Adoption of Total Neoadjuvant Therapy for Locally Advanced Rectal Cancer

Total neoadjuvant therapy for locally advanced rectal cancer

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the effectiveness and safety of total neoadjuvant therapy versus standard therapy in individuals with locally advanced rectal cancer.

Personalized surveillance in colorectal cancer: Integrating circulating tumor DNA and artificial intelligence into post-treatment follow-up

Given the growing burden of colorectal cancer (CRC) as a global health challenge, it becomes imperative to focus on strategies that can mitigate its impact. Post-treatment surveillance has emerged as essential for early detection of recurrence, significantly improving patient outcomes. However, intensive surveillance strategies have shown mixed results compared to less intensive methods, emphasizing the necessity for personalized, risk-adapted approaches. The observed suboptimal adherence to existing surveillance protocols underscores the urgent need for more tailored and efficient strategies. In this context, circulating tumor DNA (ctDNA) emerges as a promising biomarker with significant potential to revolutionize post-treatment surveillance, demonstrating high specificity [0.95, 95% confidence interval (CI): 0.91-0.97] and robust diagnostic odds (37.6, 95%CI: 20.8-68.0) for recurrence detection. Furthermore, artificial intelligence and machine learning models integrating patient-specific and tumor features can enhance risk stratification and optimize surveillance strategies. The reported area under the receiver operating characteristic curve, measuring artificial intelligence model performance in predicting CRC recurrence, ranged from 0.581 and 0.593 at the lowest to 0.979 and 0.978 at the highest in training and validation cohorts, respectively. Despite this promise, addressing cost, accessibility, and extensive validation remains crucial for equitable integration into clinical practice.

Total neoadjuvant therapy in high-risk rectal cancer: organ preservation and survival outcomes in a single-center retrospective cohort

Background

Rectal cancer poses a significant global health burden. Conventional neoadjuvant chemoradiotherapy (nCRT) demonstrates limited efficacy in achieving disease-free survival (DFS) and organ preservation. Total neoadjuvant therapy (TNT), an emerging paradigm integrating systemic chemotherapy with radiotherapy, aims to address these limitations.

Objectives

To evaluate the short- and long-term oncological outcomes and organ preservation feasibility of TNT in high-risk locally advanced rectal cancer (LARC) patients.

Designs

A retrospective study was conducted to analyze the short-term and long-term results after total nCRT.

Methods

This retrospective study involved 110 rectal cancer patients with high-risk features treated at the Fudan University Shanghai Cancer Center from 2008 to 2022. Patients underwent comprehensive staging and received nCRT followed by either total mesorectal excision (TME) or a watch and wait (W&W) strategy. The regimen included concurrent chemoradiotherapy with 50 Gy/25 fractions and at least six cycles of induction or consolidation chemotherapy. Both short-term and long-term outcomes were collected and analyzed.

Results

Among the LARC patients, 73.6% were stage III, and 47.3% opted for the W&W strategy. The combined rate of clinical complete response or confirmed pathological complete response (pCR) reached 49.1%. During follow-up, 10% of patients experienced local regrowth. The 3-year DFS and overall survival (OS) rates were 75.7% and 92.4%, respectively. The W&W strategy could achieve superior outcomes than patients without pCR in DFS (p = 0.021) and OS (p = 0.006).

Conclusion

TNT demonstrates durable survival outcomes and facilitates organ preservation in over 50% of high-risk LARC patients. Intensive surveillance is critical for the early detection of local regrowth.

Trial registration

Our study is retrospective in nature, rather than a prospective clinical trial. Therefore, registration was not conducted, and the Clinical Trial Number is not applicable.

Compliance and Toxicity of Total Neoadjuvant Therapy in Locally Advanced Rectal Cancer: A Systematic Review and Network Meta-analysis

PURPOSE

The individual chemotherapy- and radiotherapy-related toxicities between induction (iTNT) and consolidation total neoadjuvant therapy (cTNT) remain unclear. This network meta-analysis (NMA) comparing iTNT, cTNT, and traditional neoadjuvant chemoradiation (nCRT) evaluated the comparative treatment-related toxicities and compliance of the TNT schemas.

METHODS

A systematic review of randomized clinical trials and nonrandomized studies of interventions was performed as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-NMA guidelines. A Bayesian NMA was conducted, and odds ratios (OR) with 95% credible intervals (CrI) are reported for all outcomes.

RESULTS

Eighteen studies including 5730 patients were identified. iTNT ranked highest on rate of rectal bleeding (cTNT: OR 0.23 95% CrI 0.05-0.93; nCRT: OR 0.33, 95% CrI 0.09-0.96), proctitis (cTNT: OR 0.2, 95% CrI 0.06-0.55; nCRT: OR 0.2, 95% CrI 0.06-0.51), and postoperative diarrhea (cTNT: OR 0.37, 95% CrI 0.18-0.73; nCRT: OR 0.33, 95% CrI 0.15-0.71); cTNT ranked highest on rate of vomiting (iTNT: OR 0.24, 95% CrI 0.05-0.96; nCRT: OR 0.29, 95% CrI 0.06-0.89) and a higher rate of lymphopenia than iTNT (iTNT: OR 0.56, 95% CrI 0.34-0.99). Radiotherapy compliance was highest in cTNT (iTNT: OR 0.23, 95% CrI 0.05-0.72; nCRT: OR 0.18, 95% CrI 0.04-0.58). There was no difference in overall toxicity and mortality, chemotherapy compliance, and remaining individual system-based toxicities and postoperative complications.

CONCLUSIONS

Across all treatment strategies, iTNT had higher radiation-related gastrointestinal toxicities and postoperative diarrhea; cTNT had higher vomiting and lymphopenia rates. While no treatment strategy was superior in chemotherapy compliance, radiotherapy compliance was ranked highest in cTNT.

A battle of surgical strategies: Clinically enlarged lateral lymph nodes in patients with locally advanced rectal cancer; extended mesorectal excision (e-TME) versus traditional surgery (TME-alone) a meta-analysis

BACKGROUND

The infiltration of lateral lymph nodes (LLN) plays a crucial role in the staging and treatment of individuals with locally advanced rectal cancer (LARC). This meta-analysis aimed to compare the efficacy of extended mesorectal excision (eTME) versus traditional mesorectal excision (TME-alone) in patients with clinically enlarged (LLN) concomitant neoadjuvant chemoradiation.

METHODS

This study is registered with PROSPERO (CRD42023457805). A comprehensive literature search was conducted across PubMed/Medline, Scopus, Cochrane Library, EMBASE, Web of Science, and EBSCO databases for comparative studies published until June 2024. The study included patients with clinically enlarged LLN concomitant with neoadjuvant chemoradiation in rectal cancer who underwent either eTME or TME alone. Primary outcomes included local recurrence (LR), lateral local recurrence (LLR), overall survival (OS), distant metastasis, and disease-free survival (DFS).

RESULTS

The pooled mean for LR was 6.6 % in the TME group and 4.8 % in the eTME group, with no significant difference between the groups (OR, 0.569; 95 % CI, 0.180-1.792; P = 0.33). Similarly, the pooled LLR rates were 38.5 % for TME and 55.8 % for eTME, indicating a higher recurrence rate in the eTME group (P = 0.65). In the term of the (OS) rates were 93.7 % for TME and 93.2 % for eTME, with no significant difference (P = 0.56). The (DFS) rates were 84.6 % for TME and 86 % for eTME, with no significant difference (P = 0.38). Additionally, the distant recurrence rates were 6.8 % for TME and 17.5 % for eTME, with no significant difference (P = 0.479).

CONCLUSION

Our meta-analysis provides reliable information on the efficacy of eTME versus TME-alone in patients with clinically enlarged LLN concomitant with nCRT in rectal cancer, as we addressed previous limitations for a more accurate comparison. While the (eTME) does not show significant oncologic benefits over (TME alone), the study emphasizes the need for careful patient selection and further research to refine treatment guidelines. Individual patient- and tumor characteristics should guide the most appropriate surgical strategy.

The Landmark Series: Organ Preservation in Rectal Cancer-The Watch and Wait Strategy

Radical treatment of rectal cancer has evolved quite significantly over the last few decades with the development of optimal local disease staging with magnetic resonance (MR), refined surgical techniques including total mesorectal excision (TME) with or without sphincter-preservation, and multimodality treatment with the use of chemotherapy and radiation. While oncological outcomes have shown some significant improvements in terms of local disease control and distant metastases rates, complication rates and functional sequelae remain quite significant for patients undergoing TME surgery. In this setting, organ-preserving alternatives, including transanal local excision (TAE) and Watch and Wait (WW), have become increasingly attractive to patients in an attempt to avoid major surgery (TME) as an alternative treatment strategy with no oncological compromise. In the present narrative review, the fundamentals of selection and outcomes of patients undergoing WW will be covered to provide updated information for colorectal surgeons and surgical oncologists interested in this treatment alternative in clinical practice.

Comprehensive malnutritional index for predicting clinical outcomes in locally advanced rectal cancer receiving neoadjuvant chemoradiotherapy

The objective of this investigation was to assess the prognostic significance of the comprehensive malnutritional index (CNI) in patients with locally advanced rectal cancer (LARC) who underwent neoadjuvant chemoradiotherapy (nCRT) followed by surgery. A total of 240 LARC patients were recruited. The CNI was calculated using principal components analysis based on hemoglobin (Hb), total lymphocyte count (TLC), albumin (ALB), body mass index (BMI), and usual body weight percentage (UBW%). The patients were then categorized into two groups based on the median CNI value. Cox regression and survival analyses were performed. The CNI-low (120 cases) and CNI-high (120 cases) groups were classified based on the median CNI value. The results indicated that the CNI demonstrated superior predictive ability for disease-free survival (DFS) and overall survival (OS) compared to other malnutritional indexes. LARC patients in the CNI-high group had significantly longer DFS and OS compared to those in the CNI-low group. Multivariate analysis revealed that the CNI was an independent prognostic factor for DFS (hazard ratio [HR] = 0.49; 95% confidence interval [CI], 0.29-0.83; P = 0.008) and OS (HR = 0.30; 95% CI, 0.16-0.58; P < 0.001). Additionally, the CNI-high group benefited from postoperative chemotherapy (DFS: P = 0.029, OS: P = 0.024), while the CNI-low group did not show such benefits (DFS: P = 0.448, OS: P = 0.468). These findings suggest that the CNI could serve as a valuable prognostic indicator for LARC patients who undergo nCRT followed by surgery. Preoperative nutrition optimization is important for LARC patients.

[For Whom, How and to What End - Neoadjuvant Therapy for Rectal Cancer?]

Over the past few decades, considerable progress has been made in the treatment of rectal cancer, leading to a reduction in local recurrence rates and an improvement in prognosis. The current German S3 guideline on colorectal cancer recommends neoadjuvant therapy for UICC stage II and III tumours of the middle and lower rectum. Primary surgery is still recommended for UICC I tumours, although exceptions are being discussed for certain subgroups, such as cT1/2 tumours with questionable nodal involvement. Current trials are focusing on multimodality treatment concepts, in particular total neoadjuvant therapy (TNT), which has been examined in several phase II and phase III trials. Therapies with selective omission of neoadjuvant radiotherapy and organ-preserving approaches are also being investigated. This review provides a comprehensive overview of the current evidence on neoadjuvant treatment of rectal cancer, highlights new multimodal treatment approaches, and discusses future challenges and opportunities to optimise treatment according to stage and to provide patients with the best possible individualised treatment.

