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McMahon RK, O'Cathail SM, Nair H, Steele CW, Platt JJ, Digby M, McDonald AC, Horgan PG, Roxburgh CSD. The neoadjuvant rectal score and a novel magnetic resonance imaging based neoadjuvant rectal score are stage independent predictors of long-term outcome in locally advanced rectal cancer. Colorectal Dis 2023; 25:1783-1794. [PMID: 37485654 DOI: 10.1111/codi.16667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 04/24/2023] [Accepted: 06/25/2023] [Indexed: 07/25/2023]
Abstract
AIM Neoadjuvant rectal (NAR) score is an early surrogate for longer-term outcomes in rectal cancer undergoing radiotherapy and resection. In an era of increasing organ preservation, resection specimens are not always available to calculate the NAR score. Post-treatment magnetic resonance imaging (MRI) re-staging of regression is subjective, limiting reproducibility. We explored the potential for a novel MRI-based NAR score (mrNAR) adapted from the NAR formula. METHODS Locally advanced rectal cancer patients undergoing neoadjuvant therapy (nCRT) and surgery were retrospectively identified between 2008 and 2020 in a single cancer network. mrNAR was calculated by adapting the NAR formula, replacing pathological (p) stages with post-nCRT MR stages (ymr). Cox regression assessed relationships between clinicopathological characteristics, NAR and mrNAR with overall survival (OS) and recurrence-free survival (RFS). RESULTS In total, 381 NAR and 177 mrNAR scores were calculated. On univariate analysis NAR related to OS (hazard ratio [HR] 2.05, 95% confidence interval [CI] 1.33-3.14, p = 0.001) and RFS (HR 2.52, 95% CI 1.77-3.59, p = 0.001). NAR 3-year OS <8 was 95.3%, 8-16 was 88.6% and >16 was 80%. mrNAR related to OS (HR 2.96, 95% CI 1.38-6.34, p = 0.005) and RFS (HR 2.99, 95% CI 1.49-6.00, p = 0.002). 3-year OS for mrNAR <8 was 96.2%, 8-16 was 92.4% and >16 was 78%. On multivariate analysis, mrNAR was a stage-independent predictor of OS and RFS. mrNAR corresponded to NAR score category in only 15% (positive predictive value 0.23) and 47.5% (positive predictive value 0.48) of cases for categories <8 and >16, respectively. CONCLUSIONS Neoadjuvant rectal score is validated as a surrogate end-point for long-term outcomes. mrNAR categories do not correlate with NAR but have stage-independent prognostic value. mrNAR may represent a novel surrogate end-point for future neoadjuvant treatments that focus on organ preservation.
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Affiliation(s)
- Ross K McMahon
- Academic Unit of Surgery, School of Cancer Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Sean M O'Cathail
- Wolfson Wohl Cancer Research Centre, School of Cancer Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Harikrishnan Nair
- Academic Unit of Surgery, School of Cancer Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Colin W Steele
- Academic Unit of Surgery, School of Cancer Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Jonathan J Platt
- Radiology/Imaging Department, Glasgow Royal Infirmary, Glasgow, UK
| | - Michael Digby
- Radiology/Imaging Department, Glasgow Royal Infirmary, Glasgow, UK
| | - Alec C McDonald
- Department of Clinical Oncology, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Paul G Horgan
- Academic Unit of Surgery, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Campbell S D Roxburgh
- Academic Unit of Surgery, School of Cancer Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
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Wang G, Tang Z, Ye J, Tang H, Yao K, Zeng Q, Yang Y, Fu M, Luo L, Shen Q, Fang X, Ling B, Fang Y, Guo Y, Huang Y. Development and validation of neoadjuvant rectal score-based signature nomograms to predict overall survival and disease-free survival in locally advanced rectal cancer: a retrospective, double center, cohort study. Int J Clin Oncol 2023; 28:268-79. [PMID: 36534264 DOI: 10.1007/s10147-022-02281-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 12/08/2022] [Indexed: 12/23/2022]
Abstract
AIM To evaluate the prognostic significance of the NAR score and develop nomograms for locally advanced rectal cancer (LARC) treated after neoadjuvant chemo-radiotherapy (nCRT) combined with total meso-rectal excision (TME) surgery to predict prognostic. METHODS Retrospective collection among LARC patients treated at Fujian Medical University Union Hospital (training cohort) and Fujian Medical University Affiliated Zhangzhou Hospital (external validation cohort) between Jan 10, 2011 and Dec 28, 2021. The NAR score was calculated by formula: [5pN-3(cT-pT) + 12]^2/9.61. NAR score low (< 8), intermediate (8-16), and high (> 16). RESULTS 1665 patients in the training cohort and 256 patients in the external validation cohorts were enrolled. Lower NAR score was significantly associated with better cumulative incidence of OS, DFS, local recurrence (LR), and distant metastasis (DM) (all P < 0.001). Multivariate Cox regression analysis indicates that NAR score, distance to the anal verge, no.253 LN metastasis, post-CRT carbohydrate antigen 19-9, tumor regression grade, and surgery method are independent predictors of OS and DFS (all P < 0.001). Among these independent factors, the NAR score had the highest area under the curve (AUC) and the nomograms to predict OS and DFS were generated. The AUCs for the accuracy of the prediction OS were 1 year = 0.742, 3 years = 0.749, 5 years = 0.713; prediction DFS were 1 year = 0.727, 3 years = 0.739, 5 years = 0.718, the models have good accuracy. CONCLUSIONS The NAR score can effectively classify patients with LARC into groups with varying outcomes of OS, DFS, LR, and DM. Moreover, the novel nomograms comprising the NAR score were developed and validated to help predict OS and DFS.
