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Williams H, Thompson HM, Lin ST, Verheij FS, Omer DM, Qin LX, Garcia-Aguilar J. Endoscopic Predictors of Residual Tumor After Total Neoadjuvant Therapy: A Post Hoc Analysis From the Organ Preservation in Rectal Adenocarcinoma Trial. Dis Colon Rectum 2024; 67:369-376. [PMID: 38039292 PMCID: PMC10922113 DOI: 10.1097/dcr.0000000000003096] [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] [Indexed: 12/03/2023]
Abstract
BACKGROUND Restaging endoscopy plays a critical role in selecting patients with locally advanced rectal cancer who respond to neoadjuvant therapy for nonoperative management. OBJECTIVE This study evaluated the restaging endoscopic features that best predict the presence of residual tumor in the bowel wall. DESIGN This was a post hoc analysis of a prospective randomized trial. SETTINGS The Organ Preservation in Rectal Adenocarcinoma Trial randomly assigned patients across 18 institutions with stage II/III rectal adenocarcinoma to receive either induction or consolidation total neoadjuvant therapy. Surgeons completed a restaging tumor assessment form, which stratified patients across 3 tiers of clinical response. PATIENTS Patients enrolled in the Organ Preservation in Rectal Adenocarcinoma Trial with a completed tumor assessment form were included. MAIN OUTCOME MEASURES The main outcome was residual tumor, which was defined as either an incomplete clinical response or local tumor regrowth within 2 years of restaging. Independent predictors of residual tumor were identified using backward-selected multivariable logistic regression analysis. Subgroup analyses for complete and near complete clinical responders were performed. RESULTS Surgeons completed restaging forms for 263 patients at a median of 7.7 weeks after neoadjuvant therapy; 128 patients (48.7%) had a residual tumor. On multivariable regression analysis, several characteristics of a near complete response, including ulcer (OR 6.66; 95% CI, 2.54-19.9), irregular mucosa (OR 3.66; 95% CI, 1.61-8.68), and nodularity (OR 2.96; 95% CI, 1.36-6.58), remained independent predictors of residual tumor. A flat scar was associated with lower odds of harboring residual disease (OR 0.32; 95% CI, 0.11-0.93) for patients categorized as clinical complete responders. LIMITATIONS Limitations include analysis of endoscopic features at a single time point and ambiguities in tumor assessment form response criteria. CONCLUSIONS Patients with ulcer, nodularity, or irregular mucosa, on restaging endoscopy have higher odds of residual tumor. Recognizing negative prognostic implications of these features will help surgeons better select candidates for nonoperative management and suggests that patients with high-risk characteristics would benefit from close interval surveillance. See Video Abstract . PREDICTORES ENDOSCPICOS DE TUMOR RESIDUAL DESPUS DE TERAPIA NEOADYUVANTE TOTAL UN ANLISIS POST HOC DEL ENSAYO DE PRESERVACIN DE RGANOS EN ADENOCARCINOMA RECTAL ANTECEDENTES:La reestadificación por endoscopia juega un papel crítico en la selección de pacientes con cáncer de recto localmente avanzado que responden a la terapia neoadyuvante para el manejo no quirúrgico.OBJETIVO:Este estudio evaluó las características endoscópicas de reestadificación que mejor predicen la presencia de tumor residual en la pared intestinal.DISEÑO:Este fue un análisis post hoc de un ensayo prospectivo aleatorizado.ESCENARIO:El ensayo Organ Preservation in Rectal Adenocarcinoma aleatorizó a pacientes de 18 instituciones con adenocarcinoma de recto en estadio II/III para recibir terapia neoadyuvante total de inducción o consolidación. Los cirujanos completaron un formulario de reestadificación de evaluación del tumor, que estratificó a los pacientes en tres niveles de respuesta clínica.PACIENTES:Se incluyeron pacientes inscritos en el ensayo de preservación de órganos en adenocarcinoma rectal con un formulario de evaluación del tumor completado.PRINCIPALES MEDIDAS DE RESULTADO:El resultado principal fue presencia de tumor residual, que se definió como una respuesta clínica incompleta o un nuevo crecimiento local del tumor dentro de los dos años posteriores a la reestadificación. Los predictores independientes de tumor residual se identificaron mediante un análisis de regresión logística multivariable seleccionado hacia atrás. Se realizaron análisis de subgrupos para pacientes con respuesta clínica completa y casi completa.RESULTADOS:Los cirujanos completaron formularios de reestadificación para 263 pacientes en una mediana de 7.7 semanas después de la terapia neoadyuvante; 128 (48.7%) tenían tumor residual. En el análisis de regresión multivariable, varias características de una respuesta casi completa, incluyendo úlcera (OR 6.66; IC 95% 2.54-19.9), mucosa irregular (OR 3.66; IC 95% 1.61-8.68) y nodularidad (OR 2.96; IC 95% 1.36 -6.58) siguieron siendo predictores independientes de tumor residual. Una cicatriz plana se asoció con menores probabilidades de albergar enfermedad residual (OR 0.32; IC del 95 %: 0.11-0.93) para los pacientes clasificados como respondedores clínicos completos.LIMITACIONES:Las limitaciones de este estudio incluyen el análisis de las características endoscópicas en un solo momento y las ambigüedades en los criterios de respuesta.en la forma de evaluación del tumorCONCLUSIONES:Los pacientes con úlcera, nodularidad o mucosa irregular en la endoscopia de reestadificación tienen mayores probabilidades de tumor residual. El reconocer las implicaciones pronósticas negativas de estas características ayudará a los cirujanos a seleccionar mejor a los candidatos para el tratamiento no quirúrgico y sugiere que los pacientes con características de alto riesgo se beneficiarían de una vigilancia a intervalos estrechos. (Traducción-Dr. Jorge Silva Velazco ).
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Affiliation(s)
- Hannah Williams
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hannah M. Thompson
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sabrina T. Lin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Floris S. Verheij
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Dana M. Omer
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Li-Xuan Qin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Julio Garcia-Aguilar
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York
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Flom E, Schultz KS, Pantel HJ, Leeds IL. The Predictors of Complete Pathologic Response in Rectal Cancer during the Total Neoadjuvant Therapy Era: A Systematic Review. Cancers (Basel) 2023; 15:5853. [PMID: 38136397 PMCID: PMC10742121 DOI: 10.3390/cancers15245853] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/11/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023] Open
Abstract
The modern rectal cancer treatment paradigm offers additional opportunities for organ preservation, most notably via total neoadjuvant therapy (TNT) and consideration for a watch-and-wait (WW) surveillance-only approach. A major barrier to widespread implementation of a WW approach to rectal cancer is the potential discordance between a clinical complete response (cCR) and a pathologic complete response (pCR). In the pre-TNT era, the identification of predictors of pCR after neoadjuvant therapy had been previously studied. However, the last meta-analysis to assess the summative evidence on this important treatment decision point predates the acceptance and dissemination of TNT strategies. The purpose of this systematic review was to assess preoperative predictors of pCR after TNT to guide the ideal selection criteria for WW in the current era. An exhaustive literature review was performed and the electronic databases Embase, Ovid, MEDLINE, PubMed, and Cochrane were comprehensively searched up to 27 June 2023. Search terms and their combinations included "rectal neoplasms", "total neoadjuvant therapy", and "pathologic complete response". Only studies in English were included. Randomized clinical trials or prospective/retrospective cohort studies of patients with clinical stage 2 or 3 rectal adenocarcinoma who underwent at least 8 weeks of neoadjuvant chemotherapy in addition to chemoradiotherapy with pCR as a measured study outcome were included. In this systematic review, nine studies were reviewed for characteristics positively or negatively associated with pCR or tumor response after TNT. The results were qualitatively grouped into four categories: (1) biochemical factors; (2) clinical factors; (3) patient demographics; and (4) treatment sequence for TNT. The heterogeneity of studies precluded meta-analysis. The level of evidence was low to very low. There is minimal data to support any clinicopathologic factors that either have a negative or positive relationship to pCR and tumor response after TNT. Additional data from long-term trials using TNT is critical to better inform those considering WW approaches following a cCR.
