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Bauer PS, Gamboa AC, Otegbeye EE, Chapman WC, Rivard S, Regenbogen S, Mohammed M, Holder-Murray J, Wiseman JT, Ejaz A, Edwards-Hollingsworth K, Hawkins AT, Hunt SR, Balch G, Silviera ML. Short-course radiation with consolidation chemotherapy does not increase operative morbidity compared to long-course chemoradiation: A retrospective study of the US rectal cancer consortium. J Surg Oncol 2024; 129:254-263. [PMID: 37792637 PMCID: PMC10872853 DOI: 10.1002/jso.27468] [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: 08/23/2023] [Accepted: 09/19/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Neoadjuvant short-course radiation and consolidation chemotherapy (SC TNT) remains less widely used for rectal cancer in the United States than long-course chemoradiation (LCRT). SC TNT may improve compliance and downstaging; however, a longer radiation-to-surgery interval may worsen pelvic fibrosis and morbidity with total mesorectal excision (TME). A single, US-center retrospective analysis has shown comparable risk of morbidity after neoadjuvant short-course radiation with consolidation chemotherapy (SC TNT) and long-course chemoradiation (LCRT). Validation by a multi-institutional study is needed. METHODS The US Rectal Cancer Consortium database (2010-2018) was retrospectively reviewed for patients with nonmetastatic, rectal adenocarcinoma treated with neoadjuvant LCRT or SC TNT before TME. The primary endpoint was severe postoperative morbidity. Cohorts were compared by univariate analysis. Multivariable logistic regression modeled the odds of severe complication. RESULTS Of 788 included patients, 151 (19%) received SC TNT and 637 (81%) LCRT. The SC TNT group had fewer distal tumors (33.8% vs. 50.2%, p < 0.0001) and more clinical node-positive disease (74.2% vs. 47.6%, p < 0.0001). The intraoperative complication rate was similar (SC TNT 5.3% vs. 4.4%, p = 0.65). There was no difference in overall postoperative morbidity (38.4% vs. 46.3%, p = 0.08). Severe morbidity was similar with low anterior resection (9.1% vs. 15.3%, p = 0.10) and abdominoperineal resection (24.4% vs. 29.7%, p = 0.49). SC TNT did not increase the odds of severe morbidity relative to LCRT on multivariable analysis (OR 0.64, 95% CI 0.37-1.10). CONCLUSIONS SC TNT does not increase morbidity after TME for rectal cancer relative to LCRT. Concern for surgical complications should not discourage the use of SC TNT when aiming to increase the likelihood of complete clinical response.
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Affiliation(s)
- Philip S. Bauer
- Section of Colon & Rectal Surgery, Department of Surgery, Washington University School of Medicine
| | - Adriana C. Gamboa
- Division of Surgical Oncology, Winship Cancer Institute, Emory University
| | - Ebunoluwa E. Otegbeye
- Section of Colon & Rectal Surgery, Department of Surgery, Washington University School of Medicine
| | - William C. Chapman
- Section of Colon & Rectal Surgery, Department of Surgery, Washington University School of Medicine
| | - Samantha Rivard
- Division of Colorectal Surgery, Department of Surgery, University of Michigan
| | - Scott Regenbogen
- Division of Colorectal Surgery, Department of Surgery, University of Michigan
| | - Maryam Mohammed
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh Medical Center
| | - Jennifer Holder-Murray
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh Medical Center
| | - Jason T. Wiseman
- Division of Surgical Oncology, Department of Surgery, The Ohio State University
| | - Aslam Ejaz
- Division of Surgical Oncology, Department of Surgery, The Ohio State University
| | | | - Alexander T. Hawkins
- Section of Colon & Rectal Surgery, Division of General Surgery, Vanderbilt University Medical Center
| | - Steven R. Hunt
- Section of Colon & Rectal Surgery, Department of Surgery, Washington University School of Medicine
| | - Glen Balch
- Division of Colon & Rectal Surgery, Department of Surgery, Emory University
| | - Matthew L. Silviera
- Section of Colon & Rectal Surgery, Department of Surgery, Washington University School of Medicine
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2
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Liu J, Ladbury C, Glaser S, Fakih M, Kaiser AM, Chen YJ, Williams TM, Amini A. Patterns of Care for Patients With Locally Advanced Rectal Cancer Treated with Total Neoadjuvant Therapy at Predominately Academic Centers between 2016-2020: An NCDB Analysis. Clin Colorectal Cancer 2023; 22:167-174. [PMID: 36878806 DOI: 10.1016/j.clcc.2023.01.005] [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: 12/02/2022] [Revised: 01/24/2023] [Accepted: 01/31/2023] [Indexed: 02/07/2023]
Abstract
