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Long-Term Outcome in a Phase II Study of Regional Hyperthermia Added to Preoperative Radiochemotherapy in Locally Advanced and Recurrent Rectal Adenocarcinomas. Cancers (Basel) 2022; 14:cancers14030705. [PMID: 35158972 PMCID: PMC8833356 DOI: 10.3390/cancers14030705] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 01/25/2022] [Accepted: 01/25/2022] [Indexed: 12/14/2022] Open
Abstract
Hyperthermia was added to standard preoperative chemoradiation for rectal adenocarcinomas in a phase II study. Patients with T3-4 N0-2 M0 rectal cancer or local recurrences were included. Radiation dose was 54 Gy combined with capecitabine 825 mg/m2 × 2 daily and once weekly oxaliplatin 55 mg/m2. Regional hyperthermia aimed at 41.5–42.5 °C for 60 min combined with oxaliplatin infusion. Radical surgery with total or extended TME technique, was scheduled at 6–8 weeks after radiation. From April 2003 to April 2008, a total of 49 eligible patients were recruited. Median number of hyperthermia sessions were 5.4. A total of 47 out of 49 patients (96%) had the scheduled surgery, which was clinically radical in 44 patients. Complete tumour regression occurred in 29.8% of the patients who also exhibited statistically significantly better RFS and CSS. Rate of local recurrence alone at 10 years was 9.1%, distant metastases alone occurred in 25.6%, including local recurrences 40.4%. RFS for all patients was 54.8% after 5 years and CSS was 73.5%. Patients with T50 temperatures in tumours above median 39.9 °C had better RFS, 66.7% vs. 31.3%, p = 0.047, indicating a role of hyperthermia. Toxicity was acceptable.
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Prognostic importance of circumferential resection margin in the era of evolving surgical and multidisciplinary treatment of rectal cancer: A systematic review and meta-analysis. Surgery 2021; 170:412-431. [PMID: 33838883 DOI: 10.1016/j.surg.2021.02.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 01/20/2021] [Accepted: 02/13/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Circumferential resection margin is considered an important prognostic parameter after rectal cancer surgery, but its impact might have changed because of improved surgical quality and tailored multimodality treatment. The aim of this systematic review was to determine the prognostic importance of circumferential resection margin involvement based on the most recent literature. METHODS A systematic literature search of MEDLINE, Embase, and the Cochrane Library was performed for studies published between January 2006 and May 2019. Studies were included if 3- or 5-year oncological outcomes were reported depending on circumferential resection margin status. Outcome parameters were local recurrence, overall survival, disease-free survival, and distant metastasis rate. The Newcastle Ottawa Scale and Jadad score were used for quality assessment of the studies. Meta-analysis was performed using a random effects model and reported as a pooled odds ratio or hazard ratio with 95% confidence interval. RESULTS Seventy-five studies were included, comprising a total of 85,048 rectal cancer patients. Significant associations between circumferential resection margin involvement and all long-term outcome parameters were uniformly found, with varying odds ratios and hazard ratios depending on circumferential resection margin definition (<1 mm, ≤1 mm, otherwise), neoadjuvant treatment, study period, and geographical origin of the studies. CONCLUSION Circumferential resection margin involvement has remained an independent, poor prognostic factor for local recurrence and survival in most recent literature, indicating that circumferential resection margin status can still be used as a short-term surrogate endpoint.
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Persistent High Rate of Positive Margins and Postoperative Complications After Surgery for cT4 Rectal Cancer at a National Level. Dis Colon Rectum 2021; 64:389-398. [PMID: 33651005 DOI: 10.1097/dcr.0000000000001855] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND A more extensive resection is often required in locally advanced rectal cancer, depending on preoperative neoadjuvant treatment response. OBJECTIVE Circumferential margin involvement and postoperative outcomes after total mesorectal excision and multivisceral resection were assessed in patients with clinical locally advanced (cT4) rectal cancer at a national level. DESIGN This is a population-based study. SETTINGS Data were retrieved from the Dutch Colorectal Audit. PATIENTS A total of 2242 of 2881 patients with cT4 rectal cancer between January 2009 and December 2017 were selected. MAIN OUTCOME MEASURES Main outcomes were resection margins, postoperative complications, and mortality. RESULTS Multivisceral resection was performed in 936 of 2242 patients, of whom 629 underwent extended multivisceral resection. Positive circumferential margin rate was higher after multivisceral resection than after total mesorectal excision: 21.2% vs 13.9% (p < 0.001). More postoperative complications occurred after limited and extended multivisceral resections than after total mesorectal excision (44.1% and 53.8% vs 37.6%, p < 0.001). Incidence of 30-day mortality was similarly low in both groups (1.5% vs 2.2%, p = 0.20). Independent predictors of postoperative complications were age ≥70 years (OR, 1.28 [95% CI, 1.04-1.56]; p = 0.02), male sex (OR, 1.68 [95% CI, 1.38-2.04]; p< 0.001), mucinous tumors (OR, 1.55 [95% CI, 1.06-2.27]; p = 0.02), extended multivisceral resection (OR, 1.98 [95% CI, 1.56-2.52]; p< 0.001), Hartmann procedure (OR, 1.42 [95% CI, 1.07-1.90]; p = 0.02), and