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McKechnie T, Brennan K, Eskicioglu C, Farooq A, Patel SV. Applying the fragility index to randomized controlled trials evaluating total neoadjuvant therapy for rectal cancer: A methodological survey. Radiother Oncol 2024; 194:110148. [PMID: 38341094 DOI: 10.1016/j.radonc.2024.110148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 01/08/2024] [Accepted: 02/05/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND Recently, there has been significant interest in, and adoption of, total neoadjuvant therapy (TNT) for locally advanced rectal cancer (LARC). We designed the present study to assess the robustness of the randomized controlled trials (RCTs) evaluating contemporary TNTs for LARC using the fragility index (FI). MATERIALS AND METHODS Relevant articles were identified through a review article by Johnson et al. in the Canadian Journal of Surgery. Dichotomous outcomes within these RCTs were eligible for inclusion if the reported effect size had a p-value < 0.05. The main outcome was FI for each included outcome. Walsh et al.'s method of calculating FI was utilized. Correlations between FI and research characteristics were assessed using the Spearman's rank correlation coefficients. Risk of bias was assessed using Cochrane recommended tools. RESULTS Ten RCTs were identified with 25 outcomes having statistically significant differences between groups. Eleven outcomes were time-to-event outcomes, while the remainder were dichotomous outcomes. Approximately half (n = 13) were oncologic outcomes. The median FI was 2 (interquartile range [IQR] 1-16). The number of patients lost to follow-up exceeded the FI in 17 outcomes (68.0 %) and thus these results were considered "fragile". Lower FI was associated with high risk of bias (rho = -0.5594) and greater loss to follow-up (rho = -0.4394), while higher FI was associated with large study size (rho = 0.5120). CONCLUSIONS The robustness of outcomes from trials assessing TNT for LARC was found to be questionable. Most outcomes were fragile, as determined by the FI. This survey is limited by the number of included studies.
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Affiliation(s)
- Tyler McKechnie
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Kelly Brennan
- Division of General Surgery, Department of Surgery, Queen's University, Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Cagla Eskicioglu
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Ameer Farooq
- Division of General Surgery, Department of Surgery, Queen's University, Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Sunil V Patel
- Division of General Surgery, Department of Surgery, Queen's University, Kingston Health Sciences Centre, Kingston, ON, Canada.
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Isaic A, Motofelea AC, Costachescu D, Pop GN, Totolici B, Popovici D, Diaconescu RG. What Is the Comparative Efficacy of Surgical, Endoscopic, Transanal Resection, and Radiotherapy Modalities in the Treatment of Rectal Cancer? Healthcare (Basel) 2023; 11:2347. [PMID: 37628544 PMCID: PMC10454130 DOI: 10.3390/healthcare11162347] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 08/11/2023] [Accepted: 08/18/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Rectal cancer is a significant healthcare burden, and effective treatment is crucial. This research aims to compare the effectiveness of surgical and endoscopic resection, transanal resection, and radiotherapy. METHODS A literature analysis was conducted in order to identify relevant studies, by comparing the different surgical approaches and variables affecting treatment decisions. The findings were analyzed and synthesized to provide a comprehensive overview. RESULTS Surgical treatment, particularly TME (total mesorectal excision), proved consistent efficacy in achieving complete tumor resection and improving long-term survival. Endoscopic treatment and transanal resection techniques were promising for early-stage tumors but were associated with higher local recurrence rates. Radiotherapy, especially in combination with chemotherapy, played a crucial role in locally advanced cases, improving local control and reducing recurrence risk. Patient data, tumor characteristics, and healthcare system factors were identified as important factors in treatment modality selection. CONCLUSION Surgical treatment, specifically TME, remains the recommended standard approach for rectal cancer, providing excellent oncological outcomes. Endoscopic treatment and transanal resection techniques can be considered for selected early-stage cases, while radiotherapy is beneficial for locally advanced tumors. Treatment decisions should be personalized based on patient and tumor characteristics, considering the available resources and expertise within the healthcare system.