Total neoadjuvant therapy (TNT) has emerged as the preferred approach for locally advanced rectal cancer (LARC), defined as T3/4 or any T with N+ disease. Our objective was to (1) determine the proportion of patients with LARC receiving TNT over time, (2) determine the most common method in which TNT is being delivered, and (3) determine what factors are associated with a greater likelihood of receiving TNT in the United States. Retrospective data was obtained from the National Cancer Database (NCDB) for patients diagnosed with rectal cancer between 2016 and 2020. Patients were excluded if they had M1 disease, T1-2 N0 disease, incomplete staging information, nonadenocarcinoma histology, received RT to a nonrectum site, or received a nondefinitive RT dose. Data were analyzed using linear regression, χ2 test, and binary logistic regression. Of the 26,375 patients included, most patients were treated at an academic facility (94.6%). Five thousand three (19.0%) patients received TNT, and 21,372 (81.0%) patients did not receive TNT. The proportion of patients receiving TNT increased significantly over time, from 6.1% in 2016 to 34.6% in 2020 (slope = 7.36, 95% CI 4.58-10.15, R2 = 0.96, P = .040). The most common TNT regimen was multiagent chemotherapy followed by long-course chemoradiation (73.2% of cases from 2016-2020). There was a significant increase in utilization of short-course RT as part of TNT from 2.8% in 2016 to 13.7% in 2020 (slope = 2.74, 95% CI 0.37-5.11, R2 = 0.82, P = .035). Factors associated with a lower likelihood of TNT usage included age >65, female gender, Black race, and T3 N0 disease. TNT use in the United States has increased significantly from 2016-2020, with approximately 34.6% of patients with LARC receiving TNT in 2020. The observed trend appears to be in line with the recent National Comprehensive Cancer Network guidelines recommending TNT as the preferred approach.
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Affiliation(s)
- Jason Liu
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA
| | - Colton Ladbury
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA
| | - Scott Glaser
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA
| | - Marwan Fakih
- Department of Medical Oncology, City of Hope National Medical Center, Duarte, CA
| | - Andreas M Kaiser
- Department of Surgery, City of Hope National Medical Center, Duarte, CA
| | - Yi-Jen Chen
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA
| | - Terence M Williams
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA
| | - Arya Amini
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA.
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3
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Bauer PS, Chapman WC, Atallah C, Makhdoom BA, Damle A, Smith RK, Wise PE, Glasgow SC, Silviera ML, Hunt SR, Mutch MG. Perioperative Complications After Proctectomy for Rectal Cancer: Does Neoadjuvant Regimen Matter? Ann Surg 2022; 275:e428-e432. [PMID: 32209914 PMCID: PMC8245013 DOI: 10.1097/sla.0000000000003885] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Investigate the association between neoadjuvant treatment strategy and perioperative complications in patients undergoing proctectomy for nonmetastatic rectal cancer. SUMMARY OF BACKGROUND DATA Neoadjuvant SC-TNT is an alternative to neoadjuvant CRT for rectal cancer. Some have argued that short-course radiation and extended radiation-to-surgery intervals increase operative difficulty and complication risk. However, the association between SC-TNT and surgical complications has not been previously investigated. METHODS This single-center retrospective cohort study included patients undergoing total mesorectal excision for nonmetastatic rectal cancer after SC-TNT or CRT between 2010 and 2018. Univariate analysis of severe POM and multiple secondary outcomes, including overall POM, intraoperative complications, and resection margins, was performed. Logistic regression of severe POM was also performed. RESULTS Of 415 included patients, 156 (38%) received SC-TNT and 259 (62%) received CRT. The cohorts were largely similar, though patients with higher tumors (69.9% vs 47.5%, P < 0.0001) or node-positive disease (76.9% vs 62.6%, P = 0.004) were more likely to receive SC-TNT. We found no difference in incidence of severe POM (9.6% SC-TNT vs 12.0% CRT, P = 0.46) or overall POM (39.7% SC-TNT vs 37.5% CRT, P = 0.64) between cohorts. Neoadjuvant regimen was also not associated with a difference in severe POM (odds ratio 0.42, 95% confidence interval 0.04-4.70, P = 0.48) in multivariate analysis. There was no significant association between neoadjuvant regimen and any secondary outcome. CONCLUSION In rectal cancer patients treated with SC-TNT and proctectomy, we found no significant association with POM compared to patients undergoing CRT. SC-TNT does not significantly increase the risk of POM compared to CRT.
