Short course radiation as a component of definitive multidisciplinary treatment for select patients with metastatic rectal adenocarcinoma

Determining Which Patients Require Preoperative Pelvic Radiotherapy Before Curative-Intent Surgery and/or Ablation for Metastatic Rectal Cancer

BACKGROUND

The aim of this study is to determine the optimal indications for preoperative pelvic radiotherapy (RT) in patients with metastatic rectal cancer who underwent curative-intent surgical resection and/or ablation.

METHODS

Between January 2000 and October 2019, 246 patients who met our inclusion criteria were enrolled. Preoperative RT was performed in 22 patients (8.9%). Lower margin below the peritoneal reflection (p < 0.001), mesorectal fascia (MRF) invasion (p = 0.02), and lateral pelvic lymph node (LPLN) involvement (p = 0.005) were more frequent in the preoperative RT group.

RESULTS

During the median follow-up period of 13.3 months (interquartile range [IQR]: 6.0-36.3 months), local recurrence (LR) was identified in 60 patients (24.4%). It was the first site of recurrence in 45 of them (18.3%). Among them, three patients were in the preoperative RT group. On multivariable analysis, lower margin below the peritoneal reflection, MRF invasion, LPLN involvement, carcinoembryonic antigen (CEA) level ≥ 10 ng/mL before treatment, and preoperative RT were significant prognostic factors for LR-free survival (LRFS). In the patient group without any risk factors, the 2-year LRFS rate was 94.9% without preoperative RT. In the patient group with one or more risk factors, the 2-year LRFS was 64.4% without and 95.2% with preoperative RT.

CONCLUSION

LR developed in about 25% of patients within 2 years. Preoperative RT should be considered, especially in patients with a risk factor for LR, including lower margin below the peritoneal reflection, MRF invasion, LPLN involvement, or CEA ≥ 10 ng/mL before treatment.

Clinical Complete Response in Patients With Rectal Adenocarcinoma Treated With Short-Course Radiation Therapy and Nonoperative Management

PURPOSE

This study aimed to determine the clinical efficacy and safety of nonoperative management (NOM) for patients with rectal cancer with a clinical complete response (cCR) after short-course radiation therapy and consolidation chemotherapy.

METHODS AND MATERIALS

Patients with stage I-III rectal adenocarcinoma underwent short-course radiation therapy followed by consolidation chemotherapy between January 2018 and May 2019 (n = 90). Clinical response was assessed by digital rectal examination, pelvic magnetic resonance imaging, and endoscopy. Of the patients with an evaluable initial response, those with a cCR (n = 43) underwent NOM, and those with a non-cCR (n = 43) underwent surgery. The clinical endpoints included local regrowth-free survival, regional control, distant metastasis-free survival, disease-free survival, and overall survival.

RESULTS

Compared with patients with an initial cCR, patients with initial non-cCR had more advanced T and N stage (P = .05), larger primary tumors (P = .002), and more circumferential resection margin involvement on diagnostic magnetic resonance imaging (P < .001). With a median follow-up of 30.1 months, the persistent cCR rate was 79% (30 of 38 patients) in the NOM cohort. The 2-year local regrowth-free survival was 81% (95% confidence interval [CI], 70%-94%) in the initial cCR group, and all patients with local regrowth were successfully salvaged. Compared with those with a non-cCR, patients with a cCR had improved 2-year regional control (98% [95% CI, 93%-100%] vs 85% [95% CI, 74%-97%], P = .02), distant metastasis-free survival (100% [95% CI, 100%-100%] vs 80% [95% CI, 69%-94%], P < .01), disease-free survival (98% [95% CI, 93%-100%] vs 71% [95% CI, 59%-87%], P < .01), and overall survival (100% [95% CI, 100%-100%] vs 88% [95% CI, 79%-98%], P = .02). No late grade 3+ gastrointestinal or genitourinary toxicities were observed in the patients who underwent continued NOM.

CONCLUSIONS

Short-course radiation therapy followed by consolidation chemotherapy may be a feasible organ preservation strategy in rectal cancer. Additional prospective studies are necessary to evaluate the safety and efficacy of this approach.

Neoadjuvant Pelvic Radiotherapy in the Management of Rectal Cancer with Synchronous Liver Metastases: Is It Worth It?