No operation after short-course radiotherapy followed by consolidation chemotherapy in locally advanced rectal cancer (NOAHS-ARC): study protocol for a prospective, phase II trial

PURPOSE

Organ preservation through a watch-and-wait (W&W) strategy has become a viable option for select rectal cancer patients with clinical complete responses (cCR) to total neoadjuvant therapy (TNT). This approach limits the morbidity associated with multimodal treatment. However, the optimal treatment strategy and predictors of treatment response are still unresolved. Rectal cancer incidence is rising, particularly in developing countries, and the disease is a major public health concern in Chile. Prior to the no operation after short-course radiotherapy followed by consolidation chemotherapy in locally advanced rectal cancer (NOAHS-ARC) trial, TNT-based treatments and W&W programs had not been implemented in Chile.

METHODS/DESIGN

This single-arm, multicenter, phase II prospective trial, conducted in Santiago, Chile, will enroll patients with stage II/III rectal adenocarcinoma. Treatment involves induction short-course radiotherapy (25 Gy in 5 fractions) followed by consolidation chemotherapy (FOLFOX × 9 or CAPOX × 6 cycles). The response will be assessed 4-8 weeks after chemotherapy completion. Patients achieving cCR will be offered W&W, while those with incomplete responses will undergo total mesorectal excision. The primary endpoint is the rate of complete tumor response, combining pathologic complete responses (pCR) and sustained cCR (> 1 year), compared to a matched cohort treated with neoadjuvant chemoradiation alone. The trial aims to recruit 48 patients, assuming a combined pCR/sustained cCR rate of 12%. Quality of life measures will be assessed, and a biorepository of tissue and plasma samples will be established for future research, alongside serial endoscopic and MRI images.

DISCUSSION

NOAHS-ARC seeks to advance organ preservation strategies in rectal cancer while pioneering TNT and W&W protocols in Chile. The study will also focus on functional outcomes and provide valuable data for improving patient care both locally and globally.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT04864067. Registered on April 28, 2021.

The Chinese Society of Clinical Oncology (CSCO): Clinical guidelines for the diagnosis and treatment of colorectal cancer, 2024 update

The 2024 updates of the Chinese Society of Clinical Oncology (CSCO) Clinical Guidelines for the diagnosis and treatment of colorectal cancer emphasize standardizing cancer treatment in China, highlighting the latest advancements in evidence-based medicine, healthcare resource access, and precision medicine in oncology. These updates address disparities in epidemiological trends, clinicopathological characteristics, tumor biology, treatment approaches, and drug selection for colorectal cancer patients across diverse regions and backgrounds. Key revisions include adjustments to evidence levels for intensive treatment strategies, updates to regimens for deficient mismatch repair (dMMR)/ microsatellite instability-high (MSI-H) patients, proficient mismatch repair (pMMR)/ microsatellite stability (MSS) patients who have failed standard therapies, and rectal cancer patients with low recurrence risk. Additionally, recommendations for digital rectal examination and DNA polymerase epsilon (POLE)/ DNA polymerase delta 1 (POLD1) gene mutation testing have been strengthened. The 2024 CSCO Guidelines are based on both Chinese and international clinical research, as well as expert consensus, ensuring their relevance and applicability in clinical practice, while maintaining a commitment to scientific rigor, impartiality, and timely updates.

Impact of belly board immobilization devices and body mass factor on setup displacement using daily cone-beam CT in rectal cancer radiotherapy

OBJECTIVE

The objective of this study is to evaluate the impact of different belly board and daily changes in patient's body-mass factor (BMF) on setup displacement in radiotherapy for rectal cancer.

METHODS

Twenty-five patients were immobilized using the thermoplastic mask with belly board (TM-BB), and 30 used the vacuum bag cushion with belly board (VBC-BB), performing daily cone-beam computed tomography (CBCT) scans 625 times and 750 times, respectively. Daily pretreatment CBCT scans were registered to the planned CT images for BMF change determination and setup displacement measurement. Independent t-tests compared setup displacement between the two groups in left-right (LR), superior-inferior (SI), and anterior-posterior (AP) directions, as well as the BMF changes. The impact of daily BMF changes on setup displacement was evaluated using multivariate logistic regression and 10-fold cross-validation.

RESULTS

The setup displacement for TM-BB in the LR, SI, and AP directions were 0.31 ± 0.25, 0.58 ± 0.40, and 0.19 ± 0.18 cm, respectively, while VBC-BB showed 0.19 ± 0.15, 0.26 ± 0.22, and 0.36 ± 0.29 cm in the corresponding directions, respectively. Margins of planning target volume (PTV) for TM-BB were 8, 10, and 6 mm in LR, SI, and AP directions, while VBC-BB showed margins of 5,7, and 8 mm, respectively. The daily BMF changes for both groups were ranked in descending order as follows: sacral rotation angle (RS), hip lateral diameter (HLD), and hip anterior-posterior diameter (HAPD). HAPD was the main factor affecting setup displacement in both the AP and SI directions in TM-BB, while RS was the primary factor for setup displacement in the AP direction in VBC-BB.

CONCLUSION

Compared with TM-BB, VBC-BB had a larger AP displacement but smaller in LR and SI displacement. Daily changes in BMF have distinct effects on setup displacement in different immobilization devices. Image-guided radiation therapy (IGRT) is highly recommended and BMF changes should be given consideration during radiotherapy.

Correlation Between Grade of Clinical Response to Neoadjuvant Therapy for Rectal Cancer and Oncologic Outcomes in the Era of Watch-and-Wait

BACKGROUND

The watch-and-wait strategy provides an opportunity to pursue nonoperative management in rectal cancer patients with clinical complete response after neoadjuvant therapy. The management of those with near-complete response remains controversial.

OBJECTIVE

We assessed the oncologic outcomes of patients managed by watch-and-wait versus total mesorectal excision according to clinical response to neoadjuvant therapy.

DESIGN

Retrospective cohort study.

SETTINGS

Comprehensive cancer center in New York.

PATIENTS

Patients with rectal adenocarcinoma diagnosed between January 2006 and December 2020.

INTERVENTIONS

A watch-and-wait strategy of active surveillance was offered to patients if they achieved clinical complete response. Salvage surgery was used for watch-and-wait patients with local regrowth. Patients with an incomplete response underwent total mesorectal excision.

MAIN OUTCOME MEASURES

Local regrowth rate, organ preservation rate, disease-free survival, and overall survival.

RESULTS

Patients with rectal adenocarcinoma (n = 1230) were divided into 3 response cohorts-incomplete (n = 646), near-complete (n = 189), and complete (n = 395). Eighty-one patients (43%) in the near-complete group and 351 patients (89%) in the complete group entered watch-and-wait. Three-year local regrowth rates were 40% and 24% in the near-complete and complete response cohorts, respectively. The 5-year organ preservation rate was 53% in near-complete responders and 73% in complete responders. Five-year disease-free survival increased with greater clinical response to neoadjuvant therapy, with intermediate outcomes noted for patients with a near-complete (73%) compared to complete (82%) or incomplete (68%) response. Overall survival at 5 years was similar between the 3 cohorts (complete 90%, near-complete 86%, and incomplete 85%).

LIMITATIONS

Retrospective nature.

CONCLUSIONS

Greater clinical response to neoadjuvant therapy is associated with improved oncologic outcomes. Near-complete responders may avoid surgery and still achieve high organ preservation rates yet experience greater local regrowth rates than clinical complete response patients. Ongoing prospective trials integrating watch-and-wait after complete response as determined by uniform criteria will bolster the work to help treating physicians better select patients who qualify for active surveillance. See Video Abstract .

CORRELACIN ENTRE EL GRADO DE RESPUESTA CLNICA A LA TERAPIA NEOADYUVANTE CONTRA EL CNCER DEL RECTO Y LOS RESULTADOS ONCOLGICOS EN LA ERA DE OBSERVAR Y ESPERAR

ANTECEDENTES:La estrategia de observar y esperar brinda la oportunidad de buscar un tratamiento no quirúrgico en pacientes con cáncer del recto con respuesta clínica completa después de la terapia neoadyuvante. El tratamiento de aquellos con respuesta casi completa sigue siendo controversial.OBJETIVO:Evaluamos los resultados oncológicos de los pacientes tratados con observar y esperar versus escisión mesorrectal total según la respuesta clínica a la terapia neoadyuvante.DISEÑO:Estudio de cohorte retrospectivo.CONFIGURACIÓN:Centro oncológico integral en Nueva York.PACIENTES:Pacientes con adenocarcinoma rectal diagnosticado entre enero de 2006 y diciembre de 2020.INTERVENCIONES:Se ofreció una estrategia de observar y esperar de vigilancia activa a los pacientes si lograban una respuesta clínica completa. Se utilizó cirugía de rescate para pacientes en observar y esperar con recrecimiento local. Los pacientes con una respuesta incompleta se sometieron a escisión mesorrectal total.PRINCIPALES MEDIDAS DE RESULTADO:Tasa de recrecimiento local, tasa de preservación de órganos, supervivencia libre de enfermedad y supervivencia general.RESULTADOS:Los pacientes con adenocarcinoma rectal (n = 1230) se dividieron en 3 cohortes de respuesta: incompleta (n = 646), casi completa (n = 189) y completa (n = 395). Ochenta y un (43%) pacientes en el grupo casi completo y 351 (89%) pacientes en el grupo completo ingresaron en observar y esperar. Las tasas de recrecimiento local a tres años fueron del 40% y 24% en las cohortes de respuesta casi completa y completa, respectivamente. La tasa de preservación de órganos a 5 años fue del 53% en los respondedores casi completos y del 73% en los respondedores completos. La supervivencia libre de enfermedad a cinco años aumentó con una mayor respuesta clínica a la terapia neoadyuvante con resultados intermedios observados para pacientes con una respuesta casi completa (73%) en comparación con la completa (82%) o incompleta (68%). La supervivencia global a los 5 años fue similar entre las tres cohortes (completa 90%, casi completa 86% e incompleta 85%).LIMITACIONES:Naturaleza retrospectiva.CONCLUSIÓN:Una mayor respuesta clínica a la terapia neoadyuvante se asocia con mejores resultados oncológicos. Los pacientes con respuesta casi completa pueden evitar la cirugía y aun así lograr altas tasas de preservación de órganos, pero experimentar mayores tasas de recrecimiento local que los pacientes con respuesta clínica completa. Los ensayos prospectivos en curso que integran observar y esperar después de la respuesta completa según lo determinado por criterios uniformes reforzarán el trabajo para ayudar a los médicos tratantes a seleccionar mejor a los pacientes que califican para la vigilancia activa. (Traducción-Dr. Aurian Garcia Gonzalez ).

