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El Homsi M, Bercz A, Chahwan S, Fernandes MC, Javed-Tayyab S, Golia Pernicka JS, Nincevic J, Paroder V, Ruby L, Smith JJ, Petkovska I. Watch & wait - Post neoadjuvant imaging for rectal cancer. Clin Imaging 2024; 110:110166. [PMID: 38669916 PMCID: PMC11090716 DOI: 10.1016/j.clinimag.2024.110166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 04/15/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024]
Abstract
Rectal cancer management has evolved over the past decade with the emergence of total neoadjuvant therapy (TNT). For select patients who achieve a clinical complete response following TNT, organ preservation by means of the watch-and-wait (WW) strategy is an increasingly adopted alternative that preserves rectal function and quality of life without compromising oncologic outcomes. Recently, published 5-year results from the OPRA trial demonstrated that organ preservation can be achieved in approximately half of patients managed with the WW strategy, with most local regrowth events occurring within two years. Considering the potential for local regrowth, the implementation of the WW strategy mandates rigorous clinical and radiographic surveillance. Magnetic resonance imaging (MRI) serves as the conventional imaging modality for local staging and surveillance of rectal cancer given its excellent soft-tissue resolution. This review will discuss the current evidence for the WW strategy and the role of restaging rectal MRI in determining patient eligibility for this strategy. Restaging rectal MRI acquisition parameters and treatment response assessment, including important factors to assess, pitfalls, and classification systems, will be discussed in the context of the WW strategy.
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Affiliation(s)
- Maria El Homsi
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Aron Bercz
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Stephanie Chahwan
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Maria Clara Fernandes
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Sidra Javed-Tayyab
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Jennifer S Golia Pernicka
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Josip Nincevic
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Viktoriya Paroder
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Lisa Ruby
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - J Joshua Smith
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Iva Petkovska
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
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Geffen EGMV, Nederend J, Sluckin TC, Hazen SMJA, Horsthuis K, Beets-Tan RGH, Marijnen CAM, Tanis PJ, Kusters M. Prognostic significance of MRI-detected extramural venous invasion according to grade and response to neo-adjuvant treatment in locally advanced rectal cancer A national cohort study after radiologic training and reassessment. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108307. [PMID: 38581757 DOI: 10.1016/j.ejso.2024.108307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 02/20/2024] [Accepted: 03/23/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Detection of grade 3-4 extra mural venous invasion (mrEMVI) on magnetic resonance imaging (MRI) is associated with an increased distant metastases (DM)-rate. This study aimed to determine the impact of different grades of mrEMVI and their disappearance after neoadjuvant therapy. METHODS A Dutch national retrospective cross-sectional study was conducted, including patients who underwent resection for rectal cancer in 2016 from 60/69 hospitals performing rectal surgery. Patients with a cT3-4 tumour ≤8 cm from the anorectal junction were selected and their MRI-scans were reassessed by trained abdominal radiologists. Positive mrEMVI grades (3 and 4) were analyzed in regard to 4-year local recurrence (LR), DM, disease-free survival (DFS) and overall survival (OS). RESULTS The 1213 included patients had a median follow-up of 48 months (IQR 30-54). Positive mrEMVI was present in 324 patients (27%); 161 had grade 3 and 163 had grade 4. A higher mrEMVI stage (grade 4 vs grade 3 vs no mrEMVI) increased LR-risk (21% vs 18% vs 7%, <0.001) and DM-risk (49% vs 30% vs 21%, p < 0.001) and decreased DFS (42% vs 55% vs 69%, p < 0.001) and OS (62% vs 76% vs 81%, p < 0.001), which remained independently associated in multivariable analysis. When mrEMVI had disappeared on restaging MRI, DM-rate was comparable to initial absence of mrEMVI (both 26%), whereas LR-rate remained high (22% vs 9%, p = 0.006). CONCLUSION The negative oncological impact of mrEMVI on recurrence and survival rates was dependent on grading. Disappearance of mrEMVI on restaging MRI decreased the risk of DM, but not of LR.
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Affiliation(s)
- Eline G M van Geffen
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Department of Surgery, De Boelelaan 1117, Amsterdam, the Netherlands; Cancer Center Amsterdam, Treatment and Quality of Life and Imaging and Biomarkers, Amsterdam, the Netherlands
| | - Joost Nederend
- Catharina Hospital, Department of Radiology, Michelangelolaan 2, Eindhoven, the Netherlands
| | - Tania C Sluckin
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Department of Surgery, De Boelelaan 1117, Amsterdam, the Netherlands; Cancer Center Amsterdam, Treatment and Quality of Life and Imaging and Biomarkers, Amsterdam, the Netherlands
| | - Sanne-Marije J A Hazen
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Department of Surgery, De Boelelaan 1117, Amsterdam, the Netherlands; Cancer Center Amsterdam, Treatment and Quality of Life and Imaging and Biomarkers, Amsterdam, the Netherlands
| | - Karin Horsthuis
- Cancer Center Amsterdam, Treatment and Quality of Life and Imaging and Biomarkers, Amsterdam, the Netherlands; Amsterdam UMC Location Vrije Universiteit Amsterdam, Department of Radiology and Nuclear Medicine, De Boelelaan 1117, Amsterdam, the Netherlands
| | - Regina G H Beets-Tan
- The Netherlands Cancer Institute, Department of Radiology, Plesmanlaan 121, Amsterdam, the Netherlands; GROW School for Oncology and Developmental Biology, University of Maastricht, Universiteitssingel 40, Maastricht, the Netherlands; Department of Radiology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Campusvej 55, DK-5230, Odense, Denmark
| | - Corrie A M Marijnen
- LUMC, Department of Radiation Oncology, Albinusdreef 2, Leiden, the Netherlands; The Netherlands Cancer Institute, Department of Radiation Oncology, Plesmanlaan 121, Amsterdam, the Netherlands
| | - Pieter J Tanis
- Cancer Center Amsterdam, Treatment and Quality of Life and Imaging and Biomarkers, Amsterdam, the Netherlands; Amsterdam UMC Location University of Amsterdam, Department of Surgery, Meibergdreef 9, Amsterdam, the Netherlands; Erasmus MC, Department of Surgical Oncology and Gastrointestinal Surgery, Rotterdam, the Netherlands
| | - Miranda Kusters
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Department of Surgery, De Boelelaan 1117, Amsterdam, the Netherlands; Cancer Center Amsterdam, Treatment and Quality of Life and Imaging and Biomarkers, Amsterdam, the Netherlands.
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O'Brien T, Hospers G, Conroy T, Lenz HJ, Smith JJ, Andrews E, O'Neill B, Leonard G. The role of total neoadjuvant therapy in locally advanced rectal cancer: a survey of specialists attending the All-Ireland Colorectal Cancer Conference 2022 including lead investigators of OPRA, PRODIGE-23 and RAPIDO. Ir J Med Sci 2024; 193:1183-1190. [PMID: 38141097 PMCID: PMC11128399 DOI: 10.1007/s11845-023-03591-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 12/11/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND The treatment of locally advanced rectal cancer (LARC) has evolved following recent landmark trials of total neoadjuvant therapy (TNT)-the delivery of preoperative chemotherapy sequenced with radiation. AIM To assess the preferences of colorectal surgery (CRS), radiation oncology (RO) and medical oncology (MO) specialists attending the All-Ireland Colorectal Cancer Conference (AICCC) 2022 regarding the neoadjuvant management of LARC. METHODS A live electronic survey explored the preferred treatment approach and TNT regimen for early-, intermediate-, bad-, and advanced-risk categories of rectal cancer according to the European Society of Medical Oncology (ESMO) guidelines. The survey was preceded by an update from lead investigators of TNT trials (OPRA, PRODIGE-23 and RAPIDO), who then participated in a multidisciplinary panel discussion. RESULTS Ten CRS, 7 RO and 15 MO (32 of 45 specialists) participated fully in the survey resulting in a response rate of 71%. Ninety-four percent, 76% and 53% of specialists preferred a TNT approach for patients with advanced, bad, and intermediate-risk rectal cancer, respectively. A consolidation TNT regimen of long-course chemoradiotherapy followed by chemotherapy was the most preferred regimen. Upfront surgery was preferred by 77% for early-risk disease. CONCLUSION This survey illustrated the general acceptance of TNT by rectal cancer specialists attending the AICCC as a valuable treatment strategy for higher-risk category LARC. Whilst the treatment of LARC changes, it remains best practice to individualize care, incorporating the selective use of TNT as discussed by an MDT and in keeping with the patient's goals of care.
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Affiliation(s)
- Timothy O'Brien
- Patrick G Johnston Centre for Cancer Research, Queen's University, Belfast, Northern Ireland.
| | - Geke Hospers
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Thierry Conroy
- Medical Oncology Department, Institut de Cancérologie de Lorraine, Vandoeuvre-Lès-Nancy, Nancy, France
- Université de Lorraine, APEMAC, Équipe MICS, Nancy, France
| | - Heinz-Josef Lenz
- Division of Medical Oncology, Keck School of Medicine, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Jesse Joshua Smith
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering, New York, NY, USA
| | - Emmet Andrews
- Department of Surgery, Cork University Hospital, University College Cork, Cork, Ireland
| | - Brian O'Neill
- Department of Radiation Oncology, St Luke's Radiation Oncology Network, Dublin, Ireland
| | - Gregory Leonard
- Department of Medical Oncology, University Hospital Galway, Newcastle Road, Galway, Ireland
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Kennedy ED, Schmocker S, Brown C, Liberman S, Baxter NN, Drolet S, Neumann K, Simunovic M, Richard C, Brezden-Masley C, Jhaveri K, Kopek N, Kirsch R. Nonoperative management protocol for locally advanced rectal cancer. Colorectal Dis 2024. [PMID: 38797916 DOI: 10.1111/codi.17035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 04/30/2024] [Accepted: 05/07/2024] [Indexed: 05/29/2024]
Abstract
AIM The standard treatment for low rectal cancer is preoperative chemoradiotherapy followed by surgery with low anterior resection with diverting ileostomy or abdominoperineal resection, both of which have significant long-term effects on bowel and sexual function. Due to the high morbidity of surgery, there has been increasing interest in nonoperative management for low rectal cancer. The aim of this work is to conduct a pan-Canadian Phase II trial assessing the safety of nonoperative management for low rectal cancer. METHOD Patients with Stage II or III low rectal cancer completing chemoradiotherapy according to standard of care at participating centres will be assessed for complete clinical response 8-14 weeks following completion of chemoradiotherapy. Subjects achieving a clinical complete response will undergo active surveillance including endoscopy, imaging and bloodwork at regular intervals for 24 months. The primary outcome will be the rate of local regrowth 2 years after chemoradiotherapy. Nonoperative management will be considered safe (i.e. as effective as surgery to achieve local control) if the rate of local regrowth is ≤30% and surgical salvage is possible for all local regrowths. Secondary outcomes will include disease-free and overall survival. CONCLUSION The results will be highly clinically relevant, as it is expected that nonoperative management will be safe and lead to widespread adoption of nonoperative management in Canada. This change in practice has the potential to decrease the number of patients requiring surgery and the costs associated with surgery and long-term surgical morbidity.
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Affiliation(s)
- Erin D Kennedy
- Department of Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Selina Schmocker
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Carl Brown
- Department of Colorectal Surgery, St Paul's Hospital, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sender Liberman
- Department of Surgery, McGill University, Montréal, Quebec, Canada
| | - Nancy N Baxter
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Sebastien Drolet
- Department of Surgery, Université Laval, Quebec City, Quebec, Canada
| | - Katerina Neumann
- Department of Surgery, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Marko Simunovic
- Department of Surgery, McMaster University, St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Carole Richard
- Digestive Surgery Service, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada
- Division of General Surgery, Université de Montréal, Montréal, Quebec, Canada
| | - Christine Brezden-Masley
- University of Toronto, Toronto, Ontario, Canada
- Division of Medical Oncology, Sinai Health System, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Kartik Jhaveri
- University of Toronto, Toronto, Ontario, Canada
- Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital, and Women's College Hospital, Toronto, Ontario, Canada
| | - Neil Kopek
- Department of Radiation Oncology, McGill University Health Centre, Montréal, Quebec, Canada
| | - Richard Kirsch
- University of Toronto, Toronto, Ontario, Canada
- Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada
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Fazio R, Audisio A, Daprà V, Conti C, Benhima N, Abbassi FZ, Assaf I, Hendlisz A, Sclafani F. Non-operative management after immune checkpoint inhibitors for early-stage, dMMR/MSI-H gastrointestinal cancers. Cancer Treat Rev 2024; 128:102752. [PMID: 38772170 DOI: 10.1016/j.ctrv.2024.102752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 05/10/2024] [Accepted: 05/11/2024] [Indexed: 05/23/2024]
Abstract
Surgery is a standard treatment for early-stage gastrointestinal cancers, often preceded by neoadjuvant chemo(radio)therapy or followed by adjuvant therapy. While leading to cure in a proportion of patients, it has some drawbacks such as intra/post-operative complications, mutilation and life-long functional sequelae. Further to the unprecedented efficacy data from studies of immune checkpoint inhibitors for advanced mismatch repair deficient/microsatellite instable (dMMR/MSI-H) tumours, a strong interest has recently emerged for the investigation of such agents in the neoadjuvant setting. Although limited by the exploratory design and small sample size, trials of neoadjuvant immune checkpoint inhibitors for early-stage dMMR/MSI-H gastrointestinal cancers have consistently reported complete response rates ranging from 70 % to 100 %. As a result, the question has arisen as to whether surgery is still needed or organ-preserving strategies should be offered to this especially immuno-sensitive population. In this article, we discuss the available evidence for neoadjuvant immune checkpoint inhibitors in dMMR/MSI-H gastrointestinal cancers and analyse opportunities and challenges to the implementation of non-operative management approaches in this setting.
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Affiliation(s)
- Roberta Fazio
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Brussels, Belgium
| | - Alessandro Audisio
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Brussels, Belgium
| | - Valentina Daprà
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Brussels, Belgium
| | - Chiara Conti
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Brussels, Belgium
| | - Nada Benhima
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Brussels, Belgium
| | - Fatima-Zahara Abbassi
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Brussels, Belgium
| | - Irene Assaf
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Brussels, Belgium
| | - Alain Hendlisz
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Brussels, Belgium
| | - Francesco Sclafani
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Brussels, Belgium.
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Smithson M, Diffalha SA, Irwin RK, Williams G, McLeod MC, Somasundaram V, Bellis SL, Hardiman KM. ST6GAL1 is associated with poor response to chemoradiation in rectal cancer. Neoplasia 2024; 51:100984. [PMID: 38467087 PMCID: PMC11026834 DOI: 10.1016/j.neo.2024.100984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 02/26/2024] [Accepted: 02/27/2024] [Indexed: 03/13/2024]
Abstract
INTRODUCTION Colorectal cancer is the third most common cause of cancer death. Rectal cancer makes up a third of all colorectal cases. Treatment for locally advanced rectal cancer includes chemoradiation followed by surgery. We have previously identified ST6GAL1 as a cause of resistance to chemoradiation in vitro and hypothesized that it would be correlated with poor response in human derived models and human tissues. METHODS Five organoid models were created from primary human rectal cancers and ST6GAL1 was knocked down via lentivirus transduction in one model. ST6GAL1 and Cleaved Caspase-3 (CC3) were assessed after chemoradiation via immunostaining. A tissue microarray (TMA) was created from twenty-six patients who underwent chemoradiation and had pre- and post-treatment specimens of rectal adenocarcinoma available at our institution. Immunohistochemistry was performed for ST6GAL1 and percent positive cancer cell staining was assessed and correlation with pathological grade of response was measured. RESULTS Organoid models were treated with chemoradiation and both ST6GAL1 mRNA and protein significantly increased after treatment. The organoid model targeted with ST6GAL1 knockdown was found to have increased CC3 after treatment. In the tissue microarray, 42 percent of patient samples had an increase in percent tumor cell staining for ST6GAL1 after treatment. Post-treatment percent staining was associated with a worse grade of treatment response (p = 0.01) and increased staining post-treatment compared to pre-treatment was also associated with a worse response (p = 0.01). CONCLUSION ST6GAL1 is associated with resistance to treatment in human rectal cancer and knockdown in an organoid model abrogated resistance to apoptosis caused by chemoradiation.
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Affiliation(s)
- Mary Smithson
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Al 35294, USA
| | - Sameer Al Diffalha
- Department of Pathology, University of Alabama at Birmingham, Birmingham, Al 35294, USA
| | - Regina K Irwin
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Al 35294, USA
| | - Gregory Williams
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Al 35294, USA
| | - M Chandler McLeod
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Al 35294, USA
| | - Vivek Somasundaram
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Al 35294, USA
| | - Susan L Bellis
- Department of Cell, Developmental, and Integrative Biology, University of Alabama at Birmingham, Birmingham, Al 35294, USA
| | - Karin M Hardiman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Al 35294, USA; Department of Surgery, Birmingham Veterans Affairs Medical Center, Birmingham, Al 35294, USA.
