Pathological response following long-course neoadjuvant chemoradiotherapy for locally advanced rectal cancer

The tumour-stroma ratio as predictive aid towards a biopsy-based treatment strategy in rectal carcinoma

AIMS

Tumour-stroma ratio (TSR) scores of biopsy material in rectal carcinoma (RC) could aid a biomarker-based, upfront and personalised treatment strategy selection for RC patients. In a large retrospective, multicentre cohort, we aimed to validate the predictive value of biopsy-scored TSR on neoadjuvant therapy response, and secondarily, disease-free and overall survival (DFS, OS).

METHODS AND RESULTS

Scanned haematoxylin and eosin-stained RC biopsy slides were collected from Leiden University Medical Center (N = 116) and from the clinical PROCTOR-SCRIPT (N = 142) and RAPIDO (N = 271) trials. TSR was scored per protocol and categorised as stroma-low (≤ 50%) or stroma-high (> 50%). Major response was defined as tumour regression grade (TRG) 1 + 2 by Mandard, including pathological complete response. Ultimately, a large and varied cohort with 373 RC patients was established. Locally advanced RC was more often stroma-high (P < 0.001). We subsequently observed significantly lower major response rates in the stroma-high RC after a neoadjuvant treatment approach (hazard ratio = 0.63, 95% confidence interval = 0.41-0.99; P = 0.044). Despite correction for well-known risk factors in Cox hazard regression analysis, such as (y)pTNM substages or residual tumour status, the TSR had no singular significant influence on DFS nor OS in multivariate analysis (P = 0.438; P = 0.934, respectively).

CONCLUSIONS

Biopsy-scored TSR can predict neoadjuvant therapy efficacy, as RC patients with stroma-high biopsies show less major response. However, patient survival is multifactorial, although response is an important predictor, influenced by TSR. Scoring TSR on RC biopsy material is a reliable histological parameter, implementation of which in treatment guidelines could improve upfront selection for a watch-and-wait strategy.

Hand-Assisted Laparoscopic Rectal Resection-Experience of a Tertiary Oncology Center

Background: Hand-assisted laparoscopic surgery (HALS) is a possible approach for rectal anterior resection (RAR). However, evidence supporting this technique remains limited. This study aims to evaluate the perioperative and oncological outcomes of HALS for RAR at a single tertiary oncology center. Methods: A retrospective observational study was conducted using a prospectively maintained database. Patients with primary adenocarcinoma of the rectosigmoid junction and rectum who underwent HALS for RAR between 1 January 2013 and 31 December 2022 were included. All surgeries were performed by a dedicated colorectal team composed of three surgeons. Results: Among the 1911 surgeries for primary colorectal cancer performed, 469 met the inclusion criteria. The median age was 66 (57-74) years and 63% of the patients were male. Most tumors were cT3-4 (78.9%) and cN+ (71.2%), and neoadjuvant therapy was administered in 70.0% of cases. Low RAR was performed in 73.1% of cases, and an anastomosis was constructed in 95% of cases. The median operative time was 152 (135-180) min, and the conversion rate was 3.8%. Major morbidity occurred in 10.0% of cases, with 30-day and 90-day mortality rates of 0.9% and 1.3%, respectively. The overall anastomotic leak rate was 12.1%, with 9.0% early leaks and 3.1% late leaks. A complete/near-complete mesorectal excision was achieved in 89.6% of cases and an R0 resection in 96.2% of cases. With a median follow-up of 87 months, the locoregional recurrence rate was 2.5%, whereas the distant recurrence rate was 5.9%. The 5-year overall survival was 82.6%. Conclusions: When performed by experienced teams, HALS for RAR is safe and feasible and is associated with a short operative time, low conversion rate, minimal morbidity, and optimal oncologic performance.

Histopathologic Grading of Residual Tumor Predicts Survival of Intrahepatic Cholangiocarcinoma Patients Treated With Neoadjuvant Therapy: Major Pathologic Response and Its Clinical Significance

Neoadjuvant therapy (NAT) is increasingly used to treat patients with initially unresectable intrahepatic cholangiocarcinoma (iCCA). A histopathologic grading system for residual tumors that can predict patient survival is lacking in the literature. This retrospective study enrolled 151 iCCA patients who received NAT. The percentage of residual viable tumor (%RVT) extent was calculated by RVT surface area/total tumor bed area ×100 and scored in 5% increments. Kaplan-Meier and Cox regression analyses were used to investigate its correlations with recurrence-free survival (RFS) and overall survival (OS). Tumor regression grading by the College of American Pathologists (CAP) and MD Anderson (MDA) methodologies were also validated. A 10% RVT-based tumor regression score (TRS) showed a significant correlation with both OS and RFS. TRS and major pathologic response (mPR) were therefore defined as follows: TRS 1/mPR, tumor with 0 to 10% RVT; TRS 2, more than 10% RVT. Patients graded as TRS 1/mPR had superior OS ( P =0.006) and RFS ( P <0.001) compared with those with TRS 2 in univariate analysis. In a multivariate analysis including ypTNM stages, lymphovascular invasion, and perineural invasion, TRS 1/mPR was also found to be an independent prognostic factor for both OS (hazard ratio [HR]: 0.226; 95% CI: 0.053-0.966, P =0.045) and RFS (HR: 0.474; 95% CI: 0.231-0.974, P =0.042). As for the CAP and MDA grading methodologies, they were found to correlate with RFS (CAP: P =0.002; MDA: P =0.001), but not with OS (CAP: P =0.181; MDA: P =0.09). Our study revealed that a TRS of ≤10% RVT significantly correlates with longer OS and RFS and can be suggested as an mPR in iCCA. This indicator is easily applicable, prognostically relevant, and could be further validated in future prospective clinical trials.

Neoadjuvant short-course radiotherapy followed by camrelizumab and chemotherapy for locally advanced rectal cancer: 3-year survival from a phase 2 study

BACKGROUND

Neoadjuvant short-course radiotherapy (SCRT) followed by camrelizumab and chemotherapy has shown an encouraging pathological complete response rate (48.1%, primary endpoint) in patients with locally advanced rectal cancer (LARC). Here, we present the 3-year survival outcomes.

METHODS

In this phase 2 trial, patients with previously untreated T3-4N0M0 or T1-4N + M0 rectal adenocarcinoma received 5 × 5 Gy SCRT over 5 days, followed by two cycles of camrelizumab (200 mg) and CAPOX regimen every 3 weeks after 1 week. Total mesorectal excision (TME) was scheduled 1 week after the completion of neoadjuvant treatment. The 3-year disease-free survival (DFS) and overall survival (OS) were evaluated in this analysis.

RESULTS

A total of 30 patients were enrolled, of whom 28 (93.3%) had microsatellite stable status (MSS) and 27 (90.0%) underwent TME. With a median follow-up of 40.8 months, the median DFS and OS were both not reached, with the 3-year DFS and OS rates of 80.2% (95% CI 58.6-91.3) and 93.3% (95% CI 75.9-98.3), respectively. Additionally, there was a trend toward improved 3-year DFS and OS in patients with pCR, postoperative pathological node-negative status (pN0), baseline negative circumferential resection margin as assessed by MRI, baseline negative extramural venous invasion and a PD-L1 combined positive score of 1 or higher, as compared with those without these characteristics.

CONCLUSIONS

Our data support the potential efficacy of neoadjuvant SCRT followed by camrelizumab and CAPOX regimen in LARC, as indicated by 3-year survival outcomes, suggesting that this may be an alternative therapeutic strategy, especially with the potential to address an unmet need for MSS patients.

TRIAL REGISTRATION

www.

CLINICALTRIALS

gov . NCT04231552.

The Role of Pre-Treatment Inflammatory Biomarkers in Predicting Tumor Response to Neoadjuvant Chemoradiotherapy in Rectal Cancer

Background and Objectives: This study aimed to investigate the predictive and prognostic value of pre-treatment systemic inflammatory markers in patients with locally advanced rectal cancer (RC) undergoing neoadjuvant chemoradiotherapy (CRT) or radiotherapy (RT) alone. Materials and Methods: A total of 79 patients with biopsy-confirmed locally advanced RC treated at a single tertiary center between 2011 and 2017 were retrospectively analyzed. Pre-treatment blood-based inflammatory indices, including neutrophil-to-lymphocyte ratio (NLR), derived NLR, platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR), and hemoglobin levels, were recorded. Tumor response was assessed using the Ryan tumor regression grade (TRG), and associations between laboratory parameters, treatment response, and recurrence-free survival (RFS) were evaluated. Results: Among 79 patients (mean age: 55.9 ± 11.98 years; 67.1% male), 57 received neoadjuvant CRT and 22 underwent short-course RT. Complete pathological response (pCR) was observed in 10 patients (12.7%). No statistically significant associations were found between baseline inflammatory markers and TRG, tumor differentiation, or pCR. ROC analysis revealed that none of the markers demonstrated significant discriminatory power for predicting tumor response or recurrence. However, a weak but statistically significant inverse correlation was identified between poor TRG response and higher baseline values of NLR, derived NLR, and PLR (p < 0.05). Conclusions: Inflammatory biomarkers such as NLR, PLR, and LMR, while easily accessible and cost-effective, did not demonstrate strong predictive or prognostic value in this cohort of RC patients receiving neoadjuvant therapy. These findings suggest that reliance solely on systemic inflammatory indices may be insufficient for predicting treatment outcomes, emphasizing the need for integrative models incorporating molecular and pathological markers.

Mucosal Microbiome Markers of Complete Pathologic Response to Neoadjuvant Therapy in Rectal Carcinoma

Abstract

The intestinal microbiome contributes to colorectal carcinogenesis, disease progression, and response to therapy. Pathologic complete response is the therapeutic goal of neoadjuvant chemoradiation in rectal carcinoma. Nonoperative management has become an accepted strategy, and markers of complete treatment response are needed. Intestinal commensal bacteria contribute to treatment response and radiation colitis, and microbiome-targeted therapies have shown promise in clinical trials. We investigated the relationship among mucosa-associated bacteria, neoadjuvant therapy response, and radiation colitis symptoms in 57 patients who received neoadjuvant regimens with no therapy, chemotherapy only, or chemoradiation. The design was a retrospective cohort study. Microbiome profiling was performed by 16S rDNA sequencing of formalin-fixed, paraffin-embedded tissue at the proximal margin of resection. Global β diversity differed according to neoadjuvant therapy modality and was associated with radiation colitis. Taxonomic differences were detectable at phylum and lower classification levels, and radiation-induced colitis was associated with enrichment of the Bacillaceae family. Taxonomic features, including reduced Streptococcus, Lachnospiraceae, and Bacillaceae, were enriched in complete histopathologic responders to neoadjuvant therapy. Taxon-based prediction of metabolic pathways identified enrichment of prokaryotic NAD+ biosynthesis and salvage pathways in complete responders. Mucosal microbiome responses to multimodal neoadjuvant therapy reflect symptomatic radiation colitis, histopathologic evidence of radiation injury, and pathologic treatment response. Posttreatment microbiome β diversity markers of complete pathologic response may be useful in decisions to manage rectal carcinoma nonoperatively.

