1
|
Rizzo G, Amodio LE, D'Annibale G, Marzi F, Quero G, Menghi R, Tondolo V. Nonoperative management and local excision after neoadjuvant chemoradiation therapy for rectal cancer. Minerva Surg 2024; 79:470-480. [PMID: 38953759 DOI: 10.23736/s2724-5691.24.10445-5] [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: 07/04/2024]
Abstract
Locally advanced extraperitoneal rectal cancer represents a significant clinical challenge, and currently, the standard treatment is based on neoadjuvant chemoradiation therapy (CRT) followed by radical surgical resection with total mesorectal excision (TME). In the last 30 years, its management has undergone significant changes due to the improvement of complementary radio- and chemotherapy treatments, the improvement of minimally invasive surgical approaches and the diffusion of organ-sparing approaches, such as nonoperative management, commonly called "watch and wait" (NOM) and local excision (LE), in highly selected patients who achieve a major or complete response to neoadjuvant CRT. This review aimed to critically examine the efficacy and oncological safety of NOM and LE compared to those of standard TME in rectal cancer patients after neoadjuvant CRT. Both the pros and cons of these approaches were strictly analyzed, providing a comprehensive and critical overview of these novel management strategies for rectal cancer.
Collapse
Affiliation(s)
- Gianluca Rizzo
- Unit of Digestive and Colorectal Surgery, Ospedale Isola Tiberina Gemelli Isola, Università Cattolica del Sacro Cuore, Rome, Italy -
| | - Luca E Amodio
- Unit of Digestive and Colorectal Surgery, Ospedale Isola Tiberina Gemelli Isola, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giorgio D'Annibale
- Unit of Digestive and Colorectal Surgery, Ospedale Isola Tiberina Gemelli Isola, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Federica Marzi
- Unit of Digestive and Colorectal Surgery, Ospedale Isola Tiberina Gemelli Isola, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giuseppe Quero
- Unit of Digestive Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Roberta Menghi
- Unit of Digestive Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Vincenzo Tondolo
- Unit of Digestive and Colorectal Surgery, Ospedale Isola Tiberina Gemelli Isola, Università Cattolica del Sacro Cuore, Rome, Italy
| |
Collapse
|
2
|
de Moraes FCA, Kelly FA, Souza MEC, Burbano RMR. Impact of adjuvant chemotherapy on survival after pathological complete response in rectal cancer: a meta-analysis of 31,558 patients. Int J Colorectal Dis 2024; 39:96. [PMID: 38913175 PMCID: PMC11196358 DOI: 10.1007/s00384-024-04668-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/12/2024] [Indexed: 06/25/2024]
Abstract
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.
Collapse
Affiliation(s)
| | - Francinny Alves Kelly
- Department of Hypertension, Dante Pazzanese Institute of Cardiology, Sao Paulo, Brazil
| | | | - Rommel Mario Rodríguez Burbano
- Federal University of Pará, Rua Augusto Corrêa, nº 01, Guamá, Belém, Pará, 66073-000, Brazil
- Ophir Loyola Hospital, Belém, Pará, Brazil
| |
Collapse
|
3
|
Zwart WH, Temmink SJD, Hospers GAP, Marijnen CAM, Putter H, Nagtegaal ID, Blomqvist L, Kranenbarg EMK, Roodvoets AGH, Martling A, van de Velde CJH, Glimelius B, Peeters KCMJ, van Etten B, Nilsson PJ. Oncological outcomes after a pathological complete response following total neoadjuvant therapy or chemoradiotherapy for high-risk locally advanced rectal cancer in the RAPIDO trial. Eur J Cancer 2024; 204:114044. [PMID: 38636289 DOI: 10.1016/j.ejca.2024.114044] [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: 01/31/2024] [Revised: 03/25/2024] [Accepted: 04/01/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND A pathological complete response (pCR) following chemoradiation (CRT) or short-course radiotherapy (scRT) leads to a favourable prognosis in patients with rectal cancer. Total neo-adjuvant therapy (TNT) doubles the pCR rate, but it is unknown whether oncological outcomes remain favourable and whether the same characteristics are associated with pCR as after CRT. METHODS Comparison between patients with pCR in the RAPIDO trial in the experimental [EXP] (scRT, chemotherapy, surgery, as TNT) and standard-of-care treatment [STD] (CRT, surgery, postoperative chemotherapy depending on hospital policy) groups. Primary and secondary outcomes were time-to-recurrence (TTR), overall survival (OS) and association between patient, tumour, and treatment characteristics and pCR. RESULTS Among patients with a resection within six months after preoperative treatment, 120/423 (28%) [EXP] and 57/398 (14%) [STD] achieved a pCR. Following pCR, 5-year cumulative TTR and OS rates in the EXP and STD arms were 8% vs. 7% (hazard ratio 1.04, 95%CI 0.32-3.38) and 94% vs. 93% (hazard ratio 1.41, 95%CI 0.51-3.92), respectively. Besides the EXP treatment (odds ratio 2.70, 95%CI 1.83-3.97), pre-treatment carcinoembryonic antigen (CEA) <5, pre-treatment tumour size <40 mm and cT2 were associated with pCR. Distance from the anal verge was the only characteristic with a statistically significant difference in association with pCR between the EXP and STD treatment (Pinteraction=0.042). pCR rates did not increase with prolonged treatment time. CONCLUSIONS The doubled pCR rate of TNT compared to CRT results in similar oncological outcomes. Characteristics associated with pCR are the EXP treatment, normal CEA, and small tumour size.
Collapse
Affiliation(s)
- Wouter H Zwart
- University Medical Center Groningen, Department of Medical Oncology, Groningen, the Netherlands.
| | - Sofieke J D Temmink
- Karolinska Institutet, Department of Molecular Medicine and Surgery, Stockholm, Sweden
| | - Geke A P Hospers
- University Medical Center Groningen, Department of Medical Oncology, Groningen, the Netherlands
| | - Corrie A M Marijnen
- Netherlands Cancer Institute, Department of Radiation Oncology, Amsterdam, the Netherlands; Leiden University Medical Center, Department of Radiation Oncology, Leiden, the Netherlands
| | - Hein Putter
- Leiden University Medical Center, Department of Biomedical Data Sciences, Leiden, the Netherlands
| | - Iris D Nagtegaal
- Radboud University Medical Centre, Department of Pathology, Nijmegen, the Netherlands
| | - Lennart Blomqvist
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | | | - Annet G H Roodvoets
- Leiden University Medical Center, Department of Surgery, Leiden, the Netherlands
| | - Anna Martling
- Karolinska Institutet, Department of Molecular Medicine and Surgery, Stockholm, Sweden
| | | | - Bengt Glimelius
- Uppsala University, Department of Immunology, Genetics and Pathology, Uppsala, Sweden
| | - Koen C M J Peeters
- Leiden University Medical Center, Department of Surgery, Leiden, the Netherlands
| | - Boudewijn van Etten
- University Medical Center Groningen, Department of Surgery, Groningen, the Netherlands
| | - Per J Nilsson
- Karolinska Institutet, Department of Molecular Medicine and Surgery, Stockholm, Sweden
| |
Collapse
|
4
|
Chiloiro G, Romano A, Cusumano D, Boldrini L, Panza G, Placidi L, Meldolesi E, Nardini M, Meffe G, Nicolini G, Votta C, Indovina L, Gambacorta MA. THeragnostic utilities for neoplastic DisEases of the rectum by MRI guided radiotherapy (THUNDER 2) phase II trial: interim safety analysis. Radiat Oncol 2023; 18:163. [PMID: 37803322 PMCID: PMC10557246 DOI: 10.1186/s13014-023-02353-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/19/2023] [Indexed: 10/08/2023] Open
Abstract
BACKGROUND The THUNDER-2 phase II single institutional trial investigates the benefits of MRI-guided radiotherapy (MRIgRT) in treating locally advanced rectal cancer (LARC). This study focuses on evaluating the impact of escalating radiation therapy dose in non-responder patients using the Early Tumour Regression Index (ERI) for predicting complete response (CR). The trial's primary endpoint is to increase the CR rate in non-responders by 10% and assess the feasibility of the delta radiomics-based MRIgRT predictive model. This interim analysis assesses the feasibility and safety of the proposed MRIgRT dose escalation strategy in terms of acute toxicity (gastrointestinal, genitourinary and haematological) and treatment adherence. METHODS Stage cT2-3, N0-2, or cT4 patients with anal sphincter involvement, N0-2a, M0, but without high-risk features were enrolled. MRIgRT treatment consisted of a standard dose of 55 Gy to the Gross Tumor Volume (GTV) and mesorectum, and 45 Gy to the mesorectum and drainage nodes in 25 fractions with concomitant chemotherapy. 0.35 T MRI was used for simulation imaging and daily alignment. ERI was calculated at the 10th fraction. Non-responders with an ERI above 13.1 received intensified dose escalation from the 11th fraction, resulting in a total dose of 60.1 Gy. Acute toxicity was assessed using the CTCAE v.5 scale. RESULTS From March 2021 to November 2022, 33 out of the total number of 63 patients to be enrolled (52.4%) were included, with one withdrawal unrelated to treatment. Sixteen patients (50%) underwent dose escalation. Treatment was well tolerated, with only one patient (3.1%) in the standard treatment group experiencing acute Grade 3 diarrhea, proctitis, and cystitis. No significant differences in toxicity were observed between the two groups (p = 0.5463). CONCLUSIONS MRIgRT treatment with dose escalation up to 60.1 Gy is well tolerated in LARC patients predicted as non-responders by ERI, confirming the feasibility and safety of this approach. The THUNDER-2 trial's primary and secondary endpoints will be fully analyzed when all planned patients will be enrolled.
Collapse
Affiliation(s)
- Giuditta Chiloiro
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Angela Romano
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy.
| | - Davide Cusumano
- Mater Olbia Hospital, Strada Statale Orientale Sarda 125, Olbia, 07026, Italy
| | - Luca Boldrini
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Giulia Panza
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Lorenzo Placidi
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Elisa Meldolesi
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Matteo Nardini
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Guenda Meffe
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Gianluca Nicolini
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Claudio Votta
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Luca Indovina
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | | |
Collapse
|
5
|
Wu Y, Liu X, Liu F, Li Y, Xiong X, Sun H, Lin B, Li Y, Xu B. A multi-class classification algorithm based on hematoxylin-eosin staining for neoadjuvant therapy in rectal cancer: a retrospective study. PeerJ 2023; 11:e15408. [PMID: 37334122 PMCID: PMC10269576 DOI: 10.7717/peerj.15408] [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: 12/27/2022] [Accepted: 04/21/2023] [Indexed: 06/20/2023] Open
Abstract
Neoadjuvant therapy (NAT) is a major treatment option for locally advanced rectal cancer. With recent advancement of machine/deep learning algorithms, predicting the treatment response of NAT has become possible using radiological and/or pathological images. However, programs reported thus far are limited to binary classifications, and they can only distinguish the pathological complete response (pCR). In the clinical setting, the pathological NAT responses are classified as four classes: (TRG0-3), with 0 as pCR, 1 as moderate response, 2 as minimal response and 3 as poor response. Therefore, the actual clinical need for risk stratification remains unmet. By using ResNet (Residual Neural Network), we developed a multi-class classifier based on Hematoxylin-Eosin (HE) images to divide the response to three groups (TRG0, TRG1/2, and TRG3). Overall, the model achieved the AUC 0.97 at 40× magnification and AUC 0.89 at 10× magnification. For TRG0, the model under 40× magnification achieved a precision of 0.67, a sensitivity of 0.67, and a specificity of 0.95. For TRG1/2, a precision of 0.92, a sensitivity of 0.86, and a specificity of 0.89 were achieved. For TRG3, the model obtained a precision of 0.71, a sensitivity of 0.83, and a specificity of 0.88. To find the relationship between the treatment response and pathological images, we constructed a visual heat map of tiles using Class Activation Mapping (CAM). Notably, we found that tumor nuclei and tumor-infiltrating lymphocytes appeared to be potential features of the algorithm. Taken together, this multi-class classifier represents the first of its kind to predict different NAT responses in rectal cancer.
Collapse
Affiliation(s)
- Yihan Wu
- School of Medicine, Chongqing University, Chongqing, China
- Chongqing Key Laboratory of Intelligent Oncology for Breast Cancer, Chongqing University Cancer Hospital, Chongqing, China
| | - Xiaohua Liu
- Bioengineering College of Chongqing University, Chongqing, China
| | - Fang Liu
- Department of Pathology, Chongqing University Cancer Hospital, School of Medicine, Chongqing University, Chongqing, China
| | - Yi Li
- Chongqing Key Laboratory of Intelligent Oncology for Breast Cancer, Chongqing University Cancer Hospital, Chongqing, China
- Bioengineering College of Chongqing University, Chongqing, China
| | - Xiaomin Xiong
- Chongqing Key Laboratory of Intelligent Oncology for Breast Cancer, Chongqing University Cancer Hospital, Chongqing, China
- Bioengineering College of Chongqing University, Chongqing, China
| | - Hao Sun
- Department of Gastrointestinal Cancer Center, Chongqing University Cancer Hospital, Chongqing, China
| | - Bo Lin
- Chongqing Key Laboratory of Intelligent Oncology for Breast Cancer, Chongqing University Cancer Hospital, Chongqing, China
| | - Yu Li
- Department of Pathology, Chongqing University Cancer Hospital, School of Medicine, Chongqing University, Chongqing, China
| | - Bo Xu
- School of Medicine, Chongqing University, Chongqing, China
- Chongqing Key Laboratory of Intelligent Oncology for Breast Cancer, Chongqing University Cancer Hospital, Chongqing, China
| |
Collapse
|
6
|
Predictive and Prognostic Value of Oncogene Mutations and Microsatellite Instability in Locally-Advanced Rectal Cancer Treated with Neoadjuvant Radiation-Based Therapy: A Systematic Review and Meta-Analysis. Cancers (Basel) 2023; 15:cancers15051469. [PMID: 36900260 PMCID: PMC10001009 DOI: 10.3390/cancers15051469] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 02/17/2023] [Accepted: 02/22/2023] [Indexed: 03/02/2023] Open
Abstract
Markers of pathological complete response (pCR) to preoperative radiation-based therapy in locally advanced rectal cancer (LARC) are strongly needed. This meta-analysis aimed at elucidating the predictive/prognostic role of tumor markers in LARC. We systematically reviewed the impact of RAS, TP53, BRAF, PIK3CA, and SMAD4 mutations and MSI status on response (pCR, downstaging) and prognosis (risk of recurrence, survival) in LARC according to PRISMA guidelines and the PICO model. PubMed, Cochrane Library, and Web of Science Core Collection were systematically searched to identify relevant studies published before October 2022. KRAS mutations were significantly associated with the risk of not achieving pCR after preoperative treatment (summary OR = 1.80, 95% CI: 1.23-2.64). This association was even more significant in patients not receiving cetuximab (summary OR = 2.17, 95% CI: 1.41-3.33) than in patients receiving cetuximab (summary OR = 0.89, 95% CI: 0.39-20.05). MSI status was not associated with pCR (summary OR = 0.80, 95% CI: 0.41-1.57). No effect of KRAS mutation or MSI status on downstaging was detected. Meta-analysis of survival outcomes was not possible due to the large heterogeneity among studies in endpoint assessment. The minimum number of eligible studies to assess the predictive/prognostic role of TP53, BRAF, PIK3CA, and SMAD4 mutations was not reached. KRAS mutation, but not MSI status, proved to be a detrimental marker for response to preoperative radiation-based therapy in LARC. Translating this finding into the clinic could improve the management of LARC patients. More data are needed to clarify the clinical impact of TP53, BRAF, PIK3CA, and SMAD4 mutations.
