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Chapman WC, Hunt SR, Henke LE. Radiotherapy for Rectal Cancer: How Much is Enough? Clin Colon Rectal Surg 2024; 37:207-215. [PMID: 38882937 PMCID: PMC11178390 DOI: 10.1055/s-0043-1770709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
Though resection has been the mainstay of treatment for nonmetastatic rectal cancer over the past century, radiation has become an increasingly integral component of care for locally advanced disease. Today, two predominant radiotherapy approaches-hyperfractionated chemoradiotherapy and "short-course" radiation-are widely utilized to reduce local recurrence and, in some cases, cure disease. Both have been incorporated into total neoadjuvant therapy (TNT) regimens and achieved excellent local control and superior complete response rates compared to chemoradiation alone. Additionally, initial results of "watch and wait" protocols utilizing either radiation modality have been promising. Yet, differences do exist; though short course is cheaper and more convenient for patients, recently published data may show superior complete response and local recurrence rates with chemoradiation. Ultimately, direct comparisons of short-course radiotherapy against chemoradiation within the TNT framework are needed to identify optimal radiation regimens in the treatment of locally advanced rectal cancer.
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Affiliation(s)
- William C Chapman
- Department of Surgery, Section of Colon Rectal Surgery, Washington University School of Medicine, St. Louis, Missouri
- Department of Colon and Rectal Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Steven R Hunt
- Department of Surgery, Section of Colon Rectal Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Lauren E Henke
- Department of Radiation Oncology, University Hospitals, Cleveland, Ohio
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2
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Gervaso L, Ciardiello D, Gregato G, Guidi L, Valenza C, Ascione L, Boldrini L, Frassoni S, Cella CA, Spada F, Funicelli L, De Roberto G, Petz W, Borin S, Gerardi MA, Bottiglieri L, Tamayo D, Bertani E, Fumagalli Romario U, Bagnardi V, Curigliano G, Bertolini F, Fazio N, Zampino MG. Circulating tumor DNA in patients with locally advanced rectal cancer treated with multimodal treatment. Ther Adv Med Oncol 2024; 16:17588359241249602. [PMID: 38882445 PMCID: PMC11179505 DOI: 10.1177/17588359241249602] [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: 10/16/2023] [Accepted: 04/09/2024] [Indexed: 06/18/2024] Open
Abstract
Background The management of locally advanced rectal cancer (LARC) relies on a multimodal approach. Neither instrumental work-up nor molecular biomarkers are currently available to identify a risk-adapted strategy. Objectives We aim to investigate the role of circulating tumor DNA (ctDNA) and its clearance at different timepoints during chemo-radiotherapy (CRT) and correlate them with clinical outcomes. Design Between November 2014 and November 2019, we conducted a monocentric prospective observational study enrolling consecutive patients with LARC managed with neoadjuvant standard CRT (capecitabine and concomitant pelvic long-course radiotherapy), followed by consolidation capecitabine in selected cases and surgery. Methods Blood samples for ctDNA were obtained at pre-planned timepoints. We evaluated the correlation of baseline variant allele frequency (VAF) with pathologic complete response (pCR) down-staging, node regression (pN0), event-free survival (EFS), and overall survival (OS). Results Among 112 screened patients, 61 were enrolled. In all, 38 (62%) had a positive ctDNA at baseline with VAF > 0 and 23 had negative ctDNA (VAF = 0). Among patients with negative ctDNA, 30% had a complete response, while only 13% of positive ctDNA patients had pCR [odds ratio (OR) 0.35 (95% confidence interval (CI): 0.10-1.26), p = 0.11]. Similarly, 96% and 74% of pN0 were observed among negative and positive ctDNA patients, respectively [OR 0.13 (95% CI: 0.02-1.07), p = 0.058]. The presence of a baseline VAF > 0 was associated with a trend toward a lower EFS compared with VAF = 0 patients [hazard ratio (HR) = 2.30, 95% CI: 0.63-8.36, p = 0.21]. Within the limitations of small sample size, no difference in OS was observed according to the baseline ctDNA status (HR = 1.18, 95% CI: 0.35-4.06, p = 0.79). Conclusion Within the limitations of a reduced number of patients, patients with baseline negative ctDNA seem to show a higher probability of pN0 status and a trend toward improved EFS. Prospective translational studies are required to define the role of ctDNA analysis in the multimodal treatment of LARC.
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Affiliation(s)
- Lorenzo Gervaso
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology, IRCCS, Milan, Italy
- Molecular Medicine Department, University of Pavia, Pavia Italy
| | - Davide Ciardiello
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology, IRCCS, Milan Italy
| | - Giuliana Gregato
- Laboratory of Hematology-Oncology, European Institute of Oncology, IRCCS, Milan, Italy
| | - Lorenzo Guidi
- Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milan, Italy
- Department of Oncology and Haemato-Oncology, University of Milan, Milan, Italy
| | - Carmine Valenza
- Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milan, Italy
- Department of Oncology and Haemato-Oncology, University of Milan, Milan, Italy
| | - Liliana Ascione
- Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milan, Italy
- Department of Oncology and Haemato-Oncology, University of Milan, Milan, Italy
| | - Laura Boldrini
- Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milan, Italy
- Department of Oncology and Haemato-Oncology, University of Milan, Milan, Italy
| | - Samuele Frassoni
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | - Chiara Alessandra Cella
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology, IRCCS, Milan, Italy
| | - Francesca Spada
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology, IRCCS, Milan, Italy
| | - Luigi Funicelli
- Division of Radiology, European Institute of Oncology, IRCCS, Milan, Italy
| | | | - Wanda Petz
- Digestive Surgery Division, European Institute of Oncology, IRCCS, Milan, Italy
| | - Simona Borin
- Digestive Surgery Division, European Institute of Oncology, IRCCS, Milan, Italy
| | | | - Luca Bottiglieri
- Division of Pathology, European Institute of Oncology, IRCCS, Milan, Italy
| | - Darina Tamayo
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology, IRCCS, Milan, Italy
| | - Emilio Bertani
- Digestive Surgery Division, European Institute of Oncology, IRCCS, Milan, Italy
| | | | - Vincenzo Bagnardi
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | - Giuseppe Curigliano
- Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milan, Italy
- Department of Oncology and Haemato-Oncology, University of Milan, Milan, Italy
| | - Francesco Bertolini
- Laboratory of Hematology-Oncology, European Institute of Oncology, IRCCS, Milan, Italy
| | - Nicola Fazio
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology, IRCCS, Milan, Italy
| | - Maria Giulia Zampino
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology, IRCCS, Milan, Italy
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Lichter KE, Charbonneau K, Lewy JR, Bloom JR, Shenker R, Sabbagh A, Chino J, Rodrigues A, Hearn J, Grover S, Sheu RD, Witztum A, Qureshi MM, Yom SS, Anand C, Thiel CL, Mohamad O. Quantification of the environmental impact of radiotherapy and associated secondary human health effects: a multi-institutional retrospective analysis and simulation. Lancet Oncol 2024; 25:790-801. [PMID: 38821084 DOI: 10.1016/s1470-2045(24)00148-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 03/11/2024] [Accepted: 03/11/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND The health-care industry is a substantial contributor to global greenhouse gas emissions, yet the specific environmental impact of radiotherapy, a cornerstone of cancer treatment, remains under-explored. We aimed to quantify the emissions associated with the delivery of radiotherapy in the USA and propose a framework for reducing the environmental impact of oncology care. METHODS In this multi-institutional retrospective analysis and simulation study, we conducted a lifecycle assessment of external beam radiotherapy (EBRT) for ten anatomical disease sites, adhering to the International Organization for Standardization's standards ISO 14040 and ISO 14044. We analysed retrospective data from Jan 1, 2017, to Oct 1, 2023, encompassing patient and staff travel, medical supplies, and equipment and building energy use associated with the use of EBRT at four academic institutions in the USA. The primary objective was to measure the environmental impacts across ten categories: greenhouse gases (expressed as kg of carbon dioxide equivalents [CO2e]), ozone depletion, smog formation, acidification, eutrophication, carcinogenic and non-carcinogenic potential, respiratory effects, fossil fuel depletion, and ecotoxicity. Human health effects secondary to these environmental impacts were also estimated as disability-adjusted life years. We also assessed the potential benefits of hypofractionated regimens for breast and genitourinary (ie, prostate and bladder) cancers on US greenhouse gas emissions using an analytic model based on the 2014 US National Cancer Database for fractionation patterns and patient commute distances. FINDINGS We estimated that the mean greenhouse gas emissions associated with a standard 25-fraction EBRT course were 4310 kg CO2e (SD 2910), which corresponded to 0·0035 disability-adjusted life years per treatment course. Transit and building energy usage accounted for 25·73% (1110 kg CO2e) and 73·95% of (3190 kg CO2e) of total greenhouse gas emissions, respectively, whereas supplies contributed only 0·32% (14 kg CO2e). Across the other environmental impact categories, most of the environmental impact also stemmed from patient transit and energy use within facilities, with little environmental impact contributed by supplies used. Hypofractionated treatment simulations suggested a substantial reduction in greenhouse gas emissions-by up to 42% for breast and 77% for genitourinary cancer-and environmental impacts more broadly. INTERPRETATION This comprehensive lifecycle assessment of EBRT delineates the environmental and secondary health impacts of radiotherapy, and underscores the urgent need for sustainable practices in oncology. The findings serve as a reference for future decarbonisation efforts in cancer care and show the potential environmental benefits of modifying treatment protocols (when clinical equipoise exists). They also highlight strategic opportunities to mitigate the ecological footprint in an era of escalating climate change and increasing cancer prevalence. FUNDING Mount Zion Health Fund.
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Affiliation(s)
- Katie E Lichter
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA, USA.
| | - Kiley Charbonneau
- Loyola University Chicago-Stritch School of Medicine Maywood, IL, USA
| | | | - Julie R Bloom
- Department of Radiation Oncology, Mount Sinai Hospital, New York, NY, USA
| | - Rachel Shenker
- Department of Radiation Oncology, Duke Cancer Center, Durham, NC, USA
| | - Ali Sabbagh
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Junzo Chino
- Department of Radiation Oncology, Duke Cancer Center, Durham, NC, USA
| | - Anna Rodrigues
- Department of Radiation Oncology, Duke Cancer Center, Durham, NC, USA
| | - Jason Hearn
- Department of Radiation Oncology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Surbhi Grover
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Ren-Dih Sheu
- Department of Radiation Oncology, Mount Sinai Hospital, New York, NY, USA
| | - Alon Witztum
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Muhammad Mustafa Qureshi
- Department of Radiation Oncology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Sue S Yom
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Chirjiv Anand
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Cassandra L Thiel
- Department of Population Health, New York University Grossman School of Medicine and New York University Langone Health, New York, NY, USA
| | - Osama Mohamad
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Affleck AG, Herzig D. Total Neoadjuvant Therapy for Rectal Cancer. Surg Clin North Am 2024; 104:609-617. [PMID: 38677824 DOI: 10.1016/j.suc.2023.11.010] [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] [Indexed: 04/29/2024]
Abstract
The treatment of locally advanced rectal cancer has traditionally included sequenced multimodal therapy including radiation, chemotherapy, and surgery. The relative contribution of each and the order of treatments have evolved over the years. By the early twenty-first century, there was widespread use of the German Rectal Cancer Trial approach: preoperative chemoradiation, followed by standardized surgery including total mesorectal excision, and finally adjuvant chemotherapy. Recent advances have defined the superiority of moving the chemotherapy into the preoperative setting. This approach, termed total neoadjuvant therapy promises better systemic control and overall survival and expaned options for omitting surgery in selected patients.
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Affiliation(s)
- Arthur G Affleck
- Department of Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA. https://twitter.com/AffleckIv
| | - Daniel Herzig
- Division of General and Gastrointestinal Surgery, Department of Surgery, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Mail Code L-223A, Portland, OR 97239, USA.
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Gervaso L, Ciardiello D, Oliveira RA, Borghesani M, Guidi L, Benini L, Algeri L, Spada F, Zampino MG, Cella CA, Fazio N. Immunotherapy in the neoadjuvant treatment of gastrointestinal tumors: is the time ripe? J Immunother Cancer 2024; 12:e008027. [PMID: 38782539 PMCID: PMC11116869 DOI: 10.1136/jitc-2023-008027] [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] [Accepted: 04/11/2024] [Indexed: 05/25/2024] Open
Abstract
Immune checkpoint inhibitors (ICIs) revolutionized the management of mismatch repair-deficient (dMMR)/microsatellite instability-high (MSI-H) gastrointestinal (GI) cancers. Based on notable results observed in the metastatic setting, several clinical trials investigated ICIs as neoadjuvant treatment (NAT) for localized dMMR/MSI-H GI cancers, achieving striking results in terms of clinical and pathological responses and creating the opportunity to spare patients from neoadjuvant chemotherapy and/or radiotherapy and even surgical resection. Nevertheless, these impressive findings are mainly derived from small proof of concept phase II studies and there are still several open questions to address. Moreover, dMMR/MSI-H represents a limited subgroup accounting for less than 10% of GI cancers. Consequently, many efforts have been produced to investigate neoadjuvant ICIs also in mismatch repair-proficient/microsatellite stable (MSS) cancers, considering the potential synergistic effect in combining immune-targeted agents with standard therapies such as chemo and/or radiotherapy. However, results for combining ICIs to the standard of care in the unselected population are still unsatisfactory, without improvements in event-free survival in esophago-gastric adenocarcinoma for the addition of pembrolizumab to chemotherapy, and sometimes limited benefit in patients with locally advanced rectal cancer. Therefore, a major challenge will be to identify among the heterogenous spectrum of this disease, those patients that could take advantage of neoadjuvant immunotherapy and deliver the most effective treatment. In this review we discuss the rationale of NAT in GI malignancies, summarize the available evidence regarding the completed trials that evaluated this treatment strategy in both MSI-H and MSS tumors. Finally, we discuss ongoing studies and future perspectives to render neoadjuvant immunotherapy another arrow in the quiver for the treatment of locally advanced GI tumors.
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Affiliation(s)
- Lorenzo Gervaso
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, IEO IRCCS, European Institute of Oncology, Milano, Italy
- Molecular Medicine Program, University of Pavia, Pavia, Lombardia, Italy
| | - Davide Ciardiello
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, IEO IRCCS, European Institute of Oncology, Milano, Italy
| | | | - Michele Borghesani
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, IEO IRCCS, European Institute of Oncology, Milano, Italy
| | - Lorenzo Guidi
- Division of New Drugs and Early Drug Development for Innovative Therapies, IEO IRCCS, European Institute of Oncology, Milano, Italy
| | - Lavinia Benini
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, IEO IRCCS, European Institute of Oncology, Milano, Italy
| | - Laura Algeri
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, IEO IRCCS, European Institute of Oncology, Milano, Italy
| | - Francesca Spada
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, IEO IRCCS, European Institute of Oncology, Milano, Italy
| | - Maria Giulia Zampino
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, IEO IRCCS, European Institute of Oncology, Milano, Italy
| | - Chiara Alessandra Cella
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, IEO IRCCS, European Institute of Oncology, Milano, Italy
| | - Nicola Fazio
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, IEO IRCCS, European Institute of Oncology, Milano, Italy
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6
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Liu WY, Tang Y, Li N, Tang Y, Cheng YJ, Yang L, Fang H, Lu NN, Qi SN, Chen B, Wang SL, Song YW, Liu YP, Li YX, Liu Z, Liang JW, Pei W, Wang XS, Zhang HZ, Wang J, Zhou HT, Jin J. Preoperative chemoradiotherapy in older patients with rectal cancer guided by comprehensive geriatric assessment within a multidisciplinary team-a multicenter phase II trial. BMC Geriatr 2024; 24:442. [PMID: 38773457 PMCID: PMC11106876 DOI: 10.1186/s12877-024-05046-6] [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: 04/23/2023] [Accepted: 05/06/2024] [Indexed: 05/23/2024] Open
Abstract
BACKGROUND The purpose of this study was to evaluate the safety and efficacy of preoperative concurrent chemoradiotherapy (preCRT) for locally advanced rectal cancer in older people who were classified as "fit" by comprehensive geriatric assessment (CGA). METHODS A single-arm, multicenter, phase II trial was designed. Patients were eligible for this study if they were aged 70 years or above and met the standards of "fit" (SIOG1) as evaluated by CGA and of the locally advanced risk category. The primary endpoint was 2-year disease-free survival (DFS). Patients were scheduled to receive preCRT (50 Gy) with raltitrexed (3 mg/m2 on days 1 and 22). RESULTS One hundred and nine patients were evaluated by CGA, of whom eighty-six, eleven and twelve were classified into the fit, intermediate and frail category. Sixty-eight fit patients with a median age of 74 years were enrolled. Sixty-four patients (94.1%) finished radiotherapy without dose reduction. Fifty-four (79.3%) patients finished the prescribed raltitrexed therapy as planned. Serious toxicity (grade 3 or above) was observed in twenty-four patients (35.3%), and fourteen patients (20.6%) experienced non-hematological side effects. Within a median follow-up time of 36.0 months (range: 5.9-63.1 months), the 2-year overall survival (OS), cancer-specific survival (CSS) and disease-free survival (DFS) rates were 89.6% (95% CI: 82.3-96.9), 92.4% (95% CI: 85.9-98.9) and 75.6% (95% CI: 65.2-86.0), respectively. Forty-eight patients (70.6%) underwent surgery (R0 resection 95.8%, R1 resection 4.2%), the corresponding R0 resection rate among the patients with positive mesorectal fascia status was 76.6% (36/47). CONCLUSION This phase II trial suggests that preCRT is efficient with tolerable toxicities in older rectal cancer patients who were evaluated as fit based on CGA. TRIAL REGISTRATION The registration number on ClinicalTrials.gov was NCT02992886 (14/12/2016).
