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Cui Y, Song M, Tie J, Li S, Wang H, Zhang Y, Geng J, Liu Z, Teng H, Sui X, Zhu X, Cai Y, Li Y, Wang W. Clinicopathological factors predict residual lymph node metastasis in locally advanced rectal cancer with ypT0-2 after neoadjuvant chemoradiotherapy. J Cancer Res Clin Oncol 2024; 150:176. [PMID: 38575793 PMCID: PMC10995092 DOI: 10.1007/s00432-024-05662-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 02/21/2024] [Indexed: 04/06/2024]
Abstract
PURPOSE Residual lymph node metastases (RLNM) remained a great concern in the implementation of organ-preserving strategies and led to poor prognosis in locally advanced rectal cancer (LARC). In this study, we aimed to identify the clinicopathological factors correlated with RLNM in LARC patients with ypT0-2 after neoadjuvant chemoradiotherapy (NCRT). METHODS We retrospectively analyzed 417 patients histologically diagnosed middle-low LARC after NCRT and total mesorectal excision (TME), whose pathological staging was ypT0-2. All patients received pelvic magnetic resonance imaging (MRI) before NCRT. The radiation doses were 50-50.6 Gy for the planning gross tumor volume and 41.8-45 Gy for the planning target volume, respectively. A nomogram for predicting RLNM was constructed using a binary logistic regression. Nomogram performance was assessed by receiver operating characteristic (ROC) curve, calibration curve, decision curve analysis (DCA) and clinical impact curve (CIC). RESULTS After surgery, 191 patients (45.8%) were ypT0, 43 patients (10.3%) were ypT1 and 183 patients (43.9%) were ypT2, and a total of 49 patients (11.8%) were found the presence of RLNM. Multivariable analyses identified MRI-defined mesorectal fascia (MRF)-positive, high-grade histopathology at biopsy, advanced ypT-category, and the presence of perineural invasion (PNI) as the predictive factors. The nomogram, incorporating all these predictors, showed good discrimination and calibration efficacy, with the areas under the ROC curve of 0.690 (95% CI: 0.610-0.771). Both DCA and CIC demonstrated that this nomogram has good clinical usefulness. CONCLUSION The nomogram model can predict RLNM in patients with ypT0-2 tumors. It can help select suitable patients for performing organ-preserving strategies after NCRT.
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Affiliation(s)
- Yujun Cui
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Maxiaowei Song
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Jian Tie
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Shuai Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Hongzhi Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Yangzi Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Jianhao Geng
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Zhiyan Liu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Huajing Teng
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Xin Sui
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Xianggao Zhu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Yong Cai
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Yongheng Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China.
| | - Weihu Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China.
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MRI-based radiomics to predict neoadjuvant chemoradiotherapy outcomes in locally advanced rectal cancer: A multicenter study. Clin Transl Radiat Oncol 2022; 38:175-182. [DOI: 10.1016/j.ctro.2022.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/12/2022] [Accepted: 11/14/2022] [Indexed: 11/18/2022] Open
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Kim S, Huh JW, Lee WY, Yun SH, Kim HC, Cho YB, Park Y, Shin JK. Correlation between T stage and lymph node metastasis in rectal cancer treated with preoperative chemoradiotherapy. Ther Adv Med Oncol 2022; 14:17588359221132620. [PMID: 36312818 PMCID: PMC9597009 DOI: 10.1177/17588359221132620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 09/27/2022] [Indexed: 11/07/2022] Open
Abstract
Background: Depth of tumor is a risk factor for lymph node metastasis in rectal cancer,
but impact of yield pathologic T (ypT) stage on lymph node involvement in
rectal cancer remains unclear. The aim of this study was to evaluate the
correlation between ypT stage and lymph node metastasis. Methods: From January 2010 to December 2015, 602 patients who were diagnosed with
rectal cancer and treated with neoadjuvant chemoradiotherapy (CRT) followed
by radical operation were reviewed retrospectively. The correlations between
ypT stage and lymph node status and survival were evaluated. Results: On pathology, 179 (29.7%) patients exhibited regional lymph node metastasis.
Lymph node metastasis was seen in 8.5% of ypT0 patients, 20% of ypT1, 18.4%
of ypT2, 47.5% of ypT3, and 27.3% of ypT4. Positive lymph node metastasis
was correlated with ypT stage. In addition, the difference of lymph node
metastasis in ypT stage subgroups was statistically significant
(p < 0.001). Five-year disease-free survival was
significantly different in the ypT stage subgroups (88.7%
versus 86.7% versus 82.6%
versus 64.7% versus 72.7%,
p < 0.001), as was 5-year overall survival (96.2%
versus 90.0% versus 95.8%
versus 80.0% versus 90.9%,
p < 0.001). Conclusion: YpT stage is associated with lymph node metastasis in rectal cancer treated
with neoadjuvant CRT and radical operation, and ypT0 patients exhibited an
8.5% lymph node metastasis rate. Therefore, the decision for local excision
or the watch-and-wait strategy for rectal cancer treated with neoadjuvant
CRT and predicted to show a pathologic complete response should be
considered with caution.
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Affiliation(s)
- Seijong Kim
- Department of Surgery, Samsung Medical Center,
Sungkyunkwan University School of Medicine, Seoul, Korea
| | | | - Woo Yong Lee
- Department of Surgery, Samsung Medical Center,
Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seong Hyeon Yun
- Department of Surgery, Samsung Medical Center,
Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Cheol Kim
- Department of Surgery, Samsung Medical Center,
Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Beom Cho
- Department of Surgery, Samsung Medical Center,
Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoonah Park
- Department of Surgery, Samsung Medical Center,
Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Kyong Shin
- Department of Surgery, Samsung Medical Center,
Sungkyunkwan University School of Medicine, Seoul, Korea
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Comparison of tumor regression grade and clinical stage based on MRI image as a selection criterion for non-radical management after concurrent chemoradiotherapy in locally advanced rectal cancer: a multicenter, retrospective, cross-sectional study. Int J Colorectal Dis 2022; 37:1561-1568. [PMID: 35648208 DOI: 10.1007/s00384-022-04193-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/21/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE There has been no comparative study on the clinical value of magnetic resonance tumor regression grade (mrTRG)1-2 and ycT0-1N0 for the prediction of ypT0-1N0 after concurrent chemoradiotherapy (CCRT) for rectal cancer. We compared the diagnostic performance between mrTRG1-2 and ycT0-1N0 for predicting ypT0-1N0 as a selection criterion for non-radical management after CCRT in locally advanced rectal cancer. METHODS This retrospective study enrolled 291 patients from three referral hospitals between January 2018 and March 2020. The diagnostic performance of ycT0-1N0 and mrTRG1-2 for the prediction of ypT0-1N0 was compared in terms of sensitivity, specificity, positive-predictive value, negative-predictive value, and area under the curve (AUC). RESULTS Sixty-eight patients (23.4%) achieved ypT0-1N0. Nineteen patients (6.5%) had ycT0-1N0, and 91 patients (31.2%) had mrTRG1-2. For predicting ypT0-1N0, ycT0-1N0 had a sensitivity of 16.2% (95% confidence interval [CI]: 8.36‒27.10) and positive-predictive value of 57.9% (95% CI: 36.57‒76.63), while mrTRG1-2 had a sensitivity of 58.8% (95% CI: 46.23‒70.63) and positive-predictive value of 44.0% (95% CI: 36.46‒51.74). When predicting ypT0-1N0, mrTRG1-2 showed a higher AUC (0.680, 95% CI: 0.604‒0.756) than ycT0-1N0 (0.563, 95% CI: 0.481‒0.645) (P < 0.001). CONCLUSION mrTRG1-2 might be a better indicator than ycT0-1N0 for the selection of non-radical management of advanced rectal cancer post-CCRT. However, additional diagnostic tools are required for predicting ypT0-1N0 because mrTRG1-2 or yc stage on MRI has insufficient evidence for diagnosing ypT0-1N0.
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Lee JK, Cho JR, Song KS, Oh JH, Jeong SY, Kim MJ, Lee J, Kim MH, Oh HK, Kim DW, Kang SB. Oncologic comparison between nonradical management and total mesorectal excision in good responders after chemoradiotherapy in patients with mid-to-low rectal cancer. Ann Surg Treat Res 2021; 101:93-101. [PMID: 34386458 PMCID: PMC8331553 DOI: 10.4174/astr.2021.101.2.93] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/06/2021] [Accepted: 06/16/2021] [Indexed: 01/04/2023] Open
Abstract
Purpose This study was performed to compare the oncologic outcomes between nonradical management and total mesorectal excision in good responders after chemoradiotherapy. Methods We analyzed 75 patients, who underwent 14 watch-and-wait, 30 local excision, and 31 total mesorectal excision, in ycT0-1N0M0 based on magnetic resonance imaging after chemoradiotherapy for advanced mid-to-low rectal cancer in 3 referral hospitals. The nonradical management group underwent surveillance with additional sigmoidoscopy and rectal magnetic resonance imaging every 3-6 months within the first 2 years. Results Nonradical management group had more low-lying tumors (P < 0.001) and less lymph node metastasis based on magnetic resonance imaging (P = 0.004). However, cT stage, ycT, and ycN stage were not different between the 2 groups. With a median follow-up period of 64.7 months, the 5-year locoregional failure rate was higher in the nonradical management group than in the total mesorectal excision group (16.7% vs. 0%, P = 0.013). However, the 5-year overall survival and disease-free survival rates of the nonradical management and total mesorectal excision groups were not different (95.2% vs. 93.5%, P = 0.467; 76.4% vs. 83.6%, P = 0.665; respectively). Conclusion This study shows that nonradical management for ycT0-1N0 mid-to-low rectal cancer may be an alternative treatment to total mesorectal excision under proper surveillance and management for oncologic events.
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Affiliation(s)
- Ja Kyung Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jung Rae Cho
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Kwang-Seop Song
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Jae Hwan Oh
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Seung-Yong Jeong
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Min Jung Kim
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jeehye Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Min Hyun Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Heung-Kwon Oh
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Duck-Woo Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Sung-Bum Kang
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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Shao K, Zheng R, Li A, Li X, Xu B. Clinical predictors of pathological good response in locally advanced rectal cancer. Radiat Oncol 2021; 16:10. [PMID: 33436026 PMCID: PMC7805032 DOI: 10.1186/s13014-020-01741-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 12/26/2020] [Indexed: 01/10/2023] Open
Abstract
Purpose The aim of this study was to identify the clinical predictors of pathological good response (PGR) after neoadjuvant chemoradiotherapy (nCRT) in locally advanced rectal cancer (LARC) to clarify the indications for local excision. Methods and materials A total of 173 patients with LARC (cT3–4/N +) who were treated with nCRT followed by surgery were enrolled in our retrospective study. Patients were categorized into two groups according to the different tumor responses of surgical pathology. Stage ypT0–1N0 was defined as the group with PGR, and stage ypT2–4N0/ypTanyN + was the defined as the pathological poor response (PPR) group, and the potential predictors were compared. Results Of 173 patients, PGR was achieved in 57 patients (32.95%). The distance from the inferior margin of the tumor to the anal verge, cT classification, pretreatment carcinoembryonic antigen (CEA) and the interval from the end of radiation to surgery were correlated with pathological response. In the multivariate analysis, the distance from anal verge < 5 cm (OR = 0.443, p = 0.019), pretreatment CEA < 5 ng/mL (OR = 0.412, p = 0.015) and the interval from the end of radiation to surgery ≥ 84 days (OR = 2.652, p = 0.005) were independent predictors of PGR. Conclusions The distance from the inferior margin of the tumor to the anal verge, pretreatment CEA and the interval from the end of radiation to surgery were significant predictors of PGR in LARC. A prospective study is needed to further validate these results in the future.