BACKGROUND

The use of neoadjuvant pelvic radiotherapy was a major advance in oncologic care for locally advanced rectal cancer in the twentieth century. The extrapolation of the care of locally advanced rectal cancer to the management of rectal cancer with treatable liver metastases is controversial. The aim of this review is to examine the available data on the role of pelvic radiotherapy and chemoradiation in the setting of treatable metastatic liver disease.

METHODS

A systematic search of MEDLINE was performed to report the landmark randomized controlled trials between 1993 and 2021.

RESULTS

Attaining liver clearance and total mesorectal excision with R0 margin remains the mainstay of cure. There is uncertainty regarding the sequencing of treatment. The literature lacks randomized clinical trials comparing the rectal first, liver first, interval strategy, and simultaneous surgical approaches. A multidisciplinary discussion regarding the utility of radiotherapy is emphasized to achieve the goals of treatment. Short-course radiotherapy has proved comparable disease-control outcomes to long-course chemoradiation with a significantly improved cost-performance. The implementation of short-course radiotherapy in the interval strategy and simultaneous surgical approach is promising. Neoadjuvant pelvic radiotherapy can be omitted in patients with metastatic rectal cancer if adequate margin clearance is achievable.

CONCLUSION

The use of radiotherapy in metastatic rectal cancer is popular but is based on limited data. Treatment should be tailored to the local extent of rectal cancer and priority of liver metastasis management. The optimal treatment strategy in patients with rectal cancer and synchronous liver metastatic disease needs to be studied in randomized trials.

Short-course radiotherapy in stage IV rectal cancer with resectable disease

INTRODUCTION

Stage IV rectal cancer with resectable disease presents challenging issues, as the radical treatment of the whole disease is difficult. Surgery and chemotherapy (CT) play an unquestionable role, but the contribution of pelvic radiotherapy (RT) is not very clear.

METHODS

In 2009, we established a prospective treatment protocol that included CT, short-course preoperative radiotherapy (SCRT) with surgery of the primary tumour and all metastatic locations.

RESULTS

Forty patients were included. Eight (20%) patients did not receive CT due to significant comorbidities. Radical surgery treatment was possible in 22 (55%) patients. The mean follow-up was 42.81 months (3.63-105.97). Overall survival at 24 and 36 months was 71.4% and 58.2%, respectively. There was good local control of the disease, as 97.2% of pelvic surgeries were R0 and there were no local recurrences.

CONCLUSION

In stage IV with resectable metastatic disease, the proposed therapeutic regimen seems very appropriate in well selected patients able to tolerate the treatment. We bet on the role of pelvic RT, due to the good local control of the disease in our series.

Planned Short-Course Radiation (scRT) is Superior to Upfront Concurrent Chemoradiation (CCRT) in Treating Metastatic Rectal Cancer

BACKGROUND OR PURPOSE

To compare the cost-performance between planned short-course radiation and upfront concurrent chemoradiation on metastatic rectal cancer.

METHODS

A total of 75 patients with metastatic rectal cancer who underwent planned short-course radiation or upfront concurrent chemoradiation were enrolled. The Kaplan-Meier method was used to compute the survival rates. The χ² test was used to compare baseline characteristics. The Cox proportional hazards model was applied to determine the prognostic influence of clinicopathological factors.

RESULTS

The planned short-course radiation is superior to upfront concurrent chemoradiation in overall survival for the patients with metastatic rectal cancer (34.8 vs. 20.2 months, P = 0.010). The planned short-course radiation was an independent prognostic factor (P = 0.009, HR (95% CI) = 0.319(0.135-0.752)). The efficacy of radiation on downstaging was similar between planned short-course radiation and upfront concurrent chemoradiation. The total cost of concurrent chemoradiation is 4.52-fold more expensive than that of short-course radiation (340,142 vs. 75,106 NT dollars, respectively).

CONCLUSIONS

Based on the impressive cost-performance of planned short-course radiation compared with upfront concurrent chemoradiation (better OS, modest downstaging and lower cost), planned short-course radiation should be the preferred radiation approach for managing metastatic rectal cancer.

Multimorbidity and short-term overall mortality among colorectal cancer patients in Spain: A population-based cohort study

BACKGROUND

Numerous studies have analysed the effect of comorbidity on cancer outcomes, but evidence on the association between multimorbidity and short-term mortality among colorectal cancer patients is limited. We aimed to assess this association and the most frequent patterns of multimorbidity associated with a higher short-term mortality risk among colorectal cancer patients in Spain.