Collapse
|
7
|
Ulusoy C, Kamalı GH, Nikolovski A. Analysis of Survival in Complete Pathological Response after Long-Course Chemoradiotherapy in Patients with Advanced Rectal Cancer. Curr Oncol 2023; 30:1054-1064. [PMID: 36661730 PMCID: PMC9857960 DOI: 10.3390/curroncol30010081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/02/2023] [Accepted: 01/07/2023] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Neoadjuvant chemoradiotherapy prior to surgery is the standard treatment for locally advanced rectal cancer. This consists in the patient's complete pathological response being achieved with no residual tumor presence in the resected specimen, which results in survival improvement. METHODS This retrospective study aimed to examine the rate of complete pathological response in patients with advanced rectal cancer treated with neoadjuvant long-course chemoradiotherapy and to examine the survival differences between the different tumor regression grade (TRG) scores. RESULTS A total of 154 patients were operated prior to long-course chemoradiotherapy with a total of 50 Gy plus FOLFOX protocol. Complete pathologic response was achieved in 29 (18.8%) patients. There was no statistical difference for the different pathologic responses according to gender, type of surgery, and number of harvested lymph nodes. Mean survival for all the groups was 37.2 months. Survival within a different TRG score exhibited statistical significance (p = 0.006). Overall, the survival rate during the follow-up period was of 81.8%. CONCLUSIONS The complete pathological response rate in this study was of 18.8%. High tumor regression grade scores (TRG0 and TRG1) had a survival rate of over 90% during follow-up. Multivariate analysis identified perineural invasion and tumor regression grade as independent factors that affect survival.
Collapse
Affiliation(s)
- Cemal Ulusoy
- Department of General Surgery, Prof. Dr. Cemil Taşçıoğlu Şehir Hastanesi, Istanbul 34384, Turkey
| | - Gülçin Harman Kamalı
- Department of Pathology, Prof. Dr. Cemil Taşçıoğlu Şehir Hastanesi, Istanbul 34384, Turkey
| | - Andrej Nikolovski
- Department of Visceral Surgery, University Surgical Clinic “Sv. Naum Ohridski”, Ss. Cyril and Methodius University in Skopje, 1000 Skopje, North Macedonia
| |
Collapse
|
8
|
Carbonara R, Surgo A, Ciliberti MP, Gregucci F, Bonaparte I, Nicosia L, Meldolesi E, Caliandro M, Ferraro V, Inchingolo R, Memeo R, Ludovico E, Calbi R, Lavalle M, Gambacorta MA, Alongi F, Fiorentino A. Impact of preoperative chemoradiation with higher dose intensity modulated radiotherapy on pathological complete response for locally advanced rectal cancer: a systematic review. Expert Rev Anticancer Ther 2022; 22:1249-1259. [PMID: 36174658 DOI: 10.1080/14737140.2022.2130895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Neoadjuvant chemoradiation (CRT) followed by total mesorectal excision is the current standard-of-care for locally advanced UICC II-III stage rectal cancer (LARC). A pathological complete response (pCR) correlates with survival. Improvements of pCR, including dose escalation, should be explored. The aim of this explorative analysis is to assess the impact on pCR of intensity-modulated radiotherapy (IMRT) with simultaneous integrated boost (SIB). AREAS COVERED A literature search via PICO (Population, Intervention, Comparison, Outcome) in MEDLINE/PubMed and EMBASE and a systematic review according to PRISMA (Preferred Reporting Items for Systematic Reviews and Metanalysis) methodology were performed. Studies that reported pCR rate in patients with LARC in clinical stage T2N+M0 or cT3/4 N0/+M0 treated with preoperative CRT with SIB-IMRT/VMAT (Volumetric Modulated Arc Therapy) were included. Sixty-two studies were identified, but only eight clinical trials with a total of 311 patients were included . Median follow-up was 16-61 months. pCR reached the value of 38%. Good survival outcomes were observed with a mild toxicity profile. EXPERT OPINION Radiotherapy dose intensification in LARC showed a slight increase of pCR compared to historical studies. Prospective evaluations are necessary to define which patients would benefit most.
Collapse
Affiliation(s)
- Roberta Carbonara
- Radiation Oncology Department, General Regional Hospital F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - Alessia Surgo
- Radiation Oncology Department, General Regional Hospital F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - Maria Paola Ciliberti
- Radiation Oncology Department, General Regional Hospital F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - Fabiana Gregucci
- Radiation Oncology Department, General Regional Hospital F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - Ilaria Bonaparte
- Radiation Oncology Department, General Regional Hospital F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - Luca Nicosia
- IRCCS, Advanced Radiation Oncology Department, Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy
| | - Elisa Meldolesi
- Radiation Oncology Department, Fondazione Policlinico Universitario A.Gemelli, IRCCS, Rome, Italy
| | - Morena Caliandro
- Radiation Oncology Department, General Regional Hospital F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - Valentina Ferraro
- Hepatobiliary and Pancreatic Surgery Unit, General Regional Hospital F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - Riccardo Inchingolo
- Hepatobiliary and Pancreatic Surgery Unit, General Regional Hospital F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - Riccardo Memeo
- Hepatobiliary and Pancreatic Surgery Unit, General Regional Hospital F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - Elena Ludovico
- Radiology Department, General Regional Hospital F. Miulli, Acquaviva delle Fonti (BA), Bari, Italy
| | - Roberto Calbi
- Radiology Department, General Regional Hospital F. Miulli, Acquaviva delle Fonti (BA), Bari, Italy
| | - Mariadea Lavalle
- Nuclear Medicine Department, General Regional Hospital F. Miulli, Acquaviva delle Fonti (BA), Bari, Italy
| | | | - Filippo Alongi
- IRCCS, Advanced Radiation Oncology Department, Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy.,Medicine Faculty, University of Brescia, Brescia, Italy
| | - Alba Fiorentino
- Radiation Oncology Department, General Regional Hospital F. Miulli, Acquaviva delle Fonti, Bari, Italy
| |
Collapse
|
9
|
Chiloiro G, Cusumano D, Boldrini L, Romano A, Placidi L, Nardini M, Meldolesi E, Barbaro B, Coco C, Crucitti A, Persiani R, Petruzziello L, Ricci R, Salvatore L, Sofo L, Alfieri S, Manfredi R, Valentini V, Gambacorta MA. THUNDER 2: THeragnostic Utilities for Neoplastic DisEases of the Rectum by MRI guided radiotherapy. BMC Cancer 2022; 22:67. [PMID: 35033008 PMCID: PMC8760695 DOI: 10.1186/s12885-021-09158-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 12/24/2021] [Indexed: 02/07/2023] Open
Abstract
Background Neoadjuvant chemoradiation therapy (nCRT) is the standard treatment modality in locally advanced rectal cancer (LARC). Since response to radiotherapy (RT) is dose dependent in rectal cancer, dose escalation may lead to higher complete response rates. The possibility to predict patients who will achieve complete response (CR) is fundamental. Recently, an early tumour regression index (ERI) was introduced to predict pathological CR (pCR) after nCRT in LARC patients. The primary endpoints will be the increase of CR rate and the evaluation of feasibility of delta radiomics-based predictive MRI guided Radiotherapy (MRgRT) model. Methods Patients affected by LARC cT2-3, N0-2 or cT4 for anal sphincter involvement N0-2a, M0 without high risk features will be enrolled in the trial. Neoadjuvant CRT will be administered using MRgRT. The initial RT treatment will consist in delivering 55 Gy in 25 fractions on Gross Tumor Volume (GTV) plus the corresponding mesorectum and 45 Gy in 25 fractions on the drainage nodes. Chemotherapy with 5-fluoracil (5-FU) or oral capecitabine will be administered continuously. A 0.35 Tesla MRI will be acquired at simulation and every day during MRgRT. At fraction 10, ERI will be calculated: if ERI will be inferior than 13.1, the patient will continue the original treatment; if ERI will be higher than 13.1 the treatment plan will be reoptimized, intensifying the dose to the residual tumor at the 11th fraction to reach 60.1 Gy. At the end of nCRT instrumental examinations are to be performed in order to restage patients. In case of stable disease or progression, the patient will undergo surgery. In case of major or complete clinical response, conservative approaches may be chosen. Patients will be followed up to evaluate toxicity and quality of life. The number of cases to be enrolled will be 63: all the patients will be treated at Fondazione Policlinico Universitario A. Gemelli IRCCS in Rome. Discussion This clinical trial investigates the impact of RT dose escalation in poor responder LARC patients identified using ERI, with the aim of increasing the probability of CR and consequently an organ preservation benefit in this group of patients. Trial registration ClinicalTrials.gov Identifier: NCT04815694 (25/03/2021).
Collapse
Affiliation(s)
- Giuditta Chiloiro
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Davide Cusumano
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Luca Boldrini
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Angela Romano
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy.
| | - Lorenzo Placidi
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Matteo Nardini
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Elisa Meldolesi
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Brunella Barbaro
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Claudio Coco
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Antonio Crucitti
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Roberto Persiani
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Lucio Petruzziello
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Riccardo Ricci
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Lisa Salvatore
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Luigi Sofo
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Sergio Alfieri
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Riccardo Manfredi
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Vincenzo Valentini
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | | |
Collapse
|
10
|
Li JY, Huang XZ, Gao P, Song YX, Chen XW, Lv XE, Fu Y, Xiao Q, Ye SY, Wang ZN. Survival landscape of different tumor regression grades and pathologic complete response in rectal cancer after neoadjuvant therapy based on reconstructed individual patient data. BMC Cancer 2021; 21:1214. [PMID: 34773999 PMCID: PMC8590217 DOI: 10.1186/s12885-021-08922-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 10/27/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Neoadjuvant therapy can lead to different tumor regression grades (TRG) in rectal cancer after neoadjuvant therapy. The purposes of this study are to investigate the relationships among TRG, pathologic complete response (pCR) and long-term survival, on the basis of reconstructed individual patient data (IPD). METHODS The PubMed, Embase, Ovid and Cochrane CENTRAL databases were searched. The primary endpoint was to evaluate the survival landscape of different TRGs after neoadjuvant therapy and the secondary endpoint was to evaluate the associations between pCR and survival. IPD were reconstructed with Kaplan-Meier curves. RESULTS The 10-year overall survival (OS) and 5-year disease-free survival (DFS) were clearly higher in the pCR group than in the non-pCR (npCR) group (80.5% vs. 48.3, 90.1% vs. 69.8%). Furthermore, the OS and DFS increased with improvement in tumor regression after neoadjuvant therapy. According to the IPD, the pCR group had longer OS (HR = 0.240, 95% CI = 0.177-0.325, p < 0.001) and DFS (HR = 0.274, 95% CI = 0.205-0.367, p < 0.001) than the npCR group. Better tumor regression was associated with better survival outcomes (p < 0.005). Direct calculation of published HR values yielded similar results. CONCLUSIONS Our results indicate a positive relationship between better tumor regressions and improved survival benefits among the npCR group and patients with rectal cancer achieving pCR had much longer OS and DFS than patients achieving npCR, presenting a survival landscape of different TRGs and pCR in rectal cancer after neoadjuvant therapy.
Collapse
Affiliation(s)
- Jia-Yi Li
- Department of Surgical Oncology and General Surgery, Key Laboratory of Precision Diagnosis and Treatment of Gastrointestinal Tumors, Ministry of Education, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, China
| | - Xuan-Zhang Huang
- Department of Surgical Oncology and General Surgery, Key Laboratory of Precision Diagnosis and Treatment of Gastrointestinal Tumors, Ministry of Education, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, China
| | - Peng Gao
- Department of Surgical Oncology and General Surgery, Key Laboratory of Precision Diagnosis and Treatment of Gastrointestinal Tumors, Ministry of Education, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, China
| | - Yong-Xi Song
- Department of Surgical Oncology and General Surgery, Key Laboratory of Precision Diagnosis and Treatment of Gastrointestinal Tumors, Ministry of Education, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, China
| | - Xiao-Wan Chen
- Department of Surgical Oncology and General Surgery, Key Laboratory of Precision Diagnosis and Treatment of Gastrointestinal Tumors, Ministry of Education, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, China
| | - Xing-Er Lv
- Department of Surgical Oncology and General Surgery, Key Laboratory of Precision Diagnosis and Treatment of Gastrointestinal Tumors, Ministry of Education, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, China
| | - Yv Fu
- Department of Surgical Oncology and General Surgery, Key Laboratory of Precision Diagnosis and Treatment of Gastrointestinal Tumors, Ministry of Education, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, China
| | - Qiong Xiao
- Department of Surgical Oncology and General Surgery, Key Laboratory of Precision Diagnosis and Treatment of Gastrointestinal Tumors, Ministry of Education, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, China
| | - Shi-Yv Ye
- Department of Surgical Oncology and General Surgery, Key Laboratory of Precision Diagnosis and Treatment of Gastrointestinal Tumors, Ministry of Education, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, China
| | - Zhen-Ning Wang
- Department of Surgical Oncology and General Surgery, Key Laboratory of Precision Diagnosis and Treatment of Gastrointestinal Tumors, Ministry of Education, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, China.
| |
Collapse
|
11
|
Salampessy BH, Portrait FRM, van der Hijden E, Klink A, Koolman X. On the correlation between outcome indicators and the structure and process indicators used to proxy them in public health care reporting. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2021; 22:1239-1251. [PMID: 34191196 PMCID: PMC8526472 DOI: 10.1007/s10198-021-01333-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 06/02/2021] [Indexed: 06/13/2023]
Abstract
Hospital quality indicators provide valuable insights for quality improvement, empower patients to choose providers, and have become a cornerstone of value-based payment. As outcome indicators are cumbersome and expensive to measure, many health systems have relied on proxy indicators, such as structure and process indicators. In this paper, we assess the extent to which publicly reported structure and process indicators are correlated with outcome indicators, to determine if these provide useful signals to inform the public about the outcomes. Quality indicators for three conditions (breast and colorectal cancer, and hip replacement surgery) for Dutch hospitals (2011-2018) were collected. Structure and process indicators were compared to condition-specific outcome indicators and in-hospital mortality ratios in a between-hospital comparison (cross-sectional and between-effects models) and in within-hospital comparison (fixed-effects models). Systematic association could not be observed for any of the models. Both positive and negative signs were observed where negative associations were to be expected. Despite sufficient statistical power, the share of significant correlations was small [mean share: 13.2% (cross-sectional); 26.3% (between-effects); 13.2% (fixed-effects)]. These findings persisted in stratified analyses by type of hospital and in models using a multivariate approach. We conclude that, in the context of compulsory public reporting, structure and process indicators are not correlated with outcome indicators, neither in between-hospital comparisons nor in within-hospital comparisons. While structure and process indicators remain valuable for internal quality improvement, they are unsuitable as signals for informing the public about hospital differences in health outcomes.