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Affiliation(s)
- Wen-Yang Liu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuan Tang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ning Li
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Tang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Clinical Trials Center, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yun-Jie Cheng
- Department of Radiation Oncology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Lin Yang
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui Fang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ning-Ning Lu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shu-Nan Qi
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo Chen
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shu-Lian Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yong-Wen Song
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yue-Ping Liu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ye-Xiong Li
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zheng Liu
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jian-Wei Liang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Pei
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xi-Shan Wang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hai-Zeng Zhang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Wang
- Department of Radiation Oncology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China.
| | - Hai-Tao Zhou
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Jing Jin
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
- Department of Radiation Oncology, National Cancer Center/ Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China.
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7
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Mayo ZS, Fan C, Jia X, Parker SM, Kocsis J, Shah CS, Scott JG, Campbell SR. Meta-Analysis of 5-Fraction Preoperative Radiotherapy for Soft Tissue Sarcoma. Am J Clin Oncol 2024:00000421-990000000-00195. [PMID: 38764405 DOI: 10.1097/coc.0000000000001110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2024]
Abstract
OBJECTIVES Studies investigating preoperative 5-fraction radiation therapy (RT) for soft tissue sarcoma (STS) are limited. We performed a meta-analysis to determine the efficacy and safety of this treatment paradigm. METHODS This study-level meta-analysis was conducted using Bayesian methods. Statistical estimation for risk of outcome rates was conducted by posterior mean and 95% highest posterior density (HPD) intervals. Studies with 2-year local control (LC) and description of major wound complications (MWC) per the CAN-NCIC-SR2 study were included and served as the primary endpoints. Secondary endpoints included rates of acute and late toxicity. A total of 10 studies were identified and 7 met the inclusion criteria. Subgroup analyses were performed for ≥30 Gy vs <30 Gy. RESULTS A total of 209 patients from 7 studies were included. Five studies used ≥30 Gy (n=144), and 2 studies <30 Gy (n=64). Median follow-up was 29 months (range: 21 to 57 mo). Primary tumor location was lower extremity in 68% and upper extremity in 22%. Most tumors were intermediate or high grade (95%, 160/169), and 50% (79/158) were >10 cm. The two-year LC for the entire cohort was 96.9%, and the rate of MWC was 30.6%. There was a trend toward improved LC with ≥ 30 Gy (95% HPD: 0.95 to 0.99 vs 0.84 to 0.99). There was no difference in MWC (95% HPD: 0.18 to 0.42 vs 0.17 to 0.55) or late toxicity between the groups. CONCLUSION Preoperative 5-fraction RT for STS demonstrates excellent 2-year LC with MWC and toxicity similar to standard fractionation preoperative RT. Multi-institutional trials with a universal RT protocol are warranted.
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Affiliation(s)
- Zachary S Mayo
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH
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8
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Medioni M, Cervantes B, Huguet F, Bachet JB, Parc Y, André T, Lefèvre JH, Cohen R. [An update on total neoadjuvant treatment of adenocarcinoma of the rectum]. Bull Cancer 2024; 111:483-495. [PMID: 38553289 DOI: 10.1016/j.bulcan.2024.02.004] [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: 10/27/2023] [Revised: 01/23/2024] [Accepted: 02/01/2024] [Indexed: 05/13/2024]
Abstract
A major advance has been made in the management of rectal cancer, with the emergence in 2021 of total neoadjuvant treatment. The main publications from the RAPIDO and PRODIGE-23 trials reported a significant improvement in progression-free survival and the pathological complete response rate. The aim of this review is to synthesize recent data on neoadjuvant treatment of rectal cancer, to explain the long-term results of the RAPIDO and PRODIGE-23 trials, and to put them into perspective, considering current advances in de-escalation strategies. The update of the 5-year survival data from the RAPIDO trial highlights an increased risk of loco-regional relapse, with 11.7% of relapses in the experimental group and 8.1% in the control group, while the update of the PRODIGE-23 trial confirms the benefits of this treatment regimen, with a significant improvement in overall survival. In addition, the results of the OPRA and PROPSPECT trials confirm the benefit of total neoadjuvant treatment with induction chemotherapy, as well as the possibility of surgical de-escalation in the OPRA trial and radiotherapy in the PROSPECT trial. The challenge for the future is to identify patients who require total neoadjuvant treatment with the aim of curative surgery to obtain a cure without local or distant relapse, and those for whom therapeutic de-escalation can be envisaged.
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Affiliation(s)
- Maroussia Medioni
- Sorbonne université, hôpital Saint-Antoine, AP-HP, service d'oncologie médicale, 75012 Paris, France
| | - Baptiste Cervantes
- Sorbonne université, hôpital Saint-Antoine, AP-HP, service d'oncologie médicale, 75012 Paris, France
| | - Florence Huguet
- Sorbonne université, hôpital Tenon, AP-HP, service d'oncologie radiothérapie, Paris, France
| | - Jean-Baptiste Bachet
- Sorbonne université, hôpital Pitié Salpêtrière, AP-HP, service d'hépato-gastroentérologie, Paris, France
| | - Yann Parc
- Sorbonne université, hôpital Saint-Antoine, AP-HP, service de chirurgie générale et digestive, Paris, France
| | - Thierry André
- Sorbonne université, hôpital Saint-Antoine, AP-HP, service d'oncologie médicale, 75012 Paris, France; INSERM URMS_938, centre de recherche Saint-Antoine, SIRIC CURAMUS, équipe instabilité des microsatellites et cancer, équipe labellisée par la Ligue Nationale contre le Cancer, Paris, France
| | - Jérémie H Lefèvre
- Sorbonne université, hôpital Saint-Antoine, AP-HP, service de chirurgie générale et digestive, Paris, France
| | - Romain Cohen
- Sorbonne université, hôpital Saint-Antoine, AP-HP, service d'oncologie médicale, 75012 Paris, France; INSERM URMS_938, centre de recherche Saint-Antoine, SIRIC CURAMUS, équipe instabilité des microsatellites et cancer, équipe labellisée par la Ligue Nationale contre le Cancer, Paris, France.
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9
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Temmink SJD, Peeters KCMJ, Nilsson PJ, Martling A, van de Velde CJH. Surgical Outcomes after Radiotherapy in Rectal Cancer. Cancers (Basel) 2024; 16:1539. [PMID: 38672621 PMCID: PMC11048284 DOI: 10.3390/cancers16081539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 04/12/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
Over the past decade, the treatment of rectal cancer has changed considerably. The implementation of TME surgery has, in addition to decreasing the number of local recurrences, improved surgical morbidity and mortality. At the same time, the optimisation of radiotherapy in the preoperative setting has improved oncological outcomes even further, although higher perineal infection rates have been reported. Radiotherapy regimens have evolved through the adjustment of radiotherapy techniques and fields, increased waiting intervals, and, for more advanced tumours, adding chemotherapy. Concurrently, imaging techniques have significantly improved staging accuracy, facilitating more precise selection of advanced tumours. Although chemoradiotherapy does lead to the downsizing and -staging of these tumours, a very clear effect on sphincter-preserving surgery and the negative resection margin has not been proven. Aiming to decrease distant metastasis and improve overall survival for locally advanced rectal cancer, systemic chemotherapy can be added to radiotherapy, known as total neoadjuvant treatment (TNT). High complete response rates, both pathological (pCR) and clinical (cCR), are reported after TNT. Patients who follow a Watch & Wait program after a cCR can potentially avoid surgical morbidity and colostomy. For both early and more advanced tumours, trials are now investigating optimal regimens in an attempt to offer organ preservation as much as possible. Multidisciplinary deliberation should include patient preference, treatment toxicity, and likelihood of end colostomy, but also the burden of intensive surveillance in a W&W program.
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Affiliation(s)
- Sofieke J. D. Temmink
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76 Stockholm, Sweden
| | - Koen C. M. J. Peeters
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Per J. Nilsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76 Stockholm, Sweden
| | - Anna Martling
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76 Stockholm, Sweden
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10
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Koukourakis IM, Xanthopoulou E, Koukourakis MI, Tiniakos D, Kouloulias V, Zygogianni A. IFN-Type-I Response and Systemic Immunity in Rectal Adenocarcinoma Patients Treated with Conventional or Hypofractionated Neoadjuvant Radiotherapy. Biomolecules 2024; 14:448. [PMID: 38672465 PMCID: PMC11048635 DOI: 10.3390/biom14040448] [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: 02/28/2024] [Revised: 04/01/2024] [Accepted: 04/02/2024] [Indexed: 04/28/2024] Open
Abstract
The IFN-type-I pathway is involved in radiotherapy (RT)-mediated immune responses. Large RT fractions have been suggested to potently induce this pathway. Neoadjuvant hypofractionated short-course (scRT) and conventional long-course (lcRT) RT applied for the treatment of locally advanced rectal adenocarcinoma patients provides a unique model to address the immuno-stimulatory properties of RT on a systemic level. We prospectively analyzed the IFNβ plasma levels and lymphocyte counts (LCs) of rectal adenocarcinoma patients before and after treatment with scRT (n = 22) and lcRT (n = 40). Flow cytometry was conducted to assess the effects on lymphocytic subpopulations in a subset of 20 patients. A statistically significant increase in the post-RT IFNβ plasma levels was noted in patients undergoing scRT (p = 0.004). Improved pathological tumor regression was associated with elevated post-RT IFNβ levels (p = 0.003). Although all patients experienced substantial lymphopenia after treatment, the post-RT LC of patients treated with scRT were significantly higher compared to lcRT (p = 0.001). Patients undergoing scRT displayed significantly lower percentages of regulatory CD4+/CD25+ T-cells after therapy (p = 0.02). scRT enables effective stimulation of the IFN-type-I pathway on a systemic level and confers decreased lymphocytic cytotoxicity and limited regulatory T-cell activation compared to lcRT, supporting its increasing role in immuno-RT trials.
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Affiliation(s)
- Ioannis M. Koukourakis
- Radiation Oncology Unit, 1st Department of Radiology, School of Medicine, Aretaieion Hospital, National and Kapodistrian University of Athens (NKUOA), 11528 Athens, Greece;
| | - Erasmia Xanthopoulou
- Department of Radiotherapy/Oncology, Medical School, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (E.X.); (M.I.K.)
| | - Michael I. Koukourakis
- Department of Radiotherapy/Oncology, Medical School, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (E.X.); (M.I.K.)
| | - Dina Tiniakos
- Department of Pathology, Aretaieion University Hospital, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece;
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - Vassilis Kouloulias
- Radiotherapy Unit, 2nd Department of Radiology, Attikon Hospital, School of Medicine, Rimini 1, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Anna Zygogianni
- Radiation Oncology Unit, 1st Department of Radiology, School of Medicine, Aretaieion Hospital, National and Kapodistrian University of Athens (NKUOA), 11528 Athens, Greece;
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11
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Campbell SR, Wooley JR, Nystrom LM. Modern Multidisciplinary Management of Soft Tissue Sarcoma of the Extremity and Trunk. JCO Oncol Pract 2024:OP2300050. [PMID: 38574314 DOI: 10.1200/op.23.00050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 02/20/2024] [Accepted: 03/06/2024] [Indexed: 04/06/2024] Open
Abstract
Soft tissue sarcomas (STS) of the extremity and trunk are heterogeneous and rare tumors that require coordinated multidisciplinary management. Surgical resection remains the backbone of treatment for localized tumors, with the addition of radiotherapy to surgery to achieve high rates of local control. Despite this, overall survival is limited because of significant distant metastatic risk and a lack of efficacious systemic therapies. Clinical trials have produced conflicting results on the impact of systemic therapy in the neoadjuvant and adjuvant settings for patients with localized disease, leaving systemic treatment decisions largely guided by shared decision making and prognostic prediction tools such as nomograms. This article will review the foundational data as well as latest developments in surgical, radiotherapy, and systemic management supporting current practice guidelines for localized STS of the extremity and trunk.
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Affiliation(s)
| | - Joseph R Wooley
- Department of Hematology and Oncology, Cleveland Clinic, Cleveland, OH
| | - Lukas M Nystrom
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
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12
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Safont MJ, García-Figueiras R, Hernando-Requejo O, Jimenez-Rodriguez R, Lopez-Vicente J, Machado I, Ayuso JR, Bustamante-Balén M, De Torres-Olombrada MV, Domínguez Tristancho JL, Fernández-Aceñero MJ, Suarez J, Vera R. Interdisciplinary Spanish consensus on a watch-and-wait approach for rectal cancer. Clin Transl Oncol 2024; 26:825-835. [PMID: 37787973 DOI: 10.1007/s12094-023-03322-2] [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: 06/09/2023] [Accepted: 09/07/2023] [Indexed: 10/04/2023]
Abstract
Watch-and-wait has emerged as a new strategy for the management of rectal cancer when a complete clinical response is achieved after neoadjuvant therapy. In an attempt to standardize this new clinical approach, initiated by the Spanish Cooperative Group for the Treatment of Digestive Tumors (TTD), and with the participation of the Spanish Association of Coloproctology (AECP), the Spanish Society of Pathology (SEAP), the Spanish Society of Gastrointestinal Endoscopy (SEED), the Spanish Society of Radiation Oncology (SEOR), and the Spanish Society of Medical Radiology (SERAM), we present herein a consensus on a watch-and-wait approach for the management of rectal cancer. We have focused on patient selection, the treatment schemes evaluated, the optimal timing for evaluating the clinical complete response, the oncologic outcomes after the implementation of this strategy, and a protocol for surveillance of these patients.
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Affiliation(s)
- Maria Jose Safont
- Oncology Department, Consorcio Hospital General Universitario de Valencia. Valencia University, Av. de les Tres Creus, 2, 46014, València, Spain.
| | - Roberto García-Figueiras
- Radiology Department, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | | | | | - Jorge Lopez-Vicente
- Gastroenterology Department, Hospital Universitario de Mostoles, Mósteles, Spain
| | - Isidro Machado
- Instituto Valenciano de Oncología, Valencia, Spain
- Pathology Department, Patologika Laboratory QuironSalud, Valencia, Spain
- Pathology Department, University of Valencia, Valencia, Spain
| | | | - Marco Bustamante-Balén
- Gastrointestinal Endoscopy Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | | | | | - Mª Jesús Fernández-Aceñero
- Surgical Pathology Department, Hospital Clínico San Carlos, IdiSSC, Universidad Complutense de Madrid, Madrid, Spain
| | - Javier Suarez
- General Surgery Department, Hospital Universitario de Navarra, Pamplona, Spain
| | - Ruth Vera
- Medical Oncology Department, Hospital Universitario de Navarra, Instituto de Investigación (Idisna), Pamplona, Spain
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13
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Tutino R, Bonomi A, Zingaretti CC, Risi L, Ragaini EM, Viganò L, Paterno M, Pezzoli I. Locally advanced mid/low rectal cancer with synchronous resectable liver metastases: systematic review of the available strategies and outcome. Updates Surg 2024; 76:345-361. [PMID: 38182850 DOI: 10.1007/s13304-023-01735-w] [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: 11/05/2023] [Accepted: 12/12/2023] [Indexed: 01/07/2024]
Abstract
The management of patients with locally advanced mid/low rectal cancer with resectable liver metastases is complex because of the need to combine the optimal treatment of both tumors. This study aims to review the available treatment strategies and compare their outcome, focusing on radiotherapy (RT) and liver-first approach (LFA). A systematic review was performed in PubMed, Embase, and web sources including articles published between 2000 and 02/2023 and reporting mid-/long-term outcomes. Overall, twenty studies were included (n = 1837 patients). Three- and 5-year overall survival (OS) rates were 51-88% and 36-59%. Although several strategies were reported, most patients received RT (1448/1837, 79%; > 85% neoadjuvant). RT reduced the pelvic recurrence risk (5.8 vs. 13.5%, P = 0.005) but did not impact OS. Six studies analyzed LFA (n = 307 patients). LFA had a completion rate similar to the rectum-first approach (RFA, 81% vs. 79%) but the interval strategy-an LFA variant with liver surgery in the interval between radiotherapy and rectal surgery-had a better completion rate than standard LFA (liver surgery/radiotherapy/rectal surgery, 92% vs. 75%, P = 0.011) and RFA (79%, P = 0.048). Across all series, LFA achieved the best survival rates, and in one paper it led to a survival advantage in patients with multiple metastases. In conclusion, different strategies can be adopted, but RT should be included to decrease the pelvic recurrence risk. LFA should be considered, especially in patients with high hepatic tumor burden, and RT before liver surgery (interval strategy) could maximize its completion rate.