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Alvarez J, Shi Q, Dasari A, Garcia-Aguilar J, Sanoff H, George TJ, Hong TS, Yothers G, Philip PA, Nelson GD, Al Baghdadi T, Alese O, Zambare W, Omer DM, Verheij FS, Buckley J, Williams H, George M, Garcia R, O'Reilly EM, Meyerhardt JA, Shergill A, Horvat N, Romesser PB, Hall WA, Smith JJ. ALLIANCE A022104/NRG-GI010: The Janus Rectal Cancer Trial: a randomized phase II/III trial testing the efficacy of triplet versus doublet chemotherapy regarding clinical complete response and disease-free survival in patients with locally advanced rectal cancer. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.04.25.24306396. [PMID: 38712176 PMCID: PMC11071544 DOI: 10.1101/2024.04.25.24306396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
Background Recent data have demonstrated that in locally advanced rectal cancer (LARC), a total neoadjuvant therapy (TNT) approach improves compliance with chemotherapy and increases rates of tumor response compared to neoadjuvant chemoradiation (CRT) alone. They further indicate that the optimal sequencing of TNT involves consolidation (rather than induction) chemotherapy to optimize complete response rates. Data, largely from retrospective studies, have also shown that patients with clinical complete response (cCR) after neoadjuvant therapy may be managed safely with the watch and wait approach (WW) instead of preemptive total mesorectal resection (TME). However, the optimal consolidation chemotherapy regimen to achieve cCR has not been established, and a randomized clinical trial has not robustly evaluated cCR as a primary endpoint. Collaborating with a multidisciplinary oncology team and patient groups, we designed this NCI-sponsored study of chemotherapy intensification to address these issues and to drive up cCR rates, to provide opportunity for organ preservation, improve quality of life for patients and improve survival outcomes. Methods In this NCI-sponsored multi-group randomized, seamless phase II/III trial (1:1), up to 760 patients with LARC, T4N0, any T with node positive disease (any T, N+) or T3N0 requiring abdominoperineal resection or coloanal anastomosis and distal margin within 12 cm of anal verge will be enrolled. Stratification factors include tumor stage (T4 vs T1-3), nodal stage (N+ vs N0) and distance from anal verge (0-4; 4-8; 8-12 cm). Patients will be randomized to receive neoadjuvant long course chemoradiation (LCRT) followed by consolidation doublet (mFOLFOX6 or CAPOX) or triplet chemotherapy (mFOLFIRINOX) for 3-4 months. LCRT in both arms involves 4500 cGy in 25 fractions over 5 weeks + 900 cGy boost in 5 fractions with a fluoropyrimidine (capecitabine preferred). Patients will undergo assessment 8-12 (+/- 4) weeks post-TNT completion. The primary endpoint for the phase II portion will compare cCR between treatment arms. A total number of 296 evaluable patients (148 per arm) will provide statistical power of 90.5% to detect an 17% increase in cCR rate, at a one-sided alpha=0.048. The primary endpoint for the phase III portion will compare disease-free survival (DFS) between treatment arms. A total of 285 DFS events will provide 85% power to detect an effect size of hazard ratio 0.70 at a one-sided alpha of 0.025, requiring enrollment of 760 patients (380 per arm). Secondary objectives include time-to event outcomes (overall survival, organ preservation time and time to distant metastasis) and adverse effects. Biospecimens including archival tumor tissue, plasma and buffy coat in EDTA tubes, and serial rectal MRIs will be collected for exploratory correlative research. This study, activated in late 2022, is open across the NCTN and has a current accrual of 312. Support: U10CA180821, U10CA180882, U24 CA196171; https://acknowledgments.alliancefound.org . Discussion Building off of data from modern day rectal cancer trials and patient input from national advocacy groups, we have designed the current trial studying chemotherapy intensification via a consolidation chemotherapy approach with the intent to enhance cCR and DFS rates, increase organ preservation rates, and improve quality of life for patients with rectal cancer. Trial Registration Clinicaltrials.gov ID: NCT05610163 ; Support includes U10CA180868 (NRG) and U10CA180888 (SWOG).
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Pennel K, Dutton L, Melissourgou-Syka L, Roxburgh C, Birch J, Edwards J. Novel radiation and targeted therapy combinations for improving rectal cancer outcomes. Expert Rev Mol Med 2024; 26:e14. [PMID: 38623751 DOI: 10.1017/erm.2024.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
Neoadjuvant radiotherapy (RT) is commonly used as standard treatment for rectal cancer. However, response rates are variable and survival outcomes remain poor, highlighting the need to develop new therapeutic strategies. Research is focused on identifying novel methods for sensitising rectal tumours to RT to enhance responses and improve patient outcomes. This can be achieved through harnessing tumour promoting effects of radiation or preventing development of radio-resistance in cancer cells. Many of the approaches being investigated involve targeting the recently published new dimensions of cancer hallmarks. This review article will discuss key radiation and targeted therapy combination strategies being investigated in the rectal cancer setting, with a focus on exploitation of mechanisms which target the hallmarks of cancer.
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Affiliation(s)
- Kathryn Pennel
- School of Cancer Sciences, Wolfson Wohl Cancer Research Centre, University of Glasgow, Glasgow, G61 1BD, UK
| | - Louise Dutton
- School of Cancer Sciences, Wolfson Wohl Cancer Research Centre, University of Glasgow, Glasgow, G61 1BD, UK
| | - Lydia Melissourgou-Syka
- School of Cancer Sciences, Wolfson Wohl Cancer Research Centre, University of Glasgow, Glasgow, G61 1BD, UK
- CRUK Scotland Institute, Glasgow, G611BD, UK
| | - Campbell Roxburgh
- School of Cancer Sciences, Wolfson Wohl Cancer Research Centre, University of Glasgow, Glasgow, G61 1BD, UK
- Academic Unit of Surgery, Glasgow Royal Infirmary, University of Glasgow, Glasgow, G4 0SF, UK
| | - Joanna Birch
- School of Cancer Sciences, Wolfson Wohl Cancer Research Centre, University of Glasgow, Glasgow, G61 1BD, UK
| | - Joanne Edwards
- School of Cancer Sciences, Wolfson Wohl Cancer Research Centre, University of Glasgow, Glasgow, G61 1BD, UK
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9
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Zhai M, Lin Z, Wang H, Yang J, Li M, Li X, Zhang L, Zhang T. Can rectal MRI and endorectal ultrasound accurately predict the complete response to neoadjuvant immunotherapy for rectal cancer? Gastroenterol Rep (Oxf) 2024; 12:goae027. [PMID: 38590912 PMCID: PMC11001488 DOI: 10.1093/gastro/goae027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 03/17/2024] [Accepted: 03/18/2024] [Indexed: 04/10/2024] Open
Abstract
Background Standardized assessments of clinical complete response (cCR) to neoadjuvant chemoradiotherapy (nCRT) for rectal cancer have been established, but their utility and accuracy remain unclear. This study aimed to evaluate the clinical diagnostic value of rectal magnetic resonance imaging (MRI) and endorectal ultrasonography (ERUS) for the determination of cCRs after neoadjuvant immunotherapy and to investigate the concordance between cCR and pathological complete response (pCR). Methods Ninety-four patients with rectal cancer treated with neoadjuvant radiotherapy with or without immunotherapy were included. The sensitivity, specificity, and accuracy of each evaluation method were calculated. Results Combined MRI and ERUS assessments found cCR in seven of the 94 patients in our cohort. In the non-immunotherapy group, the sensitivity, specificity, and accuracy of MRI for diagnosing cCR were 50.0%, 85.2%, and 77.1%, respectively, whereas those of ERUS were 50.0%, 92.6%, and 82.9%, respectively; those of combined MRI and ERUS were 25.0%, 96.3%, and 87.5%, respectively. In the immunotherapy group, the sensitivity, specificity, and accuracy with which MRI identified CR were 51.7%, 76.7%, and 64.4%, respectively; those of ERUS were 13.8%, 90.0%, and 52.5%, respectively, and those of combined MRI and ERUS were 10.3%, 96.7%, and 54.2%, respectively. We also found that 32 of 37 patients with pCR did not meet the cCR evaluation criteria. Of these pCR patients, 78.4% (29/37) received immunotherapy. In the entire cohort, there were five pCRs among the seven cCRs. Of the four cCRs that occurred in the immunotherapy group, three were pCRs. Conclusions Rectal MRI and/or ERUS did not provide sufficiently accurate assessments of cCR in patients with rectal cancer receiving neoadjuvant therapy, especially immunotherapy, and cCR did not predict pCR.
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Affiliation(s)
- Menglan Zhai
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, P. R. China
- Hubei Key Laboratory of Precision Radiation Oncology, Wuhan, Hubei, P. R. China
- Institute of Radiation Oncology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, P. R. China
| | - Zhenyu Lin
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, P. R. China
- Hubei Key Laboratory of Precision Radiation Oncology, Wuhan, Hubei, P. R. China
- Institute of Radiation Oncology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, P. R. China
| | - Haihong Wang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, P. R. China
- Hubei Key Laboratory of Precision Radiation Oncology, Wuhan, Hubei, P. R. China
| | - Jinru Yang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, P. R. China
- Institute of Radiation Oncology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, P. R. China
| | - Mingjie Li
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, P. R. China
- Institute of Radiation Oncology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, P. R. China
| | - Xin Li
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, P. R. China
| | - Lan Zhang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, P. R. China
| | - Tao Zhang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, P. R. China
- Hubei Key Laboratory of Precision Radiation Oncology, Wuhan, Hubei, P. R. China
- Institute of Radiation Oncology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, P. R. China
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10
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Safont MJ, García-Figueiras R, Hernando-Requejo O, Jimenez-Rodriguez R, Lopez-Vicente J, Machado I, Ayuso JR, Bustamante-Balén M, De Torres-Olombrada MV, Domínguez Tristancho JL, Fernández-Aceñero MJ, Suarez J, Vera R. Interdisciplinary Spanish consensus on a watch-and-wait approach for rectal cancer. Clin Transl Oncol 2024; 26:825-835. [PMID: 37787973 DOI: 10.1007/s12094-023-03322-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 09/07/2023] [Indexed: 10/04/2023]
Abstract
Watch-and-wait has emerged as a new strategy for the management of rectal cancer when a complete clinical response is achieved after neoadjuvant therapy. In an attempt to standardize this new clinical approach, initiated by the Spanish Cooperative Group for the Treatment of Digestive Tumors (TTD), and with the participation of the Spanish Association of Coloproctology (AECP), the Spanish Society of Pathology (SEAP), the Spanish Society of Gastrointestinal Endoscopy (SEED), the Spanish Society of Radiation Oncology (SEOR), and the Spanish Society of Medical Radiology (SERAM), we present herein a consensus on a watch-and-wait approach for the management of rectal cancer. We have focused on patient selection, the treatment schemes evaluated, the optimal timing for evaluating the clinical complete response, the oncologic outcomes after the implementation of this strategy, and a protocol for surveillance of these patients.
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Affiliation(s)
- Maria Jose Safont
- Oncology Department, Consorcio Hospital General Universitario de Valencia. Valencia University, Av. de les Tres Creus, 2, 46014, València, Spain.
| | - Roberto García-Figueiras
- Radiology Department, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | | | | | - Jorge Lopez-Vicente
- Gastroenterology Department, Hospital Universitario de Mostoles, Mósteles, Spain
| | - Isidro Machado
- Instituto Valenciano de Oncología, Valencia, Spain
- Pathology Department, Patologika Laboratory QuironSalud, Valencia, Spain
- Pathology Department, University of Valencia, Valencia, Spain
| | | | - Marco Bustamante-Balén
- Gastrointestinal Endoscopy Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | | | | | - Mª Jesús Fernández-Aceñero
- Surgical Pathology Department, Hospital Clínico San Carlos, IdiSSC, Universidad Complutense de Madrid, Madrid, Spain
| | - Javier Suarez
- General Surgery Department, Hospital Universitario de Navarra, Pamplona, Spain
| | - Ruth Vera
- Medical Oncology Department, Hospital Universitario de Navarra, Instituto de Investigación (Idisna), Pamplona, Spain
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11
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Yang W, Qian C, Luo J, Chen C, Feng Y, Dai N, Li X, Xiao H, Yang Y, Li M, Li C, Wang D. Efficacy and Safety of Preoperative Transcatheter Rectal Arterial Chemoembolisation in Patients with Locally Advanced Rectal Cancer: Results from a Prospective, Phase II PCAR Trial. Clin Oncol (R Coll Radiol) 2024; 36:233-242. [PMID: 38342657 DOI: 10.1016/j.clon.2024.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 11/22/2023] [Accepted: 01/24/2024] [Indexed: 02/13/2024]
Abstract
AIMS The PCAR study aimed to assess the efficacy and safety of preoperative transcatheter rectal arterial chemoembolisation (TRACE) in patients with locally advanced rectal cancer (LARC). MATERIALS AND METHODS This was a single-centre, prospective, phase II trial conducted in China. Eligible patients were adults aged 18 years and older with histologically confirmed stage II or III rectal carcinoma and an Eastern Cooperative Oncology Group performance status of 0-1. Patients received TRACE with oxaliplatin, followed by radiotherapy with a cumulative dose of 45 Gy (1.8 Gy/time/day, five times a week for 5 weeks) and received oral S1 capsules twice daily (7 days a week for 4 weeks). Patients underwent total mesorectal excision 4-8 weeks after the completion of chemoradiotherapy, followed by mFOLFOX6 or CAPOX regimens for 4-6 months. The hypothesis of this study was that adding TRACE to preoperative neoadjuvant chemoradiotherapy would improve tumour regression and prognosis. The primary end point was the pathological complete response rate; secondary end points included the major pathological response rate, anal preservation rate, 5-year disease-free survival (DFS), 5-year overall survival and treatment-related adverse events. RESULTS In total, 111 LARC patients received TRACE and subsequent scheduled treatment plans. The pathological complete response and major pathological response rates were 20.72% and 48.65%, respectively. The 5-year DFS and 5-year overall survival were 61.89% (95% confidence interval 51.45-74.45) and 74.80% (95% confidence interval 65.05-86.01), respectively. Grade 3-4 toxicities were reported in 29 patients (26.13%). The postoperative complication rate was 21.62%, without serious surgical complications. Multivariate Cox regression analysis showed that ypN stage (hazard ratio = 4.242, 95% confidence interval 2.101-8.564, P = 0.00017) and perineural invasion (hazard ratio = 2.319, 95% confidence interval 1.058-5.084, P = 0.0487) were independent risk factors associated with DFS, whereas ypN stage (hazard ratio = 3.164, 95% confidence interval 1.347-7.432, P = 0.0101), perineural invasion (hazard ratio = 4.118, 95% confidence interval 1.664-10.188, P = 0.0134) and serum carbohydrate antigen 199 (CA199; hazard ratio = 4.142, 95% confidence interval 1.290-13.306, P = 0.0344) were independent predictors for overall survival. CONCLUSION The current study provides evidence that adding TRACE to neoadjuvant chemoradiotherapy can improve the pathological remission rate in LARC patients with acceptable toxicity. Given its promising effectiveness and safe profile, incorporating TRACE into the standard treatment strategy for patients with LARC should be considered.
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Affiliation(s)
- W Yang
- Cancer Center, Daping Hospital, Army Medical University, Chongqing, China
| | - C Qian
- Cancer Center, Daping Hospital, Army Medical University, Chongqing, China
| | - J Luo
- Cancer Center, Daping Hospital, Army Medical University, Chongqing, China
| | - C Chen
- Cancer Center, Daping Hospital, Army Medical University, Chongqing, China
| | - Y Feng
- Cancer Center, Daping Hospital, Army Medical University, Chongqing, China
| | - N Dai
- Cancer Center, Daping Hospital, Army Medical University, Chongqing, China
| | - X Li
- Cancer Center, Daping Hospital, Army Medical University, Chongqing, China
| | - H Xiao
- Cancer Center, Daping Hospital, Army Medical University, Chongqing, China
| | - Y Yang
- Cancer Center, Daping Hospital, Army Medical University, Chongqing, China
| | - M Li
- Cancer Center, Daping Hospital, Army Medical University, Chongqing, China
| | - C Li
- Department of General Surgery, Colorectal Division, Daping Hospital, Army Medical University, Chongqing, China
| | - D Wang
- Cancer Center, Daping Hospital, Army Medical University, Chongqing, China.
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12
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Kagawa Y, Smith JJ, Fokas E, Watanabe J, Cercek A, Greten FR, Bando H, Shi Q, Garcia-Aguilar J, Romesser PB, Horvat N, Sanoff H, Hall W, Kato T, Rödel C, Dasari A, Yoshino T. Future direction of total neoadjuvant therapy for locally advanced rectal cancer. Nat Rev Gastroenterol Hepatol 2024:10.1038/s41575-024-00900-9. [PMID: 38485756 DOI: 10.1038/s41575-024-00900-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/26/2024] [Indexed: 05/31/2024]
Abstract
Despite therapeutic advancements, disease-free survival and overall survival of patients with locally advanced rectal cancer have not improved in most trials as a result of distant metastases. For treatment decision-making, both long-term oncologic outcomes and impact on quality-of-life indices should be considered (for example, bowel function). Total neoadjuvant therapy (TNT), comprised of chemotherapy and radiotherapy or chemoradiotherapy, is now a standard treatment approach in patients with features of high-risk disease to prevent local recurrence and distant metastases. In selected patients who have a clinical complete response, subsequent surgery might be avoided through non-operative management, but patients who do not respond to TNT have a poor prognosis. Refined molecular characterization might help to predict which patients would benefit from TNT and non-operative management. Specifically, integrated analysis of spatiotemporal multi-omics using artificial intelligence and machine learning is promising. Three prospective trials of TNT and non-operative management in Japan, the USA and Germany are collaborating to better understand drivers of response to TNT. Here, we address the future direction for TNT.
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Affiliation(s)
- Yoshinori Kagawa
- Department of Gastroenterological Surgery, Osaka General Medical Center, Osaka, Japan
| | - J Joshua Smith
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Emmanouil Fokas
- Department of Radiotherapy and Oncology, University of Frankfurt, Frankfurt, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- Frankfurt Cancer Institute, Frankfurt, Germany
- Department of Radiation Oncology, CyberKnife and Radiation Therapy, Centre for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
- German Cancer Consortium (DKTK), Frankfurt, Germany
| | - Jun Watanabe
- Gastroenterological Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Andrea Cercek
- Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Florian R Greten
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- Frankfurt Cancer Institute, Frankfurt, Germany
- German Cancer Consortium (DKTK), Frankfurt, Germany
- Institute for Tumour Biology and Experimental Therapy, Georg-Speyer-Haus, Frankfurt, Germany
| | - Hideaki Bando
- Department of Gastroenterology and Gastrointestinal Oncology, National Cancer Center Hospital East, Chiba, Japan
| | - Qian Shi
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Julio Garcia-Aguilar
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Paul B Romesser
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Natally Horvat
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hanna Sanoff
- Department of Medicine, Division of Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - William Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Takeshi Kato
- Department of Surgery, NHO Osaka National Hospital, Osaka, Japan
| | - Claus Rödel
- Department of Radiotherapy and Oncology, University of Frankfurt, Frankfurt, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- Frankfurt Cancer Institute, Frankfurt, Germany
- German Cancer Consortium (DKTK), Frankfurt, Germany
| | - Arvind Dasari
- Department of GI Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Takayuki Yoshino
- Department of Gastroenterology and Gastrointestinal Oncology, National Cancer Center Hospital East, Chiba, Japan.
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13
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Sinclair H, Ranji T, Gilbert DC. Will Immune Checkpoint Inhibitors Allow the Non-operative Management of Mismatch Repair-deficient Colorectal Cancer to Become a Standard of Care? Clin Oncol (R Coll Radiol) 2024; 36:136-140. [PMID: 38245479 DOI: 10.1016/j.clon.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 12/10/2023] [Accepted: 01/09/2024] [Indexed: 01/22/2024]
Affiliation(s)
- H Sinclair
- University Hospitals Sussex NHS Foundation Trust, Sussex Cancer Centre, Royal Sussex County Hospital, Brighton, UK; Brighton and Sussex Medical School, Falmer, Brighton, UK
| | - T Ranji
- University Hospitals Sussex NHS Foundation Trust, Sussex Cancer Centre, Royal Sussex County Hospital, Brighton, UK
| | - D C Gilbert
- University Hospitals Sussex NHS Foundation Trust, Sussex Cancer Centre, Royal Sussex County Hospital, Brighton, UK; Brighton and Sussex Medical School, Falmer, Brighton, UK; MRC Clinical Trials Unit at UCL, London, UK.