Collapse
Affiliation(s)
- Benjamin H. Salampessy
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081 HV Amsterdam, The Netherlands
| | - France R. M. Portrait
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081 HV Amsterdam, The Netherlands
| | - Eric van der Hijden
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081 HV Amsterdam, The Netherlands
| | - Ab Klink
- Department of Political Science and Public Administration, Faculty of Social Sciences, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081 HV Amsterdam, The Netherlands
| | - Xander Koolman
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081 HV Amsterdam, The Netherlands
| |
Collapse
|
12
|
Leu M, Riebeling T, Dröge LH, Hubert L, Guhlich M, Wolff HA, Brockmöller J, Gaedcke J, Rieken S, Schirmer MA. 8-Oxoguanine DNA Glycosylase (OGG1) Cys326 Variant: Increased Risk for Worse Outcome of Patients with Locally Advanced Rectal Cancer after Multimodal Therapy. Cancers (Basel) 2021; 13:cancers13112805. [PMID: 34199885 PMCID: PMC8200071 DOI: 10.3390/cancers13112805] [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: 04/16/2021] [Revised: 05/17/2021] [Accepted: 05/31/2021] [Indexed: 11/16/2022] Open
Abstract
Despite excellent loco-regional control by multimodal treatment of locally advanced rectal cancer, a substantial portion of patients succumb to this disease. As many treatment effects are mediated via reactive oxygen species (ROS), we evaluated the effect of single nucleotide polymorphisms (SNPs) in ROS-related genes on clinical outcome. Based on the literature, eight SNPs in seven ROS-related genes were assayed. Eligible patients (n = 287) diagnosed with UICC stage II/III rectal cancer were treated multimodally starting with neoadjuvant radiochemotherapy (N-RCT) according to the clinical trial protocols of CAO/ARO/AIO-94, CAO/ARO/AIO-04, TransValid-A, and TransValid-B. The median follow-up was 64.4 months. The Ser326Cys polymorphism in the human OGG1 gene affected clinical outcome, in particular cancer-specific survival (CSS). This effect was comparable in extent to the ypN status, an already established strong prognosticator for patient outcome. Homozygous and heterozygous carriers of the Cys326 variant (n = 105) encountered a significantly worse CSS (p = 0.0004 according to the log-rank test, p = 0.01 upon multiple testing adjustment). Cox regression elicited a hazard ratio for CSS of 3.64 (95% confidence interval 1.70-7.78) for patients harboring the Cys326 allele. In a multivariable analysis, the effect of Cys326 on CSS was preserved. We propose the genetic polymorphism Ser326Cys as a promising biomarker for outcome in rectal cancer.
Collapse
Affiliation(s)
- Martin Leu
- Clinic of Radiotherapy and Radiation Oncology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany; (M.L.); (T.R.); (L.H.D.); (L.H.); (M.G.); (H.A.W.); (S.R.)
| | - Theresa Riebeling
- Clinic of Radiotherapy and Radiation Oncology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany; (M.L.); (T.R.); (L.H.D.); (L.H.); (M.G.); (H.A.W.); (S.R.)
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, 24105 Kiel, Germany
| | - Leif Hendrik Dröge
- Clinic of Radiotherapy and Radiation Oncology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany; (M.L.); (T.R.); (L.H.D.); (L.H.); (M.G.); (H.A.W.); (S.R.)
| | - Laura Hubert
- Clinic of Radiotherapy and Radiation Oncology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany; (M.L.); (T.R.); (L.H.D.); (L.H.); (M.G.); (H.A.W.); (S.R.)
| | - Manuel Guhlich
- Clinic of Radiotherapy and Radiation Oncology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany; (M.L.); (T.R.); (L.H.D.); (L.H.); (M.G.); (H.A.W.); (S.R.)
| | - Hendrik Andreas Wolff
- Clinic of Radiotherapy and Radiation Oncology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany; (M.L.); (T.R.); (L.H.D.); (L.H.); (M.G.); (H.A.W.); (S.R.)
- Medical Center, Department of Radiation Oncology, University of Regensburg, 93053 Regensburg, Germany
| | - Jürgen Brockmöller
- Institute of Clinical Pharmacology, University Medical Center Göttingen, 37075 Göttingen, Germany;
| | - Jochen Gaedcke
- Clinic of General, Visceral, and Pediatric Surgery, University Medical Center Göttingen, 37075 Göttingen, Germany;
| | - Stefan Rieken
- Clinic of Radiotherapy and Radiation Oncology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany; (M.L.); (T.R.); (L.H.D.); (L.H.); (M.G.); (H.A.W.); (S.R.)
| | - Markus Anton Schirmer
- Clinic of Radiotherapy and Radiation Oncology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany; (M.L.); (T.R.); (L.H.D.); (L.H.); (M.G.); (H.A.W.); (S.R.)
- Institute of Clinical Pharmacology, University Medical Center Göttingen, 37075 Göttingen, Germany;
- Correspondence: ; Tel.: +49-551-39-8866
| |
Collapse
|
13
|
Cusumano D, Meijer G, Lenkowicz J, Chiloiro G, Boldrini L, Masciocchi C, Dinapoli N, Gatta R, Casà C, Damiani A, Barbaro B, Gambacorta MA, Azario L, De Spirito M, Intven M, Valentini V. A field strength independent MR radiomics model to predict pathological complete response in locally advanced rectal cancer. LA RADIOLOGIA MEDICA 2021; 126:421-429. [PMID: 32833198 PMCID: PMC7937600 DOI: 10.1007/s11547-020-01266-z] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 08/12/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE Aim of this study was to develop a generalised radiomics model for predicting pathological complete response after neoadjuvant chemo-radiotherapy in locally advanced rectal cancer patients using pre-CRT T2-weighted images acquired at a 1.5 T and a 3 T scanner. METHODS In two institutions, 195 patients were scanned: 136 patients were scanned on a 1.5 T MR scanner, 59 patients on a 3 T MR scanner. Gross tumour volumes were delineated on the MR images and 496 radiomic features were extracted, applying the intensity-based (IB) filter. Features were standardised with Z-score normalisation and an initial feature selection was carried out using Wilcoxon-Mann-Whitney test: The most significant features at 1.5 T and 3 T were selected as main features. Several logistic regression models combining the main features with a third one selected by those resulting significant were elaborated and evaluated in terms of area under curve (AUC). A tenfold cross-validation was repeated 300 times to evaluate the model robustness. RESULTS Three features were selected: maximum fractal dimension with IB = 0-50, energy and grey-level non-uniformity calculated on the run-length matrix with IB = 0-50. The AUC of the model applied to the whole dataset after cross-validation was 0.72, while values of 0.70 and 0.83 were obtained when 1.5 T and 3 T patients were considered, respectively. CONCLUSIONS The model elaborated showed good performance, even when data from patients scanned on 1.5 T and 3 T were merged. This shows that magnetic field intensity variability can be overcome by means of selecting appropriate image features.
Collapse
Affiliation(s)
- Davide Cusumano
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Rome, Italy
| | - Gert Meijer
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jacopo Lenkowicz
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Giuditta Chiloiro
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Rome, Italy
| | - Luca Boldrini
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Rome, Italy
| | - Carlotta Masciocchi
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Nicola Dinapoli
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Rome, Italy
| | - Roberto Gatta
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Calogero Casà
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Andrea Damiani
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Brunella Barbaro
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Rome, Italy
| | | | - Luigi Azario
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Rome, Italy
| | - Marco De Spirito
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Rome, Italy
| | - Martijn Intven
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Vincenzo Valentini
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Rome, Italy
| |
Collapse
|
14
|
de Andrade V, Leal R, Fagundes J, Rodrigues Coy C, de Lourdes Setsuko Ayrizono M. Neoadjuvant Therapy and Surgery in Rectal Adenocarcinoma: Analysis of Patients with Complete Tumor Remission. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1016/j.jcol.2013.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Abstract
Introduction: the standard treatment for locally advanced extra-peritoneal rectal adenocarcinoma, consists of neoadjuvant treatment with radiotherapy and chemotherapy followed by total mesorectal excision.
Objective: evaluate, retrospectively, the patients submitted to neoadjuvant therapy and surgery that presents with total remission of the lesion in the anatomopathological examination.
Methods: between 2000 and 2010, 212 patients underwent surgery at the Coloproctology Unit at DMAD at FCM–UNICAMP. They were grouped as: rectosigmoidectomy and colorectal anastomosis (n = 54), rectosigmoidectomy with coloanal anastomosis (n = 41), 114 abdominoperineal resection of the rectum (n = 114) and other (n = 3).
Results: thirty (14.2%) patients (mean age 57.6 years; 60% males) showed complete remission of the rectal lesion. 4 (13.3%) had compromised lymph nodes and/or lymphatic invasionAt follow-up (mean 51.9 months), 4 (13.3%) presented with local recurrence (one patient) or distant metastases (two patients had liver metastasis, one had liver and lung, and one had bone metastasis). The mean survival was 86.7%.
Conclusion: patients with a complete tumor response show ed an increased survival rate, however, the same patients without evidence of residual tumors could develop local recurrence or distant metastases on a later follow-up.
Collapse
Affiliation(s)
- V.A. de Andrade
- School of Medical Sciences, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil
| | - R.F. Leal
- Service of Coloproctology, Departament of Surgery, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil
| | - J.J. Fagundes
- Service of Coloproctology, Departament of Surgery, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil
| | - C.S. Rodrigues Coy
- Service of Coloproctology, Departament of Surgery, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil
| | | |
Collapse
|
15
|
Cusumano D, Boldrini L, Yadav P, Yu G, Musurunu B, Chiloiro G, Piras A, Lenkowicz J, Placidi L, Broggi S, Romano A, Mori M, Barbaro B, Azario L, Gambacorta MA, De Spirito M, Bassetti MF, Yang Y, Fiorino C, Valentini V. External Validation of Early Regression Index (ERI TCP) as Predictor of Pathologic Complete Response in Rectal Cancer Using Magnetic Resonance-Guided Radiation Therapy. Int J Radiat Oncol Biol Phys 2020; 108:1347-1356. [PMID: 32758641 DOI: 10.1016/j.ijrobp.2020.07.2323] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 07/08/2020] [Accepted: 07/29/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE Tumor control probability (TCP)-based early regression index (ERITCP) is a radiobiological parameter that showed promising results in predicting pathologic complete response (pCR) on T2-weighted 1.5 T magnetic resonance (MR) images of patients with locally advanced rectal cancer. This study aims to validate the ERITCP in the context of low-tesla MR-guided radiation therapy, using images acquired with different magnetic field strength (0.35 T) and image contrast (T2/T1). Furthermore, the optimal timing for pCR prediction was estimated, calculating the ERI index at different biologically effective dose (BED) levels. METHODS AND MATERIALS Fifty-two patients with locally advanced rectal cancer treated with neoadjuvant chemoradiation therapy were enrolled in this multi-institutional retrospective study. For each patient, a 0.35 T T2/T1-weighted MR image was acquired during simulation and on each treatment day. Gross tumor volume was contoured according to International Commission on Radiation Units Report 83 guidelines. According to the original definition, ERITCP was calculated considering the residual tumor volume at BED = 25 Gy. ERI was also calculated in correspondence with several BED levels: 13, 21, 32, 40, 46, 54, 59, and 67. The predictive performance of the different ERI indices were evaluated in terms of receiver operating characteristic curve. The robustness of ERITCP with respect to the interobserver variability was also evaluated considering 2 operators and calculating the intraclass correlation index. RESULTS Fourteen patients showed pCR. ERITCP correctly 47 of 52 cases (accuracy = 90%), showing good results in terms of sensitivity (86%), specificity (92%), negative predictive value (95%), and positive predictive value (80%). The analysis at different BED levels shows that the best predictive performance is obtained when this parameter is calculated at BED = 25 Gy (area under the curve = 0.93). ERITCP results are robust with respect to interobserver variability (intraclass correlation index = 0.99). CONCLUSIONS This study confirmed the validity and the robustness of ERITCP as a pCR predictor in the context of low-tesla MR-guided radiation therapy and indicate 25 Gy as the best BED level to perform predictions.
Collapse
Affiliation(s)
- Davide Cusumano
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Luca Boldrini
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy.
| | - Poonam Yadav
- Department of Human Oncology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Gao Yu
- Department of Radiological Sciences, University of California, Los Angeles, California
| | - Bindu Musurunu
- Department of Human Oncology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Giuditta Chiloiro
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Antonio Piras
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Jacopo Lenkowicz
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Lorenzo Placidi
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Sara Broggi
- Medical Physics, San Raffaele Scientific Institute, Milano, Italy
| | - Angela Romano
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Martina Mori
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Brunella Barbaro
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Luigi Azario
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | | | - Marco De Spirito
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Michael F Bassetti
- Department of Human Oncology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Yingli Yang
- Department of Radiological Sciences, University of California, Los Angeles, California
| | - Claudio Fiorino
- Medical Physics, San Raffaele Scientific Institute, Milano, Italy
| | - Vincenzo Valentini
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| |
Collapse
|
16
|
Cecchin E, De Mattia E, Dreussi E, Montico M, Palazzari E, Navarria F, Bergamo F, Belluco C, Quartuccio L, De Vita S, Canzonieri V, Gagno S, Zanusso C, Buonadonna A, Pucciarelli S, De Paoli A, Toffoli G. Immunogenetic markers in IL17F predict the risk of metastases spread and overall survival in rectal cancer patients treated with neoadjuvant chemoradiotherapy. Radiother Oncol 2020; 149:30-37. [PMID: 32387487 DOI: 10.1016/j.radonc.2020.04.055] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 04/28/2020] [Accepted: 04/29/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND PURPOSE The role of the immune system in tumor response to chemo-radiotherapy (CRT) is an emerging issue. This work aimed at identifying predictive and prognostic immunogenetic variants in LARC patients after preoperative (po)-CRT and surgery. MATERIALS AND METHODS A set of 192 polymorphisms in 34 candidate genes involved in the regulation of the immune response signalling network, was selected and analyzed in 370 LARC patients treated with po-CRT and surgery, split into a Test Set (n = 233) and a Validation Set (n = 137). Immunogenetic markers were selected based on a concordant significant effect on 2-year relapse-free survival (2-yrRFS) (bootstrapped P < 0.05) in both patients Sets. The effect of the selected immunogenetic variants on 5-year metastases-free (5yrMFS), 5-year disease-free (5yrDFS), and 10-year overall (10yrOS) survival was tested in the entire Set of 370 patients. RESULTS Two immunogenetic IL17F (IL17F-rs641701 and IL17F-rs9463772) markers predictive of 2yrRFS, 5yrDFS, 5yrMFS, and 10yrOS were identified. The combination of tumor regression grade (TRG) and patients genotype for IL17F-rs641701 and IL17F-rs9463772 allowed the identification of subgroups of patients with differential prognosis in term of both 5yrDFS (HR 11.29, P-value <0.001, and HR 5.86, P-value = 0.001, respectively) and 10yrOS (HR 7.07, P-value = 0.005, and HR 6.05, P-value = 0.002, respectively). CONCLUSION IL17F-rs641701 and IL17F-rs9463772 were highlighted as promising immunogenetic markers significantly associated with the prognosis of LARC patients. After a prospective validation of the herein reported findings, the combination of TRG and patients genotype should be considered to provide additional stratification criteria for the selection of a personalized multimodality treatment.
