Risk factors for local recurrence following neoadjuvant chemoradiotherapy for rectal cancers

Predictive Value of the Interaction between CEA and Hemoglobin in Neoadjuvant CCRT Outcomes in Rectal Cancer Patients

The adoption of neoadjuvant concurrent chemoradiotherapy (CCRT) has reshaped the therapeutic landscape, but response prediction remains challenging. This study investigates the interaction between pre-CCRT carcinoembryonic antigen (CEA) and post-CCRT hemoglobin (Hb) levels in predicting the response of locally advanced rectal cancer (LARC) to CCRT. Retrospective data from 93 rectal cancer patients receiving neoadjuvant CCRT were analyzed. Univariate analyses assessed clinical factors associated with tumor regression grade (TRG) and T-stage outcomes. Machine learning identified predictive biomarkers. Interaction effects between CEA and Hb were explored through subgroup analyses. Post-CCRT Hb varied between pre-CCRT CEA groups. The interaction between pre-CCRT CEA and post-CCRT Hb influenced TRG. Males with normal pre-CCRT CEA and anemia showed better treatment responses. Females with elevated pre-CCRT CEA and post-CCRT anemia exhibited poorer responses. The interaction effect between them was significant, indicating that their relationship with TRG was not additive. Inflammatory biomarkers, WBC, neutrophil count, and post-CCRT platelet level correlated with CCRT response. Contrasting with previous findings, anemia was a predictor of better treatment response in males with normal pre-CCRT CEA. The interaction between pre-CCRT CEA and post-CCRT Hb levels predicts the response of LARC to CCRT. CEA, Hb, and sex should be considered when assessing treatment response. Inflammatory biomarkers contribute to response prediction. Understanding these complex relationships can enhance personalized treatment approaches in rectal cancer patients.

Close distal margin is associated with locoregional rectal cancer recurrence: A multicenter study

BACKGROUND AND OBJECTIVES

The importance of the radial margin for rectal cancer resection is well understood. However, surgeons have deemphasized the distal margin, accepting very close distal margins to perform sphincter-preserving surgery. We hypothesized that distal margins < 1 cm would be an independent risk factor for locoregional recurrence. The objective was to determine whether close distal margins are associated with increased locoregional recurrence risk.

METHODS

This was a multi-institutional retrospective cohort study conducted at six academic medical centers including patients who received low anterior resection surgery for primary rectal cancer between 2007 and 2018.

RESULTS

Of 556 low anterior resection patients, the rate of close distal margin was 12.8% (n = 71), and the locoregional recurrence rate was 5.0% (n = 28). The locoregional recurrence rate for close distal margin cases was 9.9% (n = 7) compared to 4.3% (n = 21) for distal margins ≥1.0 cm. In multivariable analysis, the only factor significantly associated with locoregional recurrence was close distal margin (adjusted odds ratio: 2.80, confidence interval: 1.08-7.25, p = 0.035).

CONCLUSIONS

Rectal cancer patients with close distal margins (<1 cm) following low anterior resection had a significantly higher risk for locoregional recurrence. Therefore, the decision to perform low anterior resection with margins < 1 cm should be taken with caution.

Combination of Changes in CEA and CA199 Concentration After Neoadjuvant Chemoradiotherapy Could Predict the Prognosis of Stage II/III Rectal Cancer Patients Receiving Neoadjuvant Chemoradiotherapy Followed by Total Mesorectal Excision

Background

Previous studies have shown that the levels of serum tumor markers CEA and CA19-9 were related to chemoradiotherapy. Therefore, it has been assumed that dynamic monitoring of these markers could predict the prognosis of stage II/III rectal cancer (RC). Therefore, this study proposed to evaluate the prognostic value of changes in serum tumor biomarkers for stage II/III RC patients undergoing neoadjuvant chemoradiotherapy (NCRT) followed by total mesorectal excision (TME).

Methods

A total of 217 patients with stage II/III RC receiving NCRT followed by TME were retrospectively analyzed. Serum CEA and CA199 levels were measured within one week before NCRT and one week before TME. The optimal cut-off points of ∆CEA% and ∆CA199% for prognosis prediction were calculated by receiver operating characteristics (ROC) analysis. Independent prognostic predictors were identified by univariate and multivariate Cox regression analyses. To avoid the efficiency of ∆CEA% and ∆CA199% on serum tumor biomarker change (STBC) score, two models including and excluding ∆CEA% and ∆CA199% were established separately in multivariate analysis.