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Affiliation(s)
- R Tutino
- Department of General and Emergency Surgery, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - A Bonomi
- Department of General Surgery, Department of Biomedical and Clinical Sciences, ASST Fatebenefratelli Sacco, Milan, Italy
- General Surgery Residency Program, University of Milan, Milan, Italy
| | - C C Zingaretti
- Department of Digestive and Hepatobiliary Surgery, Mauriziano Umberto I Hospital, Turin, Italy
| | - L Risi
- Department of Biomedical Sciences, Humanitas University, Viale Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy
- Hepatobiliary Unit, Department of Minimally Invasive General and Oncologic Surgery, Humanitas Gavazzeni University Hospital, Viale M. Gavazzeni 21, 24125, Bergamo, Italy
| | - E M Ragaini
- Department of Biomedical Sciences, Humanitas University, Viale Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy
| | - L Viganò
- Department of Biomedical Sciences, Humanitas University, Viale Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy.
- Hepatobiliary Unit, Department of Minimally Invasive General and Oncologic Surgery, Humanitas Gavazzeni University Hospital, Viale M. Gavazzeni 21, 24125, Bergamo, Italy.
| | - M Paterno
- General Surgery Residency Program, University of Milan, Milan, Italy
- Division of Oncologic and Minimally Invasive Surgery, Niguarda General Hospital, Milan, Italy
| | - I Pezzoli
- General Surgery Residency Program, University of Milan, Milan, Italy
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14
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Wang C, Liu X, Wang W, Miao Z, Li X, Liu D, Hu K. Treatment Options for Distal Rectal Cancer in the Era of Organ Preservation. Curr Treat Options Oncol 2024; 25:434-452. [PMID: 38517596 PMCID: PMC10997725 DOI: 10.1007/s11864-024-01194-4] [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] [Accepted: 02/27/2024] [Indexed: 03/24/2024]
Abstract
OPINION STATEMENT The introduction of total mesorectal excision into the radical surgery of rectal cancer has significantly improved the oncological outcome with longer survival and lower local recurrence. Traditional treatment modalities of distal rectal cancer, relying on radical surgery, while effective, take their own set of risks, including surgical complications, potential damage to the anus, and surrounding structure owing to the pursuit of thorough resection. The progress of operating methods as well as the integration of systemic therapies and radiotherapy into the peri-operative period, particularly the exciting clinical complete response of patients after neoadjuvant treatment, have paved the way for organ preservation strategy. The non-inferiority oncological outcome of "watch and wait" compared with radical surgery underscores the potential of organ preservation not only to control local recurrence but also to reduce the need for treatments followed by structure destruction, hopefully improving the long-term quality of life. Radical radiotherapy provides another treatment option for patients unwilling or unable to undergo surgery. Organ preservation points out the direction of treatment for distal rectal cancer, while additional researches are needed to answer remaining questions about its optimal use.
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Affiliation(s)
- Chen Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, 100730, China
| | - Xiaoliang Liu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, 100730, China
| | - Weiping Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, 100730, China
| | - Zheng Miao
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, 100730, China
| | - Xiaoyan Li
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, 100730, China
| | - Dingchao Liu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, 100730, China
| | - Ke Hu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, 100730, China.
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15
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Guadagnolo BA, Baldini EH. Are We Ready for Life in the Fast Lane? A Critical Review of Preoperative Hypofractionated Radiotherapy for Localized Soft Tissue Sarcoma. Semin Radiat Oncol 2024; 34:180-194. [PMID: 38508783 DOI: 10.1016/j.semradonc.2023.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
This critical review aims to summarize the relevant published data regarding hypofractionation regimens for preoperative radiation therapy (RT) prior to surgery for soft tissue sarcoma (STS) of the extremity or superficial trunk. We identified peer-reviewed publications using a PubMed search on the MeSH headings of "soft tissue sarcoma" AND "hypofractionated radiation therapy." To obtain complication data on similar anatomical radiotherapeutic scenarios we also searched "hypofractionated radiation therapy" AND "melanoma" as well as "hypofractionated radiation therapy" AND "breast cancer." We then used reference lists from relevant articles to obtain additional pertinent publications. We also incorporated relevant abstracts presented at international sarcoma meetings and relevant clinical trials as listed on the ClinicalTrials.gov website. Detailed data are presented and contextualized for ultra-hypofractionated and moderately hypofractionated regimens with respect to local control, wound complications, and amputation rates. Comparative data are also presented for late toxicities including: fibrosis, joint limitation, edema, skin integrity, and bone fracture or necrosis. These data are compared to a standard regimen of 50 Gy in 25 daily fractions delivered over 5 weeks. This analysis supports the continued use of a standard regimen for preoperative RT for STS of 25 × 2 Gy over 5 weeks without concurrent chemotherapy. Use of concurrent chemotherapy with preoperative RT for STS should be reserved for well-designed clinical trials. A randomized trial of ultra-hypofractionated and moderately hypofractionated pre op RT for STS is warranted, but it is critical for the primary endpoint (or co-primary endpoint) to be late toxicity to: bone, soft tissue, joint, and skin.
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Affiliation(s)
| | - Elizabeth H Baldini
- Department of Radiation Oncology, Dana Farber/Brigham Women's Hospital, Boston, MA
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16
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Troester AM, Gaertner WB. Contemporary management of rectal cancer. Surg Open Sci 2024; 18:17-22. [PMID: 38312301 PMCID: PMC10832461 DOI: 10.1016/j.sopen.2024.01.009] [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: 11/20/2023] [Accepted: 01/02/2024] [Indexed: 02/06/2024] Open
Abstract
The management of rectal cancer has undergone significant changes over the past 50 years, and this has been associated with major improvements in overall outcomes and quality of life. From standardization of total mesorectal excision to refinements in radiation delivery and shifting of chemoradiotherapy treatment to favor a neoadjuvant approach, as well as the development of targeted chemotherapeutics, these management strategies have continually aimed to achieve locoregional and systemic control while limiting adverse effects and enhance overall survival. This article highlights evolving aspects of rectal cancer therapy including improved staging modalities, total neoadjuvant therapy, the role of short-course and more selective radiotherapy strategies, as well as organ preservation. We also discuss the evolving role of minimally invasive surgery and comment on lateral pelvic lymph node dissection. Key message Rectal cancer management is constantly evolving through refinements in radiation timing and delivery, modification of chemoradiotherapy treatment schedules, and increasing utilization of minimally invasive surgical techniques and organ preservation strategies. This manuscript aims to provide a synopsis of recent changes in the management of rectal cancer, highlighting contemporary modifications in neoadjuvant approaches and surgical management to enhance the knowledge of surgeons who care for this challenging population.
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Affiliation(s)
- Alexander M. Troester
- Department of Surgery, University of Minnesota, Minneapolis, MN, United States of America
| | - Wolfgang B. Gaertner
- Department of Surgery, University of Minnesota, Minneapolis, MN, United States of America
- Division of Colon & Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, MN, United States of America
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17
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Daamen L, Westerhoff J, Couwenberg A, Braam P, Rütten H, den Hartogh M, Christodouleas J, Hall W, Verkooijen H, Intven M. Quality of life and clinical outcomes in rectal cancer patients treated on a 1.5T MR-Linac within the MOMENTUM study. Clin Transl Radiat Oncol 2024; 45:100721. [PMID: 38274389 PMCID: PMC10808928 DOI: 10.1016/j.ctro.2023.100721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 11/10/2023] [Accepted: 12/30/2023] [Indexed: 01/27/2024] Open
Abstract
Background and purpose This study assessed quality of life (QoL) and clinical outcomes in rectal cancer patients treated with magnetic resonance (MR) guided short-course radiation therapy (SCRT) on a 1.5 Tesla (T) MR-Linac during the first 12 months after treatment. Materials and methods Rectal cancer patients treated with 25 Gy SCRT in five fractions with curative intent in the Netherlands (2019-2022) were identified in MOMENTUM (NCT04075305). Toxicity (CTCAE v5) and QoL (EORTC QLQ-C30 and -CR29) was primarily analyzed in patients without metastatic disease (M0) and no other therapies after SCRT. Patients who underwent tumor resection were censored from surgery. A generalized linear mixed-model was used to investigate clinically meaningful (≥10) and significant (P < 0.05) QoL changes. Clinical and pathological complete response (cCR and pCR) rates were calculated in patients in whom response was documented. Results A total of 172 patients were included, of whom 112 patients were primarily analyzed. Acute and late radiation-induced high-grade toxicity were reported in one patient, respectively. CCR was observed in 8/64 patients (13 %), 14/37 patients (38 %) and 13/16 patients (91 %) at three, six and twelve months; pCR was observed in 3/69 (4 %) patients. After 12 months, diarrhea (mean difference [MD] -17.4 [95 % confidence interval [CI] -31.2 to -3.7]), blood and mucus in stool (MD -31.1 [95 % CI -46.4 to -15.8]), and anxiety (MD -22.4 [95 % CI -34.0 to -10.9]) were improved. Conclusion High-field MR-guided SCRT for the treatment of patients with rectal cancer is associated with improved disease-related symptom management and functioning one year after treatment.
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Affiliation(s)
- L.A. Daamen
- University Medical Center Utrecht, Division of Imaging and Oncology, Utrecht, The Netherlands
| | - J.M. Westerhoff
- University Medical Center Utrecht, Division of Imaging and Oncology, Utrecht, The Netherlands
| | - A.M. Couwenberg
- The Netherlands Cancer Institute, Department of Radiation Oncology, Amsterdam, The Netherlands
| | - P.M. Braam
- Radboud University Medical Center, Department of Radiation Oncology, Nijmegen, The Netherlands
| | - H. Rütten
- Radboud University Medical Center, Department of Radiation Oncology, Nijmegen, The Netherlands
| | | | - J.P. Christodouleas
- Elekta AB, Stockholm, Sweden
- Hospital of the University of Pennsylvania, Department of Radiation Oncology, Philadelphia, PA, United States
| | - W.A. Hall
- Medical College of Wisconsin, Department of Radiation Oncology, Milwaukee, WI, United States
| | - H.M. Verkooijen
- University Medical Center Utrecht, Division of Imaging and Oncology, Utrecht, The Netherlands
| | - M.P.W. Intven
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands
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18
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Stewart DB. Induction short-course radiotherapy with consolidation chemotherapy for locally-advanced rectal cancer: Is a long run and short slide preferred? Surg Open Sci 2024; 18:28. [PMID: 38312304 PMCID: PMC10834976 DOI: 10.1016/j.sopen.2024.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 01/19/2024] [Indexed: 02/06/2024] Open
Affiliation(s)
- David B. Stewart
- Professor and Division Chief, General Surgery, SIU Department of Surgery, 701 N. First Street, P.O. Box 19638, Room D326, Springfield, IL 62794-9638, United States of America
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19
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Mai M, Goldman J, Appiah D, Abdulrahman R, Kidwell J, Shi Z. Timing of Surgery and Social Determinants of Health Related to Pathologic Complete Response after Total Neoadjuvant Therapy for Rectal Adenocarcinoma: Retrospective Study of National Cancer Database. Curr Oncol 2024; 31:1291-1301. [PMID: 38534930 PMCID: PMC10969721 DOI: 10.3390/curroncol31030097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 02/26/2024] [Accepted: 02/26/2024] [Indexed: 05/26/2024] Open
Abstract
Total neoadjuvant therapy (TNT) for rectal adenocarcinoma (RAC) involves multi-agent chemotherapy and radiation before definitive surgery. Previous studies of the rest period (time between radiation and surgery) and pathologic complete response (pCR) have produced mixed results. The objective of this study was to evaluate the relationship between the rest period and pCR. This study utilized the National Cancer Database (NCDB) to retrospectively analyze 5997 stage-appropriate RAC cases treated with TNT from 2016 to 2020. The overall pCR rate was 18.6%, with most patients undergoing induction chemotherapy followed by long-course chemoradiation (81.5%). Multivariable logistic regression models revealed a significant non-linear relationship between the rest period and pCR (p = 0.033), with optimal odds at 14.7-15.9 weeks post radiation (odds ratio: 1.49, 95% confidence interval: 1.13-1.98) when compared to 4.0 weeks. Medicaid, distance to the treatment facility, and community education were associated with decreased odds of pCR. Findings highlight the importance of a 15-16-week post-radiation surgery window for achieving pCR in RAC treated with TNT and socioeconomic factors influencing pCR rates. Findings also emphasize the need for clinical trials to incorporate detailed analyses of the rest period and social determinant of health to better guide clinical practice.
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Affiliation(s)
- Megan Mai
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| | - Jodi Goldman
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| | - Duke Appiah
- Department of Public Health, School of Population and Public Health, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| | - Ramzi Abdulrahman
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
- Radiation Oncology Clinic, University Medical Center Cancer Center, Lubbock, TX 79430, USA
| | - John Kidwell
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
- Colorectal Surgery Clinic, University Medical Center Cancer Center, Lubbock, TX 79430, USA
| | - Zheng Shi
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
- Radiation Oncology Clinic, University Medical Center Cancer Center, Lubbock, TX 79430, USA
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Fritz CDL, Oduyale O, Cao Y. Overcoming Racial and Ethnic Disparities in Rectal Cancer Treatment. JAMA Netw Open 2024; 7:e240018. [PMID: 38421655 DOI: 10.1001/jamanetworkopen.2024.0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Affiliation(s)
- Cassandra D L Fritz
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St Louis, Missouri
- Editorial Fellow, JAMA Network Open
| | - Oluseye Oduyale
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Yin Cao
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St Louis, Missouri
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
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21
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Tomminen T, Huhtala H, Kotaluoto S, Veitonmäki T, Wirta EV, Hyöty M. Surgical and oncological results after rectal resections with or without previous treatment for prostate cancer. Front Surg 2024; 11:1298865. [PMID: 38362461 PMCID: PMC10867186 DOI: 10.3389/fsurg.2024.1298865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 01/15/2024] [Indexed: 02/17/2024] Open
Abstract
Introduction Previous treatment for prostate cancer (PC) may potentially affect the surgical and oncological outcomes of subsequent rectal cancer surgery, but there are only a few studies regarding this particular group. In this study, we present the 3-year surgical and oncological results of rectal cancer patients who had received previous treatment for PC at a single Finnish tertiary referral centre. Material and methods Data regarding all male patients diagnosed with rectal cancer and treated at Tampere University Hospital (TAUH) between 1997 and 2016 were gathered from medical records. In total, this study included 553 rectal cancer patients who underwent curative surgery, and 54 of them (9.8%) had a prior history of treatment for prostate cancer. Results Patients in the PC group were older and had more comorbidities compared with those in the non-PC group. The PC patients had a significantly higher risk of permanent stoma compared with the non-PC patients (61.5% vs. 45.2%, respectively, p = 0.025). The PC patients seemed to have lower tumours than the non-PC patients (87% vs. 75%, respectively, p = 0.05). Overall, the 3-year overall survival (OS) for the PC and non-PC patients was 74.1% and 80.6%, respectively. No significant differences were observed between the study groups even in the age-adjusted comparison [hazard ratio (HR): 1.07, confidence interval (CI) 95%: 0.60-1.89]. In the univariable analysis, radically operated patients without a history of PC exhibited an improved overall survival, (HR: 2.46, 95% CI: 1.34-4.53, p = 0.004). However, only a higher age-adjusted Charlson comorbidity index (CCI) and a low tumour location (<10 cm) were found to have an independent prognostic impact on worse OS in the multivariable analysis (HR: 1.57, 95% CI: 1.36-1.82, p < 0.001 and HR: 2.74, 95% CI: 1.32-5.70, p = 0.007, respectively). No significant differences were observed between the groups in terms of disease-free or local recurrence-free survival. Conclusion Rectal cancer is more frequently found in the middle or lower part of the rectum in patients who have previously received treatment for prostate cancer. These patients also have a higher likelihood of requiring a permanent stoma. In radically operated rectal cancer, the PC group had a worse OS rate, according to the univariable analysis. However, the only independent prognostic factors for a worse OS that were highlighted in the multivariable analysis included a higher CCI and a low tumour location.