METHODS

Data were obtained from two Spanish population-based cancer registries and electronic health records. We estimated the unadjusted cumulative incidence of death by comorbidity status at 6 months and 1 year. We used a flexible parametric model to derive the excess mortality hazard ratios (HRs) for multimorbidity after adjusting for sex, age at diagnosis, cancer stage and treatment. We estimated the adjusted cumulative incidence of death by comorbidity status and identified multimorbidity patterns.

RESULTS

Among the study participants, 1,048 cases were diagnosed with cancers of the colon and rectum, 2 cases with cancer of the anus with overlapping sites of the rectum and 11 cases with anal adenocarcinomas but treated as colorectal cancer patients. Among 1,061 colorectal cancer patients, 171 (16.2%) died before 6 months, 246 (23.3%) died before the 1-year follow-up, and 324 (30.5%) had multimorbidity. Patients with multimorbidity had two times higher mortality risk than those without comorbidities at 6 months (adjusted HR: 2.04; 95% confidence interval [CI]: 1.30-3.20, p = 0.002). The most frequent multimorbidity pattern was congestive heart failure + diabetes. However, patients with rheumatologic disease + diabetes had two times higher 1-year mortality risk than those without comorbidities (HR: 2.23; 95% CI: 1.23-4.07, p = 0.008).

CONCLUSIONS

Multimorbidity was a strong independent predictor of short-term mortality at 6 months and 1 year among the colorectal cancer patients in Spain. The identified multimorbidity pattern was consistent. Our findings might help identify patients at a higher risk for poor cancer and treatment outcomes.

Pathologic Response and Postoperative Complications After Short-course Radiation Therapy and Chemotherapy for Patients With Rectal Adenocarcinoma

BACKGROUND

The role of neoadjuvant short-course radiation therapy (SCRT) in treating rectal adenocarcinoma is a topic of ongoing debate. Growing interest in total neoadjuvant therapy has spurred discussion on the optimal sequence of preoperative SCRT and chemotherapy.

PATIENTS AND METHODS

All patients receiving SCRT (5 Gy × 5 fractions) were identified. Details about preoperative treatments, radiation toxicities, and postoperative complications were collected. Patients were divided into 2 groups: those who underwent surgery within 14 days of completing SCRT and those with a longer delay. Outcomes compared included extent of pathologic response, margin-negative resection rate, acute radiation toxicities, and postoperative complications.

RESULTS

Fifty-seven patients with locally advanced or metastatic rectal cancer received SCRT between 2008 and 2018. Thirty-nine of 57 patients underwent definitive pelvic surgery with total mesorectal excision. There were no significant differences in tumor downstaging, radial margin status, or percent tumor viability between patients with immediate surgery versus delayed surgery. The delay group had higher rates of nodal downstaging (64.7% vs. 18.2%; P = .003). There were no differences in total or grade 3+ gastrointestinal radiation toxicity, postoperative complications, reoperation, readmission, and mortality between the 2 groups.

CONCLUSIONS

Though not yet common in the United States, SCRT has compared favorably with long course chemoradiation in multiple trials. Moreover, it is associated with greater efficiency and less disruption to chemotherapy. Our data show similar response and toxicity outcomes between the immediate and delay groups, suggesting SCRT is well-tolerated regardless of treatment sequence. Recently completed prospective trials may reveal the optimal preoperative treatment sequence.

Addition of short course radiotherapy in newly diagnosed locally advanced rectal cancers with distant metastasis

AIM

To study the outcomes of patients presenting with locally advanced rectal cancers with distant metastasis (mLARC), treated with short course radiotherapy (SCRT).

METHOD

Between May 2012 and August 2015, 70 patients diagnosed with mLARC, treated with SCRT (25 Gy/5#) and three to six cycles of CAPOX chemotherapy (CT), were assessed for surgical feasibility for the primary and metastatic sites.

RESULTS

Sixty-five patients could complete the planned SCRT and three to six cycles of CT. Response rate and disease control rate for the primary was 68% and 97%, respectively. Radiologically, CRM became free in 44 (72%) patients out of 61 initially involved. Fifty-two (74%) were planned to receive treatment with a potentially curative intent and 18 (26%) with palliative intent. Of those treated with curative intent, 34 (65%) underwent primary tumor resection (PTR). Successful intervention for metastatic disease was done in 27 (52%) patients. At a median follow up of 43 months, the median overall survival (OS) for patients undergoing PTR was 36 months versus 12 months for those in which the tumor was still unresectable or had distant progression (P < .001). Of the operated patients, 56% were alive at the end of 3 years. The median pelvic recurrence free survival was 29 months. Symptom control in the form of pain and bleeding control was observed in 80%.