Significance

Posttreatment markers of the complete response of rectal carcinoma to neoadjuvant chemoradiation are needed to guide decisions about surgical resection. We found that mucosal microbiome β diversity, bacterial metabolic capacities, and specific taxonomic groups distinguished between complete and incomplete responders. The mucosal microbiome provides markers for complete pathologic response.

Predictors of Pathologic Non-response to Neoadjuvant Approaches in Locally Advanced Rectal Cancer

BACKGROUND

Approximately 10-20% of rectal cancer patients do not respond to neoadjuvant treatment. While the current literature has focused on pathological complete response, pinpointing those who will fail to benefit entirely from neoadjuvant approaches is crucial.

OBJECTIVE

This study aimed to determine the risk factors associated with pathological non-response (pNR) to neoadjuvant treatment.

METHODS

Patients with stage II-III rectal adenocarcinoma who underwent neoadjuvant treatment followed by curative surgical resection between 2018 and 2023 at a high-volume center were retrospectively reviewed. Patients were divided into two cohorts (pNR and pathologic responder [pR]) based on their response to neoadjuvant therapy. The pNR group included patients with a Tumor Regression Score of grade 3 or those upstaged on the final pathological report.

RESULTS

Of the 405 patients included in this study, 53 (13%) were pNR and 352 (87%) were pR. Among patients treated with standard neoadjuvant chemoradiation, 12% were pNR compared with 14% among those treated with total neoadjuvant therapy. Significantly more patients in the pNR cohort had perineural (31% vs. 8%; p < 0.001) and lymphovascular (22% vs. 6%, p = 0.001) invasions when compared with the pR cohort. After adjusting for age, sex, clinical T stages, and clinical nodal status on multivariable analysis, the presence of extramural vascular invasion (EMVI) on pretreatment magnetic resonance imaging (odds ratio 2.08, 95% confidence interval 1.03-4.20, p = 0.04) was identified as a significant predictor of pNR.

CONCLUSION

EMVI was an independent risk factor of pNR in patients with rectal cancer. Identifying pretreatment factors that predict pNR to neoadjuvant therapy is crucial as it allows for better risk stratification and personalized treatment strategies.

Phase 2 trial of perioperative chemo-immunotherapy for gastro-esophageal adenocarcinoma: The role of M2 macrophage landscape in predicting response

We present the clinical results of a phase 2 trial combining neoadjuvant docetaxel, cisplatin, 5 Flourouracil, and the PD-L1 inhibitor avelumab in locally advanced gastro-esophageal adenocarcinoma (GEA). Fifty-one patients receive neoadjuvant therapy with 50 proceeding to surgery. Grade 3-4 adverse events occur in 40%; complete/major pathological response is found in 7/50 (14%) and 9/50 (18%), with 2-year disease-free survival of 67.5%. There is no correlation between tumor regression and PD-L1 or mismatch repair (MMR) status. Multiplex immunohistochemistry and longitudinal single-cell transcriptomic profiling reveal alterations in certain innate immune cell populations, particularly noting an M2-tumor-associated macrophage (M2-TAM) proliferation in non-responding tumors. These findings describe the effective nature of this treatment regimen for GEA and reveal associated features of the inflammatory milieux associated with response to chemo-immunotherapy. The specific character of the inflammatory environment in non-responders may, in the future, help personalize treatment. This study was registered at ClinicalTrials.gov (NCT03288350).

Development of clinical inflammatory models to predict the efficacy of neoadjuvant chemoradiotherapy and survival in patients with locally advanced rectal cancer: a retrospective study

AIM

To assess the ability of clinical inflammatory models to predict tumor regression grade (TRG) in response to neoadjuvant chemoradiotherapy (NCRT) and survival in patients with locally advanced rectal cancer (LARC).

METHODS

We retrospectively analyzed 161 patients with LARC who underwent NCRT followed by total mesorectal excision at Beijing Hospital between May 2007 and March 2022. By using logistic and Cox regression analyses, we developed prediction models for TRG in response to NCRT and overall survival (OS), respectively.

RESULTS

Multivariable logistic regression analysis indicated that variations in neutrophil, lymphocyte, and monocyte counts and pre-NCRT (preneoadjuvant chemoradiotherapy) CA19 - 9 levels independently predicted TRG in response to NCRT (all P < 0.05). Multivariate Cox regression analysis revealed that clinical tumor (cT) stage, pre-NCRT platelet count, CA19 - 9 level, number of lymph node metastases, and TRG could independently predict OS (all P < 0.05). On the basis of these results, we developed models to predict TRG and OS, respectively. The final predictive model for predicting the response to NCRT had areas under the curve (AUCs) of 0.783 and 0.809 in the training and testing cohorts, respectively; for predicting the 5-year OS rate, the AUC rates were 0.842 and 0.930 in the training and test sets, respectively. The calibration and decision curves showed favorable performance in our prediction models.

CONCLUSION

We combined inflammatory markers with tumor characteristics and successfully developed clinical prediction models for TRG in response to NCRT and OS in patients with LARC. Our findings offer insights for optimizing treatment in patients with LARC.

Prognostic significance of serum MUC5AC in resected pancreatic ductal adenocarcinoma: initial insights

Background

We investigated the association between serum MUC5AC (sMUC5AC) levels and patient outcomes in individuals who underwent resection for pancreatic ductal adenocarcinoma (PDA), including those treated with neoadjuvant therapy (NAT) and those who had upfront surgery (UpS) followed by adjuvant therapy.

Methods

Serum samples from the Ohio State University biorepository collected from January 2010 to June 2021 were utilized. The human MUC5AC kit (NBP2-76703) was used to perform enzyme-linked immunoassays to measure sMUC5AC levels. Logistic regression, Cox regression models (univariate and multivariate), recurrence prediction, analysis of variance (ANOVA), t-tests, and Wilcoxon tests were used for statistical analysis.

Results

In the NAT cohort (n = 23), elevated sMUC5AC levels were significantly (P < 0.05) associated with pathological treatment response, margin positivity, and residual disease. Among 21 patients who had an R0/R1 resection (R2 resection, n=2), higher sMUC5AC levels were associated with shorter progression-free survival (PFS) (HR: 1.64, P = 0.0006) and overall survival (OS) (HR: 1.6, P = 0.005) on univariate analysis. Multivariate models confirmed sMUC5AC as an independent predictor of PFS and OS alongside pathological differentiation and postoperative therapy. Patients with lower sMUC5AC levels had more favorable pathological characteristics, better treatment responses, and improved survival outcomes. These findings were consistent in the FOLFIRINOX subgroup (n = 17). In the UpS cohort (n = 17), post-resection sMUC5AC levels tend to be associated with PFS (P = 0.07) and OS (P = 0.05). Combining sMUC5AC with Carbohydrate antigen (CA) 19-9 enhanced sensitivity (79%) and specificity (67%) to predict recurrence. Higher sMUC5AC levels were associated with earlier recurrence and poor survival outcomes, highlighting its utility in post-surgery risk stratification. Among patients with pre-treatment data (n = 11), sMUC5AC levels were significantly higher among patients with poorly differentiated tumors.

Conclusion

This study provides compelling evidence for the clinical utility of sMUC5AC as a prognostic biomarker among patients with resected PDA. Future large-scale studies are needed to validate these findings and establish standard thresholds for sMUC5AC integration into clinical practice.

Trifluridine/Tipiracil and Oxaliplatin as Induction Chemotherapy in Resectable Esophageal and Gastroesophageal Junction Adenocarcinoma: A Phase II Study

BACKGROUND

Preoperative chemoradiation (CRT) followed by surgery for localized esophageal and gastroesophageal junction adenocarcinoma (EGAC) is a standard of care with a pathologic complete response (pCR) rate of 20%. We evaluated a novel combination of trifluridine/tipiracil with oxaliplatin as induction chemotherapy (IC) followed by CRT.

METHODS

We enrolled patients with potentially resectable localized EGAC (T3, T4aN0, or node-positive disease) in this open-label, single-arm, multicenter, Phase II trial between January 2020 and October 2022. Patients received three cycles of IC with trifluridine/tipiracil and oxaliplatin and then underwent concurrent CRT with weekly carboplatin and paclitaxel followed by surgery. The primary objective was to evaluate the pCR rate. The secondary objectives were to evaluate 2-year progression-free survival (PFS), 2-year overall survival (OS), and toxicities. Circulating tumor DNA (ctDNA) was measured at prespecified intervals to assess its correlation with clinical outcomes.

RESULTS

Of the 22 enrolled patients, 19 (86.4%) were male and 20 (90.9%) were Caucasian. The median age was 61 years, and 12 (54.5%) had their primary disease at the gastroesophageal junction. Twenty (90.9%) patients had T3 disease, and 15 (68.2%) had node-positive disease. Only two patients had pCRs, and an additional five had near pCRs. Since we could not meet our predefined pCR rate at the interim analysis, the study was closed. After a median follow-up of 15.8 months, 2-year OS and PFS were 43% and 41%, respectively. ctDNA clearance was associated with a significantly higher OS rate (p = 0.012) and PFS rate (p = 0.008). Nausea (59.1%) and fatigue (59.1%) were common treatment-related adverse events (AEs); nine (40.9%) patients had Grade 3 or higher AEs.

CONCLUSION

IC with trifluridine/tipiracil and oxaliplatin followed by CRT did not improve pCR rate in resectable EGAC compared to pCR from previous reports with CRT alone. We found a correlation between ctDNA clearance and improved survival, which merits further investigation.

CLINICAL TRIAL INFORMATION

NCT04097028.

Evaluation of prognostic models to improve prediction of metastasis in patients following potentially curative treatment for primary colorectal cancer: the PROSPECT trial

Background

Despite apparently curative treatment, many patients with colorectal cancer develop subsequent metastatic disease. Current prognostic models are criticised because they are based on standard staging and omit novel biomarkers. Improved prognostication is an unmet need.

Objectives

To improve prognostication for colorectal cancer by developing a baseline multivariable model of standard clinicopathological predictors, and to then improve prediction via addition of promising novel imaging, genetic and immunohistochemical biomarkers.

Design

Prospective multicentre cohort.

Setting

Thirteen National Health Service hospitals.

Participants

Consecutive adult patients with colorectal cancer.

Interventions

Collection of prespecified standard clinicopathological variables and more novel imaging, genetic and immunohistochemical biomarkers, followed by 3-year follow-up to identify postoperative metastasis.

Main outcome

Best multivariable prognostic model including perfusion computed tomography compared with tumour/node staging. Secondary outcomes: Additive benefit of perfusion computed tomography and other biomarkers to best baseline model comprising standard clinicopathological predictors; measurement variability between local and central review; biological relationships between perfusion computed tomography and pathology variables.

