A single institution's long-term follow-up of patients with pathological complete response in locally advanced rectal adenocarcinoma following neoadjuvant chemoradiotherapy

Construction and Evaluation of Nomogram for Hematological Indicators to Predict Pathological Response after Neoadjuvant Chemoradiotherapy in Locally Advanced Rectal Cancer

OBJECTIVE

A retrospective study was conducted by developing prediction models to evaluate the association between hematological indexes, their changes during neoadjuvant chemoradiotherapy (NCRT), and tumor pathological response in patients with locally advanced rectal cancer.

METHODS

The clinical data of 202 patients who received NCRT and radical surgery in Sichuan Cancer Hospital were retrospectively analyzed. Univariate and logistic multivariate regression analyses were used to identify hematological indexes with predictive significance. The independent risk factors were imported into the R software, and a nomogram prediction model was developed. The bootstrap method and ROC curve were used to evaluate the discriminative degree of the model.

RESULTS

Univariate analysis demonstrated age, tumor diameter, preoperative T, distance from tumor to the anal verge, CEA before NCRT, preoperative CEA, lymphocyte changes, platelet changes, and pathology of rectal cancer after NCRT were associated. Multivariate analysis demonstrated that age, tumor distance from the anus, preoperative CEA, lymphocyte changes, and platelet changes were independent risk factors. The independent risk factors were imported into the R software to construct a nomogram model. The area under the ROC was 0.76, and the slope of the calibration curve of the nomogram was close to 1.

CONCLUSION

A low preoperative CEA level, a young age, a high tumor from the anal verge, the maintenance of circulating lymphocyte level, and a decreased platelet level after NCRT are important factors for favorable outcomes after NCRT. Developing a nomogram prediction model with good discrimination and consistency can provide some guidance for predicting pathological responses after NCRT.

Prognostic role of platelet-to-lymphocyte ratio, neutrophil-to-lymphocyte, and lymphocyte-to-monocyte ratio in operated rectal cancer patients: systematic review and meta-analysis

BACKGROUND

Inflammation plays an important role in tumor growth. Novel serum blood biomarkers, including neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and lymphocyte-to-monocyte ratio (LMR), have been proposed as useful prognostic indexes in cancer patients. However, their role in rectal cancer is controversial.

METHODS

A comprehensive literature review was conducted including MEDLINE/Pubmed, EMBASE, SCOPUS, and the Cochrane Database of Systematic Reviews through May 2022. The systematic review and meta-analysis were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Quality was appraised with the Methodological Index for Non-Randomized Studies (MINORS) tool. Aim of the study was to summarize available literature on PLR, NLR, and LMR in patients with rectal cancer undergoing resection.

RESULTS

Forty-seven observational studies (14,205 patients) were included; there were 42 retrospective and 5 prospective cohort studies with an average MINORS score of 14.6 (range: 12-18). Worse overall survival was associated with high NLR (HR 1.81; 95%CI 1.52-2.15; p < 0.001), high PLR (HR 1.24; 95%CI 1.06-1.46; p = 0.009), and low LMR (HR 0.67; 95%CI 0.49-0.91; p = 0.01). High NLR and low LMR were also associated with disease-free-survival (HR 1.68; 95%CI 1.35-2.08; p < 0.001 and HR 0.71; 95%CI 0.58-0.87; p < 0.001, respectively).

CONCLUSIONS

NLR, PLR, and LMR are independent clinical predictors for overall survival in patients with rectal cancer treated with curative surgery. NLR and LMR are also good predictors for disease free survival. These biomarkers, which are readily available, appear optimal prognostic indexes and may help clinicians predict the prognosis of rectal cancer and develop individualized treatment strategies.

Gene-expression profiles of pretreatment biopsies predict complete response of rectal cancer patients to preoperative chemoradiotherapy

Purpose

Preoperative (neoadjuvant) chemoradiotherapy (CRT) and total mesorectal excision is the standard treatment for rectal cancer patients (UICC stage II/III). Up to one-third of patients treated with CRT achieve a pathological complete response (pCR). These patients could be spared from surgery and its associated morbidity and mortality, and assigned to a “watch and wait” strategy. However, reliably identifying pCR based on clinical or imaging parameters remains challenging.