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Affiliation(s)
- Kongfeng Shao
- Department of Radiation Oncology, Fujian Medical University Union Hospital, No.29 Xinquan Road, Gulou District, Fuzhou, 350001, People's Republic of China.,School of Clinical Medicine, Fujian Medical University, Fuzhou, People's Republic of China.,College of Union Clinical Medicine, Fujian Medical University, Fuzhou, People's Republic of China
| | - Rong Zheng
- Department of Radiation Oncology, Fujian Medical University Union Hospital, No.29 Xinquan Road, Gulou District, Fuzhou, 350001, People's Republic of China.,College of Union Clinical Medicine, Fujian Medical University, Fuzhou, People's Republic of China
| | - Anchuan Li
- Department of Radiation Oncology, Fujian Medical University Union Hospital, No.29 Xinquan Road, Gulou District, Fuzhou, 350001, People's Republic of China.,School of Clinical Medicine, Fujian Medical University, Fuzhou, People's Republic of China.,College of Union Clinical Medicine, Fujian Medical University, Fuzhou, People's Republic of China
| | - Xiaobo Li
- Department of Radiation Oncology, Fujian Medical University Union Hospital, No.29 Xinquan Road, Gulou District, Fuzhou, 350001, People's Republic of China.,College of Medical Technology and Engineering, Fujian Medical University, Fuzhou, People's Republic of China.,School of Clinical Medicine, Fujian Medical University, Fuzhou, People's Republic of China.,College of Union Clinical Medicine, Fujian Medical University, Fuzhou, People's Republic of China
| | - Benhua Xu
- Department of Radiation Oncology, Fujian Medical University Union Hospital, No.29 Xinquan Road, Gulou District, Fuzhou, 350001, People's Republic of China. .,College of Medical Technology and Engineering, Fujian Medical University, Fuzhou, People's Republic of China. .,School of Clinical Medicine, Fujian Medical University, Fuzhou, People's Republic of China. .,College of Union Clinical Medicine, Fujian Medical University, Fuzhou, People's Republic of China.
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Kang J, Park MC, Kim J, Hur H, Min BS, Baik SH, Lee KY, Kim NK. Prediction of tumor response of rectal cancer cells via 3D cell culture and in vitro cytotoxicity assay before initiating preoperative chemoradiotherapy. Oncol Lett 2019; 18:3863-3872. [PMID: 31516597 DOI: 10.3892/ol.2019.10702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 07/23/2019] [Indexed: 11/05/2022] Open
Abstract
The aim of the present study was to investigate the utility of 3D cell culture and in vitro cytotoxicity assays, performed using cells derived from biopsies obtained prior to the initiation of preoperative chemoradiotherapy (preop-CRT), in predicting tumor response to chemoradiotherapy following preop-CRT in rectal cancer. Biopsies were obtained from 49 patients with locally advanced rectal cancer that underwent preop-CRT between August 2015 and March 2017. Tumor tissue was obtained before initiating preop-CRT. The response to chemoradiation was assessed by in vitro cytotoxicity assay following 3D cell culture and radiation treatment. The associations between the results from the cytotoxicity assay, and tumor regression grade (TRG) and yp node (ypN) positivity were investigated. Among 49 patients, 26 patients were available for analysis. Cytotoxicity ranged from 25.5-72.6% (median, 47.6%). There was no difference in cytotoxicity according to the TRGs 1-5 (P=0.940), or good tumor response (TRGs 1-2 vs. TRGs 3-5; P=0.729). However, there was a significant difference in cytotoxicity between the ypN-negative and -positive groups (53.2±14.1 and 38.7±10.1, respectively; P=0.021). Following dichotomization of patients with 45% cut-off value, the cytotoxicity assay was the only factor that predicted ypN positivity in multivariate analysis (odds ratio, 13; 95% confidence interval, 1.2-133.2; P=0.031). In conclusion, the cytotoxicity assay using the 3D cell culture method can be used to predict tumor response, particularly ypN positivity, in patients with rectal cancer who are scheduled for preop-CRT.
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Affiliation(s)
- Jeonghyun Kang
- Department of Surgery, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Min Chul Park
- CureBio Co., Ltd., Suwon, Gyeonggi 16229, Republic of Korea
| | - Jina Kim
- CureBio Co., Ltd., Suwon, Gyeonggi 16229, Republic of Korea
| | - Hyuk Hur
- Department of Surgery, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Byung Soh Min
- Department of Surgery, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Seung Hyuk Baik
- Department of Surgery, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Kang Young Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Nam Kyu Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
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Cho MS, Kim H, Han YD, Hur H, Min BS, Baik SH, Cheon JH, Lim JS, Lee KY, Kim NK. Endoscopy and magnetic resonance imaging-based prediction of ypT stage in patients with rectal cancer who received chemoradiotherapy: Results from a prospective study of 110 patients. Medicine (Baltimore) 2019; 98:e16614. [PMID: 31464897 PMCID: PMC6736480 DOI: 10.1097/md.0000000000016614] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Accurate tumor response determination remains inconclusive after preoperative chemoradiation therapy (CRT) for rectal cancer. This study aimed to investigate whether clinical assessment, such as endoscopy and magnetic resonance imaging (MRI), can accurately predict ypT stage and select candidates for pelvic organ-preserving surgery in rectal cancer after preoperative CRT. A total of 110 patients who underwent preoperative CRT followed by curative resection for rectal cancer were prospectively enrolled. Magnetic resonance tumor regression grade (mrTRG) using T2-MRI, endoscopic evaluation, and combination modality (combination of endoscopy and mrTRG) were used to analyze tumor response after preoperative CRT. Endoscopic findings were categorized as 3 grades and the mrTRG was assessed into 5 grades. Twenty-nine patients (26.4%) had achieved pathologic complete response. When predicting ypT0, endoscopy showed significantly higher area under the curve (AUC 0.818) than did mrTRG (AUC 0.568) and combination modality (AUC 0.768) in differentiating good response from poor response (P < .001). Both endoscopy and combination modality showed significantly higher diagnostic performance in sensitivity (79.31%), positive predictive value (PPV 67.65%), negative predictive value (NPV 92.11%), and accuracy (84.55%) than those of MR tumor response (sensitivity 37.93%, PPV 36.67%, NPV 77.50%, and accuracy 66.36%) for the prediction of ypT0 (P < .001). Combination modality showed significantly higher diagnostic performance in sensitivity (56.92%), NPV (56.92%), and accuracy (67.27%) compared with those of mrTRG. Neither endoscopy, nor mrTRG, nor the combination modality had adequate diagnostic performances to be clinically acceptable in selecting candidates for nonoperative treatment strategies. However, endoscopy may be incorporated in clinical restaging strategy in planning the extent of surgical resection in patients with rectal cancer.
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Affiliation(s)
- Min Soo Cho
- Division of Colon and Rectal Surgery, Yonsei University College of Medicine
| | - HonSoul Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Yoon Dae Han
- Division of Colon and Rectal Surgery, Yonsei University College of Medicine
| | - Hyuk Hur
- Division of Colon and Rectal Surgery, Yonsei University College of Medicine
| | - Byung Soh Min
- Division of Colon and Rectal Surgery, Yonsei University College of Medicine
| | - Seung Hyuk Baik
- Division of Colon and Rectal Surgery, Yonsei University College of Medicine
| | - Jae Hee Cheon
- Department of Internal Medicine and Institute of Gastroenterology
| | - Joon Seok Lim
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Kang Young Lee
- Division of Colon and Rectal Surgery, Yonsei University College of Medicine
| | - Nam Kyu Kim
- Division of Colon and Rectal Surgery, Yonsei University College of Medicine
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von den Grün JM, Hartmann A, Fietkau R, Ghadimi M, Liersch T, Hohenberger W, Weitz J, Sauer R, Wittekind C, Ströbel P, Rödel C, Fokas E. Can clinicopathological parameters predict for lymph node metastases in ypT0-2 rectal carcinoma? Results of the CAO/ARO/AIO-94 and CAO/ARO/AIO-04 phase 3 trials. Radiother Oncol 2018; 128:557-563. [PMID: 29929861 DOI: 10.1016/j.radonc.2018.06.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 05/29/2018] [Accepted: 06/04/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The advent of less radical surgical approaches has generated concern about leaving locoregional lymph node metastases (LNM) unresected that could lead to adverse outcome. We examined the prognostic role of clinicopathological factors for ypN-positivity in patients with ypT0-2 rectal carcinoma treated within the CAO/ARO/AIO-94 and CAO/ARO/AIO-04 randomized phase 3 trials. METHODS The correlation of clinicopathological factors with ypN-status (ypN0 vs ypN1/2) was examined in n = 776 patients with ypT0-2 rectal carcinoma after preoperative CRT and total mesorectal excision surgery using Pearson's Chi-squared test for categorical variables and Kruskal-Wallis' test for continuous variables. Multivariable analysis was performed using binary logistic regression to identify independent prognosticators for ypN-positivity. RESULTS Residual LNM (ypN+) were found in 6%, 20.8% and 21.4% of patients with ypT0, ypT1 and ypT2 carcinomas, respectively. Independent prognosticators for LNM were advanced ypT category (p = 0.002) and lymphatic invasion (p = 0.020). In a separate multivariable analysis performed upon exclusion of ypT-category due to multicollinearity with residual tumor diameter (RTD), lymphatic invasion (p = 0.015) and RTD ≥10 mm (p = 0.005) demonstrated strong correlation with LNM. CONCLUSION Advanced ypT-stage, lymphatic invasion and RTD ≥10 mm were prognostic factors for LNM in patients ypT0-2 rectal carcinoma treated with CRT and surgery within both phase 3 trials. The high incidence of LNM in the ypT1-2 group needs to be taken into consideration in the context of oncological safety and indicate that LE should be advocated with great caution in this patient subgroup. The prognostic pathological factor identified here could help guide decision of LE vs TME after standard CRT.
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Affiliation(s)
| | - Arndt Hartmann
- Institute of Pathology, University of Erlangen, Nürnberg, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology and Radiotherapy, University of Erlangen, Nürnberg, Germany
| | - Michael Ghadimi
- Department of General, Visceral and Pediatric Surgery, University Medical Center, Göttingen, Germany
| | - Torsten Liersch
- Department of General, Visceral and Pediatric Surgery, University Medical Center, Göttingen, Germany
| | - Werner Hohenberger
- Department of General and Visceral and Pediatric Surgery, University of Erlangen, Nürnberg, Germany
| | - Jürgen Weitz
- Department of General and Visceral and Pediatric Surgery, University of Dresden, Germany
| | - Rolf Sauer
- Department of Radiation Oncology and Radiotherapy, University of Erlangen, Nürnberg, Germany
| | | | - Philipp Ströbel
- Institute of Pathology, University Medical Center Göttingen, Germany
| | - Claus Rödel
- Department of Radiotherapy and Oncology, University of Frankfurt, Germany
| | - Emmanouil Fokas
- Department of Radiotherapy and Oncology, University of Frankfurt, Germany.