Results

Between 2011 and 2016, 448 participants were recruited; 122 (27%) were withdrawn, leaving 326 (226 male, 100 female; mean ± standard deviation 66 ± 10.7 years); 183 (56%) had rectal cancer. Most cancers were locally advanced [≥ T3 stage, 227 (70%)]; 151 (46%) were node-positive (≥ N1 stage); 306 (94%) had surgery; 79 (24%) had neoadjuvant therapy. The resection margin was positive in 15 (5%); 93 (28%) had venous invasion; 125 (38%) had postoperative adjuvant chemotherapy; 81 (25%, 57 male) developed recurrent disease. Prediction of recurrent disease by the baseline clinicopathological time-to-event Weibull multivariable model (age, sex, tumour/node stage, tumour size and location, treatment, venous invasion) was superior to tumour/node staging: sensitivity: 0.57 (95% confidence interval 0.45 to 0.68), specificity 0.74 (95% confidence interval 0.68 to 0.79) versus sensitivity 0.56 (95% confidence interval 0.44 to 0.67), specificity 0.58 (95% confidence interval 0.51 to 0.64), respectively. Addition of perfusion computed tomography variables did not improve prediction significantly: c-statistic: 0.77 (95% confidence interval 0.71 to 0.83) versus 0.76 (95% confidence interval 0.70 to 0.82). Perfusion computed tomography parameters did not differ significantly between patients with and without recurrence (e.g. mean ± standard deviation blood flow of 60.3 ± 24.2 vs. 61.7 ± 34.2 ml/minute/100 ml). Furthermore, baseline model prediction was not improved significantly by the addition of any novel genetic or immunohistochemical biomarkers. We observed variation between local and central computed tomography measurements but neither improved model prediction significantly. We found no clear association between perfusion computed tomography variables and any immunohistochemical measurement or genetic expression.

Limitations

The number of patients developing metastasis was lower than expected from historical data. Our findings should not be overinterpreted. While the baseline model was superior to tumour/node staging, any clinical utility needs definition in daily practice.

Conclusions

A prognostic model of standard clinicopathological variables outperformed tumour/node staging, but novel biomarkers did not improve prediction significantly. Biomarkers that appear promising in small single-centre studies may contribute nothing substantial to prognostication when evaluated rigorously.

Future work

It would be desirable for other researchers to externally evaluate the baseline model.

Trial registration

This trial is registered as ISRCTN95037515.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 09/22/49) and is published in full in Health Technology Assessment; Vol. 29, No. 8. See the NIHR Funding and Awards website for further award information.

No operation after short-course radiotherapy followed by consolidation chemotherapy in locally advanced rectal cancer (NOAHS-ARC): study protocol for a prospective, phase II trial

PURPOSE

Organ preservation through a watch-and-wait (W&W) strategy has become a viable option for select rectal cancer patients with clinical complete responses (cCR) to total neoadjuvant therapy (TNT). This approach limits the morbidity associated with multimodal treatment. However, the optimal treatment strategy and predictors of treatment response are still unresolved. Rectal cancer incidence is rising, particularly in developing countries, and the disease is a major public health concern in Chile. Prior to the no operation after short-course radiotherapy followed by consolidation chemotherapy in locally advanced rectal cancer (NOAHS-ARC) trial, TNT-based treatments and W&W programs had not been implemented in Chile.

METHODS/DESIGN

This single-arm, multicenter, phase II prospective trial, conducted in Santiago, Chile, will enroll patients with stage II/III rectal adenocarcinoma. Treatment involves induction short-course radiotherapy (25 Gy in 5 fractions) followed by consolidation chemotherapy (FOLFOX × 9 or CAPOX × 6 cycles). The response will be assessed 4-8 weeks after chemotherapy completion. Patients achieving cCR will be offered W&W, while those with incomplete responses will undergo total mesorectal excision. The primary endpoint is the rate of complete tumor response, combining pathologic complete responses (pCR) and sustained cCR (> 1 year), compared to a matched cohort treated with neoadjuvant chemoradiation alone. The trial aims to recruit 48 patients, assuming a combined pCR/sustained cCR rate of 12%. Quality of life measures will be assessed, and a biorepository of tissue and plasma samples will be established for future research, alongside serial endoscopic and MRI images.

DISCUSSION

NOAHS-ARC seeks to advance organ preservation strategies in rectal cancer while pioneering TNT and W&W protocols in Chile. The study will also focus on functional outcomes and provide valuable data for improving patient care both locally and globally.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT04864067. Registered on April 28, 2021.

Rectal cancer - French intergroup clinical practice guidelines for diagnosis, treatment, and follow-up (TNCD, SNFGE, FFCD, GERCOR, UNICANCER, SFCD, SFED, SFRO, ACHBT, SFP, RENAPE, SNFCP, AFEF, SFR, and GRECCAR)

BACKGROUND

This article summarizes the French intergroup guidelines regarding rectal adenocarcinoma (RA) management published in September 2023, available on the French Society of Gastroenterology website.

METHODS

This work was supervised by French medical and surgical societies involved in RA management. Recommendations were rated from A to C according to the literature until September 2023.

RESULTS

Based on the pretreatment work-up, RA treatment was divided into four groups. T1N0 can be treated by endoscopic or surgical excision alone if there is no risk factor for lymph node involvement. For T2N0, radical surgery with total mesorectal excision is recommended, but rectal conservation is possible for small tumors (<4cm) after complete/subcomplete response following chemoradiotherapy. For T12N+ or T3+any N, total neoadjuvant treatment (TNT) followed by radical surgery is the gold standard, but rectal conservation is possible for small tumors after complete/subcomplete response following TNT. T3N2 or T+any N are an indication for TNT followed by radical surgery. Immunotherapy shows promise for dMMR/MSI RA. For metastatic tumors, recommendations are based on less robust evidence and chemotherapy plays a major role.

CONCLUSION

These guidelines aim at providing a personalized therapeutic strategy and are constantly being optimized. Each case should be discussed by a multidisciplinary team.

Neuroendocrine differentiation and serotonin expression in oesophageal adenocarcinomas after neoadjuvant therapy: correlation with clinicopathological features and outcome

AIMS

Oesophageal adenocarcinoma (EAC) is a glandular or mucinous epithelial malignancy that can show immunohistochemical evidence of neuroendocrine differentiation (NED) and express the hormone serotonin. The objective of this study was to correlate the presence of NED and serotonin with clinicopathological characteristics and patient outcome after neoadjuvant chemoradiation.

METHODS AND RESULTS

A retrospective cohort of patients treated between 2002 and 2021 was established and included 218 oesophagectomy specimens with residual tumour. Representative full-face sections of tumour were stained for synaptophysin, chromogranin-A and serotonin by immunohistochemistry, and staining results were correlated with disease-free survival (DFS) and overall survival (OS). In total, 129 (59%) tumours showed evidence of NED, defined as immunohistochemical expression of synaptophysin or chromogranin-A, while 40 (18%) showed evidence of NED and expressed serotonin. Patients with neuroendocrine-positive tumours had significantly shorter median OS compared to those with neuroendocrine-negative tumours (22.5 versus 48.8 months, P = 0.006), but similar median DFS (13.3 versus 17.8 months, P = 0.34). Using Cox regression, the association between NED and OS was significant in univariate [hazard ratio (HR) = 1.68, 95% confidence interval (CI) = 1.16-2.45] and multivariate (HR = 1.65, 95% CI = 1.08-2.52) analysis. Patients with serotonin-expressing tumours had similar median OS (21.7 versus 25.9 months, P = 0.24) and DFS (7.3 versus 15.6 months, P = 0.12) compared to those with NED but lacking serotonin. Using Cox regression, serotonin expression was associated with reduced OS in univariate (HR = 1.62, 95% CI = 1.06-2.47) but not multivariate (HR = 1.03, 95% CI = 0.64-1.65) analysis.

CONCLUSIONS

Our findings support NED as independent predictor of OS in EAC after neoadjuvant chemoradiation. While a subset of tumours with NED expressed serotonin, this did not provide additional prognostic information.

Safety and clinical efficacy of neoadjuvant chemoradiation therapy with immunotherapy for organ preservation in ultra-low rectal cancer: preliminary results of the CHOICE-I trial: a prospective cohort study

OBJECTIVE

To explore the safety and efficacy of neoadjuvant chemoradiotherapy (nCRT) combined with a PD-1 antibody in improving complete clinical response (cCR) and organ preservation in patients with ultra-low rectal cancer.

METHODS

This was a prospective phase II, single-arm, open-label trial. Patients with confirmed pMMR status T 1-3a N 0-1 M 0 retcal adenocarcinoma were included. Long-course chemoradiotherapy was delivered to a dose of 50 Gy. A PD-1 antibody was added 2 weeks after the first radiotherapy session, and two courses were administered. After chemoradiotherapy, CapeOX plus PD-1 antibody was administered to patients for two cycles. After evaluation, patients with cCR were managed with a watch-and-wait (W&W) approach. Local excision or a W&W approach was performed for patients with near complete clinical response (ncCR) as per multidisciplinary team decision. Radical surgery was recommended for poorly regressed or progressed tumors.

RESULTS

Twenty-five patients were enrolled, but two patients withdrew from the study. A total of 23 patients completed the entire neoadjuvant therapy. Ten and five patients achieved cCR and ncCR, respectively, and the rest had a partial clinical response. Patients with cCR were managed with W&W. Four patients with ncCR underwent local excision and were managed using W&W. Eight patients with partial clinical response underwent anus-preserving surgery. At the last follow-up, the rectum and anus preservation rates were 63.4% (14/22) and 95.5% (21/22), respectively.

CONCLUSION

nCRT combined with immunotherapy tended to achieve better cCR and rectum preservation rates with good tolerance in patients.

Predicting complete response to neoadjuvant chemoradiotherapy in locally advanced rectal cancer: The role of baseline volumetric 18F-FDG PET/CT parameters and inflammatory markers

OBJECTIVES

We evaluated the influence of baseline volumetric 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) parameters and inflammatory prognostic markers on complete response (CR) in patients with locally advanced rectal cancer (LARC) treated with neoadjuvant chemoradiotherapy (nCRT).

MATERIALS AND METHODS

In total, 90 patients with LARC, including those with and without CR, were evaluated based on baseline volumetric PET/CT parameters, such as maximum standard uptake value, metabolic tumor volume (MTV), tumor lesion glycolysis, and inflammatory prognostic markers, including the lymphocyte-to-monocyte ratio, platelet-to-lymphocyte ratio (PLR), and neutrophil-to-lymphocyte ratio.

RESULTS

Of the 90 patients, 62 (68.9%) were male and 28 (31.1%) were female. The median age was 61 (31-81) years. A complete response was observed in 20 (22%) patients following nCRT. Of these, 5 demonstrated a clinical complete response, whereas 15 exhibited a complete response after surgery. A low pretreatment PLR, low MTV levels, and stage 2 disease were identified as significant predictors of complete response. The optimal cutoff values were 16.5 for MTV (sensitivity 80%, specificity 62%) and 121 for PLR (sensitivity 73%, specificity 65%).

CONCLUSION

Our findings suggest that stage 2 disease, low pretreatment MTV, and low PLR levels may be predictive of a CR to nCRT in patients with LARC.