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Naffouje SA, Manguso N, Imanirad I, Sahin IH, Xie H, Hoffe S, Frakes J, Sanchez J, Dessureault S, Felder S. Neoadjuvant rectal score is prognostic for survival: A population-based propensity-matched analysis. J Surg Oncol 2022; 126:1219-1231. [PMID: 35916542 DOI: 10.1002/jso.27020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 07/09/2022] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Neoadjuvant rectal (NAR) score may serve as a surrogate short-term endpoint for overall survival (OS) in clinical trials. This study aims to test the NAR score using a large, national cancer registry. METHODS National Cancer Database patients with clinical stage II/III rectal adenocarcinoma (RAC) treated with neoadjuvant chemoradiation (CRT) followed by surgery were selected and divided into low-, intermediate-, and high-NAR subgroups. OS outcomes were analyzed using Kaplan-Meier and logistic regression models. RESULTS A total of 12 452 patients were selected, of which 5071 (40.7%) were in clinical stage II and 7381 (59.3%) were in clinical stage III; 15.2% had pathologic complete response. The mean NAR score was 10.01 ± 10.61. Six thousand nine hundred and forty-one (55.7%) did not receive adjuvant chemotherapy (AC) and were propensity-matched across NAR subgroups (966 in each group). A significant difference in 5-year OS between low-, intermediate-, and high-NAR groups was observed (85% vs. 76% vs. 68%; p < 0.001). Five thousand five hundred and eleven (44.3%) received AC and 1045 triplets were propensity-matched per NAR groups. A significant difference was again observed for 5-year OS (93% vs. 88% vs. 75%; p < 0.001). Logistic regression confirmed NAR strata as a significant predictor of 5-year OS. CONCLUSION NAR score, as a neoadjuvant response measure, is a strong predictor of 5-year OS, regardless of AC receipt in a heterogenous population of locally advanced RAC patients.
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Affiliation(s)
- Samer A Naffouje
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Nicholas Manguso
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Iman Imanirad
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Ibrahim H Sahin
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Hao Xie
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Sarah Hoffe
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Jessica Frakes
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Julian Sanchez
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Sophie Dessureault
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Seth Felder
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida, USA
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Ucar G, Acikgoz Y, Ergun Y, Eren T, Dirikoc M, Esen SA, Yazıcı O, Uncu D, Ozdemir NY. Prognostic and Predictive Value of NAR Score in Gastric Cancer. J Gastrointest Cancer 2020; 52:1054-1060. [PMID: 33064272 DOI: 10.1007/s12029-020-00537-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2020] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Neoadjuvant treatment is a widely accepted approach for locally advanced rectum cancer. Efforts to explore a surrogate endpoint for clinical trials revealed a new prognostic scoring system which is named as neoadjuvant rectal score (NAR) in patients who received neoadjuvant treatment for rectal cancer. MATERIAL AND METHODS 88 patients who met inclusion criteria were included in the study. The optimal cutoff value of the NAR score was 17.6 with 71% sensitivity and 63% specificity. Patients with NAR score > 17.6 (n: 48, 54%) were defined as the high-risk group and those with NAR score ≤ 17.6 (n: 40, 56%) as the low-risk group. RESULT Survival analysis according to the NAR score group (low-risk vs high-risk) revealed that there was a statistically significant difference between groups regarding OS and DFS. The median OS for high-risk patients was 27.3 months (95% CI, 15.0-39.6); it was 76.6 months (47.3-106.0) for low-risk patients (p < 0.0001). The median DFS was 15.1 months (11.8-18.4) for high-risk patients; it was 44.3 months (95% CI, 4.1-84.6) in the low-risk group (p = 0.002). DISCUSSION As a result, we interpreted our findings as supporting data about the utility of NAR score not only as a surrogate endpoint for the clinical trial of rectal cancer but also as a prognostic marker in patients with gastric cancer who received neoadjuvant treatment.