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14
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Williams H, Thompson HM, Lin ST, Verheij FS, Omer DM, Qin LX, Garcia-Aguilar J. Endoscopic Predictors of Residual Tumor After Total Neoadjuvant Therapy: A Post Hoc Analysis From the Organ Preservation in Rectal Adenocarcinoma Trial. Dis Colon Rectum 2024; 67:369-376. [PMID: 38039292 PMCID: PMC10922113 DOI: 10.1097/dcr.0000000000003096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2023]
Abstract
BACKGROUND Restaging endoscopy plays a critical role in selecting patients with locally advanced rectal cancer who respond to neoadjuvant therapy for nonoperative management. OBJECTIVE This study evaluated the restaging endoscopic features that best predict the presence of residual tumor in the bowel wall. DESIGN This was a post hoc analysis of a prospective randomized trial. SETTINGS The Organ Preservation in Rectal Adenocarcinoma Trial randomly assigned patients across 18 institutions with stage II/III rectal adenocarcinoma to receive either induction or consolidation total neoadjuvant therapy. Surgeons completed a restaging tumor assessment form, which stratified patients across 3 tiers of clinical response. PATIENTS Patients enrolled in the Organ Preservation in Rectal Adenocarcinoma Trial with a completed tumor assessment form were included. MAIN OUTCOME MEASURES The main outcome was residual tumor, which was defined as either an incomplete clinical response or local tumor regrowth within 2 years of restaging. Independent predictors of residual tumor were identified using backward-selected multivariable logistic regression analysis. Subgroup analyses for complete and near complete clinical responders were performed. RESULTS Surgeons completed restaging forms for 263 patients at a median of 7.7 weeks after neoadjuvant therapy; 128 patients (48.7%) had a residual tumor. On multivariable regression analysis, several characteristics of a near complete response, including ulcer (OR 6.66; 95% CI, 2.54-19.9), irregular mucosa (OR 3.66; 95% CI, 1.61-8.68), and nodularity (OR 2.96; 95% CI, 1.36-6.58), remained independent predictors of residual tumor. A flat scar was associated with lower odds of harboring residual disease (OR 0.32; 95% CI, 0.11-0.93) for patients categorized as clinical complete responders. LIMITATIONS Limitations include analysis of endoscopic features at a single time point and ambiguities in tumor assessment form response criteria. CONCLUSIONS Patients with ulcer, nodularity, or irregular mucosa, on restaging endoscopy have higher odds of residual tumor. Recognizing negative prognostic implications of these features will help surgeons better select candidates for nonoperative management and suggests that patients with high-risk characteristics would benefit from close interval surveillance. See Video Abstract . PREDICTORES ENDOSCPICOS DE TUMOR RESIDUAL DESPUS DE TERAPIA NEOADYUVANTE TOTAL UN ANLISIS POST HOC DEL ENSAYO DE PRESERVACIN DE RGANOS EN ADENOCARCINOMA RECTAL ANTECEDENTES:La reestadificación por endoscopia juega un papel crítico en la selección de pacientes con cáncer de recto localmente avanzado que responden a la terapia neoadyuvante para el manejo no quirúrgico.OBJETIVO:Este estudio evaluó las características endoscópicas de reestadificación que mejor predicen la presencia de tumor residual en la pared intestinal.DISEÑO:Este fue un análisis post hoc de un ensayo prospectivo aleatorizado.ESCENARIO:El ensayo Organ Preservation in Rectal Adenocarcinoma aleatorizó a pacientes de 18 instituciones con adenocarcinoma de recto en estadio II/III para recibir terapia neoadyuvante total de inducción o consolidación. Los cirujanos completaron un formulario de reestadificación de evaluación del tumor, que estratificó a los pacientes en tres niveles de respuesta clínica.PACIENTES:Se incluyeron pacientes inscritos en el ensayo de preservación de órganos en adenocarcinoma rectal con un formulario de evaluación del tumor completado.PRINCIPALES MEDIDAS DE RESULTADO:El resultado principal fue presencia de tumor residual, que se definió como una respuesta clínica incompleta o un nuevo crecimiento local del tumor dentro de los dos años posteriores a la reestadificación. Los predictores independientes de tumor residual se identificaron mediante un análisis de regresión logística multivariable seleccionado hacia atrás. Se realizaron análisis de subgrupos para pacientes con respuesta clínica completa y casi completa.RESULTADOS:Los cirujanos completaron formularios de reestadificación para 263 pacientes en una mediana de 7.7 semanas después de la terapia neoadyuvante; 128 (48.7%) tenían tumor residual. En el análisis de regresión multivariable, varias características de una respuesta casi completa, incluyendo úlcera (OR 6.66; IC 95% 2.54-19.9), mucosa irregular (OR 3.66; IC 95% 1.61-8.68) y nodularidad (OR 2.96; IC 95% 1.36 -6.58) siguieron siendo predictores independientes de tumor residual. Una cicatriz plana se asoció con menores probabilidades de albergar enfermedad residual (OR 0.32; IC del 95 %: 0.11-0.93) para los pacientes clasificados como respondedores clínicos completos.LIMITACIONES:Las limitaciones de este estudio incluyen el análisis de las características endoscópicas en un solo momento y las ambigüedades en los criterios de respuesta.en la forma de evaluación del tumorCONCLUSIONES:Los pacientes con úlcera, nodularidad o mucosa irregular en la endoscopia de reestadificación tienen mayores probabilidades de tumor residual. El reconocer las implicaciones pronósticas negativas de estas características ayudará a los cirujanos a seleccionar mejor a los candidatos para el tratamiento no quirúrgico y sugiere que los pacientes con características de alto riesgo se beneficiarían de una vigilancia a intervalos estrechos. (Traducción-Dr. Jorge Silva Velazco ).
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Affiliation(s)
- Hannah Williams
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hannah M. Thompson
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sabrina T. Lin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Floris S. Verheij
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Dana M. Omer
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Li-Xuan Qin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Julio Garcia-Aguilar
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York
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Romesser PB, Capdevila J, Garcia-Carbonero R, Philip T, Fernandez Martos C, Tuli R, Rodriguez-Gutierrez A, Kuipers M, Becker A, Coenen-Stass A, Sarholz B, You X, Miller ED. A Phase Ib Study of the DNA-PK Inhibitor Peposertib Combined with Neoadjuvant Chemoradiation in Patients with Locally Advanced Rectal Cancer. Clin Cancer Res 2024; 30:695-702. [PMID: 38051750 PMCID: PMC10870114 DOI: 10.1158/1078-0432.ccr-23-1129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 07/31/2023] [Accepted: 12/01/2023] [Indexed: 12/07/2023]
Abstract
PURPOSE Peposertib-an orally administered DNA-dependent protein kinase inhibitor-has shown potent radiosensitization in preclinical models. This dose-escalation study (NCT03770689) aimed to define the maximum tolerated dose (MTD) and recommended phase II dose (RP2D) of peposertib plus capecitabine-based chemoradiotherapy (CRT) and assessed its safety and efficacy in locally advanced rectal cancer. PATIENTS AND METHODS Patients were treated for 5 to 5.5 weeks with 50- to 250-mg peposertib once daily, capecitabine 825 mg/m2 twice daily, and radiotherapy (RT), 5 days per week. Following clinical restaging (8 weeks after CRT completion), patients with clinical complete response (cCR) could opt for surveillance. Total mesorectal excision was recommended upon incomplete response (IR). RESULTS Nineteen patients were treated with peposertib at doses of 50 mg (n = 1), 100 mg, 150 mg, and 250 mg (n = 6 each). Dose-limiting toxicities occurred in one out of five (100 mg), one out of six (150 mg), and three out of six (250 mg) evaluable patients. Peposertib ≤150 mg once daily was tolerable in combination with CRT. After 8 weeks of treatment with peposertib and CRT, the cCR was 15.8% (n = 3). Among the three patients with cCR, two underwent surgery and had residual tumors. Among the 16 patients with IR, seven underwent surgery and had residual tumors; five of the remaining nine patients opted for consolidative chemotherapy. The combined cCR/pathologic complete response (pCR) rate was 5.3% (n = 1, 100 mg cohort). CONCLUSIONS Peposertib did not improve complete response rates at tolerable dose levels. The study was closed without declaring the MTD/RP2D.
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Affiliation(s)
| | - Jaume Capdevila
- Vall d'Hebron University Hospital, Vall d'Hebron Institute of Oncology (VHIO), IOB Quiron-Teknon, Barcelona, Spain
| | | | - Tony Philip
- Northwell Health Cancer Institute, Lake Success, New York
| | | | - Richard Tuli
- USF Health Morsani College of Medicine, Tampa, Florida
| | | | - Mirjam Kuipers
- The health care business of Merck KGaA, Darmstadt, Germany
| | - Andreas Becker
- The health care business of Merck KGaA, Darmstadt, Germany
| | | | | | | | - Eric D. Miller
- Ohio State University Comprehensive Cancer Center, Columbus, Ohio
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16
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Du R, Chang Y, Zhang J, Cheng Y, Li Y, Zhang C, Zhang J, Xu L, Liu Y. Whether the watch-and-wait strategy has application value for rectal cancer with clinical complete response after neoadjuvant chemoradiotherapy? A network meta-analysis. Asian J Surg 2024; 47:853-863. [PMID: 38042663 DOI: 10.1016/j.asjsur.2023.11.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 10/29/2023] [Accepted: 11/10/2023] [Indexed: 12/04/2023] Open
Abstract
The aim was to evaluate the efficacy and safety between the watch-and-wait strategy (WW), radical surgery (RS), and local excision (LE) for rectal cancer with clinical complete response (cCR) after neoadjuvant radiotherapy (nCRT). We searched MEDLINE, EMBASE, the Cochrane Library, and clinical trials to compare WW with RS and LE for patients with cCR until March 2023 and collected the following data: local recurrence (LR), distant metastasis (DM), cancer-related death (CRD), overall survival (OS), and disease-free survival (DFS). In total, 2240 patients from 21 studies were included. Pairwise meta-analysis revealed no statistically significant differences between the three groups in terms of CRD and 2-, 3-, and 5-year OS (P < 0.05). The RS group was significantly better than the WW group in terms of the LR rate (odds ratio [OR] = 0.12, 95 % confidence interval [CI]: 0.06-0.21, P < 0.001, I2 = 0 %], 3-year DFS (OR = 1.56, 95 % CI: 1.10-2.21, P = 0.01, I2 = 38 %), and 5-year DFS (OR = 2.30, 95 % CI: 1.53-3.46, P < 0.001, I2 = 34 %). The results of network meta-analysis were also similar. After sensitivity analysis, the 5-year OS of the RS group was significantly better than that of the WW group (OR = 2.77, 95 % CI: 1.28-6.00, P = 0.009, I2 = 33 %). Nevertheless, neither regression analysis nor subgroup analysis provided meaningful results. However, the cumulative meta-analysis of LR, DM, and 3- and 5-year DFS revealed significant turning points (P < 0.05). Our meta-analysis recommends using the WW strategy for patients with cCR having poor underlying conditions and high surgical risk; however, there is a risk of higher LR and worse survival after 3 years.
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Affiliation(s)
- Rui Du
- Department of Anorectal Surgery, The Third Affiliated Hospital of Anhui Medical University, Hefei First People's Hospital, Hefei, 230000, China
| | - Yue Chang
- Cancer Comprehensive Treatment Center, Hefei Cancer Hospital, Chinese Academy of Sciences, Hefei, 230000, China
| | - Juan Zhang
- Department of Anorectal Surgery, The Third Affiliated Hospital of Anhui Medical University, Hefei First People's Hospital, Hefei, 230000, China
| | - Yuanguang Cheng
- Department of Anorectal Surgery, The Third Affiliated Hospital of Anhui Medical University, Hefei First People's Hospital, Hefei, 230000, China
| | - Yonghai Li
- Department of Anorectal Surgery, The Third Affiliated Hospital of Anhui Medical University, Hefei First People's Hospital, Hefei, 230000, China
| | - Chengyue Zhang
- Department of Anorectal Surgery, The Third Affiliated Hospital of Anhui Medical University, Hefei First People's Hospital, Hefei, 230000, China
| | - Jinyuan Zhang
- Department of Anorectal Surgery, The Third Affiliated Hospital of Anhui Medical University, Hefei First People's Hospital, Hefei, 230000, China
| | - Liejuan Xu
- Department of Anorectal Surgery, The Third Affiliated Hospital of Anhui Medical University, Hefei First People's Hospital, Hefei, 230000, China
| | - Yuancheng Liu
- Department of Anorectal Surgery, The Third Affiliated Hospital of Anhui Medical University, Hefei First People's Hospital, Hefei, 230000, China.
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17
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Wang Y, Wang X, Huang S, Chen J, Huang Y. MRI-based parameters and clinical risk factors to predict lymph node metastasis in patients with ypT0 rectal cancer after neoadjuvant chemoradiotherapy. ANZ J Surg 2024. [PMID: 38251776 DOI: 10.1111/ans.18876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 01/23/2024]
Abstract
BACKGROUNDS The aim of this study was to assess the significant risk factors that predict lymph node metastasis in ypT0 patients with locally advanced rectal cancer following chemoradiotherapy (CRT). Additionally, the study aimed to identify high-risk groups who would not be suitable candidates for a rectal-preserving strategy, despite achieving a complete tumour response. METHODS Between 2013 and 2021, 226 ypT0 patients with stages II/III rectal cancer underwent CRT and radical surgery were enrolled. Two groups of patients were evaluated: those with lymph nodes metastasis and those without. The selection of variables for multivariable logistic regression was conducted through bivariate logistic regression analysis. Furthermore, the determination of optimal cutoff values for risk factors was achieved using ROC curve analysis. RESULTS Nearly 8% (18/226) of patients with ypT0 had positive lymph nodes (LN) on final pathology. Four variables resulted as being independent factors of LN metastasis: pre-CRT tumour movability (OR = 8.618, P = 0.003), pre-CRT maximal LN size (OR = 28.474, P = 0.004), post-CRT tumour vertical length (OR = 1.492, P = 0.050), post-CRT anaemia (OR = 10.288, P = 0.001). The optimal cutoff point of pre-CRT maximal LN size and post-CRT tumour vertical length was 7.50 mm and 3.05 cm, respectively. CONCLUSION The prevalence of lymph node metastasis remains at 8% among patients who achieve pathological complete regression of the primary tumour. In instances where patients are considered appropriate candidates for a rectal-preserving strategy after clinical complete remission, careful consideration should be given to the selection of this strategy if specific risk factors are present. These risk factors encompass a maximal LN size surpassing 7.50 mm prior to CRT, a fixed tumour prior to CRT, a tumour vertical length exceeding 3.05 cm after CRT, and the existence of anaemia subsequent to CRT.
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Affiliation(s)
- Yangyang Wang
- Department of Gastrointestinal Surgery, the Second Affiliated Hospital of Shandong First Medical University, Tai'an, People's Republic of China
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian Province, People's Republic of China
| | - Xiaojie Wang
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian Province, People's Republic of China
| | - Shenghui Huang
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian Province, People's Republic of China
| | - Jinhua Chen
- Follow-Up Center, Union Hospital, Fujian Medical University, Fuzhou, Fujian Province, People's Republic of China
| | - Ying Huang
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian Province, People's Republic of China
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18
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Thompson HM, Omer DM, Lin S, Kim JK, Yuval JB, Veheij FS, Qin LX, Gollub MJ, Wu AJC, Lee M, Patil S, Hezel AF, Marcet JE, Cataldo PA, Polite BN, Herzig DO, Liska D, Oommen S, Friel CM, Ternent CA, Coveler AL, Hunt SR, Garcia-Aguilar J. Organ Preservation and Survival by Clinical Response Grade in Patients With Rectal Cancer Treated With Total Neoadjuvant Therapy: A Secondary Analysis of the OPRA Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2350903. [PMID: 38194231 PMCID: PMC10777257 DOI: 10.1001/jamanetworkopen.2023.50903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/20/2023] [Indexed: 01/10/2024] Open
Abstract
Importance Assessing clinical tumor response following completion of total neoadjuvant therapy (TNT) in patients with locally advanced rectal cancer is paramount to select patients for watch-and-wait treatment. Objective To assess organ preservation (OP) and oncologic outcomes according to clinical tumor response grade. Design, Setting, and Participants This was secondary analysis of the Organ Preservation in Patients with Rectal Adenocarcinoma trial, a phase 2, nonblinded, multicenter, randomized clinical trial. Randomization occurred between April 2014 and March 2020. Eligible participants included patients with stage II or III rectal adenocarcinoma. Data analysis occurred from March 2022 to July 2023. Intervention Patients were randomized to induction chemotherapy followed by chemoradiation or chemoradiation followed by consolidation chemotherapy. Tumor response was assessed 8 (±4) weeks after TNT by digital rectal examination and endoscopy and categorized by clinical tumor response grade. A 3-tier grading schema that stratifies clinical tumor response into clinical complete response (CCR), near complete response (NCR), and incomplete clinical response (ICR) was devised to maximize patient eligibility for OP. Main Outcomes and Measures OP and survival rates by clinical tumor response grade were analyzed using the Kaplan-Meier method and log-rank test. Results There were 304 eligible patients, including 125 patients with a CCR (median [IQR] age, 60.6 [50.4-68.0] years; 76 male [60.8%]), 114 with an NCR (median [IQR] age, 57.6 [49.1-67.9] years; 80 male [70.2%]), and 65 with an ICR (median [IQR] age, 55.5 [47.7-64.2] years; 41 male [63.1%]) based on endoscopic imaging. Age, sex, tumor distance from the anal verge, pathological tumor classification, and clinical nodal classification were similar among the clinical tumor response grades. Median (IQR) follow-up for patients with OP was 4.09 (2.99-4.93) years. The 3-year probability of OP was 77% (95% CI, 70%-85%) for patients with a CCR and 40% (95% CI, 32%-51%) for patients with an NCR (P < .001). Clinical tumor response grade was associated with disease-free survival, local recurrence-free survival, distant metastasis-free survival, and overall survival. Conclusions and Relevance In this secondary analysis of a randomized clinical trial, most patients with a CCR after TNT achieved OP, with few developing tumor regrowth. Although the probability of tumor regrowth was higher for patients with an NCR compared with patients with a CCR, a significant proportion of patients achieved OP. These findings suggest the 3-tier grading schema can be used to estimate recurrence and survival outcomes in patients with locally advanced rectal cancer who receive TNT. Trial Registration ClinicalTrials.gov Identifier: NCT02008656.