Experimental design

We generated gene-expression profiles of 175 patients with locally advanced rectal cancer enrolled in the CAO/ARO/AIO-94 and -04 trials. One hundred and sixty-one samples were used for building, training and validating a predictor of pCR using a machine learning algorithm. The performance of the classifier was validated in three independent cohorts, comprising 76 patients from (i) the CAO/ARO/AIO-94 and -04 trials (n = 14), (ii) a publicly available dataset (n = 38) and (iii) in 24 prospectively collected samples from the TransValid A trial.

Results

A 21-transcript signature yielded the best classification of pCR in 161 patients (Sensitivity: 0.31; AUC: 0.81), when not allowing misclassification of non-complete-responders (False-positive rate = 0). The classifier remained robust when applied to three independent datasets (n = 76).

Conclusion

The classifier can identify >1/3 of rectal cancer patients with a pCR while never classifying patients with an incomplete response as having pCR. Importantly, we could validate this finding in three independent datasets, including a prospectively collected cohort. Therefore, this classifier could help select rectal cancer patients for a “watch and wait” strategy.

Translational relevance

Forgoing surgery with its associated side effects could be an option for rectal cancer patients if the prediction of a pathological complete response (pCR) after preoperative chemoradiotherapy would be possible. Based on gene-expression profiles of 161 patients a classifier was developed and validated in three independent datasets (n = 76), identifying over 1/3 of patients with pCR, while never misclassifying a non-complete-responder. Therefore, the classifier can identify patients suited for “watch and wait”.

Meta-Analysis on the Neutrophil-Lymphocyte Ratio in Rectal Cancer Treated With Preoperative Chemoradiotherapy: Prognostic Value of Pre- and Post-Chemoradiotherapy Neutrophil-Lymphocyte Ratio

Background

To evaluate the prognostic value of neutrophil-lymphocyte ratio (NLR) in rectal cancer patients treated with preoperative chemoradiotherapy (CRT) and curative surgery.

Methods

A comprehensive search of the EMBASE and PubMed databases was performed to screen studies that compared treatment outcomes according to the pre-CRT and/or post-CRT NLR in patients receiving preoperative CRT and curative surgery for locally advanced rectal cancer. Hazard ratios (HRs) for disease-free survival (DFS) and/or overall survival (OS) were extracted, and a random-effects model was used for pooled analysis.

Results

Totally, 22 retrospective studies comprising 6316 patients were included. Preoperative CRT was administered with concurrent chemotherapy (mostly fluoropyrimidine-based regimens). The elevated pre-CRT NLR was significantly associated with an increased risk of recurrence (HR, 1.54; 95% confidence interval [CI], 1.31-1.81) and death (HR, 2.14; 95% CI, 1.61-2.84). Post-CRT NLR was reported in only 3 of 22 studies, and the correlation was not statistically significant for recurrence (HR, 1.44; 95% CI, 0.86-2.41) or death (HR, 2.38; 95% CI, 0.94-6.07).

Conclusions

Elevated pre-CRT NRL, but not post-CRT NRL, is associated with inferior DFS and OS. Further studies are needed to confirm the prognostic value of NLR in rectal cancer patients receiving preoperative CRT.

Management of early rectal cancer; current surgical options and future direction

Rectal cancer is the second commonest cause of cancer death within the United Kingdom. Utilization of national screening programmes have resulted in a greater proportion of patients presenting with early-stage disease. The technique of transanal endoscopic microsurgery was first described in 1984 following which further options for local excision have emerged with transanal endoscopic operation and, more recently, transanal minimally invasive surgery. Owing to the risks of local recurrence, the current role of minimally invasive techniques for local excision in the management of rectal cancer is limited to the treatment of pre-invasive disease and low risk early-stage rectal cancer (T1N0M0 disease). The roles of chemotherapy and radiotherapy for the management of early rectal cancer are yet to be fully established. However, results of high-quality research such as the GRECCAR II, TESAR and STAR-TREC randomised control trials may highlight a wider role for local excision surgery in the future, when used in combination with oncological therapies. The aim of our review is to provide an overview in the current management of early rectal cancer, the surgical options available for local excision and the future multimodal direction of early rectal cancer treatment.

R0 Resection for Locally Advanced Pancreatic Cancer with Low-dose Gemcitabine with Wide Irradiation Area as Neoadjuvant Chemoradiotherapy

BACKGROUND

Local antitumor efficacy and the outcome of neoadjuvant chemoradiotherapy (NACRT) with low-dose gemcitabine and wide irradiation area for borderline resectable and unresectable pancreatic cancer were evaluated.