Collapse
Affiliation(s)
- Erika Cecchin
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy.
| | - Elena De Mattia
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Eva Dreussi
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Marcella Montico
- Scientific Direction, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Italy
| | - Elisa Palazzari
- Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Italy
| | - Federico Navarria
- Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Italy
| | | | - Claudio Belluco
- Surgical Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Italy
| | - Luca Quartuccio
- Department of Medical Area (DAME), Rheumatology Clinic, Santa Maria della Misericordia University Hospital, Udine (UD), Italy
| | - Salvatore De Vita
- Department of Medical Area (DAME), Rheumatology Clinic, Santa Maria della Misericordia University Hospital, Udine (UD), Italy
| | - Vincenzo Canzonieri
- Pathology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Italy; Department of Medical, Surgical and Health Sciences, University of Trieste, Italy
| | - Sara Gagno
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Chiara Zanusso
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Angela Buonadonna
- Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Italy
| | | | - Antonino De Paoli
- Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Italy
| | - Giuseppe Toffoli
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| |
Collapse
|
17
|
Li W, Peng J, Li C, Yuan L, Fan W, Pan Z, Wu X, Lin J. Prognosis and risk factors for the development of pulmonary metastases after preoperative chemoradiotherapy and radical resection in patients with locally advanced rectal cancer. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:117. [PMID: 32175410 DOI: 10.21037/atm.2019.12.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Although preoperative chemoradiotherapy (CRT) followed by total mesorectal excision (TME) is currently considered effective for treating locally advanced rectal cancer (LARC), a proportion of patients develop postoperative pulmonary metastases. The current study aimed to assess the prognostic characteristics and risk factors for the development of rectal cancer pulmonary metastases after CRT and radical resection. Methods We retrospectively analyzed data collected on 544 consecutive patients who were diagnosed with LARC and underwent preoperative CRT followed by tumor radical resection between December 2003 and June 2014. Overall survival (OS), disease-free survival (DFS), and pulmonary metastasis rates were calculated and compared among the subgroups, and risk factors for pulmonary metastases were identified by Cox models. Results A total of 61 (11.2%) patients developed pulmonary metastases postoperatively, 45 of whom (73.8%) developed the condition in the first 24 months. The 1-, 2-, and 3-year pulmonary metastasis rates were 6.7%, 10.4%, and 11.7%, respectively. Compared with the disease-free group, the pulmonary metastases group had a significantly lower proportion of downstaging and pathological complete regression (pCR) rate and a significantly higher proportion of low rectum tumor. In multivariate analysis, a distance of the tumor ≤5 cm from the anal verge [hazard ratio (HR), 1.394; 95% confidence interval (CI), 1.211-3.736; P=0.003] was identified as an independent negative predictor of the 3-year pulmonary metastasis rate, and N0 stage (HR, 0.490; 95% CI, 0.261-0.919; P=0.026) and TNM downstaging (HR, 0.514; 95% CI, 0.265-0.997; P=0.049) were identified as independent positive predictors of the 3-year pulmonary metastasis rate. Conclusions Pulmonary metastases warranted a more intensive follow-up in patients with low rectal cancer, lymph node metastases and poor response after preoperative CRT and radical tumor resection.
Collapse
Affiliation(s)
- Weihao Li
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Jianhong Peng
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Cong Li
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Lifang Yuan
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Wenhua Fan
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Zhizhong Pan
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Xiaojun Wu
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Junzhong Lin
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| |
Collapse
|
18
|
Huang Y, Lee D, Young C. Predictors for complete pathological response for stage II and III rectal cancer following neoadjuvant therapy - A systematic review and meta-analysis. Am J Surg 2020; 220:300-308. [PMID: 31937416 DOI: 10.1016/j.amjsurg.2020.01.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 12/22/2019] [Accepted: 01/01/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND There has been an increasing interest in the complete pathological response (pCR) in rectal cancers following neoadjuvant therapy. The aim of this study was to identify predictive factors of pCR in locally advanced rectal cancer following neoadjuvant therapy. METHODS The studies identified were appraised with standard selection criteria. The selection criteria included studies on patients with stage II or III rectal cancer who underwent neoadjuvant therapy. RESULTS Patients with pCR are more likely to be older (p = 0.0002), have cancers closer distance to the anal verge (p < 0.00001), smaller tumors (P < 0.0001), no clinical lymph nodes involvement (p=<0.00001) and waited more than eight weeks until definitive surgery (p = 0.002). There was no difference in gender (p = 0.15) and tumor differentiation (p = 0.21). CONCLUSIONS The 'Watch and Wait' approach may be appropriate for selected patients. Patients with lower rectal cancers, smaller tumors, and negative clinical lymph node involvement may be more likely to achieve pCR following neoadjuvant therapy.
Collapse
Affiliation(s)
- Yeqian Huang
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia, 2050; Discipline of Surgery, The University of Sydney, Sydney, NSW, Australia.
| | - Daniel Lee
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia, 2050; Discipline of Surgery, The University of Sydney, Sydney, NSW, Australia
| | - Christopher Young
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia, 2050; Discipline of Surgery, The University of Sydney, Sydney, NSW, Australia.
| |
Collapse
|
19
|
Salampessy BH, Bijlsma WR, van der Hijden E, Koolman X, Portrait FRM. On selecting quality indicators: preferences of patients with breast and colon cancers regarding hospital quality indicators. BMJ Qual Saf 2019; 29:576-585. [PMID: 31831636 PMCID: PMC7362772 DOI: 10.1136/bmjqs-2019-009818] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 11/10/2019] [Accepted: 11/21/2019] [Indexed: 12/05/2022]
Abstract
Background There is an increasing number of quality indicators being reported publicly with aim to improve the transparency on hospital care quality. However, they are little used by patients. Knowledge on patients’ preferences regarding quality may help to optimise the information presented to them. Objective To measure the preferences of patients with breast and colon cancers regarding publicly reported quality indicators of Dutch hospital care. Methods From the existing set of clinical quality indicators, participants of patient group discussions first assessed an indicator’s suitability as choice information and then identified the most relevant ones. We used the final selection as attributes in two discrete choice experiments (DCEs). Questionnaires included choice vignettes as well as a direct ranking exercise, and were distributed among patient communities. Data were analysed using mixed logit models. Results Based on the patient group discussions, 6 of 52 indicators (breast cancer) and 5 of 21 indicators (colon cancer) were selected as attributes. The questionnaire was completed by 84 (breast cancer) and 145 respondents (colon cancer). In the patient group discussions and in the DCEs, respondents valued outcome indicators as most important: those reflecting tumour residual (breast cancer) and failure to rescue (colon cancer). Probability analyses revealed a larger range in percentage change of choice probabilities for breast cancer (10.9%–69.9%) relative to colon cancer (7.9%–20.9%). Subgroup analyses showed few differences in preferences across ages and educational levels. DCE findings partly matched with those of direct ranking. Conclusion Study findings show that patients focused on a subset of indicators when making their choice of hospital and that they valued outcome indicators the most. In addition, patients with breast cancer were more responsive to quality information than patients with colon cancer.
Collapse
Affiliation(s)
- Benjamin H Salampessy
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, Noord-Holland, The Netherlands
| | - Ward R Bijlsma
- Department of Healthcare Procurement, Menzis, Enschede, The Netherlands
| | - Eric van der Hijden
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, Noord-Holland, The Netherlands
| | - Xander Koolman
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, Noord-Holland, The Netherlands
| | - France R M Portrait
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, Noord-Holland, The Netherlands
| |
Collapse
|
20
|
Russo S, Anker CJ, Abdel-Wahab M, Azad N, Das P, Dragovic J, Goodman KA, Herman JM, Jones W, Kennedy T, Konski A, Kumar R, Lee P, Patel NM, Sharma N, Small W, Suh WW, Jabbour SK. Executive Summary of the American Radium Society Appropriate Use Criteria for Local Excision in Rectal Cancer. Int J Radiat Oncol Biol Phys 2019; 105:977-993. [PMID: 31445109 PMCID: PMC11101014 DOI: 10.1016/j.ijrobp.2019.08.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 08/02/2019] [Accepted: 08/11/2019] [Indexed: 02/07/2023]
Abstract
The goal of treatment for early stage rectal cancer is to optimize oncologic outcome while minimizing effect of treatment on quality of life. The standard of care treatment for most early rectal cancers is radical surgery alone. Given the morbidity associated with radical surgery, local excision for early rectal cancers has been explored as an alternative approach associated with lower rates of morbidity. The American Radium Society Appropriate Use Criteria presented in this manuscript are evidence-based guidelines for the use of local excision in early stage rectal cancer that include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) used by a multidisciplinary expert panel to rate the appropriateness of imaging and treatment procedures. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. These guidelines are intended for the use of all practitioners and patients who desire information regarding the use of local excision in rectal cancer.
Collapse
Affiliation(s)
- Suzanne Russo
- Case Western Reserve University School of Medicine and University Hospitals, Cleveland, Ohio.
| | | | - May Abdel-Wahab
- International Atomic Energy Agency, Division of Human Health, New York, New York
| | - Nilofer Azad
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Prajnan Das
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | | | - Joseph M Herman
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - William Jones
- UT Health Cancer Center, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | | | - Andre Konski
- University of Pennsylvania Perelman School of Medicine, Chester County Hospital, West Chester, Pennsylvania
| | - Rachit Kumar
- Banner MD Anderson Cancer Center, Gilbert, Arizona
| | - Percy Lee
- University of California, Los Angeles, Jonsson Comprehensive Cancer Center, Los Angeles, California
| | | | - Navesh Sharma
- Milton S. Hershey Cancer Institute, Hershey, Pennsylvania
| | | | - W Warren Suh
- Ridley-Tree Cancer Center Santa Barbara @ Sansum Clinic, Santa Barbara California
| | | |
Collapse
|
21
|
Halverson AL, Morris AM, Cleary RK, Chang GJ. For Patients with Early Rectal Cancer, Does Local Excision Have an Impact on Recurrence, Survival, and Quality of Life Relative to Radical Resection? Ann Surg Oncol 2019; 26:2497-2506. [PMID: 31025228 DOI: 10.1245/s10434-019-07328-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND The most appropriate treatment for early-stage rectal cancers is controversial. The advantages of local excision regarding morbidity and function must be weighed against poorer oncologic efficacy. This study aimed to clarify further the role for local excision in the treatment of rectal cancer. METHODS A systematic review of Medline, SCOPUS, and Cochrane databases was conducted. Relevant studies were selected using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data addressing five key questions about outcomes of local versus radical resection of rectal cancer were analyzed. RESULTS The 16 studies identified by this study were mostly retrospective, and none were randomized. Local excision was associated with fewer complications and better functional outcome than radical resection. Of 12 studies evaluating local recurrence, 6 showed a higher local recurrence rate among patients who underwent local excision. Two additional studies showed no increase in local recurrence rate among patients who underwent local excision of T1 lesions but a significantly higher local recurrence rate among those who underwent local excision of T2 lesions. High histologic grade, angiolymphatic invasion, perineural invasion, and depth within submucosa were features associated with a higher risk of local recurrence. In 7 of 15 studies, long-term survival was reduced compared with that of patients who underwent radical resection. CONCLUSIONS Although local excision for early-stage rectal cancer is associated with increased local recurrence and decreased overall survival compared with radical resection, local excision may be appropriate for select individuals who have T1 tumors with no adverse pathologic features.
Collapse
Affiliation(s)
- Amy L Halverson
- Division of Colon and Rectal Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Arden M Morris
- Section of Colon and Rectal Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Robert K Cleary
- Division of Colon and Rectal Surgery, St Joseph Mercy Hospital, Ann Arbor, MI, USA
| | - George J Chang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| |
Collapse
|
22
|
Zhang MX, Li XB, Guan BJ, Guan GX, Lin XY, Wu XD, Chi P, Xu BH. Dose escalation of preoperative short-course radiotherapy followed by neoadjuvant chemotherapy in locally advanced rectal cancer: protocol for an open-label, single-centre, phase I clinical trial. BMJ Open 2019; 9:e025944. [PMID: 30904869 PMCID: PMC6475145 DOI: 10.1136/bmjopen-2018-025944] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Preoperative radiotherapy followed by total mesorectal excision with adjuvant chemotherapy has been recommended as the preferred treatment method for locally advanced rectal cancer (LARC). Similar rates of local control, survival and toxicity were observed in preoperative long-course chemoradiotherapy (LCRT) (45-50.4 Gy in 25-28 fractions) and in short-course radiotherapy (SCRT) with 25 Gy over five fractions. Both regimens lower the local recurrence rates compared with that of surgery followed by postoperative radiotherapy. With the simplicity and lower cost of SCRT, a growing number of patients have been receiving SCRT as preoperative radiotherapy. However, the currently established SCRT (25 Gy over five fractions) followed immediately by surgery resulted in poor downstaging and sphincter preservation rate. The pathological complete response (pCR) rate is also markedly lower with SCRT than with LCRT (0.7%vs16%). Several studies recommended SCRT with delayed surgery for more than 4 weeks with expectation of improved pathological outcomes and fewer postoperative complications. While a number of clinical trials demonstrated a persistently better overall local control with SCRT than with LCRT, overall survival advantage has not been observed. Since survival is mainly depended on distant metastases, efforts should be made towards more effective pathological response and systemic treatment. Given the apparent advantages of SCRT, we aimed to establish a dose escalation of SCRT and sequential modified FOLFOX6 (mFOLFOX6) as preoperative therapy for LARC with objectives of achieving an optimal balance of safety, cost effectiveness and clinical outcome, and to support further investigation of this regimen in a phase II/III setting. METHODS In this phase I study, three dose levels (6Gy×5F, 7Gy×5F, 8Gy×5F to gross tumour volume, while keeping the rest of irradiated volume at 5Gy×5) of SCRT followed by four cycles of mFOLFOX6 chemotherapy as neoadjuvant therapy will be tested by using the traditional 3+3 design. The pCR rate, R0 resection rate, sphincter preservation rate and treatment related toxicity will be assessed. ETHICS AND DISSEMINATION The study protocol was approved by the Ethics Committee of Fujian Medical University Union Hospital (No. 2017YF020-02) and all participants provided written informed consent. Results from our study will be disseminated in international peer-reviewed journals. All study procedures were developed in order to assure data protection and confidentiality. TRIAL REGISTRATION NUMBER NCT03466424; Pre-results.
Collapse
Affiliation(s)
- Meng-xia Zhang
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Xiao-bo Li
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Collogy of medical technology and engineering, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Bing-jie Guan
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Guo-xian Guan
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Xiao-yan Lin
- Department of Medical Oncology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Xiao-dong Wu
- Department of Radiation Oncology, Cancer Hospital of Fudan University, Shanghai, China
- Department of biomedical engineering, Innovative Cancer Institute, Miami, Florida, USA
| | - Pan Chi
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Ben-hua Xu
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- School of Clinical Medicine, Fujian Medical University, Fuzhou, Fujian, China
| |
Collapse
|
23
|
Liu H, Wang H, Wu J, Wang Y, Zhao L, Li G, Zhou M. Lymphocyte nadir predicts tumor response and survival in locally advanced rectal cancer after neoadjuvant chemoradiotherapy: Immunologic relevance. Radiother Oncol 2018; 131:52-59. [PMID: 30773187 DOI: 10.1016/j.radonc.2018.12.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 11/30/2018] [Accepted: 12/02/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND PURPOSE Neoadjuvant chemoradiation (nCRT) could reduce tumor infiltrating lymphocytes. We examined absolute lymphocyte count (ALC) nadir during nCRT, pathologic response and prognosis for locally advanced rectal cancer (LARC). MATERIALS AND METHODS 102 patients with LARC (cT3-4N0, or node-positive) treated between 2010 and 2015 with nCRT followed by complete resection were analyzed. The ALC value was obtained prior to, weekly during the treatment, and one month after nCRT. Associations of ALC nadir with immune cells' infiltrations, pathologic response and survival were analyzed. RESULTS Twenty-four (23.5%) and 60 (58.9%) patients achieved pathologic complete response and partial response respectively. Response rate was higher in high ALC nadir group than low nadir group (89.7% vs. 67.6%, p = 0.006). Compared to low ALC nadir group, increased tumor infiltrates of CD4+ (4% vs. 17.5%, p < 0.001), CD8+ (8% vs.30%, p < 0.001) T cells and CD68+ macrophages (6% vs. 25%, p < 0.001) were observed in high ALC nadir group. High ALC nadir [OR = 4.32 (95% CI, 1.22-15.26), p = 0.023] and well differentiation [OR = 10.53 (1.87-59.36), p = 0.008] were associated with pathologic response. Patients with high ALC nadir yielded better DFS [HR = 0.36 (0.16-0.81), p = 0.010] and OS [HR = 0.24 (0.08-0.69), p = 0.004]. CONCLUSIONS Higher ALC nadir during nCRT is associated with a higher rate of pathologic response and better survival for LARC patients, suggesting that ALC may be a potential stratification strategy for LARC patients.