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Affiliation(s)
- Hannah M. Thompson
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Dana M. Omer
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sabrina Lin
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jin K. Kim
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonathan B. Yuval
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Floris S. Veheij
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Li-Xuan Qin
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marc J. Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Abraham Jing-Ching Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Meghan Lee
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sujata Patil
- Department of Quantitative Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Aram F. Hezel
- James P. Wilmot Cancer Center, University of Rochester, Rochester, New York
| | | | | | - Blase N. Polite
- Department of Surgery, University of Chicago, Chicago, Illinois
| | - Daniel O. Herzig
- Department of Surgery, Oregon Health & Science University, Portland
| | - David Liska
- Department of Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Samuel Oommen
- Department of Surgery, John Muir Health, Walnut Creek, California
| | - Charles M. Friel
- Department of Surgery, University Hospital, University of Virginia Health System, Charlottesville
| | - Charles A. Ternent
- Department of Surgery, Creighton University Medical Center, Omaha, Nebraska
| | | | - Steven R. Hunt
- Department of Surgery, Washington University, St Louis, Missouri
| | - Julio Garcia-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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19
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Verheij FS, Omer DM, Lin ST, Yuval JB, Thompson HM, Kim JK, Valdivieso SC, Qin LX, Wu AJ, Saltz LB, Garcia-Aguilar J. Compliance and Toxicity of Total Neoadjuvant Therapy for Rectal Cancer: A Secondary Analysis of the OPRA Trial. Int J Radiat Oncol Biol Phys 2024; 118:115-123. [PMID: 37544412 PMCID: PMC11027192 DOI: 10.1016/j.ijrobp.2023.07.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 06/29/2023] [Accepted: 07/29/2023] [Indexed: 08/08/2023]
Abstract
PURPOSE Patients with locally advanced rectal cancer treated with total neoadjuvant therapy (TNT) may achieve organ preservation without a compromise to oncologic outcomes. However, reports on patient compliance with TNT and with treatment-related toxicities are limited. METHODS AND MATERIALS The OPRA trial assessed organ preservation rates and oncologic outcomes in patients with clinical stage II/III rectal adenocarcinoma randomized to induction chemotherapy followed by chemoradiation (INCT-CRT) or chemoradiation followed by consolidation chemotherapy (CRT-CNCT). Systemic chemotherapy consisted of 8 cycles (16 weeks) of fluorouracil, leucovorin, and oxaliplatin (FOLFOX) or 5 cycles (15 weeks) of capecitabine and oxaliplatin (CAPEOX). Patients received >4500 cGy of radiation with sensitizing capecitabine or fluorouracil. In this report, we compare compliance and treatment-related toxicity in patients receiving INCT-CRT versus CRT-CNCT. Additionally, we evaluate the association of compliance to chemotherapy, compliance to chemoradiation, and toxicity with organ preservation and disease-free survival (DFS). RESULTS Of the 324 patients randomized, fewer patients started chemoradiation in the INCT-CRT group compared with the CRT-CNCT group (93% vs 98%, P = .03), and fewer patients started systemic chemotherapy in the CRT-CNCT group compared with the INCT-CRT group (94% vs 99%, P = .04). Order of TNT did not affect the ability to complete all intended cycles of FOLFOX (86% INCT-CRT vs 83% CRT-CNCT, P = .60) or CAPEOX (74% INCT-CRT vs 77% CRT-CNCT, P = .80). A total of 97% of INCT and 98% of CRT-CNCT patients received >4500 cGy radiation (P = .93). Sixty-four patients (41%) treated with INCT-CRT and 57 CRT-CNCT patients (34%) experienced a grade 3+ adverse event (P = .30). Compliance and toxicity were not associated with organ preservation or DFS. CONCLUSIONS We identified only minor differences in treatment compliance between patients treated with INCT-CRT and CRT-CNCT. No difference in adverse events was observed between groups. Treatment compliance and toxicity did not correlate with organ preservation rates or DFS.
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Affiliation(s)
- Floris S Verheij
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Dana M Omer
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sabrina T Lin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonathan B Yuval
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hannah M Thompson
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jin K Kim
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sebastian C Valdivieso
- Columbia University College of Physicians and Surgeons at Harlem Hospital, New York, New York
| | - Li-Xuan Qin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Leonard B Saltz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Julio Garcia-Aguilar
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York.
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20
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Kennecke HF, Auer R, Cho M, Dasari NA, Davies-Venn C, Eng C, Dorth J, Garcia-Aguilar J, George M, Goodman KA, Kreppel L, Meyer JE, Monzon J, Saltz L, Schrag D, Smith JJ, Zell JA, Das P. NCI Rectal-Anal Task Force consensus recommendations for design of clinical trials in rectal cancer. J Natl Cancer Inst 2023; 115:1457-1464. [PMID: 37535679 PMCID: PMC11032701 DOI: 10.1093/jnci/djad143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/17/2023] [Accepted: 06/21/2023] [Indexed: 08/05/2023] Open
Abstract
The optimal management of locally advanced rectal cancer is rapidly evolving. The National Cancer Institute Rectal-Anal Task Force convened an expert panel to develop consensus on the design of future clinical trials of patients with rectal cancer. A series of 82 questions and subquestions, which addressed radiation and neoadjuvant therapy, patient perceptions, rectal cancer populations of special interest, and unique design elements, were subject to iterative review using a Delphi analytical approach to define areas of consensus and those in which consensus is not established. The task force achieved consensus on several areas, including the following: 1) the use of total neoadjuvant therapy with long-course radiation therapy either before or after chemotherapy, as well as short-course radiation therapy followed by chemotherapy, as the control arm of clinical trials; 2) the need for greater emphasis on patient involvement in treatment choices within the context of trial design; 3) efforts to identify those patients likely, or unlikely, to benefit from nonoperative management or minimally invasive surgery; 4) investigation of the utility of circulating tumor DNA measurements for tailoring treatment and surveillance; and 5) the need for identification of appropriate end points and recognition of challenges of data management for patients who enter nonoperative management trial arms. Substantial agreement was reached on priorities affecting the design of future clinical trials in patients with locally advanced rectal cancer.
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Affiliation(s)
- Hagen F Kennecke
- Medical Oncology, Providence Cancer Institute Franz Clinic, Portland, OR, USA
| | | | - May Cho
- University of CA–Irvine, Irvine, CA, USA
| | - N Arvind Dasari
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Cathy Eng
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jennifer Dorth
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | | | - Manju George
- Paltown Development Foundation, Crownsville, MD, USA
| | | | | | | | | | - Leonard Saltz
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Deborah Schrag
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - J Joshua Smith
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Prajnan Das
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
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21
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Welten VM, Dabekaussen KFAA, Miller MO, Yoo J, Irani JL, Goldberg JE, Bleday R, Reich AJ, Davids JS, Melnitchouk N. Patient Values and Goals Regarding Treatment for Rectal Cancer: a Mixed Methods Study. J Gastrointest Surg 2023; 27:3088-3091. [PMID: 37783908 DOI: 10.1007/s11605-023-05818-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 08/11/2023] [Indexed: 10/04/2023]
Affiliation(s)
- Vanessa M Welten
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, 02115, MA, USA.
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Kirsten F A A Dabekaussen
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, 02115, MA, USA
| | - Miquell O Miller
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, 02115, MA, USA
| | - James Yoo
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, 02115, MA, USA
| | - Jennifer L Irani
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, 02115, MA, USA
| | - Joel E Goldberg
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, 02115, MA, USA
| | - Ronald Bleday
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, 02115, MA, USA
| | - Amanda J Reich
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jennifer S Davids
- Department of Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA, USA
| | - Nelya Melnitchouk
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, 02115, MA, USA
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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22
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Kucejko RJ, Breen EM, Kleiman DA, Kuhnen AH, Marcello PW, Saraidaridis JT, Abelson JS. A Growing Divide? Social Determinants of the Use of Nonoperative Management of Rectal Cancer and Its Impact on Survival. J Surg Res 2023; 292:137-143. [PMID: 37619498 DOI: 10.1016/j.jss.2023.06.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 06/08/2023] [Accepted: 06/25/2023] [Indexed: 08/26/2023]
Abstract
INTRODUCTION Nonoperative management (NOM) of locally advanced rectal cancer was described as early as 2004. Initial national data demonstrated increase in utilization of NOM from 1998 to 2010, but newer national utilization data are not available. METHODS We performed a retrospective cohort study using the National Cancer Database to assess utilization and 5-y overall survival (OS) of NOM of locally advanced rectal cancer. All patients had American Joint Committee on Cancer stage 2 or 3 rectal cancer, were over 40 y old, received both chemotherapy and radiation therapy, and were not being treated with palliative intent. RESULTS 74,780 patients were analyzed. 64,540 (86.2%) underwent a definitive resection, 10,330 (13.8%) had NOM. Utilization of NOM steadily increased from 11.3% in 2010 to 18.6% in 2018. Multivariate regression identified the highest predictors of utilization of NOM to be uninsured status, government insurance, Black race, and treatment at a community cancer center. Multivariate regression identified NOM as the highest hazard for mortality (hazard ratio = 2.286, confidence interval 2.209-2.366). After propensity score matching, the mean estimated 5-y OS was 52.0% for those managed operatively compared to 39.8% for those managed nonoperatively. CONCLUSIONS From 2004 to 2018, the utilization of NOM of locally advanced rectal cancer significantly increased. However, there was a significant discrepancy in OS in comparison to surgical resection for these patients. Further study is needed to determine the long-term oncologic safety of NOM.
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Affiliation(s)
- Robert J Kucejko
- Department of Colon and Rectal Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts.
| | - Elizabeth M Breen
- Department of Colon and Rectal Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - David A Kleiman
- Department of Colon and Rectal Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Angela H Kuhnen
- Department of Colon and Rectal Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Peter W Marcello
- Department of Colon and Rectal Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Julia T Saraidaridis
- Department of Colon and Rectal Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Jonathan S Abelson
- Department of Colon and Rectal Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
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23
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Sawada N, Mukai S, Takehara Y, Misawa M, Kudo T, Hayashi T, Wakamura K, Enami Y, Miyachi H, Baba T, Ishida F, Kudo SE. The "Watch and Wait" Method After Chemoradiotherapy for Rectal Cancer Requiring Abdominoperineal Resection. Indian J Surg Oncol 2023; 14:765-772. [PMID: 38187830 PMCID: PMC10767130 DOI: 10.1007/s13193-023-01831-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 09/29/2023] [Indexed: 01/09/2024] Open
Abstract
The present study examined the therapeutic effects of preoperative neoadjuvant chemoradiation therapy (NACRT) and predictive factors for complete clinical remission, compared the prognosis and costs of abdominoperineal resection (APR) and the "watch and wait" method (WW), and evaluated the usefulness of WW. In our department, patients with stage II-III lower rectal cancer requiring APR receive NACRT. NACRT was performed as a preoperative treatment (52 Gy + S-1: 80-120 mg/day × 25 days). Eight weeks after the completion of NACRT, rectal examination, endoscopic, computed tomography, and magnetic resonance imaging findings were evaluated to assess its therapeutic effects. APR was indicated for patients in whom endoscopic findings suggested a residual tumor in which a deep ulcer or marginal swelling remained or lymph node metastasis. However, WW was selected for patients who refused APR after informed consent was obtained. In the APR and WW groups, 5- and 20-year treatment costs after CRT were calculated using the Medical Fee Points of Japan in 2020. No significant differences were observed in 3-year disease-free survival rates for either parameter between the two groups. Regarding expenses, treatment costs were lower in the WW group than in the APR group. Organ preservation using active surveillance with CRT for rectal cancer requiring APR is feasible with the achievement of endoluminal complete remission.
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Affiliation(s)
- Naruhiko Sawada
- Digestive Disease Center, Showa University Northern Yokohama Hospital, 35-1, Tsuzuki-Ku, Chigasakichuo, Yokohama City, Kanagawa, 224-8503 Japan
| | - Shumpei Mukai
- Digestive Disease Center, Showa University Northern Yokohama Hospital, 35-1, Tsuzuki-Ku, Chigasakichuo, Yokohama City, Kanagawa, 224-8503 Japan
| | - Yusuke Takehara
- Digestive Disease Center, Showa University Northern Yokohama Hospital, 35-1, Tsuzuki-Ku, Chigasakichuo, Yokohama City, Kanagawa, 224-8503 Japan
| | - Masashi Misawa
- Digestive Disease Center, Showa University Northern Yokohama Hospital, 35-1, Tsuzuki-Ku, Chigasakichuo, Yokohama City, Kanagawa, 224-8503 Japan
| | - Toyoki Kudo
- Digestive Disease Center, Showa University Northern Yokohama Hospital, 35-1, Tsuzuki-Ku, Chigasakichuo, Yokohama City, Kanagawa, 224-8503 Japan
| | - Takemasa Hayashi
- Digestive Disease Center, Showa University Northern Yokohama Hospital, 35-1, Tsuzuki-Ku, Chigasakichuo, Yokohama City, Kanagawa, 224-8503 Japan
| | - Kunihiko Wakamura
- Digestive Disease Center, Showa University Northern Yokohama Hospital, 35-1, Tsuzuki-Ku, Chigasakichuo, Yokohama City, Kanagawa, 224-8503 Japan
| | - Yuta Enami
- Digestive Disease Center, Showa University Northern Yokohama Hospital, 35-1, Tsuzuki-Ku, Chigasakichuo, Yokohama City, Kanagawa, 224-8503 Japan
| | - Hideyuki Miyachi
- Digestive Disease Center, Showa University Northern Yokohama Hospital, 35-1, Tsuzuki-Ku, Chigasakichuo, Yokohama City, Kanagawa, 224-8503 Japan
| | - Toshiyuki Baba
- Digestive Disease Center, Showa University Northern Yokohama Hospital, 35-1, Tsuzuki-Ku, Chigasakichuo, Yokohama City, Kanagawa, 224-8503 Japan
| | - Fumio Ishida
- Digestive Disease Center, Showa University Northern Yokohama Hospital, 35-1, Tsuzuki-Ku, Chigasakichuo, Yokohama City, Kanagawa, 224-8503 Japan
| | - Shin-ei Kudo
- Digestive Disease Center, Showa University Northern Yokohama Hospital, 35-1, Tsuzuki-Ku, Chigasakichuo, Yokohama City, Kanagawa, 224-8503 Japan
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Pan H, Gao Y, Ruan H, Chi P, Huang Y, Huang S. Transanal local excision versus intersphincteric resection for low rectal cancer with stage ypT0-1ycN0 after neoadjuvant chemoradiotherapy: an inverse probability weighting analysis for oncological and functional outcomes. J Cancer Res Clin Oncol 2023; 149:17383-17394. [PMID: 37843558 DOI: 10.1007/s00432-023-05454-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 09/30/2023] [Indexed: 10/17/2023]
Abstract
OBJECTIVES This study aimed to compare the efficacy of local excision (LE) and intersphincteric resection (ISR) in patients with locally advanced rectal cancer who achieved a significant or complete pathological response following neoadjuvant chemoradiotherapy. METHODS We performed a retrospective analysis of data from patients with stage ypT0-1ycN0 low rectal cancer after neoadjuvant chemoradiotherapy who underwent LE or ISR between June 2016 and June 2021. Baseline characteristics, short-term outcomes, long-term oncological outcomes, and functional outcomes, were compared between the two groups. To reduce the selection bias, inverse probability of treatment weighting (IPTW) was performed. RESULTS This study included 106 patients (LE group: n = 51, ISR group: n = 55). There were significant differences in baseline characteristics between the two groups (P < 0.05). After IPTW, there were almost no significant differences in baseline data between the two groups. The LE group showed less postoperative complications and better function outcomes compared to the ISR group. The LE group had significantly lower rates of complications (13.7% vs. 36.4%, P = 0.014). There were no significant differences between the two groups in terms of long-term oncological outcomes. CONCLUSIONS For patients with locally advanced low rectal cancer achieving significant or complete pathological response after neoadjuvant therapy, both LE and ISR present comparable oncological outcomes. Yet, LE seems to show more advantages in terms of postoperative complications and functional outcomes. These findings offer important insights for surgical decision-making, emphasizing the necessity to consider both oncological and functional outcomes in selecting the optimal surgical approach.
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Affiliation(s)
- Hongfeng Pan
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yihuang Gao
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Haoyang Ruan
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Pan Chi
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China.
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China.
| | - Ying Huang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China.
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China.
| | - Shenghui Huang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China.
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China.
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25
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Prata I, Eriksson M, Krdzalic J, Kranenbarg EMK, Roodvoets AGH, Beets-Tan R, van de Velde CJH, van Etten B, Hospers GAP, Glimelius B, Nilsson PJ, Marijnen CAM, Peeters KCMJ, Blomqvist LK. Results of a diagnostic imaging audit in a randomised clinical trial in rectal cancer highlight the importance of careful planning and quality control. Insights Imaging 2023; 14:206. [PMID: 38001376 PMCID: PMC10673763 DOI: 10.1186/s13244-023-01552-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 10/27/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Magnetic resonance (MR) imaging is the modality used for baseline assessment of locally advanced rectal cancer (LARC) and restaging after neoadjuvant treatment. The overall audited quality of MR imaging in large multicentre trials on rectal cancer is so far not routinely reported. MATERIALS AND METHODS We collected MR images obtained within the Rectal Cancer And Pre-operative Induction Therapy Followed by Dedicated Operation (RAPIDO) trial and performed an audit of the technical features of image acquisition. The required MR sequences and slice thickness stated in the RAPIDO protocol were used as a reference. RESULTS Out of 920 participants of the RAPIDO study, MR investigations of 668 and 623 patients in the baseline and restaging setting, respectively, were collected. Of these, 304/668 (45.5%) and 328/623 (52.6%) MR images, respectively, fulfilled the technical quality criteria. The main reason for non-compliance was exceeding slice thickness 238/668, 35.6% in the baseline setting and 162/623, 26.0% in the restaging setting. In 166/668, 24.9% and 168/623, 27.0% MR images in the baseline and restaging setting, respectively, one or more of the required pulse sequences were missing. CONCLUSION Altogether, 49.0% of the MR images obtained within the RAPIDO trial fulfilled the image acquisition criteria required in the study protocol. High-quality MR imaging should be expected for the appropriate initial treatment and response evaluation of patients with LARC, and efforts should be made to maximise the quality of imaging in clinical trials and in clinical practice. CRITICAL RELEVANCE STATEMENT This audit highlights the importance of adherence to MR image acquisition criteria for rectal cancer, both in multicentre trials and in daily clinical practice. High-resolution images allow correct staging, treatment stratification and evaluation of response to neoadjuvant treatment. KEY POINTS - Complying to MR acquisition guidelines in multicentre trials is challenging. - Neglection on MR acquisition criteria leads to poor staging and treatment. - MR acquisition guidelines should be followed in trials and clinical practice. - Researchers should consider mandatory audits prior to study initiation.