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Affiliation(s)
- Emily Flom
- Division of Colon and Rectal Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT 06520, USA
| | - Kurt S Schultz
- Division of Colon and Rectal Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT 06520, USA
| | - Haddon J Pantel
- Division of Colon and Rectal Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT 06520, USA
| | - Ira L Leeds
- Division of Colon and Rectal Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT 06520, USA
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Gao Y, Wu A. Organ Preservation in MSS Rectal Cancer. Clin Colon Rectal Surg 2023; 36:430-440. [PMID: 37795468 PMCID: PMC10547535 DOI: 10.1055/s-0043-1767710] [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] [Indexed: 10/06/2023]
Abstract
Rectal cancer is a heterogeneous disease with complex genetic and molecular subtypes. Emerging progress of neoadjuvant therapy has led to increased pathological and clinical complete response (cCR) rates for microsatellite stable (MSS) rectal cancer, which responds poorly to immune checkpoint inhibitor alone. As a result, organ preservation of MSS rectal cancer as an alternative to radical surgery has gradually become a feasible option. For patients with cCR or near-cCR after neoadjuvant treatment, organ preservation can be implemented safely with less morbidity. Patient selection can be done either before the neoadjuvant treatment for higher probability or after with careful assessment for a favorable outcome. Those patients who achieved a good clinical response are managed with nonoperative management, organ preservation surgery, or radiation therapy alone followed by strict surveillance. The oncological outcomes of patients with careful selection and organ preservation seem to be noninferior compared with those of radical surgery, with lower postoperative morbidity. However, more studies should be done to seek better regression of tumor and maximize the possibility of organ preservation in MSS rectal cancer.
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Affiliation(s)
- Yuye Gao
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Unit III, Gastrointestinal Cancer Center, Peking University Cancer Hospital and Institute, Beijing, China
| | - Aiwen Wu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Unit III, Gastrointestinal Cancer Center, Peking University Cancer Hospital and Institute, Beijing, China
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Wang J, Zhang L, Wang M, Zhang J, Wang Y, Wan J, Li G, Zhang H, Wang Y, Wu R, Zhang Z, Li X, Xu Y, Zhu J, Shen L, Xia F, Zhang Z. Long-term outcomes in a retrospective cohort of patients with rectal cancer with complete response after total neoadjuvant therapy: a propensity-score weighted analysis. Ther Adv Med Oncol 2023; 15:17588359231197955. [PMID: 37701810 PMCID: PMC10493067 DOI: 10.1177/17588359231197955] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 08/03/2023] [Indexed: 09/14/2023] Open
Abstract
Background The watch-and-wait (W&W) strategy is a novel treatment option for patients with rectal cancer who have a strong desire for organ preservation. The study aimed to explore the long-term outcomes of the W&W strategy in a large cohort of rectal cancer patients who achieved a clinical complete response (cCR) after consolidation total neoadjuvant therapy (TNT), and to compare with patients who achieved a pathological complete response (pCR) after radical surgery. Methods The W&W group comprised patients who were assessed as having a cCR after consolidation TNT and adopted the W&W strategy. Patients who underwent standard resection and achieved a pCR were compared as a reference. Inverse probability of treatment weighting (IPTW)-adjusted Kaplan-Meier analysis with log-rank test was used to compare survival outcomes. Results We included 89 and 171 patients in the W&W and pCR groups, respectively. The median follow-up period was 45 and 58 months for the W&W and pCR groups, respectively. After IPTW adjustment, the 2-year local regrowth/recurrence rate for the W&W and pCR groups were 9.9% and 2.0%, respectively (p < 0.001). The W&W and pCR groups had similar 5-year outcomes, including overall survival, disease-free survival, and distant metastasis-free survival (all p > 0.05). No significant difference was observed in the rates of distant metastasis between patients in the W&W group with local regrowth and those without local regrowth (25% versus 6.2%, p = 0.119). Conclusion Patients who were managed with a W&W strategy after consolidation TNT had favorable survival outcomes, which were similar to those of patients with a pCR. The rate of local regrowth in W&W patients was lower in our study than in other studies as a result of the implementation of consolidation TNT.
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Affiliation(s)
- Jingwen Wang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
| | - Lijie Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
| | - Minghe Wang
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Jing Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
| | - Yaqi Wang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
| | - Juefeng Wan
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, China
- Shanghai Key Laboratory of Radiation Oncology, 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
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
| | - Hui Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
| | - Yan Wang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
| | - Ruiyan Wu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
| | - Zhiyuan Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
| | - Xinxiang Li
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Ye Xu
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Ji Zhu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, China
- Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, China
- Institute of Basic Medicine and Cancer, Chinese Academy of Sciences, Hangzhou, China
- Zhejiang Key Laboratory of Radiation Oncology, Hangzhou, China
| | - Lijun Shen
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, 200032, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Fan Xia
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, 200032, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Zhen Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai, 200032, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
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van der Stel SD, van den Berg JG, Snaebjornsson P, Seignette IM, Witteveen M, Grotenhuis BA, Beets GL, Post AL, Ruers TJM. Size and depth of residual tumor after neoadjuvant chemoradiotherapy in rectal cancer - implications for the development of new imaging modalities for response assessment. Front Oncol 2023; 13:1209732. [PMID: 37736547 PMCID: PMC10509550 DOI: 10.3389/fonc.2023.1209732] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 08/21/2023] [Indexed: 09/23/2023] Open
Abstract
With the shift towards organ preserving treatment strategies in rectal cancer it has become increasingly important to accurately discriminate between a complete and good clinical response after neoadjuvant chemoradiotherapy (CRT). Standard of care imaging techniques such as CT and MRI are well equipped for initial staging of rectal tumors, but discrimination between a good clinical and complete response remains difficult due to their limited ability to detect small residual vital tumor fragments. To identify new promising imaging techniques that could fill this gap, it is crucial to know the size and invasion depth of residual vital tumor tissue since this determines the requirements with regard to the resolution and imaging depth of potential new optical imaging techniques. We analyzed 198 pathology slides from 30 rectal cancer patients with a Mandard tumor regression grade 2 or 3 after CRT that underwent surgery. For each patient we determined response pattern, size of the largest vital tumor fragment or bulk and the shortest distance from the vital tumor to the luminal surface. The response pattern was shrinkage in 14 patients and fragmentation in 16 patients. For both groups combined, the largest vital tumor fragment per patient was smaller than 1mm for 38% of patients, below 0.2mm for 12% of patients and for one patient as small as 0.06mm. For 29% of patients the vital tumor remnant was present within the first 0.01mm from the luminal surface and for 87% within 0.5mm. Our results explain why it is difficult to differentiate between a good clinical and complete response in rectal cancer patients using endoscopy and MRI, since in many patients submillimeter tumor fragments remain below the luminal surface. To detect residual vital tumor tissue in all patients included in this study a technique with a spatial resolution of 0.06mm and an imaging depth of 8.9mm would have been required. Optical imaging techniques offer the possibility of detecting majority of these cases due to the potential of both high-resolution imaging and enhanced contrast between tissue types. These techniques could thus serve as a complimentary tool to conventional methods for rectal cancer response assessment.
