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Hammarström K, Nunes L, Mathot L, Mezheyeuski A, Lundin E, Korsavidou Hult N, Imam I, Osterlund E, Sjöblom T, Glimelius B. Clinical and genetic factors associated with tumor response to neoadjuvant (chemo)radiotherapy, survival and recurrence risk in rectal cancer. Int J Cancer 2024; 155:40-53. [PMID: 38376070 DOI: 10.1002/ijc.34880] [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: 08/21/2023] [Revised: 01/14/2024] [Accepted: 01/16/2024] [Indexed: 02/21/2024]
Abstract
Rectal cancer poses challenges in preoperative treatment response, with up to 30% achieving a complete response (CR). Personalized treatment relies on accurate identification of responders at diagnosis. This study aimed to unravel CR determinants, overall survival (OS), and time to recurrence (TTR) using clinical and targeted sequencing data. Analyzing 402 patients undergoing preoperative treatment, tumor stage, size, and treatment emerged as robust response predictors. CR rates were higher in smaller, early-stage, and intensively treated tumors. Targeted sequencing analyzed 216 cases, while 120 patients provided hotspot mutation data. KRAS mutation dramatically reduced CR odds by over 50% (odds ratio [OR] = 0.3 in the targeted sequencing and OR = 0.4 hotspot cohorts, respectively). In contrast, SMAD4 and SYNE1 mutations were associated with higher CR rates (OR = 6.0 and 6.8, respectively). Favorable OS was linked to younger age, CR, and low baseline carcinoembryonic antigen levels. Notably, CR and an APC mutation increased TTR, while a BRAF mutation negatively affected TTR. Beyond tumor burden, SMAD4 and SYNE1 mutations significantly influenced CR. KRAS mutations independently correlated with radiotherapy resistance, and BRAF mutations heightened recurrence risk. Intriguingly, non-responding tumors with initially small sizes carried a higher risk of recurrence. The findings, even if limited in addition to the imperfect clinical factors, offer insights into rectal cancer treatment response, guiding personalized therapeutic strategies. By uncovering factors impacting CR, OS, and TTR, this study underscores the importance of tailored approaches for rectal cancer patients. These findings, based on extensive analysis and mutation data, pave the way for personalized interventions, optimizing outcomes in the challenges of rectal cancer preoperative treatment.
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Affiliation(s)
- Klara Hammarström
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Luís Nunes
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Lucy Mathot
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Artur Mezheyeuski
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
- Molecular Oncology Group, Vall d'Hebron Institute of Oncology, Barcelona, Spain
| | - Emma Lundin
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | | | - Israa Imam
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Emerik Osterlund
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Tobias Sjöblom
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Bengt Glimelius
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
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Pan Z, Wang Y, Li S, Cai H, Guan G. The prognostic role of the change in albumin-derived neutrophil-to-lymphocyte ratio during neoadjuvant chemoradiotherapy in patients with locally advanced rectal cancer. BIOMOLECULES & BIOMEDICINE 2024; 24:612-624. [PMID: 38041687 PMCID: PMC11088900 DOI: 10.17305/bb.2023.9787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/12/2023] [Accepted: 11/09/2023] [Indexed: 12/03/2023]
Abstract
The prognosis of patients with locally advanced rectal cancer (LARC) has improved with the adoption of a multidisciplinary treatment approach combining neoadjuvant chemoradiotherapy (nCRT) and total mesorectal excision (TME). Developing real-time, sensitive biomarkers to monitor systemic changes during nCRT is of paramount importance. Although the association between albumin-derived neutrophil-to-lymphocyte ratio (Alb-dNLR) and prognosis in various cancers is established, its prognostic value in LARC patients undergoing nCRT is not well-studied. This study enrolled a cohort of 618 LARC patients, stratifying them into two groups according to their change in Alb-dNLR (∆Alb-dNLR) values, using an optimal cut-off point: a low ∆Alb-dNLR group (≤ 0.90) and a high ∆Alb-dNLR group (> 0.90). The prognostic significance of ∆Alb-dNLR was evaluated using a Cox proportional hazards model. The 5-year overall survival (OS) rates were 75.2% in the low ∆Alb-dNLR group (≤ 0.90) and 85.9% in the high ∆Alb-dNLR group (>0.90) (P < 0.001). The 5-year disease-free survival (DFS) rates were 71.2% and 80.6%, respectively (P = 0.016). Multivariate analyses demonstrated that both ∆Alb-dNLR and pre-Alb-dNLR were independent prognostic factors for OS (P ≤ 0.001), while ∆Alb-dNLR was demonstrated as an independent prognostic factor for DFS (P = 0.016). A predictive nomogram, incorporating the ∆Alb-dNLR subgroup, demonstrated enhanced performance (concordance index [C-index] of 0.720 for OS and 0.690 for DFS) compared to the pre-treatment Alb-dNLR subgroup (C-index of 0.700 for OS and of 0.680 for DFS). Therefore, ∆Alb-dNLR shows significant potential as a usable and prognostic biomarker for predicting OS and DFS in LARC patients undergoing nCRT.