Collapse
Affiliation(s)
- Hao Liu
- Department of Radiation Medicine, Guangdong Provincial Key Laboratory of Tropical Disease Research, School of Public Health, Southern Medical University, Guangzhou, China; Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Hao Wang
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jianhua Wu
- Department of Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yiming Wang
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Liying Zhao
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Guoxin Li
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China.
| | - Meijuan Zhou
- Department of Radiation Medicine, Guangdong Provincial Key Laboratory of Tropical Disease Research, School of Public Health, Southern Medical University, Guangzhou, China.
| |
Collapse
|
24
|
Belluco C, Forlin M, Delrio P, Rega D, Degiuli M, Sofia S, Olivieri M, Pucciarelli S, Zuin M, De Manzoni G, Di Leo A, Scabini S, Zorcolo L, Restivo A. Elevated platelet count is a negative predictive and prognostic marker in locally advanced rectal cancer undergoing neoadjuvant chemoradiation: a retrospective multi-institutional study on 965 patients. BMC Cancer 2018; 18:1094. [PMID: 30419864 PMCID: PMC6233528 DOI: 10.1186/s12885-018-5022-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 10/31/2018] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND In patients with locally advanced rectal cancer treated by neoadjuvant chemoradiation, pathological complete response in the surgical specimen is associated with favourable long-term oncologic outcome. Based on this observation, nonoperative management is being explored in the subset of patients with clinical complete response. Whereas, patients with poor response have a high risk of local and distant recurrence, and appear to receive no benefit from standard neoadjuvant chemoradiation. Therefore, in order to develop alternative treatment strategies for non responding patients, predictive and prognostic factors are highly needed. Accumulating clinical observations indicate that elevated platelet count is associated with poor outcome in different type of tumors. In this study we investigated the predictive and prognostic impact of elevated platelet count on pathological response and long-term oncologic outcome in patients with locally advanced rectal cancer undergoing neoadjuvant chemoradiation. METHODS A total of 965 patients were selected from prospectively maintained databases of seven Centers within the SICO Colorectal Cancer Network. Patients were divided into two groups based on a pre-neoadjuvant chemoradiation platelet count cut-off value of 300 × 109/L identified by receiver operating characteristic curve considering complete pathological response as the outcome. RESULTS Complete pathological response rate was lower in patients with elevated platelet count (12.8% vs. 22.1%, p = 0.001). Mean follow-up was 50.1 months. Comparing patients with elevated platelet count with patients with not elevated platelet count, 5-year overall survival was 69.5% vs.76.5% (p = 0.016), and 5-year disease free survival was 63.0% vs. 68.9% (p = 0.019). Local recurrence rate was higher in patients with elevated platelet count (11.1% vs. 5.3%, p = 0.001), as higher was the occurrence of distant metastasis (23.9% vs. 16.4%, p = 0.007). At multivariate analysis of potential prognostic factors EPC was independently associated with worse overall survival (HR 1.40, 95% CI 1.06-1.86), and disease free survival (HR 1.37, 95% CI 1.07-1.76). CONCLUSIONS In locally advanced rectal cancer elevated platelet count before neoadjuvant chemoradiation is a negative predictive and prognostic factor which might help to identify subsets of patients with more aggressive tumors to be proposed for alternative therapeutic strategies.
Collapse
Affiliation(s)
- Claudio Belluco
- Department of Surgical Oncology, CRO-IRCCS, National Cancer Institute, Aviano Via Franco Gallini 2, 33081, Aviano, Italy.
| | - Marco Forlin
- Department of Surgical Oncology, CRO-IRCCS, National Cancer Institute, Aviano Via Franco Gallini 2, 33081, Aviano, Italy
| | - Paolo Delrio
- Colorectal Surgical Oncology, National Cancer Institute - IRCCS - G. Pascale Foundation, Naples, Italy
| | - Daniela Rega
- Colorectal Surgical Oncology, National Cancer Institute - IRCCS - G. Pascale Foundation, Naples, Italy
| | - Maurizio Degiuli
- School of Medicine, Department of Oncology, Head, Digestive, University of Torino, Torino, Italy.,Surgical Oncology, San Luigi University Hospital, Orbassano, Torino, Italy
| | - Silvia Sofia
- School of Medicine, Department of Oncology, Head, Digestive, University of Torino, Torino, Italy.,Surgical Oncology, San Luigi University Hospital, Orbassano, Torino, Italy
| | - Matteo Olivieri
- Department of Surgical Oncology, CRO-IRCCS, National Cancer Institute, Aviano Via Franco Gallini 2, 33081, Aviano, Italy
| | - Salvatore Pucciarelli
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
| | - Matteo Zuin
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
| | - Giovanni De Manzoni
- Department of Surgery, General and Upper G.I., Surgery Division, University of Verona, Verona, Italy
| | - Alberto Di Leo
- Department of Surgery, General and Upper G.I., Surgery Division, University of Verona, Verona, Italy
| | - Stefano Scabini
- Oncologic Surgery and Implantable Systems Unit, Department of Emergency, IRCCS San Martino IST, Genoa, Italy
| | - Luigi Zorcolo
- Colorectal Surgery Unit, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - Angelo Restivo
- Colorectal Surgery Unit, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| |
Collapse
|
25
|
Peng H, Wang C, Xiao W, Lin X, You K, Dong J, Wang Z, Yu X, Zeng Z, Zhou T, Gao Y, Wen B. Analysis of Clinical characteristics to predict pathologic complete response for patients with locally advanced rectal cancer treated with neoadjuvant chemoradiotherapy. J Cancer 2018; 9:2687-2692. [PMID: 30087709 PMCID: PMC6072814 DOI: 10.7150/jca.25493] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 04/27/2018] [Indexed: 02/07/2023] Open
Abstract
To explore clinical characteristics which could be applied to predict pathologic complete response (pCR) for patients with locally advanced rectal cancer treated with neoadjuvant chemoradiotherapy (neo-CRT) and total mesorectal excision (TME). 297 patients with locally advanced rectal cancer (cT3-4 or cN+) who were treated with neo-CRT followed by TME were retrospectively reviewed. Clinical characteristics including age, gender, tumor distance from anus, serum CEA, hemoglobin levels before treatment and clinical TN stage were used to investigate the association with pCR after neo-CRT. Seventy-nine (26.6%) patients achieved pCR after neo-CRT. pCR were achieved in 42 (34.4%) patients in cT1-3 stage and 37 (21.1%) in cT4 stage. pCR rate was 36.4% and 16.4% for patients with pre-treatment serum CEA ≤5.33ng/ml and >5.33ng/ml, respectively. Uni- and multi-variate analyses revealed that pre-treatment serum CEA level ≤5.33ng/ml and clinical T stage, (i.e., cT1-3 versus cT4) were highly correlated with pCR (p < 0.05). Clinical T stage and pre-treatment serum CEA level were strongly associated with pCR for patients with locally advanced rectal cancer treated with neo-CRT followed by TME which could be applied as clinical predictors for pCR.
Collapse
Affiliation(s)
- Haihua Peng
- Department of Radiation Oncology, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou 510075, China.,Department of Radiation Oncology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Chengtao Wang
- Department of Radiation Oncology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Weiwei Xiao
- Department of Radiation Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in Southern China, Guangzhou 510060, China
| | - Xiaodan Lin
- Department of Radiation Oncology, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou 510075, China
| | - Kaiyun You
- Department of Radiation Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China
| | - Jun Dong
- Department of Radiation Oncology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Zhenyu Wang
- Department of Radiation Oncology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Xiaobi Yu
- Department of Radiation Oncology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Zhifan Zeng
- Department of Radiation Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in Southern China, Guangzhou 510060, China
| | - Tongchong Zhou
- Department of Radiation Oncology, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou 510075, China
| | - Yuanhong Gao
- Department of Radiation Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in Southern China, Guangzhou 510060, China
| | - Bixiu Wen
- Department of Radiation Oncology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| |
Collapse
|
26
|
Rampazzo E, Del Bianco P, Bertorelle R, Boso C, Perin A, Spiro G, Bergamo F, Belluco C, Buonadonna A, Palazzari E, Leonardi S, De Paoli A, Pucciarelli S, De Rossi A. The predictive and prognostic potential of plasma telomerase reverse transcriptase (TERT) RNA in rectal cancer patients. Br J Cancer 2018; 118:878-886. [PMID: 29449673 PMCID: PMC5877438 DOI: 10.1038/bjc.2017.492] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 12/13/2017] [Accepted: 12/18/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Preoperative chemoradiotherapy (CRT) followed by surgery is the standard care for locally advanced rectal cancer, but tumour response to CRT and disease outcome are variable. The current study aimed to investigate the effectiveness of plasma telomerase reverse transcriptase (TERT) levels in predicting tumour response and clinical outcome. METHODS 176 rectal cancer patients were included. Plasma samples were collected at baseline (before CRT=T0), 2 weeks after CRT was initiated (T1), post-CRT and before surgery (T2), and 4-8 months after surgery (T3) time points. Plasma TERT mRNA levels and total cell-free RNA were determined using real-time PCR. RESULTS Plasma levels of TERT were significantly lower at T2 (P<0.0001) in responders than in non-responders. Post-CRT TERT levels and the differences between pre- and post-CRT TERT levels independently predicted tumour response, and the prediction model had an area under curve of 0.80 (95% confidence interval (CI) 0.73-0.87). Multiple analysis demonstrated that patients with detectable TERT levels at T2 and T3 time points had a risk of disease progression 2.13 (95% CI 1.10-4.11)-fold and 4.55 (95% CI 1.48-13.95)-fold higher, respectively, than those with undetectable plasma TERT levels. CONCLUSIONS Plasma TERT levels are independent markers of tumour response and are prognostic of disease progression in rectal cancer patients who undergo neoadjuvant therapy.
Collapse
Affiliation(s)
- Enrica Rampazzo
- Section of Oncology and Immunology, Department of Surgery, Oncology and Gastroenterology, University of Padova, Via Gattamelata 64, Padova 35128, Italy
| | - Paola Del Bianco
- Clinical Trials and Biostatistic Unit, Istituto Oncologico Veneto (IOV)-IRCCS, Via Gattamelata 64, Padova 35128, Italy
| | - Roberta Bertorelle
- Immunology and Molecular Oncology Unit, IOV- IRCCS, Via Gattamelata 64, Padova 35128, Italy
| | - Caterina Boso
- Radiotherapy and Nuclear Medicine Unit, IOV-IRCCS, Via Gattamelata 64, 35128 Padova, Italy
| | - Alessandro Perin
- Section of Surgery, Department of Surgery, Oncology and Gastroenterology, Via Giustiniani 1, University of Padova, Padova 35128, Italy
| | - Giovanna Spiro
- Section of Surgery, Department of Surgery, Oncology and Gastroenterology, Via Giustiniani 1, University of Padova, Padova 35128, Italy
| | - Francesca Bergamo
- Medical Oncology Unit 1, IOV-IRCCS, Via Gattamelata 64, Padova 35128, Italy
| | - Claudio Belluco
- Department of Surgical Oncology, Centro di Riferimento Oncologico (CRO)-IRCCS, Aviano, Italy
| | | | | | - Sara Leonardi
- Medical Oncology Unit 1, IOV-IRCCS, Via Gattamelata 64, Padova 35128, Italy
| | | | - Salvatore Pucciarelli
- Section of Surgery, Department of Surgery, Oncology and Gastroenterology, Via Giustiniani 1, University of Padova, Padova 35128, Italy
| | - Anita De Rossi
- Section of Oncology and Immunology, Department of Surgery, Oncology and Gastroenterology, University of Padova, Via Gattamelata 64, Padova 35128, Italy
- Immunology and Molecular Oncology Unit, IOV- IRCCS, Via Gattamelata 64, Padova 35128, Italy
| |
Collapse
|
27
|
Xu BH, Chi P, Guo JH, Guan GX, Tang TL, Yang YH, Chen MQ, Song JY, Feng CY. Pilot Study of Intense Neoadjuvant Chemoradiotherapy for Locally Advanced Rectal Cancer: Retrospective Review of a Phase II Study. TUMORI JOURNAL 2018; 100:149-57. [DOI: 10.1177/030089161410000206] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Aims and Background Locally advanced rectal adenocarcinoma is typically treated with neoadjuvant chemoradiotherapy and surgery. We assessed the effect of an additional cycle of capecitabine/oxaliplatin chemotherapy before surgery in 57 patients with T3/4, N+/- or T1/2, N+ rectal cancer. Materials and Study Design Radiotherapy (total dose, 50.4 Gy) was combined with three cycles of chemotherapy (two cycles concomitant with radiotherapy), and each cycle consisted of oxaliplatin (130 mg/m2 on day 1) and capecitabine (825 mg/m2, twice per day from day 1 to day 14) for 21 days. In addition to assessing the safety of this treatment, the primary endpoint was pathological complete response (pCR). The secondary endpoint was the change in primary tumor and node stage from pre-treatment to post-surgery. Results Eleven patients (19%) experienced complete tumor regression and 23 patients (40%) experienced tumor regression grade 3. Tumor down-staging occurred in 31 patients (54.4%) and down-staging of nodes occurred in 25 patients (43.9%). There was a significant difference in tumor stage between pre-treatment and post-surgery (P <0.001). Patients with less advanced N stages had significantly better recurrence-free survival but similar metastasis-free survival and overall survival. Tumor regression grade was not associated with overall survival, recurrence-free survival or metastasis-free survival. The most common adverse events were pulmonary infection (n = 6, 10.5%) and intestinal obstruction (n = 6, 10.5%). Conclusions An additional cycle of chemotherapy given after chemoradiotherapy and before surgery provided good efficacy and had a satisfactory safety profile in patients with locally advanced rectal cancer.
Collapse
Affiliation(s)
- Ben-hua Xu
- Department of Radiation Oncology, The Affiliated Union Hospital of Fujian Medical University, Fuzhou, China
| | - Pan Chi
- Department of General Surgery, The Affiliated Union Hospital of Fujian Medical University, Fuzhou, China
| | - Jin-hua Guo
- Department of Radiation Oncology, The Affiliated Union Hospital of Fujian Medical University, Fuzhou, China
| | - Guo-xian Guan
- Department of General Surgery, The Affiliated Union Hospital of Fujian Medical University, Fuzhou, China
| | - Tian-lan Tang
- Department of Radiation Oncology, The Affiliated Union Hospital of Fujian Medical University, Fuzhou, China
| | - Ying-hong Yang
- Department of Pathology, The Affiliated Union Hospital of Fujian Medical University, Fuzhou, China
| | - Ming-qiu Chen
- Department of Radiation Oncology, The Affiliated Union Hospital of Fujian Medical University, Fuzhou, China
| | - Jian-yuan Song
- Department of Radiation Oncology, The Affiliated Union Hospital of Fujian Medical University, Fuzhou, China
| | - Chang-yin Feng
- Department of Pathology, The Affiliated Union Hospital of Fujian Medical University, Fuzhou, China
| |
Collapse
|
28
|
Predictive value of APAF-1 and COX-2 expression in pathologic complete response to neoadjuvant chemoradiotherapy for patients with locally advanced rectal adenocarcinoma. Oncotarget 2018; 7:35233-40. [PMID: 27153549 PMCID: PMC5085224 DOI: 10.18632/oncotarget.9125] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 03/28/2016] [Indexed: 01/27/2023] Open
Abstract
Purpose To investigate predictive value of APAF-1 and COX-2 expression in pathologic complete response (pCR) for patients with rectal adenocarcinoma (RAC) who were treated with neoadjuvant chemoradiotherapy (neo-CRT) followed by total mesorectal excision (TME). Materials and Methods Immunohistochemistry assay was used to detect expression of APAF-1 and COX-2 in paraffin-wax embedded tissues obtained before neo-CRT for patients with RAC. A 5-point tumor-regression grade (TRG) based on the ratio of residual tumor to fibrosis according to Dworak's scoring system was used to assess neo-CRT response. The relationship between expression of APAF-1 and COX-2 genes and pCR was explored. Results pCR (TRG4) was observed in 23 patients (28.0%). pCR were more likely to be achieved for those with APAF-1 over-expression or lower expression of COX-2. pCR rate in patients with combination of high APAF-1 and low COX-2 expression was 56.0%, significantly higher than those with other combination of APAF1 and COX-2 expression. Multivariate analysis showed that over-expression of APAF-1 and suppressed expression of COX-2 were independent predictive factors for pCR. Conclusion Immunohistochemical evaluation of APAF-1 and COX-2 expression on pretreatment specimen may be used to predict pCR to neo-CRT in patients with RAC. The potential of the markers in monitoring pCR patient merits further investigation.