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Total Mesorectal Excision Versus Local Excision After Preoperative Chemoradiotherapy in Rectal Cancer With Lymph Node Metastasis: A Propensity Score-Matched Analysis. Int J Radiat Oncol Biol Phys 2018; 101:630-639. [PMID: 29678529 DOI: 10.1016/j.ijrobp.2018.02.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 02/05/2018] [Accepted: 02/21/2018] [Indexed: 12/21/2022]
Abstract
PURPOSE To determine whether local excision (LE) outcomes were comparable to total mesorectal excision (TME) outcomes in node-positive (cN+) rectal cancer patients who were good responders. METHODS AND MATERIALS This retrospective study included clinical T2-3 and cN+ low rectal cancer patient who received preoperative chemoradiotherapy (PCRT) followed by TME or LE. Clinical stage T1 or T4 tumors, upper-to-middle rectal tumors (>7 cm from anal verge), and synchronous distant metastases were excluded. Lymph nodes ≥5 mm in size were defined as tumor-positive, and patients with metastatic lymph nodes >20 mm in size were excluded. Preoperative chemoradiotherapy comprised radiation (50-50.4 Gy/25-28 fractions over 5 weeks) with 2 cycles of 5-fluorouracil or oral capecitabine. Propensity scores were computed from tumor and patient variables and used for 1-to-1 matched analysis. Local recurrence-free survival, disease-free survival, and overall survival were compared between the 2 matched groups. RESULTS Between January 2007 and December 2013, 563 and 55 patients underwent TME and LE, respectively. The median follow-up period was 54 months. In propensity score-matched analysis, 48 patients were included in each group. No statistical differences were observed in 3-year local recurrence-free survival (97.9% vs 97.9%, P = .994), 3-year disease-free survival (91.5% vs 91.4%, P = .968), or 3-year OS (93.7% vs 97.9%, P = .809) between the TME and LE groups. CONCLUSIONS In clinical N+ rectal cancer patients, oncologic outcomes of PCRT followed by LE were comparable to those of TME; this finding might be applicable only to those patients with good response in the primary tumor and small lymph node metastases.
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Kim JH. Controversial issues in radiotherapy for rectal cancer: a systematic review. Radiat Oncol J 2017; 35:295-305. [PMID: 29325395 PMCID: PMC5769877 DOI: 10.3857/roj.2017.00395] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 09/28/2017] [Accepted: 10/02/2017] [Indexed: 12/17/2022] Open
Abstract
The role of radiotherapy (RT) as an adjuvant to surgical options in the treatment of locally advanced rectal cancer has been established as it reduces local recurrence when combined with surgical resection and enhances survival when used in multidisciplinary treatment. However, many issues need to be addressed; some of these can render RT unnecessary, whereas others can reveal a new role of RT in rectal cancer. This review will discuss not only the basic role of RT but also the associated but controversial issues in detail in an attempt to find answers and determine future directions for the next decade.
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Affiliation(s)
- Jong Hoon Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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12
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Sun Y, Zhang Y, Wu X, Lin H, Lu X, Huang Y, Xu Z, Huang S, Wang X, Chi P. Prognostic significance of neoadjuvant rectal score in locally advanced rectal cancer after neoadjuvant chemoradiotherapy and construction of a prediction model. J Surg Oncol 2017; 117:737-744. [PMID: 29228455 DOI: 10.1002/jso.24907] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 10/17/2017] [Indexed: 12/13/2022]
Abstract
AIM To evaluate the prognostic significance of neoadjuvant rectal (NAR) score after neoadjuvant chemoradiotherapy (nCRT) for locally advanced rectal cancer (LARC), and to develop a nomogram predicting disease-free survival (DFS). METHOD A total of 522 LARC patients undergoing nCRT and surgery were included. NAR scores were calculated using the equation [5pN-3(cT-pT) + 12]^2/9.61, and classified as low (<8), intermediate (8-16), and high (>16). Clinicopathological and survival outcomes were compared. Cox regression analysis was performed to identify risk factors of DFS. A predicting nomogram was developed and validated internally. RESULTS For NAR score classification, 193 (37.0%) were low, 183 (35.0%) were intermediate, and 146 (28.0%) were high. Higher NAR score was associated with fewer pCR, lower tumor regression grade (TRG), and higher ypTNM stage. A total of 5-year DFS for low, intermediate, and high NAR groups was 85.6%, 71.9%, and 47.2%, respectively (P < 0.001). NAR score (HR = 2.488, P = 0.002), TRG (HR = 2.811, P = 0.047), CRM involvement (HR = 2.703, P = 0.002), and IMA nodal metastasis (HR = 2.441, P = 0.001) were independent prognostic factors of DFS. A predicting nomogram was developed with C-index of 0.701. CONCLUSION NAR score could help in predicting DFS after nCRT. A nomogram was developed to identify subpopulations with aggressive tumors during clinical decision-making.
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Affiliation(s)
- Yanwu Sun
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, PR China
| | - Yiyi Zhang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, PR China
| | - Xuejing Wu
- Department of Pathology, Fujian Medical University Union Hospital, Fuzhou, Fujian, PR China
| | - Huiming Lin
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, PR China
| | - Xingrong Lu
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, PR China
| | - Ying Huang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, PR China
| | - Zongbin Xu
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, PR China
| | - Shenghui Huang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, PR China
| | - Xiaojie Wang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, PR China
| | - Pan Chi
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, PR China
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13
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São Julião GP, Celentano JP, Alexandre FA, Vailati BB. Local Excision and Endoscopic Resections for Early Rectal Cancer. Clin Colon Rectal Surg 2017; 30:313-323. [PMID: 29184466 DOI: 10.1055/s-0037-1606108] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Radical surgery is considered as the standard treatment for rectal cancer. Transanal local excision has been considered an interesting alternative for the management of selected patients with rectal cancers for many decades. Different approaches had been considered for local excision, from endoscopic submucosal dissection to resections using platforms, such as transanal endoscopic microsurgery or transanal minimally invasive surgery. Identifying the ideal candidate for this approach is crucial, as a local failure after local excision is associated with poor outcomes, even for an initial early rectal tumor. In this article, the diagnostic tools and criteria to select patients for local excision, the different modalities used, and the outcomes are discussed.
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Shin YS, Yu CS, Park JH, Kim JC, Lim SB, Park IJ, Kim TW, Hong YS, Kim KP, Yoon SM, Joo JH, Kim JH. Total Mesorectal Excision Versus Local Excision After Favorable Response to Preoperative Chemoradiotherapy in "Early" Clinical T3 Rectal Cancer: A Propensity Score Analysis. Int J Radiat Oncol Biol Phys 2017; 99:136-144. [PMID: 28816139 DOI: 10.1016/j.ijrobp.2017.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 05/02/2017] [Accepted: 05/08/2017] [Indexed: 01/29/2023]
Abstract
PURPOSE To compare oncological outcomes of total mesorectal excision (TME) and local excision (LE) in patients with "early" clinical T3 rectal cancer who received preoperative chemoradiotherapy (PCRT). METHODS AND MATERIALS "Early" clinical T3 rectal cancer was radiologically defined as tumors with extramural extension of <5 mm without mesorectal fascia involvement and lateral lymph node metastasis. Patients with "early" clinical T3 rectal cancer who received PCRT followed by TME or LE between January 2007 and December 2013 were retrospectively analyzed. Propensity scores were generated using patient and tumor characteristics, and a one-to-one case-matched analysis was conducted. Local recurrence-free survival (LRFS), disease-free survival (DFS), and overall survival (OS) were compared between the TME and LE groups. RESULTS Of the 406 enrolled patients, 351 received TME and 55 received LE. The median follow-up period was 45 months. Following propensity score matching, each group contained 55 patients. Among 103 patients evaluable for pathologic tumor response, 82 patients (79.6%) showed complete response or near-complete response. No significant differences were observed between the TME and LE groups in LRFS (3-year LRFS 98.1% vs 94.4%, P=.312), DFS (3-year DFS 92.1% vs 90.8%, P=.683), and OS (3-year OS 98.2% vs 100.0%, P=.895). CONCLUSIONS In "early" clinical T3 rectal cancer, PCRT followed by LE showed comparable oncologic outcomes to TME. Because most of the matched cohort consisted of good responders to PCRT, the present results should be applied to a limited population.
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Affiliation(s)
- Young Seob Shin
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang Sik Yu
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin-Hong Park
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Jin Cheon Kim
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seok-Byung Lim
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In Ja Park
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae Won Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong Sang Hong
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyu-Pyo Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Min Yoon
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Hyeon Joo
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong Hoon Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Gomez-Millan J, Queipo MI, del Mar Delgado M, Perez-Villa L, Roman A, De la Portilla F, Torres E, De Luque V, Bayo E, Medina JA. The impact of body mass index and nuclear β-catenin on survival in locally advanced rectal cancer treated with preoperative radiochemotherapy. J Surg Oncol 2017; 115:301-306. [DOI: 10.1002/jso.24494] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 10/23/2016] [Indexed: 12/17/2022]
Affiliation(s)
- Jaime Gomez-Millan
- Department of Radiation Oncology; University Hospital Virgen de la Victoria; Málaga Spain
| | - Maria Isabel Queipo
- Department of Endocrinology; Biomedical Research Institute (IBIMA); Málaga Spain
| | - Maria del Mar Delgado
- Department of Radiation Oncology; University Hospital Juan Ramón Jiménez; Huelva Spain
| | - Lidia Perez-Villa
- Department of Pathology; University Hospital Virgen de la Victoria; Málaga Spain
| | - Alicia Roman
- Department of Radiation Oncology; University Hospital Virgen de la Victoria; Málaga Spain
| | - Fernando De la Portilla
- Department of Surgery; Colorectal Surgery; University Hospital Virgen del Rocío; Seville Spain
| | - Esperanza Torres
- Department of Medical Oncology; University Hospital Virgen de la Victoria; Málaga Spain
| | - Vanessa De Luque
- Department of Medical Oncology; University Hospital Virgen de la Victoria; Málaga Spain
| | - Eloisa Bayo
- Department of Radiation Oncology; University Hospital Juan Ramón Jiménez; Huelva Spain
| | - Jose Antonio Medina
- Department of Radiation Oncology; University Hospital Virgen de la Victoria; Málaga Spain
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Yoo BC, Yeo SG. Clinical utility of pretreatment prediction of chemoradiotherapy response in rectal cancer: a review. EPMA J 2017; 8:61-67. [PMID: 28620444 DOI: 10.1007/s13167-017-0082-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 02/02/2017] [Indexed: 12/14/2022]
Abstract
Approximately 20% of all patients with locally advanced rectal cancer experience pathologically complete responses following neoadjuvant chemoradiotherapy (CRT) and standard surgery. The utility of radical surgery for patients exhibiting good CRT responses has been challenged. Organ-sparing strategies for selected patients exhibiting complete clinical responses include local excision or no immediate surgery. The subjects of this tailored management are patients whose presenting disease corresponds to current indications of neoadjuvant CRT, and their post-CRT tumor response is assessed by clinical and radiological examinations. However, a model predictive of the CRT response, applied before any treatment commenced, would be valuable to facilitate such a personalized approach. This would increase organ preservation, particularly in patients for whom upfront CRT is not generally prescribed. Molecular biomarkers hold the greatest promise for development of a pretreatment predictive model of CRT response. A combination of clinicopathological, radiological, and molecular markers will be necessary to render the model robust. Molecular research will also contribute to the development of drugs that can overcome the radioresistance of rectal tumors. Current treatments for rectal cancer are based on the expected prognosis given the presenting disease extent. In the future, treatment schemes may be modified by including the predicted CRT response evaluated at presentation.