CONCLUSION

The addition of SCRT to CT in mLARC can downstage the primary tumor to undergo surgery, thereby, achieving better loco-regional control and survival. It achieves good palliation in patients unable to undergo surgery due to extensive primary or metastatic disease.

Emerging trends in the treatment of rectal cancer

The conventional treatment for cT3-T4 or node-positive clinically resectable rectal cancer is long course preoperative chemoradiation followed by surgery and postoperative adjuvant chemotherapy. Disadvantages of this approach include possible overtreatment of patients, 6 weeks of daily radiation treatment, and undetected metastatic disease. There are a number of emerging trends which are changing this approach to treatment. Selected topics included in this manuscript include the selective use of pelvic radiation, the role of radiation for a positive radial margin, the interval between radiation and surgery, non-operative management, new chemoradiation regimens, short vs. long course radiation, and the role of postoperative adjuvant chemotherapy.

A Concise Review of Pelvic Radiation Therapy (RT) for Rectal Cancer with Synchronous Liver Metastases

Background and Objective

Colorectal cancer is a major health concern as a very common cancer and a leading cause of cancer-related mortality worldwide. The liver is a very common site of metastatic spread for colorectal cancers, and, while nearly half of the patients develop metastases during the course of their disease, synchronous liver metastases are detected in 15% to 25% of cases. There is no standardized treatment in this setting and no consensus exists on optimal sequencing of multimodality management for rectal cancer with synchronous liver metastases.

Methods

Herein, we review the use of pelvic radiation therapy (RT) as part of potentially curative or palliative management of rectal cancer with synchronous liver metastases.

Results

There is accumulating evidence on the utility of pelvic RT for facilitating subsequent surgery, improving local tumor control, and achieving palliation of symptoms in patients with stage IV rectal cancer. Introduction of superior imaging capabilities and contemporary RT approaches such as Intensity Modulated Radiation Therapy (IMRT) and Image Guided Radiation Therapy (IGRT) offer improved precision and toxicity profile of radiation delivery in the modern era.

Conclusion

Even in the setting of stage IV rectal cancer with synchronous liver metastases, there may be potential for extended survival and cure by aggressive management of primary tumor and metastases in selected patients. Despite lack of consensus on sequencing of treatment modalities, pelvic RT may serve as a critical component of multidisciplinary management. Resectability of primary rectal tumor and liver metastases, patient preferences, comorbidities, symptomatology, and logistical issues should be thoroughly considered in decision making for optimal management of patients.

The changing face of treatment for metastatic colorectal cancer

Introduction: Since late 1990's therapy of metastatic colorectal cancer (mCRC) patients has changed considerable, and the combination of doublet or triplet chemotherapy and a targeted agent are now routinely used. With the introduction of more intensified regimens, it has become even more important to identify patients that will benefit from and can tolerate therapy. Furthermore, the increasing understanding of the biology of mCRC has led to the discovery of new potential targets. Therefore, therapy of patients with mCRC has undergone considerable change from 'one strategy fits all' towards a more personalized therapy. Areas covered: We present an overview of the recent literature on approved systemic treatment of mCRC however with focus on how the treatment strategy has changed based on clinical and molecular parameters that presently are used routinely in the clinical situation. Expert commentary: The face of treatment of mCRC has changed from 'one strategy fits all' to a personalized approach in which both clinical, molecular parameters and the aim of therapy have to be taking into account when planning the optimal treatment strategy for the individual mCRC patient.

Impact of multidisciplinary tumor boards on patients with rectal cancer

Οncological outcomes in patients with primary rectal cancer have markedly improved over the last few years, mainly due to the widespread application of the total mesorectal excision technique. This improvement should also be largely attributed to multiple specialties, other than colorectal surgery, such as radiology, oncology and pathology. Therefore, a multimodal approach is key to efficient and appropriate rectal cancer management. Multidisciplinary tumor (MDT) boards have become an important asset for the management and treatment of patients with rectal cancer, and a number of studies published to date suggest the beneficial effect of the multidisciplinary approach on the management of such patients. The available evidence demonstrates a modification of the treatment plan, attributed to the MDT implementation, in a non-negligible proportion of these patients. However, more studies are required in order to assess the exact impact of MDT boards on disease-free and overall survival of patients with primary rectal cancer.