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Affiliation(s)
- Ilaria Prata
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands.
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands.
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands.
| | - Martina Eriksson
- Department of Radiology, Capio S:T Göran Hospital, Stockholm, Sweden
| | - Jasenko Krdzalic
- Department of Radiology, Zuyderland Medical Center, Geleen, the Netherlands
| | | | - Annet G H Roodvoets
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Regina Beets-Tan
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | | | - Boudewijn van Etten
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Geke A P Hospers
- Department of Medical Oncology, University Medical Center Groningen, Groningen, the Netherlands
| | - Bengt Glimelius
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Per J Nilsson
- Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Corrie A M Marijnen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Koen C M J Peeters
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Lennart K Blomqvist
- Department of Radiation Physics/Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
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26
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Murakami N, Kojima K, Okuma K, Kashihara T, Nakamura S, Shimizu W, Suda R, Igaki H, Shikama N. Non-operative management involving chemoradiation therapy combined with high-dose-rate brachytherapy for T3 rectal cancer using a vaginal shielded cylindrical applicator: a technical report. Jpn J Clin Oncol 2023; 53:1082-1086. [PMID: 37554048 DOI: 10.1093/jjco/hyad099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 07/27/2023] [Indexed: 08/10/2023] Open
Abstract
It has been shown that a group of rectal cancer patients will achieve a pathological complete response following preoperative chemoradiotherapy, and non-operative management has recently gained attention. To escalate the tumour dose and increase the likelihood of pathological complete response, brachytherapy can play an important role in safely increasing the total dose. However, at the time this report was published, an applicator dedicated to rectal brachytherapy was unaffordable in Japan. Here, we report two T3 rectal cancer patients who were inoperable or refused surgery and treated by chemoradiotherapy following intracavitary brachytherapy involving a vaginal cylinder applicator with lead shielding.
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Affiliation(s)
- Naoya Murakami
- Department of Radiation Oncology, Juntendo University, Tokyo, Japan
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Kanako Kojima
- Department of Radiation Oncology, Juntendo University, Tokyo, Japan
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Kae Okuma
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Tairo Kashihara
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Satoshi Nakamura
- Radiation Safety and Quality Assurance Division, National Cancer Center Hospital, Tokyo, Japan
| | - Wakako Shimizu
- Department of Radiation Oncology, Kimitsu Chuo Hospital, Chiba, Japan
| | - Ryuichiro Suda
- Department of Surgery, Kimitsu Chuo Hospital, Chiba, Japan
| | - Hiroshi Igaki
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Naoto Shikama
- Department of Radiation Oncology, Juntendo University, Tokyo, Japan
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Lynch P, Ryan OK, Donnelly M, Ryan ÉJ, Davey MG, Reynolds IS, Creavin B, Hanly A, Kennelly R, Martin ST, Winter DC. Comparing neoadjuvant therapy followed by local excision to total mesorectal excision in the treatment of early stage rectal cancer: a systematic review and meta-analysis of randomised clinical trials. Int J Colorectal Dis 2023; 38:263. [PMID: 37924372 DOI: 10.1007/s00384-023-04558-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/26/2023] [Indexed: 11/06/2023]
Abstract
INTRODUCTION Total mesorectal excision (TME) is the standard-of-care in early, clinical stage (cT2-3 N0 M0) rectal cancer. Local excision (LE) may be an alternative after adequate response to neoadjuvant therapy (NAT), with either long-course chemoradiotherapy (nCRT) or short-course radiotherapy (SCRT), as a means of preserving the rectum and potentially obviating the morbidity of TME. METHODS A systematic review was performed according to PRISMA guidelines for studies that randomly assigned patients with cT2-3 N0 M0 rectal cancer to either NAT + LE or TME that reported radiologic, oncologic, surgical, and morbidity outcomes. RESULTS A total of 4 RCTs comprise 462 patients (232 patients receiving NAT + LE; nCRT n = 205; SCRT n = 27) and 230 undergoing TME, respectively. NAT compliance was 98.86%. The rate of early completion TME in the NAT + LE group was 22.3%, while the proportion of patients achieving durable organ preservation was 75.4% at mean follow-up of 5.6 years. There was no difference in disease-free survival (DFS) (HR [hazard ratio] 1.19; 95% CI 0.95, 1.49; p = 0.13) or overall survival (OS) (HR 0.94; 95% CI 0.72, 1.23; p = 0.63]) according to the assigned treatment arm. The local recurrence rate (LRR) (HR 1.22; 95% CI 0.5-3.02; p = 0.66) and distant metastases (HR 0.92; 95% CI 0.45, 1.90; p = 0.82) were also comparable between the groups. There was a significant reduction in major (OR 0.45; 95% CI 0.21, 0.95; p = 0.04) and minor morbidity (OR 0.45; 95% CI 0.24, 0.85; p = 0.01) for patients undergoing NAT + LE. Overall stoma formation was decreased in the NAT + LE group (OR 0.03; 95% CI 0.0, 0.23; p ≤ 0.00001). CONCLUSION NAT + LE reduces adverse effects of TME, without any compromise in oncological outcomes, and the potential for an organ preserving strategy should be discussed with patients with T2-3N0 rectal cancers prior to treatment.
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Affiliation(s)
- Paul Lynch
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Odhrán K Ryan
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Mark Donnelly
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Éanna J Ryan
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland.
| | - Matthew G Davey
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Ian S Reynolds
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Ben Creavin
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Ann Hanly
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Rory Kennelly
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Seán T Martin
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Des C Winter
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
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28
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Kagawa Y, Watanabe J, Uemura M, Ando K, Inoue A, Oba K, Takemasa I, Oki E. Short-term outcomes of a prospective multicenter phase II trial of total neoadjuvant therapy for locally advanced rectal cancer in Japan (ENSEMBLE-1). Ann Gastroenterol Surg 2023; 7:968-976. [PMID: 37927927 PMCID: PMC10623965 DOI: 10.1002/ags3.12715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 06/16/2023] [Accepted: 06/28/2023] [Indexed: 11/07/2023] Open
Abstract
Aim To evaluate the feasibility and safety of total neoadjuvant therapy (TNT) in patients with locally advanced rectal cancer (LARC) in Japan. Methods This prospective, multicenter, open-label, single-arm phase II trial was conducted at five institutions. The key eligibility criteria were age ≥ 20 years, LARC within 12 cm from the anal verge, and cT3-4N0M0 or TanyN+M0 at the time of diagnosis that enabled curative resection. Preoperative short-course radiation therapy (SCRT) 5 Gy × 5 days (total 25 Gy) + CAPOX (six courses) followed by total mesorectum excision (TME) was the treatment protocol. Non-operative management (NOM) was allowed if clinical complete response (cCR) was obtained in the preoperative evaluation. The primary endpoint was the pathological complete response (pCR) rate. Results Thirty patients (male, n = 26; female, n = 4; median age, 62.5 [44-74] years; cT [T2, n = 1; T3, n = 25; T4, n = 4]; cN [N0, n = 13; N1, n = 13; N2, n = 4]) were enrolled. The final analysis included 30 patients in total. The completion rates were 100% for SCRT and 83% for CAPOX. TME and NOM were performed in 20 and seven patients, respectively. pCR was observed in six patients (30% [95% CI 14.0%-50.8%]). The primary endpoint was met. pCR+cCR was observed in 13 (43.3%) patients. There were no treatment-related deaths. Grade ≥3 (CTCAE ver. 5.0) adverse events (≥20%), including diarrhea (23.3%) and neutropenia (23.3%). The median follow-up period was 15.6 (10.5-22.8) months, with no recurrence or regrowth in NOM. Conclusions ENSEMBLE-1 demonstrated satisfactory pCR and cCR, and well-tolerated safety of TNT for patients with LARC in Japan.
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Affiliation(s)
- Yoshinori Kagawa
- Department of Gastroenterological SurgeryOsaka General Medical CenterOsakaJapan
| | - Jun Watanabe
- Department of Surgery, Gastroenterological CenterYokohama City University Medical CenterYokohamaJapan
| | - Mamoru Uemura
- Department of Gastroenterological SurgeryGraduate School of Medicine, Osaka UniversitySuitaJapan
| | - Koji Ando
- Department of Surgery and Science, Graduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Akira Inoue
- Department of Gastroenterological SurgeryOsaka General Medical CenterOsakaJapan
| | - Koji Oba
- Department of Biostatistics, School of Public HealthThe University of TokyoTokyoJapan
| | - Ichiro Takemasa
- Department of Surgery, Surgical Oncology and ScienceSapporo Medical UniversitySapporoJapan
| | - Eiji Oki
- Department of Surgery and Science, Graduate School of Medical SciencesKyushu UniversityFukuokaJapan
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29
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Gao Y, Wu A. Organ Preservation in MSS Rectal Cancer. Clin Colon Rectal Surg 2023; 36:430-440. [PMID: 37795468 PMCID: PMC10547535 DOI: 10.1055/s-0043-1767710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
Rectal cancer is a heterogeneous disease with complex genetic and molecular subtypes. Emerging progress of neoadjuvant therapy has led to increased pathological and clinical complete response (cCR) rates for microsatellite stable (MSS) rectal cancer, which responds poorly to immune checkpoint inhibitor alone. As a result, organ preservation of MSS rectal cancer as an alternative to radical surgery has gradually become a feasible option. For patients with cCR or near-cCR after neoadjuvant treatment, organ preservation can be implemented safely with less morbidity. Patient selection can be done either before the neoadjuvant treatment for higher probability or after with careful assessment for a favorable outcome. Those patients who achieved a good clinical response are managed with nonoperative management, organ preservation surgery, or radiation therapy alone followed by strict surveillance. The oncological outcomes of patients with careful selection and organ preservation seem to be noninferior compared with those of radical surgery, with lower postoperative morbidity. However, more studies should be done to seek better regression of tumor and maximize the possibility of organ preservation in MSS rectal cancer.
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Affiliation(s)
- Yuye Gao
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Unit III, Gastrointestinal Cancer Center, Peking University Cancer Hospital and Institute, Beijing, China
| | - Aiwen Wu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Unit III, Gastrointestinal Cancer Center, Peking University Cancer Hospital and Institute, Beijing, China
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30
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Karbhari A, Baheti AD, Ankathi SK, Haria PD, Choudhari A, Katdare A, Guha A, Kulkarni S, Saklani A, Engineer R, Kazi M, Ostwal V. MRI in rectal cancer patients on 'watch and wait': patterns of response and their evolution. Abdom Radiol (NY) 2023; 48:3287-3296. [PMID: 37450019 DOI: 10.1007/s00261-023-04003-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 06/29/2023] [Accepted: 07/01/2023] [Indexed: 07/18/2023]
Abstract
PURPOSE Evaluate MR patterns of response and their evolution in rectal cancer patients on watch and wait (WW). METHODS We retrospectively reviewed 337 MRIs of 60 patients (median follow-up: 12 months; range: 6-49 months). Baseline MRIs (available in 34/60 patients) were evaluated for tumor morphology, location, thickness, circumferential involvement, nodal status and EMVI. First post-treatment MRIs (in all patients) were additionally evaluated for pattern of response on T2 and DWI. Change in post-treatment scar thickness and scar depth angle between the first and second post-treatment scans was also evaluated. Evolution of the response pattern/recurrence were evaluated till the last available scan. RESULTS On the baseline scans, 20/34 (59%) patients had polypoidal tumor with 12/20 having ≤ 25% circumferential wall involvement. We saw five patterns of response-normalized rectal wall (2/60-3%), minimal fibrosis (23/60-38%), full thickness fibrosis (16/60-27%), irregular fibrosis (11/60-18%) and split scar (6/60-10%), with 2/60 (3%) showing possible residual disease. On the first post-treatment scans, 12/60 (20%) had restricted diffusion, with 3/12 having persistent restriction till last follow-up. Post-treatment fibrosis/split scar remained stable in 44/60 (73%) cases and improved further in the rest. 9/60 (15%) patients developed regrowth/recurrence. Patients with recurrence had < 10 mm scar thickness and < 21° change in scar angle between the first and second post-treatment MRIs. CONCLUSION Most patients on WW protocol developed minimal or full thickness fibrosis, majority of which remained stable on follow-up.
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Affiliation(s)
- Aashna Karbhari
- Department of Radiology, Tata Memorial Centre and Homi Bhabha National Institute, E. Borges Road, Parel, Mumbai, 400012, India
| | - Akshay D Baheti
- Department of Radiology, Tata Memorial Centre and Homi Bhabha National Institute, E. Borges Road, Parel, Mumbai, 400012, India.
| | - Suman K Ankathi
- Department of Radiology, Tata Memorial Centre and Homi Bhabha National Institute, E. Borges Road, Parel, Mumbai, 400012, India
| | - Purvi D Haria
- Department of Radiology, Tata Memorial Centre and Homi Bhabha National Institute, E. Borges Road, Parel, Mumbai, 400012, India
| | - Amit Choudhari
- Department of Radiology, Tata Memorial Centre and Homi Bhabha National Institute, E. Borges Road, Parel, Mumbai, 400012, India
| | - Aparna Katdare
- Department of Radiology, Tata Memorial Centre and Homi Bhabha National Institute, E. Borges Road, Parel, Mumbai, 400012, India
| | - Amrita Guha
- Department of Radiology, Tata Memorial Centre and Homi Bhabha National Institute, E. Borges Road, Parel, Mumbai, 400012, India
| | - Suyash Kulkarni
- Department of Radiology, Tata Memorial Centre and Homi Bhabha National Institute, E. Borges Road, Parel, Mumbai, 400012, India
| | - Avnish Saklani
- Department of Surgical Oncology, Tata Memorial Centre and Homi Bhabha National Institute, E. Borges Road, Parel, Mumbai, 400012, India
| | - Reena Engineer
- Department of Radiation Oncology, Tata Memorial Centre and Homi Bhabha National Institute, E. Borges Road, Parel, Mumbai, 400012, India
| | - Mufaddal Kazi
- Department of Surgical Oncology, Tata Memorial Centre and Homi Bhabha National Institute, E. Borges Road, Parel, Mumbai, 400012, India
| | - Vikas Ostwal
- Department of Medical Oncology, Tata Memorial Centre and Homi Bhabha National Institute, E. Borges Road, Parel, Mumbai, 400012, India
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31
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Hashimoto T, Tsukamoto S, Murofushi K, Ito Y, Hirano H, Tsukada Y, Sasaki K, Mizusawa J, Fukuda H, Takashima A, Kanemitsu Y. Total neoadjuvant therapy followed by a watch-and-wait strategy for patients with rectal cancer (TOWARd): protocol for single-arm phase II/III confirmatory trial (JCOG2010). BJS Open 2023; 7:zrad110. [PMID: 37931233 PMCID: PMC10627521 DOI: 10.1093/bjsopen/zrad110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/31/2023] [Accepted: 09/05/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Radical surgery is the standard treatment for rectal cancer, but can impact quality of life. Recently, the concept of total neoadjuvant therapy with a watch-and-wait strategy has been proposed in which patients with a cCR after total neoadjuvant therapy do not proceed to surgery. However, most investigations of a watch-and-wait strategy have reported cases where cCR was achieved coincidentally via total neoadjuvant therapy. The aim is to assess whether total neoadjuvant therapy is effective in early-stage rectal cancer in patients that achieve cCR and are offered a watch-and-wait strategy. METHODS JCOG2010 (TOWARd) is a multi-institutional, single-arm phase II/III confirmatory investigation of the safety and efficacy of total neoadjuvant therapy followed by a watch-and-wait strategy for rectal cancer. Key eligibility criteria include cT2-3 N0 M0 rectal adenocarcinoma, tumour diameter less than or equal to 5 cm, age 18-75 years, performance status 0-1, and no history of pelvic irradiation or rectal surgery. Total neoadjuvant therapy involves neoadjuvant chemoradiotherapy (capecitabine and radiotherapy: 45 Gy/25 fractions to the whole pelvis plus boost of 5.4 Gy/3 fractions to the primary tumour) followed by consolidation chemotherapy (four cycles of capecitabine/oxaliplatin). Patients will be re-staged every 8 weeks after total neoadjuvant therapy, and those who achieve cCR will undergo a watch-and-wait strategy, those with near complete response will undergo a watch-and-wait strategy or local resection, and those with an incomplete response will undergo radical surgery. The primary endpoint is the cCR rate in phase II and 5-year overall survival in phase III. Secondary endpoints include postoperative anal, urinary, and sexual function. A total of 105 patients (phase II, 40 patients; phase III, 65 patients) will be enrolled over 3.5 years. CONCLUSION This trial will determine whether total neoadjuvant therapy and a watch-and-wait strategy is an effective alternative to radical surgery for early-stage rectal cancer in patients with cT2-3 N0 M0 and tumour size less than or equal to 5 cm. REGISTRATION NUMBER jRCTs031220288 (https://jrct.niph.go.jp/en-latest-detail/jRCTs031220288).