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Affiliation(s)
- Byong Chul Yoo
- Colorectal Cancer Branch, Research Institute, National Cancer Center, Goyang, Republic of Korea
| | - Seung-Gu Yeo
- Department of Radiation Oncology, Soonchunhyang University College of Medicine, Soonchunhyang University Hospital, 31, Soonchunhyang 6-gil, Cheonan, 31151 Republic of Korea
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17
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Shin YS, Yoon YS, Lim SB, Yu CS, Kim TW, Chang HM, Park JH, Ahn SD, Lee SW, Choi EK, Kim JC, Kim JH. Preoperative chemoradiotherapy followed by local excision in clinical T2N0 rectal cancer. Radiat Oncol J 2016; 34:177-185. [PMID: 27730804 PMCID: PMC5066452 DOI: 10.3857/roj.2016.01872] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 08/10/2016] [Accepted: 08/30/2016] [Indexed: 12/12/2022] Open
Abstract
Purpose To investigate whether preoperative chemoradiotherapy (PCRT) followed by local excision (LE) is feasible approach in clinical T2N0 rectal cancer patients. Materials and Methods Patients who received PCRT and LE because of clinical T2 rectal cancer within 7 cm from anal verge between January 2006 and June 2014 were retrospectively analyzed. LE was performed in case of a good clinical response after PCRT. Patients’ characteristics, treatment record, tumor recurrence, and treatment-related complications were reviewed at a median follow-up of 49 months. Results All patients received transanal excision or transanal minimally invasive surgery. Of 34 patients, 19 patients (55.9%) presented pathologic complete response (pCR). The 3-year local recurrence-free survival and disease free-survival were 100.0% and 97.1%, respectively. There was no recurrence among the patients with pCR. Except for 1 case of grade 4 enterovesical fistula, all other late complications were mild and self-limiting. Conclusion PCRT followed by an LE might be feasible as an alternative to total mesorectal excision in good responders with clinical T2N0 distal rectal cancer.
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Affiliation(s)
- Young Seob Shin
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong Sik Yoon
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seok-Byung Lim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang Sik Yu
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae Won Kim
- Department of Medical Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Heung Moon Chang
- Department of Medical Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin-Hong Park
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Do Ahn
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Wook Lee
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Kyung Choi
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Cheon Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong Hoon Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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18
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Local excision of low rectal cancer treated by chemoradiotherapy: is it safe for all patients with suspicion of complete tumor response? Int J Colorectal Dis 2016; 31:853-60. [PMID: 26951185 DOI: 10.1007/s00384-016-2546-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/25/2016] [Indexed: 02/07/2023]
Abstract
PURPOSE The purpose of this study is to assess if local excision (LE) could be proposed if suspicion of complete tumor response (CR) after neoadjuvant chemoradiotherapy (CRT) for low rectal cancer (LRC) and this despite a potential risk of nodes (N+) or other tumor deposits (OTD) left in place. The aim was to assess in patients with LRC treated by CRT: (a) pathologic results of LE and total mesorectal excision (TME) in case of preoperative suspicion of CR and (b) the risk of N+ or OTD on TME if ypT0-Tis-T1 tumor. PATIENTS Among 202 patients with LRC after CRT, 33 (16 %) with suspicion of CR underwent LE (n = 20) because of comorbidities and/or indication of definitive stoma or TME (n = 13). Pathologic examination of LE and TME specimens and oncological outcomes were assessed. Furthermore, 40/202 patients with pathologic CR on TME specimen (ypT0-Tis-T1) were assessed for possible N+ or OTD. RESULTS In the 33 patients with suspicion of CR: (a) after LE, tumor was ypT0-Tis-T1 in only 15/20 cases (75 %); (b) after TME, tumor was ypT0-Tis-T1 in only 7/13 cases (54 %). Among 40 patients with ypT0-Tis-T1 tumor on TME specimen, 4 (10 %) presented N+ and/or OTD. CONCLUSION In LRC with suspicion of CR after CRT, LE deserves a word of caution: 25 % of patients have in fact ypT2-T3 tumors. Furthermore, in patients with ypT0-Tis or T1 on TME specimen, a 10 % risk of N+ and/or ODT is observed. Thus, patient with suspicion of CR after CRT and treated by LE is exposed to a possible incomplete oncologic treatment.
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19
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Kim SH, Chang HJ, Kim DY, Park JW, Baek JY, Kim SY, Park SC, Oh JH, Yu A, Nam BH. What Is the Ideal Tumor Regression Grading System in Rectal Cancer Patients after Preoperative Chemoradiotherapy? Cancer Res Treat 2015; 48:998-1009. [PMID: 26511803 PMCID: PMC4946373 DOI: 10.4143/crt.2015.254] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 09/20/2015] [Indexed: 12/31/2022] Open
Abstract
Purpose Tumor regression grade (TRG) is predictive of therapeutic response in rectal cancer patients after chemoradiotherapy (CRT) followed by curative resection. However, various TRG systems have been suggested, with subjective categorization, resulting in interobserver variability. This study compared the prognostic validity of four different TRG systems in order to identify the most ideal TRG system. Materials and Methods This study included 933 patients who underwent preoperative CRT and curative resection. Primary tumors alone were graded according to the American Joint Committee on Cancer (AJCC), Dworak, and Ryan TRG systems, and both primary tumors and regional lymph nodes were graded according to a modified Dworak TRG system. The ability of each TRG system to predict recurrence-free survival (RFS) and overall survival (OS) was analyzed using chi-square and C statistics. Results All four TRG systems were significantly predictive of both RFS and OS (p < 0.001 each), however none was a better predictor of prognosis than ypStage. Among the four TRGs, the mDworak TRG system was a better predictor of RFS and OS than the AJCC, Dworak, and Ryan TRG systems, and both the chi-square and C statistics were higher for the former, although the differences were not statistically significant. The combination of ypStage and the modified Dworak TRG better predicted RFS and OS than ypStage alone. Conclusion The modified Dworak TRG system for evaluation of entire tumors including regional lymph nodes is a better predictor of survival than current TRG systems for evaluation of the primary tumor alone.
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Affiliation(s)
- Soo Hee Kim
- Department of Pathology, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Hee Jin Chang
- Department of Pathology, Research Institute and Hospital, National Cancer Center, Goyang, Korea.,Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Dae Yong Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Ji Won Park
- Division of Colorectal Surgery, Department of Surgery, Seoul National University, Seoul, Korea
| | - Ji Yeon Baek
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Sun Young Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Sung Chan Park
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Jae Hwan Oh
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Ami Yu
- Biometric Research Branch, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Byung-Ho Nam
- Biometric Research Branch, Research Institute and Hospital, National Cancer Center, Goyang, Korea
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Habr-Gama A, São Julião GP, Perez RO. Nonoperative management of rectal cancer: identifying the ideal patients. Hematol Oncol Clin North Am 2015; 29:135-51. [PMID: 25475576 DOI: 10.1016/j.hoc.2014.09.004] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Neoadjuvant chemoradiation (CRT) is considered one of the preferred treatment strategies for patients with locally advanced rectal cancer. This strategy may lead to significant tumor regression, ultimately leading to a complete pathologic response in up to 42% of patients. Assessment of tumor response following CRT and before radical surgery may identify patients with a complete clinical response who could possibly be managed nonoperatively with strict follow-up (watch-and-wait strategy). The present article deals with critical issues regarding appropriate selection of patients for this approach.
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Affiliation(s)
- Angelita Habr-Gama
- Angelita and Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, Paraiso, São Paulo 04001-005, Brazil; University of São Paulo School of Medicine, Rua Manoel da Nóbrega 1564, Paraiso, São Paulo 04001-005, Brazil.
| | | | - Rodrigo O Perez
- Angelita and Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, Paraiso, São Paulo 04001-005, Brazil; Colorectal Surgery Division, Department of Gastroenterology, University of São Paulo School of Medicine, Rua Manoel da Nóbrega 1564, Paraiso, São Paulo 04001-005, Brazil
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Yeo SG, Kim DY, Kim TH, Kim SY, Baek JY, Chang HJ, Park JW, Oh JH. Carbohydrate antigen 19-9 levels associated with pathological responses to preoperative chemoradiotherapy in rectal cancer. Asian Pac J Cancer Prev 2015; 15:5383-7. [PMID: 25041006 DOI: 10.7314/apjcp.2014.15.13.5383] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To investigate whether pretreatment serum carbohydrate antigen 19-9 (CA 19-9) levels are associated with pathological responses to preoperative chemoradiotherapy (CRT) in patients with rectal cancer. MATERIALS AND METHODS In total, 260 patients with locally advanced rectal cancer (cT3-4NanyM0) who underwent preoperative CRT and radical surgery were analyzed retrospectively. CRT consisted of 50.4 Gy pelvic radiotherapy and concurrent chemotherapy. Radical surgery was performed at a median of 7 weeks after CRT completion. Pathological CRT response criteria included downstaging (ypStage 0-I) and ypT0-1. A discrimination threshold of CA 19-9 level was determined using a receiver operating characteristics analysis. RESULTS The median CA 19-9 level was 8.0 (1.0-648.0) U/mL. Downstaging occurred in 94 (36.2%) patients and ypT0-1 in 50 (19.2%). The calculated optimal threshold CA 19-9 level was 10.2 U/mL for downstaging and 9.0 U/mL for ypT0-1. On multivariate analysis, CA 19-9 (≤ 9.0 U/mL) was significantly associated with downstaging (odds ratio, 2.089; 95% confidence interval, 1.189-3.669; P=0.010) or ypT0-1 (OR, 2.207; 95%CI, 1.079-4.512; P=0.030), independent of clinical stage or carcinoembryonic antigen. CONCLUSIONS This study firstly showed a significant association of pretreatment serum CA 19-9 levels with pathological CRT responses of rectal cancer. The CA 19-9 level is suggested to be valuable in predicting CRT responses of rectal cancer cases before treatment.