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Affiliation(s)
- Stefan D. van der Stel
- Faculty Technische Natuurwetenschappen (TNW), Group Nanobiophysics, Twente University, Enschede, Netherlands
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | - Petur Snaebjornsson
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, Netherlands
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Iris M. Seignette
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Mark Witteveen
- Faculty Technische Natuurwetenschappen (TNW), Group Nanobiophysics, Twente University, Enschede, Netherlands
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | - Geerard L. Beets
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, Netherlands
- GROW School for Oncology and Developmental Biology, University of Maastricht, Maastricht, Netherlands
| | - Anouk L. Post
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, Netherlands
- Department of Biomedical Engineering and Physics, Amsterdam Cardiovascular Sciences, Cancer Center Amsterdam, Amsterdam Universitair Medisch Centrum (UMC), University of Amsterdam, Amsterdam, Netherlands
| | - Theo J. M. Ruers
- Faculty Technische Natuurwetenschappen (TNW), Group Nanobiophysics, Twente University, Enschede, Netherlands
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, Netherlands
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Socha J, Bujko K. The ultimate local failure rate after the watch-and-wait strategy for rectal cancer: a systematic review of literature and meta-analysis. Acta Oncol 2023; 62:1052-1065. [PMID: 37632521 DOI: 10.1080/0284186x.2023.2245553] [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] [Received: 05/12/2023] [Accepted: 08/02/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND We hypothesise that a high rate of tumour regrowth after the watch-and-wait (w&w) strategy may lead, despite salvage surgery, to a significant impairment of ultimate local control compared with immediate surgery. MATERIALS AND METHODS To test this hypothesis, we conducted meta-analyses of studies on the w&w strategy (both opportunistic and planned) with an ultimate local failure rate as an endpoint in three patient groups: (1) in all starting radio(chemo)therapy as potential w&w candidates, (2) in a subgroup starting w&w, and (3) in a subgroup with regrowth. RESULTS We identified eight studies for evaluation of local failure in group 1 (N = 837) and 36 studies in group 2 (N = 1914) and in group 3 (N = 439). The meta-analysis revealed an ultimate local failure rate of 8.0% (95% CI 4.8%-12.1%) in group 1 and 5.4% (95% CI 3.9%-7.1) in group 2. These rates are similar to those reported in the literature following preoperative chemoradiation and surgery. However, in the most unfavourable group 3 (with regrowth), the rate of ultimate local failure was 24.1% (95% CI 17.9%-30.9%), with the most common causes being patients' refusal of salvage total mesorectal excision (TME) (9.1%), recurrence after salvage TME (7.8%), distant metastases (4.1%), frailty (2.4%), and pelvic tumour unresectability (1.7%). CONCLUSION Nearly 25% of patients with regrowth (unfavourable subgroup) experienced ultimate local failure, primarily due to refusing salvage TME. The risk of ultimate local failure in patients initiating radio(chemo)therapy as potential w&w candidates, or in patients starting w&w, appears comparable to that reported after preoperative chemoradiation and surgery. However, this comparison may be biased, because w&w studies included more early tumours compared with surgical studies.
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Affiliation(s)
- Joanna Socha
- Department of Radiotherapy, Military Institute of Medicine - National Research Institute, Warsaw, Poland
- Department of Radiotherapy, Regional Oncology Centre, Częstochowa, Poland
| | - Krzysztof Bujko
- Department of Radiotherapy I, Maria Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
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Li J, Ma Y, Wen L, Zhang G, Yao X. Outcomes after the watch-and-wait strategy and local excision treatment for rectal cancer: a meta-analysis. Expert Rev Anticancer Ther 2023; 23:555-564. [PMID: 36795784 DOI: 10.1080/14737140.2023.2181796] [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] [Indexed: 02/17/2023]
Abstract
BACKGROUND The watch-and-wait (W&W) strategy and local excision (LE) have been used in patients with clinical complete response (cCR) for rectal cancer, but the comparative outcomes of the two strategies are controversial. We compared the efficacy of the W&W strategy with LE for rectal cancer patients after neoadjuvant chemoradiotherapy (nCRT) or total neoadjuvant therapy (TNT). RESEARCH DESIGN AND METHODS Several domestic and foreign databases were searched for the relevant literature on comparative trials of the W&W strategy and LE surgery for rectal cancer after neoadjuvant therapy with the following outcomes; differences in local recurrence (LR), distant metastasis (DM/DM+LR), 3-year disease-free survival (DFS), 3-year local recurrence-free survival (LRFS) and 3-year overall survival (OS). RESULTS Nine articles, were analyzed. Overall, 442 patients were included, with 267 and 175 patients in the W&W and LE groups, respectively. Meta-analysis results showed no significant differences the between W&W and LE groups with respect to LR, DM/DM+LR, 3-year DFS, 3-year LRFS, and 3-year OS. This study has been registered in PROSPERO (registration number: CRD42022331208). CONCLUSION The W&W strategy may be preferred for some rectal cancer patients who select LE and reach cCR or near cCR after nCRT or TNT.
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Affiliation(s)
- Jinghui Li
- Gannan Medical university, Ganzhou, Jiangxi, China.,Ganzhou Hospital of Guangdong Provincial People's Hospital, Ganzhou Municipal Hospital, Ganzhou, Jiangxi, China.,Department of Gastrointestinal Surgery, Department of General Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, PR, China
| | - Yongli Ma
- Gannan Medical university, Ganzhou, Jiangxi, China.,Ganzhou Hospital of Guangdong Provincial People's Hospital, Ganzhou Municipal Hospital, Ganzhou, Jiangxi, China
| | - Liang Wen
- Gannan Medical university, Ganzhou, Jiangxi, China.,Ganzhou Hospital of Guangdong Provincial People's Hospital, Ganzhou Municipal Hospital, Ganzhou, Jiangxi, China.,Department of Gastrointestinal Surgery, Department of General Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, PR, China
| | - Guosheng Zhang
- Gannan Medical university, Ganzhou, Jiangxi, China.,Ganzhou Hospital of Guangdong Provincial People's Hospital, Ganzhou Municipal Hospital, Ganzhou, Jiangxi, China
| | - Xueqing Yao
- Gannan Medical university, Ganzhou, Jiangxi, China.,Ganzhou Hospital of Guangdong Provincial People's Hospital, Ganzhou Municipal Hospital, Ganzhou, Jiangxi, China.,Department of Gastrointestinal Surgery, Department of General Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, PR, China
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Bourbonne V, Schick U, Pradier O, Visvikis D, Metges JP, Badic B. Radiomics Approaches for the Prediction of Pathological Complete Response after Neoadjuvant Treatment in Locally Advanced Rectal Cancer: Ready for Prime Time? Cancers (Basel) 2023; 15. [PMID: 36672381 DOI: 10.3390/cancers15020432] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/03/2023] [Accepted: 01/05/2023] [Indexed: 01/12/2023] Open
Abstract
In recent years, neoadjuvant therapy of locally advanced rectal cancer has seen tremendous modifications. Adding neoadjuvant chemotherapy before or after chemoradiotherapy significantly increases loco-regional disease-free survival, negative surgical margin rates, and complete response rates. The higher complete rate is particularly clinically meaningful given the possibility of organ preservation in this specific sub-population, without compromising overall survival. However, all locally advanced rectal cancer most likely does not benefit from total neoadjuvant therapy (TNT), but experiences higher toxicity rates. Diagnosis of complete response after neoadjuvant therapy is a real challenge, with a risk of false negatives and possible under-treatment. These new therapeutic approaches thus raise the need for better selection tools, enabling a personalized therapeutic approach for each patient. These tools mostly focus on the prediction of the pathological complete response given the clinical impact. In this article, we review the place of different biomarkers (clinical, biological, genomics, transcriptomics, proteomics, and radiomics) as well as their clinical implementation and discuss the most recent trends for future steps in prediction modeling in patients with locally advanced rectal cancer.
