.4 %, 50.5 %, p = 0.003). Multivariate analysis showed that ypN stage was an independent prognostic factor for patients 5 year DFS.

Conclusions

Pathological stage is strongly associated with treatment outcomes in patients with locally advanced rectal carcinoma treated with neo-CRT followed by total mesorectal excision, which may be used as guidance for further individualized treatment.

A systematic review and meta-analysis of adjuvant chemotherapy after neoadjuvant treatment and surgery for rectal cancer

BACKGROUND

Current guidelines support the use of adjuvant chemotherapy (CT) following neoadjuvant chemoradiotherapy (CTRT) and surgery to treat rectal cancer, although clinical trials have provided little evidence that it is effective. We performed a systematic review of published studies to assess whether adjuvant CT improves outcome after neoadjuvant therapy and radical surgery in cases of rectal cancer.

MATERIALS AND METHODS

We conducted an electronic database search for randomized and nonrandomized studies in PubMed, EMBASE, Web of Science, Scopus and the Cochrane Register of Controlled Trials. We then carried out a meta-analysis by using the fixed- or random-effects models. The primary endpoint was 5-year overall survival (OS) reported as odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Two randomized controlled trials (RCTs), one pooled analysis of five RCTs and 10 retrospective studies that included a total of 5,457 patients matched our selection criteria. Meta-analysis showed that for rectal cancer patients treated with surgery and neoadjuvant CTRT, adjuvant CT improves 5-year OS (OR, 0.64; 95% CI, 0.46-0.88; p = 0.006) and 5-year disease-free survival (DFS) (OR, 0.71; 95% CI, 0.6-0.83; p < 0.0001). The 5-year OS benefit was significantly larger in downstaged patients and in retrospective series. A better DFS was instead noted in all studies due to a reduced risk of local relapse.

CONCLUSIONS

Amongst rectal cancer patients treated with neoadjuvant therapy and surgery, adjuvant CT seems to improve the 5-year DFS and OS rates and may be discussed with patients. However, the benefit derives mainly from retrospective evidence.

Adjuvant chemotherapy in rectal cancer: defining subgroups who may benefit after neoadjuvant chemoradiation and resection: a pooled analysis of 3,313 patients

Recent literature suggests that the benefit of adjuvant chemotherapy (aCT) for rectal cancer patients might depend on the response to neoadjuvant chemoradiation (CRT). Aim was to evaluate whether the effect of aCT in rectal cancer is modified by response to CRT and to identify which patients benefit from aCT after CRT, by means of a pooled analysis of individual patient data from 13 datasets. Patients were categorized into three groups: pCR (ypT0N0), ypT1-2 tumour and ypT3-4 tumour. Hazard ratios (HR) for the effect of aCT were derived from multivariable Cox regression analyses. Primary outcome measure was recurrence-free survival (RFS). One thousand seven hundred and twenty three (1723) (52%) of 3,313 included patients received aCT. Eight hundred and ninety eight (898) patients had a pCR, 966 had a ypT1-2 tumour and 1,302 had a ypT3-4 tumour. For 122 patients response, category was missing and 25 patients had ypT0N+. Median follow-up for all patients was 51 (0-219) months. HR for RFS with 95% CI for patients treated with aCT were 1.25(0.68-2.29), 0.58(0.37-0.89) and 0.83(0.66-1.10) for patients with pCR, ypT1-2 and ypT3-4 tumours, respectively. The effect of aCT in rectal cancer patients treated with CRT differs between subgroups. Patients with a pCR after CRT may not benefit from aCT, whereas patients with residual tumour had superior outcomes when aCT was administered. The test for interaction did not reach statistical significance, but the results support further investigation of a more individualized approach to administer aCT after CRT and surgery based on pathologic staging.

Adjuvant chemotherapy after neoadjuvant chemoradiation and curative resection for rectal cancer: is it necessary for all patients?

BACKGROUND

The benefit of adjuvant chemotherapy for patients with locally advanced rectal cancer who have received neoadjuvant concurrent chemoradiation therapy (CCRT) and undergone curative resection remains unclear.

METHODS

This study was a retrospective review of prospectively collected data. Patients with locally advanced rectal cancer who underwent curative surgery after neoadjuvant CCRT between January 2006 and March 2011 were identified. Four hundred forty-one patients who completed adjuvant chemotherapy (chemo group) were compared with 35 patients who did not receive any adjuvant treatment (nonchemo group).