Prognostic Value of Tumor Regression Grade Combined with Pathological Lymph Node Status in Initially Node-Positive Rectal Cancer Treated with Neoadjuvant Chemoradiotherapy

BACKGROUND

The prognostic value of tumor regression grade (TRG) after neoadjuvant chemoradiotherapy for rectal cancer is inconsistent in the literature. Both TRG and post-therapy lymph node (ypN) status could reflect the efficacy of neoadjuvant therapy. Here, we explored whether TRG combined with ypN status could be a prognostic factor for MRI-based lymph node-positive (cN+) rectal cancer following neoadjuvant chemoradiotherapy.

METHODS

671 cN + rectal cancer patients who received neoadjuvant chemoradiotherapy followed by radical resection were enrolled. Patients were innovatively divided into three groups based on TRG and ypN status: TRG0-1N0, TRG2-3N0 or TRG0-1N+, TRG2-3N+. Kaplan-Meier method and log-rank test were used to compare the disease-free survival (DFS) and overall survival (OS) among three groups. Univariate and multivariate analyses were performed to explore the prognostic value of the modified TRG in cN + rectal cancer following neoadjuvant chemoradiotherapy.

RESULTS

The mean duration of follow-up was 30.4 months. Significant survival differences were observed among the three groups. The 3-year DFS were 83.0%, 69.2% and 55.9%, respectively. The 5-year OS were 83.5%, 80.4% and 57.8%, respectively. TRG combined with ypN status was an independent predictor for both DFS and OS in multivariate analysis.

CONCLUSION

TRG combined with ypN status is a novel prognostic factor in cN + rectal cancer following neoadjuvant chemoradiotherapy, which assists clinicians make appropriate decisions regarding postoperative treatment and surveillance.

Beta-2-microglobulin positive tumor cells and CD8 positive lymphocytes are associated with outcome in post-neoadjuvant colorectal cancer resections

Locally advanced colorectal cancers are treated with neoadjuvant therapy (NAT), which has been shown to alter the characteristics of the tumor including size, lymph node yield, and histologic grade. We seek to interrogate the effect of NAT on the immune microenvironment. We compared 190 patients with colorectal adenocarcinoma treated with NAT with those without NAT (n = 926). We evaluated clinicopathologic and molecular factors and performed immunohistochemistry and quantification on tissue microarrays for HLA class I/II proteins, beta-2-microglobulin (B2M), CD8, CD163, LAG3, PD-L1, and FoxP3. Patients in the NAT group were younger (60.9 vs 67.9, p < 0.001) and more often male (59.5 vs. 47.9, p = 0.004) than those in the non-NAT group. Tumors in the NAT group were smaller (3.5 vs 4.7 cm, p < 0.001), less often high grade (6.5% vs. 16.2%, p = 0.001), more frequently in the rectum (68.9% vs. 6.6%, p < 0.001) and associated with lower lymph node yields (p = 0.002); however, the incidence of extramural venous invasion, perineural invasion, and AJCC stage 3-4 disease were not different. Immune cells positive for CD8 (p = 0.011) were significantly lower in the NAT group. A high number of CD8+ cells and higher expression of B2M in tumor cells showed a significant survival benefit in both NAT and non-NAT group. NAT is associated with an immune-low tumor environment. CD8+ cells and tumor B2M expression may help identify a subset of immune high-tumors following NAT. This identification could aid in determining patients who may benefit from conservative management of colorectal carcinomas.

Korean Practice Guidelines for Gastric Cancer 2024: An Evidence-based, Multidisciplinary Approach (Update of 2022 Guideline)

Gastric cancer is one of the most common cancers in both Korea and worldwide. Since 2004, the Korean Practice Guidelines for Gastric Cancer have been regularly updated, with the 4th edition published in 2022. The 4th edition was the result of a collaborative work by an interdisciplinary team, including experts in gastric surgery, gastroenterology, endoscopy, medical oncology, abdominal radiology, pathology, nuclear medicine, radiation oncology, and guideline development methodology. The current guideline is the 5th version, an updated version of the 4th edition. In this guideline, 6 key questions (KQs) were updated or proposed after a collaborative review by the working group, and 7 statements were developed, or revised, or discussed based on a systematic review using the MEDLINE, Embase, Cochrane Library, and KoreaMed database. Over the past 2 years, there have been significant changes in systemic treatment, leading to major updates and revisions focused on this area. Additionally, minor modifications have been made in other sections, incorporating recent research findings. The level of evidence and grading of recommendations were categorized according to the Grading of Recommendations, Assessment, Development and Evaluation system. Key factors for recommendation included the level of evidence, benefit, harm, and clinical applicability. The working group reviewed and discussed the recommendations to reach a consensus. The structure of this guideline remains similar to the 2022 version. Earlier sections cover general considerations, such as screening, diagnosis, and staging of endoscopy, pathology, radiology, and nuclear medicine. In the latter sections, statements are provided for each KQ based on clinical evidence, with flowcharts supporting these statements through meta-analysis and references. This multidisciplinary, evidence-based gastric cancer guideline aims to support clinicians in providing optimal care for gastric cancer patients.

HALP Score in Predicting Response to Treatment in Patients with Early-Stage Gastric Cancer: A Multi-Centred Retrospective Cohort Study

Background and Objectives: The HALP (Haemoglobin, Albumin, Lymphocyte and Platelet) score is used to predict the prognosis of different types of cancer. This study aimed to investigate the role of the HALP score in predicting pathological response in early-stage gastric cancer patients. Materials and Methods: This retrospective cohort study was conducted on 118 patients diagnosed with early-stage gastric cancer and subjected to perioperative (FLOT) treatment between 2018 and 2023. The role of the HALP score in predicting the pathological response to perioperative treatment in patients was investigated. Results: The mean age of the 118 patients included in the study was 61.3 ± 11.1 (min = 23; max = 86). In the ROC analysis, the optimum cut-off value for the HALP score in pathological response classification was found to be 28.9 (AUC = 0.710, sensitivity = 56.7%, specificity = 80%, PPV = 86.79%, NPV = 46.15%). The pathological response rate was 69% in all patients, 87% in patients with a HALP score ≥ 28.9, and 52% in patients with a HALP score < 28.9 (p < 0.001). The probability of pathological response is 6.5 times higher in patients with a HALP score ≥ 28.9. In the Fagan nomogram, when the HALP score was ≥28.9, our pathological response probability estimate (post-test response probability) was found to increase to 64.8% (Positive Likelihood Ratio = 3, Negative Likelihood Ratio = 0.53). In patients with HALP scores ≥ 28.9 and <28.9, progression rates were 16.7% and 47.8%, respectively (p < 0.001), and median survival times were 45.4 and 30.6 months (p < 0.001). Conclusions: The HALP score is a useful and easily accessible score for determining pathological responses in patients with locally advanced gastric cancer.

Neoadjuvant Capecitabine in Operable HPV-Negative Head and Neck Cancer: Fortuitous Findings in a Resource Constrained Setting

OBJECTIVE

Limited progress has occurred in treating operable human papillomavirus (HPV)-negative head and neck squamous cell carcinoma (HNSCC). Accessing timely care remains challenging in public health care systems, potentially resulting in disease progression before treatment initiation.

STUDY DESIGN

A prospective cohort of patients receiving neoadjuvant capecitabine (NC) was compared to stage-matched patients undergoing standard of care (SC).

SETTING

This study was performed at 2 academic centers in Montreal, Canada.

METHODS

To ascertain the effect of 2 cycles of NC in operable HPV-negative HNSCC patients on clinical-to-pathologic stage migration. Comparison to an SC group was performed to site and TNM stage matched patients. Pathologic treatment response was measured using the modified Ryan score.

RESULTS

We compared 16 NC patients (11 oral cavity, 3 skin, 2 larynx) with 32 SC patients. Ten NC patients exhibited a pathologic response (1 complete, 3 major, 6 minor). Clinical-to-pathologic stage migration differed significantly between NC and SC groups: downstage (6 vs 1), upstage (3 vs 14), no change (7 vs 17, P = .0047). There was no severe treatment toxicity related to capecitabine. All patients in the NC group underwent surgery.

CONCLUSION

NC followed by surgery demonstrates measurable pathologic response in HPV-negative HNSCC, suggesting potential utility in resource-limited health care settings.

Molecular biomarkers for predicting complete response to preoperative chemoradiation in people with locally advanced rectal cancer

OBJECTIVES

This is a protocol for a Cochrane Review (prognosis). The objectives are as follows: Primary objectives To identify and estimate the prognostic value of molecular biomarkers as predictors of pathological complete response to neoadjuvant chemoradiotherapy in people with locally advanced rectal cancer. summarises the review question in population, index prognostic factor, comparator prognostic factor(s), outcome, timing, and setting (PICOTS) format. [Table: see text] [Figure: see text] Secondary objectives To explore the following biomarker measurement, treatment, and study design factors as possible sources of heterogeneity in the association between the prognostic factor and pathological response: type of assay/measurement method, biomarker positivity criteria or cut-off point, chemotherapy regimen, and radiotherapy regimen.

Total neoadjuvant therapy followed by total mesorectal excision for rectal cancer in older patients real world data and proof of concept

Background

Rectal cancer (RC) commonly affects older patients. Total Neoadjuvant Therapy (TNT) has been introduced to improve local and systemic control of RC. The aim was to present real-world data of older patients receiving TNT followed by surgery after a frailty assessment and verify feasibility and safety of this approach.

Methods

This was a single-center retrospective study which enrolled all patients ≥70 years of age with RC who underwent TNT followed by surgery between November 2017 and April 2022. Data regarding cancer characteristics, neoadjuvant chemoradiotherapy (CRT), and toxicity were recorded. All patients underwent surgery 12-16 weeks after the end of therapy. Intra- and postoperative outcomes were recorded. Pre- and postoperative functional evaluation was carried out.

Results

Fifteen patients were enrolled. Mean age was 74 (70-81) years. Mean distance of the tumor from the anal verge was 5.2 cm. Fourteen patients had positive nodes (93.3%), 11 (73.3%) showed involvement of the circumferential margin (CRM+) and 10 (66.6%) had extramural vascular invasion (EMVI+). Ten patients (66.6%) received mFOLFOX-6 and 5 CAPOX (33.3%) followed by CRT. After CRT, positive nodes were reported in 4 cases (26.6%), CRM+ in 4 (26.6%), and EMVI+ in 1 (6.6%). Transanal total mesorectal excision (taTME) was performed in all cases. Median operative time was 280 min (110-420). Median length of stay was 4 days (3-29). One Clavien-Dindo grade 4 complication, no readmissions, and no variations in pre- and postoperative functional status within 30 days from surgery were reported. No positive distal or CRMs were detected. Three pathologic complete responses were reported (20%).

Conclusions

TNT followed by TME is feasible and safe in older patients, with good clinical and oncologic outcomes. Patient evaluation is crucial for maximizing cancer care in fit older patients.