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Affiliation(s)
- Philip S Bauer
- Washington University School of Medicine, Department of Surgery, Section of Colon and Rectal Surgery, St. Louis, MO
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4
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Weiser MR, Chou JF, Keshinro A, Chapman WC, Bauer PS, Mutch MG, Parikh PJ, Cercek A, Saltz LB, Gollub MJ, Romesser PB, Crane CH, Shia J, Markowitz AJ, Garcia-Aguilar J, Gönen M. Development and Assessment of a Clinical Calculator for Estimating the Likelihood of Recurrence and Survival Among Patients With Locally Advanced Rectal Cancer Treated With Chemotherapy, Radiotherapy, and Surgery. JAMA Netw Open 2021; 4:e2133457. [PMID: 34748003 PMCID: PMC8576585 DOI: 10.1001/jamanetworkopen.2021.33457] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE Predicting outcomes in patients receiving neoadjuvant therapy for rectal cancer is challenging because of tumor downstaging. Validated clinical calculators that can estimate recurrence-free survival (RFS) and overall survival (OS) among patients with rectal cancer who have received multimodal therapy are needed. OBJECTIVE To develop and validate clinical calculators providing estimates of rectal cancer recurrence and survival that are better for individualized decision-making than the American Joint Committee on Cancer (AJCC) staging system or the neoadjuvant rectal (NAR) score. DESIGN, SETTING, AND PARTICIPANTS This prognostic study developed risk models, graphically represented as nomograms, for patients with incomplete pathological response using Cox proportional hazards and multivariable regression analyses with restricted cubic splines. Because patients with complete pathological response to neoadjuvant therapy had uniformly favorable outcomes, their predictions were obtained separately. The study included 1400 patients with stage II or III rectal cancer who received treatment with chemotherapy, radiotherapy, and surgery at 2 comprehensive cancer centers (Memorial Sloan Kettering [MSK] Cancer Center and Siteman Cancer Center [SCC]) between January 1, 1998, and December 31, 2017. Patients from the MSK cohort received chemoradiation, surgery, and adjuvant chemotherapy from January 1, 1998, to December 31, 2014; these patients were randomly assigned to either a model training group or an internal validation group. Models were externally validated using data from the SCC cohort, who received either chemoradiation, surgery, and adjuvant chemotherapy (chemoradiotherapy group) or short-course radiotherapy, consolidation chemotherapy, and surgery (total neoadjuvant therapy with short-course radiotherapy group) from January 1, 2009, to December 31, 2017. Data were analyzed from March 1, 2020, to January 10, 2021. EXPOSURES Chemotherapy, radiotherapy, chemoradiotherapy, and surgery. MAIN OUTCOMES AND MEASURES Recurrence-free survival and OS were the outcome measures, and the discriminatory performance of the clinical calculators was measured with concordance index and calibration plots. The ability of the clinical calculators to predict RFS and OS was compared with that of the AJCC staging system and the NAR score. The models for RFS and OS among patients with incomplete pathological response included postoperative pathological tumor category, number of positive lymph nodes, tumor distance from anal verge, and large- and small-vessel venous and perineural invasion; age was included in the risk model for OS. The final clinical calculators provided RFS and OS estimates derived from Kaplan-Meier curves for patients with complete pathological response and from risk models for patients with incomplete pathological response. RESULTS Among 1400 total patients with locally advanced rectal cancer, the median age was 57.8 years (range, 18.0-91.9 years), and 863 patients (61.6%) were male, with tumors at a median distance of 6.7 cm (range, 0-15.0 cm) from the anal verge. The MSK cohort comprised 1069 patients; of those, 710 were assigned to the model training group and 359 were assigned to the internal validation group. The SCC cohort comprised 331 patients; of those, 200 were assigned to the chemoradiotherapy group and 131 were assigned to the total neoadjuvant therapy with short-course radiotherapy group. The concordance indices in the MSK validation data set were 0.70 (95% CI, 0.65-0.76) for RFS and 0.73 (95% CI, 0.65-0.80) for OS. In the external SCC data set, the concordance indices in the chemoradiotherapy group were 0.71 (95% CI, 0.62-0.81) for RFS and 0.72 (95% CI, 0.59-0.85) for OS; the concordance indices in the total neoadjuvant therapy with short-course radiotherapy group were 0.62 (95% CI, 0.49-0.75) for RFS and 0.67 (95% CI, 0.46-0.84) for OS. Calibration plots confirmed