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Doroudian S, Osterman E, Glimelius B. Risk Factors for Recurrence After Surgery for Rectal Cancer in a Modern, Nationwide Population-Based Cohort. Ann Surg Oncol 2024:10.1245/s10434-024-15552-x. [PMID: 38853216 DOI: 10.1245/s10434-024-15552-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 05/16/2024] [Indexed: 06/11/2024]
Abstract
BACKGROUND The success of modern multimodal treatment in rectal cancer is dependent on risk prediction. Better knowledge of the risk of locoregional and distant recurrence, in relation to preoperative treatment, pathological stage, and commonly used risk factors, is needed when deciding on adjuvant therapy and surveillance. METHODS The Swedish ColoRectal Cancer Registry was used to identify patients diagnosed with rectal adenocarcinoma between 2011 and 2018. Readily available variables, including patient, tumor, and treatment factors were exposures. Cox proportional hazard models were used to identify important risk factors for recurrence and calculate recurrence risks. RESULTS A total of 9428 curatively resected patients were included and followed for a median of 72 months. Eighteen percent had distal recurrence and 3% had locoregional recurrence at 5 years. Risk factors with major impact on distal recurrence were pT4a (hazard ratio [HR] 5.1, 95% confidence interval [CI] 3.3-8.0), pN2b (HR 3.4, 95% CI 2.7-4.2), tumor deposit (HR 1.7, 95% CI 1.5-1.9), lymph node yield (HR 1.5, 95% CI 1.3-1.8), and tumor level 0-5 cm (HR 1.5, 95% CI 1.3-1.8). Pathologic stage and number of risk factors identified groups with markedly different recurrence risks in all neoadjuvant treatment groups. CONCLUSIONS Readily available risk factors, as a complement to stage, are still valid and robust in all neoadjuvant treatment groups. Tumor deposit is important, while circumferential resection margin might no longer be important with improved oncological treatments and high-quality TME surgery. Tailored surveillance is possible in selected groups using risk stratification based on stage and risk factors.
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Affiliation(s)
- Sepehr Doroudian
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden.
- Center for Research and Development, Uppsala University/Region Gävleborg, Gävle, Sweden.
- Department of Surgery, Gävle County Hospital, Gävle, Sweden.
| | - Erik Osterman
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
- Department of Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Bengt Glimelius
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
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Barzola E, Cornejo L, Gómez N, Pigem A, Julià D, Ortega N, Delisau O, Bobb KA, Farrés R, Planellas P. Comparative analysis of short-term outcomes and oncological results between robotic-assisted and laparoscopic surgery for rectal cancer by multiple surgeon implementation: a propensity score-matched analysis. J Robot Surg 2023; 17:3013-3023. [PMID: 37924415 DOI: 10.1007/s11701-023-01736-2] [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: 07/27/2023] [Accepted: 09/26/2023] [Indexed: 11/06/2023]
Abstract
Robotic-assisted surgery (RAS) is becoming increasingly common for the surgical treatment of rectal cancer. However, the use and implementation of robotic surgery remains controversial. This study aimed to compare the short-term outcomes of robotic surgery, focusing on pathological results and disease-free survival (DFS), in our cohort with initial robotic experience by multiple surgeon implementation. This retrospective study enrolled 571 patients diagnosed with rectal cancer, who were treated with chemoradiotherapy and surgery between January 2015 and December 2021. Surgical outcomes after RAS and laparoscopic surgery (LS) were compared using a propensity score-matching (PSM) analysis. After matching, 200 patients (100 in each group) were included. The median operative time was significantly longer in the RAS group than in the LS group (p < 0.001). The conversion and morbidity rates were similar between the groups. A significantly higher rate of complete mesorectal excision (92% vs. 72%; p = 0.001) and number of lymph nodes harvested (p = 0.009) was observed in the RAS group. There were no statistically significant differences between the groups regarding circumferential and distal resection margin involvement. The 3-year overall and disease-free survival rate was similar between the two groups (p = 0.849 and p = 0.582, respectively). Two patients in the LS group developed local recurrence and 27 patients (15.4%) developed metastatic disease. Multivariate analysis showed that tumor stage III was the only factor associated with disease-free survival (HR, 9.34; (95% CI 1.13-77.1), p = 0.038). RAS and LS showed similar outcomes in terms of perioperative, anatomopathological, and disease-free survival, after multiple surgeon implementations.
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Affiliation(s)
- E Barzola
- Colorectal Surgery Unit, Department of General and Digestive Surgery, University Hospital of Girona, Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - L Cornejo
- Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - N Gómez
- Colorectal Surgery Unit, Department of General and Digestive Surgery, University Hospital of Girona, Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - A Pigem
- Colorectal Surgery Unit, Department of General and Digestive Surgery, University Hospital of Girona, Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - D Julià
- Colorectal Surgery Unit, Department of General and Digestive Surgery, University Hospital of Girona, Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - N Ortega
- Colorectal Surgery Unit, Department of General and Digestive Surgery, University Hospital of Girona, Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - O Delisau
- Colorectal Surgery Unit, Department of General and Digestive Surgery, University Hospital of Girona, Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - K A Bobb
- Department of Clinical Surgical Sciences, Faculty of Medical Sciences, University of the West Indies-St. Augustine, Eric Williams Medical Sciences Complex, Mount Hope, Trinidad, West Indies, Trinidad and Tobago
| | - R Farrés
- Colorectal Surgery Unit, Department of General and Digestive Surgery, University Hospital of Girona, Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - P Planellas
- Colorectal Surgery Unit, Department of General and Digestive Surgery, University Hospital of Girona, Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona Biomedical Research Institute (IDIBGI), Girona, Spain.