abdominoperineal resection (OR, 1.56 [95% CI, 1.25-1.96]; p < 0.001). LIMITATIONS Data specifying the extent of multivisceral resections and Clavien Dindo I to II complications were not available. CONCLUSIONS This population-based study revealed relatively high circumferential margin positivity and postoperative complication rates in patients with cT4 rectal cancer, especially after multivisceral resections, but low mortality rates. See Video Abstract at http://links.lww.com/DCR/B457. ALTA TASA PERSISTENTE DE MRGENES POSITIVOS Y COMPLICACIONES POSTOPERATORIAS DESPUS DE LA CIRUGA DE CNCER RECTAL CTA NIVEL NACIONAL ANTECEDENTES:A menudo se requiere una resección más extensa en el cáncer de recto localmente avanzado, según la respuesta al tratamiento neoadyuvante preoperatorio.OBJETIVO:Se evaluó la afectación del margen circunferencial y los resultados postoperatorios después de la escisión mesorrectal total y la resección multivisceral en pacientes con cáncer rectal clínico localmente avanzado (cT4) a nivel nacional.DISEÑO:Este es un estudio poblacional.ENTORNO CLINICO:Los datos se recuperaron de la Auditoría colorrectal holandesa.PACIENTES:Se seleccionaron un total de 2242 de 2881 pacientes con cáncer de recto cT4 entre enero de 2009 y diciembre de 2017.PRINCIPALES MEDIDAS DE VALORACION:Los principales resultados fueron los márgenes de resección, las complicaciones postoperatorias y la mortalidad.RESULTADOS:Se realizó resección multivisceral en 936 de 2242 pacientes, de los cuales 629 fueron sometidos a resección multivisceral extendida. La tasa de margen circunferencial positivo fue mayor después de la resección multivisceral que después de la escisión mesorrectal total: 21,2% versus a 13,9% (p <0,001). Se produjeron más complicaciones postoperatorias después de resecciones multiviscerales limitadas y extendidas en comparación con la escisión mesorrectal total (44,1% y 53,8% versus a 37,6%, p <0,001). La incidencia de mortalidad a 30 días fue igualmente baja en ambos grupos (1,5% versus a 2,2%, p = 0,20). Los predictores independientes de complicaciones posoperatorias fueron la edad ≥70 años (OR = 1,28, IC del 95% [1,04 a 1,56], p = 0,02), hombres (OR = 1,68, IC del 95% [1,38 a 2,04], p <0,001), tumores mucinosos (OR = 1,55, IC del 95% [1,06 a 2,27], p = 0,02), resección multivisceral extendida (OR = 1,98, IC del 95% [1,56 a 2,52], p <0,001), Hartmann (OR = 1,42, 95% Cl [1,07 a 1,90], p = 0,02) y resección abdominoperineal (OR 1,56, Cl 95% [1,25 a 1,96], p <0,001).LIMITACIONES:No se disponía de datos que especificaran el alcance de las resecciones multiviscerales y las complicaciones de Clavien Dindo I-II.CONCLUSIONES:Este estudio poblacional reveló tasas de complicaciones postoperatorias y positividad del margen circunferencial relativamente altas en pacientes con cáncer de recto cT4, especialmente después de resecciones multiviscerales, pero tasas de mortalidad bajas. Consulte Video Resumen en http://links.lww.com/DCR/B457.
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Chakrabarti D, Rajan S, Akhtar N, Qayoom S, Gupta S, Verma M, Srivastava K, Kumar V, Bhatt MLB, Gupta R. Short-course radiotherapy with consolidation chemotherapy versus conventionally fractionated long-course chemoradiotherapy for locally advanced rectal cancer: randomized clinical trial. Br J Surg 2021; 108:511-520. [PMID: 33724296 DOI: 10.1093/bjs/znab020] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/14/2020] [Accepted: 12/20/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND The trial hypothesis was that, in a resource-constrained situation, short-course radiotherapy would improve treatment compliance compared with conventional chemoradiotherapy for locally advanced rectal cancer, without compromising oncological outcomes. METHODS In this open-label RCT, patients with cT3, cT4 or node-positive non-metastatic rectal cancer were allocated randomly to 5 × 5 Gy radiotherapy and two cycles of XELOX (arm A) or chemoradiotherapy with concurrent capecitabine (arm B), followed by total mesorectal excision in both arms. All patients received a further six cycles of adjuvant chemotherapy with the XELOX regimen. The primary endpoint was treatment compliance, defined as the ability to complete planned treatment, including neoadjuvant radiochemotherapy, surgery, and adjuvant chemotherapy to a dose of six cycles. RESULTS Of 162 allocated patients, 140 were eligible for analysis: 69 in arm A and 71 in arm B. Compliance with planned treatment (primary endpoint) was greater in arm A (63 versus 41 per cent; P = 0.005). The incidence of acute toxicities of neoadjuvant therapy was similar (haematological: 28 versus 32 per cent, P = 0.533; gastrointestinal: 14 versus 21 per cent, P = 0.305; grade III-IV: 2 versus 4 per cent, P = 1.000). Delays in radiotherapy were less common in arm A (9 versus 45 per cent; P < 0.001), and overall times for completion of neoadjuvant treatment were shorter (P < 0.001). The rates of R0 resection (87 versus 90 per cent; P = 0.554), sphincter preservation (32 versus 35 per cent; P = 0.708), pathological complete response (12 versus 10 per cent; P = 0.740), and overall tumour downstaging (75 versus 75 per cent; P = 0.920) were similar. Downstaging of the primary tumour (ypT) was more common in arm A (P = 0.044). There was no difference in postoperative complications between trial arms (P = 0.838). CONCLUSION Reduced treatment delays and a higher rate of compliance were observed with treatment for short-course radiotherapy with consolidation chemotherapy, with no difference in early oncological surgical outcomes. In time- and resource-constrained rectal cancer units in developing countries, short-course radiotherapy should be the standard of care.