good agreement between predicted and observed events. These results compared favorably with predictions based on the AJCC staging system (concordance indices for MSK validation: RFS = 0.69 [95% CI, 0.64-0.74]; OS = 0.67 [95% CI, 0.58-0.75]) and the NAR score (concordance indices for MSK validation: RFS = 0.56 [95% CI, 0.50-0.63]; OS = 0.56 [95% CI, 0.46-0.66]). Furthermore, the clinical calculators provided more individualized outcome estimates compared with the categorical schemas (eg, estimated RFS for patients with AJCC stage IIIB disease ranged from 7% to 68%). CONCLUSIONS AND RELEVANCE In this prognostic study, clinical calculators were developed and validated; these calculators provided more individualized estimates of the likelihood of RFS and OS than the AJCC staging system or the NAR score among patients with rectal cancer who received multimodal treatment. The calculators were easy to use and applicable to both short- and long-course radiotherapy regimens, and they may be used to inform surveillance strategies and facilitate future clinical trials and statistical power calculations.
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Affiliation(s)
- Martin R. Weiser
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joanne F. Chou
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ajaratu Keshinro
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - William C. Chapman
- Department of Surgery, Washington University in St Louis, St Louis, Missouri
| | - Philip S. Bauer
- Department of Surgery, Washington University in St Louis, St Louis, Missouri
| | - Matthew G. Mutch
- Department of Surgery, Washington University in St Louis, St Louis, Missouri
| | - Parag J. Parikh
- Department of Radiation Oncology, Washington University in St Louis, St Louis, Missouri
| | - Andrea Cercek
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Leonard B. Saltz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marc J. Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Paul B. Romesser
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Christopher H. Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jinru Shia
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York, New York
| | - Arnold J. Markowitz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Julio Garcia-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mithat Gönen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
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5
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Chen B, Alvarado DM, Iticovici M, Kau NS, Park H, Parikh PJ, Thotala D, Ciorba MA. Interferon-Induced IDO1 Mediates Radiation Resistance and Is a Therapeutic Target in Colorectal Cancer. Cancer Immunol Res 2020; 8:451-464. [PMID: 32127391 PMCID: PMC7123802 DOI: 10.1158/2326-6066.cir-19-0282] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 11/08/2019] [Accepted: 02/20/2020] [Indexed: 12/13/2022]
Abstract
Colorectal cancer is a major cause of mortality worldwide. Chemotherapy and radiation remain standard treatment for locally advanced disease, with current immune-targeting therapies applying to only a small subset of patients. Expression of the immuno-oncology target indoleamine 2,3 dioxygenase 1 (IDO1) is associated with poor colorectal cancer clinical outcomes but is understudied as a potential treatment target. In this study, we examined the interaction between the IDO1 pathway and radiotherapy in colorectal cancer. We used human and mouse colorectal cancer cell lines, organoids, mouse syngeneic colorectal cancer tumor graft models, and colorectal cancer tissues from patients who received radiotherapy. IDO1 activity was blocked using the clinical IDO1 inhibitor epacadostat and by genetic disruption. We found that radiation induced IDO1 overexpression in colorectal cancer through type I and II IFN signaling. IDO1 enzymatic activity directly influenced colorectal cancer radiation sensitivity. IDO1 inhibition sensitized colorectal cancer to radiation-induced cell death, whereas the IDO1 metabolite kynurenine promoted radioprotection. IDO1 inhibition also potentiated Th1 cytokines and myeloid cell-modulating factors in the tumor microenvironment and promoted an abscopal effect on tumors outside the radiation field. Conversely, IDO1 blockade protected the normal small intestinal epithelium from radiation toxicity and accelerated recovery from radiation-induced weight loss, indicating a role in limiting side effects. These data demonstrated that IDO1 inhibition potentiates radiotherapy effectiveness in colorectal cancer. The findings also provide rationale and mechanistic insight for the study of IDO1 inhibitors as adjuvant therapy to radiation in patients with locally advanced sporadic and colitis-associated colorectal cancer.