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Naffouje SA, Manguso N, Imanirad I, Sahin IH, Xie H, Hoffe S, Frakes J, Sanchez J, Dessureault S, Felder S. Neoadjuvant rectal score is prognostic for survival: A population-based propensity-matched analysis. J Surg Oncol 2022; 126:1219-1231. [PMID: 35916542 DOI: 10.1002/jso.27020] [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: 06/16/2022] [Accepted: 07/09/2022] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Neoadjuvant rectal (NAR) score may serve as a surrogate short-term endpoint for overall survival (OS) in clinical trials. This study aims to test the NAR score using a large, national cancer registry. METHODS National Cancer Database patients with clinical stage II/III rectal adenocarcinoma (RAC) treated with neoadjuvant chemoradiation (CRT) followed by surgery were selected and divided into low-, intermediate-, and high-NAR subgroups. OS outcomes were analyzed using Kaplan-Meier and logistic regression models. RESULTS A total of 12 452 patients were selected, of which 5071 (40.7%) were in clinical stage II and 7381 (59.3%) were in clinical stage III; 15.2% had pathologic complete response. The mean NAR score was 10.01 ± 10.61. Six thousand nine hundred and forty-one (55.7%) did not receive adjuvant chemotherapy (AC) and were propensity-matched across NAR subgroups (966 in each group). A significant difference in 5-year OS between low-, intermediate-, and high-NAR groups was observed (85% vs. 76% vs. 68%; p < 0.001). Five thousand five hundred and eleven (44.3%) received AC and 1045 triplets were propensity-matched per NAR groups. A significant difference was again observed for 5-year OS (93% vs. 88% vs. 75%; p < 0.001). Logistic regression confirmed NAR strata as a significant predictor of 5-year OS. CONCLUSION NAR score, as a neoadjuvant response measure, is a strong predictor of 5-year OS, regardless of AC receipt in a heterogenous population of locally advanced RAC patients.
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Affiliation(s)
- Samer A Naffouje
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Nicholas Manguso
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Iman Imanirad
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Ibrahim H Sahin
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Hao Xie
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Sarah Hoffe
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Jessica Frakes
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Julian Sanchez
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Sophie Dessureault
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Seth Felder
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida, USA
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A nomogram for predicting good response after neoadjuvant chemoradiotherapy for locally advanced rectal cancer: a retrospective, double-center, cohort study. Int J Colorectal Dis 2022; 37:2157-2166. [PMID: 36048198 PMCID: PMC9560928 DOI: 10.1007/s00384-022-04247-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/24/2022] [Indexed: 02/04/2023]
Abstract
AIM The purpose of this study was to explore the clinical factors associated with achieving good response after neoadjuvant chemoradiotherapy (nCRT) in patients with locally advanced rectal cancer (LARC) and to develop and validate a nomogram. METHODS A total of 1724 consecutive LARC patients treated at Fujian Medical University Union Hospital from January 2010 to December 2021 were retrospectively evaluated as the training cohort; 267 consecutive LARC patients treated at Zhangzhou Affiliated Hospital of Fujian Medical University during the same period were evaluated as the external 2 cohorts. Based on the pathological results after radical surgery, treatment response was defined as follows: good response, stage ypT0∼2N0M0 and poor response, ypT3∼4N0M0 and/or N positive. Independent influencing factors were analyzed by logistic regression, a nomogram was developed and validated, and the model was evaluated using internal and external data cohorts for validation. RESULTS In the training cohort, 46.6% of patients achieved good response after nCRT combined with radical surgery. The rate of the retained anus was higher in the good response group (93.5% vs. 90.7%, P < 0.001). Cox regression analysis showed that the risk of overall survival and disease-free survival was significantly lower among good response patients than poor response patients, HR = 0.204 (95%CI: 0.146-0.287). Multivariate logistic regression analysis showed an independent association with 9 clinical factors, including histopathology, and a nomogram with an excellent predictive response was developed accordingly. The C-index of the predictive accuracy of the nomogram was 0.764 (95%CI: 0.742-0.786), the internal validation of the 200 bootstrap replication mean C-index was 0.764, and the external validation cohort showed an accuracy C-index of 0.789 (95%CI: 0.734-0.844), with good accuracy of the model. CONCLUSION We identified factors associated with achieving good response in LARC after treatment with nCRT and developed a nomogram to contribute to clinical decision-making.