Collapse
|
29
|
Jhaveri J, Rayfield L, Liu Y, Chowdhary M, Cassidy RJ, Madden NA, Tanenbaum DG, Gillespie TW, Patel PR, Patel KR, Landry JC. Prognostic relevance of human papillomavirus infection in anal squamous cell carcinoma: analysis of the national cancer data base. J Gastrointest Oncol 2017; 8:998-1008. [PMID: 29299360 DOI: 10.21037/jgo.2017.10.05] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background To examine the prognostic relevance of human papillomavirus (HPV) infection for anal squamous cell carcinoma (ASCC) patients treated with chemoradiation (CRT) in the National Cancer Data Base (NCDB). Methods The 2014 NCDB was queried for non-metastatic, histologically confirmed, ASCC patients diagnosed between 2004 and 2013. Patients were required to have HPV status documented in order to be eligible. Patients were then stratified into two groups: HPV+ and HPV-. Univariate analysis (UVA) was performed using the χ2 test for categorical covariates and ANOVA for numerical covariates. Multivariable analysis (MVA) was performed using Cox proportional hazard model for overall survival (OS). Hazard ratios (HRs) and 95% confidence intervals (CIs) were generated for each covariate. To minimize selection bias, propensity score (PS) weighting was implemented to balance OS related variables between the groups including: age, education level, stage, diagnosis year, insurance type, and agent of chemotherapy. Results A total of 1,063 patients were eligible. Patients were stratified into HPV+ (n=498, 46.8%) and HPV- (n=565, 53.2%). After PS weighting, MVA for OS showed that for men, HPV infection was associated with better OS (HR: 0.60, 95% CI: 0.38-0.96; P=0.034). However, for women, HPV infection did not significantly influence survival (HR: 1.47, 95% CI: 0.96-2.25; P=0.074). Conclusions To our knowledge, this is the largest patient series evaluating the impact of HPV infection on OS in patients with anal cancer. We found that HPV infection is associated with a statistically significant better survival for men with ASCC. In contrast, for women, HPV infection did not significantly influence survival.
Collapse
Affiliation(s)
- Jaymin Jhaveri
- Department of Radiation Oncology and Winship Cancer Institute, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Lael Rayfield
- Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Yuan Liu
- Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Mudit Chowdhary
- Department of Radiation Oncology, Rush University, Chicago, IL, USA
| | - Richard J Cassidy
- Department of Radiation Oncology and Winship Cancer Institute, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Nicholas A Madden
- Department of Radiation Oncology and Winship Cancer Institute, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Daniel G Tanenbaum
- Department of Radiation Oncology and Winship Cancer Institute, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | | | - Pretesh R Patel
- Department of Radiation Oncology and Winship Cancer Institute, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Kirtesh R Patel
- Department of Radiation Oncology and Winship Cancer Institute, Winship Cancer Institute, Emory University, Atlanta, GA, USA.,Department of Therapeutic Radiology, Yale University, New Haven, CT, USA
| | - Jerome C Landry
- Department of Radiation Oncology and Winship Cancer Institute, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| |
Collapse
|
30
|
Dreussi E, Pucciarelli S, De Paoli A, Polesel J, Canzonieri V, Agostini M, Friso ML, Belluco C, Buonadonna A, Lonardi S, Zanusso C, De Mattia E, Toffoli G, Cecchin E. Predictive role of microRNA-related genetic polymorphisms in the pathological complete response to neoadjuvant chemoradiotherapy in locally advanced rectal cancer patients. Oncotarget 2017; 7:19781-93. [PMID: 26934318 PMCID: PMC4991418 DOI: 10.18632/oncotarget.7757] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 02/16/2016] [Indexed: 12/23/2022] Open
Abstract
In rectal cancer, a pathologic complete response (pCR) to pre-operative treatment is a favourable prognostic marker, but is reported in a minority of the patients. We aimed at identifying microRNA-related host genetic polymorphisms predictive of pCR. A panel of 114 microRNA-related tagging polymorphisms was selected and analyzed on 265 locally advanced rectal cancer patients treated with neoadjuvant chemo-radiotherapy. Patients were stratified in two subgroups according to the radiotherapy dose (50.4Gy for 202 patients, 55.0Gy for 78 patients). Interactions among genetic and clinical-pathological variants were investigated by recursive partitioning analysis. Only polymorphisms with a consistent significant effect in the two subgroups of patients were selected as predictive markers of pCR. The results were validated by bootstrap analysis. SMAD3-rs744910, SMAD3-rs745103, and TRBP-rs6088619 were associated to an increased chance of pCR (p=0.0153, p=0.0471, p=0.0125). DROSHA-rs10719 and SMAD3-rs17228212 had an opposite detrimental effect on pathological tumour response (p=0.0274, p=0.0049). Recursive partitioning analysis highlighted that a longer interval time between the end of radiotherapy and surgery increases the chance of pCR in patients with a specific combination of SMAD3-rs744910 and TRBP-rs6088619 genotypes. This study demonstrated that microRNA-related host genetic polymorphisms can predict pCR to neo-adjuvant chemo-radiotherapy, and could be used to personalize the interval time between the end of radiotherapy and surgery.
Collapse
Affiliation(s)
- Eva Dreussi
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico, National Cancer Institute, Aviano, Italy
| | - Salvatore Pucciarelli
- Department of Surgical, Oncological and Gastroenterological Sciences, Section of Surgery, University of Padova, Padua, Italy
| | - Antonino De Paoli
- Radiation Oncology, Centro di Riferimento Oncologico, National Cancer Institute, Aviano, Italy
| | - Jerry Polesel
- Epidemiology and Biostatistics, Centro di Riferimento Oncologico, National Cancer Institute, Aviano, Italy
| | - Vincenzo Canzonieri
- Pathology, Centro di Riferimento Oncologico, National Cancer Institute, Aviano, Italy
| | - Marco Agostini
- Department of Surgical, Oncological and Gastroenterological Sciences, Section of Surgery, University of Padova, Padua, Italy.,Nano Inspired Biomedicine Laboratory, Istituto di Ricerca Pediatrica, Città della Speranza, Padua, Italy.,Department of Nanomedicine, The Methodist Hospital Research Institute, Houston, Texas, USA
| | - Maria Luisa Friso
- Radiation Oncology, Istituto Oncologico Veneto, IRCCS, Padova, Italy
| | - Claudio Belluco
- Surgical Oncology, Centro di Riferimento Oncologico, National Cancer Institute, Aviano, Italy
| | - Angela Buonadonna
- Medical Oncology B, Centro di Riferimento Oncologico, National Cancer Institute, Aviano, Italy
| | - Sara Lonardi
- Medical Oncology 1, Istituto Oncologico Veneto, IRCCS, Padova, Italy
| | - Chiara Zanusso
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico, National Cancer Institute, Aviano, Italy
| | - Elena De Mattia
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico, National Cancer Institute, Aviano, Italy
| | - Giuseppe Toffoli
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico, National Cancer Institute, Aviano, Italy
| | - Erika Cecchin
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico, National Cancer Institute, Aviano, Italy
| |
Collapse
|
31
|
Shin YS, Yu CS, Park JH, Kim JC, Lim SB, Park IJ, Kim TW, Hong YS, Kim KP, Yoon SM, Joo JH, Kim JH. Total Mesorectal Excision Versus Local Excision After Favorable Response to Preoperative Chemoradiotherapy in "Early" Clinical T3 Rectal Cancer: A Propensity Score Analysis. Int J Radiat Oncol Biol Phys 2017; 99:136-144. [PMID: 28816139 DOI: 10.1016/j.ijrobp.2017.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 05/02/2017] [Accepted: 05/08/2017] [Indexed: 01/29/2023]
Abstract
PURPOSE To compare oncological outcomes of total mesorectal excision (TME) and local excision (LE) in patients with "early" clinical T3 rectal cancer who received preoperative chemoradiotherapy (PCRT). METHODS AND MATERIALS "Early" clinical T3 rectal cancer was radiologically defined as tumors with extramural extension of <5 mm without mesorectal fascia involvement and lateral lymph node metastasis. Patients with "early" clinical T3 rectal cancer who received PCRT followed by TME or LE between January 2007 and December 2013 were retrospectively analyzed. Propensity scores were generated using patient and tumor characteristics, and a one-to-one case-matched analysis was conducted. Local recurrence-free survival (LRFS), disease-free survival (DFS), and overall survival (OS) were compared between the TME and LE groups. RESULTS Of the 406 enrolled patients, 351 received TME and 55 received LE. The median follow-up period was 45 months. Following propensity score matching, each group contained 55 patients. Among 103 patients evaluable for pathologic tumor response, 82 patients (79.6%) showed complete response or near-complete response. No significant differences were observed between the TME and LE groups in LRFS (3-year LRFS 98.1% vs 94.4%, P=.312), DFS (3-year DFS 92.1% vs 90.8%, P=.683), and OS (3-year OS 98.2% vs 100.0%, P=.895). CONCLUSIONS In "early" clinical T3 rectal cancer, PCRT followed by LE showed comparable oncologic outcomes to TME. Because most of the matched cohort consisted of good responders to PCRT, the present results should be applied to a limited population.
Collapse
Affiliation(s)
- Young Seob Shin
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang Sik Yu
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin-Hong Park
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Jin Cheon Kim
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seok-Byung Lim
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In Ja Park
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae Won Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong Sang Hong
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyu-Pyo Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Min Yoon
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Hyeon Joo
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong Hoon Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| |
Collapse
|
32
|
A Systematic Review of Local Excision After Neoadjuvant Therapy for Rectal Cancer: Are ypT0 Tumors the Limit? Dis Colon Rectum 2016; 59:984-97. [PMID: 27602930 DOI: 10.1097/dcr.0000000000000613] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Neoadjuvant therapy reduces local recurrence after radical surgery for rectal cancer with complete pathological response in 15% to 25% of patients. Radical surgery is associated with significant morbidity that may be avoided by local excision in selected cases. OBJECTIVE This systematic review aimed to determine the oncological outcomes and morbidity of local excision after neoadjuvant therapy. DATA SOURCES Data sources included MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials databases. STUDY SELECTION A systematic search of the databases using validated terms for rectal cancer, neoadjuvant therapy, and local excision was conducted. INTERVENTIONS Neoadjuvant therapy and local excision were the included interventions. MAIN OUTCOME MEASURES Pooled local recurrence, median survival, and pooled morbidity were measured. RESULTS Twenty unique studies were included (14 cohort, 5 comparative cohort, and 1 randomized controlled trial), describing 1068 patients. Patient choice, prohibitive comorbidity, good clinical response, and early stage disease were the most frequent indications for local excision. Pretreatment T2 and T3 tumors accounted for 46.4% and 30.7% of cases. Long-course treatment was administered in all of the studies, except to a cohort of 64 patients who received short-course radiotherapy. Pooled complete clinical response was 45.8% (95% CI, 31.4%-60.5%), and pooled complete pathological response was 44.2% (95% CI, 36.4%-52.0%). Median follow-up was 54 months (range, 12-81 months). ypT0 tumors had a pooled local recurrence rate of 4.0% (95% CI, 1.9%-6.9%) and a median disease-free survival rate of 95.0% (95% CI, 87.4%-100%). Pooled local recurrence and median disease-free survival rates for ypT1 tumors or higher were 21.9% (95% CI, 15.9%-28.5%) and 68.0% (58.3%-69.0%). Pooled incidence of complications was 23.2% (95% CI, 15.7%-31.7%), with suture-line dehiscence reported in 9.9% (95% CI, 4.8%-16.7%). LIMITATIONS Limitations included study quality, high risk of selection bias and detection bias in study designs, and limited sample sizes. CONCLUSIONS Local excision after neoadjuvant therapy should only be considered a curative treatment if complete pathological response is obtained. Given the high rate of local recurrence among incomplete responders, future studies should focus on predicting patients who will achieve complete pathological response.
Collapse
|
33
|
Belluco C, Forlin M, Olivieri M, Cannizzaro R, Canzonieri V, Buonadonna A, Bidoli E, Matrone F, Bertola G, De Paoli A. Long-Term Outcome of Rectal Cancer With Clinically (EUS/MRI) Metastatic Mesorectal Lymph Nodes Treated by Neoadjuvant Chemoradiation: Role of Organ Preservation Strategies in Relation to Pathologic Response. Ann Surg Oncol 2016; 23:4302-4309. [PMID: 27489059 PMCID: PMC5090010 DOI: 10.1245/s10434-016-5451-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Organ preservation strategies are under investigation for patients with locally advanced rectal cancer (LARC) who achieve a complete pathologic response in the primary tumor (ypT0) after neoadjuvant chemoradiation therapy (CRT). This study explored the value of this approach for cN+ patients. METHODS Data were retrieved from our institutional prospective rectal cancer database. Tumors with mesorectal lymph nodes larger than 5 mm shown on endorectal ultrasonography, pelvic magnetic resonance imaging, or both were staged as cN+. RESULTS The study population comprised 226 patients (142 men and 84 women; median age, 64 years) with LARC who underwent CRT followed by surgery including total mesorectal excision (TME) (n = 179) and full-thickness local excision (LE) (n = 47) between 1996 and 2013. At staging, 123 patients (54.4 %) were cN+. In 65 cases (28.7 %), ypCR was observed. Metastatic mesorectal lymph nodes (ypN+) were detected in 41.6 % of the cN+ patients and in 2.8 % of the cN0 patients (P < 0.01). Among the cN+ patients, 16 % of the ypT0 cases were ypN+ compared with 51.8 % of the no-ypT0 cases (P < 0.01). Among the cN+ patients who underwent TME, the 5-year disease-specific survival (DSS) and disease-free survival (DFS) rates were respectively 100 and 91.6 % for the ypT0 patients compared with 71.2 and 58.0 % for the no-ypT0 patients (P = 0.01). Among the ypN+ patients, the 5-year DSS and DFS rates were both 100 % for the ypT0 cases compared with 59.1 and 43.3 % for the no-ypT0 patients. Among the cN+ and ypT0 patients, the 5-year DSS and DFS were respectively 100 and 85.7 % for the TME patients compared with 100 and 91.6 % for the LE patients. In the multivariate analysis, ypT0 was the only independent prognostic factor. CONCLUSIONS Protocols aimed at organ preservation in LARC that achieve ypT0 after CRT can be offered also to cN+ patients.