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MESH Headings
- Animals
- Antineoplastic Agents/pharmacology
- Cell Line, Tumor
- Colorectal Neoplasms/enzymology
- Colorectal Neoplasms/immunology
- Colorectal Neoplasms/pathology
- Colorectal Neoplasms/radiotherapy
- Female
- Gene Expression Regulation, Enzymologic/drug effects
- Humans
- Indoleamine-Pyrrole 2,3,-Dioxygenase/antagonists & inhibitors
- Indoleamine-Pyrrole 2,3,-Dioxygenase/genetics
- Indoleamine-Pyrrole 2,3,-Dioxygenase/metabolism
- Interferons/pharmacology
- Intestinal Mucosa/radiation effects
- Kynurenine/metabolism
- Mice
- Mice, Inbred BALB C
- Mice, Inbred C57BL
- Mice, Knockout
- Oximes/pharmacology
- Radiation Tolerance/drug effects
- Radiation-Protective Agents/pharmacology
- Sulfonamides/pharmacology
- Tumor Microenvironment
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Affiliation(s)
- Baosheng Chen
- Inflammatory Bowel Diseases Center and the Division of Gastroenterology, Washington University in Saint Louis School of Medicine, St. Louis, Missouri.
| | - David M Alvarado
- Inflammatory Bowel Diseases Center and the Division of Gastroenterology, Washington University in Saint Louis School of Medicine, St. Louis, Missouri
| | - Micah Iticovici
- Inflammatory Bowel Diseases Center and the Division of Gastroenterology, Washington University in Saint Louis School of Medicine, St. Louis, Missouri
| | - Nathan S Kau
- Inflammatory Bowel Diseases Center and the Division of Gastroenterology, Washington University in Saint Louis School of Medicine, St. Louis, Missouri
| | - Haeseong Park
- Division of Medical Oncology, Washington University in Saint Louis School of Medicine, St. Louis, Missouri
| | - Parag J Parikh
- Department of Radiation Oncology, Washington University in Saint Louis School of Medicine, St. Louis, Missouri
| | - Dinesh Thotala
- Department of Radiation Oncology, Washington University in Saint Louis School of Medicine, St. Louis, Missouri
| | - Matthew A Ciorba
- Inflammatory Bowel Diseases Center and the Division of Gastroenterology, Washington University in Saint Louis School of Medicine, St. Louis, Missouri.
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Avila S, Chang GJ, Dasari NA, Smani DA, Das P, Herman JM, Koay E, Koong A, Krishnan S, Minsky BD, Smith GL, Taniguchi C, Taggart MW, Kaur H, Holliday EB. Pathologic Response and Postoperative Complications After Short-course Radiation Therapy and Chemotherapy for Patients With Rectal Adenocarcinoma. Clin Colorectal Cancer 2020; 19:116-122. [PMID: 32173279 DOI: 10.1016/j.clcc.2020.02.005] [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: 05/20/2019] [Revised: 12/27/2019] [Accepted: 02/02/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND The role of neoadjuvant short-course radiation therapy (SCRT) in treating rectal adenocarcinoma is a topic of ongoing debate. Growing interest in total neoadjuvant therapy has spurred discussion on the optimal sequence of preoperative SCRT and chemotherapy. PATIENTS AND METHODS All patients receiving SCRT (5 Gy × 5 fractions) were identified. Details about preoperative treatments, radiation toxicities, and postoperative complications were collected. Patients were divided into 2 groups: those who underwent surgery within 14 days of completing SCRT and those with a longer delay. Outcomes compared included extent of pathologic response, margin-negative resection rate, acute radiation toxicities, and postoperative complications. RESULTS Fifty-seven patients with locally advanced or metastatic rectal cancer received SCRT between 2008 and 2018. Thirty-nine of 57 patients underwent definitive pelvic surgery with total mesorectal excision. There were no significant differences in tumor downstaging, radial margin status, or percent tumor viability between patients with immediate surgery versus delayed surgery. The delay group had higher rates of nodal downstaging (64.7% vs. 18.2%; P = .003). There were no differences in total or grade 3+ gastrointestinal radiation toxicity, postoperative complications, reoperation, readmission, and mortality between the 2 groups. CONCLUSIONS Though not yet common in the United States, SCRT has compared favorably with long course chemoradiation in multiple trials. Moreover, it is associated with greater efficiency and less disruption to chemotherapy. Our data show similar response and toxicity outcomes between the immediate and delay groups, suggesting SCRT is well-tolerated regardless of treatment sequence. Recently completed prospective trials may reveal the optimal preoperative treatment sequence.