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Aryan M, Read T, Goldstein L, Burriss N, Grajo JR, Moser P, George TJ, Tan S, Iqbal A. Utility of Restaging MRI Following Neoadjuvant Chemoradiotherapy for Stage II-III Rectal Adenocarcinoma. Cureus 2021; 13:e19037. [PMID: 34858737 PMCID: PMC8612598 DOI: 10.7759/cureus.19037] [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] [Accepted: 10/25/2021] [Indexed: 11/12/2022] Open
Abstract
Background Magnetic resonance imaging (MRI) is currently utilized for the pretreatment staging of locally advanced rectal cancer; however, there is no consensus regarding the utility of repeat MRI for restaging following neoadjuvant chemoradiotherapy (CRT). In this study, we aimed to investigate the clinical utility of restaging MRI after CRT in patients with clinical stage II-III rectal cancer. Methodology We performed a retrospective observational study at a tertiary care hospital. Our study population included patients with clinical stage II-III rectal cancer treated with neoadjuvant CRT who underwent both pre- and post-CRT MRI followed by surgical resection from 2012 to 2017. MRIs were reviewed by radiologists with an interest in rectal cancer MRI imaging using a standardized template. The utility of post-CRT MRI was evaluated by assessing its impact on change in surgical planning, concordance with pathologic staging, and prediction of surgical margins. Results A total of 30 patients were included in the study; 67% had clinical stage III and 33% had stage II disease based on pre-CRT MRI. Post-CRT MRI findings did not lead to a change in the originally outlined surgical plan in any patient. Compared to pre-CRT MRI, post-CRT MRI was not significantly more accurate in predicting T stage (k = 0.483), N stage (k = 0.268), or positive surgical margins (k = 0.839). Conclusions Due to poor concordance with pathologic staging, inability to more accurately predict surgical margin status and the absence of a demonstrable change in surgical treatment, post-CRT restaging with MRI, in its current form, appears to be of limited clinical utility.
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Affiliation(s)
- Mahmoud Aryan
- Department of Surgery, University of Florida College of Medicine, Gainesville, USA
| | - Thomas Read
- Department of Surgery, University of Florida College of Medicine, Gainesville, USA
| | - Lindsey Goldstein
- Department of Surgery, University of Florida College of Medicine, Gainesville, USA
| | - Nathan Burriss
- Department of Surgery, University of Florida College of Medicine, Gainesville, USA
| | - Joseph R Grajo
- Department of Radiology, University of Florida College of Medicine, Gainesville, USA
| | - Patricia Moser
- Department of Radiology, University of Florida College of Medicine, Gainesville, USA
| | - Thomas J George
- Department of Hematology and Oncology, University of Florida College of Medicine, Gainesville, USA
| | - Sanda Tan
- Department of Surgery, University of Florida College of Medicine, Gainesville, USA
| | - Atif Iqbal
- Department of Surgery, University of Florida College of Medicine, Gainesville, USA
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Bong JW, Ju Y, Seo J, Lee JA, Kang SH, Lee SI, Min BW. Clinical characteristics of rectal cancer patients with neoadjuvant chemoradiotherapy: a nationwide population-based cohort study in South Korea. Ann Surg Treat Res 2021; 100:282-290. [PMID: 34012946 PMCID: PMC8103159 DOI: 10.4174/astr.2021.100.5.282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/12/2021] [Accepted: 02/26/2021] [Indexed: 01/04/2023] Open
Abstract
Purpose Neoadjuvant chemoradiotherapy has been accepted as a standard treatment for stage II–III rectal cancer. This study aimed to evaluate the clinical characteristics of patients who underwent neoadjuvant chemoradiotherapy for rectal cancer and effects on overall survival (OS) of neoadjuvant chemoradiotherapy in South Korea. Methods Patients who underwent curative resection for rectal cancer from 2014 to 2016 were retrospectively reviewed from the database of the National Quality Assessment program in South Korea. Patients were categorized into the upfront surgery group and neoadjuvant chemoradiotherapy group. We evaluated factors associated with the administration of neoadjuvant chemoradiotherapy and its effects on OS. Inverse probability of treatment weighting was performed to account for baseline differences between subgroups. Results A total of 6,141 patients were categorized into the upfront surgery group (n = 4,237) and neoadjuvant chemoradiotherapy group (n = 1,904). The neoadjuvant chemoradiotherapy was more frequently administered to male, midrectal cancer, and younger patients. In the neoadjuvant chemoradiotherapy group, old age, underweight, and pathologic stage were significant risk factors of OS, and male sex, the level of tumor and clinical stages were not associated with OS. After adjustment, the OS of the neoadjuvant chemoradiotherapy group followed the OS of the upfront surgery group of the same pathologic stage. Conclusion Male sex and the level of tumor were not related to the OS of rectal cancer patients with neoadjuvant chemoradiotherapy. The OS of patients who underwent neoadjuvant chemoradiotherapy was decided by their pathologic stages regardless of clinical stages.
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Affiliation(s)
- Jun Woo Bong
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Yeonuk Ju
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jihyun Seo
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jung Ae Lee
- Department of Radiation Oncology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Sang Hee Kang
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Sun Il Lee
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Byung Wook Min
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
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Liu S, He F, Guan Y, Ju HQ, Ma Y, Li ZH, Fan XJ, Wan XB, Zheng J, Pang XL, Ma TH. Pathologic-Based Nomograms for Predicting Overall Survival and Disease-Free Survival Among Patients with Locally Advanced Rectal Cancer. Cancer Manag Res 2021; 13:1777-1789. [PMID: 33654427 PMCID: PMC7910108 DOI: 10.2147/cmar.s296593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/04/2021] [Indexed: 12/21/2022] Open
Abstract
Purpose Preoperative neoadjuvant therapy is standard before surgery for locally advanced rectal cancer in current clinical treatment. However, patients with the same clinical TNM stage before treatment vary in clinical outcomes. More and more studies noted that pathological findings after preoperative neoadjuvant therapy are better prognostic factors to determine prognosis than clinical TNM stage in patients with locally advanced rectal cancer. The purpose of this study is to develop and validate models based on pathological findings to predict overall survival (OS) and disease-free survival (DFS). Patients and Methods A total of 3026 patients from two hospitals were included. The endpoint was OS and DFS. Significant predictors of OS on multivariate analysis were used to establish the nomogram. Results The Harrell’s C index for OS prediction was 0.72 (95% confidence interval [CI], 0.68 to 0.77) in the training cohort, 0.66 (95% CI, 0.60 to 0.72) and 0.68 (95% CI, 0.64 to 0.73) in the internal and external validation cohorts. Using this nomogram, high- and low-risk groups for OS were defined in the training cohort. The 3-year OS was 78.1% (95% CI: 72.4–84.2%) for the high-risk group and 95% (95% CI: 93.6–96.5%) in the low-risk group (HR: 4.42, 95% CI: 3.22–6.05; P<0.001). This finding was also applied in the two external cohorts. Similarly, a nomogram that contained the same indices was developed and validated to predict for DFS. Conclusion Nomograms based on pathological findings are a reliable tool to predict 3-year OS and DFS rate in patients with locally advanced rectal cancer.
