1
|
Wu Q, Zhou J, Huang J, Deng X, Li C, Meng W, He Y, Wang Z. Total neoadjuvant therapy versus chemoradiotherapy for locally advanced rectal cancer: Bayesian network meta-analysis. Br J Surg 2023; 110:784-796. [PMID: 37191308 DOI: 10.1093/bjs/znad120] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 03/08/2023] [Accepted: 03/23/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Total neoadjuvant therapy is a promising treatment for locally advanced rectal cancer, utilizing either short-course radiotherapy or long-course chemoradiotherapy, but their relative efficacy remains unclear. The aim of this Bayesian network meta-analysis was to investigate clinical outcomes amongst patients receiving total neoadjuvant therapy with short-course radiotherapy or long-course chemoradiotherapy, and those receiving long-course chemoradiotherapy alone. METHODS A systematic literature search was performed. All studies that compared at least two of these three treatments for locally advanced rectal cancer were included. The primary endpoint was the pathological complete response rate, and survival outcomes were adopted as secondary outcomes. RESULTS Thirty cohorts were included. Compared with long-course chemoradiotherapy, both total neoadjuvant therapy with long-course chemoradiotherapy (OR 1.78, 95 per cent c.i. 1.43 to 2.26) and total neoadjuvant therapy with short-course radiotherapy (OR 1.75, 95 per cent c.i. 1.23 to 2.50) improved the pathological complete response rate. Similar benefits were observed in the sensitivity and subgroup analyses, except for short-course radiotherapy with one to two cycles of chemotherapy. No significant differences in survival outcomes were found amongst the three treatments. Long-course chemoradiotherapy with consolidation chemotherapy (HR 0.44, 95 per cent c.i. 0.20 to 0.99) exhibited higher disease-free survival than long-course chemoradiotherapy alone. CONCLUSION Compared with long-course chemoradiotherapy, both short-course radiotherapy with greater than or equal to three cycles of chemotherapy and total neoadjuvant therapy with long-course chemoradiotherapy can improve the pathological complete response rate, and long-course chemoradiotherapy with consolidation chemotherapy may lead to a marginal benefit in disease-free survival. The pathological complete response rate and survival outcomes are similar for total neoadjuvant therapy with short-course radiotherapy or long-course chemoradiotherapy.
Collapse
Affiliation(s)
- Qingbin Wu
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
- Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Jiahao Zhou
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
- Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Jun Huang
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
- Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Xiangbing Deng
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
- Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Changtao Li
- Department of Epidemiology and Medical Statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Wenjian Meng
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
- Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yazhou He
- Department of Oncology, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Ziqiang Wang
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
- Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| |
Collapse
|
2
|
Rectal Cancer: Clinical and Molecular Predictors of a Complete Response to Total Neoadjuvant Therapy. Dis Colon Rectum 2023; 66:521-530. [PMID: 34984995 DOI: 10.1097/dcr.0000000000002245] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Total neoadjuvant therapy in rectal cancer may increase pathological complete response rates, potentially allowing for a nonoperative approach. OBJECTIVE The objective of this study was to identify patient and tumor characteristics that predict a complete response following total neoadjuvant therapy. DESIGN This was a retrospective cohort study. SETTINGS This study was conducted at a university-based National Cancer Institute-designated Comprehensive Cancer Center. PATIENTS The patients include those with stage 2 or 3 rectal adenocarcinoma. INTERVENTIONS Interventions included total neoadjuvant therapy, total mesorectal excision, and nonoperative management. MAIN OUTCOME MEASURES Complete response was defined as either patients with a clinical complete response undergoing nonoperative management who remained cancer-free or patients undergoing surgery with a pathological complete response. RESULTS Among 102 patients, median age was 54 years, 69% were male, median carcinoembryonic antigen level was 3.0 ng/mL, and the median distance of the tumor above the anorectal ring was 3 cm. Thirty-eight (37%) patients had a complete response, including 15 of 18 (83%) nonoperative patients who remained cancer free at a median of 22 months (range, 7-48 months) and 23 of 84 (27%) patients who underwent surgery and had a pathological complete response. The incomplete response group consisted of 61 patients who underwent initial surgery and 3 nonoperative patients with regrowth. There were no differences in gender, T-stage, or tumor location between groups. Younger age (median, 49 vs 55 years), normal carcinoembryonic antigen (71% vs 41%), clinical node-negative (24% vs 9%), smaller tumors (median 3.9 vs 5.4 cm), and wild-type p53 (79% vs 47%) and SMAD4 (100% vs 81%) were