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Affiliation(s)
- Santiago Avila
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - George J Chang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - N Arvind Dasari
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Danyal A Smani
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Joeseph M Herman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Eugene Koay
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Albert Koong
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sunil Krishnan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Bruce D Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Grace L Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Cullen Taniguchi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Melissa W Taggart
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Harmeet Kaur
- Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Emma B Holliday
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
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7
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Jia AY, Narang A, Safar B, Zaheer A, Murphy A, Azad NS, Gearhart S, Fang S, Efron J, Warczynski T, Hacker-Prietz A, Meyer J. Sequential short-course radiation therapy and chemotherapy in the neoadjuvant treatment of rectal adenocarcinoma. Radiat Oncol 2019; 14:147. [PMID: 31426827 PMCID: PMC6700789 DOI: 10.1186/s13014-019-1358-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 08/12/2019] [Indexed: 01/13/2023] Open
Abstract
Background There is continued debate regarding the optimal combinations of radiation therapy and chemotherapy in the preoperative treatment of locally advanced rectal adenocarcinomas. We report our single-institution experience of feasibility and early oncologic outcomes of short-course preoperative radiation therapy (5 Gy X 5 fractions) followed by consolidation neoadjuvant chemotherapy. Methods We reviewed the records of 26 patients with locally advanced rectal adenocarcinoma. All patients underwent short course radiotherapy (5 Gy X 5 fractions) followed by chemotherapy [either modified infusional and bolus 5-fluorouracail and oxalipatin (mFOLFOX6) or capecitabine and oxaliplatin] prior to consideration for surgery. A full course of chemotherapy was defined as at least 8 weeks of chemotherapy. Results There were five clinical (c) T2, 16 cT3, and five cT4 rectal tumors, with 88% cN+. Twenty-five patients received a median of 4 cycles (range 3 to 8) of mFOLFOX6 (with one cycle defined as a two-week period); one patient received 3 cycles of capecitabine and oxaliplatin. All patients completed SCRT; 81% completed the full course of neoadjuvant chemotherapy with 19% requiring dose reductions in chemotherapy, most commonly due to neuropathy. Nineteen patients underwent post-treatment endoscopic evaluation, and nine patients were noted to achieve a complete clinical response (CCR). Six of the nine patients who achieved CCR opted for a non-operative approach of watch-and-wait. Twenty patients underwent surgical resection; pathologic complete response was observed in seven (35%) of these twenty. The main radiation-associated toxicity was proctitis with CTCAE Grade 2 proctitis observed in seven patients (27%). Post-operative Clavien-Dindo Grade 3 complications within 30 days of surgery were identified in six patients (30%), with no Grade 4 or 5 adverse events. Median length of hospital stay was 4.5 days (range 2–16 days); three patients were readmitted within a 30 day period. Conclusions Short course preoperative radiotherapy followed by neoadjuvant chemotherapy was well-tolerated and achieved oncologic outcomes that compare favorably with short-course radiation therapy alone or long-course chemoradiotherapy. This regimen is associated with high rates of clinical and pathologic complete response.