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Affiliation(s)
- T. Tomminen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - H. Huhtala
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - S. Kotaluoto
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - T. Veitonmäki
- Department of Urology, Tampere University Hospital, Tampere, Finland
| | - E.-V. Wirta
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - M. Hyöty
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
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Xu X, Zhong H, You J, Ren M, Fingerhut A, Zheng M, Li J, Yang X, Song H, Zhang S, Ding C, Abuduaini N, Yu M, Liu J, Zhang Y, Kang L, Cai Z, Feng B. Revolutionizing sphincter preservation in ultra-low rectal cancer: exploring the potential of transanal endoscopic intersphincteric resection (taE-ISR): a propensity score-matched cohort study. Int J Surg 2024; 110:709-720. [PMID: 38016136 PMCID: PMC10871607 DOI: 10.1097/js9.0000000000000945] [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: 07/20/2023] [Accepted: 11/13/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND With the optimization of neoadjuvant treatment regimens, the indications for intersphincteric resection (ISR) have expanded. However, limitations such as unclear surgical field, impaired anal function, and failure of anal preservation still exist. Transanal total mesorectal excision can complement the drawbacks of ISR. Therefore, this study combined these two techniques and proposed transanal endoscopic intersphincteric resection (taE-ISR), aiming to explore the value of this novel technique in anal preservation for ultra-low rectal cancer. MATERIAL AND METHODS Four high-volume centres were involved. After 1:1 propensity score-matching, patients with ultra-low rectal cancer underwent taE-ISR ( n =90) or ISR ( n =90) were included. Baseline characteristics, perioperative outcomes, pathological results, and follow-up were compared between the two groups. A nomogram model was established to assess the potential risks of anal preservation. RESULTS The incidence of adjacent organ injury (0.0% vs. 5.6%, P =0.059), positive distal resection margin (1.1% vs. 8.9%, P =0.034), and incomplete specimen (2.2% vs. 13.3%, P =0.012) were lower in taE-ISR group. Moreover, the anal preservation rate was significantly higher in taE-ISR group (97.8% vs. 82.2%, P =0.001). Patients in the taE-ISR group showed a better disease-free survival ( P =0.044) and lower cumulative recurrence ( P =0.022) compared to the ISR group. Surgery procedure, tumour distance, and adjacent organ injury were factors influencing anal preservation in patients with ultra-low rectal cancer. CONCLUSION taE-ISR technique was safe, feasible, and improved surgical quality, anal preservation rate and survival outcomes in ultra-low rectal cancer patients. It held significant clinical value and showed promising application prospects for anal preservation.
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Affiliation(s)
- Ximo Xu
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of General Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Hao Zhong
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jun You
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Xiamen University, Teaching Hospital of Fujian Medical University, Xiamen
| | - Mingyang Ren
- Department of Gastrointestinal Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong
| | - Abe Fingerhut
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Section for Surgical Research, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29, Graz, Austria
| | - Minhua Zheng
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jianwen Li
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiao Yang
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Haiqin Song
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Sen Zhang
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chengsheng Ding
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Naijipu Abuduaini
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mengqin Yu
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jingyi Liu
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yi Zhang
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Liang Kang
- Department of General Surgery (Colorectal Surgery)
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Zhenghao Cai
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bo Feng
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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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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Lee SF, Yip PL, Wo B, Wong NSM, Vellayappan BA, Mamon HJ, Lee FAS. Neoadjuvant short-course radiotherapy or chemoradiation plus consolidative chemotherapy followed by radical operation for locally advanced rectal cancer. Front Oncol 2024; 13:1284569. [PMID: 38322287 PMCID: PMC10844885 DOI: 10.3389/fonc.2023.1284569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 12/21/2023] [Indexed: 02/08/2024] Open
Abstract
Introduction Limited evidence compares short-course radiotherapy (SCRT) and long-course chemoradiotherapy (LCCRT), both of which are followed by consolidative chemotherapy before radical rectal surgery. We conducted a retrospective cohort study to assess treatment response, survival outcomes, and toxicity in patients with locally advanced rectal cancer. Materials and methods Patients (cT3-4 and/or N+) treated with SCRT or LCCRT, consolidative chemotherapy, or total mesorectal excision between 2013 and 2021 were identified. the cause-specific cumulative incidence of disease-related treatment failure, locoregional recurrence, distant metastases, and overall survival were evaluated using flexible parametric competing risk analysis and Kaplan-Meier methods, adjusted for treatment regimens and clinicopathological factors. A pathological complete response (pCR), tumor downstaging, and toxicity have been reported. Results Among the 144 patients, 115 (80%) underwent curative rectal surgery. The LCCRT and SCRT groups achieved pCR in 10 (18%) and seven (12%) patients, respectively (odds ratio, 1.68; 95% confidence interval [CI], 0.59-4.78). The adjusted cause-specific hazard ratio for disease-related treatment failure with LCCRT versus SCRT was 0.26 (95% CI, 0.08-0.87). Three-year cumulative probability of disease-related treatment failure was 10.0% and 25.6% for LCCRT and SCRT, respectively. No significant differences in T-downstaging, N-downstaging, significant pathologic downstaging (ypT0-2N0), locoregional failure, distant metastasis, or overall survival were found. Late rectal toxicity occurred in 10 (15%) LCCRT and two (3%) SCRT patients, respectively. Conclusion LCCRT with consolidative chemotherapy demonstrated improved disease-related treatment failure compared with SCRT, despite higher late rectal toxicity. Further research is needed to assess the long-term oncologic outcomes and toxicity.
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Affiliation(s)
- Shing Fung Lee
- Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong, Hong Kong SAR, China
- Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore, Singapore
| | - Pui Lam Yip
- Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong, Hong Kong SAR, China
- Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore, Singapore
| | - Barry Wo
- Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong, Hong Kong SAR, China
| | - Natalie Sean-Man Wong
- Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong, Hong Kong SAR, China
| | - Balamurugan A. Vellayappan
- Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore, Singapore
| | - Harvey J. Mamon
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women’s Hospital, Boston, MA, United States
| | - Francis Ann Shing Lee
- Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong, Hong Kong SAR, China
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Amjad R, Moldovan N, Raziee H, Leung E, D’Souza D, Mendez LC. Hypofractionated Radiotherapy in Gynecologic Malignancies-A Peek into the Upcoming Evidence. Cancers (Basel) 2024; 16:362. [PMID: 38254851 PMCID: PMC10814353 DOI: 10.3390/cancers16020362] [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: 12/31/2023] [Accepted: 01/09/2024] [Indexed: 01/24/2024] Open
Abstract
Radiotherapy (RT) has a fundamental role in the treatment of gynecologic malignancies, including cervical and uterine cancers. Hypofractionated RT has gained popularity in many cancer sites, boosted by technological advances in treatment delivery and image verification. Hypofractionated RT uptake was intensified during the COVID-19 pandemic and has the potential to improve universal access to radiotherapy worldwide, especially in low-resource settings. This review summarizes the rationale, the current challenges and investigation efforts, together with the recent developments associated with hypofractionated RT in gynecologic malignancies. A comprehensive search was undertaken using multiple databases and ongoing trial registries. In the definitive radiotherapy setting for cervical cancers, there are several ongoing clinical trials from Canada, Mexico, Iran, the Philippines and Thailand investigating the role of a moderate hypofractionated external beam RT regimen in the low-risk locally advanced population. Likewise, there are ongoing ultra and moderate hypofractionated RT trials in the uterine cancer setting. One Canadian prospective trial of stereotactic hypofractionated adjuvant RT for uterine cancer patients suggested a good tolerance to this treatment strategy in the acute setting, with a follow-up trial currently randomizing patients between conventional fractionation and the hypofractionated dose regimen delivered in the former trial. Although not yet ready for prime-time use, hypofractionated RT could be a potential solution to several challenges that limit access to and the utilization of radiotherapy for gynecologic cancer patients worldwide.
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Affiliation(s)
- Razan Amjad
- Department of Radiation Oncology, King Abdulaziz University, Rabigh 25732, Saudi Arabia
- Department of Radiation Oncology, London Health Sciences Centre, London, ON N6A 5W9, Canada
| | - Nataliya Moldovan
- Department of Radiation Oncology, BC Cancer, Kelowna, BC V1Y 5L3, Canada
| | - Hamid Raziee
- Department of Radiation Oncology, BC Cancer, Kelowna, BC V1Y 5L3, Canada
| | - Eric Leung
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
| | - David D’Souza
- Department of Radiation Oncology, London Health Sciences Centre, London, ON N6A 5W9, Canada
| | - Lucas C. Mendez
- Department of Radiation Oncology, London Health Sciences Centre, London, ON N6A 5W9, Canada
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Conces ML, Mahipal A. Adoption of Total Neoadjuvant Therapy in the Treatment of Locally Advanced Rectal Cancer. Curr Oncol 2024; 31:366-382. [PMID: 38248109 PMCID: PMC10813931 DOI: 10.3390/curroncol31010024] [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: 10/20/2023] [Revised: 12/11/2023] [Accepted: 01/01/2024] [Indexed: 01/23/2024] Open
Abstract
Local and metastatic recurrence are primary concerns following the treatment of locally advanced rectal cancer (LARC). Chemoradiation (CRT) can reduce the local recurrence rates and has subsequently moved to the neoadjuvant setting from the adjuvant setting. Pathological complete response (pCR) rates have also been noted to be greater in patients treated with neoadjuvant CRT prior to surgery. The standard approach to treating LARC would often involve CRT followed by surgery and optional adjuvant chemotherapy and remained the treatment paradigm for almost two decades. However, patients were often unable to complete adjuvant chemotherapy due to a decreased tolerance of chemotherapy following surgery, which led to upfront treatment with both CRT and chemotherapy, and total neoadjuvant therapy, or TNT, was created. The efficacy outcomes of local recurrence, disease-free survival, and pCR have improved in patients receiving TNT compared to the standard approach. Additionally, more recent data suggest a possible improvement in overall survival as well. Patients with a complete clinical response following TNT have the opportunity for watch-and-wait surveillance, allowing some patients to undergo organ preservation. Here, we discuss the clinical trials and studies that led to the adoption of TNT as the standard of care for LARC, with the possibility of watch-and-wait surveillance for patients achieving complete responses. We also review the possibility of overtreating some patients with LARC.
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Affiliation(s)
| | - Amit Mahipal
- University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH 44106, USA
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Hearn N, Leppien A, O’Connor P, Cahill K, Atwell D, Vignarajah D, Min M. Radiotherapy dose escalation using pre-treatment diffusion-weighted imaging in locally advanced rectal cancer: a planning study. BJR Open 2024; 6:tzad001. [PMID: 38352181 PMCID: PMC10860507 DOI: 10.1093/bjro/tzad001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/14/2023] [Accepted: 10/09/2023] [Indexed: 02/16/2024] Open
Abstract
Objectives Diffusion-weighted MRI (DWI) may provide biologically relevant target volumes for dose-escalated radiotherapy in locally advanced rectal cancer (LARC). This planning study assessed the dosimetric feasibility of delivering hypofractionated boost treatment to intra-tumoural regions of restricted diffusion prior to conventional long-course radiotherapy. Methods Ten patients previously treated with curative-intent standard long-course radiotherapy (50 Gy/25#) were re-planned. Boost target volumes (BTVs) were delineated semi-automatically using 40th centile intra-tumoural apparent diffusion coefficient value with expansions (anteroposterior 11 mm, transverse 7 mm, craniocaudal 13 mm). Biased-dosed combined plans consisted of a single-fraction volumetric modulated arc therapy flattening-filter-free (VMAT-FFF) boost (phase 1) of 5, 7, or 10 Gy before long-course VMAT (phase 2). Phase 1 plans were assessed with reference to stereotactic conformality and deliverability measures. Combined plans were evaluated with reference to standard long-course therapy dose constraints. Results Phase 1 BTV dose targets at 5/7/10 Gy were met in all instances. Conformality constraints were met with only 1 minor violation at 5 and 7 Gy. All phase 1 and combined phase 1 + 2 plans passed patient-specific quality assurance. Combined phase 1 + 2 plans generally met organ-at-risk dose constraints. Exceptions included high-dose spillage to bladder and large bowel, predominantly in cases where previously administered, clinically acceptable non-boosted plans also could not meet constraints. Conclusions Targeted upfront LARC radiotherapy dose escalation to DWI-defined is feasible with appropriate patient selection and preparation. Advances in knowledge This is the first study to evaluate the feasibility of DWI-targeted upfront radiotherapy boost in LARC. This work will inform an upcoming clinical feasibility study.
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Affiliation(s)
- Nathan Hearn
- Department of Medical Imaging, Sunshine Coast University Hospital, Birtinya, QLD 4575, Australia
- Thompson Institute, University of the Sunshine Coast, Birtinya, QLD 4575, Australia
| | - Alexandria Leppien
- Department of Radiation Oncology, Sunshine Coast University Hospital, Birtinya, QLD 4575, Australia
| | - Patrick O’Connor
- Department of Radiation Oncology, Sunshine Coast University Hospital, Birtinya, QLD 4575, Australia
- School of Information Technology and Electrical Engineering, University of Queensland, St Lucia, QLD 4072, Australia
| | - Katelyn Cahill
- Thompson Institute, University of the Sunshine Coast, Birtinya, QLD 4575, Australia
- Department of Radiation Oncology, Sunshine Coast University Hospital, Birtinya, QLD 4575, Australia
| | - Daisy Atwell
- Thompson Institute, University of the Sunshine Coast, Birtinya, QLD 4575, Australia
- Department of Radiation Oncology, Sunshine Coast University Hospital, Birtinya, QLD 4575, Australia
| | - Dinesh Vignarajah
- Department of Radiation Oncology, Sunshine Coast University Hospital, Birtinya, QLD 4575, Australia
- School of Medicine and Dentistry, Griffith University, Sunshine Coast Health Institute, Birtinya, QLD 4575, Australia
| | - Myo Min
- Thompson Institute, University of the Sunshine Coast, Birtinya, QLD 4575, Australia
- Department of Radiation Oncology, Sunshine Coast University Hospital, Birtinya, QLD 4575, Australia
- School of Medicine and Dentistry, Griffith University, Sunshine Coast Health Institute, Birtinya, QLD 4575, Australia
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Janczak J, Ukegjini K, Bischofberger S, Turina M, Müller PC, Steffen T. Quality of Surgical Outcome Reporting in Randomised Clinical Trials of Multimodal Rectal Cancer Treatment: A Systematic Review. Cancers (Basel) 2023; 16:26. [PMID: 38201454 PMCID: PMC10778098 DOI: 10.3390/cancers16010026] [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: 11/07/2023] [Revised: 12/07/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
INTRODUCTION Randomised controlled trials (RCTs) continue to provide the best evidence for treatment options, but the quality of reporting in RCTs and the completeness rate of reporting of surgical outcomes and complication data vary widely. The aim of this study was to measure the quality of reporting of the surgical outcome and complication data in RCTs of rectal cancer treatment and whether this quality has changed over time. METHODS Eligible articles with the keywords ("rectal cancer" OR "rectal carcinoma") AND ("radiation" OR "radiotherapy") that were RCTs and published in the English, German, Polish, or Italian language were identified by reviewing all abstracts published from 1982 through 2022. Two authors independently screened and analysed all studies. The quality of the surgical outcome and complication data was assessed based on fourteen criteria, and the quality of RCTs was evaluated based on a modified Jadad scale. The primary outcome was the quality of reporting in RCTs and the completeness rate of reporting of surgical results and complication data. RESULTS A total of 340 articles reporting multimodal therapy outcomes for 143,576 rectal cancer patients were analysed. A total of 7 articles (2%) met all 14 reporting criteria, 13 met 13 criteria, 27 met from 11 to 12 criteria, 36 met from 9 to 10 criteria, 76 met from 7 to 8 criteria, and most articles met fewer than 7 criteria (mean 5.5 criteria). Commonly underreported criteria included complication severity (15% of articles), macroscopic integrity of mesorectal excision (17% of articles), length of stay (18% of articles), number of lymph nodes (21% of articles), distance between the tumour and circumferential resection margin (CRM) (26% of articles), surgical radicality according to the site of the primary tumour (R0 vs. R1 + R2) (29% of articles), and CRM status (38% of articles). CONCLUSION Inconsistent surgical outcome and complication data reporting in multimodal rectal cancer treatment RCTs is standard. Standardised reporting of clinical and oncological outcomes should be established to facilitate comparing studies and results of related research topics.