Rectal Cancer and Lateral Lymph Node Staging: Interobserver Agreement and Success in Predicting Locoregional Recurrence

Objectives: To evaluate the agreement among radiologists in the evaluation of rectal cancer staging and restaging (after neoadjuvant therapy) and assess whether locoregional recurrence can be predicted with this information. Materials and Methods: Pre-neoadjuvant and after-neoadjuvant therapy magnetic resonance imaging (MRI) examinations of 239 patients diagnosed with locally advanced rectal cancer were retrospectively reviewed by three radiologists. The agreement between the MRI findings (localization of tumor involvement, tumor coverage pattern, external sphincter involvement, mucin content of the mass and lymph node, changes in the peritoneum, MRI T stage, distance between tumor and MRF, submucosal sign, classification of locoregional lymph node, and EMVI) was discussed at the September 2023 meeting of the Society of Abdominal Radiology (SAR) and the interobserver and histopathological findings were examined. The patients were evaluated according to locoregional rectal cancer and lateral lymph node (LLN) staging, and re-staging was performed using MRI images after neoadjuvant treatment. The ability of the locoregional and LLN staging system to predict locoregional recurrence was evaluated. Results: Among the parameters examined, for the MRI T stage and distance between the tumor and the MRF, a moderate agreement (kappa values: 0.61-0.80) was obtained, while for all other parameters, the interobserver agreement was notably high (kappa values 0.81-1.00). LLNs during the restaging with an OR of 2.1 (95% CI = 0.33-4.87, p = 0.004) and a distance between the tumor and the MRF of less than 1 mm with an OR of 2.1 (95% CI = 1.12-3.94, p = 0.023) affected locoregional recurrence. A multivariable Cox regression test revealed that the restaging of lymph nodes among the relevant parameters had an impact on locoregional recurrence, with an OR of 1.6 (95% CI = 0.32-1.82, p = 0.047). With the LLN staging system, an increase in stage was observed in 37 patients (15.5%), and locoregional recurrence was detected in 33 of them (89.2%) (p < 0.001). Conclusions: LLN staging is not only successful in predicting locoregional recurrence among MRI parameters but is also associated with a very high level of interobserver agreement. The presence of positive LLN in the restaging phase is one of the most valuable MRI parameters for poor prognosis.

Evaluation of Volumetric Magnetic Resonance Imaging in Determining the Indication for Total Neoadjuvant Therapy in Rectal Cancer

BACKGROUND

This study aims to evaluate the relationship between volumetric measurements of residual tumor via magnetic resonance imaging (MRI) and pathologic complete response (pCR) in rectal cancer patients undergoing neoadjuvant chemoradiotherapy (nCRT).

METHODS

Patients with locally advanced rectal cancer who had pelvic MRI for clinical staging and completed nCRT followed by radical resection were included. Two experienced radiologists measured tumor volume on MRI obtained before and after nCRT. We compared the pre- and post-CRT tumor volume and measured tumor volume reduction rates.

RESULTS

The median value of tumor volume reduction rate in all patients was 64.7% (min-max - 81.1-98.1%). When the relationship between tumor volume and tumor regression grade (TRG) after nCRT was assessed, it was found that 18 of 21 (86%) patients with a good response (TRG 1) had a post-CRT tumor volume of ≤ 8 cm3 (p = 0.001). While 9 of 10 patients with pCR after nCRT had a tumor volume of ≤ 8 cm3, one patient had pCR despite having a tumor volume greater than 8 cm3 (p = 0.015).

CONCLUSION

The correlation between post-nCRT residual tumor volume and pCR underscores the potential of volumetric MRI as a predictive tool in tailoring rectal cancer treatment. For patients with residual tumor volumes greater than 8 cm3, extending neoadjuvant chemotherapy as part of TNT may enhance the likelihood of achieving pCR. This approach advocates for a more personalized treatment strategy, potentially optimizing outcomes for rectal cancer patients.

Neoadjuvant Chemotherapy vs Chemoradiotherapy for Malignancy of Esophagus: A Prospective Comparative Study

INTRODUCTION

Neoadjuvant chemoradiation (NACRT) followed by surgery has become the standard of care for esophageal squamous cell carcinoma (ESCC). This study compared the tolerability and oncological benefit of neoadjuvant chemotherapy (NACT) with those of NACRT for the treatment of ESCC.

METHODS

A prospective quasi-experimental comparative study was conducted from July 2019 to August 2023 to assess the efficacy of the NACT regimen of two cycles of paclitaxel and carboplatin as an alternative to standard NACRT. Either NACT or NACRT was given to patients with resectable ESCC (clinical stage IB-IIIC), after which they underwent minimally invasive esophagectomy with two-field lymphadenectomy. Radiological and pathological responses to neoadjuvant therapy, perioperative morbidity, mortality, and recurrence-free and overall survival rates were compared.

RESULTS

Out of the 74 patients enrolled, 63 were included in the study after exclusion. Of these, 30 received NACT, and 33 received NACRT. The baseline demographics, tumor characteristics, incidence of neoadjuvant therapy-related adverse events, and perioperative morbidity were comparable between the two groups. The median number of lymph nodes retrieved (21 vs 19, p=0.19) and R0 resection rate (100% vs 94%) were similar. Although the pathological response was significantly better in the NACRT arm, at a median follow-up of 32.5 (20.75-48) months, there was a non-significant trend toward better recurrence-free survival in the NACRT group (57 vs 36 months, p-value - 0.831), with median overall survival yet to be achieved in both groups.

CONCLUSION

Compared with NACRT, NACT for ESCC is well tolerated and has non-inferior oncological outcomes. NACT could be a feasible alternative to NACRT in such patients, especially if the radiotherapy option is not feasible or available.

Analysis of the therapeutic effect and influencing factors on unresectable gastric cancer treated with conversion therapy

Background

Gastric cancer (GC) is one of the leading causes of cancer-related death in China, and with the extensive development of conversion therapy, the treatment of advanced unresectable gastric cancer (AUGC) patients has ushered in a new dawn. This study aimed to analyze the efficacy of conversion therapy in AUGC patients and explored the relevant factors affecting the efficacy.

Method

We collected information from GC patients who received conversion therapy from this center and designed a retrospective study.

Results

We collected relevant clinical data from 160 patients with AUGC. A total of 120 patients who underwent routine R0 resection were identified as conversion cases. A total of 25 patients (15.6%) achieved pCR, 92 patients (57.5%) achieved objective response rate (ORR), 140 patients (87.5%) achieved disease control rate (DCR), and 20 cases (12.5%) observed tumor progression. There were 86 patients who achieved pathological downgrading, with a total downgrading rate of 53.8%. Among the 160 patients, 37 patients (23.1%) had postoperative complications of varying degrees. A total of 72 patients (45.0%) had tumor recurrence/progression at the end of follow-up. The last chemotherapy and surgery (CST) (OR = 1.046, 95% CI 1.013-1.081, p = 0.006), tumor invasion (OR = 32.096, 95% CI 5.091-202.349, p < 0.001), and distant metastasis (OR = 7.050, 95% CI 1.888-26.323, p = 0.004) were independent factors influencing the efficacy of conversion therapy.

Conclusion

Conversion therapy may have a good therapeutic efficacy for AUGC, and some clinical factors affect the efficacy response.

Circulating Neoplastic-Immune Hybrid Cells Are Biomarkers of Occult Metastasis and Treatment Response in Pancreatic Cancer

BACKGROUND/OBJECTIVES

Pancreatic ductal adenocarcinoma (PDAC) presents significant diagnostic and prognostic challenges, as current biomarkers frequently fail to accurately stage disease, predict rapid metastatic recurrence (rPDAC), or assess response to neoadjuvant therapy (NAT). We investigated the potential for circulating neoplastic-immune hybrid cells (CHCs) as a non-invasive, multifunctional biomarker for PDAC.

METHODS

Peripheral blood specimens were obtained from patients diagnosed with PDAC. CHCs were detected by co-expression of pan-cytokeratin and CD45, normalized to 50,000 peripheral blood mononuclear cells. rPDAC was defined as metastatic recurrence within six months of margin-negative pancreatectomy. Cyclic immunofluorescence (CyCIF) analyses compared hybrid phenotypes in blood and tumors.

RESULTS

Blood samples were collected from 42 patients with PDAC prior to resection. Those with radiographically occult metastatic disease and rPDAC had higher preoperative CHC numbers compared to patients who did not (65.0 and 74.4, vs. 11.52 CHCs; p < 0.001). Patients with complete or near-complete pathologic responses to NAT had lower preoperative CHC numbers than partial and/or non-responders (1.7 vs. 13.1 CHCs; p = 0.008). When assessed longitudinally, those with partial pathologic response saw CHC levels become undetectable while on treatment but increase in the interval between NAT completion and resection. In contrast, patients with poor responses or development of metastatic disease experienced persistent CHC detection during therapy or rising levels prior to radiographic evidence of metastases. Further, in metastatic PDAC patients, treatment-induced phenotypic changes in hybrid cells mirrored those in paired metastatic tumor samples.

CONCLUSIONS

CHC enumeration and phenotyping display promise as a real-time indicator of disease burden, recurrence risk, and treatment response in PDAC. CHCs have great potential as tumor-derived biomarkers to optimize therapeutic strategies and improve survival in patients with PDAC.

Lymphocyte-to-monocyte, platelet-to-albumin and platelet-to-lymphocyte ratios as prognostic biomarkers for neoadjuvant treatment response in rectal cancer patients

INTRODUCTION

Systemic inflammatory response (SIR) indicators are an emerging category of serum biomarkers with significant potential as prognostic and predictive factors in various types of cancers The primary focus of our study was to determine the prognostic value of the lymphocyte-to-monocyte ratio (LMR), platelet-to-albumin ratio (PLR) and platelet-to-albumin ratio (PAR) in evaluating the response to neoadjuvant treatment for patients with rectal cancer.

MATERIALS AND METHODS

We included 99 consecutive patients with rectal cancer which were admitted for surgery in our institution after completing a standard neoadjuvant radio-chemotherapy regimen. Several hematologic parameters, including LMR, PAR and PLR, were calculated by collecting and analyzing blood samples preoperatively. Cases were divided into groups using ROC curve analysis to determine optimal cutoff values for each of the investigated parameters. Treatment response was assessed through histopathological analysis of the resected specimens.

RESULTS

PLR values over 215.2 were correlated with the presence of lymph node metastasis. A similar correlation was observed between PAR values over 41.89 and lymph node positivity. A significant correlation was observed between the presence of tumor budding on histopathological analysis and high-PAR values. A statistically significant correlation between a high PLR and a good response to neoadjuvant treatment was determined.

CONCLUSIONS

High PLR values may be associated with a more favorable treatment response to neoadjuvant radio-chemotherapy. A high PAR may be associated with unfavorable histopathological characteristics. Further studies on these readily available biomarkers are required in order to validate their clinical utility.

Development of a Composite Score Based on Carbohydrate Antigen 19-9 Dynamics to Predict Survival in Carbohydrate Antigen 19-9-Producing Patients With Pancreatic Ductal Adenocarcinoma After Neoadjuvant Treatment

PURPOSE

Dynamics of carbohydrate antigen 19-9 (CA19-9) often inform treatment decisions during and after neoadjuvant chemotherapy (NAT) of patients with pancreatic ductal adenocarcinoma (PDAC). However, considerable dispute persists regarding the clinical relevance of specific CA19-9 thresholds and dynamics. Therefore, we aimed to define optimal thresholds for CA19-9 values and create a biochemically driven composite score to predict survival in CA19-9-producing patients with PDAC after NAT.