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Affiliation(s)
- D Chakrabarti
- Department of Radiation Oncology, King George's Medical University, Lucknow, India
| | - S Rajan
- Department of Surgical Oncology, King George's Medical University, Lucknow, India
| | - N Akhtar
- Department of Surgical Oncology, King George's Medical University, Lucknow, India
| | - S Qayoom
- Department of Pathology, King George's Medical University, Lucknow, India
| | - S Gupta
- Department of Surgical Oncology, King George's Medical University, Lucknow, India
| | - M Verma
- Department of Radiation Oncology, King George's Medical University, Lucknow, India
| | - K Srivastava
- Department of Radiation Oncology, King George's Medical University, Lucknow, India
| | - V Kumar
- Department of Surgical Oncology, King George's Medical University, Lucknow, India
| | - M L B Bhatt
- Department of Radiation Oncology, King George's Medical University, Lucknow, India
| | - R Gupta
- Department of Radiation Oncology, King George's Medical University, Lucknow, India
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Bao F, Shang J, Xiang C, Li G, Zhi X, Liu W, Wang D, Xian-Yu J, Deng Z. Gender aspects of survival after abdominoperineal resection for low rectal cancer: a retrospective study. Int J Colorectal Dis 2020; 35:2001-2010. [PMID: 32564125 DOI: 10.1007/s00384-020-03671-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE The difference in prognosis between genders after abdominoperineal resection (APR) for low rectal cancer (LRC) is unclear. This study aimed to compare survival outcomes between genders in patients with LRC who underwent curative APR. METHODS This retrospective cohort study used a database of consecutive colorectal resections. Patients who received curative APR with LRC were grouped according to their gender. Female patients were frequency-matched 1:1 on American Joint Committee on Cancer (AJCC) stage to male patients. Overall survival (OS), disease-free survival (DFS), and their independent risk factors were examined. RESULTS A total of 140 patients with APR for LRC were included after matching: 70 (50.0%) males and 70 (50.0%) females. No significant differences were found between the groups in terms of age, operation methods, AJCC stage, and adjuvant therapy (all P > 0.05). Median follow-up was 39 (range: 3-128) months. Male gender was independently associated with worse OS (adjusted hazard ratio [HR] = 2.755, 95% CI: 1.507-5.038, P = 0.001) and worse DFS (adjusted HR = 2.440, 95% CI: 1.254-4.746, P = 0.009). Subgroup analysis revealed that female patients with stage III disease had better OS (P = 0.001) and DFS (P < 0.001) than male patients. CONCLUSION Gender affects survival after a curative APR for LRC. Compared with females, male patients with LRC after curative APR had worse prognosis, especially for stage III disease.
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Affiliation(s)
- Feng Bao
- Department of General Surgery, Mianyang Central Hospital, 12 Changjia Lane, Jingzhong Street, Mianyang, 621000, Sichuan, China
| | - Jianying Shang
- Department of General Surgery, Mianyang Central Hospital, 12 Changjia Lane, Jingzhong Street, Mianyang, 621000, Sichuan, China
| | - Chunhua Xiang
- Department of General Surgery, Mianyang Central Hospital, 12 Changjia Lane, Jingzhong Street, Mianyang, 621000, Sichuan, China
| | - Guoqiang Li
- Department of General Surgery, Mianyang Central Hospital, 12 Changjia Lane, Jingzhong Street, Mianyang, 621000, Sichuan, China
| | - Xing Zhi
- Department of General Surgery, Mianyang Central Hospital, 12 Changjia Lane, Jingzhong Street, Mianyang, 621000, Sichuan, China
| | - Wen Liu
- Department of General Surgery, Mianyang Central Hospital, 12 Changjia Lane, Jingzhong Street, Mianyang, 621000, Sichuan, China
| | - Dong Wang
- Department of General Surgery, Mianyang Central Hospital, 12 Changjia Lane, Jingzhong Street, Mianyang, 621000, Sichuan, China
| | - Jianbo Xian-Yu
- Department of General Surgery, Mianyang Central Hospital, 12 Changjia Lane, Jingzhong Street, Mianyang, 621000, Sichuan, China
| | - Zhigang Deng
- Department of General Surgery, Mianyang Central Hospital, 12 Changjia Lane, Jingzhong Street, Mianyang, 621000, Sichuan, China.