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Affiliation(s)
- Zhen Pan
- Department of Colorectal Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Ye Wang
- Department of Colorectal Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Shoufeng Li
- Department of Colorectal Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Huajun Cai
- Department of Colorectal Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Guoxian Guan
- Department of Colorectal Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Colorectal Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fuzhou, China
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Romero-Zoghbi SE, López-Campos F, Couñago F. Management of lateral pelvic lymph nodes in rectal cancer: Is it time to reach an Agreement? World J Clin Oncol 2024; 15:472-477. [PMID: 38689627 PMCID: PMC11056856 DOI: 10.5306/wjco.v15.i4.472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/01/2024] [Accepted: 03/11/2024] [Indexed: 04/22/2024] Open
Abstract
In this editorial, we proceed to comment on the article by Chua et al, addressing the management of metastatic lateral pelvic lymph nodes (mLLN) in stage II/III rectal cancer patients below the peritoneal reflection. The treatment of this nodal area sparks significant controversy due to the strategic differences followed by Eastern and Western physicians, albeit with a higher degree of convergence in recent years. The dissection of lateral pelvic lymph nodes without neoadjuvant therapy is a standard practice in Eastern countries. In contrast, in the West, preference leans towards opting for neoadjuvant therapy with chemoradiotherapy or radiotherapy, that would cover the treatment of this area without the need to add the dissection of these nodes to the total mesorectal excision. In the presence of high-risk nodal characteristics for mLLN related to radiological imaging and lack of response to neoadjuvant therapy, the risk of lateral local recurrence increases, suggesting the appropriate selection of strategies to reduce the risk of recurrence in each patient profile. Despite the heterogeneous and retrospective nature of studies addressing this area, an international consensus is necessary to approach this clinical scenario uniformly.