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Affiliation(s)
- Alexandru Isaic
- IInd Surgery Clinic, Timisoara Emergency County Hospital, 300723 Timisoara, Romania;
- Department X of General Surgery, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Alexandru Cătălin Motofelea
- Department of Internal Medicine, Faculty of Medicine, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Dan Costachescu
- Department of Orthopedics-Traumatology, Urology, Radiology, and Medical Imaging, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania;
- Department of Oncology, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania;
| | - Gheorghe Nicusor Pop
- Center for Modeling Biological Systems and Data Analysis, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania;
| | - Bogdan Totolici
- 1st Clinic of General Surgery, Arad County Emergency Clinical Hospital, 310158 Arad, Romania;
- Department of General Surgery, Faculty of Medicine, “Victor Babes” Western University of Arad, 310025 Arad, Romania
| | - Dorel Popovici
- Department of Oncology, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania;
| | - Razvan Gheorghe Diaconescu
- OncoHelp Hospital, 300239 Timisoara, Romania;
- Department of Surgery, Faculty of Medicine, “Victor Babes” Western University of Arad, 310025 Arad, Romania
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Saravanabavan S, Kazi M, Murugan J, Vispute T, Vijayakumaran P, Desouza A, Saklani A. Outcomes of extended total mesorectal excision in patients with locally advanced rectal cancer. Colorectal Dis 2023. [PMID: 37246309 DOI: 10.1111/codi.16606] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 04/09/2023] [Accepted: 04/25/2023] [Indexed: 05/30/2023]
Abstract
AIM Extended total mesorectal excision (eTME) is a complex procedure involving en bloc resection of the structures surrounding the various quadrants of the rectum. This study, presenting the largest series so far of patients undergoing eTME, aimed to assess the surgical and survival outcomes of patients following treatment with eTME and to compare these outcomes with historical data on pelvic exenteration. METHOD The study is a retrospective review of all patients with locally advanced rectal cancer requiring an eTME (2014-2020). The database includes the demographic profile, operative details, histopathological features and follow-up. RESULTS One hundred and sixty three patients who underwent eTME were analysed. The overall Clavien-Dindo complication rate of > IIIa was 21.1%. The anterior quadrant was the most common anatomical site resected (68.5%). The R1 resection rate was 10.4%. After a median follow-up of 28 months, there were 51 recurrences in the study and twenty two deaths were recorded. The local recurrence rate was 7.3% among the study population. The disease-free survival (DFS) and overall survival were 66.7% and 80.4%, respectively, at 3 years. The majority of the recurrences were distant metastasis (84.3%). In univariate analysis, the quadrant involved did not affect survival. In multivariate analysis, signet ring histology, metastatic presentation, inadequate tumour response and R1 resection affected DFS. CONCLUSION The recurrence pattern, R1 resection rate and survival outcomes of patients in the present study were comparable with those for patients undergoing an exenteration. Therefore, eTME is probably a safe alternative to pelvic exenterations when R0 resection is achievable and when the procedure is performed in high-volume specialist tertiary care centres.
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Affiliation(s)
- Srivishnu Saravanabavan
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Mufaddal Kazi
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Janesh Murugan
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Tejas Vispute
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Preeti Vijayakumaran
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Ashwin Desouza
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Avanish Saklani
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
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Bedrikovetski S, Fitzsimmons T, Perry J, Vather R, Carruthers S, Selva-Nayagam S, Thomas ML, Moore JW, Sammour T. Personalized total neoadjuvant therapy (pTNT) for advanced rectal cancer with tailored treatment sequencing based on clinical stage at presentation. ANZ J Surg 2023; 93:173-181. [PMID: 36059157 DOI: 10.1111/ans.18021] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/21/2022] [Accepted: 08/23/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND This study aimed to assess short-term outcomes of a personalized total neoadjuvant treatment (pTNT) protocol, with treatment sequencing based on clinical stage at presentation. METHODS A multidisciplinary pTNT protocol was implemented across two metropolitan hospitals. This consists of two-schema based on clinical stage: patients with distant failure risk were offered induction chemotherapy before chemoradiation (nCRT), and patients with locoregional failure risk received nCRT followed by consolidation chemotherapy. Patients underwent surgical resection unless a complete clinical response (cCR) was achieved, in which case non-operative management (NOM) was offered. A prospective cohort analysis of all patients with rectal cancer who underwent pTNT with curative intent between Jan 2019 and Aug 2022 was performed. RESULTS Of 270 patients referred with rectal cancer, 102 received pTNT with curative intent and 79 have completed their treatment thus far. Thirty-three patients (41.8%) received induction chemotherapy and 46 (58.2%) received consolidation chemotherapy per protocol. The percentage of patients with EMVI, resectable M1 disease, cT4 disease, and positive lateral lymph nodes were 54.4%, 36.7%, 27.8% and 15.2%, respectively. Overall, 32 (40.5%) patients had cCR and 4 (5.1%) pCR, and 40 (50.6%) patients had non-operative management. Grade 3 toxicity was reported in 10.1% of patients and only three patients (3.8%) experienced Grade 4 chemotherapy-related toxicity, with no treatment related mortality. CONCLUSION Early results with a defined two-schema pTNT protocol are encouraging and suggest that tailoring sequencing to disease risk at presentation may represent the optimal balance between local and distant disease control, as well as treatment toxicity.