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Cooper EA, Hodder RJ, Finlayson A, Filgate R, Coveney A, Balasuriya HD, Warner MW. Cost analysis of a watch-and-wait approach in patients with a complete clinical response to chemoradiotherapy for rectal cancer. ANZ J Surg 2022; 92:2956-2960. [PMID: 35855528 DOI: 10.1111/ans.17914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 03/29/2022] [Revised: 06/29/2022] [Accepted: 07/02/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND There is increasing interest in the watch-and-wait approach for patients with rectal cancer who have had a complete clinical response following neoadjuvant long course chemoradiotherapy. This study is a cost analysis of expenditure on patients in the watch-and-wait program versus patients who underwent standard rectal resection followed by routine surveillance. METHODS Data were prospectively collated and retrospectively analysed in all patients who presented with rectal cancer from January 2016 to January 2018 at Sir Charles Gairdner Hospital, Perth, Western Australia. Software developed by the North Metropolitan Health Service was used to capture comprehensive data to calculate the in-hospital expenditure for an individual patient throughout their treatment journey. RESULTS For a patient enrolled in the watch-and-wait pathway, the total cost of surveillance over a 5-year period was $45 246. This was compared with the cost of an ultra-low anterior resection/loop ileostomy/closure of loop and routine postoperative surveillance which came to a total of $87 473. While a patient who had an abdominoperineal resection followed by routine 5-year surveillance had an expenditure of $82 290. CONCLUSION There is growing evidence that the watch-and-wait strategy is a valid management option. In the cost-conscious environment of the current health care system, the watch-and-wait pathway is a cost-effective and economically advantage treatment.
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Affiliation(s)
- Edward A Cooper
- Department of Colorectal Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Rupert J Hodder
- Department of Colorectal Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,Department of Surgery, Curtin University, Perth, Western Australia, Australia
| | - Andrew Finlayson
- Department of Colorectal Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Rhys Filgate
- Department of Colorectal Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Andrew Coveney
- Department of Colorectal Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Hasitha Dinesh Balasuriya
- Department of Colorectal Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Michael W Warner
- Department of Colorectal Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
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Custers PA, Hupkens BJP, Grotenhuis BA, Kuhlmann KFD, Breukink SO, Beets GL, Melenhorst J, Buijsen J, Festen S, de Graaf EJR, Haak HE, Hilling DE, Hoff C, Intven M, Komen N, Kusters M, van Leerdam ME, Peeters KCMJ, Peters FP, Pronk A, van der Sande ME, Schreurs WH, Sonneveld DJA, Talsma AK, Tuynman JB, Valkenburg‐van Iersel LBJ, Vermaas M, de Vos‐Geelen J, van Westreenen HL, de Wilt JHW, Zimmerman DDE. Selected stage IV rectal cancer patients managed by the watch-and-wait approach after pelvic radiotherapy: a good alternative to total mesorectal excision surgery? Colorectal Dis 2022; 24:401-410. [PMID: 35060263 PMCID: PMC9305558 DOI: 10.1111/codi.16034] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 12/16/2021] [Accepted: 12/20/2021] [Indexed: 12/18/2022]
Abstract
AIM The aim of this study was to assess the clinical and oncological outcome of a selected group of stage IV rectal cancer patients managed by the watch-and-wait approach following a (near-)complete response of the primary rectal tumour after radiotherapy. METHOD Patients registered in the Dutch watch-and-wait registry since 2004 were selected when diagnosed with synchronous stage IV rectal cancer. Data on patient characteristics, treatment details, follow-up and survival were collected. The 2-year local regrowth rate, organ-preservation rate, colostomy-free rate, metastatic progression-free rate and 2- and 5-year overall survival were analysed. RESULTS After a median follow-up period of 35 months, local regrowth was observed in 17 patients (40.5%). Nine patients underwent subsequent total mesorectal excision, resulting in a permanent colostomy in four patients. The 2-year local regrowth rate was 39.9%, the 2-year organ-preservation rate was 77.1%, the 2-year colostomy-free rate was 88.1%, and the 2-year metastatic progression-free rate was 46.7%. The 2- and 5-year overall survival rates were 92.0% and 67.5%. CONCLUSION The watch-and-wait approach can be considered as an alternative to total mesorectal excision in a selected group of stage IV rectal cancer patients with a (near-)complete response following pelvic radiotherapy. Despite a relatively high regrowth rate, total mesorectal excision and a permanent colostomy can be avoided in the majority of these patients.
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Affiliation(s)
- Petra A. Custers
- Department of SurgeryNetherlands Cancer Institute – Antoni van LeeuwenhoekAmsterdamThe Netherlands,GROW School for Oncology and Developmental Biology – Maastricht UniversityMaastrichtThe Netherlands
| | - Britt J. P. Hupkens
- Department of RadiotherapyMaastricht University Medical Centre (MAASTRO)MaastrichtThe Netherlands
| | - Brechtje A. Grotenhuis
- Department of SurgeryNetherlands Cancer Institute – Antoni van LeeuwenhoekAmsterdamThe Netherlands
| | - Koert F. D. Kuhlmann
- Department of SurgeryNetherlands Cancer Institute – Antoni van LeeuwenhoekAmsterdamThe Netherlands
| | | | - Geerard L. Beets
- Department of SurgeryNetherlands Cancer Institute – Antoni van LeeuwenhoekAmsterdamThe Netherlands,GROW School for Oncology and Developmental Biology – Maastricht UniversityMaastrichtThe Netherlands
| | - Jarno Melenhorst
- Department of SurgeryMaastricht University Medical CentreMaastrichtThe Netherlands
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Kim JK, Thompson H, Jimenez-Rodriguez RM, Wu F, Sanchez-Vega F, Nash GM, Guillem JG, Paty PB, Wei IH, Pappou EP, Widmar M, Weiser MR, Smith JJ, Garcia-Aguilar J. Adoption of Organ Preservation and Surgeon Variability for Patients with Rectal Cancer Does Not Correlate with Worse Survival. Ann Surg Oncol 2022; 29:1172-1179. [PMID: 34601641 PMCID: PMC8727510 DOI: 10.1245/s10434-021-10877-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 05/05/2021] [Accepted: 09/04/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND OBJECTIVES Watch-and-wait is variably adopted by surgeons and the impact of this on outcomes is unknown. We compared the disease-free survival and organ preservation rates of locally advanced rectal cancer patients treated by expert colorectal surgeons at a comprehensive cancer center. METHODS This study included retrospective data on patients diagnosed with stage II/III rectal adenocarcinoma from January 2013 to June 2017 who initiated neoadjuvant therapy (either with chemoradiation, chemotherapy, or a combination of both) and were treated by an expert colorectal surgeon. RESULTS Overall, 444 locally advanced rectal cancer patients managed by five surgeons were included. Tumor distance from the anal verge, type of neoadjuvant therapy, and organ preservation rates varied by treating surgeon. There was no difference in disease-free survival after stratifying by the treating surgeon (p = 0.2). On multivariable analysis, neither the type of neoadjuvant therapy nor the treating surgeon was associated with disease-free survival. CONCLUSIONS While neoadjuvant therapy type and organ preservation rates varied among surgeons, there were no meaningful differences in disease-free survival. These data suggest that among expert colorectal surgeons, differing thresholds for selecting patients for watch-and-wait do not affect survival.