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Affiliation(s)
| | - Fernando López-Campos
- Department of Radiation Oncology, Hospital Universitario Ramón Y Cajal, Madrid 28034, Spain
- Department of Radiation Oncology, GenesisCare - Hospital Universitario Vithas Madrid La Milagrosa, Madrid 28010, Spain
| | - Felipe Couñago
- Department of Radiation Oncology, GenesisCare - Hospital Universitario Vithas Madrid La Milagrosa, Madrid 28010, Spain
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Bedrikovetski S, Traeger L, Fitzsimmons T, Price TJ, Ruszkiewicz AR, Vather R, Sammour T. Association Between RAS/BRAF Mutations and Complete Response Following Total Neoadjuvant Therapy in Patients with Rectal Cancer: A Prospective Multicentered Study. Ann Surg Oncol 2024; 31:1681-1689. [PMID: 38071720 DOI: 10.1245/s10434-023-14722-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 11/19/2023] [Indexed: 02/08/2024]
Abstract
BACKGROUND The impact of RAS/BRAF mutation on primary response rates after total neoadjuvant therapy (TNT) in patients with advanced rectal cancer is unclear. The aim of this study was to assess complete response rates after TNT according to RAS/BRAF mutation status. METHODS A prospective observational study was performed in patients with rectal cancer who underwent TNT with curative intent at three South Australian hospitals between 2019 and 2023. Patients were classified according to their mutation status: mutant RAS/BRAF (mutRAS) or wild-type RAS/BRAF (wtRAS). The primary endpoint was overall complete response (oCR) rate, defined as the proportion of patients who achieved clinical complete response (cCR) and/or pathological complete response (pCR). RESULTS Of the 150 patients eligible for inclusion, 80 patients with RAS/BRAF status available were identified. Of these, 43 (53.8%) patients were classified as mutRAS and 37 (46.3%) patients as wtRAS. Patients with mutRAS had significantly lower cCR and oCR rates after TNT than patients with wtRAS (14% vs. 37.8%, p = 0.014; 11.6% vs. 43.2%, p = 0.001, respectively). There was no significant difference in pCR rate between the groups. Of the 80 rectal cancer patients tested, 35 (43.8%) had metastatic disease (M1). There was no significant difference in complete M1 response rates between the groups (17.6% vs. 38.9%, p = 0.254). CONCLUSION RAS/BRAF mutations negatively impact primary tumor response rates after TNT in patients with advanced rectal cancer. Large-scale national studies are needed to determine whether RAS/BRAF status could be used to select optimal oncologic therapy in rectal cancer patients.
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Affiliation(s)
- Sergei Bedrikovetski
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, SA, Australia.
| | - Luke Traeger
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, SA, Australia
- Discipline of Surgery, Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, Adelaide, SA, Australia
| | - Tracy Fitzsimmons
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, SA, Australia
- Discipline of Surgery, Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, Adelaide, SA, Australia
| | - Timothy J Price
- Department of Medical Oncology, The Queen Elizabeth Hospital, Adelaide, SA, Australia
| | - Andrew R Ruszkiewicz
- Centre for Cancer Biology, University of South Australia and SA Pathology, Adelaide, SA, Australia
- Surgical Pathology, SA Pathology, Adelaide, SA, Australia
| | - Ryash Vather
- Discipline of Surgery, Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, Adelaide, SA, Australia
- Centre for Cancer Biology, University of South Australia and SA Pathology, Adelaide, SA, Australia
| | - Tarik Sammour
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, SA, Australia
- Discipline of Surgery, Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, Adelaide, SA, Australia
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Romero Zoghbi SE, Martín Martín M, García JC, Valero M, Rincón D, Peña Huertas M, Fusco JP, López E, Zafra J, Fernández Luengas D, López Campos F, Couñago F. Total Neoadjuvant Therapy Approach for the Treatment of Locally Advanced Rectal Cancer: Where Do We Stand? Oncology 2023; 102:646-658. [PMID: 37935161 PMCID: PMC11216349 DOI: 10.1159/000534888] [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: 08/21/2023] [Accepted: 10/27/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND For the management of locally advanced rectal cancer (LARC), initial treatment with neoadjuvant chemoradiotherapy followed by surgery and chemotherapy in selected patients is considered one of the recommended options by the main international clinical guidelines. Nonetheless, the administration of all chemotherapy before definitive treatment (total neoadjuvant therapy [TNT]) is an optimal alternative with a growing level of evidence that must be evaluated in multidisciplinary boards. This review summarizes the available data and controversies in this scenario. SUMMARY We have analyzed the characteristics of the main published studies that assess the use of TNT in patients with LARC, evaluating their inclusion criteria and distinguishing between the employed radiotherapy fractionations, systemic agents, timing, and the implications of these treatments with regard to surgery and long-term oncological results. Our aim was to describe the evidence that supports the use of a specific regime in everyday clinical practice. KEY POINTS There is solid evidence for the use of TNT in patients with LARC. There are no data indicating the superiority of one specific TNT scheme among all the existing options. International clinical guidelines leave the door open to choose the most adequate treatment based on the clinical and pathological characteristics of each patient. This review shows the different approaches to TNT and assesses the best options based on clinical evidence.
