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Kus Ozturk S, Graham Martinez C, Sheahan K, Winter DC, Aherne S, Ryan ÉJ, van de Velde CJ, Marijnen CA, Hospers GA, Roodvoets AG, Doukas M, Mens D, Verhoef C, van der Post RS, Nagtegaal ID. Relevance of shrinkage versus fragmented response patterns in rectal cancer. Histopathology 2023; 83:870-879. [PMID: 37609761 DOI: 10.1111/his.15027] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/06/2023] [Accepted: 07/31/2023] [Indexed: 08/24/2023]
Abstract
AIMS Partial response to neoadjuvant chemoradiotherapy (CRT) presents with one of two main response patterns: shrinkage or fragmentation. This study investigated the relevance of these response patterns in rectal cancer, correlation with other response indicators, and outcome. METHODS AND RESULTS The study included a test (n = 197) and a validation cohort (n = 218) of post-CRT patients with rectal adenocarcinoma not otherwise specified and a partial response. Response patterns were scored by two independent observers using a previously developed three-step flowchart. Tumour regression grading (TRG) was established according to both the College of American Pathologists (CAP) and Dworak classifications. In both cohorts, the predominant response pattern was fragmentation (70% and 74%), and the scoring interobserver agreement was excellent (k = 0.85). Patients with a fragmented pattern presented with significantly higher pathological stage (ypTNM II-IV, 78% versus 35%; P < 0.001), less tumour regression with Dworak (P = 0.004), and CAP TRG (P = 0.005) compared to patients with a shrinkage pattern. As a predictor of prognosis, the shrinkage pattern outperformed the TRG classification and stratified patients better in overall (fragmented pattern, hazard ratio [HR] 2.04, 95% confidence interval [CI] 1.19-3.50, P = 0.008) and disease-free survival (DFS; fragmented pattern, HR 2.50, 95% CI 1.23-5.10, P = 0.011) in the combined cohorts. The multivariable regression analyses revealed pathological stage as the only independent predictor of DFS. CONCLUSIONS The heterogeneous nature of tumour response following CRT is reflected in fragmentation and shrinkage. In rectal cancer there is a predominance of the fragmented pattern, which is associated with advanced stage and less tumour regression. While not independently associated with survival, these reproducible patterns give insights into the biology of tumour response.
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Affiliation(s)
- Sonay Kus Ozturk
- Department of Pathology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | | - Kieran Sheahan
- Department of Pathology, St. Vincent's University Hospital, Dublin, Ireland
| | - Desmond C Winter
- Department of Surgery, St. Vincent's University Hospital, Dublin, Ireland
| | - Susan Aherne
- Department of Pathology, St. Vincent's University Hospital, Dublin, Ireland
| | - Éanna J Ryan
- Department of Surgery, St. Vincent's University Hospital, Dublin, Ireland
| | | | - Corrie Am Marijnen
- Department of Radiotherapy, Leiden University Medical Centre, Leiden, The Netherlands
| | - Geke Ap Hospers
- Department of Oncology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Annet Gh Roodvoets
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Michail Doukas
- Department of Pathology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - David Mens
- Department of Surgical Oncology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Cornelis Verhoef
- Department of Surgical Oncology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Rachel S van der Post
- Department of Pathology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Iris D Nagtegaal
- Department of Pathology, Radboud University Medical Centre, Nijmegen, The Netherlands
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van der Stel SD, van den Berg JG, Snaebjornsson P, Seignette IM, Witteveen M, Grotenhuis BA, Beets GL, Post AL, Ruers TJM. Size and depth of residual tumor after neoadjuvant chemoradiotherapy in rectal cancer - implications for the development of new imaging modalities for response assessment. Front Oncol 2023; 13:1209732. [PMID: 37736547 PMCID: PMC10509550 DOI: 10.3389/fonc.2023.1209732] [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: 04/21/2023] [Accepted: 08/21/2023] [Indexed: 09/23/2023] Open
Abstract
With the shift towards organ preserving treatment strategies in rectal cancer it has become increasingly important to accurately discriminate between a complete and good clinical response after neoadjuvant chemoradiotherapy (CRT). Standard of care imaging techniques such as CT and MRI are well equipped for initial staging of rectal tumors, but discrimination between a good clinical and complete response remains difficult due to their limited ability to detect small residual vital tumor fragments. To identify new promising imaging techniques that could fill this gap, it is crucial to know the size and invasion depth of residual vital tumor tissue since this determines the requirements with regard to the resolution and imaging depth of potential new optical imaging techniques. We analyzed 198 pathology slides from 30 rectal cancer patients with a Mandard tumor regression grade 2 or 3 after CRT that underwent surgery. For each patient we determined response pattern, size of the largest vital tumor fragment or bulk and the shortest distance from the vital tumor to the luminal surface. The response pattern was shrinkage in 14 patients and fragmentation in 16 patients. For both groups combined, the largest vital tumor fragment per patient was smaller than 1mm for 38% of patients, below 0.2mm for 12% of patients and for one patient as small as 0.06mm. For 29% of patients the vital tumor remnant was present within the first 0.01mm from the luminal surface and for 87% within 0.5mm. Our results explain why it is difficult to differentiate between a good clinical and complete response in rectal cancer patients using endoscopy and MRI, since in many patients submillimeter tumor fragments remain below the luminal surface. To detect residual vital tumor tissue in all patients included in this study a technique with a spatial resolution of 0.06mm and an imaging depth of 8.9mm would have been required. Optical imaging techniques offer the possibility of detecting majority of these cases due to the potential of both high-resolution imaging and enhanced contrast between tissue types. These techniques could thus serve as a complimentary tool to conventional methods for rectal cancer response assessment.