RESULTS

The 5-year disease-free survival (DFS) was significantly higher in the chemo group (78.5% vs. 63.1%, P =  0.016). After stratification of the patients according to nodal status, these differences were no longer significant, but there were trends toward inferior DFS in the nonchemo group in all survival curves. In multivariate Cox regression analysis, no adjuvant chemotherapy (HR, 2.306; 95% CI, 1.101-4.829; P = 0.027) emerged as an independent prognostic factor associated with decreased DFS.

CONCLUSIONS

Adjuvant chemotherapy was significantly associated with increased DFS among patients who had undergone neoadjuvant CCRT and radical resection for locally advanced rectal cancer. Adjuvant chemotherapy should be considered in every patient after neoadjuvant CCRT irrespective of the final pathology stage.

Which is the best postoperative chemotherapy regimen in patients with rectal cancer after neoadjuvant therapy?

Background

There is no general agreement about whether patients who have already received neoadjuvant chemoradiotherapy need further postoperative chemotherapy based on 5-fluorouracil(5-FU) or 5-FU plus oxaliplatin.

Methods

Medicare beneficiaries from 1992 to 2008 with Union for International Cancer Control ypStages I to III primary carcinoma of the rectum who underwent 5-FU-based neoadjuvant chemoradiotherapy and surgery for curative intent were identified through the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database. A Cox proportional hazards model and propensity score-matched techniques were used to evaluate the effect of treatment on survival.

Results

For patients with resected rectal cancer who have already received 5-FU-based neoadjuvant chemoradiotherapy, postoperative 5-FU-based chemotherapy did not prolong cancer-specific survival (CSS) in ypStage I (P = 0.960) and ypStage II (P = 0.134); however, it significantly improved the CSS in ypStage III (hazard ratio = 1.547, 95% CI = 1.101-2.173, P = 0.012). No significant differences in survival between the 5-FU group and oxaliplatin group were observed.

Conclusions

For patients with resected rectal cancer who have already received 5-FU-based neoadjuvant chemoradiotherapy, postoperative 5-FU-based chemotherapy prolongs the CSS of groups in ypStage III. Adding oxaliplatin to fluoropyrimidines in the postoperative chemotherapy did not improve the CSS for patients who received neoadjuvant chemoradiotherapy.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2407-14-888) contains supplementary material, which is available to authorized users.

Helical tomotherapy combined with capecitabine in the preoperative treatment of locally advanced rectal cancer

The aim of this study was to evaluate the efficacy of helical tomotherapy plus capecitabine as a preoperative chemoradiotherapy (CRT) in patients with locally advanced rectal cancer (LARC). Thirty-six LARC patients receiving preoperative CRT were analyzed. Radiotherapy (RT) consisted of 45 Gy to the regional lymph nodes and simultaneous-integrated boost (SIB) 50.4 Gy to the tumor, 5 days/week for 5 weeks. Chemotherapy consisted of capecitabine 850 mg/m(2), twice daily, during the RT days. Patients underwent surgery 6-8 weeks after completion of CRT. Information was collected for patient characteristics, treatment response, and acute and late toxicities. Grade 3/4 (G3+) toxicities occurred in 11.1% of patients (4/36). Sphincter preservation rate was 85.2% (23/27). Five patients (14.3%) achieved pathological complete response. Tumor, nodal, and ypT0-2N0 downstaging were noted in 60% (21/35), 69.6% (16/23), and 57.1% (20/35). Tumor regression grade 2~4 was achieved in 28 patients (80%). After a median follow-up time of 35 months, the most common G3+ late morbidity was ileus and fistula (5.7%, 2/35). The study showed that capecitabine plus helical tomotherapy with an SIB is feasible in treatment of LARC. The treatment modality can achieve a very encouraging sphincter preservation rate and a favorable ypT0-2N0 downstaging rate without excessive toxicity.

Selective use of adjuvant chemotherapy for rectal cancer patients with ypN0

BACKGROUND

The administration of adjuvant chemotherapy for rectal cancer patients with ypN0 is controversial. The purposes of this study were to evaluate the role of adjuvant chemotherapy in ypN0 patients and to optimize its use for these patients.

METHODS

We performed a retrospective study of 160 rectal cancer patients who had the final pathology of ypN0 between March 2003 and November 2010. Overall survival (OS), disease-free survival (DFS), local recurrence-free survival (LRFS), and distant metastasis-free survival (DMFS) were compared between patients who did and did not receive adjuvant chemotherapy. Multivariate analysis was performed to explore clinical factors significantly associated with DFS, LRFS, and DMFS.