METHODS

Patients with PDAC who underwent NAT and surgical resection from 2012 to 2022 were retrospectively identified from three high-volume centers. CA19-9 nonproducers and patients with 90-day mortality, and macroscopically incomplete resections were excluded. A composite score was created on the basis of relative CA19-9 change and newly defined optimal thresholds of pre- and postneoadjuvant values for overall survival (OS) using patients from two centers and validated using data from the third center.

RESULTS

A total of 492 patients met inclusion criteria in the development cohort. Optimal CA19-9 cutoff values for predicting a difference in OS were 202 U/mL for preneoadjuvant and 78 U/mL for postneoadjuvant levels. Furthermore, increase in CA19-9 during neoadjuvant treatment was associated with worse OS (median-OS, 17.5 months v 26.0 months; P = .008). Not surpassing any or only one of these thresholds (composite score of 0-1) was associated with improved OS compared with patients with 2-3 points (median-OS, 29.9 months v 15.8 months; P < .001). Major serological response (90% decrease of CA19-9) had a positive and negative predictive value of 32% and 88%, respectively.

CONCLUSION

The composite score consisting of CA19-9 levels at diagnosis, after neoadjuvant treatment, and its dynamics demonstrates prognostic discrimination between low and high scores. However, better predictive biomarkers are needed to facilitate treatment decisions during neoadjuvant treatment.

Results of an Integrated Phase I/II Prospective Clinical Trial (NEXIS) for Neoadjuvant Anti-PD-L1 (Durvalumab) and Anti-CTLA-4 (Tremelimumab) With Radiation for High-Risk Soft-Tissue Sarcoma of the Trunk and Extremities

Background The current management of large, high-grade soft tissue sarcoma (STS) of the trunk and extremities includes radiation and surgical resection. The initial use of chemotherapy and targeted therapy are controversial and although most patients present with localized disease, many eventually develop incurable metastases. The results and analysis of the safety and antitumor activity of combined checkpoint inhibitor immunotherapy with neoadjuvant radiation for high-risk primary STS are presented here. Methods This was an integrated phase I/II prospective single-arm trial (Nutrition and Exercise in Critical Illness Trial (NEXIS) trial). Eligible patients were age ≥18 years with histologically confirmed intermediate or high-grade STS of the trunk or extremity ≥5 cm diameter and were Eastern Cooperative Oncology Group performance status 0-1. The treatment algorithm included neoadjuvant anti-PD-L1 (Durvalumab) and anti-CTLA-4 (Tremelimumab) for three cycles of four weeks/cycle along with external beam radiation for five weeks, followed by wide surgical resection, and adjuvant Durvalumab monotherapy for four cycles. High-grade toxicity was continually assessed for the first 12 patients in phase I and the primary endpoint for phase II was an excellent histological response (grade 0 or 1 score on a semi-quantitative assessment for tumor regression). This study was registered with ClinicalTrials.gov, number NCT03116529. Findings Between October 2017 and November 2021, 23 patients were enrolled. Five patients had progression of distant disease during neoadjuvant treatment and withdrew from the study before surgery. A total of 18 patients who completed at least the neoadjuvant immunotherapy, radiation and surgery were included for analysis. The most common tumor was undifferentiated pleomorphic sarcoma (n=9, 50%). The occurrence of any adverse event (AE) was recorded in 16 (88.9%) patients, and 3 (16.7%) patients had a serious AE. Eight out of 18 patients (44.4%) had disease-free survival at a median of 39.7 months. Four out of 18 patients (22.2%) were alive-with-disease at a median of 37.1 months from diagnosis of distant metastasis, and six out of 18 (33.3%) died of disease at a median of 20.8 months from diagnosis of distant metastasis. Local recurrence occurred in two patients (11.1%) and was concomitant with distant disease in each case. Based on Response Evaluation Criteria in Solid Tumors v1.1, a partial response was noted in five (27.8%) cases, stable disease in 10 (55.6%) cases, and progressive disease in three (16.7%) cases. Histological semiquantitative analysis revealed a "good" response in eight (44.4%) patients, a "moderate" response in four (22.2%) patients, and a "poor" response in six (33.3%) patients. The mean patient-reported outcome measures regarding fatigue, physical function, or physical interference demonstrated no significant differences between various timepoints before, during, or after treatment. Conclusion Neoadjuvant combined immunotherapy and radiation for high-risk STS was relatively well-tolerated. The histological, radiologic, and clinical outcome data in this novel trial were relatively similar to historical literature for non-immunotherapy treatment regimens.

A re-look at the modified Ryan regression scoring system in esophageal cancer-validation of prognostic significance and comparison with other less commonly used systems

BACKGROUND

Neoadjuvant chemoradiotherapy (NACRT) using CROSS protocol is currently the treatment of choice for esophageal cancer (EC). Tumor response grade (TRG) is a mandatory reporting criterion in most guidelines. One of the most commonly used TRG systems is the modified Ryan system. We aim to assess the TRG using modified Ryan and seven other systems (Mandard, Chireac, Swisher, Japanese esophageal society guidelines, modified rectal cancer regression grading (mRCRG), CROSS, and Becker) to evaluate their reproducibility and role as a prognostic marker.

MATERIALS AND METHODS

Two pathologists independently reviewed all cases of post-NACRT (CROSS) EC, to score TRGs and other histological parameters. Inter-rater agreement assessment for different TRG systems and correlation with disease-free survival (DFS) was performed.

RESULTS

Our series includes 93 patients with predominantly mid-esophageal squamous cell carcinoma. Complete pathological response (pCR) was noted in 47% (44/93) patients. The kappa inter-rater agreement score for the Ryan system was substantial (0.774), while it was almost perfect agreement for tumor percentage assessment-based systems (Swisher, CROSS, and Becker). Only the mRCRG TRGs correlated significantly with prognosis, while the Ryan system did not. Tumor stage and pCR status did not correlate with DFS, though the nodal stage was clinically significant.

CONCLUSION

Though the inter-rater concordance was optimal for all the TRG systems studied, only the mRCRG system showed prognostic significance, while the commonly used modified Ryan system did not. It may be worthwhile to look at further evaluating other systems like mRCRG for inclusion in minimum dataset reporting.

Impact of Dose-Escalated Chemoradiation on Pathological Complete Response in Patients with Locally Advanced Rectal Cancer

Locally advanced rectal cancer requires a multimodal treatment. Radiotherapy is being explored for intensification to improve the rates of pathological complete responses (ypCR rates) which are correlated with better outcomes. This study reports a comparison between standard versus escalated doses in a preoperative scenario. The ypCR rates, toxicity, postoperative complications, and disease-free and overall survival at 5 years are described. From 2012 to 2019, 99 patients were analyzed retrospectively: standard arm (mean of 47.5 Gy) vs. dose-escalated arm (mean of 54.3 Gy). All patients were treated with 3DRT in 25 fractions, with concomitant capecitabine and surgery performed according to the total mesorectal excision principles in both arms. The ypCR was reported using the "College of American Pathologist grades"; the gastrointestinal (GI) and genitourinary (GU) toxicity was reported using the "Common Terminology Criteria for Adverse Events" (CTCAE 4.0). The ypCR rates were higher in the dose-escalated group (25% vs. 10.64%; p = 0.07), with a lower rate of non-treatment response (61.36% vs. 38.64%; p = 0.11). No statistical differences between the arms were found in terms of the oncological outcomes, postoperative complications (p = 0.15), second surgeries (p = 0.62), or deaths (p = 0.62). The CTCAE acute GI and GU toxicity were grade I or II in both arms. Our study presents a long-term follow-up in comparative cohorts.

Tumor response rates based on initial TNM stage and tumor size in locally advanced rectal cancer: a useful tool for shared decision-making

BACKGROUND

It is accepted that tumor stage and size can influence response to neoadjuvant therapy in locally advanced rectal cancer (LARC). Studies on organ preservation to date have included a wide variety of size and TNM stage tumors. The aim of this study was to report tumor response based on each relevant TNM stage and tumor size.

METHODS

Patients treated with LARC from 2014 to 2021 with cT2-3NxM0 tumors who received neoadjuvant chemoradiotherapy with or without induction chemotherapy were included. Tumors were staged and tumor size calculated on pelvic MRI at the time of diagnosis (cTNM). Tumor size was based on the largest dimension taken on the longest axis of each tumor. Clinical response was defined on the basis of post-treatment pelvic MRI and pathological response following surgery, when performed. Statistical analysis was performed using IBM SPSS Statistics™, version 20. Data from 432 patients were analyzed as follows: cT2N0 (n = 51), cT2N+ (n = 36), cT3N0 (n = 76), cT3N+ (n = 270).

RESULTS

The rate of complete or near-complete response (cCR or nCR) varied from 77% in cT2N0 ≤ 3 cm to 20% in cT3N+ > 4 cm. Organ preservation without recurrence at 2 years was achieved in 86% of patients with cT2N0, 50% in cT2N+, 39% in cT3N0, and 12% in cT3N+.

CONCLUSION

There is significant variation in tumor response according to tumor stage and size. Tumor response appears inversely proportional to increasing TNM stage and tumor size. This data can support both refinement of selective patient recruitment to organ preservation programs and shared decision-making.

Neoadjuvant Chemotherapy in Colon Cancer: More Than Just an Optical Illusion

The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice.

Brazil-TNT: A Randomized Phase 2 Trial of Neoadjuvant Chemoradiation Followed by FOLFIRINOX Versus Chemoradiation for Stage II/III Rectal Cancer

BACKGROUND

Neoadjuvant radiation and oxaliplatin-based systemic therapy (total neoadjuvant therapy-TNT) have been shown to increase response and organ-preservation rates in localized rectal cancer. However, trials have been heterogeneous regarding treatment protocols and few have used a watch-and-wait (WW) approach for complete responders. This trial evaluates if conventional long-term chemoradiation followed by consolidation of FOLFIRINOX increases complete response rates and the number of patients managed by WW.

METHODS

This was a pragmatic randomized phase II trial conducted in 2 Cancer Centers in Brazil that included patients with T3+ or N+ rectal adenocarcinoma. After completing a long-course 54 Gy chemoradiation with capecitabine patients were randomized 1:1 to 4 cycles of mFOLFIRINOX (Oxaliplatin 85, irinotecan 150, 5-FU 2400)-TNT-arm-or to the control arm, that did not include further neoadjuvant treatment. All patients were re-staged with dedicated pelvic magnetic resonance imaging and sigmoidoscopy 12 weeks after the end of radiation. Patients with a clinical complete response were followed using a WW protocol. The primary endpoint was complete response: clinical complete response (cCR) or pathological response (pCR).