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Affiliation(s)
| | | | - Juan Carlos García
- Department of General and Digestive Surgery, Hospital Universitario Ramón y Cajal, Madrid,Spain
| | - Mireia Valero
- Department of Radiation Oncology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Diego Rincón
- Department of Radiation Oncology, GenesisCare, Hospital Universitario Vithas Madrid La Milagrosa, Madrid, Spain
| | - Marina Peña Huertas
- Department of Radiation Oncology, Hospital Universitario Quirónsalud, Madrid, Spain
| | - Juan Pablo Fusco
- Department of Medical Oncology, Hospital Universitario La Luz, Madrid, Spain
| | - Escarlata López
- Department of Radiation Oncology, GenesisCare, Hospital Universitario Vithas Madrid La Milagrosa, Madrid, Spain
| | - Juan Zafra
- Department of Radiation Oncology, Hospital Clínico Universitario Virgen de la Victoria, Málaga, Spain
- Group of Translational Research in Cancer Immunotherapy (CIMO 2), Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
| | - David Fernández Luengas
- Department of General and Digestive Surgery, Hospital Universitario Quirónsalud, Madrid, Spain
| | - Fernando López Campos
- Department of Radiation Oncology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Felipe Couñago
- Department of Radiation Oncology, GenesisCare, Hospital Universitario Vithas Madrid La Milagrosa, Madrid, Spain
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Zhang S, Li N, Wang F, Liu H, Zhang Y, Xiao J, Qiu W, Zhang C, Fan X, Qiu M, Li M, Tang H, Fan S, Wang J, Luo H, Li X, Lin J, Huang Y, Liang L. Characterization of the tumor microenvironment and identification of spatially predictive biomarkers associated with beneficial neoadjuvant chemoradiotherapy in locally advanced rectal cancer. Pharmacol Res 2023; 197:106974. [PMID: 37898442 DOI: 10.1016/j.phrs.2023.106974] [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] [Received: 08/26/2023] [Revised: 10/11/2023] [Accepted: 10/25/2023] [Indexed: 10/30/2023]
Abstract
Neoadjuvant chemoradiotherapy (nCRT) has become the standard treatment for patients with locally advanced rectal cancer (LARC). However, 20-40% of patients with LARC show little to no response to nCRT. Thus, comprehensively understanding the tumor microenvironment (TME), which might influence therapeutic efficacy, and identifying robust predictive biomarkers is urgently needed. Pre-treatment tumor biopsy specimens from patients with LARC were evaluated in detail through digital spatial profiling (DSP), public RNA sequencing datasets, and multiplex immunofluorescence (mIF). DSP analysis revealed distinct characteristics of the tumor stroma compared to the normal stroma and tumor compartments. We identified high levels of human leukocyte antigen-DR/major histocompatibility complex class II (HLA-DR/MHC-II) in the tumor compartment and B cells in the stroma as potential spatial predictors of nCRT efficacy in the Discovery cohort. Public datasets validated their predictive capacity for clinical outcomes. Using mIF in an independent nCRT cohort and/or the total cohort, we validated that a high density of HLA-DR/MHC-II+ cells in the tumor and CD20 + B cells in the stroma was associated with nCRT efficacy (all p ≤ 0.021). Spatial profiling successfully characterized the LARC TME and identified robust biomarkers with the potential to accurately predict nCRT response. These findings have important implications for individualized therapy.