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Affiliation(s)
- Jin K. Kim
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Hannah Thompson
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | | | - Fan Wu
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Francisco Sanchez-Vega
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA,Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Garrett M. Nash
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Jose G. Guillem
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Philip B. Paty
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Iris H. Wei
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Emmanouil P. Pappou
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Maria Widmar
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Martin R. Weiser
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - J. Joshua Smith
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Julio Garcia-Aguilar
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
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Jimenez-Rodriguez RM, Quezada-Diaz F, Hameed I, Kalabin A, Patil S, Smith JJ, Garcia-Aguilar J. Organ Preservation in Patients with Rectal Cancer Treated with Total Neoadjuvant Therapy. Dis Colon Rectum 2021; 64:1463-1470. [PMID: 34508014 PMCID: PMC8820240 DOI: 10.1097/dcr.0000000000002122] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [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] [Indexed: 12/26/2022]
Abstract
BACKGROUND Retrospective studies suggest that watch-and-wait is a safe alternative to total mesorectal excision in selected patients with a clinical complete response after chemoradiotherapy. OBJECTIVE This study aimed to determine the proportion of patients with rectal cancer who may benefit from watch-and-wait. DESIGN This study is a retrospective analysis of data from prospectively maintained databases. SETTING This study was conducted at a comprehensive cancer center. PATIENTS Consecutive patients with stage II or III rectal adenocarcinoma who were treated with total neoadjuvant therapy using induction chemotherapy between 2012 and 2019 under the care of the same surgeon were included. INTERVENTION Induction-type total neoadjuvant therapy consisted of 8 cycles of leucovorin-fluorouracil-oxaliplatin or 5 cycles of capecitabine-oxaliplatin before chemoradiotherapy. Patients with a clinical complete response were offered watch-and-wait, and patients with residual tumor were offered total mesorectal excision. MAIN OUTCOMES AND MEASURES Tumor response was assessed with a digital rectal examination, endoscopy, and MRI. Patient characteristics and recurrence-free survival were compared between the watch-and-wait group and the total mesorectal excision group. RESULTS A total of 88 patients were included in the analysis. One (1%) died during neoadjuvant therapy. Fifty-five patients (62.5%) had an incomplete clinical response and underwent surgery, 10 (18%) of the 55 developed distant metastasis, and 3 (5%) developed local recurrence. The remaining 32 patients (36.3%) had a clinical complete response and underwent watch-and-wait. On average, patients in the watch-and-wait group were older and had smaller, more distal tumors compared with patients in the surgery group. The median radiation dose, number of chemotherapy cycles, rate of adverse events, and length of follow-up did not differ substantively between the total mesorectal excision group and the watch-and-wait group. In the watch-and-wait group, 2 (6%) patients developed tumor regrowth, and one of them had distant metastasis. Recurrence-free survival was significantly higher in the watch-and-wait group. LIMITATIONS Generalizability, sample size, and follow-up duration were limitations of this study. CONCLUSIONS Approximately one-third of patients with stage II or III rectal cancer can benefit from a watch-and-wait approach with the aim of preserving the rectum if treated with induction-type total neoadjuvant therapy and followed by an experienced multidisciplinary team. See Video Abstract at http://links.lww.com/DCR/B688. CONSERVACIN DE RGANOS EN PACIENTES CON CNCER DE RECTO TRATADOS CON TERAPIA NEOADYUVANTE TOTAL ANTECEDENTES:Estudios retrospectivos sugieren que observar y esperar es una alternativa segura a la escisión mesorrectal total en pacientes seleccionados con una respuesta clínica completa después de la quimiorradioterapia.OBJETIVO:Determinar la proporción de pacientes con cáncer de recto que pueden beneficiarse de observar y esperar.DISEÑO:Análisis retrospectivo de datos de bases de datos mantenidas de forma prospectiva.ESCENARIO:Centro Oncológico Integral.PACIENTES:Pacientes consecutivos con adenocarcinoma de recto en estadio II o III tratados con TNT utilizando quimioterapia de inducción entre 2012 y 2019 bajo el cuidado del mismo cirujano.INTERVENCIÓN:La terapia neoadyuvante total de tipo inducción consistió en ocho ciclos de leucovorín-fluorouracilo-oxaliplatino o cinco ciclos de capecitabina-oxaliplatino antes de la quimiorradioterapia. A los pacientes con una respuesta clínica completa se les ofreció observar y esperar, y a los pacientes con tumor residual se les ofreció la escisión mesorrectal total.PRINCIPALES RESULTADOS Y MEDIDAS:La respuesta del tumor se evaluó con un tacto rectal, endoscopia y resonancia magnética. Se compararon las características de los pacientes y la supervivencia libre de recurrencia entre el grupo de observación y espera y el grupo de escisión mesorrectal total.RESULTADOS:Se incluyó en el análisis a un total de 88 pacientes. Uno (1%) murió durante la terapia neoadyuvante. Cincuenta y cinco pacientes (62.5%) tuvieron una respuesta clínica incompleta y se sometieron a cirugía; 10 (18%) de los 55 desarrollaron metástasis a distancia y 3 (5%) desarrollaron recidiva local. Los 32 pacientes restantes (36.3%) tuvieron una cCR (respuesta clínica completa) y se sometieron a observar y esperar. En promedio, los pacientes del grupo de observación y espera eran mayores y tenían tumores más pequeños y distales en comparación con el grupo de cirugía. La dosis mediana de radiación, el número de ciclos de quimioterapia, la tasa de eventos adversos y la duración del seguimiento no difirieron sustancialmente entre el grupo de escisión mesorrectal total y el grupo de observación y espera. En el grupo de observación y espera, 2 (6%) pacientes desarrollaron recrecimiento del tumor y uno de ellos tuvo metástasis a distancia. La supervivencia libre de recurrencia fue significativamente mayor en el grupo de observación y espera.LIMITACIONES:Generalizabilidad, tamaño de la muestra, duración del seguimiento.CONCLUSIONES:Aproximadamente un tercio de los pacientes con cáncer de recto en estadio II o III pueden beneficiarse de un abordaje de observación y espera con el objetivo de preservar el recto si se tratan con terapia neoadyuvante total de tipo inducción y son seguidos por un equipo multidisciplinario experimentado. Consulte Video Resumen en http://links.lww.com/DCR/B688.