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Nonoperative Management Versus Radical Surgery of Rectal Cancer After Neoadjuvant Therapy-Induced Clinical Complete Response: A Markov Decision Analysis. Dis Colon Rectum 2020; 63:1080-1089. [PMID: 32398412 DOI: 10.1097/dcr.0000000000001665] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Nonoperative management of rectal cancer was introduced for patients with clinical complete response after neoadjuvant chemoradiotherapy to avoid short- and long-term surgical morbidity related to radical resection. OBJECTIVE The purpose of this study was to determine the expected life-years and quality-adjusted life-years for nonoperative management and radical resection of locally advanced rectal cancer after clinical complete response following neoadjuvant chemoradiotherapy. DESIGN Markov modeling was used to simulate nonoperative management and radical surgery for a base case scenario over a 10-year time horizon. Estimates for various clinical variables were obtained after extensive literature search. Outcome was expressed in both life-years and quality-adjusted life-years. Deterministic sensitivity analyses were completed to assess the impact of variation in key parameters. SETTING A decision model using a Markov model was designed. PATIENTS The base case was a 65-year-old man with a distal rectal tumor who had achieved clinical complete response after neoadjuvant chemoradiotherapy. MAIN OUTCOME MEASURES Life-years and quality-adjusted life-years were measured. RESULTS Quality-adjusted life-years (5.79 for nonoperative management vs 5.62 for radical surgery) and life-years (6.92 for nonoperative management vs 6.96 for radical surgery) were similar between nonoperative management and radical surgery. The preferred treatment strategy changed with variations in the probability of local regrowth in nonoperative management, the probability of salvage surgery for regrowth in nonoperative management, utilities associated with nonoperative management and low anterior resection, and the utility of low anterior resection syndrome. The model was not sensitive to (dis)utilities associated with stoma, chemotherapy, or postoperative morbidity and mortality. LIMITATIONS The study was limited by assumptions inherent to modeling studies. CONCLUSIONS Nonoperative management and radical surgery resulted in similar (quality-adjusted) life-years. Nonoperative management should therefore be considered as a reasonable treatment option. See Video Abstract at http://links.lww.com/DCR/B246. MANEJO NO-QUIRÚRGICO VERSUS CIRUGÍA RADICAL DEL CÁNCER RECTAL DESPUÉS DE LA RESPUESTA CLÍNICA COMPLETA INDUCIDA POR TERAPIA NEOADYUVANTE: UN ANÁLISIS DE DECISIÓN DE MARKOV: Se introdujo el tratamiento no quirúrgico del cáncer rectal para pacientes con respuesta clínica completa después de la quimiorradioterapia neoadyuvante para evitar la morbilidad quirúrgica a corto y largo plazo relacionada con la resección radical.Determinar los años de vida esperados y los años de vida ajustados por calidad para el tratamiento no-quirúrgico y la resección radical del cáncer rectal localmente avanzado, después de la respuesta clínica completa siguiente de la quimiorradioterapia neoadyuvante.El modelo de Markov se usó para simular el manejo no-quirúrgico y la cirugía radical para un escenario de caso base en un horizonte temporal de 10 años. Se obtuvieron estimaciones para diversas variables clínicas después de una extensa búsqueda bibliográfica. El resultado se expresó tanto en años de vida como en años de vida ajustados por calidad. Se completaron análisis determinísticos de sensibilidad para evaluar el impacto de la variación en los parámetros clave.Se diseñó un modelo de decisión utilizando un modelo de Markov.El caso base fue un hombre de 65 años con un tumor rectal distal que había logrado una respuesta clínica completa después de la quimiorradioterapia neoadyuvante.Años de vida y años de vida ajustados por calidad.Los años de vida ajustados por calidad (5.79 para el tratamiento no-quirúrgico frente a 5.62 para la cirugía radical) y los años de vida (6.92 para el tratamiento no-quirúrgico frente a 6.96 para la cirugía radical) fueron similares entre el tratamiento no-quirúrgico y la cirugía radical. La estrategia de tratamiento preferida cambió con las variaciones en la probabilidad de nuevo crecimiento local en el manejo no-operatorio, la probabilidad de cirugía de rescate para el rebrote en el manejo no-operatorio, las utilidades asociadas con el manejo no-operatorio, y la resección anterior baja y la utilidad de el syndrome de resección anterior baja. El modelo no era sensible a las (des) utilidades asociadas con el estoma, la quimioterapia o la morbilidad y mortalidad postoperatorias.El estudio estuvo limitado por suposiciones inherentes a los estudios de modelado.El manejo no-quirúrgico y la cirugía radical resultaron en años de vida similares (ajustados por calidad). Por lo tanto, el tratamiento no-quirúrgico debe considerarse como una opción de tratamiento razonable. Consulte Video Resumen en http://links.lww.com/DCR/B246.