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Affiliation(s)
- Joanna Janczak
- Clinic for General and Visceral Surgery, Hospital for the Region Fürstenland Toggenburg, CH-9500 Wil, Switzerland;
| | - Kristjan Ukegjini
- Department of Surgery, Hospital of the Canton of St. Gallen, CH-9007 St. Gallen, Switzerland; (K.U.); (S.B.)
| | - Stephan Bischofberger
- Department of Surgery, Hospital of the Canton of St. Gallen, CH-9007 St. Gallen, Switzerland; (K.U.); (S.B.)
| | - Matthias Turina
- Department of Surgery and Transplantation, University Hospital Zurich, CH-8091 Zurich, Switzerland;
| | - Philip C. Müller
- Department of Surgery, Clarunis—University Centre for Gastrointestinal and Hepatopancreatobiliary Diseases, CH-4002 Basel, Switzerland;
| | - Thomas Steffen
- Department of Surgery, Hospital of the Canton of St. Gallen, CH-9007 St. Gallen, Switzerland; (K.U.); (S.B.)
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Boublikova L, Novakova A, Simsa J, Lohynska R. Total neoadjuvant therapy in rectal cancer: the evidence and expectations. Crit Rev Oncol Hematol 2023; 192:104196. [PMID: 37926376 DOI: 10.1016/j.critrevonc.2023.104196] [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: 08/16/2023] [Revised: 10/14/2023] [Accepted: 11/01/2023] [Indexed: 11/07/2023] Open
Abstract
Current management of locally advanced rectal cancer achieves high cure rates, distant metastatic spread being the main cause of patients' death. Total neoadjuvant therapy (TNT) employs (chemo)radiotherapy and combined chemotherapy prior to surgery to improve the treatment outcomes. TNT has been shown to reduce significantly distant metastases, increase disease-free survival by 5 - 10% in 3 years, and finally also overall survival (≈ 5% in 7 years). It proved to double the rate of pathologic complete responses, making it an attractive strategy for non-operative management to avoid permanent colostomy in patients with distal tumors. In addition, it endorses adherence to the therapy due to better tolerance and, potentially, shortens its overall duration. A number of questions related to TNT remain currently unresolved including the indications, preferred radiotherapy and chemotherapy regimens, their sequence, timing of surgery, and role of adjuvant therapy. A stratified approach may be the optimal way to go.
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Affiliation(s)
- Ludmila Boublikova
- Department of Oncology, 1st Faculty of Medicine, Charles University and Thomayer University Hospital, Prague, Czech Republic; CLIP - Department of Pediatric Hematology and Oncology, 2nd Faculty of Medicine, Charles University and University Hospital in Motol, Prague, Czech Republic.
| | - Alena Novakova
- Department of Oncology, 1st Faculty of Medicine, Charles University and Thomayer University Hospital, Prague, Czech Republic
| | - Jaromir Simsa
- Department of Surgery, 1st Faculty of Medicine, Charles University and Thomayer University Hospital, Prague, Czech Republic
| | - Radka Lohynska
- Department of Oncology, 1st Faculty of Medicine, Charles University and Thomayer University Hospital, Prague, Czech Republic
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He X, Cui J, Ma H, Abuduaini N, Huang Y, Tang L, Wang W, Zhang Y, Wang Y, Lu W, Feng B, Huang J. Berberrubine is a novel and selective IMPDH2 inhibitor that impairs the growth of colorectal cancer. Biochem Pharmacol 2023; 218:115868. [PMID: 37871880 DOI: 10.1016/j.bcp.2023.115868] [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: 08/14/2023] [Revised: 10/16/2023] [Accepted: 10/17/2023] [Indexed: 10/25/2023]
Abstract
Inosine monophosphate dehydrogenase (IMPDH) catalyzes the rate-limiting reaction in the de novo synthesis pathway of guanine nucleotides that is highly required for cancer cell outgrowth. Herein, we found that IMPDH isoform 2 (IMPDH2) is highly expressed in colorectal cancer (CRC) and is correlated with poor patient prognosis. Via structure-based virtual screening, we identified berberrubine, a critical ingredient of the medical plant Coptis chinensis, as a novel, selective, and competitive inhibitor of IMPDH2, which demonstrated over 15-fold selectivity to IMPDH2 than IMPDH1. Besides, we also confirmed the interaction between berberrubine and IMPDH2. Of note, berberrubine treatment significantly impairs the growth of human CRC cells in a dose-dependent manner, which can be rescued by supplementing with guanosine. Furthermore, oral administration of berberrubine remarkably reduced tumor volume and weight in a human cell line-derived xenograft model. Importantly, the anti-cancer activity of berberrubine was also confirmed by using the azoxymethane (AOM) / dextran sulfate sodium (DSS)-induced spontaneous CRC mouse model. Taken together, our study highlights that berberrubine acts as a novel IMPDH2 inhibitor, suppressing the growth of CRC in vitro and in vivo, providing a fresh perspective for its potential application in the treatment of CRC.
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Affiliation(s)
- Xiangli He
- Shanghai Frontiers Science Center of Optogenetic Techniques for Cell Metabolism, School of Pharmacy, East China University of Science and Technology, Shanghai, China
| | - Jiayan Cui
- Shanghai Frontiers Science Center of Optogenetic Techniques for Cell Metabolism, School of Pharmacy, East China University of Science and Technology, Shanghai, China
| | - Hui Ma
- Shanghai Frontiers Science Center of Optogenetic Techniques for Cell Metabolism, School of Pharmacy, East China University of Science and Technology, Shanghai, China
| | - Naijipu Abuduaini
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ying Huang
- Drug Inspection Technology, Guangdong Institute For Drug Control, 766 Shenzhou Road, Guangzhou 510663, China
| | - Lu Tang
- Shanghai Frontiers Science Center of Optogenetic Techniques for Cell Metabolism, School of Pharmacy, East China University of Science and Technology, Shanghai, China
| | - Wanyan Wang
- Shanghai Frontiers Science Center of Optogenetic Techniques for Cell Metabolism, School of Pharmacy, East China University of Science and Technology, Shanghai, China
| | - Yuanyuan Zhang
- Shanghai Frontiers Science Center of Optogenetic Techniques for Cell Metabolism, School of Pharmacy, East China University of Science and Technology, Shanghai, China
| | - Yang Wang
- Department of Urology, The Fifth People's Hospital of Shanghai, Fudan University, Shanghai, China
| | - Weiqiang Lu
- Shanghai Key Laboratory of Regulatory Biology, Institute of Biomedical Sciences and School of Life Sciences, East China Normal University, Shanghai, China.
| | - Bo Feng
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Jin Huang
- Shanghai Frontiers Science Center of Optogenetic Techniques for Cell Metabolism, School of Pharmacy, East China University of Science and Technology, Shanghai, China.
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Donnelly SM, Wyatt J, Powell SG, Jones N, Altaf K, Ahmed S. What is the optimal timing of surgery after short-course radiotherapy for rectal cancer? Surg Oncol 2023; 51:101992. [PMID: 37757518 DOI: 10.1016/j.suronc.2023.101992] [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: 05/10/2023] [Revised: 09/08/2023] [Accepted: 09/17/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND Short-course neoadjuvant radiotherapy is a valuable tool in managing rectal cancers and has improved local recurrence rates. However, limited and conflicting data has resulted in variable usage and a lack of consensus on the optimal timing of surgery following short-course radiotherapy. This review aims to provide a contemporary summation of the available evidence regarding the optimal time interval between short-course neoadjuvant radiotherapy and surgery. METHODS A focused literature search was undertaken using the PubMed and Embase databases from January 1980 until January 2023. Randomised control trials, large observational studies and systematic reviews focusing on the use of short-course preoperative radiotherapy for localised rectal cancers, with a focus on the timing of surgery, were included. Primary outcomes were overall survival, disease-free survival and perioperative complications. RESULTS Five randomised control trials, two meta-analyses, and two large, population-based studies were included for their eligibility and relevance. Increased downstaging and fewer postoperative complications are demonstrated in patients receiving delayed surgery (> four weeks), but more recent data raise concerns regarding increased rates of local recurrence in this cohort. Studies directly comparing different time intervals to surgery following short-course radiotherapy have failed to demonstrate an effect on overall survival. CONCLUSIONS This review highlights the complexities and relative shortcomings of the available data with few high-quality studies and randomised control trials directly comparing different time intervals to surgery following short-course radiotherapy. Continuing research is needed to confirm existing findings and explore gaps in the current literature.
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Affiliation(s)
| | - James Wyatt
- The University of Liverpool, L69 3BX, United Kingdom; Liverpool University Hospitals NHS Foundation Trust, L7 8XP, United Kingdom.
| | - Simon G Powell
- The University of Liverpool, L69 3BX, United Kingdom; Liverpool University Hospitals NHS Foundation Trust, L7 8XP, United Kingdom
| | - Nia Jones
- Liverpool University Hospitals NHS Foundation Trust, L7 8XP, United Kingdom
| | - Kiran Altaf
- Liverpool University Hospitals NHS Foundation Trust, L7 8XP, United Kingdom
| | - Shakil Ahmed
- Liverpool University Hospitals NHS Foundation Trust, L7 8XP, United Kingdom
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Meillat H, Garnier J, Palen A, Ewald J, de Chaisemartin C, Tyran M, Mitry E, Lelong B. Organ sparing to cure stage IV rectal cancer: A case report and review of literature. World J Gastrointest Surg 2023; 15:2619-2626. [PMID: 38111764 PMCID: PMC10725537 DOI: 10.4240/wjgs.v15.i11.2619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/03/2023] [Accepted: 08/28/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Rectal sparing is an option for some rectal cancers with complete or good response after chemoradiotherapy (CRT); however, it has never been evaluated in patients with metastases. We assessed long-term outcomes of a rectal-sparing approach in a liver-first strategy for patients with rectal cancer with resectable liver metastases. CASE SUMMARY We examined patients who underwent an organ-sparing approach for rectal cancer with synchronous liver metastases using a liver-first strategy during 2010-2015 (n = 8). Patients received primary chemotherapy and pelvic CRT. Liver surgery was performed during the interval between CRT completion and rectal tumor re-evaluation. Clinical and oncological characteristics and long-term outcomes were assessed.All patients underwent liver metastatic resection with curative intent. The R0 rate was 100%. Six and two patients underwent local excision and a watch-and-wait (WW) approach, respectively. All patients had T3N1 tumors at diagnosis and had good clinical response after CRT. The median survival time was 60 (range, 14-127) mo. Three patients were disease free for 5, 8, and 10 years after the procedure. Five patients developed metastatic recurrence in the liver (n = 5) and/or lungs (n = 2). Only one patient developed local recurrence concurrent with metastatic recurrence 24 mo after the WW approach. Two patients died during follow-up. CONCLUSION The results suggest good local control in patients undergoing organ-sparing strategies for rectal cancer with synchronous liver metastasis. Prospective trials are required to validate these data and identify good candidates for these strategies.
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Affiliation(s)
- Hélène Meillat
- Department of Digestive Surgical Oncology, Institut Paoli Calmettes, Marseille 13009, France
| | - Jonathan Garnier
- Department of Digestive Surgical Oncology, Institut Paoli Calmettes, Marseille 13009, France
| | - Anais Palen
- Department of Digestive Surgical Oncology, Institut Paoli Calmettes, Marseille 13009, France
| | - Jacques Ewald
- Department of Digestive Surgical Oncology, Institut Paoli Calmettes, Marseille 13009, France
| | - Cécile de Chaisemartin
- Department of Digestive Surgical Oncology, Institut Paoli Calmettes, Marseille 13009, France
| | - Marguerite Tyran
- Department of Radiotherapy, Institut Paoli Calmettes, Marseille 13009, France
| | - Emmanuel Mitry
- Department of Digestive Surgical Oncology, Institut Paoli Calmettes, Marseille 13009, France
| | - Bernard Lelong
- Department of Digestive Surgical Oncology, Institut Paoli Calmettes, Marseille 13009, France
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Cai X, Li P, Zhao J, Wang W, Cheng J, Zhang G, Cai S, Zhang Z, Jiang G, Zhang Q, Wang Z. Definitive carbon ion re-irradiation with pencil beam scanning in the treatment of unresectable locally recurrent rectal cancer. JOURNAL OF RADIATION RESEARCH 2023; 64:933-939. [PMID: 37738440 PMCID: PMC10665299 DOI: 10.1093/jrr/rrad068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/04/2023] [Indexed: 09/24/2023]
Abstract
This study aimed to evaluate the oncological outcomes and safety of carbon ion re-irradiation with pencil beam scanning (PBS) delivery technique for previously irradiated and unresectable locally recurrent rectal cancer (LRRC). Between June 2017 and September 2021, 24 patients of unresectable LRRC with prior pelvic photon radiotherapy who underwent carbon ion re-irradiation at our institute were retrospectively analyzed. Carbon ion radiotherapy was delivered by raster scanning with a median relative biological effectiveness-weighted dose of 72 Gy in 20 fractions. Weekly CT reviews were carried out, and offline adaptive replanning was performed whenever required. The median follow-up duration was 23.8 months (range, 6.2-47.1 months). At the last follow-up, two patients had a local disease progression, and 11 patients developed distant metastases. The 1- and 2-year local control, progression-free survival and overall survival rates were 100 and 93.3%, 70.8 and 45.0% and 86.7 and 81.3%, respectively. There were no Grade 3 or higher acute toxicities observed. Three patients developed Grade 3 late toxicities, one each with gastrointestinal toxicity, skin reaction and pelvic infection. In conclusion, definitive carbon ion re-irradiation with PBS provided superior oncologic results with tolerable toxicities and may be served as a curative treatment strategy in unresectable LRRC.
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Affiliation(s)
- Xin Cai
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Shanghai, China
- Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, China
- Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China
| | - Ping Li
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Shanghai, China
- Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, China
- Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China
| | - Jingfang Zhao
- Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, China
- Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China
- Department of Medical Physics, Shanghai Proton and Heavy Ion Center, Shanghai, China
| | - Weiwei Wang
- Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, China
- Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China
- Department of Medical Physics, Shanghai Proton and Heavy Ion Center, Shanghai, China
| | - Jingyi Cheng
- Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, China
- Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China
- Department of Nuclear Medicine, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Shanghai, China
| | - Guangyuan Zhang
- Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, China
- Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China
- Department of Radiology, Shanghai Proton and Heavy Ion Center, Shanghai, China
| | - Sanjun Cai
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Zhen Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Guoliang Jiang
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Shanghai, China
- Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, China
- Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China
| | - Qing Zhang
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Shanghai, China
- Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, China
- Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Shanghai, China
| | - Zheng Wang
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Shanghai, China
- Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, China
- Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Shanghai, China
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Kang MK, Park SY, Park JS, Kim HJ, Kim JG, Kang BW, Baek JH, Cho SH, Seo AN, Kim DW, Kim J, Baek SJ, Kim JH, Kim JY, Ha GW, Park EJ, Park IJ, Kim CH, Kang H, Choi GS. Preoperative sequential short-course radiation therapy and FOLFOX chemotherapy versus long-course chemoradiotherapy for locally advanced rectal cancer: a multicenter, randomized controlled trial (SOLAR trial). BMC Cancer 2023; 23:1059. [PMID: 37923987 PMCID: PMC10623855 DOI: 10.1186/s12885-023-11363-7] [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: 07/16/2023] [Accepted: 09/04/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND Preoperative (chemo)radiotherapy has been widely used as an effective treatment for locally advanced rectal cancer (LARC), leading to a significant reduction in pelvic recurrence rates. Because early administration of intensive chemotherapy for LARC has more advantages than adjuvant chemotherapy, total neoadjuvant therapy (TNT) has been introduced and evaluated to determine whether it can improve tumor response or treatment outcomes. This study aims to investigate whether short-course radiotherapy (SCRT) followed by intensive chemotherapy improves oncologic outcomes compared with traditional preoperative long-course chemoradiotherapy (CRT). METHODS A multicenter randomized phase II trial involving 364 patients with LARC (cT3-4, cN+, or presence of extramural vascular invasion) will be conducted. Patients will be randomly assigned to the experimental or control arm at a ratio of 1:1. Participants in the experimental arm will receive SCRT (25 Gy in 5 fractions, daily) followed by four cycles of FOLFOX (oxaliplatin, 5-fluorouracil, and folinic acid) as a neoadjuvant treatment, and those in the control arm will receive conventional radiotherapy (45-50.4 Gy in 25-28 fractions, 5 times a week) concurrently with capecitabine or 5-fluorouracil. As a mandatory surgical procedure, total mesorectal excision will be performed 2-5 weeks from the last cycle of chemotherapy in the experimental arm and 6-8 weeks after the last day of radiotherapy in the control arm. The primary endpoint is 3-year disease-free survival, and the secondary endpoints are tumor response, overall survival, toxicities, quality of life, and cost-effectiveness. DISCUSSION This is the first Korean randomized controlled study comparing SCRT-based TNT with traditional preoperative LC-CRT for LARC. The involvement of experienced colorectal surgeons ensures high-quality surgical resection. SCRT followed by FOLFOX chemotherapy is expected to improve disease-free survival compared with CRT, with potential advantages in tumor response, quality of life, and cost-effectiveness. TRIAL REGISTRATION This trial is registered at Clinical Research Information under the identifier Service KCT0004874 on April 02, 2020, and at Clinicaltrial.gov under the identifier NCT05673772 on January 06, 2023.