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Affiliation(s)
- Stefan D. van der Stel
- Faculty Technische Natuurwetenschappen (TNW), Group Nanobiophysics, Twente University, Enschede, Netherlands
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | - Petur Snaebjornsson
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, Netherlands
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Iris M. Seignette
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Mark Witteveen
- Faculty Technische Natuurwetenschappen (TNW), Group Nanobiophysics, Twente University, Enschede, Netherlands
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | - Geerard L. Beets
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, Netherlands
- GROW School for Oncology and Developmental Biology, University of Maastricht, Maastricht, Netherlands
| | - Anouk L. Post
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, Netherlands
- Department of Biomedical Engineering and Physics, Amsterdam Cardiovascular Sciences, Cancer Center Amsterdam, Amsterdam Universitair Medisch Centrum (UMC), University of Amsterdam, Amsterdam, Netherlands
| | - Theo J. M. Ruers
- Faculty Technische Natuurwetenschappen (TNW), Group Nanobiophysics, Twente University, Enschede, Netherlands
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, Netherlands
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Bokhorst JM, Nagtegaal ID, Fraggetta F, Vatrano S, Mesker W, Vieth M, van der Laak J, Ciompi F. Deep learning for multi-class semantic segmentation enables colorectal cancer detection and classification in digital pathology images. Sci Rep 2023; 13:8398. [PMID: 37225743 DOI: 10.1038/s41598-023-35491-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 05/18/2023] [Indexed: 05/26/2023] Open
Abstract
In colorectal cancer (CRC), artificial intelligence (AI) can alleviate the laborious task of characterization and reporting on resected biopsies, including polyps, the numbers of which are increasing as a result of CRC population screening programs ongoing in many countries all around the globe. Here, we present an approach to address two major challenges in the automated assessment of CRC histopathology whole-slide images. We present an AI-based method to segment multiple ([Formula: see text]) tissue compartments in the H &E-stained whole-slide image, which provides a different, more perceptible picture of tissue morphology and composition. We test and compare a panel of state-of-the-art loss functions available for segmentation models, and provide indications about their use in histopathology image segmentation, based on the analysis of (a) a multi-centric cohort of CRC cases from five medical centers in the Netherlands and Germany, and (b) two publicly available datasets on segmentation in CRC. We used the best performing AI model as the basis for a computer-aided diagnosis system that classifies colon biopsies into four main categories that are relevant pathologically. We report the performance of this system on an independent cohort of more than 1000 patients. The results show that with a good segmentation network as a base, a tool can be developed which can support pathologists in the risk stratification of colorectal cancer patients, among other possible uses. We have made the segmentation model available for research use on https://grand-challenge.org/algorithms/colon-tissue-segmentation/ .
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Affiliation(s)
- John-Melle Bokhorst
- Department of pathology, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Iris D Nagtegaal
- Department of pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Filippo Fraggetta
- Pathology Unit Gravina Hospital, Gravina Hospital, Caltagirone, Italy
| | - Simona Vatrano
- Pathology Unit Gravina Hospital, Gravina Hospital, Caltagirone, Italy
| | - Wilma Mesker
- Leids Universitair Medisch Centrum, Leiden, The Netherlands
| | - Michael Vieth
- Klinikum Bayreuth, Friedrich-Alexander-University Erlangen-Nuremberg, Bayreuth, Germany
| | - Jeroen van der Laak
- Department of pathology, Radboud University Medical Center, Nijmegen, The Netherlands
- Center for Medical Image Science and Visualization, Linköping University, Linköping, Sweden
| | - Francesco Ciompi
- Department of pathology, Radboud University Medical Center, Nijmegen, The Netherlands
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Mills MN, Naz A, Sanchez J, Dessureault S, Imanirad I, Lauwers G, Moore M, Hoffe S, Frakes J, Felder S. Rectal tumor fragmentation as a response pattern following chemoradiation. J Gastrointest Oncol 2022; 13:2951-2962. [PMID: 36636056 PMCID: PMC9830359 DOI: 10.21037/jgo-22-477] [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] [Received: 05/14/2022] [Accepted: 09/05/2022] [Indexed: 11/23/2022] Open
Abstract