Short-Course TNT Improves Rectal Tumor Downstaging in a Retrospective Study of the US Rectal Cancer Consortium

BACKGROUND AND OBJECTIVES

The RAPIDO trial showed promising rates of pathologic complete response (pCR) after neoadjuvant short-course radiation with consolidation chemotherapy (total neoadjuvant therapy [SC TNT]) for rectal cancer. Only single-center reviews comparing tumor downstaging between SC TNT and long-course chemoradiation (LCRT) have been published in the United States. We reviewed our multi-institutional experience with both.

METHODS

The US Rectal Cancer Consortium database (2007-2018) including data from six high-volume rectal cancer care centers was reviewed. Patients with nonmetastatic, rectal adenocarcinoma who had neoadjuvant LCRT alone or SC TNT before excision or definitive nonoperative management were included. The primary outcome was the rate of complete response (CR), including pCR or durable (12 month) clinical complete response.

RESULTS

Of 857 included patients, 175 (20%) received SC TNT and 682 (80%) received LCRT. The LCRT group had more low tumors (51.8% vs. 37.1%, p < 0.0001) and more clinically node-negative disease (31.8% vs. 22.3%, p < 0.0001). The CR rate was higher after SC TNT (34.1% vs. 20.3%, p = 0.0001). SC TNT was a predictor of CR (OR: 2.52, CI: 1.68-3.78). SC TNT patients completing 5-6 months of consolidation chemotherapy had a CR rate of 42.9%. There was no difference in 3-year PFS.

CONCLUSIONS

SC TNT increases CR rate when compared to LCRT. For patients seeking nonoperative options or fewer radiation treatments, SC TRT should be preferred over LCRT alone.

The New Era of Total Neoadjuvant FLOT Therapy for Locally Advanced, Resectable Gastric Cancer: A Propensity-Matched Comparison With Standard Perioperative Therapy

BACKGROUND

The FLOT 4-AIO trial established the docetaxel-based regimen's superiority over epirubicin-based triplet therapy in terms of survival rates and acceptable toxicity for locally advanced resectable gastric (LARGC). Yet, fewer than half of the patients achieved completion of eight prescribed FLOT cycles. We proposed that administering all FLOT cycles in the form of total neoadjuvant therapy may improve completion rates and downstaging. This study contrasted total neoadjuvant therapy (FLOT x8) with standard neoadjuvant therapy (FLOT 4+4) for patients LARGC adenocarcinoma who underwent curative resection with routine D2 lymphadenectomy, focusing on histopathological outcomes, toxicity, and survival outcomes.

METHODS

We reviewed patients with histologically confirmed advanced clinical stage cT2 or higher, nodal positive stage (cN+), or both, with resectable gastric tumors and no distant metastases (January 2017 to July 2023). We divided patients into two groups, FLOT 4+4 and FLOT x8; FLOT 4+4 patients underwent four preoperative and four postoperative bi-weekly cycles of docetaxel, oxaliplatin, leucovorin, and fluorouracil, while FLOT x8 patients received all eight cycles preoperatively after a gradual practice change starting from January 2020. Propensity score matching adjusted for age, clinical stage, tumor location, and histology.

RESULTS

Of the 77 patients in the FLOT x8 group, 37 were propensity-matched to an equal number in the FLOT 4+4 group. Demographics, duration of surgery, and hospital stay showed no significant differences between the groups. The FLOT x8 group exhibited a significantly higher all-cycle completion rate at 89.1% compared to FLOT 4+4's 67.6% (p < 0.01). Both groups demonstrated comparable hematological and non-hematological toxicity rates, Clavien-Dindo ≥ 3 complications, and CAP tumor regression grades. The mean number of harvested lymph nodes was 42.5 and 41.2 in the FLOT 4+4 and FLOT x8 groups, respectively. Similar rates of disease-free survival and overall survival were noted in both groups, despite a trend toward a higher pathological complete response rate, albeit not statistically significant (8.1% vs. 18.9%, p = 0.29), in the FLOT x8 group at a median follow-up of 36 months.

CONCLUSION

Total neoadjuvant therapy with the FLOT x8 protocol corresponds to higher treatment completion rates, a safety profile similar to standard perioperative therapy, and a twofold increase in complete pathological response. Further research on long-term oncological outcomes is needed to confirm the effectiveness of total neoadjuvant therapy.

Nonoperative Management of Rectal Cancer: Is "Near-Complete" Response Safe to Surveil?

BACKGROUND

Nonoperative management of rectal cancer in patients who achieve near-complete response following total neoadjuvant therapy remains controversial and understudied.

METHODS

This retrospective cohort study conducted at a tertiary National Cancer Institute-designated cancer center included patients with rectal cancer who initiated active surveillance after achieving near-complete response following induction radiotherapy and consolidation chemotherapy. Near-complete response was determined based on restaging endoluminal evaluation and pelvic magnetic resonance imaging. Time-to-event analyses were used to estimate regrowth-free, proctectomy-free, disease-free, and overall survival.

RESULTS

Of 61 patients who achieved near-complete response and initiated nonoperative management between February 2017 and March 2024, 36 (59.0%) maintained organ preservation with a median follow-up of 27.1 (interquartile range [IQR] 17.4-37.4) months. Twenty-five patients (41.0%) developed local regrowth by a median of 5.7 (IQR 3.2-8.2) months. All regrowths occurred within 17.5 months of initial restaging. Twenty-one patients with regrowth underwent salvage proctectomy, of which 20 (95.2%) achieved R0 resection margins. Following salvage proctectomy, four patients (19.0%) developed local recurrence. Disease-free and overall survival 2 years from restaging were 79.2% (95% confidence interval [CI] 67.0-93.6) and 93.3% (95% CI 86.3-100), respectively. Overall survival was not significantly different between patients with versus without local regrowth (log-rank p = 0.09).

CONCLUSIONS

Nonoperative management achieves clinically significant organ preservation rates without compromising oncologic outcomes in patients with near-complete response to total neoadjuvant therapy. Active surveillance allows time for continued evolution of tumor response and may substantially expand organ preservation in a patient population who otherwise would undergo avoidable radical surgery.

Cost-Effectiveness of Total Neoadjuvant Therapy With Selective Nonoperative Management for Locally Advanced Rectal Cancer: Analysis of Data From the Organ Preservation for Rectal Adenocarcinoma Trial

PURPOSE

The clinical efficacy of total neoadjuvant therapy (TNT) followed by selective nonoperative management (NOM) for locally advanced rectal cancer (LARC) was examined in the Organ Preservation for Rectal Adenocarcinoma (OPRA) trial. We investigated the cost and quality-of-life implications of adopting this treatment approach.

METHODS

We analyzed clinical, cost, and quality-of-life outcomes for TNT with selective NOM in comparison with chemoradiotherapy (CRT)-surgery-adjuvant chemotherapy (standard of care [SOC]) using data from OPRA, prospective cohorts, and published studies. Cost-effectiveness was evaluated over varying willingness-to-pay thresholds, and sensitivity analyses evaluated cost-effectiveness for different surgical contexts and SOC variants as well as a 10-year time horizon.

RESULTS

SOC was dominated by TNT with selective NOM in the base case analysis. TNT in which CRT was followed by consolidation chemotherapy (CNCT) was the least costly at $89,712 in Medicare proportionate US dollars (MP$), followed by TNT in which induction chemotherapy was followed by CRT (INCT) at MP$90,259 and SOC at MP$98,755. INCT was the preferred strategy, with 4.56 quality-adjusted life years, followed by CNCT at 4.42 and SOC at 4.29. TNT with selective NOM dominated SOC in all sensitivity analyses except when SOC omitted adjuvant chemotherapy without an impact on disease-free survival. CNCT was more cost effective than SOC when the proportion of patients entering NOM after TNT was ≥22% or ≥43%, for SOC with and without adjuvant therapy, both well below the rates seen in OPRA.

CONCLUSION

TNT with selective NOM is cost effective. The cost-effectiveness of CNCT with NOM relative to SOC is dependent on CNCT being made available to a sufficiently large proportion of patients with LARC. Additional analyses are needed to validate these findings from a societal perspective and in the context of other emerging treatment paradigms for LARC.

Comparison of Standard Neoadjuvant Therapy and Total Neoadjuvant Therapy in Terms of Effectiveness in Patients Diagnosed with Locally Advanced Rectal Cancer

Background/Objectives: The study aimed to compare the treatment effectiveness of patients with locally advanced rectal cancer undergoing standard neoadjuvant therapy or total neoadjuvant therapy. It also sought to identify prognostic factors for disease-free survival and overall survival and parameters predictive of pathological complete response. Materials and Methods: A retrospective analysis was conducted on 239 patients diagnosed with locally advanced rectal cancer between 2016 and 2022 at several medical centers in Turkey. Clinical data, including neoadjuvant chemoradiotherapy types, chemotherapy regimens, surgical outcomes, and survival metrics, were collected. Statistical analyses included chi-square tests, Kaplan-Meier survival analysis, and Cox proportional hazard models to evaluate prognostic factors for disease-free survival and overall survival and logistic regression to identify predictors of pathological complete response. Results: Among 239 patients, 46.9% received total neoadjuvant therapy, while 53.1% underwent standard neoadjuvant therapy. Total neoadjuvant therapy was associated with a significantly higher pathological complete response rate (45.5% vs. 14.9% in standard neoadjuvant therapy; p < 0.001) and longer disease-free survival (median 124.2 vs. 72.4 months). The 3-year overall survival rate for all patients was 90.7%, and disease-free survival was 76.8%. Multivariate analysis identified pathological complete response (HR: 2.34), total neoadjuvant therapy (HR: 5.12), and type of surgery (HR: 8.12) as independent prognostic factors for disease-free survival, and pathological complete response and absence of lymphovascular invasion as independent prognostic factors for overall survival. Logistic regression analysis showed that total neoadjuvant therapy (OR: 4.40) and initial neoadjuvant chemotherapy (OR: 2.02) were independent predictors of achieving pathological complete response. Conclusions: Total neoadjuvant therapy significantly improves pathological complete response rates, disease-free survival, and overall survival in patients with locally advanced rectal cancer compared to standard neoadjuvant therapy. Total neoadjuvant therapy and achieving pathological complete response are strong independent prognostic factors for both disease-free survival and overall survival, suggesting that a more intensive neoadjuvant approach may lead to better outcomes in locally advanced rectal cancer. The increased pathological complete responses rate with total neoadjuvant therapy has created an opportunity for the development of new treatment modalities and the advancement of non-surgical management strategies in the future.