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Affiliation(s)
| | | | - Irbaz Hameed
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York
| | - Aleksandr Kalabin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York
| | - Sujata Patil
- Department of Epidemiology-Biostatistics, Memorial Sloan Kettering Cancer Center, New York
| | - J. Joshua Smith
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York
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Pennings AJ, Kimman ML, Gielen AHC, Beets GL, Melenhorst J, Breukink SO. Burden of disease experienced by patients following a watch-and-wait policy for locally advanced rectal cancer: A qualitative study. Colorectal Dis 2021; 23:2870-2878. [PMID: 34314550 PMCID: PMC9291314 DOI: 10.1111/codi.15838] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 05/25/2021] [Accepted: 06/16/2021] [Indexed: 02/08/2023]
Abstract
AIM Patient-reported outcome measures (PROMs) are increasingly being used in routine cancer care to evaluate treatment and monitor symptoms, function and other aspects of quality of life (QoL). There is no suitable PROM for rectal cancer patients following a watch-and-wait (W&W) programme. Insight into patient experiences with this programme is an essential step in the development of a PROM. The aim of this qualitative study was to provide insights into the most important functional outcomes and QoL features experienced by patients during our W&W programme. METHOD Patients with locally advanced rectal cancer who are enrolled in the W&W programme in the Netherlands were interviewed by telephone using a semistructured interview guide. All interviews were digitally audio-recorded, transcribed verbatim and coded. A thematic approach was used to analyse the data and identify themes and subthemes of importance to patients. RESULTS Eighteen patients were interviewed (78% male, mean age 68 years, range 52-83 years). Physical complaints after treatment were present, most notably gastrointestinal problems, neuropathy and fatigue. Furthermore, patients were anxious about a possible recurrence, had a fear of surgery or a stoma, or were experiencing a general feeling of apprehension in daily life. Many patients had different coping mechanisms, such as acceptance, and there were few limitations in daily life. CONCLUSION We identified important functional outcomes, such as gastrointestinal complaints, fatigue and neuropathy, in patients who were enrolled in this W&W programme. Furthermore, an emotional burden and unmet needs were reported by these patients. These findings can be used to improve clinical practice and inform the development of a PROM.
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Affiliation(s)
- Alexander J. Pennings
- Department of SurgeryMaastricht University Medical CenterMaastrichtThe Netherlands,GROW School for Oncology and Developmental BiologyMaastrichtThe Netherlands
| | - Merel L. Kimman
- Clinical Epidemiology and Medical Technology AssessmentMaastricht University Medical Center+MaastrichtThe Netherlands
| | - Anke H. C. Gielen
- Department of SurgeryMaastricht University Medical CenterMaastrichtThe Netherlands,Faculty of Health, Medicine and Life SciencesMaastricht UniversityMaastrichtThe Netherlands
| | - Geerard L. Beets
- GROW School for Oncology and Developmental BiologyMaastrichtThe Netherlands,Department of SurgeryNetherlands Cancer InstituteAmsterdamThe Netherlands
| | - Jarno Melenhorst
- Department of SurgeryMaastricht University Medical CenterMaastrichtThe Netherlands,NUTRIMSchool of Nutrition and Translational Research in MetabolismMaastrichtThe Netherlands
| | - Stephanie O. Breukink
- Department of SurgeryMaastricht University Medical CenterMaastrichtThe Netherlands,GROW School for Oncology and Developmental BiologyMaastrichtThe Netherlands,NUTRIMSchool of Nutrition and Translational Research in MetabolismMaastrichtThe Netherlands
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14
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Zhang S, Zhang R, Li RZ, Wang QX, Chang H, Ding PR, Li LR, Wu XJ, Chen G, Zeng ZF, Xiao WW, Gao YH. Beneficiaries of radical surgery among clinical complete responders to neoadjuvant chemoradiotherapy in rectal cancer. Cancer Sci 2021; 112:3607-3615. [PMID: 34146368 PMCID: PMC8409289 DOI: 10.1111/cas.15039] [Citation(s) in RCA: 2] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 06/05/2021] [Accepted: 06/15/2021] [Indexed: 12/24/2022] Open
Abstract
This study aimed to identify patients who benefit from radical surgery among those with rectal cancer who achieved clinical complete response (cCR). Patients with locally advanced rectal cancer (LARC; stage II/III) who achieved cCR after neoadjuvant chemoradiotherapy (nCRT) were included (n = 212). Univariate/multivariate Cox analysis was performed to validate predictors for distant metastasis‐free survival (DMFS). A decision tree was generated using recursive partitioning analysis (RPA) to categorize patients into different risk stratifications. Total mesorectal excision (TME) was compared with the watch‐and‐wait (W&W) strategy in each risk group. Two molecular predicators of CEA and CA19‐9 were selected to establish the RPA‐based risk stratification, categorizing LARC patients into low‐risk (n = 139; CA19‐9 < 35 U/mL and CEA < 5 ng/mL) and high‐risk (n = 73; CA19‐9 ≥ 35 U/mL or CEA ≥5 ng/mL) groups. Superior 5‐y DMFS was observed in the low‐risk group vs. the high‐risk group (92.9% vs. 76.2%, P = .002). Low‐risk LARC patients who underwent TME had significantly improved 5‐y DMFS compared with their counterparts receiving the W&W strategy (95.9% vs. 84.3%; P = .028). No significant survival difference was observed in high‐risk patients receiving the 2 treatment modalities (77.9% vs. 94.1%; P = .143). LARC patients with cCR who had both baseline CA19‐9 < 35 U/mL and CEA < 5 ng/mL may benefit from radical surgery.
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Affiliation(s)
- Shu Zhang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangzhou, China.,Department of Radiation Oncology, The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Rong Zhang
- Department of Endoscopy, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangzhou, China
| | - Rong-Zhen Li
- Department of Radiation Oncology, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangzhou, China
| | - Qiao-Xuan Wang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangzhou, China
| | - Hui Chang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangzhou, China
| | - Pei-Rong Ding
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangzhou, China
| | - Li-Ren Li
- Department of Endoscopy, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangzhou, China
| | - Xiao-Jun Wu
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangzhou, China
| | - Gong Chen
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangzhou, China
| | - Zhi-Fan Zeng
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangzhou, China
| | - Wei-Wei Xiao
- Department of Radiation Oncology, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangzhou, China
| | - Yuan-Hong Gao
- Department of Radiation Oncology, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangzhou, China
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15
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Haak HE, Žmuc J, Lambregts DMJ, Beets-Tan RGH, Melenhorst J, Beets GL, Maas M. The evaluation of follow-up strategies of watch-and-wait patients with a complete response after neoadjuvant therapy in rectal cancer. Colorectal Dis 2021; 23:1785-1792. [PMID: 33725387 DOI: 10.1111/codi.15636] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/19/2021] [Accepted: 03/05/2021] [Indexed: 12/25/2022]
Abstract
AIM Many of the current follow-up schedules in a watch-and-wait approach include very frequent MRI and endoscopy examinations to ensure early detection of local regrowth (LR). The aim of this study was to analyse the occurrence and detection of LR in a watch-and-wait cohort and to suggest a more efficient follow-up schedule. METHOD Rectal cancer patients with a clinical complete response after neoadjuvant therapy were prospectively and retrospectively included in a multicentre watch-and-wait registry between 2004 and 2018, with the current follow-up schedule with 3-monthly endoscopy and MRI in the first year and 6 monthly thereafter. A theoretical comparison was constructed for the detection of LR in the current follow-up schedule against four other hypothetical schedules. RESULTS In all, 50/304 (16%) of patients developed a LR. The majority (98%) were detected at ≤2 years, located in the lumen (94%) and were visible on endoscopy (88%). The theoretical comparison of the different hypothetical schedules suggests that the optimal follow-up schedule should focus on the first 2 years with 3-monthly endoscopy and 3-6 monthly MRI. Longer intervals in the first 2 years will cause delays in diagnosis of LR ranging from 0 to 5 months. After 2 years, increasing the interval from 6 to 12 months did not cause important delays. CONCLUSION The optimal follow-up schedule for a watch-and-wait policy in patients with a clinical complete response after chemoradiation for rectal cancer should include frequent endoscopy and to a lesser degree MRI in the first 2 years. Longer intervals, up to 12 months, can be considered after 2 years.