Results

The optimal cut-off point for ∆CEA% and ∆CA199% were −30.29% and 20.30%, respectively. Univariate analysis showed that ∆CEA%, ∆CA199%, STBC score, ypT staging and yN staging could predict OS. ypT staging and STBC score could predict DFS. In multivariate analysis, only ∆CA199% (HR = 0.468, 95% CI: 0.220–0.994, p = 0.048), ypT staging (HR = 0.420, 95% CI: 0.182–0.970, p = 0.042), and STBC score (HR = 0.204, 95% CI: 0.078–0.532, p = 0.001) were independently related to OS; and STBC score (HR = 0.412, 95% CI: 0.216–0.785, p=0.007) and ypT staging (HR = 0.421, 95% CI: 0.224–0.792, p = 0.007) were independently related to DFS.

Conclusion

We established a combined STBC score to predict the prognosis of stage II/III RC patients receiving NCRT followed by TME. The predictive value of the combined score was stronger than a single marker alone and even stronger than several pathological indicators.

Surgical treatment of locally recurrent rectal cancer: a narrative review

Objective

To summarize the recent literature on surgical treatment of locally recurrent rectal cancer (LRRC).

Background

LRRC is a heterogeneous disease that requires a multidisciplinary treatment approach. The treatment and prognosis depend on the site and type of recurrence. Radical resection remains the primary method for achieving long-term survival and improving symptom control. Preoperative chemoradiotherapy can reduce tumor volume and improve the R0 resection rate. Surgeons must clearly understand pelvic anatomy, develop a detailed preoperative plan, adopt a multidisciplinary approach for the surgical resection of the tumor as well as any invaded soft tissues, vessels, and bones, and ensure proper reconstruction. However, extended radical surgery often leads to a higher risk of postoperative complications and a low quality of life.

Methods

We searched English-language articles with keywords “locally recurrent rectal cancer”, “surgery” and “multidisciplinary team” in PubMed published between January 2000 to October 2020.

Conclusions

LRRC is a complex problem. Long-term survival is not impossible following multidisciplinary treatment in appropriately selected LRRC patients. The management of LRRC relies on a specialist team that determines the biological behavior of the tumor and evaluates treatment options through multidisciplinary discussions, thereby balancing the surgical costs and benefits, alleviating postoperative complications, and improving patients’ quality of life.

Factors predicting recurrence after curative resection for rectal cancer: a 16-year study

BACKGROUND

The recurrence after curative surgery of the rectal adenocarcinoma is a serious complication, considered as a failure of the therapeutic strategy. The aim of this study was to identify the different prognostic factors affecting the recurrence of adenocarcinoma of the rectum.

METHODS

A retrospective analysis of patients operated for adenocarcinoma of the rectum between January 2000 and December 2015 was conducted. The study of the recurrence rate and prognostic factors was performed through the Kaplan Meier survival curve and the Cox regression analysis.

RESULTS

During the study period, 188 patients underwent curative surgery for rectal adenocarcinoma, among which 53 had a recurrence. The recurrence rate was 44.6% at 5 years. The multivariate analysis identified four parameters independently associated with the risk of recurrence after curative surgery: a distal margin ≤ 2 cm (HR = 6.8, 95% CI 2.7-16.6, 6), extracapsular invasion of lymph node metastasis (HR = 4.4, 95% CI 1.3-14), tumor stenosis (HR = 4.3, 95% CI 1.2-15.2), and parietal invasion (pT3/T4 disease) (HR = 3, 95% CI 1.1-9.4).

CONCLUSION

The determination of the prognostic factors affecting the recurrence of rectal adenocarcinoma after curative surgery allows us to define the high-risk patients for recurrence.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03899870 . Registered on 2 February 2019, retrospectively registered.

Pathologic response grade after long-course neoadjuvant chemoradiation does not influence morbidity in locally advanced mid-low rectal cancer resected by laparoscopy

PURPOSE

Patients with locally advanced rectal cancer and pathologic complete response to neoadjuvant chemoradiation therapy have lower rates of recurrence compared to those who do not. However, the influences of the pathologic response on surgical complications and survival remain unclear. This study aimed to investigate the influence of neoadjuvant therapy for rectal cancer on postoperative morbidity and long-term survival.

METHODS

This was a comparative study of consecutive patients who underwent laparoscopic total mesorectal excision for rectal cancer in two European tertiary hospitals between 2004 and 2014. Patients with and without pathologic complete responses were compared in terms of postoperative morbidity, mortality, and survival.