Cancer Vaccines and Beyond: The Transformative Role of Nanotechnology in Immunotherapy

Cancer is one of the leading causes of morbidity and mortality globally, responsible for approximately 10 million deaths in 2022 and an estimated 21 million new cases in 2024. Traditional cancer treatments such as surgery, radiation therapy, and chemotherapy often present limitations in efficacy and side effects. However, immunotherapeutic vaccines have emerged as a promising approach, leveraging the body's immune system to target and eliminate cancer cells. This review examines the evolving landscape of cancer vaccines, differentiating between preventive and therapeutic strategies and highlighting the significance of tumor-specific antigens, including tumor-associated antigens (TAAs) and neoantigens. Recent advancements in vaccine technology, particularly through nanotechnology, have resulted in the development of nanovaccines, which enhance antigen stability, optimize delivery to immune cells, and promote robust immune responses. Notably, clinical data indicate that patients receiving immune checkpoint inhibitors can achieve overall survival rates of approximately 34.8 months compared to just 15.7 months for traditional therapies. Despite these advancements, challenges remain, such as the immunosuppressive tumor microenvironment and tumor heterogeneity. Emerging evidence suggests that combining nanovaccines with immunomodulators may enhance therapeutic efficacy by overcoming these obstacles. Continued research and interdisciplinary collaboration will be essential to fully exploit the promise of nanovaccines, ultimately leading to more effective and accessible treatments for cancer patients. The future of cancer immunotherapy appears increasingly hopeful as these innovative strategies pave the way for enhanced patient outcomes and an improved quality of life in oncology.

Predicting complete response to neoadjuvant chemoradiotherapy in locally advanced rectal cancer: The role of baseline volumetric 18F-FDG PET/CT parameters and inflammatory markers

OBJECTIVES

We evaluated the influence of baseline volumetric 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) parameters and inflammatory prognostic markers on complete response (CR) in patients with locally advanced rectal cancer (LARC) treated with neoadjuvant chemoradiotherapy (nCRT).

MATERIALS AND METHODS

In total, 90 patients with LARC, including those with and without CR, were evaluated based on baseline volumetric PET/CT parameters, such as maximum standard uptake value, metabolic tumor volume (MTV), tumor lesion glycolysis, and inflammatory prognostic markers, including the lymphocyte-to-monocyte ratio, platelet-to-lymphocyte ratio (PLR), and neutrophil-to-lymphocyte ratio.

RESULTS

Of the 90 patients, 62 (68.9%) were male and 28 (31.1%) were female. The median age was 61 (31-81) years. A complete response was observed in 20 (22%) patients following nCRT. Of these, 5 demonstrated a clinical complete response, whereas 15 exhibited a complete response after surgery. A low pretreatment PLR, low MTV levels, and stage 2 disease were identified as significant predictors of complete response. The optimal cutoff values were 16.5 for MTV (sensitivity 80%, specificity 62%) and 121 for PLR (sensitivity 73%, specificity 65%).

CONCLUSION

Our findings suggest that stage 2 disease, low pretreatment MTV, and low PLR levels may be predictive of a CR to nCRT in patients with LARC.

Is Early, Postinduction Restaging of Rectal Cancer Undergoing Total Neoadjuvant Therapy Associated With Ultimate Treatment Response?

BACKGROUND

Among patients with rectal cancer treated with total neoadjuvant therapy, it is unclear whether early, postinduction restaging is associated with final tumor response. If so, interim restaging may alter rectal cancer decision-making.

OBJECTIVE

To determine whether postinduction restaging with endoscopy and MRI is associated with final tumor response.

DESIGN

Retrospective cohort study.

SETTINGS

US tertiary care institution accredited by the National Accreditation Program for Rectal Cancer.

PATIENTS

Patients with biopsy-proven rectal cancer who underwent total neoadjuvant therapy with interim (postinduction) restaging.

MAIN OUTCOME MEASURES

Association between response assessment on postinduction restaging and final treatment response.

RESULTS

One hundred seven patients were analyzed. Patients with postinduction magnetic resonance tumor response grade 1 and 2 or complete endoscopic response were significantly more likely (OR 5.4, p < 0.01 and OR 3.7, p = 0.03, respectively) to ultimately achieve a final complete response. Likewise, the odds of a final incomplete response were significantly higher for patients with postinduction composite partial (OR 4.1, p < 0.01) or minimal (OR 12.0, p < 0.01) responses.

LIMITATIONS

Retrospective analysis and lack of detailed subclassification of partial endoscopic response may have limited the conclusions of these data. The limited sample size may also have biased these conclusions.

CONCLUSIONS

Tumor response to induction therapy is associated with the ultimate treatment response to total neoadjuvant therapy among complete or minimal responders; the significance of a partial interim response remains unclear. See Video Abstract .

EST ASOCIADA LA REESTADIFICACIN TEMPRANA POSTINDUCCIN DEL CANCER DE RECTO SOMETIDO A TERAPIA NEOADYUVANTE TOTAL CON LA RESPUESTA TERAPUTICA FINAL

ANTECEDENTES:Entre los pacientes con cáncer de recto tratados con terapia neoadyuvante total, no está claro si la re-estadificación temprana posterior a la inducción está asociada con la respuesta tumoral final. De ser así, la re-estadificación provisoria podría alterar la toma de decisiones sobre el cáncer rectal.OBJETIVO:Determinar si la re-estadificación posterior a la inducción con endoscopia y resonancia magnética están asociadas con la respuesta tumoral final.DISEÑO:Estudio de cohorte retrospectivoESCENARIO:Institución de atención terciaria de Estados Unidos, certificada por el Programa Nacional de Acreditación para el Cáncer de Recto.PACIENTES:Pacientes con cáncer rectal confirmado por biopsia que fueron sometidos a terapia neoadyuvante total con re-estadificación provisoria (posterior a la inducción).PRINCIPALES MEDIDAS DE RESULTADOS:La asociación entre la evaluación de la respuesta en la re-estadificación posterior a la inducción y la respuesta al final del tratamiento.RESULTADOS:Se estudiaron 107 pacientes. Aquellos que presentaban respuesta tumoral a la resonancia magnética post-inducción grado 1-2 o respuesta endoscópica completa tuvieron significativamente más probabilidades (OR (odds ratio) 5,4 [ p < 0,01] y OR: 3,7 [ p = 0,03], respectivamente) de lograr finalmente una respuesta completa final. Asimismo, las probabilidades de una respuesta incompleta final fueron significativamente mayores para los pacientes con respuestas parciales compuestas post-inducción (OR: 4,1, p < 0,01) o mínimas (OR: 12,0, p < 0,01).LIMITACIONES:El análisis retrospectivo y la falta de una subclasificación detallada de la respuesta endoscópica parcial pueden haber limitado las conclusiones de estos datos. El tamaño limitado de la muestra también puede haber sesgado las conclusiones mencionadas.CONCLUSIÓN:La respuesta tumoral a la terapia de inducción está asociada con la respuesta final al tratamiento con terapia neoadyuvante total entre los respondedores completos o mínimos; la importancia de una respuesta parcial provisional sigue sin estar clara. (Traducción-Dr. Xavier Delgadillo ).

Clinical significance of the maximum standardized uptake value on positron emission tomography to predict treatment response and outcomes in patients with rectal cancer undergoing neoadjuvant chemoradiotherapy

PURPOSES

The association between the reduction rate of the maximum standardized uptake value (SUVmax) on positron emission tomography (PET) during neoadjuvant chemoradiotherapy (NACRT) and the prognosis in patients with locally advanced rectal cancer is unknown.

METHODS

We retrospectively analyzed 62 patients with locally advanced rectal cancer who underwent curative surgery after NACRT at Kobe University between 2008 and 2021. The SUVmax reduction rate was calculated from preoperative and postoperative PET scans, and its association with the prognosis was investigated.

RESULTS

The cutoff value for SUVmax reduction rate was 61.5%. Twenty patients had an SUVmax reduction rate > 61.5% (SUV responder group) and 38 patients had an SUVmax reduction rate ≤ 61.5% (SUV nonresponder group). Regarding pathological outcomes, the rate of a good histological response was significantly higher in the SUV responder group than in the SUV nonresponder group (80.0% vs. 21.1%, p < 0.001). Both the overall (OS) and relapse-free survival (RFS) rates were significantly better in the SUV responder group than in the SUV nonresponder group (OS, p = 0.035; RFS, p = 0.019). In the SUV responder group, only 1 case of recurrence was observed, with a median follow-up period of 56 months.

CONCLUSION

The rate of SUVmax reduction during NACRT might predict the long-term prognosis of patients with locally advanced rectal cancer.

Mastering rectal cancer MRI: From foundational concepts to optimal staging

MRI plays a critical role in the local staging, restaging, surveillance, and risk stratification of patients, ensuring they receive the most tailored therapy. As such, radiologists must be familiar not only with the key MRI findings that influence management decisions but also with the appropriate MRI protocols and structured reporting. Given the complexity of selecting the optimal therapy for each patient-which often requires multidisciplinary discussions-radiologists should be well-versed in relevant treatment strategies and surgical terms, understanding their significance in guiding patient care. In this manuscript, we review the most common treatment options for managing patients with rectal adenocarcinoma, emphasizing key MRI principles and protocol characteristics for accurate staging. We also highlight important anatomical landmarks and essential factors to be described during baseline assessment. Additionally, we discuss crucial information for restaging and surveillance.

Neoadjuvant immunotherapy for DNA mismatch repair proficient/microsatellite stable non-metastatic rectal cancer: a systematic review and meta-analysis

Background

Neoadjuvant immunotherapy (NIT) has been endorsed by clinical guidelines for the management of DNA mismatch repair deficiency/microsatellite instability-high (dMMR/MSI-H) locally advanced rectal cancer (LARC). Nonetheless, the therapeutic efficacy of NIT in mismatch repair-proficient/microsatellite stable (pMMR/MSS) non-metastatic rectal cancer (RC) remain pending matters. Therefore, a meta-analysis was carried out to assess the efficacy and safety of NIT in patients with non-metastatic pMMR/MSS RC.

Methods

PubMed, Embase, Web of Science, the Cochrane Library, ClinicalTrials.gov, ASCO and ESMO were searched to obtain related studies up to July 2024. Two reviewers independently screened the included articles and extracted the pertinent data. The risk of publication bias was assessed by Begg or Egger tests and in cases of publication bias, the trim and fill method was applied. Heterogeneity was assessed using I 2 statistics.

Results

Thirteen articles including 582 eligible patients were analyzed. The pooled pCR, MPR, cCR and anus preservation rate were 37%, 57%, 26% and 77% separately and the incidence of irAEs≥3 grades and TRAEs≥3 grades were 3% and 29%, respectively. Non-metastatic pMMR/MSS RC receiving the short-course radiotherapy (SCRT) in neoadjuvant setting exhibited superior pooled pCR and MPR than long-course radiotherapy (LCRT) without upregulating the incidence of adverse effects. Furthermore, patients with MSS RC underwent neoadjuvant treatment with anti-PD-1 inhibitors demonstrated higher pooled pCR, MPR, cCR compared to those receiving PD-L1 inhibitors. Additionally, yielded improved pooled MPR and anal preservation rates compared to sequential immuno-radiotherapy (63.4% vs 51.2% and 88.5% vs 69.9%), without raising the incidence of irAEs≥3 grade. Interestingly, RC patients with lymph node metastasis showed a higher pooled pCR than those without lymph node metastasis (43% vs 35%).