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Narang AK, Meyer J. Neoadjuvant Short-Course Radiation Therapy for Rectal Cancer: Trends and Controversies. Curr Oncol Rep 2018; 20:68. [DOI: 10.1007/s11912-018-0714-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Does the addition of oxaliplatin to preoperative chemoradiation benefit cT4 or fixed cT3 rectal cancer treatment? A subgroup analysis from a prospective study. Eur J Surg Oncol 2016; 42:1859-1865. [DOI: 10.1016/j.ejso.2016.08.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Revised: 07/27/2016] [Accepted: 08/03/2016] [Indexed: 01/08/2023] Open
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Bujko K, Wyrwicz L, Rutkowski A, Malinowska M, Pietrzak L, Kryński J, Michalski W, Olędzki J, Kuśnierz J, Zając L, Bednarczyk M, Szczepkowski M, Tarnowski W, Kosakowska E, Zwoliński J, Winiarek M, Wiśniowska K, Partycki M, Bęczkowska K, Polkowski W, Styliński R, Wierzbicki R, Bury P, Jankiewicz M, Paprota K, Lewicka M, Ciseł B, Skórzewska M, Mielko J, Bębenek M, Maciejczyk A, Kapturkiewicz B, Dybko A, Hajac Ł, Wojnar A, Leśniak T, Zygulska J, Jantner D, Chudyba E, Zegarski W, Las-Jankowska M, Jankowski M, Kołodziejski L, Radkowski A, Żelazowska-Omiotek U, Czeremszyńska B, Kępka L, Kolb-Sielecki J, Toczko Z, Fedorowicz Z, Dziki A, Danek A, Nawrocki G, Sopyło R, Markiewicz W, Kędzierawski P, Wydmański J. Long-course oxaliplatin-based preoperative chemoradiation versus 5 × 5 Gy and consolidation chemotherapy for cT4 or fixed cT3 rectal cancer: results of a randomized phase III study. Ann Oncol 2016; 27:834-42. [PMID: 26884592 DOI: 10.1093/annonc/mdw062] [Citation(s) in RCA: 260] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 02/08/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Improvements in local control are required when using preoperative chemoradiation for cT4 or advanced cT3 rectal cancer. There is therefore a need to explore more effective schedules. PATIENTS AND METHODS Patients with fixed cT3 or cT4 cancer were randomized either to 5 × 5 Gy and three cycles of FOLFOX4 (group A) or to 50.4 Gy in 28 fractions combined with two 5-day cycles of bolus 5-Fu 325 mg/m(2)/day and leucovorin 20 mg/m(2)/day during the first and fifth week of irradiation along with five infusions of oxaliplatin 50 mg/m(2) once weekly (group B). The protocol was amended in 2012 to allow oxaliplatin to be then foregone in both groups. RESULTS Of 541 entered patients, 515 were eligible for analysis; 261 in group A and 254 in group B. Preoperative treatment acute toxicity was lower in group A than group B, P = 0.006; any toxicity being, respectively, 75% versus 83%, grade III-IV 23% versus 21% and toxic deaths 1% versus 3%. R0 resection rates (primary end point) and pathological complete response rates in groups A and B were, respectively, 77% versus 71%, P = 0.07, and 16% versus 12%, P = 0.17. The median follow-up was 35 months. At 3 years, the rates of overall survival and disease-free survival in groups A and B were, respectively, 73% versus 65%, P = 0.046, and 53% versus 52%, P = 0.85, together with the cumulative incidence of local failure and distant metastases being, respectively, 22% versus 21%, P = 0.82, and 30% versus 27%, P = 0.26. Postoperative and late complications rates in group A and group B were, respectively, 29% versus 25%, P = 0.18, and 20% versus 22%, P = 0.54. CONCLUSIONS No differences were observed in local efficacy between 5 × 5 Gy with consolidation chemotherapy and long-course chemoradiation. Nevertheless, an improved overall survival and lower acute toxicity favours the 5 × 5 Gy schedule with consolidation chemotherapy. CLINICAL TRIAL NUMBER The trial is registered as ClinicalTrials.gov number NCT00833131.