RESULTS

Fifty patients with complete response (ypT0N0) were compared with 141 patients who exhibited non-complete response. No group differences were observed in the postoperative mortality or morbidity rates. The median follow-up time was 57 months (range 1-121). Over this period, 11 (5.8 %) patients, all of whom were in the non-complete response group, exhibited local recurrence. The 5-year overall survival and disease-free survival were significantly better in the complete response group, 92.5 vs. 75.3 % (p = 0.004) and 89 vs. 73.4 % (p = 0.002), respectively.

CONCLUSIONS

Postoperative complication rate after laparoscopic total mesorectal excision is not associated with the pathologic response grade to neoadjuvant chemoradiation therapy.

Focal adhesion kinase: predictor of tumour response and risk factor for recurrence after neoadjuvant chemoradiation in rectal cancer

Rectal cancer represents about 30% of colorectal cancers, being around 50% locally advanced at presentation. Chemoradiation (CRT) followed by total mesorectal excision is the standard of care for these locally advanced stages. However, it is not free of adverse effects and toxicity and the complete pathologic response rate is between 10% and 30%. This makes it extremely important to define factors that can predict response to this therapy. Focal adhesion kinase (FAK) expression has been correlated with worse prognosis in several tumours and its possible involvement in cancer radio‐ and chemosensitivity has been suggested; however, its role in rectal cancer has not been analysed yet. To analyse the association of FAK expression with tumour response to CRT in locally advanced rectal cancer. This study includes 73 patients with locally advanced rectal cancer receiving standard neoadjuvant CRT followed by total mesorectal excision. Focal adhesion kinase protein levels were immunohistochemically analysed in the pre‐treatment biopsies of these patients and correlated with tumour response to CRT and patients survival. Low FAK expression was significantly correlated with local and distant recurrence (P = 0.013). Low FAK expression was found to be a predictive marker of tumour response to neoadjuvant therapy (P = 0.007) and patients whose tumours did not express FAK showed a strong association with lower disease‐free survival (P = 0.01). Focal adhesion kinase expression predicts neoadjuvant CRT response in rectal cancer patients and it is a clinically relevant risk factor for local and distant recurrence.

Laparoscopic salvage lateral pelvic lymph node dissection for locally recurrent rectal cancer

AIM

The lateral pelvic lymph nodes are one of the major sites and sources of local recurrence (LR) after surgery for rectal cancer. Salvage lateral pelvic lymph node dissection (LPLD) is potentially curative, but the value of laparoscopic surgery in such cases is unknown. Our aim was to report the technical details of laparoscopic salvage LPLD for LR at these nodes after rectal cancer surgery.

METHOD

The study was based on nine patients who underwent laparoscopic salvage LPLD for LR at the lateral pelvic lymph nodes after surgery for rectal cancer. The safety and feasibility of this procedure were determined.

RESULTS

The median operation time was 381 min and the median estimated blood loss was 130 ml. There were no conversions. Adjacent structures removed en bloc were the pelvic plexus in four patients, the internal iliac artery in seven patients and the seminal vesicle in one patient. The median number of metastatic lymph nodes was 1 (range 1-11).

CONCLUSION

Our novel technique of laparoscopic salvage LPLD for LR at the lateral pelvic lymph nodes is safe and feasible.

Association between irrigation fluids, washout volumes and risk of local recurrence of anterior resection for rectal cancer: a meta-analysis of 427 cases and 492 controls

BACKGROUND

Rectal washout can prevent local recurrence after anterior resection of rectal cancer. Few studies have focused particularly on the association between irrigation fluids volume or agents and the risk of local recurrence after anterior resection of rectal cancer.

OBJECTIVE

To estimate the association between irrigation fluids types, volumes of rectal washout and risk of local recurrence after anterior resection for cancer.

DATA SOURCES

Relevant studies were identified by a search of Medline, Embase, Wiley Online Library, China National Knowledge Infrastructure, Cochrane Oral Health Group Specialized Register, Wanfang databases and Google Website from their inception until October 18,2013.

STUDY SELECTION

Studies reporting the association between rectal washout types and volumes and risk of local recurrence after anterior resection for cancer were included.

INTERVENTIONS

Eligible studies used rectal washout. Control groups were defined as no washout.

STUDY APPRAISAL AND SYNTHESIS METHODS

Random-effects model were used to obtain summary estimates of RR and 95% CI, with Stata version 11 and RevMan 5.2.5 softwares used. The quality of report was appraised in reference to the MINORS item.