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Affiliation(s)
- Shuai Liu
- Department of Radiation Oncology, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, 510655, People's Republic of China
| | - Fang He
- Department of Radiation Oncology, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, 510655, People's Republic of China
| | - Ying Guan
- Department of Radiation Oncology, Affiliated Tumor Hospital of Guangxi Medical University, Cancer Institute of Guangxi Zhuang Autonomous Region, Nanning, 530000, People's Republic of China
| | - Huai-Qiang Ju
- Collaborative Innovation Center for Cancer Medicine, State Key Laboratory of Oncology in South China, Sun Yat-Sen University Cancer Center, Guangzhou, 510030, People's Republic of China
| | - Yan Ma
- Department of Radiation Oncology, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, 510655, People's Republic of China
| | - Zhen-Hui Li
- Department of Radiology, The Third Affiliated Hospital of Kunming Medical University, Yunnan Cancer Hospital, Yunnan Cancer Center, Kunming, 650118, People's Republic of China
| | - Xin-Juan Fan
- Department of Pathology, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, 510655, People's Republic of China
| | - Xiang-Bo Wan
- Department of Radiation Oncology, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, 510655, People's Republic of China
| | - Jian Zheng
- Department of Radiation Oncology, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, 510655, People's Republic of China
| | - Xiao-Lin Pang
- Department of Radiation Oncology, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, 510655, People's Republic of China
| | - Teng-Hui Ma
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangdong Institute of Gastroenterology, Guangzhou, 510655, People's Republic of China
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Lim YJ, Song C, Jeon SH, Kim K, Chie EK. Risk Stratification Using Neoadjuvant Rectal Score in the Era of Neoadjuvant Chemoradiotherapy: Validation With Long-term Outcome Data. Dis Colon Rectum 2021; 64:60-70. [PMID: 33306532 DOI: 10.1097/dcr.0000000000001777] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Despite the widespread use of neoadjuvant chemoradiotherapy, there is no prognostic surrogate marker established in locally advanced rectal cancer. OBJECTIVE This study evaluated the role of neoadjuvant rectal score as a prognostic factor to stratify individual-level risks of survival and tumor recurrence. DESIGN This is a retrospective study. SETTINGS This study was conducted at the Seoul National University Hospital. PATIENTS A total of 397 patients who underwent chemoradiotherapy plus total mesorectal excision were analyzed. INTERVENTIONS There was no intervention. MAIN OUTCOME MEASURES Harrell C statistic and receiver operating characteristic analysis, as well as Cox regression analysis, were used to assess the prognostic strength. RESULTS The low (<8), intermediate (8-16), and high (>16) neoadjuvant rectal score groups included 91 (23%), 208 (52%), and 98 patients (25%). A high neoadjuvant rectal score was independently associated with inferior overall survival and disease-free survival (p = 0.011 and 0.008). Regarding the prognostic models adjusted for neoadjuvant rectal score (I) and ypT/N stage (II), the c-index was higher in model I (0.799 and 0.787, p = 0.009 for overall survival; 0.752 and 0.743, p = 0.093 for disease-free survival). The predictive ability of the neoadjuvant rectal score was superior to tumor regression grade, ypT, and ypN in the receiver operating characteristic analyses (p < 0.05 for all). Adjuvant chemotherapy was associated with better overall and disease-free survival (p = 0.003 and 0.052) in the high neoadjuvant rectal score group. LIMITATIONS Potential selection bias attributed to the retrospective study design was a limitation. CONCLUSIONS We verified the applicability of the neoadjuvant rectal score to stratify the relapse risk at the individual level for patients with stage II/III rectal cancer undergoing neoadjuvant chemoradiotherapy. Additional studies are needed to validate the usability of neoadjuvant rectal score levels as a determinant of adjuvant strategy. See Video Abstract at http://links.lww.com/DCR/B354. ESTRATIFICACIÓN DE RIESGO UTILIZANDO LA PUNTUACIÓN RECTAL NEOADYUVANTE EN LA ERA DE LA QUIMIORRADIOTERAPIA NEOADYUVANTE: VALIDACIÓN CON DATOS DE RESULTADOS A LARGO PLAZO: A pesar del uso generalizado de la quimiorradioterapia neoadyuvante, no existe un marcador subrogado pronóstico establecido en el cáncer de recto localmente avanzado.Este estudio evaluó el papel de la puntuación rectal neoadyuvante como factor pronóstico para estratificar los riesgos a nivel individual de supervivencia y recurrencia tumoral.Este es un estudio retrospectivo.Este estudio se realizó en el Hospital de la Universidad Nacional de