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Affiliation(s)
- Shifen Zhang
- Department of Pathology, Nanfang Hospital/School of Basic Medical Sciences, Southern Medical University, Guangzhou 510515, China; Guangdong Province Key Laboratory of Molecular Tumor Pathology, Guangzhou 510515, China; Department of Pathology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen 518020, China
| | - Na Li
- Shenzhen Engineering Center for Translational Medicine of Precision Cancer Immunodiagnosis and Therapy, YuceBio Technology Co., Ltd, Shenzhen 518000, China.
| | - Feifei Wang
- Department of Pathology, Nanfang Hospital/School of Basic Medical Sciences, Southern Medical University, Guangzhou 510515, China; Guangdong Province Key Laboratory of Molecular Tumor Pathology, Guangzhou 510515, China
| | - Hailing Liu
- Department of Pathology, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, China
| | - Yuhan Zhang
- Shenzhen Engineering Center for Translational Medicine of Precision Cancer Immunodiagnosis and Therapy, YuceBio Technology Co., Ltd, Shenzhen 518000, China
| | - Jinyuan Xiao
- Shenzhen Engineering Center for Translational Medicine of Precision Cancer Immunodiagnosis and Therapy, YuceBio Technology Co., Ltd, Shenzhen 518000, China
| | - Weihao Qiu
- Department of Pathology, Nanfang Hospital/School of Basic Medical Sciences, Southern Medical University, Guangzhou 510515, China; Guangdong Province Key Laboratory of Molecular Tumor Pathology, Guangzhou 510515, China
| | - Ceng Zhang
- Department of Pathology, Nanfang Hospital/School of Basic Medical Sciences, Southern Medical University, Guangzhou 510515, China; Guangdong Province Key Laboratory of Molecular Tumor Pathology, Guangzhou 510515, China
| | - Xinjuan Fan
- Department of Pathology, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, China
| | - Mingxin Qiu
- Department of Pathology, Nanfang Hospital/School of Basic Medical Sciences, Southern Medical University, Guangzhou 510515, China; Guangdong Province Key Laboratory of Molecular Tumor Pathology, Guangzhou 510515, China
| | - Mingzhou Li
- Department of Pathology, Nanfang Hospital/School of Basic Medical Sciences, Southern Medical University, Guangzhou 510515, China; Guangdong Province Key Laboratory of Molecular Tumor Pathology, Guangzhou 510515, China
| | - Hongzhen Tang
- Shenzhen Engineering Center for Translational Medicine of Precision Cancer Immunodiagnosis and Therapy, YuceBio Technology Co., Ltd, Shenzhen 518000, China
| | - Shiheng Fan
- Shenzhen Engineering Center for Translational Medicine of Precision Cancer Immunodiagnosis and Therapy, YuceBio Technology Co., Ltd, Shenzhen 518000, China
| | - Jiaqian Wang
- Shenzhen Engineering Center for Translational Medicine of Precision Cancer Immunodiagnosis and Therapy, YuceBio Technology Co., Ltd, Shenzhen 518000, China
| | - Haitao Luo
- Shenzhen Engineering Center for Translational Medicine of Precision Cancer Immunodiagnosis and Therapy, YuceBio Technology Co., Ltd, Shenzhen 518000, China
| | - Xiangzhao Li
- Department of Pathology, Nanfang Hospital/School of Basic Medical Sciences, Southern Medical University, Guangzhou 510515, China; Guangdong Province Key Laboratory of Molecular Tumor Pathology, Guangzhou 510515, China
| | - Jie Lin
- Department of Pathology, Nanfang Hospital/School of Basic Medical Sciences, Southern Medical University, Guangzhou 510515, China; Guangdong Province Key Laboratory of Molecular Tumor Pathology, Guangzhou 510515, China; Jinfeng Laboratory, Chongqing 401329, China
| | - Yan Huang
- Department of Pathology, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, China.
| | - Li Liang
- Department of Pathology, Nanfang Hospital/School of Basic Medical Sciences, Southern Medical University, Guangzhou 510515, China; Guangdong Province Key Laboratory of Molecular Tumor Pathology, Guangzhou 510515, China; Jinfeng Laboratory, Chongqing 401329, China.
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