RESULTS

Of the 919 rectal cancer patients in 8 included studies, a total of 61(6.64%) cases of local recurrence were reported, with a pooled RR 0.51 (95%CI = 0.28-0.92, P = 0.03). The RRs 0.37 and 0.39 in normal saline and washout volume (≥ 1500 ml normal saline) subgroup, respectively, indicated that rectal washout with normal saline, or ≥ 1500 ml in volume could significantly reduce local recurrence (LR) rate (95% CI = 0.17-0.79, P = 0.01; 95% CI = 0.18-0.87, P = 0.02) after anterior resection for cancer.

LIMITATION

The included studies were non-randomized observational studies, with diversity of study designs.

CONCLUSION

Rectal washout with normal saline alone can reduce the risk of local recurrence in patients with resectable rectal cancer, and 1.5 liters rectal washout in volume is recommended.

Association between irrigation fluids, washout volumes and risk of local recurrence of anterior resection for rectal cancer: a meta-analysis of 427 cases and 492 controls

BACKGROUND

Rectal washout can prevent local recurrence after anterior resection of rectal cancer. Few studies have focused particularly on the association between irrigation fluids volume or agents and the risk of local recurrence after anterior resection of rectal cancer.

OBJECTIVE

To estimate the association between irrigation fluids types, volumes of rectal washout and risk of local recurrence after anterior resection for cancer.

DATA SOURCES

Relevant studies were identified by a search of Medline, Embase, Wiley Online Library, China National Knowledge Infrastructure, Cochrane Oral Health Group Specialized Register, Wanfang databases and Google Website from their inception until October 18,2013.

STUDY SELECTION

Studies reporting the association between rectal washout types and volumes and risk of local recurrence after anterior resection for cancer were included.

INTERVENTIONS

Eligible studies used rectal washout. Control groups were defined as no washout.

STUDY APPRAISAL AND SYNTHESIS METHODS

Random-effects model were used to obtain summary estimates of RR and 95% CI, with Stata version 11 and RevMan 5.2.5 softwares used. The quality of report was appraised in reference to the MINORS item.

RESULTS

Of the 919 rectal cancer patients in 8 included studies, a total of 61(6.64%) cases of local recurrence were reported, with a pooled RR 0.51 (95%CI = 0.28-0.92, P = 0.03). The RRs 0.37 and 0.39 in normal saline and washout volume (≥ 1500 ml normal saline) subgroup, respectively, indicated that rectal washout with normal saline, or ≥ 1500 ml in volume could significantly reduce local recurrence (LR) rate (95% CI = 0.17-0.79, P = 0.01; 95% CI = 0.18-0.87, P = 0.02) after anterior resection for cancer.

LIMITATION

The included studies were non-randomized observational studies, with diversity of study designs.

CONCLUSION

Rectal washout with normal saline alone can reduce the risk of local recurrence in patients with resectable rectal cancer, and 1.5 liters rectal washout in volume is recommended.

Systematic review and meta-analysis of rectal washout on risk of local recurrence for cancer

BACKGROUND

It has been shown that intraluminal washout (WO) can prevent local recurrence (LR) of rectal cancer. This meta-analysis was to evaluate the association of rectal WO and the risk of LR after anterior resection in patients with rectal cancer.

METHODS

The relevant studies were identified by a search of the MEDLINE, Embase, Wiley Online Library, and Cochrane Oral Health Group Specialized Register with no restrictions on October 18, 2013, and these studies were included in a systematic review and meta-analysis. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated in fixed effects model.

RESULTS

A total of nine studies were included in our study, yielding a total of 5519 patients, and pooled ORs for overall LR in corresponding subgroups were calculated. Rectal WO was associated with a lower risk for LR (240/4176, 5.75% versus 9.75%, 131/1343, OR = 0.53, 95% CI = 0.42-0.68, and P < 0.00001) in patients with anterior resection, having total mesorectal excisions (234/3942, 5.93% versus 9.34%, 97/1039, OR = 0.59, 95% CI = 0.46-0.75, and P < 0.00001), and after radical resection (RR; 122/2665, 4.99% versus 8.90%, 74/831, OR = 0.56, 95% CI = 0.41-0.78, and P = 0.0005), with an overall LR rate of 6.72% (371/5519). But, the stability of RRs is not high in the total mesorectal excisions or RR subgroup by sensitivity analysis.

CONCLUSIONS

The use of rectal WO decreases risks of LR in patients after anterior resection of cancer.