Seúl.Se analizaron un total de 397 pacientes que se sometieron a quimiorradioterapia más escisión mesorrectal total.No hubo intervención.El análisis estadístico C de Harrell y las características operativas del receptor, así como el análisis de regresión de Cox, se utilizaron para evaluar la fuerza pronóstica.Los grupos de puntaje rectal neoadyuvante bajo (<8), intermedio (8-16) y alto (> 16) incluyeron 91 (23%), 208 (52%) y 98 (25%) pacientes, respectivamente. Una puntuación rectal neoadyuvante alta se asoció independientemente con una supervivencia general y una supervivencia libre de enfermedad inferiores (p = 0.011 y 0.008, respectivamente). Con respecto a los modelos pronósticos ajustados por la puntuación rectal neoadyuvante (I) y el estadio ypT/N (II), el índice c fue mayor en el modelo I (0.799 y 0.787, p = 0.009 para la supervivencia general; 0.752 y 0.743, p = 0.093 para supervivencia libre de enfermedad). La capacidad predictiva de la puntuación rectal neoadyuvante fue superior al grado de regresión tumoral, ypT y ypN en los análisis de características operativas del receptor (p <0.05 para todos). La quimioterapia adyuvante se asoció con una mejor supervivencia global y libre de enfermedad (p = 0.003 y 0.052, respectivamente) en el grupo de puntaje rectal neoadyuvante alto.El sesgo de selección potencial debido al diseño retrospectivo del estudio fue la limitación.Verificamos la aplicabilidad de la puntuación rectal neoadyuvante para estratificar el riesgo de recurrencia a nivel individual para pacientes con cáncer rectal en estadio II/III sometidos a quimiorradioterapia neoadyuvante. Se necesitan más estudios para validar la usabilidad de los niveles de puntuación rectal neoadyuvante como determinante de la estrategia adyuvante. Consulte Video Resumen en http://links.lww.com/DCR/B354.
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Affiliation(s)
- Yu Jin Lim
- Department of Radiation Oncology, Kyung Hee University College of Medicine, Kyung Hee University Medical Center, Seoul, Republic of Korea
| | - Changhoon Song
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Seung Hyuck Jeon
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kyubo Kim
- Department of Radiation Oncology, Ewha University College of Medicine, Seoul, Republic of Korea
| | - Eui Kyu Chie
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Republic of Korea.,Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
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Chen Z, Li S, Wang Y, Fu Z, Liu N, Wang H, Liu X. Overall Survival Benefit in Rectal Cancer After Neoadjuvant Radiotherapy and Adjuvant Chemotherapy: A Propensity-Matched Population-Based Study. Front Oncol 2020; 10:584835. [PMID: 33363014 PMCID: PMC7756087 DOI: 10.3389/fonc.2020.584835] [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: 08/04/2020] [Accepted: 11/09/2020] [Indexed: 11/13/2022] Open
Abstract
Background It is well known that neoadjuvant radiotherapy could reduce local recurrence followed by surgical resection. However, evidence about oncologic efficacy of radiotherapy and survival benefit of adjuvant chemotherapy after neoadjuvant radiotherapy is still lacking. Methods This retrospective propensity score-matched cohort study identified patients with pathologically confirmed rectal cancer and receiving surgery with curative intent from the Surveillance, Epidemiology, and End Results database from 2004 through 2014. Overall survival was compared using the stratified log-rank test. Multivariate Cox regression analysis was used for identifying risk factor and developing prediction nomogram. Results A total of 22,008 (11,004 for each group) propensity-matched patients were identified. In the context of receiving adjuvant chemotherapy after surgical resection, there was no significant difference in terms of overall survival between surgery alone group and neoadjuvant radiotherapy and surgery group, whether for stage I (log-rank test p = 0.467), stage II (log-rank test p = 0.310), or stage III (p = 0.994). In case of receiving a prior combination therapy of neoadjuvant radiotherapy and surgery, the following adjuvant chemotherapy could significantly improve overall survival for patients with stage I (log-rank test p <0.001), stage II (log-rank test p = 0.038), and stage III (log-rank test p = 0.014). Nomogram integrating clinicopathologic factors was developed to predict survival benefit associated with neoadjuvant radiotherapy. Calibration and ROC curves validated promising performance for the nomogram. Conclusion Patients with rectal cancer underwent neoadjuvant radiotherapy yield acceptable outcomes and are more likely to benefit from adjuvant chemotherapy in terms of overall survival. These data would be evidential for advocating consistency in guideline adherence to the use of adjuvant chemotherapy after neoadjuvant radiotherapy.