RESULTS

Between April 2021 and June 2023, 55 patients were randomized to TNT and 53 to the control arm. Tumors were 74% stage 3, median distance from the anal verge was 6 cm, 63% had an at-risk circumferential margin, and 33% an involved sphincter. The rates of cCR + pCR were (31%) for TNT versus (17%) for controls (odds ratio 2.19, CI 95% 0.8-6.22 P = .091) and rates of WW were 16% and 9% (P = ns). Median follow-up was 8.1 months and recurrence rates were 16% versus 21% for TNT and controls (P = ns).

CONCLUSIONS

TNT with consolidation FOLFIRINOX is feasible and has high response rates, consistent with the current literature for TNT. This trial was supported by a grant from the Brazilian Government (PROADI-SUS - NUP 25000.164382/2020-81).

Mature MUC5AC Expression in Resected Pancreatic Ductal Adenocarcinoma Predicts Treatment Response and Outcomes

Neoadjuvant therapy (NAT) for early-stage pancreatic ductal adenocarcinoma (PDA) has recently gained prominence. We investigated the clinical significance of mucin 5 AC (MUC5AC), which exists in two major glycoforms, a less-glycosylated immature isoform (IM) and a heavily glycosylated mature isoform (MM), as a biomarker in resected PDA. Immunohistochemistry was performed on 100 resected PDAs to evaluate the expression of the IM and MM of MUC5AC using their respective monoclonal antibodies, CLH2 (NBP2-44455) and 45M1 (ab3649). MUC5AC localization (cytoplasmic, apical, and extra-cellular (EC)) was determined, and the H-scores were calculated. Univariate and multivariate (MVA) Cox regression models were used to estimate progression-free survival (PFS) and overall survival (OS). Of 100 resected PDA patients, 43 received NAT, and 57 were treatment-naïve with upfront surgery (UpS). In the study population (n = 100), IM expression (H-scores for objective response vs. no response vs. UpS = 104 vs. 152 vs. 163, p = 0.01) and MM-MUC5AC detection rates (56% vs. 63% vs. 82%, p = 0.02) were significantly different. In the NAT group, MM-MUC5AC-negative patients had significantly better PFS according to the MVA (Hazard Ratio: 0.2, 95% CI: 0.059-0.766, p = 0.01). Similar results were noted in a FOLFIRINOX sub-group (n = 36). We established an association of MUC5AC expression with treatment response and outcomes.

Tumor-associated macrophage clusters linked to immunotherapy in a pan-cancer census

Transcriptional heterogeneity of tumor-associated macrophages (TAMs) has been investigated in individual cancers, but the extent to which these states transcend tumor types and represent a general feature of cancer remains unclear. We performed pan-cancer single-cell RNA sequencing analysis across nine cancer types and identified distinct monocyte/TAM composition patterns. Using spatial analysis from clinical study tissues, we assessed TAM functions in shaping the tumor microenvironment (TME) and influencing immunotherapy. Two specific TAM clusters (pro-inflammatory and pro-tumor) and four TME subtypes showed distinct immunological features, genomic profiles, immunotherapy responses, and cancer prognosis. Pro-inflammatory TAMs resided in immune-enriched niches with exhausted CD8+ T cells, while pro-tumor TAMs were restricted to niches associated with a T-cell-excluded phenotype and hypoxia. We developed a machine learning model to predict immune checkpoint blockade response by integrating TAMs and clinical data. Our study comprehensively characterizes the common features of TAMs and highlights their interaction with the TME.

Tumour budding as a prognostic biomarker in biopsies and resections of neoadjuvant-treated rectal adenocarcinoma

BACKGROUND

Tumour budding (TB) is a marker of tumour aggressiveness which, when measured in rectal cancer resection specimens, predicts worse outcomes and response to neoadjuvant therapy. We investigated the utility of TB assessment in the setting of neoadjuvant treatment.

METHODS AND RESULTS

A single-centre, retrospective cohort study was conducted. TB was assessed using the hot-spot International Tumour Budding Consortium (ITBCC) method and classified by the revised ITBCC criteria. Haematoxylin and eosin (H&E) and AE1/AE3 cytokeratin (CK) stains for ITB (intratumoural budding) in biopsies with PTB (peritumoural budding) and ITB (intratumoural budding) in resection specimens were compared. Logistic regression assessed budding as predictors of lymph node metastasis (LNM). Cox regression and Kaplan-Meier analyses investigated their utility as a predictor of disease-free (DFS) and overall (OS) survival. A total of 146 patients were included; 91 were male (62.3%). Thirty-seven cases (25.3%) had ITB on H&E and 79 (54.1%) had ITB on CK assessment of biopsy tissue. In univariable analysis, H&E ITB [odds (OR) = 2.709, 95% confidence interval (CI) = 1.261-5.822, P = 0.011] and CK ITB (OR = 2.165, 95% CI = 1.076-4.357, P = 0.030) predicted LNM. Biopsy-assessed H&E ITB (OR = 2.749, 95% CI = 1.258-6.528, P = 0.022) was an independent predictor of LNM. In Kaplan-Meier analysis, ITB identified on biopsy was associated with worse OS (H&E, P = 0.003, CK: P = 0.009) and DFS (H&E, P = 0.012; CK, P = 0.045). In resection specimens, CK PTB was associated with worse OS (P = 0.047), and both CK PTB and ITB with worse DFS (PTB, P = 0.014; ITB: P = 0.019). In multivariable analysis H&E ITB predicted OS (HR = 2.930, 95% CI = 1.261-6.809) and DFS (HR = 2.072, 95% CI = 1.031-4.164). CK PTB grading on resection also independently predicted OS (HR = 3.417, 95% CI = 1.45-8.053, P = 0.005).

CONCLUSION

Assessment of TB using H&E and CK may be feasible in rectal cancer biopsy and post-neoadjuvant therapy-treated resection specimens and is associated with LNM and worse survival outcomes. Future management strategies for rectal cancer might be tailored to incorporate these findings.

Computed tomography-based radiomics nomogram for predicting therapeutic response to neoadjuvant chemotherapy in locally advanced gastric cancer : A scale for treatment predicting

BACKGROUND AND OBJECTIVE

Neoadjuvant chemotherapy results in various responses when used to treat locally advanced gastric cancer, we aimed to develop and validate a predictive model of the response to neoadjuvant chemotherapy in patients with gastric cancer.

METHODS

A total of 128 patients with locally advanced gastric cancer who underwent pre-treatment computed tomography (CT) scanning followed by neoadjuvant chemoradiotherapy were included (training cohort: n = 64; validation cohort: n = 64). We built a radiomics score combined with laboratory parameters to create a nomogram for predicting the efficacy of neoadjuvant chemotherapy and calculating scores for risk factors.

RESULTS

The radiomics score system demonstrated good stability and prediction performance for the response to neoadjuvant chemotherapy, with the area under the curve of the training and validation cohorts being 0.8 and 0.64, respectively. The radiomics score proved to be an independent risk factor affecting the efficacy of neoadjuvant chemotherapy. In addition to the radiomics score, four other risk factors were included in the nomogram, namely the platelet-to-lymphocyte ratio, total bilirubin, ALT/AST, and CA199. The model had a C-index of 0.8.

CONCLUSIONS

Our results indicated that radiomics features could be potential biomarkers for the early prediction of the response to neoadjuvant treatment.

Progression of Site-specific Recurrence of Pancreatic Cancer and Implications for Treatment

OBJECTIVE

To analyze postrecurrence progression in the context of recurrence sites and assess implications for postrecurrence treatment.

BACKGROUND

Most patients with resected pancreatic ductal adenocarcinoma (PDAC) recur within 2 years. Different survival outcomes for location-specific patterns of recurrence are reported, highlighting their prognostic value. However, a lack of understanding of postrecurrence progression and survival remains.

METHODS

This retrospective analysis included surgically treated patients with PDAC at NYU Langone Health (2010-2021). Sites of recurrence were identified at the time of diagnosis and further follow-up. Kaplan-Meier curves, log-rank test, and Cox regression analyses were applied to assess survival outcomes.

RESULTS

Recurrence occurred in 57.3% (196/342) patients with a median time to recurrence of 11.3 months (95% CI: 12.6-16.5). The first site of recurrence was local in 43.9% of patients, liver in 23.5%, peritoneal in 8.7%, lung in 3.6%, whereas 20.4% had multiple sites of recurrence. Progression to secondary sites was observed in 11.7%. Only lung involvement was associated with significantly longer survival after recurrence compared with other sites (16.9 vs 8.49 months, P = 0.003). In local recurrence, 21 (33.3%) patients were alive after 1 year without progression to secondary sites. This was associated with a CA19-9 of <100 U/mL at the time of primary diagnosis ( P = 0.039), nodal negative disease ( P = 0.023), and well-moderate differentiation ( P = 0.042) compared with patients with progression.

CONCLUSION

Except for lung recurrence, postrecurrence survival after PDAC resection is associated with poor survival. A subset of patients with local-only recurrence do not quickly succumb to systemic spread. This is associated with markers for favorable tumor biology, making them candidates for potential curative re-resections when feasible.

PERIOPERATIVE CHEMOTHERAPY, ADJUVANT CHEMOTHERAPY AND ADJUVANT CHEMORADIOTHERAPY IN THE SURGICAL TREATMENT OF GASTRIC CANCER IN A HOSPITAL OF THE BRAZILIAN UNIFIED HEALTH SYSTEM

BACKGROUND

Despite the preference for multimodal treatment for gastric cancer, abandonment of chemotherapy treatment as well as the need for upfront surgery in obstructed patients brings negative impacts on the treatment. The difficulty of accessing treatment in specialized centers in the Brazilian Unified National Health System (SUS) scenario is an aggravating factor.

AIMS

To identify advantages, prognostic factors, complications, and neoadjuvant and adjuvant therapies survival in gastric cancer treatment in SUS setting.

METHODS

The retrospective study included 81 patients with gastric adenocarcinoma who underwent treatment according to INT0116 trial (adjuvant chemoradiotherapy), CLASSIC trial (adjuvant chemotherapy), FLOT4-AIO trial (perioperative chemotherapy), and surgery with curative intention (R0 resection and D2 lymphadenectomy) in a single cancer center between 2015 and 2020. Individuals with other histological types, gastric stump, esophageal cancer, other treatment protocols, and stage Ia or IV were excluded.

RESULTS

Patients were grouped into FLOT4-AIO (26 patients), CLASSIC (25 patients), and INT0116 (30 patients). The average age was 61 years old. More than 60% of patients had pathological stage III. The treatment completion rate was 56%. The pathological complete response rate of the FLOT4-AIO group was 7.7%. Among the prognostic factors that impacted overall survival and disease-free survival were alcoholism, early postoperative complications, and anatomopathological status pN2 and pN3. The 3-year overall survival rate was 64.9%, with the CLASSIC subgroup having the best survival (79.8%).

CONCLUSIONS

The treatment strategy for gastric cancer varies according to the need for initial surgery. The CLASSIC subgroup had better overall survival and disease-free survival. The INT0116 regimen also protected against mortality, but not with statistical significance. Although FLOT4-AIO is the preferred treatment, the difficulty in carrying out neoadjuvant treatment in SUS scenario had a negative impact on the results due to the criticality of food intake and worse treatment tolerance.