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Affiliation(s)
- Tadayoshi Hashimoto
- Japan Clinical Oncology Group Data Centre/Operations Office, National Cancer Centre Hospital, Tokyo, Japan
- Translational Research Support Section, National Cancer Centre Hospital East, Kashiwa, Japan
- Department of Gastroenterology and Gastrointestinal Oncology, National Cancer Centre Hospital East, Kashiwa, Japan
| | - Shunsuke Tsukamoto
- Department of Colorectal Surgery, National Cancer Centre Hospital, Tokyo, Japan
| | - Keiko Murofushi
- Division of Radiation Oncology, Tokyo Metropolitan Cancer and Infectious Disease Centre Komagome Hospital, Tokyo, Japan
| | - Yoshinori Ito
- Department of Radiation Oncology, Showa University School of Medicine, Tokyo, Japan
| | - Hidekazu Hirano
- Department of Gastrointestinal Medical Oncology, National Cancer Centre Hospital, Tokyo, Japan
| | - Yuichiro Tsukada
- Department of Colorectal Surgery, National Cancer Centre Hospital East, Kashiwa, Japan
| | - Keita Sasaki
- Japan Clinical Oncology Group Data Centre/Operations Office, National Cancer Centre Hospital, Tokyo, Japan
| | - Junki Mizusawa
- Japan Clinical Oncology Group Data Centre/Operations Office, National Cancer Centre Hospital, Tokyo, Japan
| | - Haruhiko Fukuda
- Japan Clinical Oncology Group Data Centre/Operations Office, National Cancer Centre Hospital, Tokyo, Japan
| | - Atsuo Takashima
- Department of Gastrointestinal Medical Oncology, National Cancer Centre Hospital, Tokyo, Japan
| | - Yukihide Kanemitsu
- Department of Colorectal Surgery, National Cancer Centre Hospital, Tokyo, Japan
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32
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Lei YP, Song QZ, Liu S, Xie JY, Lv GQ. Predicting lymph node metastasis in colorectal cancer: An analysis of influencing factors to develop a risk model. World J Gastrointest Surg 2023; 15:2234-2246. [PMID: 37969707 PMCID: PMC10642478 DOI: 10.4240/wjgs.v15.i10.2234] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 09/07/2023] [Accepted: 09/14/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Colorectal cancer (CRC) is a significant global health issue, and lymph node metastasis (LNM) is a crucial prognostic factor. Accurate prediction of LNM is essential for developing individualized treatment strategies for patients with CRC. However, the prediction of LNM is challenging and depends on various factors such as tumor histology, clinicopathological features, and molecular characteristics. The most reliable method to detect LNM is the histopathological examination of surgically resected specimens; however, this method is invasive, time-consuming, and subject to sampling errors and interobserver variability. AIM To analyze influencing factors and develop and validate a risk prediction model for LNM in CRC based on a large patient queue. METHODS This study retrospectively analyzed 300 patients who underwent CRC surgery at two Peking University Shenzhen hospitals between January and December 2021. A deep learning approach was used to extract features potentially associated with LNM from primary tumor histological images while a logistic regression model was employed to predict LNM in CRC using machine-learning-derived features and clinicopathological variables as predictors. RESULTS The prediction model constructed for LNM in CRC was based on a logistic regression framework that incorporated machine learning-extracted features and clinicopathological variables. The model achieved high accuracy (0.86), sensitivity (0.81), specificity (0.87), positive predictive value (0.66), negative predictive value (0.94), area under the curve for the receiver operating characteristic (0.91), and a low Brier score (0.10). The model showed good agreement between the observed and predicted probabilities of LNM across a range of risk thresholds, indicating good calibration and clinical utility. CONCLUSION The present study successfully developed and validated a potent and effective risk-prediction model for LNM in patients with CRC. This model utilizes machine-learning-derived features extracted from primary tumor histology and clinicopathological variables, demonstrating superior performance and clinical applicability compared to existing models. The study provides new insights into the potential of deep learning to extract valuable information from tumor histology, in turn, improving the prediction of LNM in CRC and facilitate risk stratification and decision-making in clinical practice.
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Affiliation(s)
- Yun-Peng Lei
- Department of Gastrointestinal Surgery, Peking University Shenzhen Hospital, Shenzhen 518036, Guangdong Province, China
| | - Qing-Zhi Song
- Department of Gastrointestinal Surgery, Peking University Shenzhen Hospital, Shenzhen 518036, Guangdong Province, China
| | - Shuang Liu
- Department of Gastrointestinal Surgery, Peking University Shenzhen Hospital, Shenzhen 518036, Guangdong Province, China
| | - Ji-Yan Xie
- Department of Gastrointestinal Surgery, Peking University Shenzhen Hospital, Shenzhen 518036, Guangdong Province, China
| | - Guo-Qing Lv
- Department of Gastrointestinal Surgery, Shenzhen Peking University-The Hong Kong University of Science and Technology Medical Center, Peking University Shenzhen Hospital, Shenzhen 518036, Guangdong Province, China
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Lin N, Wang Y, Yu C, Wu W, Fang Y, Yang J, Liu W, Wang R, Jiang Y, Wang Y. Endoscopic ultrasound-guided injection of carbon nanoparticles suspension to label rectal cancer before neoadjuvant chemoradiotherapy: a retrospective cohort study. Gastroenterol Rep (Oxf) 2023; 11:goad062. [PMID: 37842199 PMCID: PMC10570992 DOI: 10.1093/gastro/goad062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 09/17/2023] [Accepted: 09/19/2023] [Indexed: 10/17/2023] Open
Abstract
Background Localization of the primary tumor and ensuring safe distal surgical margins (DSMs) following neoadjuvant chemoradiotherapy (nCRT) are challenging in locally advanced rectal cancers (LARCs). This study investigated the effectiveness of carbon nanoparticles suspension (CNS) for labeling the primary tumor and allowing precise tumor resection after nCRT. Methods Clinicopathological data of LARC patients who underwent nCRT followed by laparoscopic radical anal preservation surgery at our center between January 2018 and February 2023 were prospectively collected. The patients were divided into the CNS tattooed (CNS) and non-tattooed (control) groups. In the CNS group, CNS was injected in four quadrants on the anal side 1 cm away from the lower tumor margin. DSMs were determined through intraoperative distal rectal examination in the control group and observation of CNS tattoos in the CNS group. DSM lengths and positive DSM rates were compared between the two groups to analyse the feasibility and effectiveness of CNS for labeling LARCs before nCRT. Results There was no statistically significant difference in the basic demographic data, effectiveness of nCRT, or post-operative recovery rates between the two groups (all P > 0.05). In the CNS group, CNS tattoos were observed on the outside of the rectal wall, with an overall efficiency of 87.1% (27/31). The CNS group had fewer positive DSMs and safer DSM lengths (2.73 ± 0.88 vs 2.12 ± 1.15 cm, P = 0.012) than the control group (P < 0.05). Conclusions Endoscopic ultrasound-guided injection of CNS tattoos before nCRT could effectively label the LARCs, ensuring safe DSMs during anus-preserving surgeries (Chictr.org.cn No.: ChiCTR2300068991).
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Affiliation(s)
- Nan Lin
- Fuzong Clinical Medical College of Fujian Medical University, Department of General Surgery, 900th Hospital of Joint Logistics Support Force, Fuzhou, P. R. China
| | - Yuanzhao Wang
- Department of General Surgery, Dongfang Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, P. R. China
| | - Changwei Yu
- Department of Breast Surgery, Affiliated Fuzhou First Hospital of Fujian Medical University, Fuzhou, P. R. China
| | - Weihang Wu
- Fuzong Clinical Medical College of Fujian Medical University, Department of General Surgery, 900th Hospital of Joint Logistics Support Force, Fuzhou, P. R. China
| | - Yongchao Fang
- Fuzong Clinical Medical College of Fujian Medical University, Department of General Surgery, 900th Hospital of Joint Logistics Support Force, Fuzhou, P. R. China
| | - Jin Yang
- Fuzong Clinical Medical College of Fujian Medical University, Department of General Surgery, 900th Hospital of Joint Logistics Support Force, Fuzhou, P. R. China
| | - Wangwu Liu
- Fuzong Clinical Medical College of Fujian Medical University, Department of General Surgery, 900th Hospital of Joint Logistics Support Force, Fuzhou, P. R. China
| | - Rong Wang
- Department of Gastroenterology, 900th Hospital of Joint Logistics Support Force, Fuzhou, P. R. China
| | - Yanyan Jiang
- Department of Ultrasonography, 900th Hospital of Joint Logistics Support Force, Fuzhou, P. R. China
| | - Yu Wang
- Fuzong Clinical Medical College of Fujian Medical University, Department of General Surgery, 900th Hospital of Joint Logistics Support Force, Fuzhou, P. R. China
- Department of General Surgery, Dongfang Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, P. R. China
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Huang W, Huang P, Guo H, Huang Z, Wei M, Guo J, Lin C, Li Y, Luo B, Lin J, Wang L. Single-arm, phase II study of intra-arterial chemotherapy plus total neoadjuvant therapy to optimise complete response in distal rectal cancer: a study protocol. BMJ Open 2023; 13:e075023. [PMID: 37798027 PMCID: PMC10565178 DOI: 10.1136/bmjopen-2023-075023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 09/13/2023] [Indexed: 10/07/2023] Open
Abstract
INTRODUCTION Organ preservation is now considered an acceptable alternative option in distal rectal cancer patients with clinical complete response (cCR) after neoadjuvant chemoradiation (CRT). But the cCR rate is low and about one-third of tumour will regrow, which requires more effective local treatment. CRT combined with intra-arterial chemotherapy (IAC) might be a promising approach. Additionally, total neoadjuvant therapy using FOLFIRINOX induction chemotherapy improved survival while consolidation chemotherapy improved organ preservation. We assess whether IAC plus CRT and FOLFIRINOX consolidation chemotherapy can improve the chance of organ preservation and survival in distal rectal cancer. METHODS AND ANALYSIS This prospective, monocentric, open-label, single-arm phase II study will include 32 patients with cT3-4NanyM0 distal rectal adenocarcinoma. All patients will receive one cycle of IAC (irinotecan, raltitrexed and oxaliplatin), followed by CRT (50 Gy/25 fractions with concomitant capecitabine) and then with six cycles of FOLFIRINOX (leucovorin, 5-fluorouracil, oxaliplatin and irinotecan). After final evaluation, patients with cCR will receive non-operative management or surgery at their own discretion and others are mandatorily referred to surgery. Adjuvant chemotherapy with six cycles of mFOLFOX6 (leucovorin, 5-fluorouracil and oxaliplatin) will be used for patients with adverse pathological features. The primary endpoint is the rate of complete response (CR; pathological CR or sustained cCR≥2 years). The main secondary endpoints are toxicity, compliance, short-term and long-term oncological outcomes, surgical morbidity and quality of life. This protocol has been designed in accordance with the Standard Protocol Items: Recommendations for Interventional Trials 2013 guidelines. ETHICS AND DISSEMINATION This study was approved by the Academic and Ethics Committee of The Affiliated Hospital of Youjiang Medical University for Nationalities in March 2023. Trial results will be published in peer-reviewed international journals and on the ChiCTR website. PROTOCOL VERSION Registered on 18 April 2023; version #1. TRIAL REGISTRATION NUMBER ChiCTR2300070620.
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Affiliation(s)
- Wenpeng Huang
- Department of Colon and Rectal Surgery, The Affiliated Hospital of Youjiang Medical University for Nationalities, Youjiang Medical University for Nationalities, Baise, Guangxi, China
| | - Puda Huang
- Department of Colon and Rectal Surgery, The Affiliated Hospital of Youjiang Medical University for Nationalities, Youjiang Medical University for Nationalities, Baise, Guangxi, China
| | - Houji Guo
- Department of Colon and Rectal Surgery, The Affiliated Hospital of Youjiang Medical University for Nationalities, Youjiang Medical University for Nationalities, Baise, Guangxi, China
| | - Zanyi Huang
- Department of Colon and Rectal Surgery, The Affiliated Hospital of Youjiang Medical University for Nationalities, Youjiang Medical University for Nationalities, Baise, Guangxi, China
| | - Mingwei Wei
- Department of Colon and Rectal Surgery, The Affiliated Hospital of Youjiang Medical University for Nationalities, Youjiang Medical University for Nationalities, Baise, Guangxi, China
| | - Junyu Guo
- Department of Colon and Rectal Surgery, The Affiliated Hospital of Youjiang Medical University for Nationalities, Youjiang Medical University for Nationalities, Baise, Guangxi, China
| | - Cheng Lin
- Department of Interventional Oncology, The Affiliated Hospital of Youjiang Medical University for Nationalities, Youjiang Medical University for Nationalities, Baise, Guangxi, China
| | - Yepeng Li
- Department of Medical Oncology, The Affiliated Hospital of Youjiang Medical University for Nationalities, Youjiang Medical University for Nationalities, Baise, Guangxi, China
| | - Biao Luo
- Department of Radiation Oncology, The Affiliated Hospital of Youjiang Medical University for Nationalities, Youjiang Medical University for Nationalities, Baise, Guangxi, China
| | - Jie Lin
- Department of Pathology, The Affiliated Hospital of Youjiang Medical University for Nationalities, Youjiang Medical University for Nationalities, Baise, Guangxi, China
| | - Lixue Wang
- Department of Radiology, The Affiliated Hospital of Youjiang Medical University for Nationalities, Youjiang Medical University for Nationalities, Baise, Guangxi, China
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Tan S, Gao Q, Cui Y, Ou Y, Huang S, Feng W. Oncologic outcomes of watch-and-wait strategy or surgery for low to intermediate rectal cancer in clinical complete remission after adjuvant chemotherapy: a systematic review and meta-analysis. Int J Colorectal Dis 2023; 38:246. [PMID: 37787779 DOI: 10.1007/s00384-023-04534-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND A watch-and-wait (WW) strategy or surgery for low to intermediate rectal cancer that has reached clinical complete remission (cCR) after neoadjuvant chemotherapy (nCRT) or total neoadjuvant therapy (TNT) has been widely used in the clinic, but both treatment strategies are controversial. OBJECTIVE The aim of this study was to compare the oncologic outcomes of a watch-and-wait strategy or a surgical approach to treat rectal cancer in complete remission and to report the evidence-based clinical advantages of the two treatment strategies. METHODS Seven national and international databases were searched for clinical trials comparing the watch-and-wait strategy with surgical treatment for oncological outcomes in patients with rectal cancer in clinical complete remission. RESULTS In terms of oncological outcomes, there was no significant difference between the watch-and-wait strategy and surgical treatment in terms of overall survival (OS) (HR = 0.92, 95% CI (0.52, 1.64), P = 0.777), and subgroup analysis showed no significant difference in 5-year disease-free survival (5-year DFS) between WW and both local excision (LE) and radical surgery (RS) (HR = 1.76, 95% CI (0.97, 3.19), P = 0.279; HR = 1.98, 95% CI (0.95, 4.13), P = 0.164), in distant metastasis rate (RR = 1.12, 95% CI (0.73, 1.72), P = 0.593), mortality rate (RR = 1.62, 95% CI (0.93, 2.84), P = 0.09), and organ preservation rate (RR = 1.05, 95% CI (0.94, 1.17), P = 0.394) which were not statistically significant and on the outcome indicators of local recurrence rate (RR = 2.09, 95% CI (1.44, 3.03), P < 0.001) and stoma rate (RR = 0.35, 95% CI (0.20, 0.61), P < 0.001). There were significant differences between the WW group and the surgical treatment group. CONCLUSION There were no differences in OS, 5-year DFS, distant metastasis, and mortality between the WW strategy group and the surgical treatment group. The WW strategy did not increase the risk of local recurrence compared with local resection but may be at greater risk of local recurrence compared with radical surgery, and the WW group was significantly better than the surgical group in terms of stoma rate; the WW strategy was evidently superior in preserving organ integrity compared to radical excision. Consequently, for patients who exhibit a profound inclination towards organ preservation and the evasion of stoma formation in the scenario of clinically complete remission of rectal cancer, the WW strategy can be contemplated as a pragmatic alternative to surgical interventions. It is, however, paramount to emphasize that the deployment of such a strategy should be meticulously undertaken within the ambit of a multidisciplinary team's management and within specialized centers dedicated to rectal cancer management.
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Affiliation(s)
- Shufa Tan
- Shaanxi University of Chinese Medicine, Xianyang, Shaanxi, China
| | - Qiangqiang Gao
- Affiliated Hospital of Shaanxi University of Traditional Chinese Medicine, Deputy No. 2, West Weiyang Road, Xianyang City, Shaanxi Province, 712000, China
| | - Yaping Cui
- Affiliated Hospital of Shaanxi University of Traditional Chinese Medicine, Deputy No. 2, West Weiyang Road, Xianyang City, Shaanxi Province, 712000, China
| | - Yan Ou
- Affiliated Hospital of Shaanxi University of Traditional Chinese Medicine, Deputy No. 2, West Weiyang Road, Xianyang City, Shaanxi Province, 712000, China
| | - Shuilan Huang
- Shaanxi University of Chinese Medicine, Xianyang, Shaanxi, China
| | - Wenzhe Feng
- Affiliated Hospital of Shaanxi University of Traditional Chinese Medicine, Deputy No. 2, West Weiyang Road, Xianyang City, Shaanxi Province, 712000, China.
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Je HJ, Cho SH, Oh HS, Seo AN, Park BG, Lee SM, Kim SH, Kim GC, Ryeom H, Choi GS. Response Prediction after Neoadjuvant Chemotherapy for Colon Cancer Using CT Tumor Regression Grade: A Preliminary Study. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2023; 84:1094-1109. [PMID: 37869127 PMCID: PMC10585072 DOI: 10.3348/jksr.2022.0124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 10/13/2022] [Accepted: 02/06/2023] [Indexed: 10/24/2023]
Abstract
Purpose To investigate whether CT-based tumor regression grade (ctTRG) can be used to predict the response to neoadjuvant chemotherapy (NAC) in colon cancer. Materials and Methods A total of 53 patients were enrolled. Two radiologists independently assessed the ctTRG using the length, thickness, layer pattern, and luminal and extraluminal appearance of the tumor. Changes in tumor volume were also analyzed using the 3D Slicer software. We evaluated the association between pathologic TRG (pTRG) and ctTRG. Patients with Rödel's TRG of 2, 3, or 4 were classified as responders. In terms of predicting responder and pathologic complete remission (pCR), receiver operating characteristic was compared between ctTRG and tumor volume change. Results There was a moderate correlation between ctTRG and pTRG (ρ = -0.540, p < 0.001), and the interobserver agreement was substantial (weighted κ = 0.672). In the prediction of responder, there was no significant difference between ctTRG and volumetry (Az = 0.749, criterion: ctTRG ≤ 3 for ctTRG, Az = 0.794, criterion: ≤ -27.1% for volume, p = 0.53). Moreover, there was no significant difference between the two methods in predicting pCR (p = 0.447). Conclusion ctTRG might predict the response to NAC in colon cancer. The diagnostic performance of ctTRG was comparable to that of CT volumetry.