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Grants
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
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Affiliation(s)
- Min Kyu Kang
- Department of Radiation Oncology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Soo Yeun Park
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, 807 Hogukro, Buk-gu, Daegu, 41404, South Korea
| | - Jun Seok Park
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, 807 Hogukro, Buk-gu, Daegu, 41404, South Korea
| | - Hye Jin Kim
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, 807 Hogukro, Buk-gu, Daegu, 41404, South Korea
| | - Jong Gwang Kim
- Department of Oncology/Hematology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Byung Woog Kang
- Department of Oncology/Hematology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Jin Ho Baek
- Department of Oncology/Hematology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Seung Hyun Cho
- Department of Radiology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - An Na Seo
- Department of Pathology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Duck-Woo Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jin Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University College of Medicine, Seoul, South Korea
| | - Se Jin Baek
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University College of Medicine, Seoul, South Korea
| | - Ji Hoon Kim
- Division of Colorectal Surgery, Department of Surgery, Incheon St. Mary's Hospital, the Catholic University of Korea, Incheon, South Korea
| | - Ji Yeon Kim
- Division of Colorectal Surgery, Department of Surgery, Chungnam National University Hospital, Daejeon, South Korea
| | - Gi Won Ha
- Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Jeonbuk, South Korea
| | - Eun Jung Park
- Division of Colon and Rectal Surgery, Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - In Ja Park
- Division of Colon and Rectal Surgery, Department of surgery, , University of Ulsan College of Medicine and Asan Medical Center, Seoul, South Korea
| | - Chang Hyun Kim
- Department of Surgery, Chonnam National University Hwasun Hospital and Medical School, Hwasun, South Korea
| | - Hyun Kang
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, South Korea
| | - Gyu-Seog Choi
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, 807 Hogukro, Buk-gu, Daegu, 41404, South Korea.
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Temmink SJD, Martling A, Angenete E, Nilsson PJ. Complete response rates in rectal cancer: Temporal changes over a decade in a population-based nationwide cohort. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:106991. [PMID: 37495447 DOI: 10.1016/j.ejso.2023.106991] [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: 03/30/2023] [Accepted: 07/19/2023] [Indexed: 07/28/2023]
Abstract
INTRODUCTION In the past decade many changes in neoadjuvant treatment for patients with rectal cancer have taken place and are expected to impact complete response rates. The aim of this study was to investigate the impact on pathological, and overall, complete response rates in a nationwide population-based cohort, in relation to changes in neoadjuvant treatment and the start of a Watch & Wait (WoW) study. MATERIALS AND METHODS A nationwide register study using prospectively collected data from the Swedish Colorectal Cancer Register between 2009 and 2020. Patients with rectal cancer stage I-III with a ypT0N0 in the resected specimen after neoadjuvant treatment and clinical complete responders from the yearly inclusion data of the national WoW study were included. Temporal changes in pathological and overall complete response rates were analysed, and differences in neoadjuvant treatment regimens over time and per region were studied. RESULTS Between 2009 and 2020 the pathological complete response rate for rectal cancer remained similar (Mann-Kendall tau of 0.091, p = 0.68) while the overall complete response rate increased significantly from 3.0% to 9.6% (Mann-Kendall tau of 0.818, p < 0.001). The pathological complete response rate for patients receiving short course radiotherapy followed by chemotherapy was reduced by 50% after the introduction of the WoW study. CONCLUSIONS During the studied time period the overall complete response rate increased significantly presumably due to changes in national neoadjuvant treatment regimens. Since the start of the national WoW study clinical complete response seem to partly replace pathological complete response.
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Affiliation(s)
- Sofieke J D Temmink
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
| | - Anna Martling
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
| | - Eva Angenete
- Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Surgery, Gothenburg, Sweden.
| | - Per J Nilsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
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Huang Y, Gomaa A, Semrau S, Haderlein M, Lettmaier S, Weissmann T, Grigo J, Tkhayat HB, Frey B, Gaipl U, Distel L, Maier A, Fietkau R, Bert C, Putz F. Benchmarking ChatGPT-4 on a radiation oncology in-training exam and Red Journal Gray Zone cases: potentials and challenges for ai-assisted medical education and decision making in radiation oncology. Front Oncol 2023; 13:1265024. [PMID: 37790756 PMCID: PMC10543650 DOI: 10.3389/fonc.2023.1265024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 08/23/2023] [Indexed: 10/05/2023] Open
Abstract
Purpose The potential of large language models in medicine for education and decision-making purposes has been demonstrated as they have achieved decent scores on medical exams such as the United States Medical Licensing Exam (USMLE) and the MedQA exam. This work aims to evaluate the performance of ChatGPT-4 in the specialized field of radiation oncology. Methods The 38th American College of Radiology (ACR) radiation oncology in-training (TXIT) exam and the 2022 Red Journal Gray Zone cases are used to benchmark the performance of ChatGPT-4. The TXIT exam contains 300 questions covering various topics of radiation oncology. The 2022 Gray Zone collection contains 15 complex clinical cases. Results For the TXIT exam, ChatGPT-3.5 and ChatGPT-4 have achieved the scores of 62.05% and 78.77%, respectively, highlighting the advantage of the latest ChatGPT-4 model. Based on the TXIT exam, ChatGPT-4's strong and weak areas in radiation oncology are identified to some extent. Specifically, ChatGPT-4 demonstrates better knowledge of statistics, CNS & eye, pediatrics, biology, and physics than knowledge of bone & soft tissue and gynecology, as per the ACR knowledge domain. Regarding clinical care paths, ChatGPT-4 performs better in diagnosis, prognosis, and toxicity than brachytherapy and dosimetry. It lacks proficiency in in-depth details of clinical trials. For the Gray Zone cases, ChatGPT-4 is able to suggest a personalized treatment approach to each case with high correctness and comprehensiveness. Importantly, it provides novel treatment aspects for many cases, which are not suggested by any human experts. Conclusion Both evaluations demonstrate the potential of ChatGPT-4 in medical education for the general public and cancer patients, as well as the potential to aid clinical decision-making, while acknowledging its limitations in certain domains. Owing to the risk of hallucinations, it is essential to verify the content generated by models such as ChatGPT for accuracy.
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Affiliation(s)
- Yixing Huang
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Ahmed Gomaa
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Sabine Semrau
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Marlen Haderlein
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Sebastian Lettmaier
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Thomas Weissmann
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Johanna Grigo
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Hassen Ben Tkhayat
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Pattern Recognition Lab, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Benjamin Frey
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Udo Gaipl
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Luitpold Distel
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Andreas Maier
- Pattern Recognition Lab, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Christoph Bert
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Florian Putz
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
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Southern J, Gonzalez G, Borgas P, Poynter L, Laponogov I, Zhong Y, Mirnezami R, Veselkov D, Bronstein M, Veselkov K. Genomic-driven nutritional interventions for radiotherapy-resistant rectal cancer patient. Sci Rep 2023; 13:14862. [PMID: 37684345 PMCID: PMC10491580 DOI: 10.1038/s41598-023-41833-8] [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: 12/07/2022] [Accepted: 08/31/2023] [Indexed: 09/10/2023] Open
Abstract
Radiotherapy response of rectal cancer patients is dependent on a myriad of molecular mechanisms including response to stress, cell death, and cell metabolism. Modulation of lipid metabolism emerges as a unique strategy to improve radiotherapy outcomes due to its accessibility by bioactive molecules within foods. Even though a few radioresponse modulators have been identified using experimental techniques, trying to experimentally identify all potential modulators is intractable. Here we introduce a machine learning (ML) approach to interrogate the space of bioactive molecules within food for potential modulators of radiotherapy response and provide phytochemically-enriched recipes that encapsulate the benefits of discovered radiotherapy modulators. Potential radioresponse modulators were identified using a genomic-driven network ML approach, metric learning and domain knowledge. Then, recipes from the Recipe1M database were optimized to provide ingredient substitutions maximizing the number of predicted modulators whilst preserving the recipe's culinary attributes. This work provides a pipeline for the design of genomic-driven nutritional interventions to improve outcomes of rectal cancer patients undergoing radiotherapy.
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Affiliation(s)
- Joshua Southern
- Department of Computing, Imperial College London, London, SW7 2BX, UK
| | - Guadalupe Gonzalez
- Department of Computing, Imperial College London, London, SW7 2BX, UK
- Prescient Design, Genentech, Basel, 4052, Switzerland
| | - Pia Borgas
- North Middlesex University Hospital, London, N18 1QX, UK
| | - Liam Poynter
- Department of Surgery and Cancer, Imperial College London, London, SW7 2BX, UK
| | - Ivan Laponogov
- Department of Surgery and Cancer, Imperial College London, London, SW7 2BX, UK
| | - Yoyo Zhong
- Department of Surgery and Cancer, Imperial College London, London, SW7 2BX, UK
| | | | - Dennis Veselkov
- Department of Computing, Imperial College London, London, SW7 2BX, UK
| | - Michael Bronstein
- Department of Computer Science, University of Oxford, Oxford, OX1 3QD, UK
| | - Kirill Veselkov
- Prescient Design, Genentech, Basel, 4052, Switzerland.
- Department of Environmental Health Sciences, Yale University, New Haven, CT, 06510, USA.
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38
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Donnelly M, Ryan OK, Ryan ÉJ, Creavin B, O'Reilly M, McDermott R, Kennelly R, Hanly A, Martin ST, Winter DC. Total neoadjuvant therapy versus standard neoadjuvant treatment strategies for the management of locally advanced rectal cancer: network meta-analysis of randomized clinical trials. Br J Surg 2023; 110:1316-1330. [PMID: 37330950 DOI: 10.1093/bjs/znad177] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/10/2023] [Accepted: 05/20/2023] [Indexed: 06/20/2023]
Abstract
BACKGROUND This study compared the advantages and disadvantages of total neoadjuvant therapy (TNT) strategies for patients with locally advanced rectal cancer, compared with the more traditional multimodal neoadjuvant management strategies of long-course chemoradiotherapy (LCRT) or short-course radiotherapy (SCRT). METHODS A systematic review and network meta-analysis of exclusively RCTs was undertaken, comparing survival, recurrence, pathological, radiological, and oncological outcomes. The last date of the search was 14 December 2022. RESULTS In total, 15 RCTs involving 4602 patients with locally advanced rectal cancer, conducted between 2004 and 2022, were included. TNT improved overall survival compared with LCRT (HR 0.73, 95 per cent credible interval 0.60 to 0.92) and SCRT (HR 0.67, 0.47 to 0.95). TNT also improved rates of distant metastasis compared with LCRT (HR 0.81, 0.69 to 0.97). Reduced overall recurrence was observed for TNT compared with LCRT (HR 0.87, 0.76 to 0.99). TNT showed an improved pCR compared with both LCRT (risk ratio (RR) 1.60, 1.36 to 1.90) and SCRT (RR 11.32, 5.00 to 30.73). TNT also showed an improvement in cCR compared with LCRT (RR 1.68, 1.08 to 2.64). There was no difference between treatments in disease-free survival, local recurrence, R0 resection, treatment toxicity or treatment compliance. CONCLUSION This study provides further evidence that TNT has improved survival and recurrence benefits compared with current standards of care, and may increase the number of patients suitable for organ preservation, without negatively influencing treatment toxicity or compliance.
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Affiliation(s)
- Mark Donnelly
- Department of Surgery, St Vincent's University Hospital, Dublin, Ireland
- School of Medicine, University College, Dublin, Ireland
| | - Odhrán K Ryan
- Department of Surgery, St Vincent's University Hospital, Dublin, Ireland
- School of Medicine, University College, Dublin, Ireland
| | - Éanna J Ryan
- Department of Surgery, St Vincent's University Hospital, Dublin, Ireland
| | - Ben Creavin
- Department of Surgery, St Vincent's University Hospital, Dublin, Ireland
| | - Mary O'Reilly
- Department of Oncology, St Vincent's University Hospital, Dublin, Ireland
| | - Ray McDermott
- School of Medicine, University College, Dublin, Ireland
- Department of Oncology, St Vincent's University Hospital, Dublin, Ireland
| | - Rory Kennelly
- Department of Surgery, St Vincent's University Hospital, Dublin, Ireland
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - Ann Hanly
- Department of Surgery, St Vincent's University Hospital, Dublin, Ireland
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - Seán T Martin
- Department of Surgery, St Vincent's University Hospital, Dublin, Ireland
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - Des C Winter
- Department of Surgery, St Vincent's University Hospital, Dublin, Ireland
- School of Medicine, University College, Dublin, Ireland
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
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Gill S, Ahmed S, Anderson B, Berry S, Lim H, Phang T, Sharma A, Solar Vasconcelos JP, Gill K, Iqbal M, Tankel K, Chan T, Recsky M, Nuk J, Paul J, Mahmood S. Report from the 24th Annual Western Canadian Gastrointestinal Cancer Consensus Conference on Colorectal Cancer, Richmond, British Columbia, 28-29, October 2022. Curr Oncol 2023; 30:7964-7983. [PMID: 37754494 PMCID: PMC10529884 DOI: 10.3390/curroncol30090579] [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: 06/21/2023] [Revised: 08/10/2023] [Accepted: 08/23/2023] [Indexed: 09/28/2023] Open
Abstract
The 24th annual Western Canadian Gastrointestinal Cancer Consensus Conference (WCGCCC) was held in Richmond, British Columbia, on 28-29 October 2022. The WCGCCC is an interactive multidisciplinary conference attended by healthcare professionals from across Western Canada (British Columbia, Alberta, Saskatchewan, and Manitoba) who are involved in the care of patients with gastrointestinal cancer. Surgical, medical, and radiation oncologists; pathologists; radiologists; and allied health care professionals such as dieticians, nurses and a genetic counsellor participated in presentation and discussion sessions for the purpose of developing the recommendations presented here. This consensus statement addresses current issues in the management of colorectal cancer.
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Affiliation(s)
- Sharlene Gill
- British Columbia Cancer Agency, Vancouver, BC V5Z 4E6, Canada; (H.L.); (J.P.S.V.); (K.G.)
| | - Shahid Ahmed
- Saskatchewan Cancer Agency, Saskatoon, SK S4W 0G3, Canada;
| | - Brady Anderson
- Western Manitoba Cancer Center, Brandon, MB R7A 5M8, Canada;
| | - Scott Berry
- Department of Oncology, Queen’s University, Kingston, ON K7L 3N6, Canada;
| | - Howard Lim
- British Columbia Cancer Agency, Vancouver, BC V5Z 4E6, Canada; (H.L.); (J.P.S.V.); (K.G.)
| | - Terry Phang
- Department of Surgery, University of British Columbia, Vancouver, BC V6T 1Z4, Canada;
| | - Ankur Sharma
- Central Alberta Cancer Centre, School of Medicine, University of Calgary Cumming, Red Deer, AB T4N 6R2, Canada;
| | | | - Karamjit Gill
- British Columbia Cancer Agency, Vancouver, BC V5Z 4E6, Canada; (H.L.); (J.P.S.V.); (K.G.)
| | | | - Keith Tankel
- Cross Cancer Institute, Edmonton, AB T6G 1Z2, Canada; (K.T.); (S.M.)
| | - Theresa Chan
- British Columbia Cancer Agency, Surrey, BC V3V 1Z2, Canada;
| | | | - Jennifer Nuk
- British Columbia Cancer Hereditary Cancer Program, Victoria, BC V8R 6V5, Canada;
| | - James Paul
- CancerCare Manitoba, University of Manitoba, Winnipeg, MB R3E 0V9, Canada;
| | - Shazia Mahmood
- Cross Cancer Institute, Edmonton, AB T6G 1Z2, Canada; (K.T.); (S.M.)