PATIENTS AND METHODS

Thirty-four cases of borderline resectable and unresectable pancreatic cancer were recruited. Three-dimensional conformal radiotherapy to the pancreatic bed and the region scheduled for lymph node dissection was performed to a total dose of 50.4 Gy28 fractions with gemcitabine at a dose of 150 mg/m² weekly. Clinical and pathological results were examined.

RESULTS

Twenty-seven patients (79.4%) completed the protocol. Grade 3/4 leucopenia (n=10), and grade 3 anorexia (n=1) occurred. Seven cases were excluded (two refused treatment; five had progressive disease), 20 underwent laparotomy, and 16 resected (47.1%) cases achieved R0 resection. Median survival time, and 3-year and 5-year survival rates were 39.0 months, and 56.3% and 28.1% in resected cases, respectively.

CONCLUSION

NACRT with low-dose gemcitabine and wide irradiation area achieved 100% R0 resection and acceptable prognosis.

The value of neutrophil-to-lymphocyte ratio for response and prognostic effect of neoadjuvant chemotherapy in solid tumors: A systematic review and meta-analysis

Introduction: The neutrophil-to-lymphocyte ratio (NLR) has been found to be an indicator of poor prognosis in many tumour types. However, little is known about the relationship between the NLR and patients with tumours who receive neoadjuvant chemotherapy (NAC) in terms of response rate and prognostic ability. We thus performed this meta-analysis to further investigate this relationship. Methods: An electronic systematic literature search for articles published before September 2017 was performed to explore the association between the pretreatment NLR and outcome in patients treated with NAC. Data were extracted by the reported odds ratios (ORs) and hazard ratios (HRs) with their 95% confidence intervals (CIs) for the response rate and the survival outcome, respectively. The results were pooled using the random-effect or fixed-effect model. Results: Thirty-three studies were eventually included in our study, and all were published no earlier than 2011. An NLR that was higher than the cut-off was associated with a lower pathological complete response (pCR) rate in patients with cancer (OR = 1.72, 95% CI, 1.26-2.33). A lower NLR was associated with better overall survival (OS) (HR = 1.58, 95% CI, 1.34-1.86), cancer-specific survival (CSS) (HR = 2.22, 95% CI, 1.32-3.74), disease-free survival (DFS) (HR = 1.32, 95% CI, 1.10-1.59) and recurrence-free survival (RFS) (HR = 1.90, 95% CI, 1.50-2.40). Conclusion: Overall, an NLR lower than the cut-off value indicated a greater chance for pCR and may predict good survival outcomes after NAC for patients with solid tumours. The use of the NLR for risk stratification before NAC should be further demonstrated by future large-scale prospective studies.

Lower lymph node yield following neoadjuvant therapy for rectal cancer has no clinical significance

Background

Obtaining 12 lymph nodes following resection for rectal cancer is an important prognostic marker. However, patients who have received neoadjuvant therapy are known to have a lower lymph node yield. We conducted this study to determine the clinical significance of evaluating <12 versus ≥12 lymph nodes in individuals who underwent surgery following neoadjuvant therapy for rectal cancer.

Methods

A retrospective analysis of all patients who received neoadjuvant therapy for locally advanced rectal cancer between January 2008 and December 2014 followed by proctectomy was conducted.

Results

In total, 217 patients were treated for rectal cancer. Mean follow-up was 23.4 (interquartile range, 9-40.5) months. Sixty-three (29.0%) patients received neoadjuvant therapy. There was a statistically significant difference in the number of patients with <12 lymph node yield between those who received neoadjuvant therapy and those who did not (27.0% vs. 9.1%, P=0.001). Amongst the 63 patients who received neoadjuvant therapy, lymph node yield of ≥12 was not associated with a statistically significant difference in time to recurrence [hazard ratio (HR) 0.17; 95% confidence interval (CI), 0.01-2.01, P=0.160] or time to death (HR 1.07; 0.15-7.90, P=0.946). Kaplan-Meier curves also did not show any significant difference between those with <12 lymph nodes and those with ≥12 lymph nodes in terms of recurrence and death (P=0.203 and P=0.762 respectively).

Conclusions

Although neoadjuvant therapy reduces the lymph node yield during surgery for locally advanced rectal cancer, this has no significance on the overall survival of the patient.