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Affiliation(s)
| | - L Wyrwicz
- Department of Gastroenterological Oncology
| | | | | | | | - J Kryński
- Department of Gastroenterological Oncology
| | - W Michalski
- Department of Bioinformatics and Biostatistics Unit, M. Skłodowska-Curie Memorial Cancer Centre, Warsaw
| | - J Olędzki
- Department of Colorectal Surgery, Medical University, Warsaw
| | - J Kuśnierz
- Department of Gynecology, M. Skłodowska-Curie Memorial Cancer Centre, Warsaw
| | - L Zając
- Department of Gastroenterological Oncology
| | | | - M Szczepkowski
- Department of Rehabilitation, Jozef Piłsudski University of Physical Education, Warsaw Clinical Department of General and Colorectal Surgery, Bielański Hospital, Warsaw
| | - W Tarnowski
- Department of General, Oncologic and Digestive Tract Surgery, Medical Centre of Postgraduate Education, Orłowski Hospital, Warsaw
| | | | | | - M Winiarek
- Department of Gastroenterological Oncology
| | | | | | | | - W Polkowski
- Department of Surgical Oncology, Medical University of Lublin, Lublin
| | - R Styliński
- First Department of General Surgery, Transplantology and Nutritional Therapy, Medical University of Lublin, Lublin
| | | | - P Bury
- II Chair and Department of General and Gastrointestinal Surgery and Surgical Oncology of the Alimentary Tract, Medical University, Lublin
| | - M Jankiewicz
- Department of Surgical Oncology, Medical University of Lublin, Lublin Department of Radiotherapy, St John's Cancer Center, Lublin
| | - K Paprota
- Department of Radiotherapy, St John's Cancer Center, Lublin
| | - M Lewicka
- Department of Surgical Oncology, Medical University of Lublin, Lublin
| | - B Ciseł
- Department of Surgical Oncology, Medical University of Lublin, Lublin
| | - M Skórzewska
- Department of Surgical Oncology, Medical University of Lublin, Lublin
| | - J Mielko
- Department of Surgical Oncology, Medical University of Lublin, Lublin
| | | | | | | | | | | | - A Wojnar
- Pathology, Silesian Oncological Centre, Wroclaw
| | - T Leśniak
- Department of Surgery, Beskid Centre of Oncology, Bielsko-Biala
| | - J Zygulska
- Department of Radiotherapy, Beskid Centre of Oncology, Bielsko-Biala
| | - D Jantner
- Department of Surgery, Beskid Centre of Oncology, Bielsko-Biala
| | - E Chudyba
- Department of Radiotherapy, Beskid Centre of Oncology, Bielsko-Biala
| | - W Zegarski
- Department of Oncological Surgery, Collegium Medicum Nicolaus Copernicus University and Oncology Centre, Bydgoszcz
| | - M Las-Jankowska
- Department of Oncological Surgery, Collegium Medicum Nicolaus Copernicus University and Oncology Centre, Bydgoszcz
| | - M Jankowski
- Department of Oncological Surgery, Collegium Medicum Nicolaus Copernicus University and Oncology Centre, Bydgoszcz
| | | | - A Radkowski
- Department of Radiotherapy, Regional Cancer Centre, Tarnów
| | | | - B Czeremszyńska
- Department Radiotherapy, Independent Public Health Care Facility of the Ministry of the Interior and Warmian-Masurian Oncology Centre, Olsztyn
| | - L Kępka
- Department Radiotherapy, Independent Public Health Care Facility of the Ministry of the Interior and Warmian-Masurian Oncology Centre, Olsztyn
| | - J Kolb-Sielecki
- Department Radiotherapy, Independent Public Health Care Facility of the Ministry of the Interior and Warmian-Masurian Oncology Centre, Olsztyn
| | - Z Toczko
- Department of Surgery, Regional Hospital, Elbląg
| | - Z Fedorowicz
- Department of Surgery, Regional Hospital, Elbląg
| | - A Dziki
- Department of Surgery, Medical University, Lódź
| | | | - G Nawrocki
- Department of Surgery, M. Skłodowska-Curie Memorial Cancer Centre, Warsaw
| | - R Sopyło
- Department of Surgery, M. Skłodowska-Curie Memorial Cancer Centre, Warsaw
| | - W Markiewicz
- Department of Surgery, Regional Cancer Centre, Białystok
| | - P Kędzierawski
- Department of Radiotherapy, Regional Oncological Centre, Kielce
| | - J Wydmański
- Department of Radiotherapy, M. Skłodowska-Curie Memorial Cancer Centre, Gliwice, Poland
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10
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Clinicopathological outcomes of preoperative chemoradiotherapy using S-1 plus Irinotecan for T4 lower rectal cancer. Surg Today 2015; 46:852-9. [PMID: 26363781 DOI: 10.1007/s00595-015-1250-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 08/21/2015] [Indexed: 01/03/2023]
Abstract
PURPOSE To investigate the clinicopathological outcomes of patients with T4 lower rectal cancer treated using preoperative chemoradiotherapy with S-1 plus Irinotecan. METHODS Between 2005 and 2011, 35 patients with T4M0 lower rectal cancer, diagnosed initially as T4a in 12 and as T4b in 23, were treated with 45 Gy of radiotherapy concomitantly with S-1 plus Irinotecan. The median follow-up period was 50.6 months (range 2-123 months). RESULTS A total of 32 patients (91.4 %) completed the radiotherapy and 26 (74.3 %) completed the full chemotherapy regimen. Radical surgery was then performed in 33 (94.3 %) of the 35 patients after the exclusion of two patients, who had macroscopic residual disease. The pathological diagnosis was downstaged from T4a to ypT0-3 in all 12 of those patients (100 %) and from T4b to ypT0-4a in 20 of those 23 patients (87.0 %). The tumor regression grade of 1a/1b/2/3 (complete response) was 10/8/15/2, respectively. In terms of long-term survival, the 5-year local relapse-free survival rate was 74.8 % and the recurrence-free survival rate was 52.0 %. CONCLUSIONS This regimen may result in favorable downstaging. Moreover, in this series, pathological evidence of involvement of adjacent organs was rare following preoperative chemoradiotherapy, in the patients with disease diagnosed as T4b at the initial staging.