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Affiliation(s)
- Hester E Haak
- Department of Surgery, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands.,GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Jan Žmuc
- Department of Surgical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Doenja M J Lambregts
- Department of Radiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Regina G H Beets-Tan
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands.,Department of Radiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Jarno Melenhorst
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Geerard L Beets
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands.,Department of Radiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Monique Maas
- Department of Radiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
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Hipp J, Nagavci B, Schmoor C, Meerpohl J, Hoeppner J, Schmucker C. Post-Neoadjuvant Surveillance and Surgery as Needed Compared with Post-Neoadjuvant Surgery on Principle in Multimodal Treatment for Esophageal Cancer: A Scoping Review. Cancers (Basel) 2021; 13:cancers13030429. [PMID: 33561090 PMCID: PMC7865772 DOI: 10.3390/cancers13030429] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/15/2021] [Accepted: 01/20/2021] [Indexed: 12/11/2022] Open
Abstract
Simple Summary A substantial fraction of patients with esophageal cancer show post-neoadjuvant pathological complete response (pCR). Principal esophagectomy after neoadjuvant treatment is the standard of care for all patients, including those with pCR. Surveillance and surgery as needed may be a treatment alternative for these patients. We performed a scoping review and described all relevant clinical studies addressing these two treatment approaches. We identified three completed randomized controlled trials (RCTs) including 468 participants, three planned/ongoing RCTs with a planned sample size of 752 participants, one non-randomized controlled study with 53 participants, ten retrospective cohort studies (2228 participants) and one survey on patients’ preferences (100 participants). The current scoping review reveals that although surveillance and surgery as needed has been investigated within different study designs, the available study pool show methodological limitations and clinical results are heterogeneous. A thoroughly planned RCT considering these limitations will be of great importance to provide these patients with the best treatment. Abstract Background: A substantial fraction of patients with esophageal cancer show post-neoadjuvant pathological complete response (pCR). Principal esophagectomy after neoadjuvant treatment is the standard of care for all patients, although surveillance and surgery as needed in case of local recurrence may be a treatment alternative for patients with complete response (CR). Methods: We performed a scoping review to describe key characteristics of relevant clinical studies including adults with non-metastatic esophageal cancer receiving multimodal treatment. Until September 2020, relevant studies were identified through systematic searches in the bibliographic databases Medline, Web of Science, Cochrane Library, Science Direct, ClinicalTrials, the German study register, and the WHO registry platform. Results: In total, three completed randomized controlled trials (RCTs, with 468 participants), three planned/ongoing RCTs (with a planned sample size of 752 participants), one non-randomized controlled study (NRS, with 53 participants), ten retrospective cohort studies (with 2228 participants), and one survey on patients’ preferences (with 100 participants) were identified. All studies applied neoadjuvant chemoradiation protocols. None of the studies examined neoadjuvant chemotherapeutic protocols. Studies investigated patient populations with esophageal squamous cell carcinoma, adenocarcinoma, and mixed cohorts. Important outcomes reported were overall, disease-free and local recurrence-free survival. Limitations of the currently available study pool include heterogeneous chemoradiation protocols, a lack of modern neoadjuvant treatment protocols in RCTs, short follow-up times, the use of heterogeneous diagnostic methods, and different definitions of clinical CR. Conclusion: Although post-neoadjuvant surveillance and surgery as needed compared with post-neoadjuvant surgery on principle has been investigated within different study designs, the currently available results are based on a wide variation of diagnostic tools to identify patients with pCR, short follow-up times, small sample sizes, and variations in therapeutic procedures. A thoroughly planned RCT considering the limitations in the currently available literature will be of great importance to provide patients with CR with the best and less harmful treatment.
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Affiliation(s)
- Julian Hipp
- Center of Surgery, Department of General and Visceral Surgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany;
| | - Blin Nagavci
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, 79110 Freiburg, Germany; (B.N.); (J.M.)
| | - Claudia Schmoor
- Clinical Trials Unit, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, 79110 Freiburg, Germany;
| | - Joerg Meerpohl
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, 79110 Freiburg, Germany; (B.N.); (J.M.)
- Cochrane Germany, Cochrane Germany Foundation, 79110 Freiburg, Germany
| | - Jens Hoeppner
- Department of Surgery, University Medical Center Schleswig-Holstein, UKSH Campus Lübeck, 23538 Lübeck, Germany;
| | - Christine Schmucker
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, 79110 Freiburg, Germany; (B.N.); (J.M.)
- Correspondence: ; Tel.: +49(0)761-203-6695
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Fischer J, Eglinton TW, Richards SJ, Frizelle FA. Predicting pathological response to chemoradiotherapy for rectal cancer: a systematic review. Expert Rev Anticancer Ther 2021; 21:489-500. [PMID: 33356679 DOI: 10.1080/14737140.2021.1868992] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction: Pathological complete response (pCR) rates of approximately 20% following neoadjuvant long-course chemoradiotherapy for rectal cancer have given rise to non-operative or watch-and-wait (W&W) management. To improve outcomes there has been significant research into predictors of response. The goal is to optimize selection for W&W, avoid chemoradiotherapy in those who won't benefit and improve treatment to maximize the clinical complete response (cCR) rate and the number of patients who can be considered for W&W.Areas covered: A systematic review of articles published 2008-2018 and indexed in PubMed, Embase or Medline was performed to identify predictors of pathological response (including pCR and recognized tumor regression grades) to fluoropyrimidine-based chemoradiotherapy in patients who underwent total mesorectal excision for rectal cancer. Evidence for clinical, biomarker and radiological predictors is discussed as well as potential future directions.Expert opinion: Our current ability to predict the response to chemoradiotherapy for rectal cancer is very limited. cCR of 40% has been achieved with total neoadjuvant therapy. If neoadjuvant treatment for rectal cancer continues to improve it is possible that the treatment for rectal cancer may eventually parallel that of anal squamous cell carcinoma, with surgery reserved for the minority of patients who don't respond to chemoradiotherapy.
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Affiliation(s)
- Jesse Fischer
- Department of Surgery, University of Otago, Christchurch, New Zealand.,Department of General Surgery, North Shore Hospital, Auckland, New Zealand
| | - Tim W Eglinton
- Department of Surgery, University of Otago, Christchurch, New Zealand.,Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Simon Jg Richards
- Department of Surgery, University of Otago, Christchurch, New Zealand.,Department of General Surgery, The Royal Melbourne Hospital, Melbourne, Australia
| | - Frank A Frizelle
- Department of Surgery, University of Otago, Christchurch, New Zealand.,Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
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Fischer J, Eglinton TW, Frizelle FA. Clinical predictors of response to chemoradiotherapy for rectal cancer as an aid to organ preservation. ANZ J Surg 2021; 91:1190-1195. [PMID: 33404195 DOI: 10.1111/ans.16531] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 08/30/2020] [Revised: 12/07/2020] [Accepted: 12/08/2020] [Indexed: 12/15/2022]
Abstract
AIM Clinical predictors of pathological response to chemoradiotherapy for rectal cancer can influence patient management including selection for organ preservation. This study aimed to identify clinical predictors at a tertiary referral hospital. METHODS A retrospective review of clinical records was undertaken after identifying all patients with stage 1-3 rectal cancer treated with long course chemoradiotherapy and total mesorectal excision from 2013 to 2018. Clinicopathological factors were recorded and multivariate analysis performed to identify predictors of pathological complete response (pCR) and good response (AJCC TRG 0-1). RESULTS A total of 470 patients with rectal cancer were identified of which 164 met the inclusion criteria for the study. The pCR rate was 14.6% and good response (TRG 0-1) rate 43.7%. On univariate analysis, lower T stage, older age, node negative status, anterior tumour position and shorter tumour length on magnetic resonance imaging (MRI) were associated with good response (TRG 0-1). On univariate analysis cN stage, carcinoembryonic antigen <5 and shorter tumour length on MRI were associated with pCR. On binary logistic regression shorter length on MRI and lower clinical nodal stage were predictive of pCR and lower body mass index, anterior tumour position and higher haemoglobin were predictive of good response (TRG 0-1). CONCLUSION Anterior tumour position is newly identified as an independent predictor of good response (TRG 0-1) to nCRT for rectal cancer and this should be explored in future studies. Higher haemoglobin and lower body mass index were also independent predictors of good response (TRG 0-1) and optimisation of these factors should be considered when using neoadjuvant chemoradiotherapy for rectal cancer.