Conclusion

NIT was linked to favorable response rates and anal preservation, alongside an acceptable safety profile. Non-metastatic pMMR/MSS RC patients receiving SCRT, PD-1 inhibitors, or concurrent immuno-radiotherapy in the neoadjuvant setting exhibited enhanced outcomes. This meta-analysis provides evidence for further exploration and application of NIT in non-metastatic pMMR/MSS RC and highlights the potential for organ preservation with this approach. The relatively small sample size and the uneven quality of included studies may have had some impact on the generality of the results. Therefore, further analysis with a higher number of high-quality studies is needed to verify the conclusions.

Systematic review registration

https://inplasy.com/, identifier: INPLASY202470110.

A management of patients achieving clinical complete response after neoadjuvant therapy and perspectives: on locally advanced rectal cancer

Neoadjuvant chemoradiotherapy (nCRT) followed by total mesorectal excision (TME) and selective use of adjuvant chemotherapy is currently considered the standard of care for locally advanced rectal cancer (LARC). Despite this, the concept of organ preservation is gradually challenging this approach. The management of complete clinical remission (cCR) lacks international consensus, leading scholars to develop their own perspectives based on well-designed studies and long-term data from large multicenter cohorts. To ensure appropriate treatment, this review focuses on the choice of neoadjuvant therapy, criteria for defining cCR, and treatment strategies for patients who achieve cCR after neoadjuvant therapy. By providing guidance on the accurate management of LARC patients after cCR, this review aims to prevent over- or under-treatment.

Local excision for T1 rectal cancer: A population-based study of practice patterns and oncological outcomes

AIM

Local excision (LE) for T1 rectal cancer may be recommended in those with low-risk disease, while resection is typically recommended in those with a high risk of luminal recurrence or lymph node metastasis. The aim of this work was to compare survival between resection and LE.

METHOD

This was a population-based retrospective cohort study set in the Canadian province of Ontario. Patients were individuals with T1Nx rectal cancer between 2010 and 2014 and demographics, disease characteristics, treatments and outcomes were determined using linked administrative databases. This study does not include clinical information regarding individual patient treatment decisions. The main outcome measure was overall survival (OS).

RESULTS

A total of 719 patients were identified, including 359 with upfront resection, 113 with LE and immediate resection (<90 days) and 247 with LE with definitive intent. The majority of LEs were performed via colonoscopy. Piecemeal excision (42% vs. 49%, p = 0.28) and positive margin (50% vs. 77%, p < 0.01) rates were high in both LE groups, with the highest rate in those with immediate resection. The prevalence of poor differentiation (<5%, p = 0.70) and lymphovascular invasion (LVI) (14%, p = 0.80) was similar across groups. In those with LE with definitive intent, 21% ultimately underwent resection (median 150 days, interquartile range 114-181 days) and 4% received radiation. There was no difference in 5-year OS between groups (resection 83.2% vs. LE and immediate resection 82.3% vs. definitive LE 83.3%; p = 0.33). Adjusted analyses demonstrated no association between approach and survival [definitive intent LE hazard ratio (HR) 0.97 (95% CI 0.70-1.35), LE and immediate resection HR 0.97 (95% CI 0.60-1.45), upfront resection HR 1 (Ref); p = 0.98]. Differentiation, piecemeal excisions and LVI were not associated with OS in the LE groups.

CONCLUSION

There were no observed differences in survival between those who underwent resection, LE and immediate resection and definitive intent LE. Although, these are observational data, they call into question the reflexive decision to offer radical resection for those with suspected T1 rectal cancer.

What Predicts Complete Response to Total Neoadjuvant Therapy in Locally Advanced Rectal Cancer?

BACKGROUND

Total neoadjuvant therapy in the treatment of stage II and III rectal cancer involves the administration of either induction or consolidation chemotherapy with chemoradiation before surgery. Total neoadjuvant therapy is associated with an increased complete response rate, which is defined as the proportion of patients who either had a pathological complete response after surgery or sustained a clinical complete response for at least 1 year under surveillance.

OBJECTIVE

To identify the predictors of complete response to total neoadjuvant therapy and compare different diagnostic tools in predicting complete response.

DESIGN

Retrospective cohort study.

SETTINGS

A single tertiary care center.

PATIENTS

Patients with stage II and III rectal cancer who were diagnosed between January 2015 and December 2021.

INTERVENTION

Total neoadjuvant therapy.

MAIN OUTCOME MEASURES

Complete response rate, predictors of complete response, sensitivity and specificity of sigmoidoscopy, and MRI in predicting complete response.

RESULTS

One hundred nineteen patients (mean age 56 [±11.3] years, 47 [39.5%] women, 100 [84%] stage III rectal cancer) were included. The median tumor size was 5.1 (4-6.5) cm, and 63 (52.9%) were low rectal tumors. Twenty-one patients (17.6%) had extramural vascular invasion and 62 (52.1%) had elevated CEA at baseline. One hundred eight patients (90.8%) received consolidation chemotherapy. After total neoadjuvant therapy, 88 of 119 patients (73.9%) underwent surgery, of whom 20 (22.7%) had pathological complete response. Thirty-one patients (26.1%) underwent watch-and-wait, of whom 24 (77.4%) had sustained clinical complete response. Overall, the complete response rate was 37%. Low rectal tumors (OR 1.5 [95% CI, 1.03-2.4], p = 0.04) and absence of extramural vascular invasion (OR 2.2 [95% CI, 1.1-5.6], p = 0.01) were predictors of complete response. In predicting complete response, sigmoidoscopy was more sensitive (76.0% vs 62.5%) and specific (72.5% vs 69.2%) than MRI. The specificity further increased when 2 techniques were combined (82.5%).

LIMITATIONS

Retrospective study.

CONCLUSIONS

The complete response rate after total neoadjuvant therapy was 37%. Low rectal tumors and the absence of extramural vascular invasion were predictors of complete response. Sigmoidoscopy was better in predicting incomplete response, whereas combination (MRI and sigmoidoscopy) was better in predicting complete response. See Video Abstract.

QU PREDICE LA RESPUESTA COMPLETA A LA TERAPIA NEOADYUVANTE TOTAL EN EL CNCER DE RECTO LOCALMENTE AVANZADO

ANTECEDENTES:La terapia neoadyuvante total en el tratamiento del cáncer de recto en estadios II-III implica la administración de quimioterapia de inducción o de consolidación con quimio radiación antes de la cirugía. La terapia neoadyuvante total se asocia con una mayor tasa de respuesta completa, que se define como la proporción de pacientes que tuvieron una respuesta patológica completa después de la cirugía o una respuesta clínica completa sostenida al menos durante un año bajo vigilancia.OBJETIVO:Identificar los predictores de respuesta completa a la terapia neoadyuvante total y comparar diferentes herramientas de diagnóstico para predecir la respuesta completa.DISEÑO:Estudio de cohorte retrospectivo.LUGARES:Un único centro de atención terciaria.PACIENTES:Pacientes con cáncer de recto en estadio II-III diagnosticados entre enero de 2015 y diciembre de 2021.INTERVENCIÓN(S):Terapia neoadyuvante total.PRINCIPALES MEDIDAS DE RESULTADO:Tasa de respuesta completa, predictores de respuesta completa, sensibilidad y especificidad de la sigmoidoscopia y la resonancia magnética para predecir la respuesta completa.RESULTADOS:Se incluyeron 119 pacientes [edad media 56 (±11,3) años, 47 (39,5%) mujeres, 100 (84%) cáncer de recto en estadio III]. La mediana del tamaño tumoral fue de 5,1 (4-6,5) cm, 63 (52,9%) fueron tumores rectales bajos. Veintiún (17,6%) pacientes tenían invasión vascular extramural (EMVI), 62 (52,1%) tenían CEA elevado al inicio del estudio. Ciento ocho (90,8%) pacientes recibieron quimioterapia de consolidación. Después de la TNT, 88 (73,9%) de 119 pacientes fueron intervenidos quirúrgicamente, de los cuales 20 (22,7%) tuvieron respuesta patológica completa. Treinta y un (26,1%) pacientes fueron sometidos a observación y espera, de los cuales 24 (77,4%) tuvieron una respuesta clínica completa sostenida. La tasa de respuesta completa general fue del 37%. Los tumores rectales bajos [OR 1,5 (IC 95% 1,03-2,4), p = 0,04] y la ausencia de EMVI [OR 2,2 (IC 95% 1,1-5,6), p = 0,01] fueron predictores de respuesta completa. Para predecir la respuesta completa, la sigmoidoscopia fue más sensible (76,0 % frente a 62,5 %) y específica (72,5 % frente a 69,2 %) que la resonancia magnética. La especificidad aumentó aún más cuando se combinaron dos técnicas (82,5%).LIMITACIONES:Estudio retrospectivo.CONCLUSIONES:La tasa de respuesta completa después de la terapia neoadyuvante total fue del 37%. Los tumores rectales bajos y la ausencia de EMVI fueron predictores de respuesta completa. La sigmoidoscopia fue mejor para predecir la respuesta incompleta, mientras que la combinación (MRI y sigmoidoscopia) fue mejor para predecir la respuesta completa. (Traducción-Dr Osvaldo Gauto ).

Outcomes of Distal Rectal Cancer Patients Who Did Not Qualify for Watch-and-Wait: Comparison of Intersphincteric Resection Versus Abdominoperineal Resection

INTRODUCTION

Total mesorectal excision (TME) with intersphincteric resection and handsewn coloanal anastomosis (ISR-CAA) has been shown to be oncologically safe in patients with distal rectal cancer treated with preoperative chemoradiation. The introduction of the watch-and-wait (WW) strategy for rectal cancer patients with a clinical complete response to neoadjuvant therapy is changing the profile of patients undergoing TME surgery immediately following neoadjuvant treatment. The outcomes of ISR-CAA for patients with locally advanced rectal cancers not qualifying for WW have not been investigated.

METHODS

We conducted a retrospective analysis comparing the outcomes of ISR-CAA and abdominoperineal resection (APR) in patients with distal rectal cancer treated with neoadjuvant therapy and not qualifying for WW, at a comprehensive cancer center with an established WW program. The primary outcome was local recurrence-free survival.

RESULTS

Sixty-seven patients had ISR-CAA and 79 had APR. Median follow-up was 61.1 months. The two groups were similar in sex, tumor stage, grade, and distance from the anal verge, but patients in the APR group were older on average. An R0 resection was achieved in 94% of ISR-CAA patients and 91% of APR patients. Patients in the ISR-CAA group had a lower 5-year rate of local recurrence-free survival (79% vs. 93%; p = 0.038) compared with the APR group; however, 5-year disease-free survival did not differ significantly between groups (67% for ISR-CAA and 64% for APR; p = 0.19).

CONCLUSIONS

The local recurrence rate after ISR-CAA may be higher than after APR for patients without a clinical complete response to neoadjuvant therapy requiring TME surgery.