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11
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Rate of Pulmonary Metastasis Varies with Location of Rectal Cancer in the Patients Undergoing Curative Resection. World J Surg 2014; 39:759-68. [DOI: 10.1007/s00268-014-2870-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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12
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Vermeer T, Orsini R, Daams F, Nieuwenhuijzen G, Rutten H. Anastomotic leakage and presacral abscess formation after locally advanced rectal cancer surgery: Incidence, risk factors and treatment. Eur J Surg Oncol 2014; 40:1502-9. [DOI: 10.1016/j.ejso.2014.03.019] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Revised: 03/04/2014] [Accepted: 03/18/2014] [Indexed: 12/13/2022] Open
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13
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Bosman S, Vermeer T, Dudink R, de Hingh I, Nieuwenhuijzen G, Rutten H. Abdominosacral resection: Long-term outcome in 86 patients with locally advanced or locally recurrent rectal cancer. Eur J Surg Oncol 2014; 40:699-705. [DOI: 10.1016/j.ejso.2014.02.233] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 01/22/2014] [Accepted: 02/17/2014] [Indexed: 12/24/2022] Open
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14
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EURECCA colorectal: Multidisciplinary management: European consensus conference colon & rectum. Eur J Cancer 2014; 50:1.e1-1.e34. [DOI: 10.1016/j.ejca.2013.06.048] [Citation(s) in RCA: 298] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Accepted: 06/19/2013] [Indexed: 02/06/2023]
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15
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Abstract
The management of rectal cancer has changed dramatically over the last few decades. Due to improvements in the multimodality treatment and the introduction of neoadjuvant chemoradiation, previously irresectable tumours can nowadays be cured by extensive multivisceral resections. These highly complex operations are associated with significant morbidity and mortality. Due to optimization of chemoradiotherapy, the introduction of IORT, increasing knowledge of tumour pathology and patterns of recurrence the need for extensive surgery diminishes. The question arises which patients with T4 rectal cancer really need extensive surgery and who can safely be considered for an organ preserving approach.
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16
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van de Velde CJH, Boelens PG, Tanis PJ, Espin E, Mroczkowski P, Naredi P, Pahlman L, Ortiz H, Rutten HJ, Breugom AJ, Smith JJ, Wibe A, Wiggers T, Valentini V. Experts reviews of the multidisciplinary consensus conference colon and rectal cancer 2012: science, opinions and experiences from the experts of surgery. Eur J Surg Oncol 2013; 40:454-68. [PMID: 24268926 DOI: 10.1016/j.ejso.2013.10.013] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 10/23/2013] [Indexed: 12/12/2022] Open
Abstract
The first multidisciplinary consensus conference on colon and rectal cancer was held in December 2012, achieving a majority of consensus for diagnostic and treatment decisions using the Delphi Method. This article will give a critical appraisal of the topics discussed during the meeting and in the consensus document by well-known leaders in surgery that were involved in this multidisciplinary consensus process. Scientific evidence, experience and opinions are collected to support multidisciplinary teams (MDT) with arguments for medical decision-making in diagnosis, staging and treatment strategies for patients with colon or rectal cancer. Surgery is the cornerstone of curative treatment for colon and rectal cancer. Standardizing treatment is an effective instrument to improve outcome of multidisciplinary cancer care for patients with colon and rectal cancer. In this article, a review of the following focuses; Perioperative care, age and colorectal surgery, obstructive colorectal cancer, stenting, surgical anatomical considerations, total mesorectal excision (TME) surgery and training, surgical considerations for locally advanced rectal cancer (LARC) and local recurrent rectal cancer (LRRC), surgery in stage IV colorectal cancer, definitions of quality of surgery, transanal endoscopic microsurgery (TEM), laparoscopic colon and rectal surgery, preoperative radiotherapy and chemoradiotherapy, and how about functional outcome after surgery?
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Affiliation(s)
- C J H van de Velde
- Department of Surgery, Leiden University Medical Center, The Netherlands.
| | - P G Boelens
- Department of Surgery, Leiden University Medical Center, The Netherlands.
| | - P J Tanis
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - E Espin
- Colorectal Surgery Unit, Hospital Valle de Hebron, Autonomous University of Barcelona, Barcelona, Spain
| | - P Mroczkowski
- Department of General, Visceral and Vascular Surgery/An-Institute for Quality Assurance in Operative Medicine, Otto-von-Guericke University of Magdeburg, Germany
| | - P Naredi
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - L Pahlman
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - H Ortiz
- Department of Surgery, Public University of Navarra, Spain
| | - H J Rutten
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - A J Breugom
- Department of Surgery, Leiden University Medical Center, The Netherlands
| | - J J Smith
- Department of Colorectal Surgery, West Middlesex University Hospital, Isleworth, UK
| | - A Wibe
- Department of Surgery, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - T Wiggers
- Department of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - V Valentini
- Unviersita Cattolica S. Cuore, Radioterapia 1, Largo A. Gemelli, 8, 00168 Rome, Italy
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17
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Nelson VM, Benson AB. Pathological complete response after neoadjuvant therapy for rectal cancer and the role of adjuvant therapy. Curr Oncol Rep 2013; 15:152-61. [PMID: 23381584 DOI: 10.1007/s11912-013-0297-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Both the addition of neoadjuvant chemoradiation therapy and improvements in surgical techniques have improved local control and overall survival for locally advanced rectal cancer patients over the past few decades. The addition of adjuvant chemotherapy has likely improved outcomes as well, though the contribution has been more difficult to quantify. At present, the majority of resected locally advanced rectal cancer patients receive adjuvant chemotherapy, though there is great variability in this practice based on both patient and institution characteristics. Recently, questions have been raised regarding which sub-groups of patients benefit most from adjuvant chemotherapy. As pathologic complete response (pCR) is increasingly found to be a reasonable surrogate for long-term favorable outcomes, some have questioned the need for adjuvant therapy in this select group of patients. Multiple retrospective analyses have shown minimal to no benefit for adjuvant chemotherapy in this group. Indeed, the patients most consistently shown to benefit from adjuvant therapy both in terms of disease free survival (DFS) and overall survival (OS) are those who achieve an intermediate pathologic response to neoadjuvant treatment. Tumors that have high expression of thymidylate synthetase have also shown to benefit from adjuvant therapy. More study is needed into clinical and molecular features that predict patient benefit from adjuvant therapy.