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Affiliation(s)
- Gokhan Ucar
- Medical Oncology, Ankara City Hospital, Ankara, Turkey.
| | - Yusuf Acikgoz
- Medical Oncology, Ankara City Hospital, Ankara, Turkey
| | - Yakup Ergun
- Medical Oncology, Ankara City Hospital, Ankara, Turkey
| | - Tulay Eren
- Medical Oncology, Yıldırım Beyazıt Dışkapı Training and Research Hospital, Ankara, Turkey
| | - Merve Dirikoc
- Medical Oncology, Ankara City Hospital, Ankara, Turkey
| | | | - Ozan Yazıcı
- Medical Oncology, Medicine Faculty of Gazi University, Ankara, Turkey
| | - Dogan Uncu
- Medical Oncology, Ankara City Hospital, Ankara, Turkey
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Mukai T, Uehara K, Aiba T, Ogura A, Tsuzuki T, Tanaka A, Sando M, Ohara N, Sato Y, Hattori N, Nakayama G, Kodera Y, Nagino M. Importance of the neoadjuvant rectal (NAR) score to the outcome of neoadjuvant chemotherapy alone for locally advanced rectal cancer. Surg Today 2020; 50:912-9. [PMID: 31989238 DOI: 10.1007/s00595-020-01964-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 01/10/2020] [Indexed: 12/22/2022]
Abstract
PURPOSE The neoadjuvant rectal (NAR) score is a promising indicator of survival after preoperative chemoradiotherapy for rectal cancer. However, its effectiveness after neoadjuvant chemotherapy (NAC) alone has not been fully investigated. METHODS We analyzed data retrospectively on 61 patients with rectal cancer, who received NAC followed by surgical resection between 2010 and 2015, and evaluated the impact of the NAR score on survival. RESULTS The median NAR score was 14.9. Of the 61 patients, 13, 35, and 13 were classified as having NAR-low (< 8), NAR-intermediate (8-16), and NAR-high (> 16) scores, respectively. The median observation period was 49.0 months. According to the NAR score, the 3-year DFS in the NAR-low group was 100%, which was significantly better than that in the NAR-intermediate (64.8%, p = 0.041), and NAR-high (61.5%, p = 0.018) groups. When the NAR-intermediate and NAR-high groups were investigated as a single high-risk group, the 3-year DFS of the patients who received adjuvant chemotherapy was 88.7%, which was significantly better than that of the patients who did not receive adjuvant chemotherapy (53.3%, p = 0.042). CONCLUSIONS The NAR score may predict the DFS and could serve as a favorable indicator of adjuvant chemotherapy after NAC alone.
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Gelsomino F, Bertolini F, Luppi G, Spallanzani A, Pettorelli E, Reggiani Bonetti L, Meduri B, Manco G, Conte P, Cascinu S. A Dose-finding and Biomarker Evaluation Phase Ib Study of Everolimus in Association With 5-Fluorouracil and Pelvic Radiotherapy as Neoadjuvant Treatment of Locally Advanced Rectal Cancer (E-LARC Study). Clin Colorectal Cancer 2017; 16:410-415.e1. [PMID: 28410832 DOI: 10.1016/j.clcc.2017.03.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 03/16/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND During the past 20 years, considerable improvement has occurred in the treatment of patients with locally advanced rectal cancer (LARC). With the introduction of multimodal treatment, refinements in preclinical staging and improvements in surgical skills, local relapse is no longer the major problem for patients with LARC. However, many patients die of metastatic disease. The present phase Ib study aimed to establish the maximum tolerated dose of everolimus combined with 5-fluorouracil and radiotherapy in patients with LARC. PATIENTS AND METHODS Patients were sequentially assigned to 4 cohorts with an increasing dose of everolimus, starting from 14 days before 5-fluorouracil and radiotherapy and continuing throughout concomitant treatment. The secondary endpoints were the Dworak tumor regression grade, pathologic complete response rate, neoadjuvant rectal score, biomarker assessment (phosphorylated mTOR [mammalian target of rapamycin] protein and phosphorylated-p70S6K protein). RESULTS At the time of this report, 12 patients had been treated, and no dose-limiting toxicity was recorded. The most frequently reported acute toxicities were rectal tenesmus, skin rash, diarrhea, and dysuria. All 12 patients underwent curative R0 resection. Two patients had Dworak tumor regression grade 4 (pathologic complete response). No everolimus-related postoperative complications were observed. No relationship was found between biomarker expression and the clinicopathologic outcomes. CONCLUSION Although the addition of everolimus did not appear to worsen the toxicity of chemoradiation in patients with LARC, evaluation of its activity deserves further investigation in larger clinical trials.