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Lee S, Kassam Z, Baheti AD, Hope TA, Chang KJ, Korngold EK, Taggart MW, Horvat N. Rectal cancer lexicon 2023 revised and updated consensus statement from the Society of Abdominal Radiology Colorectal and Anal Cancer Disease-Focused Panel. Abdom Radiol (NY) 2023; 48:2792-2806. [PMID: 37145311 PMCID: PMC10444656 DOI: 10.1007/s00261-023-03893-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/17/2023] [Accepted: 03/17/2023] [Indexed: 05/06/2023]
Abstract
The Society of Abdominal Radiology's Colorectal and Anal Cancer Disease-Focused Panel (DFP) first published a rectal cancer lexicon paper in 2019. Since that time, the DFP has published revised initial staging and restaging reporting templates, and a new SAR user guide to accompany the rectal MRI synoptic report (primary staging). This lexicon update summarizes interval developments, while conforming to the original lexicon 2019 format. Emphasis is placed on primary staging, treatment response, anatomic terminology, nodal staging, and the utility of specific sequences in the MRI protocol. A discussion of primary tumor staging reviews updates on tumor morphology and its clinical significance, T1 and T3 subclassifications and their clinical implications, T4a and T4b imaging findings/definitions, terminology updates on the use of MRF over CRM, and the conundrum of the external sphincter. A parallel section on treatment response reviews the clinical significance of near-complete response and introduces the lexicon of "regrowth" versus "recurrence". A review of relevant anatomy incorporates updated definitions and expert consensus of anatomic landmarks, including the NCCN's new definition of rectal upper margin and sigmoid take-off. A detailed review of nodal staging is also included, with attention to tumor location relative to the dentate line and locoregional lymph node designation, a new suggested size threshold for lateral lymph nodes and their indications for use, and imaging criteria used to differentiate tumor deposits from lymph nodes. Finally, new treatment terminologies such as organ preservation, TNT, TAMIS and watch-and-wait management are introduced. This 2023 version aims to serve as a concise set of up-to-date recommendations for radiologists, and discusses terminology, classification systems, MRI and clinical staging, and the evolving concepts in diagnosis and treatment of rectal cancer.
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Affiliation(s)
- Sonia Lee
- Radiological Sciences, University of California, Irvine, Irvine, CA, USA.
- University of California at Irvine, 101 The City Dr. S, Orange, CA, 92868, USA.
| | - Zahra Kassam
- Department of Medical Imaging, Schulich School of Medicine, St Joseph's Hospital, Western University, London, ON, N6A4V2, Canada
| | - Akshay D Baheti
- Department of Radiology, Tata Memorial Hospital and Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Thomas A Hope
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
| | - Kevin J Chang
- Department of Radiology, Boston University Medical Center, Boston, MA, USA
| | - Elena K Korngold
- Department of Radiology, Oregon Health & Science University, Portland, OR, USA
| | - Melissa W Taggart
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Natally Horvat
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Gollub MJ, Costello JR, Ernst RD, Lee S, Maheshwari E, Petkovska I, Wasnik AP, Horvat N. A primer on rectal MRI in patients on watch-and-wait treatment for rectal cancer. Abdom Radiol (NY) 2023; 48:2836-2873. [PMID: 37099182 DOI: 10.1007/s00261-023-03900-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 03/23/2023] [Accepted: 03/23/2023] [Indexed: 04/27/2023]
Abstract
Total neoadjuvant treatment (TNT) for rectal cancer is becoming an accepted treatment paradigm and is changing the landscape of this disease, wherein up to 50% of patients who undergo TNT are able to avoid surgery. This places new demands on the radiologist in terms of interpreting degrees of response to treatment. This primer summarizes the Watch-and-Wait approach and the role of imaging, with illustrative "atlas-like" examples as an educational guide for radiologists. We present a brief literature summary of the evolution of rectal cancer treatment, with a focus on magnetic resonance imaging (MRI) assessment of response. We also discuss recommended guidelines and standards. We outline the common TNT approach entering mainstream practice. A heuristic and algorithmic approach to MRI interpretation is also offered. To illustrate management and common scenarios, we arranged the illustrative figures as follows: (I) Clinical complete response (cCR) achieved at the immediate post-TNT "decision point" scan time; (II) cCR achieved at some point during surveillance, later than the first post-TNT MRI; (III) near clinical complete response (nCR); (IV) incomplete clinical response (iCR); (V) discordant findings between MRI and endoscopy where MRI is falsely positive, even at follow-up; (VI) discordant cases where MRI seems to be falsely positive but is proven truly positive on follow-up endoscopy; (VII) cases where MRI is falsely negative; (VIII) regrowth of tumor in the primary tumor bed; (IX) regrowth outside the primary tumor bed; and (X) challenging scenarios, i.e., mucinous cases. This primer is offered to achieve its intended goal of educating radiologists on how to interpret MRI in patients with rectal cancer undergoing treatment using a TNT-type treatment paradigm and a Watch-and-Wait approach.
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Affiliation(s)
- Marc J Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA.
| | - James R Costello
- Department of Diagnostic Imaging and Intervention, Motiff Cancer Center, Tampa, FL, 33612, USA
| | - Randy D Ernst
- Division of Diagnostic Imaging, Department of Abdominal Imaging, MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Sonia Lee
- Department of Radiology, University of California, Irvine, Orange, CA, 92868, USA
| | - Ekta Maheshwari
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA, 15213, USA
| | - Iva Petkovska
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Ashish P Wasnik
- Department of Radiology, University of MI-Michigan Medicine, Ann Arbor, MI, 48109, USA
| | - Natally Horvat
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
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Quezada-Diaz FF, Smith JJ. Is Nonoperative Management of Rectal Cancer Feasible? Adv Surg 2023; 57:141-154. [PMID: 37536849 PMCID: PMC10926904 DOI: 10.1016/j.yasu.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
During the past decade, the treatment of locally advanced rectal cancer (LARC) has become more complex. Total neoadjuvant treatment (TNT) has increased the rates of both clinical and pathologic complete response, resulting in improved long-term oncological outcomes. The feasibility to implement nonoperative management (NOM) depends on solving current challenges such as how to correctly identify the best candidates for a NOM without compromising oncologic safety. NOM should be part of the treatment discussion of LARC, considering increasing rates of clinical complete response, potential quality of life gains, avoidance of surgical morbidity, and patient preferences.
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Affiliation(s)
- Felipe F Quezada-Diaz
- Colorectal Unit, Department of Surgery, Complejo Asistencial Doctor Sótero del Río, Santiago, Región Metropolitana, Chile. https://twitter.com/ffquezad
| | - Jesse Joshua Smith
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue | SR-201, New York, NY 10065, USA.
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Kimura C, Crowder SE, Kin C. Is It Really Gone? Assessing Response to Neoadjuvant Therapy in Rectal Cancer. J Gastrointest Cancer 2023; 54:703-711. [PMID: 36417142 DOI: 10.1007/s12029-022-00889-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE Non-operative management of rectal cancer is a feasible and appealing treatment option for patients who develop a complete response after neoadjuvant therapy. However, identifying patients who are complete responders is often a challenge. This review aims to present and discuss current evidence and recommendations regarding the assessment of treatment response in rectal cancer. METHODS A review of the current literature on rectal cancer restaging was performed. Studies included in this review explored the optimal interval between the end of neoadjuvant therapy and restaging, as well as modalities of assessment and their diagnostic performance. RESULTS The current standard for restaging rectal cancer is a multimodal assessment with the digital rectal examination, endoscopy, and T2-weighted MRI with diffusion-weighted imaging. Other diagnostic procedures under investigation are PET/MRI, radiomics, confocal laser endomicroscopy, artificial intelligence-assisted endoscopy, cell-free DNA, and prediction models incorporating one or more of the above-mentioned exams. CONCLUSION Non-operative management of rectal cancer requires a multidisciplinary approach. Understanding of the robustness and limitations of each exam is critical to inform patient selection for that treatment strategy.
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Affiliation(s)
- Cintia Kimura
- Department of Surgery, Division of General Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, H3680K94305, USA
| | - Sarah Elizabeth Crowder
- Department of Surgery, Division of General Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, H3680K94305, USA
- Brigham Young University, Provo, UT, USA
| | - Cindy Kin
- Department of Surgery, Division of General Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, H3680K94305, USA.
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Yuval JB, Patil S, Gangai N, Omer DM, Akselrod DG, Fung A, Harmath CB, Kampalath R, Krehbiel K, Lee S, Liu PS, Millet JD, O'Malley RB, Purysko AS, Veniero JC, Wasnik AP, Garcia-Aguilar J, Gollub MJ. MRI assessment of rectal cancer response to neoadjuvant therapy: a multireader study. Eur Radiol 2023; 33:5761-5768. [PMID: 36814032 PMCID: PMC10394731 DOI: 10.1007/s00330-023-09480-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 12/05/2022] [Accepted: 01/27/2023] [Indexed: 02/24/2023]
Abstract
OBJECTIVES A watch and wait strategy with the goal of organ preservation is an emerging treatment paradigm for rectal cancer following neoadjuvant treatment. However, the selection of appropriate patients remains a challenge. Most previous efforts to measure the accuracy of MRI in assessing rectal cancer response used a small number of radiologists and did not report variability among them. METHODS Twelve radiologists from 8 institutions assessed baseline and restaging MRI scans of 39 patients. The participating radiologists were asked to assess MRI features and to categorize the overall response as complete or incomplete. The reference standard was pathological complete response or a sustained clinical response for > 2 years. RESULTS We measured the accuracy and described the interobserver variability of interpretation of rectal cancer response between radiologists at different medical centers. Overall accuracy was 64%, with a sensitivity of 65% for detecting complete response and specificity of 63% for detecting residual tumor. Interpretation of the overall response was more accurate than the interpretation of any individual feature. Variability of interpretation was dependent on the patient and imaging feature investigated. In general, variability and accuracy were inversely correlated. CONCLUSIONS MRI-based evaluation of response at restaging is insufficiently accurate and has substantial variability of interpretation. Although some patients' response to neoadjuvant treatment on MRI may be easily recognizable, as seen by high accuracy and low variability, that is not the case for most patients. KEY POINTS • The overall accuracy of MRI-based response assessment is low and radiologists differed in their interpretation of key imaging features. • Some patients' scans were interpreted with high accuracy and low variability, suggesting that these patients' pattern of response is easier to interpret. • The most accurate assessments were those of the overall response, which took into consideration both T2W and DWI sequences and the assessment of both the primary tumor and the lymph nodes.
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Affiliation(s)
- Jonathan B Yuval
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, NY, USA
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Sujata Patil
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, USA
| | - Natalie Gangai
- Department of Radiology, Memorial Sloan Kettering Cancer Center, NY, USA
| | - Dana M Omer
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, NY, USA
| | | | - Alice Fung
- Department of Radiology, Oregon Health & Sciences University, Portland, USA
| | - Carla B Harmath
- Department of Radiology, University of Chicago, Chicago, USA
| | - Rony Kampalath
- Department of Radiology, University of California Irvine, Irvine, USA
| | - Kyle Krehbiel
- Department of Radiology, Creighton University Medical Center - Bergan Mercy, Omaha, USA
| | - Sonia Lee
- Department of Radiology, University of California Irvine, Irvine, USA
| | - Peter S Liu
- Department of Radiology, Cleveland Clinic, Cleveland, USA
| | - John D Millet
- Department of Radiology, University of Michigan, Ann Arbor, USA
| | - Ryan B O'Malley
- Department of Radiology, University of Washington, Seattle, USA
| | | | | | - Ashish P Wasnik
- Department of Radiology, University of Michigan, Ann Arbor, USA
| | - Julio Garcia-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, NY, USA
| | - Marc J Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, NY, USA.
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Puri R, Rastogi M, Gandhi AK, Khurana R, Hadi R, Sapru S, Pandey A, Agarwal A, Srivastava AK, Mishra SP, Khatoon F, Bharati A, Mishra VK, Manral A, Mishra P. Prospective evaluation of dose-escalated preoperative concurrent chemo-radiation with image guided-IMRT in locally advanced rectal cancers. Ecancermedicalscience 2023; 17:1583. [PMID: 37533948 PMCID: PMC10393306 DOI: 10.3332/ecancer.2023.1583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Indexed: 08/04/2023] Open
Abstract
Purpose To analyse the safety and efficacy of neoadjuvant chemoradiation (NACRT) with dose-escalated image-guided intensity modulated radiation therapy (IG-IMRT) in locally advanced (T3/4; T1-4N1-2) rectal cancers (LARCs). Materials and methods Twenty patients with the diagnosis of LARC were recruited in this prospective interventional single-arm study treated by IG-IMRT with 45 Gray (Gy) in 25 fractions to elective nodal volumes and 55 Gy in 25 fractions to the gross primary and nodal disease with concurrent capecitabine 825 mg/m2 twice daily on radiotherapy days. Patients underwent total mesorectal excision 6-8 weeks post completion of NACRT followed by adjuvant chemotherapy (Capecitabine and oxaliplatin every 3 weekly for 6-8 cycles). Primary end point was acute toxicity assessment and secondary end points were pathological complete response (pCR) and loco-regional control (LRC). Results Clinical T stage was T3:T4 in 19:1 and clinical N0:N1: N2 in 2:7:11 patients, respectively. With a median follow up of 21.2 months (13.8-25.6 months), 18 of 20 (90%) patients received the full course of treatment. Tumour and nodal downstaging was achieved in 78% and 84% of patients, respectively. pCR and overall complete response (defined as pCR and near CR) was achieved in 22.2% and 44.4% of patients, respectively. 2 (10%) patients completed NACRT, and achieved complete clinical response but refused surgery. Adjuvant chemotherapy course was completed by 17/18 (94.5%) patients. Grade 3 toxicities were observed in 2 (10%) patients during NACRT. All patients were disease-free at the time of the last follow up. Conclusion Dose-escalation of NACRT therapy with IG-IMRT in LARC patients offers decent rates of pCR and overall response with excellent LRC and acceptable toxicities.
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Affiliation(s)
- Raunaq Puri
- Department of Radiation Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow 226010, India
| | - Madhup Rastogi
- Department of Radiation Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow 226010, India
| | - Ajeet Kumar Gandhi
- Department of Radiation Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow 226010, India
| | - Rohini Khurana
- Department of Radiation Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow 226010, India
| | - Rahat Hadi
- Department of Radiation Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow 226010, India
| | - Shantanu Sapru
- Department of Radiation Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow 226010, India
| | - Anshuman Pandey
- Department of Surgical Gastroenterology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow 226010, India
| | - Akash Agarwal
- Department of Surgical Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow 226010, India
| | - Anoop Kumar Srivastava
- Department of Radiation Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow 226010, India
| | - Surendra Prasad Mishra
- Department of Radiation Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow 226010, India
| | - Farhana Khatoon
- Department of Radiation Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow 226010, India
| | - Avinav Bharati
- Department of Radiation Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow 226010, India
| | - Vachaspati Kumar Mishra
- Department of Radiation Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow 226010, India
| | - Akanksha Manral
- Department of Radiation Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow 226010, India
| | - Prasoon Mishra
- Department of Radiation Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow 226010, India
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Yang R, Wu T, Yu J, Cai X, Li G, Li X, Huang W, Zhang Y, Wang Y, Yang X, Ren Y, Hu R, Feng Q, Ding P, Zhang X, Li Y. Locally advanced rectal cancer with dMMR/MSI-H may be excused from surgery after neoadjuvant anti-PD-1 monotherapy: a multiple-center, cohort study. Front Immunol 2023; 14:1182299. [PMID: 37441082 PMCID: PMC10333582 DOI: 10.3389/fimmu.2023.1182299] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 06/13/2023] [Indexed: 07/15/2023] Open
Abstract
Objective Examine patients with locally advanced rectal cancer (LARC) with deficient mismatch repair (dMMR) or microsatellite instability-high (MSI-H) who received neoadjuvant immunotherapy (nIT), and compare the outcomes of those who chose a watch-and-wait (WW) approach after achieving clinical complete response (cCR) or near-cCR with those who underwent surgery and were confirmed as pathological complete response (pCR). Methods LARC patients with dMMR/MSI-H who received nIT were retrospectively examined. The endpoints were 2-year overall survival (OS), 2-year disease-free survival (DFS), local recurrence (LR), and distant metastasis (DM). The efficacy of programmed cell death protein-1 (PD-1) inhibitor, immune-related adverse events (irAEs), surgery-related adverse events (srAEs), and enterostomy were also recorded. Results Twenty patients who received a PD-1 inhibitor as initial nIT were examined. Eighteen patients (90%) achieved complete response (CR) after a median of 7 nIT cycles, including 11 with pCR after surgery (pCR group), and 7 chose a WW strategy after evaluation as cCR or near-cCR (WW group). Both groups had median follow-up times of 25.0 months. Neither group had a case of LR or DM, and the 2-year DFS and OS in each group was 100%. The two groups had similar incidences of irAEs (P=0.627). In the pCR group, however, 2 patients (18.2%) had permanent colostomy, 3 (27.3%) had temporary ileostomy, and 2 (18.2%) had srAEs. Conclusion Neoadjuvant PD-1 blockade had high efficacy and led to a high rate of CR in LARC patients with dMMR/MSI-H. A WW strategy appears to be a safe and reliable option for these patients who achieve cCR or near-cCR after nIT.
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Affiliation(s)
- Renfang Yang
- Department of Colorectal Surgery, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Tao Wu
- Department of Colorectal Surgery, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Jiehai Yu
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Xinyi Cai
- Department of Colorectal Surgery, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Guoyu Li
- Department of Colorectal Surgery, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Xiangshu Li
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Weixin Huang
- Department of Gastrointestinal Surgery, Honghe Prefecture Third People’s Hospital, Honghe Cancer Hospital, Gejiu, China
| | - Ya Zhang
- Department of Imaging, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Yuqin Wang
- Department of Pathology, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Xudong Yang
- Department of Colorectal Surgery, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Yongping Ren
- Department of Colorectal Surgery, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Ruixi Hu
- Department of Colorectal Surgery, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Qing Feng
- Department of Colorectal Surgery, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Peirong Ding
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Xuan Zhang
- Department of Colorectal Surgery, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Yunfeng Li
- Department of Colorectal Surgery, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, China
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Martorana E, Castorina P, Ferini G, Forte S, Mare M. Forecasting Individual Patients' Best Time for Surgery in Colon-Rectal Cancer by Tumor Regression during and after Neoadjuvant Radiochemotherapy. J Pers Med 2023; 13:jpm13050851. [PMID: 37241020 DOI: 10.3390/jpm13050851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 04/24/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023] Open
Abstract
The standard treatment of locally advanced rectal cancer is neoadjuvant chemoradiotherapy before surgery. For those patients experiencing a complete clinical response after the treatment, a watch-and-wait strategy with close monitoring may be practicable. In this respect, the identification of biomarkers of the response to therapy is extremely important. Many mathematical models have been developed or used to describe tumor growth, such as Gompertz's Law and the Logistic Law. Here we show that the parameters of those macroscopic growth laws, obtained by fitting the tumor evolution during and immediately after therapy, are a useful tool for evaluating the best time for surgery in this type of cancer. A limited number of experimental observations of the tumor volume regression, during and after the neoadjuvant doses, permits a reliable evaluation of a specific patient response (partial or complete recovery) for a later time, and one can evaluate a modification of the scheduled treatment, following a watch-and-wait approach or an early or late surgery. Neoadjuvant chemoradiotherapy effects can be quantitatively described by applying Gompertz's Law and the Logistic Law to estimate tumor growth by monitoring patients at regular intervals. We show a quantitative difference in macroscopic parameters between partial and complete response patients, reliable for estimating the treatment effects and best time for surgery.