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Affiliation(s)
- Seung-Gu Yeo
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea E-mail :
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Oncological outcomes of local excision compared with radical surgery after neoadjuvant chemoradiotherapy for rectal cancer: a systematic review and meta-analysis. Int J Colorectal Dis 2015; 30:19-29. [PMID: 25367179 DOI: 10.1007/s00384-014-2045-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/21/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND Low rectal cancer is conventionally managed with neoadjuvant chemoradiotherapy (CRT) followed by radical surgery (RS). In patients who refuse a stoma or are unfit for RS, an alternative approach may be the use of pre-op CRT and local excision (LE) where tumours are responsive. The aim of this systematic review is to determine whether differences exist in local recurrence (LR), overall survival (OS) and disease-free (DFS) survival between patients treated with CRT + LE and CRT + RS. METHODS A literature search was performed using MEDLINE/PubMed/Ovid databases and Google Scholar between 1946 and 2013. Studies comparing outcome following LE and RS post-CRT were included. A pooled analysis was carried out using the Mantel-Haenszel statistical (random effects) model to identify differences in LR, OS and DFS between CRT + LE and CRT + RS. RESULTS Eight studies were suitable for pooled analyses of LR whereas five and four studies were analysed for OS and DFS, respectively. When RS was used as the reference group, LR rate was higher in the LE group. However, this was non-significant (odds ratio (OR) 1.29, confidence interval (CI) 0.72-2.31, p = 0.40). Similarly, no difference was observed in 10-year OS (OR 0.96, CI 0.38-2.43, p = 0.93) or 5-year DFS (OR 1.04, CI 0.61-1.76, p = 0.89). There was evidence of publication bias in studies used for DFS. Subgroup analysis of above outcomes in T3/any N stage cancers showed no difference in LE versus RS. CONCLUSION In the current evidence synthesis, there was no statistical difference in the LR, OS and DFS rates observed between patients treated with LE and RS for rectal cancer post-CRT. LE post-CRT may represent a viable alternative to RS for some patients wishing to avoid RS. However, further randomised studies are required to confirm these results.
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Habr-Gama A, São Julião GP, Perez RO. Pitfalls of transanal endoscopic microsurgery for rectal cancer following neoadjuvant chemoradiation therapy. MINIM INVASIV THER 2014; 23:63-9. [PMID: 24635719 DOI: 10.3109/13645706.2014.893891] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Transanal endoscopic microsurgery has become a very useful surgical tool for the management of selected cases of rectal cancer. However, the considerably high local recurrence rates led to the introduction of neoadjuvant therapies including radiation with or without chemotherapy. This treatment strategy may result in significant rates of tumor regression allowing the procedure to be offered to a significant proportion of cases. On the other hand, neoadjuvant chemoradiation (CRT) may also determine wound-healing difficulties with significant postoperative pain. In addition, salvage total mesorectal excision in the case of local recurrence may also be a challenging task. Finally, accurate selection criteria for this minimally invasive approach are still lacking and may be influenced by baseline staging, post-treatment staging and final pathology information. Ultimately, selection of patients for this treatment modality remains a significant challenge for the colorectal surgeon who should be aware of the pitfalls of this procedure in the setting of neoadjuvant CRT.
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Affiliation(s)
- Angelita Habr-Gama
- Angelita & Joaquim Gama Institute/Hospital Alemão Oswaldo Cruz , São Paulo , Brazil
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Moszkowicz D, Peschaud F, Hajjam ME, Julié C, Beauchet A, Penna C, Nordlinger B, Benoist S. Can We Predict Complete or Major Response after Chemoradiotherapy for Rectal Cancer by Noninvasive Methods? Results of a Prospective Study on 61 Patients. Am Surg 2014. [DOI: 10.1177/000313481408001131] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Rectal preservation has been proposed as an alternative to radical resection in patients with presumed complete or major response to chemoradiotherapy (CRT). The aim of this prospective study was to evaluate the accuracy of digital rectal examination (DRE) and magnetic resonance imaging (MRI) to predict major or complete rectal cancer response to CRT. Over 2 years, 61 patients underwent radical resection after CRT for rectal cancer. DRE and MRI were carried out before and 6 to 8 weeks after the end of CRT. Data from DRE and MRI post-CRT were compared with pathological examinations. At pathological examination, major/complete responses were recorded for tumors classified ypT1N0 and ypT0N0, respectively. DRE post-CRT showed major/complete response in 26 cases, of which 14 (54%) were confirmed by pathology. The positive (PPV) and negative (NPV) predictive values of DRE to predict major/complete response were 54 and 88 per cent, respectively. MRI post-CRT showed major/complete response in 12 cases, of which nine (75%) were confirmed by pathology. The PPV and NPV of MRI to predict major/complete response were 75 and 82 per cent, respectively. Data from DRE and RMI post-CRT were concordant in 45 patients. The PPV and NPV of concordant DRE and MRI to predict major/complete response were 82 and 91 per cent, respectively. DRE and MRI do not appear to be sufficiently accurate for safe selection of patients appropriate for a rectum-sparing strategy because the risk of leaving an invasive tumor untreated is 18 per cent.
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Affiliation(s)
- David Moszkowicz
- Departments of Surgery, Assistance-Publique-Hôpitaux de Paris, Hôpital Ambroise Paré, Boulogne, France
- Université Versailles Saint Quentin en Yvelines, Montigny-Le-Bretonneux, France
| | - FréDéRique Peschaud
- Departments of Surgery, Assistance-Publique-Hôpitaux de Paris, Hôpital Ambroise Paré, Boulogne, France
- Université Versailles Saint Quentin en Yvelines, Montigny-Le-Bretonneux, France
| | - Mostafa El Hajjam
- Departments of Radiology, Assistance-Publique-Hôpitaux de Paris, Hôpital Ambroise Paré, Boulogne, France
| | - Catherine Julié
- Departments of Pathology, Assistance-Publique-Hôpitaux de Paris, Hôpital Ambroise Paré, Boulogne, France
- Université Versailles Saint Quentin en Yvelines, Montigny-Le-Bretonneux, France
| | - Alain Beauchet
- Biostatistical Department, Assistance-Publique-Hôpitaux de Paris, Hôpital Ambroise Paré, Boulogne, France
| | - Christophe Penna
- Departments of Surgery, Assistance-Publique-Hôpitaux de Paris, Hôpital Ambroise Paré, Boulogne, France
- Université Versailles Saint Quentin en Yvelines, Montigny-Le-Bretonneux, France
| | - Bernard Nordlinger
- Departments of Surgery, Assistance-Publique-Hôpitaux de Paris, Hôpital Ambroise Paré, Boulogne, France
- Université Versailles Saint Quentin en Yvelines, Montigny-Le-Bretonneux, France
| | - StéPhane Benoist
- Departments of Surgery, Assistance-Publique-Hôpitaux de Paris, Hôpital Ambroise Paré, Boulogne, France
- Université Versailles Saint Quentin en Yvelines, Montigny-Le-Bretonneux, France
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Vignali A, Nardi PD. Multidisciplinary treatment of rectal cancer in 2014: Where are we going? World J Gastroenterol 2014; 20:11249-11261. [PMID: 25170209 PMCID: PMC4145763 DOI: 10.3748/wjg.v20.i32.11249] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2014] [Revised: 05/08/2014] [Accepted: 05/26/2014] [Indexed: 02/06/2023] Open
Abstract
In the present review we discuss the recent developments and future directions in the multimodal treatment of locally advanced rectal cancer, with respect to staging and re-staging modalities, to the current role of neoadjuvant chemo-radiation and to the conservative and more limited surgical approaches based on tumour response after neoadjuvant combined therapy. When initial tumor staging is considered a high accuracy has been reported for T pre-treatment staging, while preoperative lymph node mapping is still suboptimal. With respect to tumour re-staging, all the current available modalities still present a limited accuracy, in particular in defining a complete response. The role of short vs long-course radiotherapy regimens as well as the optimal time of surgery are still unclear and under investigation by means of ongoing randomized trials. Observational management or local excision following tumour complete response are promising alternatives to total mesorectal excision, but need further evaluation, and their use outside of a clinical trial is not recommended. The preoperative selection of patients who will benefit from neoadjuvant radiotherapy or not, as well as the proper identification of a clinical complete tumour response after combined treatment modalities,will influence the future directions in the treatment of locally advanced rectal cancer.
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Wasserberg N. Interval to surgery after neoadjuvant treatment for colorectal cancer. World J Gastroenterol 2014; 20:4256-62. [PMID: 24764663 PMCID: PMC3989961 DOI: 10.3748/wjg.v20.i15.4256] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Revised: 11/11/2013] [Accepted: 01/14/2014] [Indexed: 02/06/2023] Open
Abstract
The current standard treatment of low-lying locally advanced rectal cancer consists of chemoradiation followed by radical surgery. The interval between chemoradiation and surgery varied for many years until the 1999 Lyon R90-01 trial which compared the effects of a short (2-wk) and long (6-wk) interval. Results showed a better clinical tumor response (71.7% vs 53.1%) and higher rate of positive and pathologic tumor regression (26% vs 10.3%) after the longer interval. Accordingly, a 6-wk interval between chemoradiation and surgery was set to balance the oncological results with the surgical complexity. However, several recent retrospective studies reported that prolonging the interval beyond 8 or even 12 wk may lead to significantly higher rates of tumor downstaging and pathologic complete response. This in turn, according to some reports, may improve overall and disease-free survival, without increasing the surgical difficulty or complications. This work reviews the data on the effect of different intervals, derived mostly from retrospective analyses using a wide variation of treatment protocols. Prospective randomized trials are currently ongoing.
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Lee NK, Kim DY, Kim SY, Oh JH, Park W, Choi DH, Nam TK, Lee KJ. Clinical outcomes of local excision following preoperative chemoradiotherapy for locally advanced rectal cancer. Cancer Res Treat 2014; 46:158-64. [PMID: 24851107 PMCID: PMC4022824 DOI: 10.4143/crt.2014.46.2.158] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Accepted: 05/17/2013] [Indexed: 12/18/2022] Open
Abstract
PURPOSE To evaluate the treatment outcomes of local excision following preoperative chemoradiotherapy in patients with locally advanced rectal cancer who have not undergone radical surgery for any reason. MATERIALS AND METHODS The data of 27 patients with locally advanced rectal cancer who underwent preoperative chemoradiotherapy followed by local excision were analyzed retrospectively. The primary endpoint was the 5-year relapse-free survival rate, and the secondary endpoint was the pattern of recurrence. RESULTS The median follow-up time was 81.8 months (range, 28.6 to 138.5 months). The 5-year local relapse-free survival (LRFS), distant metastasis-free survival (DMFS), relapse-free survival (RFS), and overall survival (OS) were 88.9%, 81.1%, 77.8%, and 85.0%, respectively. Six (22%) patients developed treatment failure; one (4%) patient had local recurrence only, three (11%) patients had distant recurrence only, and two (7%) patients had both. The 5-year LRFS, DMFS, RFS, and OS for patients with ypT0-1 compared with ypT2-3 were 94.1% vs. 77.8% (p=0.244), 94.1% vs. 55.6% (p=0.016), 88.2% vs. 55.6% (p=0.051), and 94.1% vs. 66.7% (p=0.073), respectively. CONCLUSION Local excision following preoperative chemoradiotherapy may be an alternative treatment for highly selected patients with locally advanced rectal cancer who have achieved ypT0-1 after preoperative chemoradiotherapy.