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Affiliation(s)
- Zhiju Chen
- The First Department of Gastrointestinal Surgery, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Shaowei Li
- Department of Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yehong Wang
- The First Department of Gastrointestinal Surgery, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Zhiming Fu
- The First Department of Gastrointestinal Surgery, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Ning Liu
- The First Department of Gastrointestinal Surgery, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Hao Wang
- The First Department of Gastrointestinal Surgery, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Xin Liu
- The First Department of Gastrointestinal Surgery, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, China
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10
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Ye SB, Cheng YK, Zhang L, Zou YF, Chen P, Deng YH, Huang Y, Peng JH, Wu XJ, Lan P. Association of mismatch repair status with survival and response to neoadjuvant chemo(radio)therapy in rectal cancer. NPJ Precis Oncol 2020; 4:26. [PMID: 32964128 PMCID: PMC7477257 DOI: 10.1038/s41698-020-00132-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 08/04/2020] [Indexed: 12/14/2022] Open
Abstract
Prior reports have indicated that defective mismatch repair (MMR) has a favorable impact on outcome in colorectal cancer patients treated with surgery, immunotherapy, or adjuvant chemotherapy. However, the impact of MMR status on response to neoadjuvant radiotherapy in rectal cancer is not well understood. Here we report that dMMR was associated with improved disease-free survival (DFS) (P = 0.034) in patients receiving neoadjuvant chemotherapy (NCT). Patients with dMMR tumors who received neoadjuvant chemoradiotherapy (NCRT) achieved significantly worse DFS (P = 0.026) than those treated with NCT. Conversely, NCRT improved DFS (P = 0.043) in patients with pMMR tumors, especially for stage III disease with improved DFS (P = 0.02). The presence of dMMR was associated with better prognosis in rectal cancer patients treated with NCT. NCT benefited patients with dMMR tumors; while NCRT benefited patients with stage III disease and pMMR tumors. Patients stratified by MMR status may provide a more tailored approach to rectal cancer neoadjuvant therapy.
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Affiliation(s)
- Shu-Biao Ye
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, Guangdong People's Republic of China
| | - Yi-Kan Cheng
- Department of Radiation Oncology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, People's Republic of China
| | - Lin Zhang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China.,Department of Clinical Laboratory, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Yi-Feng Zou
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, Guangdong People's Republic of China
| | - Ping Chen
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China.,Department of VIP Region, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Yan-Hong Deng
- Department of Oncology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, People's Republic of China
| | - Yan Huang
- Department of Pathology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, People's Republic of China
| | - Jian-Hong Peng
- State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China.,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Xiao-Jian Wu
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, Guangdong People's Republic of China
| | - Ping Lan
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, Guangdong People's Republic of China
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11
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Huang WS, Kuan FC, Lin MH, Chen MF, Chen WC. Prognostic Significance of Neoadjuvant Rectal Scores in Preoperative Short-Course Radiotherapy and Long-Course Concurrent Chemoradiotherapy for Patients with Locally Advanced Rectal Cancer. Ann Surg Oncol 2020; 27:4309-4318. [PMID: 32794029 DOI: 10.1245/s10434-020-09018-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 07/28/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND This study aimed to investigate the prognostic factors and the utility of the neoadjuvant rectal (NAR) score for patients who have locally advanced rectal cancer (LARC) treated with preoperative short-course radiotherapy (SRT) or long-course concurrent chemoradiotherapy (CRT). METHODS Of 314 consecutive stage 2 or 3 rectal cancer patients enrolled from January 2006 to December 2017, 205 underwent preoperative SRT (2500 cGy/5 fractions), and 109 underwent preoperative CRT (4200-5080 cGy/21-28 fractions) after total mesorectal excision (TME). The study calculated NAR scores using the following equation: [5 pN - 3(cT - pT) + 12]2/9.61. RESULTS The multivariate analysis showed that age above 65 years, pT4, pN2, NAR scores higher than 16, and distance from anal verges (< 8 cm) were significant prognostic factors for overall survival (OS), whereas, pN2, NAR scores lower than 16, and distance from anal verges (< 8 cm) were significant prognostic factors for disease-free survival (DFS) and distant metastasis (DM). The patients with an NAR score higher than 16, had a 5-year OS rate of 67.6%, a DFS rate of 56.9%, a locoregional recurrence (LRR) rate of 7.7%, and a DM rate of 35% compared with corresponding rates of 87.6%, 76.7%, 5.4%, and 7.2% for the patients with an NAR score of 16 or lower (p < 0.001 for OS, < 0.001 for DFS, 0.25 for LRR, and < 0.001 for DM). CONCLUSIONS For patients who undergo SRT or CRT for LARC, a higher NAR score is associated with worse OS and DFS and higher DM rates at 5 years. The NAR score could be used as a short-term surrogate end point after neoadjuvant therapy for LARC.
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Affiliation(s)
- Wen-Shih Huang
- Department of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Feng-Che Kuan
- Department of Hematology and Oncology, Chang Gung Memorial Hospital, Chiayi, Taiwan.,Graduate Institute of Clinical Medical Sciences, Chang-Gung University, Tao-Yuan, Taiwan
| | - Meng-Hung Lin
- Health Information and Epidemiology Laboratory, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Miao-Fen Chen
- Graduate Institute of Clinical Medical Sciences, Chang-Gung University, Tao-Yuan, Taiwan. .,Department of Radiation Oncology, Chang Gung Memorial Hospital, Chia-Yi, Hsien, Taiwan. .,School of Medicine, Chang Gung University, Taoyuan, Taiwan.
| | - Wen-Cheng Chen
- Department of Radiation Oncology, Chang Gung Memorial Hospital, Chia-Yi, Hsien, Taiwan. .,School of Medicine, Chang Gung University, Taoyuan, Taiwan.
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12
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Capanu M, Giurcanu M, Begg CB, Gönen M. Optimized variable selection via repeated data splitting. Stat Med 2020; 39:2167-2184. [PMID: 32282097 DOI: 10.1002/sim.8538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 02/14/2020] [Accepted: 03/09/2020] [Indexed: 12/24/2022]
Abstract
Model selection in high-dimensional settings has received substantial attention in recent years, however, similar advancements in the low-dimensional setting have been lacking. In this article, we introduce a new variable selection procedure for low to moderate scale regressions (n>p). This method repeatedly splits the data into two sets, one for estimation and one for validation, to obtain an empirically optimized threshold which is then used to screen for variables to include in the final model. In an extensive simulation study, we show that the proposed variable selection technique enjoys superior performance compared with candidate methods (backward elimination via repeated data splitting, univariate screening at 0.05 level, adaptive LASSO, SCAD), being amongst those with the lowest inclusion of noisy predictors while having the highest power to detect the correct model and being unaffected by correlations among the predictors. We illustrate the methods by applying them to a cohort of patients undergoing hepatectomy at our institution.
