Prospective phase II study of preoperative chemoradiation with capecitabine in locally advanced rectal cancer

MRI for Rectal Cancer: Staging, mrCRM, EMVI, Lymph Node Staging and Post-Treatment Response

Rectal cancer is a relatively common malignancy in the United States. Magnetic resonance imaging (MRI) of rectal cancer has evolved tremendously in recent years, and has become a key component of baseline staging and treatment planning. In addition to assessing the primary tumor and locoregional lymph nodes, rectal MRI can be used to help with risk stratification by identifying high-risk features such as extramural vascular invasion and can assess treatment response for patients receiving neoadjuvant therapy. As the practice of rectal MRI continues to expand further into academic centers and private practices, standard MRI protocols, and reporting are critical. In addition, it is imperative that the radiologists reading these cases work closely with surgeons, medical oncologists, radiation oncologists, and pathologists to ensure we are providing the best possible care to patients. This review aims to provide a broad overview of the role of MRI for rectal cancer.

MRI of Rectal Cancer: An Overview and Update on Recent Advances

OBJECTIVE

MRI is the modality of choice for rectal cancer staging. The high soft-tissue contrast of MRI accurately assesses the extramural tumor spread and relation to mesorectal fascia and the sphincter complex. This article reviews the role of MRI in the staging and treatment of rectal cancer. The relevant anatomy, MRI techniques, preoperative staging, post-chemoradiation therapy (CRT) imaging, and tumor recurrence are discussed with special attention to recent advances in knowledge.

CONCLUSION

MRI is the modality of choice for staging rectal cancer to assist surgeons in obtaining negative surgical margins. MRI facilitates the accurate assessment of mesorectal fascia and the sphincter complex for surgical planning. Multiparametric MRI may also help in the prediction and estimation of response to treatment and in the detection of recurrent disease.

Current controversies in neoadjuvant chemoradiation of rectal cancer

Total mesorectal excision with preoperative radiation and chemotherapy provide the lowest local recurrence rates for rectal cancer. Timing of surgery after preoperative chemoradiation is being increased to optimize tumor downstaging. In cases of complete clinical response from chemoradiation, permissive observation without resection is being investigated. Significant anorectal dysfunction results from low anterior resection and radiation. Good prognostic tumor characteristics are being investigated with the aim of selecting cases for whom preoperative radiation may be avoided. Preoperative and postoperative radiation provides improved local cancer control for superficial cancers removed by local excision.

Tailored rectal cancer treatment--a time for implementing contemporary prognostic factors?

AIM

To report data supporting the development of tailored treatment strategies for rectal cancer.

METHOD

A comprehensive review of the literature on the impact of prognostic factors cur-rently not included in international guidelines in rectal cancer management.

RESULTS

There is considerable variation in treatment guidelines for rectal cancer worldwide, especially for Stage II and Stage III disease. Long-term side effects of chemoradiotherapy are not considered in any guideline. Detailed knowledge, and the prognostic impact, of the circumferential resection margin, tumour grade and venous invasion should be factored into the development of a treatment strategy.

CONCLUSION

Factors additional to the TNM system should improve decision making for contemporary rectal cancer treatment. Optimized radiological and pathological evaluations, and a focus on detailed clinical factors, should be the basis for treatment decisions. International guidelines should consider all known prognostic factors for long-term oncological and functional outcomes.

Oncologic outcome after preoperative chemoradiotherapy in patients with pathologic T0 (ypT0) rectal cancer

BACKGROUND

Little is known about the oncologic outcomes of patients with ypT0 rectal cancer after preoperative chemoradiotherapy.

OBJECTIVE

To evaluate the clinicopathologic characteristics and oncologic outcomes of patients with ypT0 rectal cancer after preoperative chemoradiotherapy and curative radical surgery.

DESIGN AND SETTINGS

This was a retrospective review of factors influencing outcome of patients treated with preoperative chemoradiotherapy for rectal cancer at a tertiary care university medical center in Seoul, Korea between 2000 and 2008.

PATIENTS

A total of 830 rectal cancer patients underwent surgery after preoperative chemoradiotherapy. Patients were included in the study if they had a pretreatment clinical classification of T3-4 or N+ (or T2N0 and preoperative chemoradiotherapy for sphincter preservation) and if they were classified on pathologic examination as ypT0 after preoperative CRT and curative radical surgery. Patients were classified as.

MAIN OUTCOME MEASURES

Overall survival and disease-free survival were evaluated in relation to ypT0N0 or ypT0N1-2 status and other factors that might influence outcome.

RESULTS

Of 91 patients included in the study, 54 (59.3%) were men; the mean patient age was 55 (SD, 11) years, and mean follow-up duration was 44 (SD, 23) months. Surgical procedures included low anterior resection in 68 patients, abdominoperineal resection in 21, and intersphincteric resection in 2. Mean tumor distance from the anal verge was 4.7 (SD, 1.8) cm. Of the 91 patients, 85 were classified as ypT0N0 and 6 as ypT0N1-2. No patient experienced local recurrence. A total of 11 patients (12.1%) had distant metastases, after a mean 11.1 months, including 7 (8.2%) with ypT0N0 and 4 (66.7%) with ypT0N1-2 tumors. One patient with ypT0N0 and 2 patients with ypT0N1-2 tumors died of metastasis. In patients classified as ypT0N0, the 5-year disease free survival and overall survival rates were 82.3% and 89.2%, respectively. Multivariate analysis showed that ypN1-2 status (p = 0.001) was a significant independent risk factor for recurrence (decreased 5-year disease-free survival), but no factor was associated with 5-year overall survival.

LIMITATIONS

The study is limited by its retrospective nature.

CONCLUSION

Oncologic outcomes in patients with ypT0N0 rectal cancer were excellent. The presence of residual cancer cells in mesorectal lymph nodes represents a risk factor for distant metastasis.

Phase II study of concurrent chemoradiotherapy with capecitabine and cisplatin in patients with locally advanced squamous cell carcinoma of the head and neck

We aimed to evaluate the efficacy and safety of concurrent chemoradiotherapy with capecitabine and cisplatin in patients with locally advanced squamous cell carcinoma of the head and neck (SCCHN). In total, 37 patients with stage III or IV SCCHN were enrolled on the study. The chemotherapy consisted of two cycles of intravenous cisplatin of 80 mg m⁻² on day 1 and oral capecitabine 825 mg m⁻² twice daily from day 1 to day 14 at 3-week intervals. The radiotherapy (1.8–2.0 Gy 1 fraction day⁻¹ to a total dose of 70–70.2 Gy) was delivered to the primary tumour site and neck. The primary tumour sites were as follows: oral cavity (n=6), oropharynx (n=11), hypopharynx (n=8), larynx (n=3), nasopharynx (n=6), and paranasal sinus (n=3). After the chemoradiotherapy, 29 complete responses (78.4%) and 6 partial responses (16.2%) were confirmed. Grade 3 or 4 neutropenia occurred only in two patients, plus grade 3 febrile neutropenia was observed only in one patient. At a median follow-up duration of 19.8 months, the estimated overall survival and progression-free survival rate at 2-year was 76.8 and 57.9%, respectively. Concurrent chemoradiotherapy with capecitabine and cisplatin was found to be well tolerated and effective in patients with locally advanced SCCHN.