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Affiliation(s)
- Nam Kwon Lee
- Proton Therapy Center, Research Institute and Hospital, National Cancer Center, Goyang, Korea
- Department Radiation Oncology, Korea University Medical Center, Korea University College of Medicine, Seoul, Korea
| | - Dae Yong Kim
- Proton Therapy Center, Research Institute and Hospital, National Cancer Center, Goyang, Korea
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Sun Young Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Jae Hwan Oh
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Won Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Doo Ho Choi
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Taek-Keun Nam
- Department of Radiation Oncology, Chonnam National University Ewha Womans University Mokdong Hospital, Gwangju, Korea
| | - Kyung-Ja Lee
- Department of Radiation Oncology, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea
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Habr-Gama A, Gama-Rodrigues J, São Julião GP, Proscurshim I, Sabbagh C, Lynn PB, Perez RO. Local Recurrence After Complete Clinical Response and Watch and Wait in Rectal Cancer After Neoadjuvant Chemoradiation: Impact of Salvage Therapy on Local Disease Control. Int J Radiat Oncol Biol Phys 2014; 88:822-8. [DOI: 10.1016/j.ijrobp.2013.12.012] [Citation(s) in RCA: 306] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 11/29/2013] [Accepted: 12/10/2013] [Indexed: 12/19/2022]
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Peng JY, Li ZN, Wang Y. Risk factors for local recurrence following neoadjuvant chemoradiotherapy for rectal cancers. World J Gastroenterol 2013; 19:5227-5237. [PMID: 23983425 PMCID: PMC3752556 DOI: 10.3748/wjg.v19.i32.5227] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Revised: 06/14/2013] [Accepted: 07/18/2013] [Indexed: 02/06/2023] Open
Abstract
Local recurrence (LR) has an adverse impact on rectal cancer treatment. Neoadjuvant chemoradiotherapy (nCRT) is increasingly administered to patients with progressive cancers to improve the prognosis. However, LR still remains a problem and its pattern can alter. Correspondingly, new risk factors have emerged in the context of nCRT in addition to the traditional risk factors in patients receiving non-neoadjuvant therapies. These risk factors are decisive when reviewing treatment options. This review aims to elucidate the distinctive risk factors related to LR of rectal cancers in patients receiving nCRT and to clarify their clinical significance. A search was conducted on PubMed to identify original studies investigating patients with rectal cancer receiving nCRT. Outcomes of interest, especially potential risk factors for LR in patients with nCRT, were then analyzed. The clinical importance of these risk factors is discussed. Remnant cancer cells, lymph-nodes and tumor response were found to be major risk factors. Remnant cancer cells decide the status of resection margins. Local excision following nCRT is promising in ypT0-1N0M0 cases. Dissection of lateral lymph nodes should be considered in advanced low-lying cancers. Although better tumor response resulted in a relatively lower recurrence rate, the evidence available is insufficient to justify a non-operative approach in clinical complete responders to nCRT. LR cannot be totally avoided by current multidisciplinary approaches. The related risk factors resulting from nCRT should be considered when making decisions regarding treatment selection.
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Sclafani F, Cunningham D. Non-operative management for locally advanced rectal cancer: critical review and future perspective. COLORECTAL CANCER 2013. [DOI: 10.2217/crc.13.33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
SUMMARY Over the last few decades we have observed important advances in diagnostic imaging, surgery, pathology and multimodal treatments for rectal cancer, as well as increased efforts to reduce treatment-related toxicities and preserve quality of life for curatively treated patients. Neoadjuvant short-course radiotherapy and long-course chemoradiotherapy followed by total mesorectal excision remain widely accepted as the standard of care for patients with locally advanced rectal cancer. However, a carefully selected group of patients achieving a complete response to neoadjuvant chemoradiotherapy may be spared the effects of surgery and achieve satisfactory oncologic outcomes with a ‘wait-and-see’ strategy. Although supported by the results of previous studies, this intriguing paradigm shift needs prospective evaluation within a clinical trial setting and a more accurate prediction and assessment of response by means of tumor biomarkers and diagnostic imaging.
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Affiliation(s)
- Francesco Sclafani
- Department of Medicine, The Royal Marsden NHS Foundation Trust, Sutton, Surrey, SM2 5PT, UK
| | - David Cunningham
- Department of Medicine, The Royal Marsden NHS Foundation Trust, Sutton, Surrey, SM2 5PT, UK
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31
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Histopathological regression grading matches excellently with local and regional spread after neoadjuvant therapy of rectal cancer. Pathol Res Pract 2013; 209:424-8. [DOI: 10.1016/j.prp.2013.04.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Revised: 12/12/2012] [Accepted: 04/19/2013] [Indexed: 02/06/2023]
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Allaix ME, Fichera A. Modern rectal cancer multidisciplinary treatment: the role of radiation and surgery. Ann Surg Oncol 2013; 20:2921-8. [PMID: 23604783 DOI: 10.1245/s10434-013-2966-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Treatment of rectal cancer has evolved during the last few decades due to more in-depth knowledge of rectal cancer biology and major advances in the field of preoperative staging, medical management and surgical techniques. Consequently, treatment strategies are shifting moving towards a more personalized approach based on the response to treatment. Currently topics of controversy are centered around the indication for neoadjuvant radiation therapy in locally advanced rectal cancer and the role of surgery in patients with complete clinical response after neoadjuvant combined modality therapy. This manuscript aims to critically evaluate the evolution of treatment of rectal cancer during the last three decades and future directions. METHODS A review of the literature has been performed in PubMed/Medline electronic databases. RESULTS Treatment modalities are moving towards a tailored approach to rectal cancer patients based on the response to chemoradiation. A "wait-and-see" approach and local excision by Transanal Endoscopic Microsurgery (TEM) are strategies recently proposed in case of complete clinical response. CONCLUSIONS The standard of care still requires that locally advanced rectal cancer should be treated by neoadjuvant chemoradiation therapy followed by total mesorectal excision, including patients with a clinical complete response. Further evidence is needed to endorse a "wait-and-see" strategy and to define the role of TEM.
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Affiliation(s)
- Marco E Allaix
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
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Abstract
Thanks to major advances in the field of surgical techniques and neoadjuvant chemoradiation therapy, along with more accurate pre-operative staging tools and the widespread introduction of population-based screening programs, treatment of rectal cancer has been evolving over the past few decades, moving towards a more tailored approach. This has brought a shift in the treatment algorithm of benign rectal lesions and selected early rectal cancers, for which today transanal endoscopic microsurgery (TEM) is accepted as an effective alternative to abdominal surgery. In 2013, topics of controversy are the role of TEM in the treatment of more advanced rectal cancers, in cases of complete pathological response after chemoradiation therapy and the role of TEM as a platform for single-port surgery and NOTES. This article reviews the current indications for TEM and the future perspectives of this approach in the treatment of rectal tumors.
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Affiliation(s)
- Mario Morino
- Digestive, Colorectal, Oncologic and Minimally Invasive Surgery, Department of Surgical Sciences, University of Turin, Italy
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Issa N, Murninkas A, Powsner E, Dreznick Z. Long-term outcome of local excision after complete pathological response to neoadjuvant chemoradiation therapy for rectal cancer. World J Surg 2013; 36:2481-7. [PMID: 22736345 DOI: 10.1007/s00268-012-1697-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Neoadjuvant chemoradiotion therapy (CRT) for advanced rectal cancer has improved local disease. Complete rectal wall tumor regression may be associated with the absence of viable cancer cells in the mesorectum, and thus local excision (LE) of such lesions as an alternative to radical surgery has recently gained interest. We report the long-term outcome of LE in patients with a mural pathological complete response (ypT0) after CRT. METHODS A retrospective review of patients with rectal cancer treated by CRT and followed by LE with pathological complete response in the specimen between 1998 and 2009 was performed. RESULTS A total of 174 patients had neoadjuvant CRT, and 68 (39 %) showed complete clinical response (cCR). Thirty-one of the cCR patients underwent LE; 23 of them resulted in ypT0 and 8 had residual disease. The ypT0 group included 12 men and 11 women with a median age of 66. The pretreatment stage was T3N1 in 4 (17 %) patients, T3N0 in 11 (48 %), T2N1 in 3 (13 %), and T2N0 in 5 (22 %). The median tumor distance from the anal verge was 6 cm. Sixteen patients (70 %) underwent transanal excision, and 7 (30 %) were treated by transanal-endoscopic microsurgery. Three patients died: one of pneumonia, one of melanoma of the rectum, and one of lung carcinoma. No local or distant recurrences were detected in the remaining 20 patients. The median follow-up was 87 months. CONCLUSIONS Although radical rectal resection is the treatment of choice, LE of complete rectal tumor regression could be a safe alternative with an acceptable result in selected patients.
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Affiliation(s)
- Nidal Issa
- Department of Surgery, Hasharon Hospital, Rabin Medical Center, 7 Keren-Kayemet St, 49100, Petah Tikva, Israel.
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Kim NK, Kim MS, Al-Asari SF. Update and debate issues in surgical treatment of middle and low rectal cancer. JOURNAL OF THE KOREAN SOCIETY OF COLOPROCTOLOGY 2012. [PMID: 23185702 PMCID: PMC3499423 DOI: 10.3393/jksc.2012.28.5.230] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Based on a review of the literature, this paper provides an update on surgical treatment of middle and low rectal cancer and discusses issues of debate surrounding that treatment. The main goal of the surgical treatment of rectal cancer is radical resection of the tumor and surrounding lymphatic tissue. Local excision of early rectal cancer can be another treatment option, in which the patient can avoid possible complications related to radical surgery. Neoadjuvant chemoradiation therapy (CRT) has been recommended for patients with cT3-4N0 or any T N+ rectal cancer because CRT shows better local control and less toxicity than adjuvant CRT. However, recent clinical trials showed promising results for local excision after neoadjuvant CRT in selected patients with low rectal cancer. In addition, the "wait and see" concept is another modality that has been reported for the management of tumors that show complete clinical remission after neoadjuvant CRT. Although radical surgery for middle and low rectal cancer is the cornerstone therapy, an ultralow anterior resection with or without intersphincteric resection (ISR) has become an alternative standard surgical method for selected patients. Many studies have reported on the oncological safety of the ISR, but few of them have addressed the issue the functional outcome. Furthermore, an abdominoperineal resection (APR) has problems with high rates of tumor perforations and positive circumferential resection margins, and those factors have contributed to its having a high rate of local recurrence and a poor survival rate for rectal cancer compared with sphincter-saving procedures. Recently, great efforts have been made to reduce these problems, and the total levator excision or the extended APR concept has emerged. Surgical management for low rectal cancer should aim to radically excise the tumor and to preserve as much of the sphincter function as possible by using multidisciplinary approaches. However, further prospective clinical trials are needed for tailored treatment of rectal cancer patients.
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Affiliation(s)
- Nam Kyu Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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Yeo SG, Kim DY. An update on preoperative radiotherapy for locally advanced rectal cancer. JOURNAL OF THE KOREAN SOCIETY OF COLOPROCTOLOGY 2012; 28:179-87. [PMID: 22993703 PMCID: PMC3440486 DOI: 10.3393/jksc.2012.28.4.179] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Accepted: 08/09/2012] [Indexed: 02/08/2023]
Abstract
Even in patients undergoing an optimal surgical technique (e.g., total mesorectal excision), radiotherapy provides a significant benefit in the local control of rectal cancer. Compared with postoperative treatment, chemoradiotherapy given preoperatively has been shown to decrease local recurrence rates and toxicity. Additionally, preoperative chemoradiotherapy permits the early identification of tumor responses to this cytotoxic treatment by surgical pathology. Pathological parameters reflecting the tumor response to chemoradiotherapy have been shown to be surrogate markers for long-term clinical outcomes. Post-chemoradiotherapy downstaging from cStage II-III to ypStage 0-I indicates a favorable prognosis, with no difference between ypStage 0 and ypStage I. Research is ongoing to develop useful tools (clinical, molecular, and radiological) for clinical determination of the pathologic chemoradiotherapeutic response before surgery, and possibly even before preoperative treatment. In the future, risk-adapted strategies, including intensification of preoperative therapy, conservative surgery, or the selective administration of postoperative chemotherapy, will be realized for locally-advanced rectal cancer patients based on their response to preoperative chemoradiotherapy.