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Affiliation(s)
- Jesse Fischer
- Department of Surgery, University of Otago, Christchurch, New Zealand.,Department of General Surgery, North Shore Hospital, Auckland, New Zealand
| | - Tim W Eglinton
- Department of Surgery, University of Otago, Christchurch, New Zealand.,Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Frank A Frizelle
- Department of Surgery, University of Otago, Christchurch, New Zealand.,Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
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Ronceray L, Abla O, Barzilai-Birenboim S, Bomken S, Chiang AK, Jazbec J, Kabickova E, Lazic J, Beishuizen A, Mellgren K, Tanaka F, Pillon M, Devalck C, Gouttenoire M, Makarova O, Burkhardt B, Attarbaschi A. Children and adolescents with marginal zone lymphoma have an excellent prognosis with limited chemotherapy or a watch-and-wait strategy after complete resection. Pediatr Blood Cancer 2018; 65. [PMID: 29286565 DOI: 10.1002/pbc.26932] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 11/15/2017] [Accepted: 11/27/2017] [Indexed: 12/22/2022]
Abstract
Data on management of pediatric marginal zone lymphoma (MZL) are scarce. This retrospective study assessed characteristics and outcome in 66 patients who were <18 years old. Forty-four (67%) had an extranodal MZL (EMZL), 21 (32%) a nodal MZL (NMZL), and one patient a splenic MZL. Thirty-three patients (50%) received a variable combination of adjuvant chemotherapy/immunotherapy/radiotherapy, while the remainder, including 20 of 21 with NMZL, entered an active observation period. Overall survival was excellent (98 ± 2%), although 11 patients relapsed (17%; NMZL, n = 1; EMZL, n = 10), seven after any therapy and four after complete resection only. In conclusion, outcome of NZML, in particular, seems to be excellent after (in)complete resection and observation only.
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Affiliation(s)
- Leila Ronceray
- Pediatric Hematology and Oncology, St. Anna Children's Hospital, Medical University of Vienna, Vienna, Austria
| | - Oussama Abla
- Division of Hematology and Oncology, Department of Pediatrics, Hospital for Sick Children, Toronto, Canada
| | - Shlomit Barzilai-Birenboim
- Pediatric Hematology and Oncology, Schneider Children's Medical Center of Israel, Petah-Tivka, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Simon Bomken
- Northern Institute for Cancer Research, Newcastle University, Newcastle, UK
| | - Alan Ks Chiang
- Department of Pediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
| | - Janez Jazbec
- Division of Pediatrics, Hematology and Oncology, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Edita Kabickova
- Pediatric Hematology and Oncology, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Jelena Lazic
- Pediatric Hematology and Oncology, University Children's Hospital, School of Medicine University of Belgrade, Belgrade, Serbia
| | - Auke Beishuizen
- Pediatric Hematology and Oncology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Karin Mellgren
- Pediatric Hematology and Oncology, The Queen Silvia's Hospital for Children and Adolescents, University of Göteborg, Göteborg, Sweden
| | - Fumiko Tanaka
- Department of Pediatrics, Saiseikai Yokohamashi Nanbu Hospital, Yokohama, Japan
| | - Marta Pillon
- Pediatric Hematology and Oncology, University of Padova, Padova, Italy
| | - Christine Devalck
- Pediatric Hematology and Oncology, Hopital Universitaire des Enfants Reine Fabiola, Brussels, Belgium
| | - Marina Gouttenoire
- Pediatric Hematology and Oncology, University Hospital, Saint Etienne, France
| | - Olga Makarova
- Pediatric Hematology and Oncology, University of Münster, Münster, Germany
| | - Birgit Burkhardt
- Pediatric Hematology and Oncology, University of Münster, Münster, Germany
| | - Andishe Attarbaschi
- Pediatric Hematology and Oncology, St. Anna Children's Hospital, Medical University of Vienna, Vienna, Austria
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- Pediatric Hematology and Oncology, St. Anna Children's Hospital, Medical University of Vienna, Vienna, Austria
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Abstract
Organ preservation is considered in the management of selected patients with rectal cancer. Complete clinical response observed after neoadjuvant chemoradiation for rectal cancer is one of these cases. Patients who present complete clinical response are candidates to the watch-and-wait approach, when radical surgery is not immediately performed and is offered only to patients in the event of a local relapse. These patients are included in a strict follow-up, and up of 70% of them will never be operated during the follow-up. This strategy is associated with similar oncological outcomes as patients operated on, and the advantage of avoiding the morbidity associated to the radical operation. In this article we will discuss in detail the best candidates for this approach, the protocol itself, and the long-term outcomes.
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Affiliation(s)
- Angelita Habr-Gama
- Angelita & Joaquim Gama Institute, Sao Paulo, SP, Brazil.,University of Sao Paulo School of Medicine, Sao Paulo, SP, Brazil
| | | | | | - Ivana Castro
- Angelita & Joaquim Gama Institute, Sao Paulo, SP, Brazil
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Abstract
BACKGROUND Standard management for locally advanced rectal cancer (LARC) involves preoperative chemoradiotherapy (CRT) and radical surgery. However, this level of treatment may be unnecessary for a subgroup of LARC patients. Previous reports have shown that approximately 20% of LARC patients experience a complete tumor response to preoperative CRT. Post-CRT nonoperative management of these patients may prevent morbidities associated with radical surgery. To our knowledge, this case report firstly presents the favorable long-term outcomes of a LARC patient who underwent definitive aim CRT. METHODS The patient was 73 years' old, and staging workups revealed T3N2bM0 rectal adenocarcinoma. He agreed to receive CRT, but refused surgery. A radiotherapy (RT) dose of 64.8 Gy was prescribed, which was higher than conventional (50.4 Gy) preoperative aim RT. The regimen of concurrent chemotherapy was the same as that used in preoperative aim CRT: 2 cycles of 5-fluorouracil and leucovorin. RESULTS Three months after CRT completion, a complete tumor response was identified clinically. Colonoscopic biopsy after 1 year showed no tumor cells. This patient is alive after 4 years with no evidence of recurrence or severe toxicity. CONCLUSION The long-term outcomes of this case indicate the feasibility of definitive high-dose RT with concurrent chemotherapy for LARC.
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Affiliation(s)
- Min-Jeong Kim
- Department of Radiology, Hallym University College of Medicine, Hallym University Sacred Heart Hospital, Anyang
| | - Eun Seok Kim
- Department of Radiation Oncology, Soonchunhyang University College of Medicine, Soonchunhyang University Hospital, Cheonan, Republic of Korea
| | - Seung-Gu Yeo
- Department of Radiation Oncology, Soonchunhyang University College of Medicine, Soonchunhyang University Hospital, Cheonan, Republic of Korea
- Correspondence: Seung-Gu Yeo, Department of Radiation Oncology, Soonchunhyang University Hospital, 31, Soonchunhyang 6-gil, Cheonan 31151, Republic of Korea (e-mail: )
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