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Affiliation(s)
- Marinela Capanu
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Mihai Giurcanu
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois, USA
| | - Colin B Begg
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Mithat Gönen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
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13
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Lavryk OA, Manilich E, Valente MA, Miriam A, Gorgun E, Kalady MF, Shawki S, Delaney CP, Steele SR. Neoadjuvant chemoradiation improves oncologic outcomes in low and mid clinical T3N0 rectal cancers. Int J Colorectal Dis 2020; 35:77-84. [PMID: 31776698 DOI: 10.1007/s00384-019-03452-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Controversial data exists in the current literature in regard to the use of neoadjuvant chemoradiation (nCRT) in patients with clinical T3N0 (cT3N0) rectal cancers, specifically based on location and relation to peritoneal reflection. We aimed to analyze the impact of nCRT on oncologic outcomes among cT3N0 rectal cancers, depending on the tumor height from anal verge (AV). METHODS A retrospective analysis of patients with cT3N0 rectal cancers was included from a query of a prospectively maintained rectal cancer database from 1980 to 2016. Patients were divided into 3 groups based on the tumor height: low (1-5 cm from AV), mid (6-10 cm from AV), and upper (11-15 cm from AV). Patients were stratified by use of nCRT. MAIN OUTCOMES 5-year overall survival (OS), disease-free survival (DFS), cancer-specific survival (CSS), and local recurrence (LR) using Kaplan-Meier curves. RESULTS Five hundred ninety-two patients were included. Overall, 364 (61.4%) patients received nCRT and 228 (38.6%) patients did not. There were 251 (43%) patients with low, 302 (51%) with mid, and 39 (7%) with upper rectal cancer. Patients with low and mid rectal cancers received nCRT more frequently than those with upper rectal cancers (68.5% and 61.2% vs 43.6%, p = 0.007). The 5-year OS was 78% and 63%, DFS-88% and 73%, LR-1% and 8% in nCRT followed by resection vs. surgery alone (p < 0.001). In regard to cancer location after nCRT compared with surgery alone, low and mid cancers had better OS, DFS, and CSS, compared with upper ones. CONCLUSION nCRT prolongs survival among patients with rectal cancer below 10 cm from AV; however, it has no effect on 5-year oncologic survival of patients with upper rectal cancer located below peritoneal reflection.
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Affiliation(s)
- Olga A Lavryk
- Department of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Avenue/A30, Cleveland, OH, 44195, USA
| | | | - Michael A Valente
- Department of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Avenue/A30, Cleveland, OH, 44195, USA
| | | | - Emre Gorgun
- Department of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Avenue/A30, Cleveland, OH, 44195, USA
| | - Matthew F Kalady
- Department of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Avenue/A30, Cleveland, OH, 44195, USA
| | - Sherief Shawki
- Department of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Avenue/A30, Cleveland, OH, 44195, USA
| | - Conor P Delaney
- Department of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Avenue/A30, Cleveland, OH, 44195, USA.,John Carroll University, Cleveland, OH, USA
| | - Scott R Steele
- Department of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Avenue/A30, Cleveland, OH, 44195, USA.
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14
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Swords DS, Brooke BS, Skarda DE, Stoddard GJ, Tae Kim H, Sause WT, Scaife CL. Facility Variation in Local Staging of Rectal Adenocarcinoma and its Contribution to Underutilization of Neoadjuvant Therapy. J Gastrointest Surg 2019; 23:1206-1217. [PMID: 30421120 DOI: 10.1007/s11605-018-4039-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 10/25/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Guidelines recommend neoadjuvant therapy (NT) for clinical stage II-III (locally advanced) rectal adenocarcinoma, but utilization remains suboptimal. The causes of NT omission remain poorly understood. METHODS The main outcomes in this study of patients with resected clinically non-metastatic rectal adenocarcinoma in the 2010-2015 National Cancer Database were local staging utilization in patients with non-metastatic tumors (i.e., undocumented clinical stage/pathologic stage I-III) and NT utilization for locally advanced tumors. Multivariable regression was used to examine predictors of these outcomes. Facility-specific risk- and reliability-adjusted local staging and NT rates were calculated. Positive margins and overall survival (OS) were examined as secondary outcomes. RESULTS Local staging was omitted in 7737/43,819 (17.7%) patients with clinically non-metastatic tumors and NT was omitted in 5199/31,632 (16.4%) patients with locally advanced tumors. NT was utilized in 24,826 (91.1%) locally advanced patients who had local staging vs. 1607 (36.6%) patients who did not; 2785 (53.6%) locally advanced patients with NT omitted also had local staging omitted. Treatment at facilities with lowest quintile local staging rates was associated with NT omission (relative risk 2.41, 95% confidence interval 2.11, 2.75). Adjusted facility local staging rates varied sixfold (16.1-98.0%), facility NT rates varied twofold (43.9-95.9%), and they were correlated (r = 0.58; P < 0.001). Local staging omission and NT omission were independently associated with positive margins and decreased OS. CONCLUSIONS Local staging omission is a common care process in over half of cases of omitted NT. These data emphasize the need for quality improvement efforts directed at providing facilities feedback about their local staging rates.