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Affiliation(s)
- Seung-Gu Yeo
- Department of Radiation Oncology, Soonchunhyang University College of Medicine, Cheonan, Korea
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Lim SB, Yu CS, Hong YS, Kim TW, Kim JH, Kim JC. Long-term outcomes in patients with locally advanced rectal cancer treated with preoperative chemoradiation followed by curative surgical resection. J Surg Oncol 2012; 106:659-66. [DOI: 10.1002/jso.23181] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Accepted: 05/14/2012] [Indexed: 12/13/2022]
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Perez RO, Habr-Gama A, Pereira GV, Lynn PB, Alves PA, Proscurshim I, Rawet V, Gama-Rodrigues J. Role of biopsies in patients with residual rectal cancer following neoadjuvant chemoradiation after downsizing: can they rule out persisting cancer? Colorectal Dis 2012; 14:714-20. [PMID: 22568644 DOI: 10.1111/j.1463-1318.2011.02761.x] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIM The study aimed to determine the value of postchemoradiation biopsies, performed after significant tumour downsizing following neoadjuvant therapy, in predicting complete tumour regression in patients with distal rectal cancer. METHOD A retrospective comparative study was performed in patients with rectal cancer who achieved an incomplete clinical response after neoadjuvant chemoradiotherapy. Patients with significant tumour downsizing (> 30% of the initial tumour size) were compared with controls (< 30% reduction of the initial tumour size). During flexible proctoscopy carried out postchemoradiation, biopsies were performed using 3-mm biopsy forceps. The biopsy results were compared with the histopathological findings of the resected specimen. UICC (Union for International Cancer Control) ypTNM classification, tumour differentiation and regression grade were evaluated. The main outcome measures were sensitivity and specificity, negative and positive predictive values, and accuracy of a simple forceps biopsy for predicting pathological response after neoadjuvant chemoradiotherapy. RESULTS Of the 172 patients, 112 were considered to have had an incomplete clinical response and were included in the study. Thirty-nine patients achieved significant tumour downsizing and underwent postchemoradiation biopsies. Overall, 53 biopsies were carried out. Of the 39 patients who achieved significant tumour downsizing, the biopsy result was positive in 25 and negative in 14. Only three of the patients with a negative biopsy result were found to have had a complete pathological response (giving a negative predictive value of 21%). Considering all biopsies performed, only three of 28 negative biopsies were true negatives, giving a negative predictive value of 11%. CONCLUSION In patients with distal rectal cancer undergoing neoadjuvant chemoradiation, post-treatment biopsies are of limited clinical value in ruling out persisting cancer. A negative biopsy result after a near-complete clinical response should not be considered sufficient for avoiding a radical resection.
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Affiliation(s)
- R O Perez
- Colorectal Surgery Division, University of São Paulo, School of Medicine Angelita & Joaquim Gama Institute, São Paulo, Brazil.
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Kosinski L, Habr-Gama A, Ludwig K, Perez R. Shifting concepts in rectal cancer management: a review of contemporary primary rectal cancer treatment strategies. CA Cancer J Clin 2012; 62:173-202. [PMID: 22488575 DOI: 10.3322/caac.21138] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The management of rectal cancer has transformed over the last 3 decades and continues to evolve. Some of these changes parallel progress made with other cancers: refinement of surgical technique to improve organ preservation, selective use of neoadjuvant (and adjuvant) therapy, and emergence of criteria suggesting a role for individually tailored therapy. Other changes are driven by fairly unique issues including functional considerations, rectal anatomic features, and surgical technical issues. Further complexity is due to the variety of staging modalities (each with its own limitations), neoadjuvant treatment alternatives, and competing strategies for sequencing multimodal treatment even for nonmetastatic disease. Importantly, observations of tumor response made in the era of neoadjuvant therapy are reshaping some traditionally held concepts about tumor behavior. Frameworks for prioritizing and integrating complex data can help to formulate treatment plans for patients.
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Affiliation(s)
- Lauren Kosinski
- Division of Colorectal Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA.
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Bökkerink GMJ, de Graaf EJR, Punt CJA, Nagtegaal ID, Rütten H, Nuyttens JJME, van Meerten E, Doornebosch PG, Tanis PJ, Derksen EJ, Dwarkasing RS, Marijnen CAM, Cats A, Tollenaar RAEM, de Hingh IHJT, Rutten HJT, van der Schelling GP, Ten Tije AJ, Leijtens JWA, Lammering G, Beets GL, Aufenacker TJ, Pronk A, Manusama ER, Hoff C, Bremers AJA, Verhoef C, de Wilt JHW. The CARTS study: Chemoradiation therapy for rectal cancer in the distal rectum followed by organ-sparing transanal endoscopic microsurgery. BMC Surg 2011; 11:34. [PMID: 22171697 PMCID: PMC3295682 DOI: 10.1186/1471-2482-11-34] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2011] [Accepted: 12/15/2011] [Indexed: 12/15/2022] Open
Abstract
Background The CARTS study is a multicenter feasibility study, investigating the role of rectum saving surgery for distal rectal cancer. Methods/Design Patients with a clinical T1-3 N0 M0 rectal adenocarcinoma below 10 cm from the anal verge will receive neoadjuvant chemoradiation therapy (25 fractions of 2 Gy with concurrent capecitabine). Transanal Endoscopic Microsurgery (TEM) will be performed 8 - 10 weeks after the end of the preoperative treatment depending on the clinical response. Primary objective is to determine the number of patients with a (near) complete pathological response after chemoradiation therapy and TEM. Secondary objectives are the local recurrence rate and quality of life after this combined therapeutic modality. A three-step analysis will be performed after 20, 33 and 55 patients to ensure the feasibility of this treatment protocol. Discussion The CARTS-study is one of the first prospective multicentre trials to investigate the role of a rectum saving treatment modality using chemoradiation therapy and local excision. The CARTS study is registered at clinicaltrials.gov (NCT01273051)
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Affiliation(s)
- Guus M J Bökkerink
- Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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Garajová I, Di Girolamo S, de Rosa F, Corbelli J, Agostini V, Biasco G, Brandi G. Neoadjuvant treatment in rectal cancer: actual status. CHEMOTHERAPY RESEARCH AND PRACTICE 2011; 2011:839742. [PMID: 22295206 PMCID: PMC3263610 DOI: 10.1155/2011/839742] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Revised: 06/20/2011] [Accepted: 06/28/2011] [Indexed: 02/07/2023]
Abstract
Neoadjuvant (preoperative) concomitant chemoradiotherapy (CRT) has become a standard treatment of locally advanced rectal adenocarcinomas. The clinical stages II (cT3-4, N0, M0) and III (cT1-4, N+, M0) according to International Union Against Cancer (IUCC) are concerned. It can reduce tumor volume and subsequently lead to an increase in complete resections (R0 resections), shows less toxicity, and improves local control rate. The aim of this review is to summarize actual approaches, main problems, and discrepancies in the treatment of locally advanced rectal adenocarcinomas.
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Affiliation(s)
- Ingrid Garajová
- Department of Hematology and Oncology Sciences “L. A. Seragnoli”, Sant'Orsola-Malpighi Hospital, University of Bologna, via Massarenti 9, 40138 Bologna, Italy
| | - Stefania Di Girolamo
- Department of Hematology and Oncology Sciences “L. A. Seragnoli”, Sant'Orsola-Malpighi Hospital, University of Bologna, via Massarenti 9, 40138 Bologna, Italy
| | - Francesco de Rosa
- Department of Hematology and Oncology Sciences “L. A. Seragnoli”, Sant'Orsola-Malpighi Hospital, University of Bologna, via Massarenti 9, 40138 Bologna, Italy
| | - Jody Corbelli
- Department of Hematology and Oncology Sciences “L. A. Seragnoli”, Sant'Orsola-Malpighi Hospital, University of Bologna, via Massarenti 9, 40138 Bologna, Italy
| | - Valentina Agostini
- Department of Hematology and Oncology Sciences “L. A. Seragnoli”, Sant'Orsola-Malpighi Hospital, University of Bologna, via Massarenti 9, 40138 Bologna, Italy
| | - Guido Biasco
- Department of Hematology and Oncology Sciences “L. A. Seragnoli”, Sant'Orsola-Malpighi Hospital, University of Bologna, via Massarenti 9, 40138 Bologna, Italy
| | - Giovanni Brandi
- Department of Hematology and Oncology Sciences “L. A. Seragnoli”, Sant'Orsola-Malpighi Hospital, University of Bologna, via Massarenti 9, 40138 Bologna, Italy
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Gruppo M, Militello C, Mazzalai F, Martella B, Spirch S, Terranova O. ADVANCED AGE IS AN INDEPENDENT PREDICTING FACTOR FOR RECURRENCE IN PATIENTS WITH N0 COLONIC CANCER. J Am Geriatr Soc 2011; 59:1149-51. [DOI: 10.1111/j.1532-5415.2011.03431.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Perez RO, Habr-Gama A, São Julião GP, Proscurshim I, Scanavini Neto A, Gama-Rodrigues J. Transanal endoscopic microsurgery for residual rectal cancer after neoadjuvant chemoradiation therapy is associated with significant immediate pain and hospital readmission rates. Dis Colon Rectum 2011; 54:545-51. [PMID: 21471754 DOI: 10.1007/dcr.0b013e3182083b84] [Citation(s) in RCA: 111] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Transanal endoscopic microsurgery may represent appropriate diagnostic and therapeutic procedure in selected patients with distal rectal cancer following neoadjuvant chemoradiation. Even though this procedure has been associated with low rates of postoperative complications, patients undergoing neoadjuvant chemoradiation seem to be at increased risk for suture line dehiscence. In this setting, we compared the clinical outcomes of patients undergoing transanal endoscopic microsurgery with and without neoadjuvant chemoradiation. METHODS Thirty-six consecutive patients were treated by transanal endoscopic microsurgery at a single institution. Twenty-three patients underwent local excision after neoadjuvant chemoradiation therapy for rectal adenocarcinoma, and 13 patients underwent local excision without any neoadjuvant treatment for benign and malignant rectal tumors. Chemoradiation therapy included 50.4 to 54 Gy and 5-fluorouracil-based chemotherapy. All patients underwent transanal endoscopic microsurgery with primary closure of the rectal defect. Complications (immediate and late) and readmission rates were compared between groups. RESULTS Overall, median hospital stay was 2 days. Immediate (30-d) complication rate was 44% for grade II/III complications. Patients undergoing neoadjuvant chemoradiation therapy were more likely to develop grade II/III immediate complications (56% vs 23%; P = .05). Overall, the 30-day readmission rate was 30%. Wound dehiscence was significantly more frequent among patients undergoing neoadjuvant chemoradiation therapy (70% vs 23%; P = .03). Patients undergoing neoadjuvant chemoradiation therapy were at significantly higher risk of requiring readmission (43% vs 7%; P = .02). CONCLUSION Transanal local excision with the use of endoscopic microsurgical approach may result in significant postoperative morbidity, wound dehiscence, and readmission rates, in particular, because of rectal pain secondary to wound dehiscence. In this setting, the benefits of this minimally invasive approach either for diagnostic or therapeutic purposes become significantly restricted to highly selected patients that can potentially avoid a major operation but will still face a significantly morbid and painful procedure.