Background Tumor response to neoadjuvant therapy is heterogenous and prognostically important for locally advanced rectal adenocarcinoma (LARC) patients. Commonly applied response classification approaches including tumor regression grading (TRG) and TN downstaging can be discordant. The aim of this study is to compare the prognostic value of discordant tumor response measurement categorized according to the AJCC/CAP TRG schema and ypTN stage. Methods This is a single-center retrospective review of 90 consecutive patients with stage II-III rectal cancer receiving neoadjuvant chemoradiation (nCRT), total mesorectal excision (TME) and adjuvant chemotherapy (ACT) between 2007 and 2018. Two pathologists re-examined each case to assign a consensus AJCC TRG. A Cox proportional hazards ratio model assessed the effect of patient, tumor, and treatment factors on disease-free survival (DFS). Results Median follow-up after surgery was 46 months (95% CI: 41-50 months). Median age at diagnosis was 55 years (range: 27-80). Most patients were male (58%) and Caucasian (92%) with clinical stage III disease (68%). Seventy-three patients (81%) underwent low anterior resection (LAR), 17 (19%) underwent abdominoperineal resection (APR). The median interval from completion of nCRT to surgery was 62 days (IQR: 56-70 days). The 4-year OS, DFS, and LC was 92.4%, 74.4%, and 90.2%, respectively. In the multivariate analysis, ypTN downstaging was not prognostically significant; however, AJCC TRG score 3 (minimal tumor response to treatment) was strongly predictive for inferior DFS (3-year DFS 79% vs. 25%, P<0.001). Patients with TRG 3 had a significantly higher risk of both local (75% vs. 5%) and distant failure (75% vs. 19%). Conclusions Minimal tumor response to neoadjuvant therapy, AJCC TRG 3, irrespective of ypTN downstaging, is a pattern of residual disease that is at highest risk for recurrence. Response categorization discrepancies may be partly explained by alternative patterns of residual disease, including tumor fragmentation, and may be best reflected by TRG. The optimal tumor response categorization method requires further study to best stratify patient risk and management.
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Affiliation(s)
- Matthew N. Mills
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Afrin Naz
- University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Julian Sanchez
- Department of Surgery, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Sophie Dessureault
- Department of Surgery, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Iman Imanirad
- Department of Medical Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Gregory Lauwers
- Department of Pathology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Michelle Moore
- Department of Cellular Pathology, Belfast Health and Social Care Trust, Belfast, UK
| | - Sarah Hoffe
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Jessica Frakes
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Seth Felder
- Department of Surgery, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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Graham Martínez C, Barella Y, Kus Öztürk S, Ansems M, Gorris MA, van Vliet S, Marijnen CA, Nagtegaal ID. The immune microenvironment landscape shows treatment-specific differences in rectal cancer patients. Front Immunol 2022; 13:1011498. [PMID: 36238289 PMCID: PMC9552175 DOI: 10.3389/fimmu.2022.1011498] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 08/29/2022] [Indexed: 11/22/2022] Open
Abstract
Neoadjuvant therapy is the cornerstone of modern rectal cancer treatment. Insights into the biology of tumor responses are essential for the successful implementation of organ-preserving strategies, as different treatments may lead to specific tumor responses. In this study, we aim to explore treatment-specific responses of the tumor microenvironment. Patients with locally advanced adenocarcinoma of the rectum who had received neo-adjuvant chemotherapy (CT), neo-adjuvant radiochemotherapy (RCT), neo-adjuvant radiotherapy with a long-interval (LRT) or short-interval (SRT) or no neoadjuvant therapy (NT) as control were included. Multiplex-immunofluorescence was performed to determine the presence of cytotoxic T-cells (T-cyt; CD3+CD8+), regulatory T-cells (T-reg; CD3+FOXP3+), T-helper cells (T-helper; CD3+CD8-FOXP3-), B cells (CD20+), dendritic cells (CD11c+) and tumor cells (panCK+). A total of 80 rectal cancer patients were included. Treatment groups were matched for gender, tumor location, response to therapy, and TNM stage. The pattern of response (shrinkage vs. fragmentation) was, however, different between treatment groups. Our analyses reveal that RCT-treated patients exhibited lower stromal T-helper, T-reg, and T-cyt cells compared to other treatment regimens. In conclusion, we demonstrated treatment-specific differences in the immune microenvironment landscape of rectal cancer patients. Understanding the underlying mechanisms of this landscape after a specific therapy will benefit future treatment decisions.
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Affiliation(s)
- Cristina Graham Martínez
- Department of Pathology, Radboud University Medical Centre, Nijmegen, Netherlands
- *Correspondence: Cristina Graham Martínez,
| | - Yari Barella
- Department of Pathology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Sonay Kus Öztürk
- Department of Pathology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Marleen Ansems
- Radiotherapy & OncoImmunology Laboratory, Department of Radiation Oncology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Mark A.J Gorris
- Department of Tumor Immunology, Radboud University Medical Centre, Nijmegen, Netherlands
- Oncode Institute, Utrecht, Netherlands
| | - Shannon van Vliet
- Department of Pathology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Corrie A.M Marijnen
- Department of Radiotherapy, Netherlands Cancer Institute, Amsterdam, Netherlands
- Department of Medical Oncology, Leiden University Medical Centre, Leiden, Netherlands
| | - Iris D Nagtegaal
- Department of Pathology, Radboud University Medical Centre, Nijmegen, Netherlands
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