Efficacy of Neoadjuvant Short-Course Radiation Therapy Followed by Oxaliplatin-Based Chemotherapy for Locally Advanced Rectal Adenocarcinoma: A Single-Center Experience From Saudi Arabia

Background The 5-fluorouracil (5-FU), capecitabine-based long-course or short-course radiotherapy (SCRT) eventually preceded or followed by induction or consolidation chemotherapy (CT) and resection represents the preferred regimen for the treatment of locally advanced rectal cancer (LARC). This study aims to report our experience as a large medical center in Saudi Arabia, with the efficacy of short-course radiation therapy followed by oxaliplatin-based CT in achieving a pathologic complete response (pCR) in patients with LARC. Materials and methods This retrospective analysis encompassed 57 patients diagnosed with LARC at a large tertiary center in Riyadh, Saudi Arabia, from June 2020 to December 2022. All participants underwent short-term radiotherapy (25 Grays (Gy) over fractions within one week) followed by CT with 5-FU, leucovorin, and oxaliplatin (FOLFOX) or capecitabine and oxaliplatin (CAPOX), constituting the total neoadjuvant therapy (TNT). Surgical intervention and total mesorectal excision were performed six to eight weeks post-preoperative treatment. The primary endpoint was the pCR rate. Results Of the study participants, 34 (60%) were males, with a mean age of 57.6 ± 13.9 years. Two-thirds (n = 37,65%) were classified as T3. The overall response rates were 12 (21%), 12 (21%), 24 (42%), and nine (16%), for complete response (CR), near-complete response (nCR), partial response (PR), and progressive disease (PD), respectively. The multivariable logistic regression model identified five independent predictors for overall CR after adjusting for disease-related factors: N-stage, the circumferential resection margin (CRM), average vascularity (AV), surgical procedure, and postoperative tumor size. Patients with N2 disease had an 18% lower chance of achieving CR (OR = 0.824; 95% CI: 0.634-0.974; p = 0.035). Positive CRM was linked to a 71% reduction in the probability of CR (OR = 0.268; 95% CI: 0.087-0.823; p = 0.021). Each 1 cm increase in AV corresponded to a 28.5% increase in the likelihood of complete response (OR = 1.285; 95% CI: 1.029-1.605; p = 0.027). Patients who underwent AR had 2.8 times greater chances of achieving CR than those who underwent abdominoperineal resection (APR) (OR = 2.801; 95% CI: 1.057-9.324; p = 0.044). Lastly, each 1 cm increase in postoperative tumor size was associated with a 92.5% reduction in the odds of CR (OR = 0.074; 95% CI: 0.017-0.330; p = 0.001). Conclusions The current study supports the efficacy of TNT for treating LARC, with a pCR rate of 21% and near-complete response in nearly half of the patients with LARC. Significant predictors of pCR included N-stage, CRM status, AV size, and surgical approach. These insights could refine patient selection for TNT and inform future strategies to optimize treatment outcomes in rectal cancer. Prospective multicenter studies are warranted.

Exercise and Nutrition to Improve Cancer Treatment-Related Outcomes (ENICTO)

Chemotherapy treatment-related side effects are common and increase the risk of suboptimal outcomes. Exercise interventions during cancer treatment improve self-reported physical functioning, fatigue, anxiety, and depression, but it is unclear whether these interventions improve important clinical outcomes, such as chemotherapy relative dose intensity. The National Cancer Institute funded the Exercise and Nutrition to Improve Cancer Treatment-Related Outcomes (ENICTO) Consortium to address this knowledge gap. This article describes the mechanisms hypothesized to underpin intervention effects on clinically relevant treatment outcomes, briefly outlines each project's distinct research aims, summarizes the scope and organizational structure of ENICTO, and provides an overview of the integrated common data elements used to pursue research questions collectively. In addition, the article includes a description of consortium-wide activities and broader research community opportunities for collaborative research. Findings from the ENICTO Consortium have the potential to accelerate a paradigm shift in oncology care such that patients with cancer could receive exercise and nutrition programming as the standard of care in tandem with chemotherapy to improve relative dose intensity for a curative outcome.

Total neoadjuvant therapy based on short-course radiotherapy versus standard long-course chemoradiotherapy for locally advanced rectal cancer: a systematic review and meta-analysis of randomized controlled trials

Background

We conducted the meta-analysis to compare the therapeutic effects of total neoadjuvant therapy (TNT) based on short-course radiotherapy followed by consolidation chemotherapy (SCRT/CCT) and long-course chemoradiotherapy (LCCRT) for locally advanced rectal cancer (LARC) according to certain significant randomized controlled trials (RCTs).

Methods

The researchers retrieved several databases, including PubMed, Embase, Web of Science, and the Cochrane Library, to collect all the relevant literature published since the establishment of the databases until July 30, 2024, and then screened to determine the qualified literature and extracted the relevant information. Finally, RevMan 5.4 software was utilized to conduct the meta-analysis for determining the 95% confidence interval (CI) and pooled risk ratio (RR). There were 9 study indicators, including the pathologic complete remission (pCR) rate, tumor downstaging rate, R0 resection rate, sphincter preservation rate, disease-free survival (DFS), overall survival (OS), acute ≥3 grade toxicity rate, surgery complication rate, and distant recurrence rate. When moderate, even severe, heterogeneity was found, a random-effect model was applied; otherwise, a fixed-effect model was used for the analysis.

Results

A total of 6 eligible RCTs and 2259 participants were included in this meta-analysis. Compared with the standard LCCRT, TNT treatment on the basis of SCRT/CCT increased the pCR rate significantly [RR = 1.67, 95% CI (1.36, 2.04), P < 0.00001], especially in ≥ 4 cycles of the CCT arm [RR = 1.77, 95% CI: (1.41-2.23), p < 0.00001], and led to a similar tumor downstaging rate [RR = 0.99, 95% CI (0.85, 1.15), P = 0.92]. Moreover, survival outcomes, distant recurrence rate, and surgical indicators were comparable between the two groups.

Conclusion

For LARC patients, the SCRT/CCT regimen not only has a higher pCR rate, equivalent OS, and comparable additional indicators versus standard LCCRT but also shortens the treatment time, costs less, and improves patients' adherence to the innovative anti-tumor therapy; hence, with the concept of acute toxicity control, it could be further widely and safely utilized, especially in resource-limited settings.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42024600180.

Nonoperative management of rectal cancer

The management of locally advanced rectal cancer has changed drastically in the last few decades due to improved surgical techniques, development of multimodal treatment approaches and the introduction of a watch and wait (WW) strategy. For patients with a complete response to neoadjuvant treatment, WW offers an opportunity to avoid the morbidity associated with total mesorectal excision in favor of organ preservation. Despite growing interest in WW, prospective data on the safety and efficacy of nonoperative management are limited. Challenges remain in optimizing multimodal treatment regimens to maximize tumor regression and in improving the accuracy of patient selection for WW. This review summarizes the history of treatment for rectal cancer and the development of a WW strategy. It also provides an overview of clinical considerations for patients interested in nonoperative management, including restaging strategies, WW selection criteria, surveillance protocols and long-term oncologic outcomes.

Wavelets-Based Texture Analysis of Post Neoadjuvant Chemoradiotherapy Magnetic Resonance Imaging as a Tool for Recognition of Pathological Complete Response in Rectal Cancer, a Retrospective Study

Background: Patients with locally advanced rectal cancer (LARC) treated by neoadjuvant chemoradiotherapy (nCRT) may experience pathological complete response (pCR). Tools that can identify pCR are required to define candidates suitable for the watch and wait (WW) strategy. Automated image analysis is used for predicting clinical aspects of diseases. Texture analysis of magnetic resonance imaging (MRI) wavelets algorithms provides a novel way to identify pCR. We aimed to evaluate wavelets-based image analysis of MRI for predicting pCR. Methods: MRI images of rectal cancer from 22 patients who underwent nCRT were captured at best representative views of the tumor. The MRI images were digitized and their texture was analyzed using different mother wavelets. Each mother wavelet was used to scan the image repeatedly at different frequencies. Based on these analyses, coefficients of similarity were calculated providing a variety of textural variables that were subsequently correlated with histopathology in each case. This allowed for proper identification of the best mother wavelets able to predict pCR. The predictive formula of complete response was computed using the independent statistical variables that were singled out by the multivariate regression model. Results: The statistical model used four wavelet variables to predict pCR with an accuracy of 100%, sensitivity of 100%, specificity of 100%, and PPV and NPV of 100%. Conclusions: Wavelet-transformed texture analysis of radiomic MRI can predict pCR in patients with LARC. It may provide a potential accurate surrogate method for the prediction of clinical outcomes of nCRT, resulting in an effective selection of patients amenable to WW.

Landscape of Biomarkers and Pathologic Response in Rectal Cancer: Where We Stand?

Colorectal cancer (CRC) is a neoplasm with a high prevalence worldwide, with a multimodal treatment that includes a combination of chemotherapy, radiotherapy, and surgery in locally advanced stages with acceptable pathological complete response (pCR) rates, this has improved with the introduction of total neoadjuvant therapy (TNT) reaching pCR rates up to 37% in compare with classic neoadjuvant treatment (NAT) where pCR rates of around 20-25% are achieved. However, the patient population that benefits most from this therapy has not been determined, and there is a lack of biomarkers that can predict the course of the disease. Multiple biomarkers have been studied, ranging from hematological and molecular markers by imaging technique and combinations of them, with contradictory results that prevent their use in routine clinical practice. In this review, we evaluate the most robust prognostic biomarkers to be used in clinical practice, highlighting their advantages and disadvantages and emphasizing biomarker combinations and their predictive value.

Oncological Outcomes and Response Rate After Total Neoadjuvant Therapy for Locally Advanced Rectal Cancer: A Network Meta-Analysis Comparing Induction vs. Consolidation Chemotherapy vs. Standard Chemoradiation

TNT is now considered the preferred option for stage II-III locally advanced rectal cancer (LARC). However, the prognostic benefit and optimal sequence of TNT remains unclear. This network meta-analysis (NMA) compared short- and long-term outcomes amongst patients with LARC receiving total neoadjuvant therapy (TNT) as induction (iTNT) or consolidation chemotherapy (cTNT) with those receiving neoadjuvant chemoradiation (nCRT) alone. A systematic literature search was performed between 2012 and 2023. A Bayesian NMA was conducted using a Markov Chain Monte Carlo method with a random-effects model and vague prior distribution to calculate odds ratios (OR) with 95% credible intervals (CrI). The surface under the cumulative ranking (SUCRA) curves were used to rank treatment(s) for each outcome. In total, 11 cohorts involving 8360 patients with LARC were included. There was no significant difference in disease-free survival (DFS) and overall survival (OS) amongst the 3 treatments. Compared with nCRT, both cTNT (OR 2.36; 95% CrI, 1.57-3.66) and iTNT (OR 1.99; 95% CrI, 1.44-2.95) significantly improved complete response (CR) rate. Notably, cTNT ranked as the best treatment for CR (SUCRA 0.90) and iTNT as the best treatment for 3-year DFS and OS (SUCRA 0.72 and 0.87, respectively). Both iTNT and cTNT strategies significantly improved CR rates compared with nCRT. cTNT was ranked highest for CR rates, while iTNT was ranked highest for 3-year survival outcomes. However, no other significant differences in DFS, OS, sphincter-saving surgery, R0 resection and postoperative complications were found amongst the treatment groups.