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Min BS, Kim NK, Pyo JY, Kim H, Seong J, Keum KC, Sohn SK, Cho CH. Clinical impact of tumor regression grade after preoperative chemoradiation for locally advanced rectal cancer: subset analyses in lymph node negative patients. JOURNAL OF THE KOREAN SOCIETY OF COLOPROCTOLOGY 2011; 27:31-40. [PMID: 21431095 PMCID: PMC3053500 DOI: 10.3393/jksc.2011.27.1.31] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2010] [Accepted: 12/07/2010] [Indexed: 12/13/2022]
Abstract
BACKGROUND We investigated the prognostic significance of tumor regression grade (TRG) after preoperative chemoradiation therapy (preop-CRT) for locally advanced rectal cancer especially in the patients without lymph node metastasis. METHODS One-hundred seventy-eight patients who had cT3/4 tumors were given 5,040 cGy preoperative radiation with 5-fluorouracil/leucovorin chemotherapy. A total mesorectal excision was performed 4-6 weeks after preop-CRT. TRG was defined as follows: grade 1 as no cancer cells remaining; grade 2 as cancer cells outgrown by fibrosis; grade 3 as a minimal presence or absence of regression. The prognostic significance of TRG in comparison with histopathologic staging was analyzed. RESULTS Seventeen patients (9.6%) showed TRG1. TRG was found to be significantly associated with cancer-specific survival (CSS; P = 0.001) and local recurrence (P = 0.039) in the univariate study, but not in the multivariate analysis. The ypN stage was the strongest prognostic factor in the multivariate analysis. Subgroup analysis revealed TRG to be an independent prognostic factor for the CSS of ypN0 patients (P = 0.031). TRG had a stronger impact on the CSS of ypN (-) patients (P = 0.002) than on that of ypN (+) patients (P = 0.521). In ypT2N0 and ypT3N0, CSS was better for TRG2 than for TRG3 (P = 0.041, P = 0.048), and in ypN (-) and TRG2 tumors, CSS was better for ypT1-2 than for ypT3-4 (P = 0.034). CONCLUSION TRG was found to be the strongest prognostic factor in patients without lymph node metastasis (ypN0), and different survival was observed according to TRG among patients with a specific histopathologic stage. Thus, TRG may provide an accurate prediction of prognosis and may be used for f tailoring treatment for patients without lymph node metastasis.
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Affiliation(s)
- Byung Soh Min
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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Is local excision after complete pathological response to neoadjuvant chemoradiation for rectal cancer an acceptable treatment option? Dis Colon Rectum 2010; 53:1624-31. [PMID: 21178856 DOI: 10.1007/dcr.0b013e3181f5b64d] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE The role of local excision in patients with good histological response to neoadjuvant chemoradiation for locally advanced rectal cancer is unclear, mainly because of possible regional nodal involvement. This study aims to evaluate the correlation between pathological T and N stages following neoadjuvant chemoradiation for locally advanced rectal cancer and the outcome of patients with mural pathological complete response undergoing local excision. METHODS This investigation was conducted as a retrospective analysis. Between January 1997 and December 2007, 320 patients with T3 to 4Nx, TxN+ or distal (≤ 6 cm from the anus) T2N0 rectal cancer underwent neoadjuvant concurrent chemoradiation followed by surgery. Radiotherapy was standard and chemotherapy consisted of common fluoropyrimidine-based regimens. RESULTS After chemoradiation, 93% patients had radical surgery, 6% had local excision, and 3% did not have surgery. In the 291 patients undergoing radical surgery, the pathological T stage correlated with the N stage (P = .036). We compared the outcome of patients with mural complete pathological response (n = 37) who underwent radical surgery (group I) and those (n = 14) who had local excision only (group II). With a median follow-up of 48 months, 4 patients in group I had a recurrence and none in group II had a recurrence; one patient died in group I and none died in group II. Disease-free survival, pelvic recurrence-free survival, and overall survival rates were similar in both groups. CONCLUSION In this retrospective study, nodal metastases were rare in patients with mural complete pathological response following neoadjuvant chemoradiation (3%), and local excision did not compromise their outcome. Therefore, local excision may be an acceptable option in these patients.
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Yeo SG, Kim DY, Kim TH, Kim SY, Chang HJ, Park JW, Choi HS, Oh JH. Local excision following pre-operative chemoradiotherapy-induced downstaging for selected cT3 distal rectal cancer. Jpn J Clin Oncol 2010; 40:754-60. [PMID: 20457724 DOI: 10.1093/jjco/hyq062] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To investigate the long-term outcomes of selected patients with cT3 distal rectal cancer treated with local excision following pre-operative chemoradiotherapy. METHODS Between January 2003 and February 2008, 11 patients with cT3 distal rectal cancer received a local excision following pre-operative chemoradiotherapy. The median age of the patients was 61 years (range, 42-71). The median tumor size was 3 cm (range, 2-5), and the median distance of the caudal tumor edge from the anal verge was 3 cm (range, 1-4). Clinical lymph node status was positive in five patients. Pre-operative chemoradiotherapy consisted of a 50.4 Gy in 28 fractions with concurrent chemotherapy. A transanal full-thickness local excision was performed after a median of 54 days (range, 31-90) from chemoradiotherapy completion. Ten patients received post-operative chemotherapy. RESULTS Pathologically complete responses occurred in eight patients, ypT1 in two and ypT2 in one. The pathologic tumor size for three ypT1-2 tumors was 0.9, 1.1 and 2.2 cm. The follow-up period was a median of 59 months (range, 24-85). One patient (ypT0) developed recurrence at the excision site 14 months after surgery, but was successfully salvaged with an abdominoperineal resection and adjuvant chemotherapy. Another patient (ypT2) developed bone metastasis after 8 months and died of the disease. The 5-year local recurrence-free, disease-free and overall survival rates were 90.9%, 81.8% and 88.9%, respectively. No Grade 3 or worse gastrointestinal toxicity was detected. CONCLUSIONS Full-thickness local excision following chemoradiotherapy may be an acceptable option for cT3 distal rectal cancer that responds well to chemoradiotherapy.
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Affiliation(s)
- Seung-Gu Yeo
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do 410-769, Republic of Korea
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Downstaging after chemoradiotherapy for locally advanced rectal cancer: is there more (tumor) than meets the eye? Dis Colon Rectum 2010; 53:251-6. [PMID: 20173469 DOI: 10.1007/dcr.0b013e3181bcd3cc] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE Preoperative chemoradiotherapy can lead to pathologic complete response of rectal cancer. This study was designed to determine the relationship between postchemoradiotherapy pathologic T stage (ypT stage) and nodal metastases and to evaluate whether pathologic complete response of the primary tumor results in sterilization of mesorectal lymph nodes. METHODS Clinicopathological data from 1997 to 2007 of a prospectively maintained colorectal cancer database were examined. Inclusion criteria were patients with extraperitoneal rectal cancer who underwent preoperative chemoradiotherapy and subsequent radical resection. Statistical analysis was performed by use of Kruskall-Wallis and Wilcoxon rank-sum tests. RESULTS Two hundred forty-two patients were identified (73.1% male, median age, 57 y (range, 36-85 y)). Data regarding preoperative chemoradiotherapy were available for 177 patients (73.1%). The median dose of radiotherapy was 5040 cGy (3060-6100 cGy). The mean preoperative radiotherapy dose and interval between chemoradiotherapy and surgery are similar when stratified by ypT stage (P = .55 and P = .72, respectively). Low anterior resection was performed in 174 patients (71.6%), and the remainder underwent abdominoperineal resection. A mural pathologic complete response was achieved in 62 patients (25.6%). In this pathologic complete-response group, positive lymph nodes were found in 2 patients (3.2%). The rate of metastatic lymph nodes increased as ypT stage increased (ypT1 = 11.1%, ypT2 = 29.2%, ypT3 = 37.3%). CONCLUSION Patients with a mural pathologic complete response have a low rate of positive lymph nodes. These findings may have implications for the management strategies of these patients, including the use of local resection or a watch-and-wait policy. When the response to chemoradiotherapy is not complete, radical surgery should remain the treatment based on high rates of lymph node involvement.
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Yeo SG, Kim DY, Kim TH, Jung KH, Hong YS, Chang HJ, Park JW, Lim SB, Choi HS, Jeong SY. Tumor volume reduction rate measured by magnetic resonance volumetry correlated with pathologic tumor response of preoperative chemoradiotherapy for rectal cancer. Int J Radiat Oncol Biol Phys 2009; 78:164-71. [PMID: 20004532 DOI: 10.1016/j.ijrobp.2009.07.1682] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2009] [Revised: 07/09/2009] [Accepted: 07/15/2009] [Indexed: 01/24/2023]
Abstract
PURPOSE To determine whether the tumor volume reduction rate (TVRR) measured using three-dimensional region-of-interest magnetic resonance volumetry correlates with the pathologic tumor response after preoperative chemoradiotherapy (CRT) for locally advanced rectal cancer. METHODS AND MATERIALS The study included 405 patients with locally advanced rectal cancer (cT3-T4) who had undergone preoperative CRT and radical proctectomy. The tumor volume was measured using three-dimensional region-of-interest magnetic resonance volumetry before and after CRT but before surgery. We analyzed the correlation between the TVRR and the pathologic tumor response in terms of downstaging and tumor regression grade (TRG). Downstaging was defined as ypStage 0-I (ypT0-T2N0M0), and the TRG proposed by Dworak et al. was used. RESULTS The mean TVRR was 65.0% +/- 22.3%. Downstaging and complete regression occurred in 167 (41.2%) and 58 (14.3%) patients, respectively. The TVRRs according to ypT classification (ypT0-T2 vs. ypT3-T4), ypN classification (ypN0 vs. ypN1-N2), downstaging (ypStage 0-I vs. ypStage II-III), good regression (TRG 3-4 vs. TRG 1-2), and complete regression (TRG 4 vs. TRG 1-3) were all significantly different (p <.05). When the TVRR was categorized into three groups (<60%, 60-80%, and >80%), the rates of ypT0-T2, ypN0, downstaging, and good regression were all significantly greater for patients with a TVRR of >or=60%, as was the complete regression rate for patients with a TVRR >80% (p <.05). CONCLUSION The TVRR measured using three-dimensional region-of-interest magnetic resonance volumetry correlated significantly with the pathologic tumor response in terms of downstaging and TRG after preoperative CRT for locally advanced rectal cancer.
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Affiliation(s)
- Seung-Gu Yeo
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
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Berardi R, Mantello G, Scartozzi M, Del Prete S, Luppi G, Martinelli R, Fumagalli M, Grillo-Ruggieri F, Bearzi I, Mandolesi A, Marmorale C, Cascinu S. Locally Advanced Rectal Cancer Patients Receiving Radio-Chemotherapy: A Novel Clinical–Pathologic Score Correlates With Global Outcome. Int J Radiat Oncol Biol Phys 2009; 75:1437-43. [DOI: 10.1016/j.ijrobp.2009.01.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2008] [Revised: 01/04/2009] [Accepted: 01/06/2009] [Indexed: 01/08/2023]
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