Collapse
Affiliation(s)
- Claudio Belluco
- Department of Surgical Oncology, CRO-IRCCS, National Cancer Institute, Aviano, Italy.
| | - Marco Forlin
- Department of Surgical Oncology, CRO-IRCCS, National Cancer Institute, Aviano, Italy
| | - Matteo Olivieri
- Department of Surgical Oncology, CRO-IRCCS, National Cancer Institute, Aviano, Italy
| | - Renato Cannizzaro
- Department of Gastroenterology, CRO-IRCCS, National Cancer Institute, Aviano, Italy
| | - Vincenzo Canzonieri
- Department of Pathology, CRO-IRCCS, National Cancer Institute, Aviano, Italy
| | - Angela Buonadonna
- Department of Medical Oncology, CRO-IRCCS, National Cancer Institute, Aviano, Italy
| | - Ettore Bidoli
- Department of Epidemiology, CRO-IRCCS, National Cancer Institute, Aviano, Italy
| | - Fabio Matrone
- Department of Radiation Oncology, CRO-IRCCS, National Cancer Institute, Aviano, Italy
| | - Giulio Bertola
- Department of Surgical Oncology, CRO-IRCCS, National Cancer Institute, Aviano, Italy
| | - Antonino De Paoli
- Department of Radiation Oncology, CRO-IRCCS, National Cancer Institute, Aviano, Italy
| |
Collapse
|
34
|
Cui J, Fang H, Zhang L, Wu YL, Zhang HZ. Advances for achieving a pathological complete response for rectal cancer after neoadjuvant therapy. Chronic Dis Transl Med 2016; 2:10-16. [PMID: 29063019 PMCID: PMC5643745 DOI: 10.1016/j.cdtm.2016.06.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Indexed: 12/21/2022] Open
Abstract
Neoadjuvant therapy has become the standard of care for locally advanced mid-low rectal cancer. Pathological complete response (pCR) can be achieved in 12%–38% of patients. Patients with pCR have the most favorable long-term outcomes. Intensifying neoadjuvant therapy and extending the interval between termination of neoadjuvant treatment and surgery may increase the pCR rate. Growing evidence has raised the issue of whether local excision or observation rather than radical surgery is an alternative for patients who achieve a clinical complete response after neoadjuvant therapy. Herein, we highlight many of the advances and resultant controversies that are likely to dominate the research agenda for pCR of rectal cancer in the modern era.
Collapse
Affiliation(s)
- Jian Cui
- Department of Colorectal Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China
| | - Hui Fang
- Department of Radiation Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China
| | - Lin Zhang
- Department of Colorectal Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China
| | - Yun-Long Wu
- Department of Colorectal Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China
| | - Hai-Zeng Zhang
- Department of Colorectal Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China
| |
Collapse
|
35
|
Li Y, Wang J, Ma X, Tan L, Yan Y, Xue C, Hui B, Liu R, Ma H, Ren J. A Review of Neoadjuvant Chemoradiotherapy for Locally Advanced Rectal Cancer. Int J Biol Sci 2016; 12:1022-31. [PMID: 27489505 PMCID: PMC4971740 DOI: 10.7150/ijbs.15438] [Citation(s) in RCA: 125] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 06/04/2016] [Indexed: 12/19/2022] Open
Abstract
Neoadjuvant chemoradiotherapy has become the standard treatment for locally advanced rectal cancer. Neoadjuvant chemoradiotherapy not only can reduce tumor size and recurrence, but also increase the tumor resection rate and anus retention rate with very slight side effect. Comparing with preoperative chemotherapy, preoperative chemoradiotherapy can further reduce the local recurrence rate and downstage. Middle and low rectal cancers can benefit more from neoadjuvant chemradiotherapy than high rectal cancer. It needs to refine the selection of appropriate patients and irradiation modes for neoadjuvant chemoradiotherapy. Different therapeutic reactions to neoadjuvant chemoradiotherapy affect the type of surgical techniques, hence calling for the need of much attention. Furthermore, many problems such as accurate staging before surgery, selection of suitable neoadjuvant chemoradiotherapy method, and sensitivity prediction to preoperative radiotherapy need to be well settled.
Collapse
Affiliation(s)
- Yi Li
- 2. Department of Chemotherapy, Oncology Department, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Ji Wang
- 3. Intensive Care Unit, China Mei Tan General Hospital, ChaoYang, Beijing 100028, P.R. China
| | - Xiaowei Ma
- 4. Medical School, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Li Tan
- 4. Medical School, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Yanli Yan
- 4. Medical School, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Chaofan Xue
- 4. Medical School, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Beina Hui
- 1. Department of Radiotherapy, Oncology Department, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Rui Liu
- 1. Department of Radiotherapy, Oncology Department, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Hailin Ma
- 1. Department of Radiotherapy, Oncology Department, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Juan Ren
- 1. Department of Radiotherapy, Oncology Department, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| |
Collapse
|
36
|
Morris ZS, Saha S, Magnuson WJ, Morris BA, Borkenhagen JF, Ching A, Hirose G, McMurry V, Francis DM, Harari PM, Chappell R, Tsuji S, Ritter MA. Increased tumor response to neoadjuvant therapy among rectal cancer patients taking angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Cancer 2016; 122:2487-95. [PMID: 27203227 DOI: 10.1002/cncr.30079] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 01/27/2016] [Accepted: 02/02/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are commonly used antihypertensive medications that have been reported to affect aberrant angiogenesis and the dysregulated inflammatory response. Because of such mechanisms, it was hypothesized that these medications might affect the tumor response to neoadjuvant radiation in patients with rectal cancer. METHODS One hundred fifteen patients who were treated with neoadjuvant radiation at the University of Wisconsin (UW) between 1999 and 2012 were identified. Univariate analyses were performed with anonymized patient data. In a second independent data set, 186 patients with rectal cancer who were treated with neoadjuvant radiation at the Queen's Medical Center of the University of Hawaii (UH) between 1995 and 2010 were identified. These data were independently analyzed as before. Multivariate analyses were performed with aggregate data. RESULTS Among patients taking ACEIs/ARBs in the UW data set, a significant 3-fold increase in the rate of pathologic complete response (pCR) to neoadjuvant therapy (52% vs 17%, P = .001) was observed. This finding was confirmed in the UH data set, in which a significant 2-fold-increased pCR rate (24% vs 12%, P = .03) was observed. Identified patient and treatment characteristics were otherwise balanced between patients taking and not taking ACEIs/ARBs. No significant effect was observed on pCR rates with other medications, including statins, metformin, and aspirin. Multivariate analyses of aggregate data identified ACEI/ARB use as a strong predictor of pCR (odds ratio, 4.02; 95% confidence interval, 2.06-7.82; P < .001). CONCLUSIONS The incidental use of ACEIs/ARBs among patients with rectal cancer is associated with a significantly increased rate of pCR after neoadjuvant treatment. Cancer 2016;122:2487-95. © 2016 American Cancer Society.
Collapse
Affiliation(s)
- Zachary S Morris
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Sandeep Saha
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - William J Magnuson
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.,Department of Therapeutic Radiology, Yale University, New Haven, Connecticut
| | - Brett A Morris
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Jenna F Borkenhagen
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Alisa Ching
- Queen's Medical Center, University of Hawaii, Honolulu, Hawaii
| | - Gayle Hirose
- Queen's Medical Center, University of Hawaii, Honolulu, Hawaii
| | - Vanesa McMurry
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - David M Francis
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Paul M Harari
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Rick Chappell
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Stuart Tsuji
- Queen's Medical Center, University of Hawaii, Honolulu, Hawaii
| | - Mark A Ritter
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| |
Collapse
|
37
|
Vaccaro CA, Yazyi FJ, Ojra Quintana G, Santino JP, Sardi ME, Beder D, Tognelli J, Bonadeo F, Lastiri JM, Rossi GL. Locally advanced rectal cancer: Preliminary results of rectal preservation after neoadjuvant chemoradiotherapy. Cir Esp 2016; 94:274-9. [PMID: 26980259 DOI: 10.1016/j.ciresp.2015.12.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 10/17/2015] [Accepted: 12/19/2015] [Indexed: 12/28/2022]
Abstract
INTRODUCTION The standard treatment for locally advanced rectal cancer is total mesorectal excision. However, organ preservation has been proposed for tumors with good response to neoadjuvant treatment. The aim of this study was to evaluate the oncologic results of this strategy. METHODS This is a retrospective cohort study (2005-2014) including a consecutive series of patients with rectal adenocarcinoma with complete or almost complete clinical response after preoperative chemo-radiotherapy, that were treated according to a strategy of preservation of the rectum. RESULTS A total of 204 patients with rectal cancer received neoadjuvant therapy. Thirty (14.7%) had a good response and were treated with rectal preservation (23 «Watch and Wait» and 7 local resections). Median follow-up was 46 months (interquartile range: 30-68). In the group of «Watch & Wait», 4 patients had local recurrence before 12 months (actuarial local recurrence rate=18.5%). All of them underwent salvage surgery (2 with radical surgery and 2 local resections) without any further recurrence. Disease-free survival actuarial rate at 3 years follow-up was 94.1% (95% CI 82.9-100). None of the 7 patients that were treated by local excision had local recurrence. The organ preservation rate for the whole group was 93%. CONCLUSION The strategy of organ preservation in locally advanced rectal cancer is feasible in cases with good response to neoadjuvant therapy. When implemented in a highly selected group of patients this strategy is associated with satisfactory oncologic results.
Collapse
Affiliation(s)
- Carlos Alberto Vaccaro
- Servicio Cirugía General, Sector de Coloproctología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | - Federico Julio Yazyi
- Servicio Cirugía General, Sector de Coloproctología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Guillermo Ojra Quintana
- Servicio Cirugía General, Sector de Coloproctología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Juan Pablo Santino
- Servicio Anatomía Patológica, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Mabel Edith Sardi
- Servicio Oncología Radiante, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Damián Beder
- Servicio Cirugía General, Sector de Coloproctología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Joaquin Tognelli
- Servicio Cirugía General, Sector de Coloproctología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Fernando Bonadeo
- Servicio Cirugía General, Sector de Coloproctología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - José María Lastiri
- Servicio Oncología Radiante, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Gustavo Leandro Rossi
- Servicio Cirugía General, Sector de Coloproctología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| |
Collapse
|
38
|
Wan J, Liu K, Zhu J, Li G, Zhang Z. Implications for selecting local excision in locally advanced rectal cancer after preoperative chemoradiation. Oncotarget 2016; 6:11714-22. [PMID: 25909169 PMCID: PMC4484489 DOI: 10.18632/oncotarget.3418] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 02/19/2015] [Indexed: 12/27/2022] Open
Abstract
Local excision may offer the possibility of organ preservation for the management of locally advanced rectal cancer after neoadjuvant chemoradiotherapy (CRT). However, the oncological outcomes of this strategy have been largely associated with the risk of nodal metastases. In this study, Surveillance, Epidemiology, and End Results Program (SEER)-registered rectal cancer patients, and patients from Fudan University Shanghai Cancer Center (FUSCC) after preoperative chemoradiation were combined to analyze the incidence of lymph node metastasis. The results showed that there was a high risk for residual lymph node metastasis among patients even with complete pathologic response of primary tumor after preoperative CRT (12.6–13.2%). However, in the selected group of patients with pre-CRT MRI staging cN0 rectal cancer, there was only one ypN+ case (3.3%) in ypT0–1 group. These results suggest that pre-CRT MRI staging cN0 patients achieved ypT0–1 of bowel wall tumor may be suitable for local resection.
Collapse
Affiliation(s)
- Juefeng Wan
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Kaitai Liu
- Department of Radiation Oncology, Lihuili Hospital, Ningbo Medical Center, Ningbo, China
| | - Ji Zhu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Guichao Li
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Zhen Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| |
Collapse
|
39
|
Shimodaira Y, Harada K, Lin Q, Ajani JA. The best timing for administering systemic chemotherapy in patients with locally advanced rectal cancer. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:38. [PMID: 26889491 DOI: 10.3978/j.issn.2305-5839.2016.01.08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Over the past several decades, outcomes for patients with rectal cancer have improved considerably. However, several questions have emerged as survival times have lengthened and quality of life has improved for these patients. Currently patients with locally advanced rectal cancer (LARC) are often recommended multimodality therapy with fluoropyrimidine-based chemotherapy (CT) and radiation followed by total mesorectal excision (TME), with consideration given to FOLFOX before chemoradiotherapy (CRT). Recently, Garcia-Aguilar and colleagues reported in Lancet Oncology that the addition of mFOLFOX6 administered between CRT and surgery affected the number of patients achieving pathologic complete response (pathCR), which is of great interest from the standpoint of pursuit of optimal timing of systemic CT delivery. This was a multicenter phase II study consisting of 4 sequential treatment groups of patients with LARC, and they reported that patients given higher number CT cycles between CRT and surgery achieved higher rates of pathCR than those given standard treatment. There was no association between response improvement and tumor progression, increased technical difficulty, or surgical complications. Ongoing phase III clinical trial further assessing this strategy might result in a paradigm shift.
Collapse
Affiliation(s)
- Yusuke Shimodaira
- Department of Gastrointestinal Medical Oncology, the University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Kazuto Harada
- Department of Gastrointestinal Medical Oncology, the University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Quan Lin
- Department of Gastrointestinal Medical Oncology, the University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Jaffer A Ajani
- Department of Gastrointestinal Medical Oncology, the University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| |
Collapse
|
40
|
Srikumar T, Markow M, Centeno B, Hoffe S, Tao J, Fernandez H, Strosberg J, Shibata D. Synchronous rectal adenocarcinoma and splenic marginal zone lymphoma. ACTA ACUST UNITED AC 2016; 23:e70-4. [PMID: 26966416 DOI: 10.3747/co.23.2711] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Synchronous cancers of different primary origin are rare. Here, we describe the case of a patient with concomitant diagnoses of rectal adenocarcinoma and splenic marginal zone lymphoma (smzl). A 57-year-old woman initially presented with abdominal pain. Physical examination and computed tomography demonstrated massive splenomegaly, and a complete blood count revealed microcytic anemia and lymphopenia. During the subsequent evaluation, she presented with hematochezia, melena, and constipation, which prompted gastroenterology referral. Subsequent endoscopic rectal ultrasonography revealed a T3N1 moderately differentiated rectal adenocarcinoma, with computed tomography imaging of chest, abdomen, and pelvis confirming no metastasis. Thus, the cancer was classified as clinical stage T3N1M0, stage iii. Bone marrow biopsy confirmed co-existing marginal zone lymphoma, and with the clinical presentation of massive splenomegaly, a diagnosis of smzl was made. The patient's management was individually tailored for simultaneous optimal treatment of both conditions. Concurrent treatment with neoadjuvant rituximab and 5-fluorouracil chemotherapy, with external-beam radiation therapy to the pelvis, was administered, followed by surgery consisting of en bloc splenectomy and distal pancreatectomy, and low anterior resection. The patient completed a standard course of adjuvant folfox (fluorouracil-leucovorin-oxaliplatin) chemotherapy and has remained disease-free for 7 years. To our knowledge, this report is the first to specifically describe simultaneous diagnoses of locally advanced rectal cancer and smzl. We also describe the successful combined neoadjuvant treatment combination of 5-fluorouracil, rituximab, and pelvic radiation.