The roles of PD-L1 in the various stages of tumor metastasis

The interaction between tumor programmed death ligand 1 (PD-L1) and T-cell programmed cell death 1 (PD-1) has long been acknowledged as a mechanism for evading immune surveillance. Recent studies, however, have unveiled a more nuanced role of tumor-intrinsic PD-L1 in reprograming tumoral phenotypes. Preclinical models emphasize the synchronized effects of both intracellular and extracellular PD-L1 in promoting metastasis, with intricate interactions with the immune system. This review aims to summarize recent findings to elucidate the spatiotemporal heterogeneity of PD-L1 expression and the pro-metastatic roles of PD-L1 in the entire process of tumor metastasis. For example, PD-L1 regulates the epithelial-to-mesenchymal transition (EMT) process, facilitates the survival of circulating tumor cells, and induces the formation of immunosuppressive environments at pre-metastatic niches and metastatic sites. And the complexed and dynamic regulation process of PD-L1 for tumor metastasis is related to the spatiotemporal heterogeneity of PD-L1 expression and functions from tumor primary sites to various metastatic sites. This review extends the current understandings for the roles of PD-L1 in mediating tumor metastasis and provides new insights into therapeutic decisions in clinical practice.

Localized Rectal Cancer: Indian Consensus and Guidelines

The rising incidence of colorectal cancer (CRC) in India, particularly the prevalence of rectal cancer over colon cancer (0.7:1), has been a growing concern in recent decades; especially notable is the trend of increasing cases among young CRC patients. Given the diverse treatment approaches for rectal cancer globally and the varying economic capacities of patients in low to middle-income countries (LMICs) like India, it is essential to establish consensus guidelines that are specifically tailored to meet the needs of these patients. To achieve this, a panel comprising 30 eminent rectal cancer experts convened to conduct a comprehensive and impartial evaluation of existing practices and recent advancements in the field. Through meticulous scrutiny of published literature and a consensus-building process that involved voting on pertinent questions, the panel formulated management strategies. These recommendations are the result of a rigorous, evidence-based process and encapsulate the collective wisdom and judgment of leading authorities in the field.

CPT1A mediates radiation sensitivity in colorectal cancer

The prevalence and mortality rates of colorectal cancer (CRC) are increasing worldwide. Radiation resistance hinders radiotherapy, a standard treatment for advanced CRC, leading to local recurrence and metastasis. Elucidating the molecular mechanisms underlying radioresistance in CRC is critical to enhance therapeutic efficacy and patient outcomes. Bioinformatic analysis and tumour tissue examination were conducted to investigate the CPT1A mRNA and protein levels in CRC and their correlation with radiotherapy efficacy. Furthermore, lentiviral overexpression and CRISPR/Cas9 lentiviral vectors, along with in vitro and in vivo radiation experiments, were used to explore the effect of CPT1A on radiosensitivity. Additionally, transcriptomic sequencing, molecular biology experiments, and bioinformatic analyses were employed to elucidate the molecular mechanisms by which CPT1A regulates radiosensitivity. CPT1A was significantly downregulated in CRC and negatively correlated with responsiveness to neoadjuvant radiotherapy. Functional studies suggested that CPT1A mediates radiosensitivity, influencing reactive oxygen species (ROS) scavenging and DNA damage response. Transcriptomic and molecular analyses highlighted the involvement of the peroxisomal pathway. Mechanistic exploration revealed that CPT1A downregulates the FOXM1-SOD1/SOD2/CAT axis, moderating cellular ROS levels after irradiation and enhancing radiosensitivity. CPT1A downregulation contributes to radioresistance in CRC by augmenting the FOXM1-mediated antioxidant response. Thus, CPT1A is a potential biomarker of radiosensitivity and a novel target for overcoming radioresistance, offering a future direction to enhance CRC radiotherapy.

Organ preservation after neoadjuvant long-course chemoradiotherapy versus short-course radiotherapy

BACKGROUND

Potential differences in organ preservation between total neoadjuvant therapy (TNT) regimens integrating long-course chemoradiotherapy (LCCRT) and short-course radiotherapy (SCRT) in rectal cancer remain undefined.

PATIENTS AND METHODS

This natural experiment arose from a policy change in response to the COVID-19 pandemic during which our institution switched from uniformly treating patients with LCCRT to mandating that all patients be treated with SCRT. Our study includes 323 locally advanced rectal adenocarcinoma patients treated with LCCRT-based or SCRT-based TNT from January 2018 to January 2021. Patients who achieved clinical complete response were offered organ preservation with watch-and-wait (WW) management. The primary outcome was 2-year organ preservation. Additional outcomes included local regrowth, distant recurrence, disease-free survival (DFS), and overall survival (OS).

RESULTS

Patient and tumor characteristics were similar between LCCRT (n = 247) and SCRT (n = 76) cohorts. Median follow-up was 31 months. Similar clinical complete response rates were observed following LCCRT and SCRT (44.5% versus 43.4%). Two-year organ preservation was 40% [95% confidence interval (CI) 34% to 46%] and 31% (95% CI 22% to 44%) among all patients treated with LCCRT and SCRT, respectively. In patients managed with WW, LCCRT resulted in higher 2-year organ preservation (89% LCCRT, 95% CI 83% to 95% versus 70% SCRT, 95% CI 55% to 90%; P = 0.005) and lower 2-year local regrowth (19% LCCRT, 95% CI 11% to 26% versus 36% SCRT, 95% CI 16% to 52%; P = 0.072) compared with SCRT. The 2-year distant recurrence (10% versus 6%), DFS (90% versus 90%), and OS (99% versus 100%) were similar between WW patients treated with LCCRT and SCRT, respectively.

CONCLUSIONS

While WW eligibility was similar between cohorts, WW patients treated with LCCRT had higher 2-year organ preservation and lower local regrowth than those treated with SCRT, yet similar DFS and OS. These data support induction LCCRT followed by consolidation chemotherapy as the preferred TNT regimen for patients with locally advanced rectal cancer pursuing organ preservation.

The Rise of Patients Declining Rectal Cancer Surgery in the Era of Total Neoadjuvant Therapy

BACKGROUND

The treatment landscape for rectal cancer is rapidly evolving, particularly with the increasing use of neoadjuvant therapies. Still, up to 50% of patients with stage II-III disease require surgical resection post-neoadjuvant therapy to achieve the best oncologic outcomes. Many patients, however, hope to avoid surgery. This study aimed to assess trends and factors associated with declining recommended oncologic resection after systemic therapy nationally and in our institution.

PATIENTS AND METHODS

This is a retrospective analysis using the National Cancer Database from 2009 to 2021 and an institutional cohort at an academic center between 2009 and 2022 including adults with stage I-III rectal adenocarcinoma who underwent neoadjuvant therapy and were suitable for surgery.

RESULTS

Of 96,997 patients nationally, the rate of declining surgery increased from 2.3% in 2009 to 6.3% in 2021, a trend mirrored in our institutional cohort of 365 patients (0% in 2009/2010 to approximately 6-12% in 2021/2022). Locally, patients who declined surgery had higher rates of tobacco use, temporary loss to follow-up during therapy, and a more robust, albeit incomplete, tumor response to neoadjuvant therapy compared with controls who underwent surgery. Despite a stoma being the most cited reason for declining surgery, 30.4% of patients who declined oncologic resection died with a stoma.

CONCLUSIONS

Our findings underscore a notable trend of patients declining oncologic resections following neoadjuvant therapy for rectal cancer. By shedding light on the outcomes of patients who opt against surgery, we address a critical gap in the literature essential for informing patients about potential risks.

Neoadjuvant chemotherapy followed by definitive local treatment in locally advanced sinonasal squamous cell carcinoma

Background

Sinonasal squamous cell carcinoma (SCC) is a rare disease entity, comprising less than 5% of malignancies of the head and neck. While surgery is the primary treatment approach, neoadjuvant and adjuvant therapies play crucial roles in enhancing the prognosis of patients undergoing treatment with the goal of cure. In this study, we aimed to explore the treatment outcomes of neoadjuvant chemotherapy (NAC) in patients with locally advanced sinonasal SCC.

Methods

Medical records of patients diagnosed of locally advanced (cT3-4b, N0-3) sinonasal SCC treated with a definitive aim between January 2005 and March 2023 were retrospectively reviewed. Patients were categorized into the following groups based on the initial treatment: NAC followed by surgery, NAC followed by concurrent chemoradiotherapy (CCRT), definitive CCRT, or upfront surgery. Initial treatment plan was decided by a multidisciplinary team. Primary endpoint was overall survival (OS) and objective response rate, and secondary endpoints were progression free survival (PFS), cumulative incidence of local and distant failures, and treatment-related toxicity. The treatment response was assessed according to the RECIST criteria.

Results

Total 126 patients were included, and the median follow-up period was 25.6 months. The objective response rate to NAC was 48.2%. The subsequent resection rate was 70%, 42.9%, and 16.7% for patients with stage T3, T4a, and T4b disease, respectively. Two-year progression-free survival did not differ significantly between the NAC followed by surgery and upfront surgery groups (53.6% vs. 60.6%, P = 0.615) or between the NAC followed by CCRT and definitive CCRT groups (26.7% vs. 37.4%, P = 0.506).

Conclusion

NAC may be a valuable treatment option for patients with locally advanced sinonasal SCC, as it provides an opportunity for curative surgery and exhibits non-inferior oncological outcomes compared with upfront definitive local treatments.

Association Between Chemotherapy-Induced Peripheral Neuropathy and Low Anterior Resection Syndrome

INTRODUCTION

Low anterior resection syndrome (LARS) can be a debilitating condition that develops after undergoing sphincter-preserving surgery for rectal cancer. Chemotherapy-induced peripheral neuropathy is a common side effect of platinum-based chemotherapy agents used as systemic therapy for rectal cancer treatment. The purpose of this study was to determine the potential relationship between CIPN and LARS.

METHODS

This was a retrospective review of patients who underwent a low anterior resection for rectal cancer and received systemic therapy contacted at least six months from the most recent surgery. Eligible patients were called and completed the relevant surveys over the phone or email.

RESULTS

There was a total of 42 patients who completed the surveys with 33 (79%) having major LARS. Presence of a diverting ileostomy was the only significantly differentcharacteristic in those with major LARS versus those without. CIPN was independently associated with LARS (p = 0.046) on linear regression when controlling for neoadjuvant chemoradiation, diverting ileostomy and tumor distance from the anal verge.

CONCLUSIONS

Developing severe CIPN is associated with developing LARS. Further studies evaluating the etiology behind this relationship should be conducted.

Optimal Sequence for Total Neoadjuvant Therapy in Locally Advanced Rectal Cancer: An Evidence-Based Review

INTRODUCTION

Historically, multimodal therapeutic strategies involving preoperative chemoradiotherapy (CRT), surgery, and adjuvant chemotherapy (CT) have been employed to treat locally advanced rectal cancer (LARC). Total Neoadjuvant Therapy (TNT) is showing promise in improving outcomes. Despite its benefits, the optimal sequencing within TNT-whether induction chemotherapy should precede or follow chemoradiotherapy-remains a critical question. This study endeavors to explore the effects of different TNT sequencing strategies on patient outcomes, including tumor downstaging, pathological response, organ preservation, and the balance between efficacy and tolerability.