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Affiliation(s)
- Angela Y Jia
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amol Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bashar Safar
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Atif Zaheer
- Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Adrian Murphy
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nilofer S Azad
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Susan Gearhart
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sandy Fang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan Efron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tam Warczynski
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amy Hacker-Prietz
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jeffrey Meyer
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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8
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Utilization of short-course radiation therapy for patients with nonmetastatic rectal adenocarcinoma in the United States. Adv Radiat Oncol 2018; 3:611-620. [PMID: 30370362 PMCID: PMC6200897 DOI: 10.1016/j.adro.2018.07.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 07/25/2018] [Accepted: 07/26/2018] [Indexed: 12/19/2022] Open
Abstract
Purpose Preoperative short-course radiation therapy (SCRT) for patients with nonmetastatic rectal adenocarcinoma has been studied in European trials, but is not often used in the United States. We aim to describe the utilization of preoperative SCRT among patients with nonmetastatic rectal cancer in the National Cancer Database and describe factors associated with its use. Methods and materials The National Cancer Database was queried for patients treated with preoperative radiation therapy followed by surgery for nonmetastatic rectal adenocarcinoma between 2004 and 2014. Patient, tumor, and treatment-related characteristics were compared between patients treated with SCRT (20-25 Gy in <7 fractions) and patients treated with long-course radiation therapy (45-70 Gy in ≥ 25 fractions). Univariate and multivariate Cox regression analyses were used to evaluate factors associated with overall survival. Survival rates were compared using an inverse-probability-weighted regression adjustment method. Results A total of 42,336 patients were included for analysis of which 41,867 patients (98.9%) were treated with long-course radiation therapy and 469 patients (1.1%) with SCRT. Patients treated with SCRT were older, had more comorbidities, had earlier T-stage, and were more likely to be clinically node-negative. Patients treated with SCRT were more likely to be treated at an academic center, have Medicare insurance, and be treated without chemotherapy. Patients treated with SCRT had lower pathological complete response rates (4.3% vs 6.9%; P < .001) and higher rates of positive circumferential resection margins (8.3% vs 5.2%; P = .001). On multivariate analysis, radiation fractionation was not significantly associated with overall survival. Conclusions SCRT is used for only approximately 1% of patients treated preoperatively for nonmetastatic rectal cancer in the United States. The results of recently completed randomized trials may further inform patterns of practice in the United States and abroad.
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Holliday EB, Hunt A, You YN, Chang GJ, Skibber JM, Rodriguez-Bigas MA, Bednarski BK, Eng C, Koay EJ, Minsky BD, Taniguchi C, Krishnan S, Herman JM, Das P. Short course radiation as a component of definitive multidisciplinary treatment for select patients with metastatic rectal adenocarcinoma. J Gastrointest Oncol 2017; 8:990-997. [PMID: 29299359 DOI: 10.21037/jgo.2017.09.02] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Background Select patients with rectal adenocarcinoma with metastatic disease at presentation can be cured with multimodality management. However, the optimal components and sequencing of therapy is unknown. The aim of this study is to evaluate outcomes for patients treated with chemotherapy, short course radiation therapy (SCRT) and surgical resection. Methods Patients with newly diagnosed metastatic rectal adenocarcinoma who received SCRT from 2010-2016 were identified. All patients were evaluated by a multidisciplinary team and deemed candidates for treatment with curative intent. Overall survival (OS) and progression-free survival (PFS) were calculated using the Kaplan-Meier method. Patient, tumor and treatment characteristics were evaluated as prognostic factors using a Cox proportional hazards model. Results Thirty-four patients were included with a median [interquartile range (IQR)] follow-up of 25 (14.75-42.25) months; 26 patients (76.5%) received definitive surgery for their rectal tumor, and 24 patients (70.6%) received definitive local management of metastatic disease. One-, 2- and 3-year OS were 97%, 86.2% and 76.0%, respectively, and 1-, 2-, and 3-year PFS were 52.1%, 22.7% and 17%, respectively. On multivariate analysis, definitive management of metastases was associated with improved OS [hazard ratio (HR) 0.03, 95% confidence interval (CI): 0.01-0.33]; P=0.003, and ≤2 months of neoadjuvant chemotherapy was associated with decreased OS (HR 11.7, 95% CI: 2.11-106; P=0.004). Conclusions These findings suggest that SCRT can be successfully integrated into a definitive, multidisciplinary approach to metastatic rectal adenocarcinoma. Benefits to this approach include decreased time off systemic therapy as compared to standard course RT. Further study is needed to determine the optimum interval between SCRT and surgery.