Collapse
Affiliation(s)
- T Srikumar
- Morsani College of Medicine, University of South Florida, Tampa, FL, U.S.A.;; Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, U.S.A
| | - M Markow
- Department of Pathology and Cell Biology, Morsani College of Medicine, University of South Florida, Tampa, FL, U.S.A.;; Department of Anatomic Pathology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, U.S.A
| | - B Centeno
- Department of Anatomic Pathology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, U.S.A
| | - S Hoffe
- Department of Radiation Oncology and Therapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, U.S.A
| | - J Tao
- Department of Hematopathology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, U.S.A
| | - H Fernandez
- Department of Blood and Marrow Transplant, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, U.S.A
| | - J Strosberg
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, U.S.A
| | - D Shibata
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, U.S.A
| |
Collapse
|
41
|
Torok JA, Palta M, Willett CG, Czito BG. Nonoperative management of rectal cancer. Cancer 2015; 122:34-41. [DOI: 10.1002/cncr.29735] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 09/16/2015] [Accepted: 09/21/2015] [Indexed: 12/13/2022]
Affiliation(s)
- Jordan A. Torok
- Department of Radiation Oncology; Duke University Medical Center; Durham North Carolina
| | - Manisha Palta
- Department of Radiation Oncology; Duke University Medical Center; Durham North Carolina
| | | | - Brian G. Czito
- Department of Radiation Oncology; Duke University Medical Center; Durham North Carolina
| |
Collapse
|
42
|
Russo S, Blackstock AW, Herman JM, Abdel-Wahab M, Azad N, Das P, Goodman KA, Hong TS, Jabbour SK, Jones WE, Konski AA, Koong AC, Kumar R, Rodriguez-Bigas M, Small W, Thomas CR, Suh WW. ACR Appropriateness Criteria® Local Excision in Early Stage Rectal Cancer. Am J Clin Oncol 2015; 38:520-5. [PMID: 26371522 PMCID: PMC10862362 DOI: 10.1097/coc.0000000000000197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Low anterior resection or abdominoperineal resection are considered standard treatments for early rectal cancer but may be associated with morbidity in selected patients who are candidates for early distal lesions amenable to local excision (LE). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. The panel recognizes the importance of accurate staging to identify patients who may be candidates for a LE approach. Patients who may be candidates for LE alone include those with small, low-lying T1 tumors, without adverse pathologic features. Several surgical approaches can be utilized for LE however none include lymph node evaluation. Adjuvant radiation±chemotherapy may be warranted depending on the risk of nodal metastases. Patients with high-risk T1 tumors, T2 tumors not amenable to radical surgery may also benefit from adjuvant treatment; however, patients with positive margins or T3 lesions should be offered abdominoperineal resection or low anterior resection. Neoadjuvant radiation±chemotherapy followed by LE in higher risk patients results in excellent local control, but it is not clear if this approach reduces recurrence rates over surgery alone.
Collapse
Affiliation(s)
- Suzanne Russo
- Department of Radiation Oncology, University Hospitals Case Western Seidman Cancer Center, Cleveland, OH
| | | | - Joseph M. Herman
- Sidney Kimmel Cancer Center, Johns Hopkins University, Baltimore, MD, American Society of Clinical Oncology
| | | | - Nilofer Azad
- Sidney Kimmel Cancer Center, Johns Hopkins University, Baltimore, MD, American Society of Clinical Oncology
| | - Prajnan Das
- MD Anderson Cancer Center, Houston, TX, American College of Surgeons
| | | | | | - Salma K. Jabbour
- Robert Wood Johnson Medical School, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ
| | - William E. Jones
- University of Texas Health Science Center at San Antonio, San Antonio, TX
| | | | - Albert C. Koong
- Department of Radiation Oncology, Stanford University Medical Center, Stanford, CA
| | - Rachit Kumar
- Department of Radiation Oncology, Johns Hopkins University, Baltimore, MD
| | | | - William Small
- Stritch School of Medicine, Loyola University Chicago, Maywood, IL
| | - Charles R. Thomas
- Knight Cancer Institute, Oregon Health and Science University, Portland, OR
| | | |
Collapse
|
43
|
Wen B, Zhang L, Wang C, Huang R, Peng H, Zhang T, Dong J, Xiao W, Zeng Z, Liu M, Gao Y. Prognostic significance of clinical and pathological stages on locally advanced rectal carcinoma after neoadjuvant chemoradiotherapy. Radiat Oncol 2015; 10:124. [PMID: 26040453 PMCID: PMC4490617 DOI: 10.1186/s13014-015-0425-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 05/21/2015] [Indexed: 02/06/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Bixiu Wen
- Department of Radiation Oncology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China.
| | - Luning Zhang
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, 510060, China.
| | - Chengtao Wang
- Department of Radiation Oncology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China.
| | - Rong Huang
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, 510060, China.
| | - Haihua Peng
- Department of Radiation Oncology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China.
| | - Tian Zhang
- Department of Radiation Oncology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China.
| | - Jun Dong
- Department of Radiation Oncology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China.
| | - Weiwei Xiao
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, 510060, China.
| | - Zhifan Zeng
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, 510060, China.
| | - Mengzhong Liu
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, 510060, China.
| | - Yuanhong Gao
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, 510060, China.
| |
Collapse
|
44
|
Althumairi AA, Gearhart SL. Local excision for early rectal cancer: transanal endoscopic microsurgery and beyond. J Gastrointest Oncol 2015; 6:296-306. [PMID: 26029457 DOI: 10.3978/j.issn.2078-6891.2015.022] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 01/26/2015] [Indexed: 12/13/2022] Open
Abstract
The goal of treatment for early stage rectal cancer is to optimize oncologic control while minimizing the long-term impact of treatment on quality of life. The standard of care treatment for most stage I and II rectal cancers is radical surgery alone, specifically total mesorectal excision (TME). For early rectal cancers, this procedure is usually curative but can have a substantial impact on quality of life, including the possibility of permanent colostomy and the potential for short and long-term bowel, bladder, and sexual dysfunction. Given the morbidity associated with radical surgery, alternative approaches to management of early rectal cancer have been explored, including local excision (LE) via transanal excision (TAE) or transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS). Compared to the gold standard of radical surgery, local procedures for strictly selected early rectal cancers should lead to identical oncological results and even better outcomes regarding morbidity, mortality, and quality of life.
Collapse
Affiliation(s)
- Azah A Althumairi
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Susan L Gearhart
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| |
Collapse
|
45
|
Hongo K, Kazama S, Tsuno NH, Ishihara S, Sunami E, Kitayama J, Watanabe T. Immunohistochemical detection of high-mobility group box 1 correlates with resistance of preoperative chemoradiotherapy for lower rectal cancer: a retrospective study. World J Surg Oncol 2015; 13:7. [PMID: 25622595 PMCID: PMC4417215 DOI: 10.1186/1477-7819-13-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2014] [Accepted: 11/18/2014] [Indexed: 12/29/2022] Open
Abstract
Background High-mobility group box 1 (HMGB1) is a nucleoprotein that is related to inflammation. It has been implicated in a variety of biologically important processes, including transcription, DNA repair, differentiation, development, and extracellular signaling. Recently, its important role in the process of tumor invasion, metastasis, and resistance to anti-cancer therapies has been demonstrated. In this study, we aimed to investigate the correlation of HMGB1 expression and resistance of rectal cancer patients to chemoradiotherapy (CRT) prior to curative operation. Methods We retrospectively reviewed the data of 75 lower rectal cancer patients without complete pathological response who had received preoperative CRT and had undergone curative resection at the University of Tokyo Hospital between May 2003 and June 2010. HMGB1 expression in surgically resected specimens was evaluated using immunohistochemical detection and specimens were classified into high or low HMGB1 expression groups. Clinicopathologic features, degree of tumor reduction, regression of tumor grade, and patient survival were compared between the groups using non-paired Student’s t-tests and Kaplan-Meier analysis. Results A total of 52 (69.3%) patients had high HMGB1 expression, and 23 (30.7%) had low expression. HMGB1 expression was significantly correlated with histologic type (P = 0.02), lymphatic invasion (P = 0.02), and venous invasion (P = 0.05). Compared to patients with low HMGB1 expression, those with high expression had a poorer response to CRT, in terms of tumor reduction ratio (42.2 versus 28.9%, respectively; P <0.01) and post-CRT histological tumor regression grade (56.5 versus 30.8% grade 2; respectively; P = 0.03). However, no significant correlation was found between HMGB1 expression and recurrence-free and overall survival rates. Conclusions HMGB1 expression may be one of the key factors regulating the response of rectal cancer to preoperative CRT in terms of tumor invasiveness and resistance to therapy.
Collapse
Affiliation(s)
- Kumiko Hongo
- Department of Surgical Oncology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Shinsuke Kazama
- Department of Surgical Oncology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Nelson H Tsuno
- Department of Transfusion Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Soichiro Ishihara
- Department of Surgical Oncology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Eiji Sunami
- Department of Surgical Oncology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Joji Kitayama
- Department of Surgical Oncology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Toshiaki Watanabe
- Department of Surgical Oncology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| |
Collapse
|
46
|
Abstract
BACKGROUND Local excision, as an alternative to radical resection for patients with pathological complete response (ypT0) after preoperative chemoradiation, is under investigation. OBJECTIVE The aim of the present study was to evaluate the long-term clinical outcome of a selected group of patients with ypT0 rectal cancer who underwent local excision with transanal endoscopic microsurgery as a definitive treatment. PATIENTS Between 1993 and 2013, 43 patients with rectal adenocarcinoma underwent complete full-thickness local excision with a transanal endoscopic microsurgery procedure after a regimen of chemoradiation. In all patients, rectal wall penetration was preoperatively assessed by endorectal ultrasound and/or magnetic resonance. Chemoradiation and transanal endoscopic microsurgery were indicated in patients refusing radical procedures or patients unfit for major abdominal procedures. MAIN OUTCOME MEASURES Patient characteristics, operative record, pathology report, and tumor recurrence were analyzed at a median follow-up of 81 months. The potential prognostic factors for recurrence, screened in univariate analysis, were analyzed by multivariate analysis by using the Cox regression model. RESULTS Thirteen patients (30.2%), without residual tumor in the surgical specimen (ypT0), were treated with transanal endoscopic microsurgery only. In this ypT0 group, 2 patients (15.4%) had postoperative complications: 1 bleeding and 1 suture dehiscence. Postoperative mortality was nil. No local and distal recurrences were observed, and no tumor-related mortality occurred. In 30 patients (69.8%), partial tumor chemoradiation response or the absence of tumor chemoradiation response was observed. In this group, recurrence occurred in 17 patients (56.7%). LIMITATIONS The study was limited by its retrospective nature, different protocols of chemoradiation and preoperative staging over time, and the small sample size. CONCLUSIONS Local excision with transanal endoscopic microsurgery can be considered a definitive therapeutic option in patients with rectal cancer treated with preoperative chemoradiation, when no residual tumor is found in the specimen. In this selected group, local excision offers excellent results in terms of survival and recurrence rates. In the presence of residual tumor, transanal endoscopic microsurgery should be considered as a large excisional biopsy (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A157).
Collapse
|
47
|
Sebio A, Salazar J, Páez D, Berenguer-Llergo A, del Río E, Tobeña M, Martín-Richard M, Sullivan I, Targarona E, Balart J, Baiget M, Barnadas A. EGFR ligands and DNA repair genes: genomic predictors of complete response after capecitabine-based chemoradiotherapy in locally advanced rectal cancer. THE PHARMACOGENOMICS JOURNAL 2014; 15:77-83. [DOI: 10.1038/tpj.2014.33] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 03/31/2014] [Accepted: 05/22/2014] [Indexed: 02/06/2023]
|
48
|
Noh JM, Park W, Kim JS, Koom WS, Kim JH, Choi DH, Park HC. Outcome of Local Excision Following Preoperative Chemoradiotherapy for Clinically T2 Distal Rectal Cancer: A Multicenter Retrospective Study (KROG 12-06). Cancer Res Treat 2014; 46:243-9. [PMID: 25038759 PMCID: PMC4132444 DOI: 10.4143/crt.2014.46.3.243] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 07/03/2013] [Indexed: 12/13/2022] Open
Abstract
PURPOSE The aim of this study was to examine the clinical implications of a pathologically complete response after neoadjuvant chemoradiotherapy (CRT) followed by local excision for patients with cT2 rectal cancer who refused radical surgery. MATERIALS AND METHODS Seventeen patients with cT2 primary rectal cancer within 6 cm from the anal verge who received neoadjuvant CRT and local excision because of patient refusal of radical surgery or poor performance status were included. Two patients had clinical involvement of a regional lymph node. Preoperative radiotherapy was delivered to the whole pelvis at a dose of 44 to 50.4 Gy in 22 to 28 fractions. All patients underwent transanal excision and eight patients (47%) received postoperative chemotherapy. RESULTS Ten patients (59%) achieved ypT0. At a median follow-up period of 75 months (range, 22 to 126 months), four (24%) patients developed recurrence (two locoregional and two distant). The 5-year disease-free survival of all patients was 82%, and was higher in patients with ypT0 (90%) than in patients with ypT1-2 (69%, p=0.1643). Decreased disease-free survival was also observed in patients receiving capecitabine compared with 5-fluorouracil (54% vs. 100%, p=0.0298). CONCLUSION Local excision could be a feasible alternative to radical surgery in patients with ypT0 after neoadjuvant CRT for cT2 distal rectal cancer without further radical surgery.
Collapse
Affiliation(s)
- Jae Myoung Noh
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Won Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae-Sung Kim
- Department of Radiation Oncology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Woong Sub Koom
- Department of Radiation Oncology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Hee Kim
- Department of Radiation Oncology, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Doo Ho Choi
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Chul Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| |
Collapse
|
49
|
Nomogram to predict ypN status after chemoradiation in patients with locally advanced rectal cancer. Br J Cancer 2014; 111:249-54. [PMID: 24967873 PMCID: PMC4102937 DOI: 10.1038/bjc.2014.256] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Revised: 04/10/2014] [Accepted: 04/13/2014] [Indexed: 12/23/2022] Open
Abstract
Background: Pelvic lymph node (LN) status after preoperative chemoradiotherapy (CRT) is an important indicator of oncologic outcome in patients with locally advanced rectal cancer. The purpose of this study was to develop a nomogram to predict LN status after preoperative CRT in locally advanced rectal cancer patients. Methods: The nomogram was developed in a training cohort (n=891) using logistic regression analyses and validated in a validation cohort (n=258) from a prospectively registered tumour registry at Asan Medical Center. The model was internally and externally validated for discrimination and calibration using bootstrap resampling. Model performance was evaluated by the concordance index (c-index) and calibration curve. Results: Pretreatment ypT stage, patient age, preCRT tumour differentiation, cN stage, lymphovascular invasion, and perineural invasion were reliable predictors of LN metastasis after preoperative CRT. The nomogram developed using these parameters had c-indices of 0.81 (training) and 0.77 (validation). The calibration plot suggested good agreement between actual and nomogram-predicted LN status after preoperative CRT. Conclusions: This nomogram improves prediction of LN status after preoperative CRT in patients with locally advanced rectal cancer. It will be useful for counselling patients as well as for the design and stratification of patients in clinical trials.
Collapse
|
50
|
Leibold T, Hui VW, Shia J, Ruby JA, Riedel ER, Guillem JG. p27 expression in post-treatment rectal cancer: a potential novel approach for predicting residual nodal disease. Am J Surg 2014; 208:228-34. [PMID: 24814310 DOI: 10.1016/j.amjsurg.2014.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Revised: 01/14/2014] [Accepted: 02/06/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Expression profiles of p21, p27, p53, Ki-67, and thymidylate synthase may be associated with response to neoadjuvant chemoradiation. The relationship between post-treatment protein expression and regional lymph node involvement has not been fully explored. METHODS Tumor cores from 126 rectal cancer patients underwent immunohistochemical analysis for the aforementioned proteins. Staining indices (SIs) using percentage of stained cells and staining intensity were calculated for 10 tumor cores per patient. SI for each marker was compared between node negative and node positive patients. RESULTS Twenty-six (20.6%) cancer patients had a pathologic complete response and 37 had inadequate tissue or cancer cells, leaving 63 for analysis. Thirty-seven (58.7%) cancer patients were node negative and 26 (41.3%) were node positive. There was an association between increased p27 SI and nodal positivity (P = .04). CONCLUSION Increased p27 expression in post-treatment rectal cancer is associated with nodal positivity and may determine which patients are suitable for local excision.
Collapse
Affiliation(s)
- Tobias Leibold
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Vanessa W Hui
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Jinru Shia
- Department of Pathology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Jeannine A Ruby
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Elyn R Riedel
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - José G Guillem
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
| |
Collapse
|