METHODS

Our methodology entailed a comprehensive literature review conducted on Medline, focusing on recent research, including retrospective studies, systematic reviews, and clinical trials. The review emphasized the comparison of induction chemotherapy versus consolidation chemotherapy within TNT regimens, assessing outcomes such as pathological response, organ preservation rates, and adverse effects. To ensure the selection of appropriate and high-quality studies, specific inclusion and exclusion criteria were applied.

RESULTS

The analysis revealed that induction chemotherapy might lead to decreased adherence to subsequent chemoradiotherapy while offering an early intervention against micrometastasis and potentially improving overall chemotherapy compliance. Conversely, consolidation chemotherapy has been associated with higher pathological complete response (pCR) rates and improved tolerability, indicating its potential for patients requiring local symptom relief or those eligible for a nonoperative management approach. Comparative studies like CAO/ARO/AIO-12 and the OPRA trials have significantly contributed to our understanding, suggesting that while both strategies have distinct advantages, the choice between induction and consolidation chemotherapy should be tailored based on individual patient profiles and tumor characteristics.

CONCLUSION

This narrative review underscores the importance of a nuanced approach to TNT sequencing in locally advanced rectal cancer, highlighting the need for further research to refine treatment strategies.

Evaluating complete response rates and predictors in total neoadjuvant therapy for rectal cancer

BACKGROUND

There is a paradigm shift in the management of locally advanced rectal cancer (LARC) from conventional neoadjuvant treatment to total neoadjuvant therapy (TNT). Despite its growing acceptance, there are limited studies that have examined its effects on disease presentation. In addition, it is important to determine the factors that play a role in complete response (CR). Our previous data from 119 patients revealed that the CR rate was 37%, and low rectal tumors and the absence of extramural vascular invasion (EMVI) were predictors of CR. Unfortunately, there continues to be a lack of data, and reliable markers are still needed to consistently identify the best respondents. Therefore, this study aimed to determine the factors associated with CR. Moreover, this study hypothesized that both predictive factors and the CR ratio might evolve over time because of the growing patient population.

METHODS

This retrospective study included patients who completed TNT for LARC at our tertiary care center between 2015 and 2022. The primary outcome was to determine the predictors of CR. The secondary outcomes were the 2-year disease-free survival (DFS) rate and overall survival (OS) rate. CR consists of patients who sustained clinical CR (cCR) for at least 12 months under watch and wait or had pathologic CR (pCR) after surgery.

RESULTS

Of 339 patients with LARC, 208 (61.3%) successfully completed TNT. Among 208 patients, 57 (27.4%) achieved cCR, and 166 (80.0%) sustained cCR without tumor regrowth after 1 year. The remaining 151 patients (72.6%) underwent surgery, and 42 patients had pCR. The final CR rate was 42.3%. The median age of the patients was 56 years (IQR, 49-66). Moreover, 132 participants (63.5%) were male, whereas 76 participants (36.5%) were female. The median tumor size was 4.95 cm (IQR, 3.60-6.43), with most tumors in the low rectum (119 [57.2%]). Based on the MRI findings, the mesorectal facia (MRF) involvement rate was 25.0% (n = 52), and EMVI was observed in 43 patients (20.7%). Low rectal tumors, the absence of MRF involvement, and the absence of EMVI were predictors of CR. With a median follow-up of 24.7 months, 2-year DFS and OS were significantly higher among patients with CR than among patients with incomplete response (91.3% vs 71.0% [P < .01] and 98.8% vs 90.2% [P = .03], respectively).

CONCLUSION

An increasing CR rate was observed in our updated dataset compared with that in our previous study. In addition to previously identified predictors, low tumor location, and the absence of EMVI, the absence of MRF involvement was determined as a predictor of CR. Our findings offer valuable insights into clinical practice and help clinicians set clear expectations when counseling patients.

Curative immune checkpoint inhibitors therapy in patients with mismatch repair-deficient locally advanced rectal cancer: a real-world observational study

BACKGROUND

Sustained clinical complete remissions were reported in all of 23 mismatch repair deficient/microsatellite instable (dMMR/MSI) locally advanced rectal cancer (LARC) patients treated with dostarlimab alone in a recent phase II study. These results led to off-label use of dostarlimab or other immune checkpoint inhibitors (ICIs) in dMMR/MSI-LARC even before regulatory approval. The present study [STAR(t)-IT-REDUCE] describes the outcome of dMMR/MSI-LARC patients treated with ICI in Italy.

MATERIALS AND METHODS

Investigator-initiated, observational, retrospective-cohort, multicentric study of ICI treatment in dMMR/MSI-LARC. Patients were eligible if treated with ≥1 ICI dose from July 2022 to December 2023 (date of approval of dostarlimab for this indication in Italy).

RESULTS

Seventeen dMMR/MSI-LARC patients (13 of 17 treatment-naïve) were eligible. Fourteen patients completed 6 months of treatment, two discontinued after four doses and one after five doses because of immune-related pneumonia, social constraints, or non-oncological bowel obstruction, respectively. Overall, 16 of 17 assessable patients [94.1%; 95% confidence interval (CI) 69.24% to 99.69%, 'ITT analysis'] achieved complete clinical response (cCR). Ten of 11 treatment-naïve patients completing 6 months of treatment had cCR (90.9%; 95% CI 57.12% to 99.52%, 'per-protocol analysis'). One patient with near-CR underwent rectal surgery and minimal residual intramucosal tumor was found. With a median follow-up of 9.5 months, no local relapse occurred. One patient developed unconfirmed lung metastases. Two grade 3 and no grade 4 adverse events were reported.

CONCLUSION

The present STAR(t)-IT-REDUCE study documents the immunoablative and curative activity of ICI monotherapy in dMMR/MSI-LARC. Toxicity and compliance issues inherent to real-world practice are limited and do not affect achievement of initial complete tumor response but may limit response duration.

The effect of long-standing lymphopenia after radiation therapy on survival in rectal cancer

BACKGROUND

Lymphopenia and high neutrophil-to-lymphocyte ratio are known negative prognostic factors in rectal cancer. Until recently, however, lymphopenia was regarded as a minor sequela following radiation therapy (RT). The immune system's influence on rectal cancer treatment outcomes led us to evaluate the impact of lymphopenia at various time points, before, during, and following radiotherapy. We hypothesized that chronic lymphopenia following radiotherapy might negatively influence the survival of patients, and pre-treatment lymphopenia may be predictive of poor outcomes.

METHODS

This retrospective study involved 110 patients treated for rectal cancer between 2015 and 2019. The oncological outcomes are defined as alive without disease (AWOD), alive with disease (AWD), and death. These outcome probabilities tested against variables of lymphopenia before RT, during RT, and at several post-RT follow-up time points.

RESULTS

At the end of the study, 69 patients were AWOD (63 %), 13 were AWD (12 %) and 28 had died (25 %). Treatment results were assessed with according level of lymphocytes measured one year following RT: 35 out of 39 patients (89.7 %) with normal values were AWOD. In 65 patients with sustained lymphopenia, 52 % were AWOD, 18.5 % AWD and 29 % died. A similar difference was found at all time-points up to 2 years following RT (p < 0.004). The results of our study shows that pre-existing lymphopenia (prior to RT) is associated with a 3 times greater chance of death compared to patients with normal lymphocyte levels prior to RT. The PFS significantly affected by lymphopenia at all time-points after RT. An NLR of more than 4 was associated with a 3-time higher risk of recurrence than lower NLR scores (p = 0.0054).

CONCLUSION

Our results support the relevance of lymphopenia and NLR in the prognosis of rectal cancer. We believe this is the first study showing a negative correlation between sustained lymphopenia and OS following RT.

Chemoradiotherapy plus induction or consolidation chemotherapy as total neoadjuvant therapy for locally advanced rectal cancer: Pooled analysis of the CAO/ARO/AIO-12 and the OPRA randomized phase 2 trials

BACKGROUND

Total neoadjuvant therapy (TNT) has been used for patients with locally advanced rectal cancer. The optimal sequence of chemoradiotherapy (CRT) and chemotherapy (CT) is a matter of debate.

METHODS

We performed a pooled analysis of the CAO/ARO/AIO-12 and OPRA multicenter, randomized phase 2 trials to identify patient subsets that could benefit from one TNT sequence over the other regarding disease-free survival (DFS). Patients with stage II/III rectal cancer were randomized to CRT (50.4-54 Gy) with either induction (INCT-CRT) or consolidation CT (CRT-CNCT) with fluorouracil, leucovorin, oxaliplatin (CAO/ARO/AIO-12 and OPRA) or capecitabine and oxaliplatin (OPRA) followed by mandatory total mesorectal excision (TME) (CAO/ARO/AIO-12) or selective watch-and-wait surveillance (OPRA). 311 and 324 patients were recruited from June 15, 2015 to January 31, 2018; and from April 12, 2014 to March 30, 2020 in the two trials, respectively. Pretreatment clinical and tumor characteristics included were age, sex, ECOG, cT-category, cN-category, clinical UICC stage, location from anal verge, and tumor grade.

FINDINGS

In total, 628 eligible patients were included in the pooled analysis (CAO/ARO/AIO-12, n = 304; OPRA, n = 324). Of those, 313 were randomly assigned to the INCT-CRT group, and 315 to the CRT-CNCT group. Median follow-up was 43 months (IQR, 35-49) months in the CAO/ARO/AIO-12 trial and 61,2 months (IQR, 42-68,4) in the OPRA trial. Pooled analysis of baseline clinical and tumor characteristics did not identify any subgroups of patients that would benefit by the one TNT sequence over the other with regard to DFS.

INTERPRETATION

To our knowledge, this is the first pooled analysis of two randomized trials after direct head-to-head comparison of both TNT sequences. Both trials reported higher rates of complete response with CRT-CNCT, and this should be considered the preferred TNT sequence if organ preservation is a priority.

Colorectal cancer: Recent advances in management and treatment

Colorectal cancer (CRC) is the third most common cancer worldwide, and the second most common cause of cancer-related death. In 2020, the estimated number of deaths due to CRC was approximately 930000, accounting for 10% of all cancer deaths worldwide. Accordingly, there is a vast amount of ongoing research aiming to find new and improved treatment modalities for CRC that can potentially increase survival and decrease overall morbidity and mortality. Current management strategies for CRC include surgical procedures for resectable cases, and radiotherapy, chemotherapy, and immunotherapy, in addition to their combination, for non-resectable tumors. Despite these options, CRC remains incurable in 50% of cases. Nonetheless, significant improvements in research techniques have allowed for treatment approaches for CRC to be frequently updated, leading to the availability of new drugs and therapeutic strategies. This review summarizes the most recent therapeutic approaches for CRC, with special emphasis on new strategies that are currently being studied and have great potential to improve the prognosis and lifespan of patients with CRC.