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Affiliation(s)
- Emma B Holliday
- Division of Radiation Oncology, MD Anderson Cancer Center, The University of Texas, Houston, Texas, USA
| | - Andrew Hunt
- San Antonio School of Medicine, Health Science Center, The University of Texas, San Antonio, Texas, USA
| | - Y Nancy You
- Department of Surgical Oncology, MD Anderson Cancer Center, The University of Texas, Houston, Texas, USA
| | - George J Chang
- Department of Surgical Oncology, MD Anderson Cancer Center, The University of Texas, Houston, Texas, USA
| | - John M Skibber
- Department of Surgical Oncology, MD Anderson Cancer Center, The University of Texas, Houston, Texas, USA
| | - Miguel A Rodriguez-Bigas
- Department of Surgical Oncology, MD Anderson Cancer Center, The University of Texas, Houston, Texas, USA
| | - Brian K Bednarski
- Department of Surgical Oncology, MD Anderson Cancer Center, The University of Texas, Houston, Texas, USA
| | - Cathy Eng
- Department of Gastrointestinal Medical Oncology, MD Anderson Cancer Center, The University of Texas, Houston, Texas, USA
| | - Eugene J Koay
- Division of Radiation Oncology, MD Anderson Cancer Center, The University of Texas, Houston, Texas, USA
| | - Bruce D Minsky
- Division of Radiation Oncology, MD Anderson Cancer Center, The University of Texas, Houston, Texas, USA
| | - Cullen Taniguchi
- Division of Radiation Oncology, MD Anderson Cancer Center, The University of Texas, Houston, Texas, USA
| | - Sunil Krishnan
- Division of Radiation Oncology, MD Anderson Cancer Center, The University of Texas, Houston, Texas, USA
| | - Joseph M Herman
- Division of Radiation Oncology, MD Anderson Cancer Center, The University of Texas, Houston, Texas, USA
| | - Prajnan Das
- Division of Radiation Oncology, MD Anderson Cancer Center, The University of Texas, Houston, Texas, USA
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Lee KC, Chung KC, Chen HH, Liu CC, Lu CC. Prognostic factors of overall survival and cancer-specific survival in patients with resected early-stage rectal adenocarcinoma: a SEER-based study. J Investig Med 2017; 65:1148-1154. [PMID: 28735257 DOI: 10.1136/jim-2017-000496] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2017] [Indexed: 12/21/2022]
Abstract
The benefits of radiotherapy for colorectal cancer are well documented, but the impact of adjuvant radiotherapy on early-stage rectal adenocarcinoma remains unclear. This study aimed to identify predictors of overall survival (OS) and cancer-specific survival (CSS) in patients with stage II rectal adenocarcinoma treated with preoperative or postoperative radiation therapy. Patients with early-stage rectal adenocarcinoma in the postoperative state were identified using the Surveillance, Epidemiology, and End Results database. The primary endpoints were OS and overall CSS. Stage IIA patients without radiotherapy had significantly lower OS and CSS compared with those who received radiation before or after surgery. Stage IIB patients with radiotherapy before surgery had significantly higher OS and CSS compared with patients in the postoperative or no radiotherapy groups. Patients with signet ring cell carcinoma had the poorest OS among all the groups. Multivariable analysis showed that ethnicity (HR, 0.388, p=0.006) and radiation before surgery (HR, 0.614, p=0.006) were favorable prognostic factors for OS, while age (HR, 1.064, p<0.001), race (HR, 1.599, p=0.041), stage IIB (HR, 3.011, p=0.011), and more than one tumor deposit (TD) (HR, 2.300, p=0.001) were unfavorable prognostic factors for OS. Old age (HR, 1.047, p<0.00 L), stage IIB (HR, 8.619, p=0.005), circumferential resection margin between 0.1 mm and 10 mm (HR, 1.529, p=0.039), and more than one TD (HR, 2.688, p=0.001) were unfavorable prognostic factors for CSS. This population-based study identified predictors of OS and CSS in patients with early-stage resected rectal adenocarcinoma, which may help to guide future management of this patient population.
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Affiliation(s)
- Ko-Chao Lee
- Division of Colorectal Surgery, Department of Surgery, Chang Gung Memorial Hospital - Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Kuan-Chih Chung
- Department of Anesthesiology, Chang Gung Memorial Hospital - Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hong-Hwa Chen
- Division of Colorectal Surgery, Department of Surgery, Chang Gung Memorial Hospital - Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chia-Cheng Liu
- Department of Surgery, Pingtung Christian Hospital, Pingtung, Taiwan
| | - Chien-Chang Lu
- Division of Colorectal Surgery, Department of Surgery, Chang Gung Memorial Hospital - Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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