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Affiliation(s)
- Valerie M Nelson
- Hematology/Oncology, Department of Medicine, Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL 60601, USA
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18
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Traa MJ, Orsini RG, Oudsten BLD, Vries JD, Roukema JA, Bosman SJ, Dudink RL, Rutten HJ. Measuring the health-related quality of life and sexual functioning of patients with rectal cancer: Does type of treatment matter? Int J Cancer 2013; 134:979-87. [DOI: 10.1002/ijc.28430] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Revised: 06/25/2013] [Accepted: 06/26/2013] [Indexed: 01/08/2023]
Affiliation(s)
- Marjan J. Traa
- CoRPS - Center of Research on Psychology in Somatic Diseases; Department of Medical Psychology; Tilburg University; Tilburg The Netherlands
| | - Ricardo G. Orsini
- Department of Surgery; Catharina Hospital; Eindhoven The Netherlands
| | - Brenda L. Den Oudsten
- CoRPS - Center of Research on Psychology in Somatic Diseases; Department of Medical Psychology; Tilburg University; Tilburg The Netherlands
- Department of Education and Research; St. Elisabeth Hospital; Tilburg The Netherlands
| | - Jolanda De Vries
- CoRPS - Center of Research on Psychology in Somatic Diseases; Department of Medical Psychology; Tilburg University; Tilburg The Netherlands
- Department of Medical Psychology; St. Elisabeth Hospital; Tilburg The Netherlands
| | - Jan A. Roukema
- CoRPS - Center of Research on Psychology in Somatic Diseases; Department of Medical Psychology; Tilburg University; Tilburg The Netherlands
- Department of Surgery; St. Elisabeth Hospital; Tilburg The Netherlands
| | - Sietske J. Bosman
- Department of Surgery; Catharina Hospital; Eindhoven The Netherlands
| | - Ralph L. Dudink
- Department of Surgery; Catharina Hospital; Eindhoven The Netherlands
| | - Harm J.T. Rutten
- Department of Surgery; Catharina Hospital; Eindhoven The Netherlands
- Research Institute Growth and Development; Maastricht University Medical Center; The Netherlands
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19
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Bujko K, Nasierowska-Guttmejer A, Wyrwicz L, Malinowska M, Krynski J, Kosakowska E, Rutkowski A, Pietrzak L, Kepka L, Radziszewski J, Olszyna-Serementa M, Bujko M, Danek A, Kryj M, Wydmanski J, Zegarski W, Markiewicz W, Lesniak T, Zygulski I, Porzuczek-Zuziak D, Bebenek M, Maciejczyk A, Polkowski W, Czeremszynska B, Cieslak-Zeranska E, Toczko Z, Radkowski A, Kolodziejski L, Szczepkowski M, Majewski A, Jankowski M. Neoadjuvant treatment for unresectable rectal cancer: an interim analysis of a multicentre randomized study. Radiother Oncol 2013; 107:171-7. [PMID: 23590986 DOI: 10.1016/j.radonc.2013.03.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Revised: 02/18/2013] [Accepted: 03/03/2013] [Indexed: 01/08/2023]
Abstract
PURPOSE To present an interim analysis of the trial comparing two neoadjuvant therapies for unresectable rectal cancer. METHODS Patients with fixed cT3 or cT4 or locally recurrent rectal cancer without distant metastases were randomized to either 5 × 5 Gy and 3 courses of FOLFOX4 (schedule I) or 50.4 Gy delivered in 28 fractions given simultaneously with 5-Fu, leucovorin and oxaliplatin (schedule II). Surgery in both groups was performed 12 weeks after the beginning of radiation and 6 weeks after neoadjuvant treatment. RESULTS 49 patients were treated according to schedule I and 48 according to schedule II. Grade III+ acute toxicity was observed in 26% of patients in group I and in 25% in group II. There were two toxic deaths, both in group II. The microscopically radical resection (primary endpoint) rate was 73% in group I and 71% in group II. Overall and severe postoperative complications were recorded in 27% and 9% of patients vs. 16% and 7%, respectively. Pathological complete response was observed in 21% of the patients in group I and in 9% in group II. CONCLUSIONS The interim analysis revealed no major differences in acute toxicity and local efficacy between the two evaluated strategies.
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Affiliation(s)
- Krzysztof Bujko
- Department of Radiotherapy II, M. Sklodowska-Curie Memorial Cancer Centre, Warsaw, Poland.
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