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Affiliation(s)
| | - Paolo Castorina
- Istituto Oncologico del Mediterraneo, 95029 Viagrande, Italy
- Istituto Nazionale di Fisica Nucleare (INFN), Sezione di Catania, 95123 Catania, Italy
- Faculty of Mathematics and Physics, Charles University, V Holešovičkách 2, 18000 Prague, Czech Republic
| | | | - Stefano Forte
- Istituto Oncologico del Mediterraneo, 95029 Viagrande, Italy
| | - Marzia Mare
- Istituto Oncologico del Mediterraneo, 95029 Viagrande, Italy
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45
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Cuicchi D, Castagna G, Cardelli S, Larotonda C, Petrello B, Poggioli G. Restaging rectal cancer following neoadjuvant chemoradiotherapy. World J Gastrointest Oncol 2023; 15:700-712. [PMID: 37275455 PMCID: PMC10237020 DOI: 10.4251/wjgo.v15.i5.700] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/01/2023] [Accepted: 03/29/2023] [Indexed: 05/12/2023] Open
Abstract
Correct tumour restaging is pivotal for identifying the most personalised surgical treatment for patients with locally advanced rectal cancer undergoing neoadjuvant therapy, and works to avoid both poor oncological outcome and overtreatment. Digital rectal examination, endoscopy, and pelvic magnetic resonance imaging are the recommended modalities for local tumour restaging, while chest and abdominal computed tomography are utilised for the assessment of distant disease. The optimal length of time between neoadjuvant treatment and restaging, in terms of both oncological safety and clinical effectiveness of treatment, remains unclear, especially for patients receiving prolonged total neoadjuvant therapy. The timely identification of patients who are radioresistant and at risk of disease progression remains challenging.
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Affiliation(s)
- Dajana Cuicchi
- Department of Medical and Surgical Sciences, Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna 40138, Italy
| | - Giovanni Castagna
- Department of Medical and Surgical Sciences, Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna 40138, Italy
| | - Stefano Cardelli
- Department of Medical and Surgical Sciences, Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna 40138, Italy
| | - Cristina Larotonda
- Department of Medical and Surgical Sciences, Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna 40138, Italy
| | - Benedetta Petrello
- Department of Medical and Surgical Sciences, Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna 40138, Italy
| | - Gilberto Poggioli
- Department of Medical and Surgical Sciences, Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna 40138, Italy
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Ludford K, Ho WJ, Thomas JV, Raghav KP, Murphy MB, Fleming ND, Lee MS, Smaglo BG, You YN, Tillman MM, Kamiya-Matsuoka C, Thirumurthi S, Messick C, Johnson B, Vilar E, Dasari A, Shin S, Hernandez A, Yuan X, Yang H, Foo WC, Qiao W, Maru D, Kopetz S, Overman MJ. Neoadjuvant Pembrolizumab in Localized Microsatellite Instability High/Deficient Mismatch Repair Solid Tumors. J Clin Oncol 2023; 41:2181-2190. [PMID: 36623241 PMCID: PMC10489404 DOI: 10.1200/jco.22.01351] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 10/09/2022] [Accepted: 11/21/2022] [Indexed: 01/11/2023] Open
Abstract
PURPOSE Pembrolizumab significantly improves clinical outcomes in advanced/metastatic microsatellite instability high (MSI-H)/deficient mismatch repair (dMMR) solid tumors but is not well studied in the neoadjuvant space. METHODS This is a phase II open-label, single-center trial of localized unresectable or high-risk resectable MSI-H/dMMR tumors. Treatment is pembrolizumab 200 mg once every 3 weeks for 6 months followed by surgical resection with an option to continue therapy for 1 year followed by observation. To continue on study, patients are required to have radiographic or clinical benefit. The coprimary end points are safety and pathologic complete response. Key secondary end points are response rate and organ-sparing at one year for patients who declined surgery. Exploratory analyses include interrogation of the tumor immune microenvironment using imaging mass cytometry. RESULTS A total of 35 patients were enrolled, including 27 patients with colorectal cancer and eight patients with noncolorectal cancer. Among 33 evaluable patients, best overall response rate was 82%. Among 17 (49%) patients who underwent surgery, the pathologic complete response rate was 65%. Ten patients elected to receive one year of pembrolizumab followed by surveillance without surgical resection (median follow-up of 23 weeks [range, 0-54 weeks]). An additional eight did not undergo surgical resection and received less than 1 year of pembrolizumab. During the study course of the trial and subsequent follow-up, progression events were seen in six patients (four of whom underwent salvage surgery). There were no new safety signals. Spatial immune profiling with imaging mass cytometry noted a significantly closer proximity between granulocytic cells and cytotoxic T cells in patients with progressive events compared with those without progression. CONCLUSION Neoadjuvant pembrolizumab in dMMR/MSI-H cancers is safe and resulted in high rates of pathologic, radiographic, and endoscopic response, which has implications for organ-sparing strategies.
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Affiliation(s)
- Kaysia Ludford
- Department of General Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Gastrointestinal Medical Oncology, The University of Texas. MD Anderson Cancer Center, Houston, TX
| | - Won Jin Ho
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Jane V. Thomas
- Department of Gastrointestinal Medical Oncology, The University of Texas. MD Anderson Cancer Center, Houston, TX
| | - Kanwal P.S. Raghav
- Department of Gastrointestinal Medical Oncology, The University of Texas. MD Anderson Cancer Center, Houston, TX
| | - Mariela Blum Murphy
- Department of Gastrointestinal Medical Oncology, The University of Texas. MD Anderson Cancer Center, Houston, TX
| | - Nicole D. Fleming
- Department of Gynecologic Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Michael S. Lee
- Department of Gastrointestinal Medical Oncology, The University of Texas. MD Anderson Cancer Center, Houston, TX
| | - Brandon G. Smaglo
- Department of Gastrointestinal Medical Oncology, The University of Texas. MD Anderson Cancer Center, Houston, TX
| | - Y. Nancy You
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Matthew M. Tillman
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Carlos Kamiya-Matsuoka
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Selvi Thirumurthi
- Department of Gastroenterology Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Craig Messick
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Benny Johnson
- Department of Gastrointestinal Medical Oncology, The University of Texas. MD Anderson Cancer Center, Houston, TX
| | - Eduardo Vilar
- Department of Clinical Cancer Prevention, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Arvind Dasari
- Department of Gastrointestinal Medical Oncology, The University of Texas. MD Anderson Cancer Center, Houston, TX
| | - Sarah Shin
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Alexei Hernandez
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Xuan Yuan
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Hongqui Yang
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Wai Chin Foo
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Wei Qiao
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Dipen Maru
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Scott Kopetz
- Department of Gastrointestinal Medical Oncology, The University of Texas. MD Anderson Cancer Center, Houston, TX
| | - Michael J. Overman
- Department of Gastrointestinal Medical Oncology, The University of Texas. MD Anderson Cancer Center, Houston, TX
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André T, Cohen R. Designing Trials for Neoadjuvant Immune Checkpoint Inhibition in Microsatellite Instability-High Localized Colorectal Cancer. JCO Oncol Pract 2023; 19:261-262. [PMID: 37011336 DOI: 10.1200/op.23.00125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
Affiliation(s)
- Thierry André
- Department of Medical Oncology, Saint-Antoine Hospital, Sorbonne University, Paris, France
- AP-HP, SIRIC CURAMUS, INSERM, Unité Mixte de Recherche Scientifique 938, Centre de Recherche Saint-Antoine, Equipe Instabilité des Microsatellites et Cancer, Equipe Labellisée par la Ligue Nationale Contre le Cancer, Paris, France
| | - Romain Cohen
- Department of Medical Oncology, Saint-Antoine Hospital, Sorbonne University, Paris, France
- AP-HP, SIRIC CURAMUS, INSERM, Unité Mixte de Recherche Scientifique 938, Centre de Recherche Saint-Antoine, Equipe Instabilité des Microsatellites et Cancer, Equipe Labellisée par la Ligue Nationale Contre le Cancer, Paris, France
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Jayaprakasam VS, Alvarez J, Omer DM, Gollub MJ, Smith JJ, Petkovska I. Watch-and-Wait Approach to Rectal Cancer: The Role of Imaging. Radiology 2023; 307:e221529. [PMID: 36880951 PMCID: PMC10068893 DOI: 10.1148/radiol.221529] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 11/09/2022] [Accepted: 11/14/2022] [Indexed: 03/08/2023]
Abstract
The diagnosis and treatment of rectal cancer have evolved dramatically over the past several decades. At the same time, its incidence has increased in younger populations. This review will inform the reader of advances in both diagnosis and treatment. These advances have led to the watch-and-wait approach, otherwise known as nonsurgical management. This review briefly outlines changes in medical and surgical treatment, advances in MRI technology and interpretation, and landmark studies or trials that have led to this exciting juncture. Herein, the authors delve into current state-of-the-art methods to assess response to treatment with MRI and endoscopy. Currently, these methods for avoiding surgery can be used to detect a complete clinical response in as many as 50% of patients with rectal cancer. Finally, the limitations of imaging and endoscopy and future challenges will be discussed.
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Affiliation(s)
- Vetri Sudar Jayaprakasam
- From the Departments of Radiology (V.S.J., M.J.G., I.P.) and Surgery
(J.A., D.M.O., J.J.S.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave,
Box 29, New York, NY 10065
| | - Janet Alvarez
- From the Departments of Radiology (V.S.J., M.J.G., I.P.) and Surgery
(J.A., D.M.O., J.J.S.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave,
Box 29, New York, NY 10065
| | - Dana M. Omer
- From the Departments of Radiology (V.S.J., M.J.G., I.P.) and Surgery
(J.A., D.M.O., J.J.S.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave,
Box 29, New York, NY 10065
| | - Marc J. Gollub
- From the Departments of Radiology (V.S.J., M.J.G., I.P.) and Surgery
(J.A., D.M.O., J.J.S.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave,
Box 29, New York, NY 10065
| | - J. Joshua Smith
- From the Departments of Radiology (V.S.J., M.J.G., I.P.) and Surgery
(J.A., D.M.O., J.J.S.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave,
Box 29, New York, NY 10065
| | - Iva Petkovska
- From the Departments of Radiology (V.S.J., M.J.G., I.P.) and Surgery
(J.A., D.M.O., J.J.S.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave,
Box 29, New York, NY 10065
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49
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Wang L, Zhang XY, Zhao YM, Li SJ, Li ZW, Sun YS, Wang WH, Wu AW. Intentional Watch and Wait or Organ Preservation Surgery Following Neoadjuvant Chemoradiotherapy Plus Consolidation CAPEOX for MRI-defined Low-risk Rectal Cancer: Findings From a Prospective Phase 2 Trial (PKUCH-R01 Trial, NCT02860234). Ann Surg 2023; 277:647-654. [PMID: 35766394 PMCID: PMC9994840 DOI: 10.1097/sla.0000000000005507] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the efficacy and safety of intentional watch and wait (W&W) and organ preservation surgery following neoadjuvant chemoradiotherapy plus consolidation CAPEOX in magnetic resonance imaging (MRI)-defined low-risk rectal cancer. BACKGROUND Clinical T2/early T3 rectal cancers can achieve high yield pathological complete response (ypCR) rates after chemoradiotherapy; thus, an intentional W&W or organ preservation strategy for good clinical responders in these subgroups can be further tested. METHODS This prospective, single-arm, phase 2 trial enrolled patients with low-risk MRI prestaged rectal cancers, who concurrently received chemoradiation, followed by four 3-weekly cycles of CAPEOX regimen. Following reassessment, clinical complete response (cCR) or near-cCR patients underwent W&W/organ preservation surgery; the primary endpoint was a 3-year organ preservation rate. RESULTS Of the 64 participants, 58 completed treatment, with 6.4% and 33.9% grade 3 to 4 toxicities in the radiotherapy and consolidation CAPEOX phases, respectively, during a median 39.5-month follow-up. Initial cCR, and non-cCR occurred in 33, 13, and 18 patients, respectively. Of the 31 cCR and 7 near-cCR cases managed by W&W, local regrowth occurred in 7; of these, 6 received salvage surgery. The estimated 2-year local regrowth rates were 12.9% [95% confidence interval (CI): 1.1%-24.7%] in cCR and 42.9% (95% CI: 6.2%-79.6%) in near-cCR cases, respectively. Eight patients received local excision, including 2 with regrowth salvage. Lung metastases occurred in 3 patients and multiple metastasis occurred in 1 patient; no local recurrence occurred. The estimated 3-year organ preservation rate was 67.2% (95% CI: 55.6%-78.8%). The estimated 3-year cancer-specific survival, non-regrowth disease-free survival, and stoma-free survival were 96.6% (95% CI: 92.1%-100%), 92.2% (95% CI: 85.5%-98.9%), and 82.7% (95% CI: 73.5%-91.9%), respectively. CONCLUSIONS Chemoradiotherapy plus consolidation CAPEOX for MRI-defined low-risk rectal cancer can lead to high rates of organ preservation through intentional W&W or local excision. The oncologic safety of this strategy should be further tested.
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Affiliation(s)
- Lin Wang
- Department of Gastrointestinal Surgery, Peking University Cancer Hospital, Beijing, PR China
| | - Xiao-Yan Zhang
- Department of Radiology, Peking University Cancer Hospital, Beijing, PR China
| | - Yi-Ming Zhao
- Department of Gastrointestinal Surgery, Peking University Cancer Hospital, Beijing, PR China
| | - Shi-Jie Li
- Department of Endoscopy Center, Peking University Cancer Hospital, Beijing, PR China
| | - Zhong-Wu Li
- Department of Pathology, Peking University Cancer Hospital, Beijing, PR China
| | - Ying-Shi Sun
- Department of Radiology, Peking University Cancer Hospital, Beijing, PR China
| | - Wei-Hu Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing, PR China
| | - Ai-Wen Wu
- Department of Gastrointestinal Surgery, Peking University Cancer Hospital, Beijing, PR China
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Thompson HM, Kim JK, Jimenez-Rodriguez RM, Garcia-Aguilar J, Veeraraghavan H. Deep Learning-Based Model for Identifying Tumors in Endoscopic Images From Patients With Locally Advanced Rectal Cancer Treated With Total Neoadjuvant Therapy. Dis Colon Rectum 2023; 66:383-391. [PMID: 35358109 PMCID: PMC10185333 DOI: 10.1097/dcr.0000000000002295] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND A barrier to the widespread adoption of watch-and-wait management for locally advanced rectal cancer is the inaccuracy and variability of identifying tumor response endoscopically in patients who have completed total neoadjuvant therapy (chemoradiotherapy and systemic chemotherapy). OBJECTIVE This study aimed to develop a novel method of identifying the presence or absence of a tumor in endoscopic images using deep convolutional neural network-based automatic classification and to assess the accuracy of the method. DESIGN In this prospective pilot study, endoscopic images obtained before, during, and after total neoadjuvant therapy were grouped on the basis of tumor presence. A convolutional neural network was modified for probabilistic classification of tumor versus no tumor and trained with an endoscopic image set. After training, a testing endoscopic imaging set was applied to the network. SETTINGS The study was conducted at a comprehensive cancer center. PATIENTS Images were analyzed from 109 patients who were diagnosed with locally advanced rectal cancer between December 2012 and July 2017 and who underwent total neoadjuvant therapy. MAIN OUTCOME MEASURES The main outcomes were accuracy of identifying tumor presence or absence in endoscopic images measured as area under the receiver operating characteristic for the training and testing image sets. RESULTS A total of 1392 images were included; 1099 images (468 of no tumor and 631 of tumor) were for training and 293 images (151 of no tumor and 142 of tumor) for testing. The area under the receiver operating characteristic for training and testing was 0.83. LIMITATIONS The study had a limited number of images in each set and was conducted at a single institution. CONCLUSIONS The convolutional neural network method is moderately accurate in distinguishing tumor from no tumor. Further research should focus on validating the convolutional neural network on a large image set. See Video Abstract at http://links.lww.com/DCR/B959 . MODELO BASADO EN APRENDIZAJE PROFUNDO PARA IDENTIFICAR TUMORES EN IMGENES ENDOSCPICAS DE PACIENTES CON CNCER DE RECTO LOCALMENTE AVANZADO TRATADOS CON TERAPIA NEOADYUVANTE TOTAL ANTECEDENTES:Una barrera para la aceptación generalizada del tratamiento de Observar y Esperar para el cáncer de recto localmente avanzado, es la imprecisión y la variabilidad en la identificación de la respuesta tumoral endoscópica, en pacientes que completaron la terapia neoadyuvante total (quimiorradioterapia y quimioterapia sistémica).OBJETIVO:Desarrollar un método novedoso para identificar la presencia o ausencia de un tumor en imágenes endoscópicas utilizando una clasificación automática basada en redes neuronales convolucionales profundas y evaluar la precisión del método.DISEÑO:Las imágenes endoscópicas obtenidas antes, durante y después de la terapia neoadyuvante total se agruparon en base de la presencia del tumor. Se modificó una red neuronal convolucional para la clasificación probabilística de tumor versus no tumor y se entrenó con un conjunto de imágenes endoscópicas. Después del entrenamiento, se aplicó a la red un conjunto de imágenes endoscópicas de prueba.ENTORNO CLINICO:El estudio se realizó en un centro oncológico integral.PACIENTES:Analizamos imágenes de 109 pacientes que fueron diagnosticados de cáncer de recto localmente avanzado entre diciembre de 2012 y julio de 2017 y que se sometieron a terapia neoadyuvante total.PRINCIPALES MEDIDAS DE VALORACION:La precisión en la identificación de la presencia o ausencia de tumores en imágenes endoscópicas medidas como el área bajo la curva de funcionamiento del receptor para los conjuntos de imágenes de entrenamiento y prueba.RESULTADOS:Se incluyeron mil trescientas noventa y dos imágenes: 1099 (468 sin tumor y 631 con tumor) para entrenamiento y 293 (151 sin tumor y 142 con tumor) para prueba. El área bajo la curva operativa del receptor para entrenamiento y prueba fue de 0,83.LIMITACIONES:El estudio tuvo un número limitado de imágenes en cada conjunto y se realizó en una sola institución.CONCLUSIÓN:El método de la red neuronal convolucional es moderadamente preciso para distinguir el tumor de ningún tumor. La investigación adicional debería centrarse en validar la red neuronal convolucional en un conjunto de imágenes mayor. Consulte Video Resumen en http://links.lww.com/DCR/B959 . (Traducción -Dr. Fidel Ruiz Healy ).
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Affiliation(s)
- Hannah M Thompson
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jin K Kim
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Julio Garcia-Aguilar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Harini Veeraraghavan
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
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