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Affiliation(s)
- Fabio Gelsomino
- Division of Oncology, Department of Oncology and Haematology, University Hospital of Modena, Modena, Italy.
| | - Federica Bertolini
- Division of Oncology, Department of Oncology and Haematology, University Hospital of Modena, Modena, Italy
| | - Gabriele Luppi
- Division of Oncology, Department of Oncology and Haematology, University Hospital of Modena, Modena, Italy
| | - Andrea Spallanzani
- Division of Oncology, Department of Oncology and Haematology, University Hospital of Modena, Modena, Italy
| | - Elisa Pettorelli
- Division of Oncology, Department of Oncology and Haematology, University Hospital of Modena, Modena, Italy
| | - Luca Reggiani Bonetti
- Pathology Unit, Department of Diagnostic Medicine and Public Health, University Hospital of Modena, Modena, Italy
| | - Bruno Meduri
- Division of Radiotherapy, Department of Oncology and Haematology, University Hospital of Modena, Modena, Italy
| | - Gianrocco Manco
- Department of Surgical, Medical, Dental, and Morphological Sciences With Interest in Transplant, Oncological and Regenerative Medicine, University Hospital of Modena, Modena, Italy
| | - Pierfranco Conte
- Division of Medical Oncology 2, Istituto Oncologico Veneto Istituto di Ricovero e Cura a Carattere Scientifico, Padua, Italy
| | - Stefano Cascinu
- Division of Oncology, Department of Oncology and Haematology, University Hospital of Modena, Modena, Italy
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Abstract
The conduct of clinical trials in colorectal cancer has historically relied upon endpoints such as disease-free (DFS) or overall survival (OS). While ideal, these endpoints require long-term follow-up, thus contributing to a slow pace of scientific progress in clinical research. Identification of short-term endpoints to serve as surrogates for DFS and OS would enable more rapid determination of success or failure of an experimental intervention and thus facilitate more scientific discovery and progress leading to clinical practice improvements. In rectal cancer clinical trials, there have been few validated alternatives to DFS and OS, including pathologic complete response (ypCR). The neoadjuvant rectal (NAR) score was developed as a composite short-term endpoint for clinical trials involving neoadjuvant therapy for rectal cancer. The NAR score is based upon variables routinely collected and available to clinical investigators during the conduct of prospective studies. Based upon two independent validation datasets, the NAR score predicts OS in rectal cancer clinical trials better than ypCR. While final dataset validation is ongoing, the NAR score offers an opportunity to incorporate a novel surrogate endpoint into early phase rectal cancer clinical trials.
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Affiliation(s)
- Thomas J. George
- />University of Florida Health Cancer Center, Gainesville, 1600 SW Archer Rd, PO Box 100278, Gainesville, FL 32610 USA
- />NRG Oncology, Four Penn Center, 1600 JFK Blvd, Suite 1020, Philadelphia, PA 19103 USA
| | - Carmen J. Allegra
- />University of Florida Health Cancer Center, Gainesville, 1600 SW Archer Rd, PO Box 100278, Gainesville, FL 32610 USA
- />NRG Oncology, Four Penn Center, 1600 JFK Blvd, Suite 1020, Philadelphia, PA 19103 USA
| | - Greg Yothers
- />University of Pittsburgh, One Sterling Plaza, 201 N Craig St, Ste 350, Pittsburgh, PA 15213 USA
- />NRG Oncology, Four Penn Center, 1600 JFK Blvd, Suite 1020, Philadelphia, PA 19103 USA
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