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40
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Castelluccia A, Marchesano D, Grimaldi G, Annessi I, Bianciardi F, Borrazzo C, Dipalma A, El Gawhary R, Masi M, Rago M, Valentino M, Verna L, Portaluri M, Gentile P. Stereotactic MR-guided adaptive radiotherapy (SMART) for primary rectal cancer: evaluation of early toxicity and pathological response. Rep Pract Oncol Radiother 2023; 28:437-444. [PMID: 37795221 PMCID: PMC10547417 DOI: 10.5603/rpor.a2023.0051] [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: 04/15/2023] [Accepted: 07/17/2023] [Indexed: 10/06/2023] Open
Abstract
Background The purpose of this study is to measure the effects of stereotactic MR-guided adaptive radiotherapy (SMART) for rectal cancer patients in terms of early toxicity and pathological response. Materials and methods For this prospective pilot study, patients diagnosed with locally advanced rectal cancer (LARC) with positive lymph node clinical staging underwent SMART on rectal lesion and mesorectum using hybrid MR-Linac (MRIdian ViewRay). Dose prescription at 80% isodose for the rectal lesion and mesorectum was 40 Gy (8 Gy/fr) and 25 Gy (5 Gy/fr), respectively, delivered on 5 days (3 fr/week). Response assessment by MRI was performed 3 weeks after SMART, then patients fit for surgery underwent total mesorectal excision. Primary endpoint was evaluation of adverse effect of radiotherapy. Secondary endpoint was pathological complete response rate. Early toxicity was graded according to the Common Terminology Criteria for Adverse Events (CTCAE v5.0). Results From October 2020 to January 2022, twenty patients underwent rectal SMART. No grade 3-5 toxicity was recorded. Twelve patients were eligible for total mesorectal excision (TME). Mean interval between the completion of SMART and surgery was 4 weeks. Pathological downstaging occurred in all patients; rate of pathological complete response (pCR) was 17%. pCR occurred with a prolonged time to surgery (> 7 weeks). Conclusion To our knowledge, this is the first study to use stereotactic radiotherapy for primary rectal cancer. SMART for rectal cancer is well tolerated and effective in terms of tumor regression, especially if followed by delayed surgery.
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Affiliation(s)
| | - Domenico Marchesano
- Radiation Oncology, Provincia Religiosa di San Pietro Fatebenefratelli, Roma, Italy
| | - Gianmarco Grimaldi
- Radiation Oncology, Provincia Religiosa di San Pietro Fatebenefratelli, Roma, Italy
| | - Ivan Annessi
- Radiation Oncology, Provincia Religiosa di San Pietro Fatebenefratelli, Roma, Italy
| | - Federico Bianciardi
- Radiation Oncology, Provincia Religiosa di San Pietro Fatebenefratelli, Roma, Italy
- Radiation Oncology, UPMC Hillman Cancer Center San Pietro FBF, Rome, Italy
| | - Cristian Borrazzo
- Radiation Oncology, Provincia Religiosa di San Pietro Fatebenefratelli, Roma, Italy
| | - Annamaria Dipalma
- Radiation Oncology, Provincia Religiosa di San Pietro Fatebenefratelli, Roma, Italy
| | - Randa El Gawhary
- Radiation Oncology, Provincia Religiosa di San Pietro Fatebenefratelli, Roma, Italy
| | - Marica Masi
- Radiation Oncology, Provincia Religiosa di San Pietro Fatebenefratelli, Roma, Italy
| | - Maria Rago
- Radiation Oncology, Provincia Religiosa di San Pietro Fatebenefratelli, Roma, Italy
| | - Maria Valentino
- Radiation Oncology, Provincia Religiosa di San Pietro Fatebenefratelli, Roma, Italy
| | - Laura Verna
- Radiation Oncology, Provincia Religiosa di San Pietro Fatebenefratelli, Roma, Italy
| | | | - PierCarlo Gentile
- Radiation Oncology, Provincia Religiosa di San Pietro Fatebenefratelli, Roma, Italy
- Radiation Oncology, UPMC Hillman Cancer Center San Pietro FBF, Rome, Italy
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41
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Sellés EG, Pieretti DG, Higuero PP, Del Portillo EG, Macías VM, Domínguez MM, Mateos RF, Campos FL, Díaz-Gavela AA, Ferraris G, Couñago F. Total neoadjuvant therapy for locally advanced rectal cancer: a narrative review. Future Oncol 2023; 19:1753-1768. [PMID: 37650764 DOI: 10.2217/fon-2023-0481] [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] [Indexed: 09/01/2023] Open
Abstract
Locally advanced rectal cancer has traditionally been treated with chemoradiotherapy (CRT) followed by surgery and adjuvant chemotherapy. However, a new strategy, total neoadjuvant therapy, involves the administration of CRT and neoadjuvant chemotherapy with the aim of eradicating micrometastases earlier and achieving greater control of the disease. The use of total neoadjuvant therapy has shown higher rates of pathological complete response and resectability compared with CRT, including improved survival. Nevertheless, distant relapse is the main cause of morbidity and mortality in locally advanced rectal cancer. To address this, new biomarkers are being developed to predict disease response.
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Affiliation(s)
- Elías Gomis Sellés
- Department of Radiation Oncology, University Hospital Virgen del Rocío, Biomedical Institute of Seville (IBIS)/CSIC/University of Seville, Seville, 41013, Spain
| | | | - Paula Peleteiro Higuero
- Department of Radiation Oncology, University Hospital Santiago de Compostela, 15706, Santiago de Compostela, Spain
| | | | | | | | - Raquel Fuentes Mateos
- Department of Medical Oncology, University Hospital Ramón y Cajal, Madrid, 28034, Spain
| | - Fernando Lopez Campos
- Radiation Oncology Department, University Hospital Ramon y Cajal, Madrid, 28034, Spain
| | - Ana Aurora Díaz-Gavela
- Quironsalud Madrid University Hospital, Radiation Therapy Department, Medicine Department, School of Biomedical Sciences, Universidad Europea, Madrid, 28223, Spain
| | - Gustavo Ferraris
- Radiotherapy Unit, Centro de Radioterapia Dean Funes, Córdoba, X5003 CVY, Argentina
| | - Felipe Couñago
- San Francisco de Asís and La Milagrosa Hospitals, GenesisCare, Madrid, 28002, Spain
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42
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Dalby M, Nabhani-Gebara S. Editorial: Impact of COVID-19 on cancer care and rehabilitation. FRONTIERS IN REHABILITATION SCIENCES 2023; 4:1257427. [PMID: 37588001 PMCID: PMC10425539 DOI: 10.3389/fresc.2023.1257427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 07/21/2023] [Indexed: 08/18/2023]
Affiliation(s)
- Melanie Dalby
- Department of Pharmacy, King’s College Hospital NHS Foundation Trust, London, United Kingdom
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43
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Daprà V, Airoldi M, Bartolini M, Fazio R, Mondello G, Tronconi MC, Prete MG, D’Agostino G, Foppa C, Spinelli A, Puccini A, Santoro A. Total Neoadjuvant Treatment for Locally Advanced Rectal Cancer Patients: Where Do We Stand? Int J Mol Sci 2023; 24:12159. [PMID: 37569532 PMCID: PMC10418822 DOI: 10.3390/ijms241512159] [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: 07/03/2023] [Revised: 07/20/2023] [Accepted: 07/27/2023] [Indexed: 08/13/2023] Open
Abstract
The therapeutic landscape in locally advanced rectal cancer (LARC) has undergone a significant paradigm shift in recent years with the rising adoption of total neoadjuvant treatment (TNT). This comprehensive approach entails administering chemotherapy and radiation therapy before surgery, followed by optional adjuvant chemotherapy. To establish and deliver the optimal tailored treatment regimen to the patient, it is crucial to foster collaboration among a multidisciplinary team comprising healthcare professionals from various specialties, including medical oncology, radiation oncology, surgical oncology, radiology, and pathology. This review aims to provide insights into the current state of TNT for LARC and new emerging strategies to identify potential directions for future research and clinical practice, such as circulating tumor-DNA, immunotherapy in mismatch-repair-deficient tumors, and nonoperative management.
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Affiliation(s)
- Valentina Daprà
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy
| | - Marco Airoldi
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy
| | - Michela Bartolini
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy
| | - Roberta Fazio
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy
| | - Giuseppe Mondello
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy
| | - Maria Chiara Tronconi
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy
| | - Maria Giuseppina Prete
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy
| | - Giuseppe D’Agostino
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy
| | - Caterina Foppa
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy
| | - Alberto Puccini
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy
| | - Armando Santoro
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy
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Foppa C, Maroli A, Luberto A, La Raja C, Spaggiari P, Bonifacio C, De Zanet S, Montorsi M, Piscuoglio S, Terracciano LM, Santoro A, Spinelli A. Early Age of Onset Is an Independent Predictor for a Worse Response to Neoadjuvant Therapies in Sporadic Rectal Cancer Patients. Cancers (Basel) 2023; 15:3750. [PMID: 37509411 PMCID: PMC10378654 DOI: 10.3390/cancers15143750] [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: 05/30/2023] [Revised: 07/15/2023] [Accepted: 07/20/2023] [Indexed: 07/30/2023] Open
Abstract
The incidence of rectal cancer (RC) is increasing in the population aged ≤ 49 (early-onset RC-EORC). EORC patients are more likely to present with locally advanced disease at diagnosis than late-onset RC (LORC; aged ≥ 50) patients. As a consequence, more EORC patients undergo neoadjuvant therapies. The response to treatment in EORC patients is still unknown. This study aims to explore the effect of age of onset on the pathological response to neoadjuvant therapies in sporadic locally advanced RC (LARC) patients. Based on an institutional prospectively maintained database, LARC patients undergoing neoadjuvant therapies and radical surgery between January 2010 and December 2022 were allocated to the EORC and LORC groups. The primary endpoint was the rate of incomplete response (Dworak 0-2). A total of 326 LORC and 79 EORC patients were included. Pre-neoadjuvant tumor features were comparable. A significantly higher rate of incomplete response was observed in EORC patients (49% vs. 35%; p = 0.028). From multivariable analysis, early age of onset, smoking and extramural invasion presented as independent risk factors for a worse response. This study demonstrates that an early age of onset is related to a worse response and calls for different multimodal strategies in this group of patients.
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Affiliation(s)
- Caterina Foppa
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
| | - Annalisa Maroli
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
| | - Antonio Luberto
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
| | - Carlotta La Raja
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
| | - Paola Spaggiari
- Division of Pathology, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
| | - Cristiana Bonifacio
- Division of Diagnostic Radiology, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
| | - Stefano De Zanet
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
| | - Marco Montorsi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy
- Division of General and Digestive Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
| | - Salvatore Piscuoglio
- Institute of Medical Genetics and Pathology, University Hospital Basel, University of Basel, 4001 Basel, Switzerland
- Department of Biomedicine, University Hospital Basel, University of Basel, 4001 Basel, Switzerland
| | - Luigi Maria Terracciano
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy
- Division of Pathology, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
| | - Armando Santoro
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy
- Division of Medical Oncology and Hematology, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
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45
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Xu Z, Valente MA, Sklow B, Liska D, Gorgun E, Kessler H, Rosen DR, Steele SR. Impact of Total Neoadjuvant Therapy on Postoperative Outcomes After Proctectomy for Rectal Cancer. Dis Colon Rectum 2023; 66:1022-1028. [PMID: 36538720 DOI: 10.1097/dcr.0000000000002555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Total neoadjuvant therapy is an alternative to neoadjuvant chemoradiation alone for rectal cancer and has the benefits of more completion of planned therapy, increased downstaging, earlier treatment of micrometastases, and assessment of chemosensitivity; however, it may increase surgical complications, especially with increased radiation-to-surgery interval. OBJECTIVE The study aimed to determine the impact of total neoadjuvant therapy on postoperative complications compared with neoadjuvant chemoradiation alone. DESIGN Retrospective cohort study. SETTINGS Single tertiary referral center. PATIENTS The patient included was a stage II/III rectal cancer patient who underwent total neoadjuvant therapy or long-course neoadjuvant chemoradiation followed by surgical resection from 2018-2020. MAIN OUTCOME MEASURES The main outcome measures included severe postoperative complications (Clavien-Dindo grade ≥3). RESULTS Of 181 patients, 86 (47.5%) underwent total neoadjuvant therapy and 95 (52.5%) underwent neoadjuvant chemoradiation. There was no difference in severe postoperative complications or any complications. There was also no difference in the rate of complete total mesorectal excision or negative circumferential margin. Total neoadjuvant therapy had a mean operative time of 355.5 minutes and estimated blood loss of 263.6 mL compared with 326.7 minutes and 297.5 mL in the neoadjuvant chemoradiation group. Total neoadjuvant therapy patients had a lower mean lymph node yield than neoadjuvant chemoradiation patients. On multivariable analysis, total neoadjuvant therapy was associated with increased operative time (OR, 1.19; p < 0.001) and estimated blood loss (OR, 1.22; p < 0.001) and decreased lymph node yield (OR, 0.67; p < 0.001). There was no difference in severe complications or any complications. LIMITATIONS Selection bias uncontrolled by modeling. CONCLUSIONS We found no difference in risk of postoperative complications between patients who received total neoadjuvant therapy vs neoadjuvant chemoradiation. Total neoadjuvant therapy patients had longer operations and greater estimated blood loss. This may be a reflection of increased operative difficulty because of increased radiation-to-surgery interval and/or the effects of chemotherapy; however, the absolute differences were small and, therefore, should be interpreted cautiously. See Video Abstract at http://links.lww.com/DCR/C44 . IMPACTO DE LA TERAPIA NEOADYUVANTE TOTAL EN LOS RESULTADOS POSOPERATORIOS DESPUS DE UNA PROCTECTOMA POR CNCER DE RECTO ANTECEDENTES:La terapia neoadyuvante total es una alternativa a la quimiorradiación neoadyuvante sola para el cáncer de recto y tiene los beneficios de una mayor finalización de la terapia planificada, mayor reducción del estadiage, tratamiento más temprano de las micrometástasis y evaluación de la quimiosensibilidad; sin embargo, puede aumentar las complicaciones quirúrgicas, especialmente con un mayor intervalo entre la radiación y la cirugía.OBJETIVO:Determinar el impacto de la terapia neoadyuvante total sobre las complicaciones posoperatorias en comparación con la quimiorradiación neoadyuvante sola.DISEÑO:Estudio de cohorte retrospectivo.ENTORNO CLINICO:Centro único de referencia terciario.PACIENTES:Paciente con cáncer de recto en estadio II/III que se sometieron a terapia neoadyuvante total o quimiorradiación neoadyuvante de larga duración seguida de resección quirúrgica entre 2018 y 2020.PRINCIPALES MEDIDAS DE RESULTADO:Complicaciones postoperatorias graves (grado de Clavien-Dindo ≥3).RESULTADOS:De 181 pacientes, 86 (47,5%) se sometieron a terapia neoadyuvante total y 95 (52,5%) se sometieron a quimiorradioterapia neoadyuvante. No hubo diferencia en las complicaciones postoperatorias graves o cualquier otra complicación. Tampoco hubo diferencia en la tasa de escisión mesorrectal total completa o margen circunferencial negativo. La terapia neoadyuvante total tuvo un tiempo operatorio promedio de 355,5 minutos y una pérdida de sangre estimada de 263,6 ml en comparación con 326,7 minutos y 297,5 ml en el grupo de quimiorradiación neoadyuvante. Los pacientes con terapia neoadyuvante total tuvieron una media de ganglios linfáticos más bajo en comparación con los pacientes con quimiorradioterapia neoadyuvante. En el análisis multivariable, la terapia neoadyuvante total se asoció con un mayor tiempo operatorio (OR = 1,19, p < 0,001) y pérdida de sangre estimada (OR = 1,22, p < 0,001) y menor cantidad los ganglios linfáticos (OR = 0,67, p < 0,001). No hubo diferencia en las complicaciones graves o cualquier complicación.LIMITACIONES:Sesgo de selección no controlado por modelado.CONCLUSIONES:No encontramos diferencias en el riesgo de complicaciones postoperatorias entre los pacientes que recibieron terapia neoadyuvante total versus quimiorradiación neoadyuvante. Los pacientes con terapia neoadyuvante total tuvieron operaciones más prolongadas y una mayor pérdida de sangre estimada. Esto puede ser un reflejo de una mayor dificultad quirúrgica como resultado de un mayor intervalo entre la radiación y la cirugía y/o los efectos de la quimioterapia; sin embargo, las diferencias absolutas fueron pequeñas y, por lo tanto, deben interpretarse con cautela. Consulte Video Resumen en http://links.lww.com/DCR/C44 . (Traducción- Dr. Francisco M. Abarca-Rendon ).