RESULTS

For ypT0-2N0 patients, the 5-year OS, DFS, LRFS, and DMFS were similar between patients who did and did not receive adjuvant chemotherapy (P > 0.05). For patients with ypT3-4N0, those who were given adjuvant chemotherapy exhibited a higher 5-year OS than those who were not (P = 0.026), with also an extended 5-year DFS (P = 0.050). Further analysis indicated that adjuvant chemotherapy could decrease the rates of distant metastases for ypT3-4N0 patients with no impact on local control. In multivariable analysis, both the final pathological stage and adjuvant chemotherapy were independent predictors of DMFS for the whole group. When stratified by pathological stage, adjuvant chemotherapy was still significantly associated with DMFS in the ypT3-4 stratum.

CONCLUSIONS

Adjuvant chemotherapy may not improve survival for ypT0-2N0 patients. However, it may be clinically meaningful for ypT3-4N0 patients by decreasing rates of distant metastases. Further randomized controlled clinical trials are needed to address this problem.

Increased use of multidisciplinary treatment modalities adds little to the outcome of rectal cancer treated by optimal total mesorectal excision

PURPOSE

Total mesorectal excision (TME) is the standard surgical treatment for rectal cancer. The roles of chemotherapy and radiotherapy have become more defined, accompanied by improvements in preoperative staging and histopathological assessment. We analyse our ongoing results in the light of changing patterns of treatment over consecutive time periods.

METHODS

In total, 151 consecutive patients underwent potentially curative rectal excision for cancer in a single institution. Management and outcomes were compared between 1993-1999 and 2000-2007 which corresponded with the restructuring of the regional oncological services.

RESULTS

We found an increase in patients treated with neoadjuvant chemoradiotherapy after 1999 (20/89 vs 1/62, p < 0.001). There was an increase in the mean number of lymph nodes examined (11.9 vs 9.4, p = 0.037). The locoregional recurrence rate was 5.3%. The rates were not significantly different between the two study periods [4/89 (4.5%) 1999-2007 vs 4/62 (6.5%) 1993-1999, p = 0.597]. There was no statistical difference in overall or disease-free survival in the time periods examined.

CONCLUSIONS

Increasing use of neoadjuvant therapy and concomitant improvement in lymph node assessment did not translate into a concurrent reduction in the local recurrence, disease-free and overall survival rates. Our results demonstrate the enduring benefit of specialist training in TME in the outcome of rectal cancer surgery. This observational study suggests that low local recurrence rates are surrogate markers for improved overall and disease-free survival. Multidisciplinary team practice should be examined and made cost effective according to the individual unit's local recurrence rate in the light of this and other reports.

Challenging the feasibility and clinical significance of current guidelines on lymph node examination in rectal cancer in the era of neoadjuvant therapy

PURPOSE

We sought to examine the feasibility and clinical significance of current guidelines on nodal assessment in patients with rectal cancer (RC) treated with neoadjuvant radiation.

METHODS

All patients with RC treated with curative surgery from 1991 to 2003 were included. Number of lymph nodes (LNs) assessed was compared between patients who received neoadjuvant therapy and surgery (NEO) and patients who underwent surgery alone (SURG). Impact of node retrieval on node positivity and disease-specific survival (DSS) in NEO patients was assessed.

RESULTS

In total, 708 patients were identified, of whom 429 (61%) were in the NEO group. These patients had significantly fewer nodes assessed than SURG patients (unadjusted mean, 10.8 v 15.5; adjusted mean difference, -5.0 nodes; P < .001). In the NEO group, 63% of patients had fewer than 12 nodes retrieved (P < .001 v SURG). The proportion of patients diagnosed with node-positive disease in the NEO group was significantly and monotonically associated with the number of lymph nodes retrieved, with no plateau in the relationship. Fewer nodes retrieved was not associated with inferior DSS.

CONCLUSION

In a tertiary cancer center, the 12-LN threshold was not relevant and often not achievable in patients with RC treated with neoadjuvant therapy. Lower LN count after neoadjuvant treatment was not associated with understaging or inferior survival. Although we support the critical importance of careful pathologic examination and adequate nodal staging, we challenge the relevance of LN count both in clinical practice and as a quality indicator in RC.