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Affiliation(s)
- Douglas S Swords
- Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA.
- Surgical Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA.
| | - Benjamin S Brooke
- Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA
| | - David E Skarda
- Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA
- Surgical Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Gregory J Stoddard
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - H Tae Kim
- Surgical Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA
| | - William T Sause
- Oncology Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Courtney L Scaife
- Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA
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15
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Azin A, Khorasani M, Quereshy FA. Neoadjuvant chemoradiation in locally advanced rectal cancer: the surgeon's perspective. J Clin Pathol 2019; 72:133-134. [PMID: 30670565 DOI: 10.1136/jclinpath-2018-205595] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 11/23/2018] [Indexed: 01/12/2023]
Affiliation(s)
- Arash Azin
- Division of General Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Fayez A Quereshy
- Division of General Surgery, University of Toronto, Toronto, Ontario, Canada .,Division of General Surgery, University Health Network, Toronto, Ontario, Canada
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16
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Swords DS, Skarda DE, Sause WT, Gawlick U, Cannon GM, Lewis MA, Scaife CL, Gygi JA, Tae Kim H. Surgeon-Level Variation in Utilization of Local Staging and Neoadjuvant Therapy for Stage II-III Rectal Adenocarcinoma. J Gastrointest Surg 2019; 23:659-669. [PMID: 30706375 DOI: 10.1007/s11605-019-04107-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 01/04/2019] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Neoadjuvant therapy (NT) is the standard of care for clinical stage II-III rectal adenocarcinoma, but utilization remains suboptimal. We aimed to determine the underlying reasons for omission of local staging and NT. METHODS We conducted a retrospective study of patients with clinical stage II-III or undocumented clinical stage/pathologic stage II-III rectal adenocarcinoma who were treated in 2010-2016 in one of nine Intermountain Healthcare hospitals. The outcomes of omission of local staging and NT were examined with multivariable models. Risk- and reliability-adjusted rates of local staging and NT were calculated for surgeons who treated ≥ 3 patients. Pathologic and long-term outcomes were examined after excluding patients who were not resected or who underwent local excision (N = 11). RESULTS Local staging was omitted in 43/240 (17.9%) patients and NT was omitted in 41/240 (17.1%). The strongest risk factors for local staging and NT omission were upper rectal tumors and surgeons who treated ≤ 3 cases/year. Thirty-six of 41 (87.8%) cases of omitted NT had local staging omitted. Adjusted surgeon-specific local staging rates varied 1.6-fold (56.3-92.4%) and NT rates varied 2.8-fold (34.1-97.1%). Surgeon local staging and NT rates were strongly correlated (r = 0.92). NT was associated with lower rates of positive circumferential radial margins (7.9 vs. 20.0%; P = 0.02), node positivity (33.3 vs. 55.0%; P = 0.01), and local recurrences (7.6 vs. 14.9% at 5 years; P = 0.0176). CONCLUSIONS NT omission should be understood as a consequence of surgeon failure to perform local staging in most cases. Quality improvement efforts should focus on improving utilization of local staging.
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MESH Headings
- Adenocarcinoma/mortality
- Adenocarcinoma/pathology
- Adenocarcinoma/therapy
- Adult
- Aged
- Aged, 80 and over
- Chemoradiotherapy, Adjuvant/standards
- Chemoradiotherapy, Adjuvant/statistics & numerical data
- Female
- Follow-Up Studies
- Healthcare Disparities/statistics & numerical data
- Humans
- Male
- Margins of Excision
- Middle Aged
- Neoadjuvant Therapy/standards
- Neoadjuvant Therapy/statistics & numerical data
- Neoplasm Recurrence, Local/epidemiology
- Neoplasm Recurrence, Local/etiology
- Neoplasm Recurrence, Local/prevention & control
- Neoplasm Staging
- Practice Patterns, Physicians'/standards
- Practice Patterns, Physicians'/statistics & numerical data
- Procedures and Techniques Utilization/standards
- Procedures and Techniques Utilization/statistics & numerical data
- Proctectomy
- Quality Assurance, Health Care
- Quality Indicators, Health Care/statistics & numerical data
- Rectal Neoplasms/mortality
- Rectal Neoplasms/pathology
- Rectal Neoplasms/therapy
- Reproducibility of Results
- Retrospective Studies
- Surgeons/standards
- Surgeons/statistics & numerical data
- Treatment Outcome
- United States/epidemiology
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Affiliation(s)
- Douglas S Swords
- Surgical Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA.
- Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA.
| | - David E Skarda
- Surgical Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA
- Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA
| | - William T Sause
- Oncology Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Ute Gawlick
- Surgical Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA
| | - George M Cannon
- Oncology Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Mark A Lewis
- Oncology Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Courtney L Scaife
- Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA
| | - Jesse A Gygi
- Oncology Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA
| | - H Tae Kim
- Surgical Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA
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17
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Delitto D, Loftus TJ, Iqbal A. Pathologic stage dictates survival after neoadjuvant radiation for rectal cancer. Oncotarget 2018; 9:35474-35475. [PMID: 30464801 PMCID: PMC6231453 DOI: 10.18632/oncotarget.26262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 10/15/2018] [Indexed: 11/29/2022] Open
Affiliation(s)
- Daniel Delitto
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Tyler J Loftus
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Atif Iqbal
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
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