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Affiliation(s)
- Sergei Bedrikovetski
- Department of Surgical Specialties, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia.,Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Tracy Fitzsimmons
- Department of Surgical Specialties, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia.,Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Joanne Perry
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Ryash Vather
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Scott Carruthers
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Sudarsha Selva-Nayagam
- Department of Medical Oncology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Michelle L Thomas
- Department of Surgical Specialties, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia.,Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - James W Moore
- Department of Surgical Specialties, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia.,Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Tarik Sammour
- Department of Surgical Specialties, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia.,Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Bedrikovetski S, Traeger L, Fitzsimmons T, Perry J, Vather R, Moore JW, Sammour T. Personalized total neoadjuvant therapy versus chemotherapy during the ‘wait period’ versus standard chemoradiotherapy for locally advanced rectal cancer. ANZ J Surg 2022; 93:1267-1273. [DOI: 10.1111/ans.18229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 12/16/2022] [Indexed: 12/28/2022]
Affiliation(s)
- Sergei Bedrikovetski
- Department of Surgical Specialties, Adelaide Medical School, Faculty of Health and Medical Sciences University of Adelaide Adelaide South Australia Australia
- Colorectal Unit, Department of Surgery Royal Adelaide Hospital Adelaide South Australia Australia
| | - Luke Traeger
- Department of Surgical Specialties, Adelaide Medical School, Faculty of Health and Medical Sciences University of Adelaide Adelaide South Australia Australia
- Colorectal Unit, Department of Surgery Royal Adelaide Hospital Adelaide South Australia Australia
| | - Tracy Fitzsimmons
- Department of Surgical Specialties, Adelaide Medical School, Faculty of Health and Medical Sciences University of Adelaide Adelaide South Australia Australia
- Colorectal Unit, Department of Surgery Royal Adelaide Hospital Adelaide South Australia Australia
| | - Joanne Perry
- Colorectal Unit, Department of Surgery Royal Adelaide Hospital Adelaide South Australia Australia
| | - Ryash Vather
- Colorectal Unit, Department of Surgery Royal Adelaide Hospital Adelaide South Australia Australia
| | - James W. Moore
- Department of Surgical Specialties, Adelaide Medical School, Faculty of Health and Medical Sciences University of Adelaide Adelaide South Australia Australia
- Colorectal Unit, Department of Surgery Royal Adelaide Hospital Adelaide South Australia Australia
| | - Tarik Sammour
- Department of Surgical Specialties, Adelaide Medical School, Faculty of Health and Medical Sciences University of Adelaide Adelaide South Australia Australia
- Colorectal Unit, Department of Surgery Royal Adelaide Hospital Adelaide South Australia Australia
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Negri F, Aschele C. Unconsolidated Results of Consolidation Chemotherapy Following Short-Course Radiotherapy in Locally Advanced Rectal Cancer. J Clin Oncol 2022; 40:4028. [PMID: 35930759 DOI: 10.1200/jco.22.00923] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Francesca Negri
- Francesca Negri, MD, PhD, Gastroenterology and Endoscopy Unit, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy; and Carlo Aschele, MD, PhD, Medical Oncology Unit, Department of Oncology, Ospedale Sant'Andrea, La Spezia, Italy
| | - Carlo Aschele
- Francesca Negri, MD, PhD, Gastroenterology and Endoscopy Unit, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy; and Carlo Aschele, MD, PhD, Medical Oncology Unit, Department of Oncology, Ospedale Sant'Andrea, La Spezia, Italy
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