Predicting outcomes in esophageal adenocarcinoma following neoadjuvant chemoradiation: Interactions between tumor response and survival

OBJECTIVES

The prognostic value of tumor regression scores (TRS) in patients with esophageal adenocarcinoma (EAC) who underwent neoadjuvant chemoradiation remains unclear. We sought to investigate the prognostic value of pathologic and metabolic treatment response among EAC patients undergoing neoadjuvant chemoradiation.

METHODS

Patients who underwent esophagectomy for EAC after neoadjuvant CROSS protocol between 2016 and 2020 were evaluated. TRS was grouped according to the modified Ryan score; metabolic response, according to the PERCIST criteria. Variables from endoscopic ultrasound, endoscopic biopsies, and positron emission tomography (primary and regional lymph node standardized uptake values [SUVs]) were collected.

RESULTS

The study population comprised 277 patients. A TRS of 0 (complete response) was identified in 66 patients (23.8%). Seventy-eight patients (28.1%) had TRS 1 (partial response), 97 (35%) had TRS 2 (poor response), and 36 (13%) had TRS 3 (no response). On survival analysis for overall survival (OS), patients with TRS 0 had longer survival compared to those with TRS 1, 2, or 3 (P = .010, P < .001, and P = .005, respectively). On multivariable logistic regression, the presence of signet ring cell features on endoscopic biopsy (odds ratio [OR], 7.54; P = .012) and greater SUV uptake at regional lymph nodes (OR, 1.42; P = .007) were significantly associated with residual tumor at pathology (TRS 1, 2, or 3). On multivariate Cox regression for predictors of OS, higher SUVmax at the most metabolically active nodal station (hazard ratio [HR], 1.08; P = .005) was independently associated with decreased OS, whereas pathologic complete response (HR, 0.61; P = .021) was independently associated with higher OS.

CONCLUSIONS

Patients with pathologic complete response had prolonged OS, whereas no difference in survival was detected among other TRS categories. At initial staging, the presence of signet ring cells and greater SUV uptake at regional lymph nodes predicted residual disease at pathology and shorter OS, suggesting the need for new treatment strategies for these patients.

NBS1 lactylation is required for efficient DNA repair and chemotherapy resistance

The Warburg effect is a hallmark of cancer that refers to the preference of cancer cells to metabolize glucose anaerobically rather than aerobically1,2. This results in substantial accumulation of lacate, the end product of anaerobic glycolysis, in cancer cells3. However, how cancer metabolism affects chemotherapy response and DNA repair in general remains incompletely understood. Here we report that lactate-driven lactylation of NBS1 promotes homologous recombination (HR)-mediated DNA repair. Lactylation of NBS1 at lysine 388 (K388) is essential for MRE11-RAD50-NBS1 (MRN) complex formation and the accumulation of HR repair proteins at the sites of DNA double-strand breaks. Furthermore, we identify TIP60 as the NBS1 lysine lactyltransferase and the 'writer' of NBS1 K388 lactylation, and HDAC3 as the NBS1 de-lactylase. High levels of NBS1 K388 lactylation predict poor patient outcome of neoadjuvant chemotherapy, and lactate reduction using either genetic depletion of lactate dehydrogenase A (LDHA) or stiripentol, a lactate dehydrogenase A inhibitor used clinically for anti-epileptic treatment, inhibited NBS1 K388 lactylation, decreased DNA repair efficacy and overcame resistance to chemotherapy. In summary, our work identifies NBS1 lactylation as a critical mechanism for genome stability that contributes to chemotherapy resistance and identifies inhibition of lactate production as a promising therapeutic cancer strategy.

Can the Pathological Response in Patients with Locally Advanced Gastric Cancer Receiving Neoadjuvant Treatment Be Predicted by the CEA/Albumin and CRP/Albumin Ratios?

Background: The purposes of neoadjuvant chemotherapy are to tumor size to improve the tumor removal rate, extend survival, and prevent metastasis. In this study, the importance of CRP/albumin ratio and CEA/albumin ratio in the prediction of neoadjuvant treatment response in gastric cancer patients was evaluated. Methods: This study retrospectively included 135 gastric cancer patients who received neoadjuvant chemotherapy at Çukurova University Balcalı Hospital between January 2018 and December 2023. Preoperative CRP/albumin and CEA/albumin ratios were compared according to treatment response and multivariate logistic regression analysis was performed to determine the potential importance of these ratios in predicting pathological response. Results: The mean age of the 135 patients was 58.79 ± 10.83 (min = 26-max = 78). The CRP/albumin and CEA/albumin ratios were found to be significantly lower in patients who did not respond to neoadjuvant therapy. Each 1-unit increase in the CRP/albumin ratio was associated with a 1.16-fold decrease in the odds of pathological complete response to neoadjuvant therapy. Both CRP/albumin and CEA/albumin ratios were found to be significant in distinguishing neoadjuvant therapy response. The optimal cut-off value was 2.74 for the CRP/albumin ratio (sensitivity = 60%, specificity = 78.4%) and 1.40 for the CEA/albumin ratio (sensitivity = 74.2%, specificity = 67.6%). Values below these cut-off points favored neoadjuvant therapy response. Pathological complete response to neoadjuvant therapy was 4.75 times higher in patients with a CRP/albumin ratio below 2.74 and 5.14 times higher in patients with a CEA/albumin ratio below 1.40. Conclusions: Findings demonstrate that in patients with locally advanced gastric cancer receiving neoadjuvant treatment, CRP/Albumin and CEA/Albumin ratios are significant markers of pathological response.

Prediction of survival after neoadjuvant therapy in locally advanced rectal cancer - a retrospective analysis

Purpose

The aim of this retrospective analysis was to determine if the response to preoperative radio(chemo)therapy is predictive for survival among patients with locally advanced rectal cancer and may act as a potential surrogate endpoint for disease free survival and overall survival.

Results

Eight hundred seventy-eight patients from five centers were analyzed. There were 304 women and 574 men; the median age was 64.7 years. 77.6% and 22.4% of patients received neoadjuvant radiochemotherapy or short-course radiotherapy, resulting in a pathological complete response in 7.3%. T-downstaging and N-downstaging occurred in 50.5% and 37% of patients after neoadjuvant therapy. In patients with T-downstaging, the 10-year DFS and 10-year OS were 64.8% and 66.8% compared to 37.1% and 45.9% in patients without T-downstaging. N-downstaging resulted in 10-year DFS and 10-year OS in 56.2% and 62.5% compared to 47.3% and 52.3% without N-downstaging. Based on routinely evaluated clinical parameters, an absolute risk prediction calculator was generated for 5-year disease-free survival, and 5-year overall survival.

Conclusion

T-downstaging and N-downstaging after neoadjuvant radiochemotherapy or short-course radiotherapy resulted in better DFS and OS compared to patients without response. Based on clinical parameters, 5-year DFS, and 5-year OS can be predicted using a prediction calculator.

Prognostic value of neutrophil-to-lymphocyte ratio (NLR) and platelet-neutrophil (PN) index in locally advanced rectal cancer patients: a retrospective cohort study

Introduction

In locally advanced rectal cancers (LARC), tumour node metastasis (TNM) staging is far from optimal. The authors aimed to investigate the value of previously described circulating biomarkers as predictors of prognosis.

Methods

Retrospective analysis of 245 LARC patients diagnosed between January 2010 and December 2022, who underwent neoadjuvant chemoradiotherapy and surgery at two centres. A Cox regression and Kaplan-Meier analysis were performed.

Results

Post-treatment platelet-to-lymphocyte ratio (PLR) predicted pathological complete response. The neutrophil-to-lymphocyte ratio (NLR) in two timepoints of the treatment significantly predicted overall survival, whereas the platelet-neutrophil (PN) index significantly predicted disease-free survival. In pathological stage II, the PN index predicted patients with a higher risk of disease-free survival.

Conclusion

Blood parameters might allow the definition of subgroups of risk beyond TNM for the application of different therapeutic strategies.

Lymph node regression after neoadjuvant chemoradiotherapy in rectal cancer

AIMS

Lymph node metastases (LNM) are one of the most important prognostic indicators in solid tumours and a major component of cancer staging. Neoadjuvant therapy might influence nodal status by induction of regression. Our aim is to determine the prevalence and role of regression of LNM on outcomes in patients with rectal cancer.

METHODS AND RESULTS

Four independent study populations of rectal cancer patients treated with similar regimens of chemoradiotherapy were pooled together to obtain a total cohort of 469 patients. Post-treatment nodal status (ypN) and signs of tumour regression (Reg) were incorporated to form three-tiered (ypN- Reg+, ypN- Reg- and ypN+) and four-tiered (ypN- Reg+, ypN- Reg-, ypN+ Reg+ and ypN+ Reg-) classifications. In our cohort, 31% of patients presented with ypN+ rectal cancer. As expected, we found significantly worse overall survival (OS) in ypN+ patients compared to ypN- patients (P = 0.002). The percentage of ypN- patients with lymph nodes with complete regression was 20% in our cohort. While node-negative patients with and without regression had similar OS (P = 0.09), disease-free survival (DFS) was significantly better in node-negative patients with regression (P = 0.009).

CONCLUSIONS

Regression in lymph nodes is frequent, and node-negative patients with evidence of lymph node regression have better DFS compared to node-negative patients without such evidence.

Texture analysis of apparent diffusion coefficient maps: can it identify nonresponse to neoadjuvant chemotherapy for additional radiation therapy in rectal cancer patients?

Background

Neoadjuvant chemotherapy (NCT) alone can achieve comparable treatment outcomes to chemoradiotherapy in locally advanced rectal cancer (LARC) patients. This study aimed to investigate the value of texture analysis (TA) in apparent diffusion coefficient (ADC) maps for identifying non-responders to NCT.

Methods

This retrospective study included patients with LARC after NCT, and they were categorized into nonresponse group (pTRG 3) and response group (pTRG 0-2) based on pathological tumor regression grade (pTRG). Predictive texture features were extracted from pre- and post-treatment ADC maps to construct a TA model using RandomForest. The ADC model was developed by manually measuring pre- and post-treatment ADC values and calculating their changes. Simultaneously, subjective evaluations based on magnetic resonance imaging assessment of TRG were performed by two experienced radiologists. Model performance was compared using the area under the curve (AUC) and DeLong test.

Results

A total of 299 patients from two centers were divided into three cohorts: the primary cohort (center A; n = 194, with 36 non-responders and 158 responders), the internal validation cohort (center A; n = 49, with 9 non-responders) and external validation cohort (center B; n = 56, with 33 non-responders). The TA model was constructed by post_mean, mean_change, post_skewness, post_entropy, and entropy_change, which outperformed both the ADC model and subjective evaluations with an impressive AUC of 0.997 (95% confidence interval [CI], 0.975-1.000) in the primary cohort. Robust performances were observed in internal and external validation cohorts, with AUCs of 0.919 (95% CI, 0.805-0.978) and 0.938 (95% CI, 0.840-0.985), respectively.

Conclusions

The TA model has the potential to serve as an imaging biomarker for identifying nonresponse to NCT in LARC patients, providing a valuable reference for these patients considering additional radiation therapy.