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Affiliation(s)
- Zhaomin Xu
- Department of Colorectal Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, Ohio
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Liscu HD, Liscu BR, Mitre R, Anghel IV, Antone-Iordache IL, Balan A, Coniac S, Miron AI, Halcu G. The Conditioning of Adjuvant Chemotherapy for Stage II and III Rectal Cancer Determined by Postoperative Pathological Characteristics in Romania. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1224. [PMID: 37512037 PMCID: PMC10384917 DOI: 10.3390/medicina59071224] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 06/17/2023] [Accepted: 06/28/2023] [Indexed: 07/30/2023]
Abstract
The management of locally advanced rectal cancer (LARC) suffered changes thanks to the development of improved surgical procedures, radiation delivery, and chemotherapy. Although treatment options improved individually, the optimal order is still debated. Neoadjuvant chemo-radiotherapy followed by total mesorectal excision (TME) has been the "golden standard" for locally advanced rectal cancer. There is no common ground in international guidelines on the indications of adjuvant chemotherapy (ADJCHT), with differences between the American, European, and Japanese guidelines. This paper studies the preferences of Romanian oncologists in prescribing ADJCHT. We conducted a single-institution, retrospective study of all nonmetastatic, ECOG 0-1 LARC patients staged II-III who underwent TME and were admitted to the Oncology or Radiotherapy Department of Colțea Clinical Hospital, Bucharest between January 2017 and March 2021. A total of 186 patients were included in the study. A positive correlation was found between ADJCHT and each of the following: (y)pT > 2, (y)pN > 0, and the presence of perineural invasion (PNI+). A strong positive correlation was found between ADJCHT and the presence of at least one risk factor: (y)pT > 2, (y)pN > 0, PNI+, lymphovascular invasion, positive margins, or tumor grade > 1. Tumor downstaging decreased the risk of metastases in the first 2 years and was associated with the use of neoadjuvant radiotherapy, while adding neoadjuvant chemotherapy increased the chance of nodal downstaging. ADJCHT practice for LARC in Romania follows either NCCN or ESMO guidelines, at the discretion of the oncologist, due to the lack of national guideline.
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Affiliation(s)
- Horia-Dan Liscu
- Discipline of Oncological Radiotherapy and Medical Imaging, University of Medicine and Pharmacy "Carol Davila", 020021 Bucharest, Romania
- Radiotherapy Department, Colțea Clinical Hospital, 030167 Bucharest, Romania
| | - Bogdan-Radu Liscu
- Radiotherapy Department, Colțea Clinical Hospital, 030167 Bucharest, Romania
| | - Ruxandra Mitre
- Medical Oncology Department, Colțea Clinical Hospital, 030167 Bucharest, Romania
| | - Ioana-Valentina Anghel
- Discipline of Oncological Radiotherapy and Medical Imaging, University of Medicine and Pharmacy "Carol Davila", 020021 Bucharest, Romania
| | - Ionut-Lucian Antone-Iordache
- Discipline of Oncological Radiotherapy and Medical Imaging, University of Medicine and Pharmacy "Carol Davila", 020021 Bucharest, Romania
| | - Andrei Balan
- Discipline of Oncological Radiotherapy and Medical Imaging, University of Medicine and Pharmacy "Carol Davila", 020021 Bucharest, Romania
| | - Simona Coniac
- Medical Oncology Department, Colțea Clinical Hospital, 030167 Bucharest, Romania
| | - Andreea-Iuliana Miron
- Discipline of Oncological Radiotherapy and Medical Imaging, University of Medicine and Pharmacy "Carol Davila", 020021 Bucharest, Romania
- Medical Oncology Department, Colțea Clinical Hospital, 030167 Bucharest, Romania
| | - Georgian Halcu
- Discipline of Pathological Anatomy, University of Medicine and Pharmacy "Carol Davila", 020021 Bucharest, Romania
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Mantello G, Galofaro E, Caravatta L, Di Carlo C, Montrone S, Arpa D, Chiloiro G, De Paoli A, Donato V, Gambacorta MA, Genovesi D, Lupattelli M, Macchia G, Montesi G, Niespolo RM, Palazzari E, Pontoriero A, Scricciolo M, Valvo F, Franco P. Pattern of care for re-irradiation in locally recurrent rectal cancer: a national survey on behalf of the AIRO gastrointestinal tumors study group. LA RADIOLOGIA MEDICA 2023:10.1007/s11547-023-01652-3. [PMID: 37365381 DOI: 10.1007/s11547-023-01652-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 05/25/2023] [Indexed: 06/28/2023]
Abstract
PURPOSE Radical resection (R0) represents the best curative treatment for local recurrence (LR) rectal cancer. Re-irradiation (re-RT) can increase the rate of R0 resection. Currently, there is a lack of guidelines on Re-RT for LR rectal cancer. The Italian Association of Radiation and clinical oncology for gastrointestinal tumors (AIRO-GI) study group released a national survey to investigate the current clinical practice of external beam radiation therapy in these patients. MATERIAL AND METHODS In February 2021, the survey was designed and distributed to members of the GI working group. The questionnaire consisted of 40 questions regarding center characteristics, clinical indications, doses, and treatment techniques of re-RT for LR rectal cancer. RESULTS A total of 37 questionnaires were collected. Re-RT was reported as an option for neoadjuvant treatment in resectable and unresectable disease by 55% and 75% of respondents, respectively. Long-course treatment with 30-40 Gy (1.8-2 Gy/die, 1.2 Gy bid) and hypofractionated regimen of 30-35 Gy in 5 fractions were used in most centers. A total dose of 90-100 Gy as EqD2 dose (α/β = 5 Gy) was delivered by 46% of the respondents considering the previous treatment. Modern conformal techniques and daily image-guided radiation therapy protocols were used in 94% of centers. CONCLUSION Our survey showed that re-RT treatment is performed with advanced technology that allow a good management of LR rectal cancer. Significant variations were observed in terms of dose and fractionation, highlighting the need for a consensus on a common treatment strategy that could be validated in prospective studies.
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Affiliation(s)
- Giovanna Mantello
- Radiotherapy Department, Azienda Ospedaliero Universitaria delle Marche, Via Conca 71, 60126, Ancona, Italy
| | - Elena Galofaro
- Radiotherapy Department, Azienda Ospedaliero Universitaria delle Marche, Via Conca 71, 60126, Ancona, Italy.
| | - Luciana Caravatta
- Department of Radiation Oncology, SS Annunziata Hospital, Chieti, Italy
| | - Clelia Di Carlo
- Radiotherapy Department, Azienda Ospedaliero Universitaria delle Marche, Via Conca 71, 60126, Ancona, Italy
| | | | - Donatella Arpa
- IRCCS Istituto Scientifico Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Radiotherapy Unit, Meldola, Italy
| | - Giuditta Chiloiro
- Departments of Radiation Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Antonino De Paoli
- Division of Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Vittorio Donato
- Radiation Oncology Division, Oncology and Speciality Medicine Department, San Camillo-Forlanini Hospital, Rome, Italy
| | | | - Domenico Genovesi
- Department of Radiation Oncology, SS Annunziata Hospital, Chieti, Italy
| | - Marco Lupattelli
- Radiation Oncology Section, University of Perugia and Perugia General Hospital, Perugia, Italy
| | - Gabriella Macchia
- Radiotherapy Unit, Gemelli Molise Hospital, Catholic University of Sacred Heart, Campobasso, Italy
| | | | | | - Elisa Palazzari
- Division of Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Antonio Pontoriero
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Melissa Scricciolo
- UOC di Radioterapia Oncologica Mestre, Ospedale dell'Angelo, Venice, Mestre, Italy
| | - Francesca Valvo
- Fondazione CNAO, National Center of Oncological Hadrontherapy, Pavia, Italy
| | - Pierfrancesco Franco
- Department of Translational Medicine, Department of Radiation Oncology, Maggiore Della Carità University Hospital, University of Eastern Piedmont, Novara, Italy
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Verweij ME, Tanaka MD, Kensen CM, van der Heide UA, Marijnen CAM, Janssen T, Vijlbrief T, van Grevenstein WMU, Moons LMG, Koopman M, Lacle MM, Braat MNGJA, Chalabi M, Maas M, Huibregtse IL, Snaebjornsson P, Grotenhuis BA, Fijneman R, Consten E, Pronk A, Smits AB, Heikens JT, Eijkelenkamp H, Elias SG, Verkooijen HM, Schoenmakers MMC, Meijer GJ, Intven M, Peters FP. Towards Response ADAptive Radiotherapy for organ preservation for intermediate-risk rectal cancer (preRADAR): protocol of a phase I dose-escalation trial. BMJ Open 2023; 13:e065010. [PMID: 37321815 PMCID: PMC10277084 DOI: 10.1136/bmjopen-2022-065010] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 05/07/2023] [Indexed: 06/17/2023] Open
Abstract
INTRODUCTION Organ preservation is associated with superior functional outcome and quality of life (QoL) compared with total mesorectal excision (TME) for rectal cancer. Only 10% of patients are eligible for organ preservation following short-course radiotherapy (SCRT, 25 Gy in five fractions) and a prolonged interval (4-8 weeks) to response evaluation. The organ preservation rate could potentially be increased by dose-escalated radiotherapy. Online adaptive magnetic resonance-guided radiotherapy (MRgRT) is anticipated to reduce radiation-induced toxicity and enable radiotherapy dose escalation. This trial aims to establish the maximum tolerated dose (MTD) of dose-escalated SCRT using online adaptive MRgRT. METHODS AND ANALYSIS The preRADAR is a multicentre phase I trial with a 6+3 dose-escalation design. Patients with intermediate-risk rectal cancer (cT3c-d(MRF-)N1M0 or cT1-3(MRF-)N1M0) interested in organ preservation are eligible. Patients are treated with a radiotherapy boost of 2×5 Gy (level 0), 3×5 Gy (level 1), 4×5 Gy (level 2) or 5×5 Gy (level 3) on the gross tumour volume in the week following standard SCRT using online adaptive MRgRT. The trial starts on dose level 1. The primary endpoint is the MTD based on the incidence of dose-limiting toxicity (DLT) per dose level. DLT is a composite of maximum one in nine severe radiation-induced toxicities and maximum one in three severe postoperative complications, in patients treated with TME or local excision within 26 weeks following start of treatment. Secondary endpoints include the organ preservation rate, non-DLT, oncological outcomes, patient-reported QoL and functional outcomes up to 2 years following start of treatment. Imaging and laboratory biomarkers are explored for early response prediction. ETHICS AND DISSEMINATION The trial protocol has been approved by the Medical Ethics Committee of the University Medical Centre Utrecht. The primary and secondary trial results will be published in international peer-reviewed journals. TRIAL REGISTRATION NUMBER WHO International Clinical Trials Registry (NL8997; https://trialsearch.who.int).
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Affiliation(s)
- Maaike E Verweij
- Department of Radiation-Oncology, University Medical Centre Utrecht, Utrecht, The Netherlands
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Max D Tanaka
- Department of Radiation-Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Chavelli M Kensen
- Department of Radiation-Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Uulke A van der Heide
- Department of Radiation-Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Corrie A M Marijnen
- Department of Radiation-Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Tomas Janssen
- Department of Radiation-Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Tineke Vijlbrief
- Department of Radiation-Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Leon M G Moons
- Department of Gastroenterology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Miriam Koopman
- Department of Medical Oncology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Miangela M Lacle
- Department of Pathology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Manon N G J A Braat
- Department of Radiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Myriam Chalabi
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Monique Maas
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Inge L Huibregtse
- Department of Gastroenterology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Petur Snaebjornsson
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Remond Fijneman
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Esther Consten
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - Apollo Pronk
- Department of Surgery, Diakonessenhuis Utrecht Zeist Doorn, Utrecht, The Netherlands
| | - Anke B Smits
- Department of Surgery, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Joost T Heikens
- Department of Surgery, Hospital Rivierenland, Tiel, The Netherlands
| | - Hidde Eijkelenkamp
- Department of Radiation-Oncology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Sjoerd G Elias
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Helena M Verkooijen
- Department of Radiation-Oncology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | | | - Gert J Meijer
- Department of Radiation-Oncology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Martijn Intven
- Department of Radiation-Oncology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Femke P Peters
- Department of Radiation-Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
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Wu Q, Zhou J, Huang J, Deng X, Li C, Meng W, He Y, Wang Z. Total neoadjuvant therapy versus chemoradiotherapy for locally advanced rectal cancer: Bayesian network meta-analysis. Br J Surg 2023; 110:784-796. [PMID: 37191308 DOI: 10.1093/bjs/znad120] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 03/08/2023] [Accepted: 03/23/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Total neoadjuvant therapy is a promising treatment for locally advanced rectal cancer, utilizing either short-course radiotherapy or long-course chemoradiotherapy, but their relative efficacy remains unclear. The aim of this Bayesian network meta-analysis was to investigate clinical outcomes amongst patients receiving total neoadjuvant therapy with short-course radiotherapy or long-course chemoradiotherapy, and those receiving long-course chemoradiotherapy alone. METHODS A systematic literature search was performed. All studies that compared at least two of these three treatments for locally advanced rectal cancer were included. The primary endpoint was the pathological complete response rate, and survival outcomes were adopted as secondary outcomes. RESULTS Thirty cohorts were included. Compared with long-course chemoradiotherapy, both total neoadjuvant therapy with long-course chemoradiotherapy (OR 1.78, 95 per cent c.i. 1.43 to 2.26) and total neoadjuvant therapy with short-course radiotherapy (OR 1.75, 95 per cent c.i. 1.23 to 2.50) improved the pathological complete response rate. Similar benefits were observed in the sensitivity and subgroup analyses, except for short-course radiotherapy with one to two cycles of chemotherapy. No significant differences in survival outcomes were found amongst the three treatments. Long-course chemoradiotherapy with consolidation chemotherapy (HR 0.44, 95 per cent c.i. 0.20 to 0.99) exhibited higher disease-free survival than long-course chemoradiotherapy alone. CONCLUSION Compared with long-course chemoradiotherapy, both short-course radiotherapy with greater than or equal to three cycles of chemotherapy and total neoadjuvant therapy with long-course chemoradiotherapy can improve the pathological complete response rate, and long-course chemoradiotherapy with consolidation chemotherapy may lead to a marginal benefit in disease-free survival. The pathological complete response rate and survival outcomes are similar for total neoadjuvant therapy with short-course radiotherapy or long-course chemoradiotherapy.
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Affiliation(s)
- Qingbin Wu
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
- Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Jiahao Zhou
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
- Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Jun Huang
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
- Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Xiangbing Deng
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
- Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Changtao Li
- Department of Epidemiology and Medical Statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Wenjian Meng
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
- Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yazhou He
- Department of Oncology, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Ziqiang Wang
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
- Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
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50
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Verweij ME, Franzen J, van Grevenstein WMU, Verkooijen HM, Intven MPW. Timing of rectal cancer surgery after short-course radiotherapy: national database study. Br J Surg 2023; 110:839-845. [PMID: 37172197 PMCID: PMC10364516 DOI: 10.1093/bjs/znad113] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 02/13/2023] [Accepted: 03/29/2023] [Indexed: 05/14/2023]
Abstract
BACKGROUND Previous randomized trials found that a prolonged interval between short-course radiotherapy (SCRT, 25 Gy in 5 fractions) and surgery for rectal cancer (4-8 weeks, SCRT-delay) results in a lower postoperative complication rate and a higher pCR rate than SCRT and surgery within a week (SCRT-direct surgery). This study sought to confirm these results in a Dutch national database. METHODS Patients with intermediate-risk rectal cancer (T3(mesorectal fascia (MRF)-) N0 M0 and T1-3(MRF-) N1 M0) treated with either SCRT-delay (4-12 weeks) or SCRT-direct surgery in 2018-2021 were selected from a Dutch national colorectal cancer database. Confounders were adjusted for using inverse probability of treatment weighting (IPTW). The primary endpoint was the 90-day postoperative complication rate. Secondary endpoints included the pCR rate. Endpoints were compared using log-binomial and Poisson regression. RESULTS Some 664 patients were included in the SCRT-direct surgery and 238 in the SCRT-delay group. After IPTW, the 90-day postoperative complication rate was comparable after SCRT-direct surgery and SCRT-delay (40.1 versus 42.3 per cent; risk ratio (RR) 1.1, 95 per cent c.i. 0.9 to 1.3). A pCR occurred more often after SCRT-delay than SCRT-direct surgery (10.7 versus 0.4 per cent; RR 39, 11 to 139). CONCLUSION There was no difference in surgical complication rates between SCRT-delay and SCRT-direct, but SCRT-delay was associated with more patients having a pCR.
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Affiliation(s)
- Maaike E Verweij
- Division of Imaging and Oncology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Jolien Franzen
- Division of Imaging and Oncology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | | | - Helena M Verkooijen
- Division of Imaging and Oncology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Martijn P W Intven
- Division of Imaging and Oncology, University Medical Centre Utrecht, Utrecht, the Netherlands
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