more likely to have a complete response (all p < 0.05). LIMITATIONS This was a retrospective study with a small sample size. CONCLUSIONS In patients with rectal cancer treated with total neoadjuvant therapy, more than one-third will achieve a pathological complete response or sustained clinical complete response with nonoperative management, making oncological resection superfluous in these patients. Smaller, wild-type p53 and SMAD4, and clinically node-negative cancers are predictive features of a complete response. See Video Abstract at http://links.lww.com/DCR/B889 . CNCER DE RECTO PREDICTORES CLNICOS Y MOLECULARES DE UNA RESPUESTA COMPLETA A LA TERAPIA NEOADYUVANTE TOTAL ANTECEDENTES:La terapia neoadyuvante total en el cáncer de recto puede aumentar las tasas de respuesta patológica completa y permitir potencialmente un enfoque no quirúrgico.OBJETIVO:El objetivo fue identificar las características tanto del paciente y del tumor que logren predecir una respuesta completa después de la terapia neoadyuvante total.DISEÑO:Este fue un estudio de cohorte retrospectivo.AJUSTES:Este estudio se realizó en un Centro Integral de Cáncer designado por el Instituto Nacional del Cáncer con sede universitaria.PACIENTES:Los pacientes incluyen aquellos con adenocarcinoma de recto en estadio 2 o 3.INTERVENCIONES:Terapia neoadyuvante total, escisión total del mesorrecto, manejo conservador no quirúrgico.PRINCIPALES MEDIDAS DE RESULTADO:La respuesta completa se definió como pacientes con una respuesta clínica completa sometidos a tratamiento no quirúrgico que permanecieron libres de cáncer o pacientes sometidos a cirugía con una respuesta patológica completa.RESULTADOS:Entre 102 pacientes, la mediana de edad fue de 54 años, el 69% fueron hombres, la mediana del nivel de antígeno carcinoembrionario fue de 3.0 ng/ml y la mediana de la distancia del tumor por encima del anillo anorrectal fue de 3 cm. Thirty-eight (37%) pacientes tuvieron una respuesta completa que incluyó a 15 de 18 (83%) pacientes con manejo no operatorio y que permanecieron libres de cáncer en una mediana de 22 meses (rango 7- 48 meses) y 23 de 84 (27%) pacientes que fueron sometidos a cirugía y tuvieron una respuesta patológica completa. El grupo de respuesta incompleta consistió en 61 pacientes que fueron sometidos inicialmente a cirugía y 3 pacientes no quirúrgicos con recrecimiento. No se encontró diferencias de género, estadio T o ubicación del tumor entre los grupos. Edad más joven (mediana 49 frente a 55), antígeno carcinoembrionario normal (71% frente a 41%), ganglios clínicos negativos (24% frente a 9%), tumores más pequeños (mediana de 3,9 frente a 5,4 cm) y p53 de tipo salvaje (79 % vs 47%) y SMAD4 (100% vs 81%) tenían más probabilidades de tener una respuesta completa (todos p < 0,05).LIMITACIONES:Este fue un estudio retrospectivo y con un tamaño de muestra pequeño.CONCLUSIONES:En pacientes con cáncer de recto tratados con terapia neoadyuvante total, más de un tercio logrará una respuesta patológica completa o una respuesta clínica completa sostenida con manejo no operatorio, logrando que la resección oncológica sea superflua en estos pacientes. Los cánceres más pequeños, clínicamente con ganglios negativos, con p53 de tipo salvaje y SMAD4, son características predictoras de una respuesta completa. Consulte Video Resumen en http://links.lww.com/DCR/B889 . (Traducción-Dr. Osvaldo Gauto ).
Collapse
|
3
|
Moyer AM, Vogel JD, Lai SH, Kim H, Chin RI, Moskalenko M, Olsen JR, Birnbaum EH, Silviera ML, Mutch MG, Chapman BC. Total Neoadjuvant Therapy in Rectal Cancer: Multi-center Comparison of Induction Chemotherapy and Long-Course Chemoradiation Versus Short-Course Radiation and Consolidative Chemotherapy. J Gastrointest Surg 2023; 27:980-989. [PMID: 36759387 DOI: 10.1007/s11605-023-05601-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 12/29/2022] [Indexed: 02/11/2023]
Abstract
BACKGROUND Total neoadjuvant therapy for locally advanced rectal cancer may include induction chemotherapy and chemoradiation or short-course radiotherapy and consolidative chemotherapy. METHODS Patients with clinical stage 2 or 3 rectal cancer who received induction chemotherapy followed by long-course chemoradiation at the University of Colorado (2016-2020) or short-course radiotherapy followed by consolidative chemotherapy at Washington University (2017-2020) were assessed. RESULTS Eighty-four patients received induction chemotherapy and chemoradiation and 83 received short-course radiotherapy and consolidative chemotherapy. Among patients with complete re-staging evaluation, clinical complete response rates were similar, 49% (18/37) and 53% (44/83), respectively (p = 0.659). In the induction chemotherapy and chemoradiation group, 80% (n = 67) underwent surgery and 28% (n = 19) achieved a pathologic complete response. In the short-course radiotherapy and consolidative chemotherapy group, 44 (53%) patients underwent surgery and 11% (n = 5) had a pathologic complete response. Overall, a complete response was observed in 43% (n = 36) of patients who received induction chemotherapy and chemoradiation compared to 53% (n = 44) who received short-course radiotherapy and consolidative chemotherapy (p = 0.189). Perioperative outcomes were similar in patients who received induction chemotherapy and chemoradiation compared to short-course radiotherapy and consolidative chemotherapy: intraoperative complications (2% vs 7%), complete mesorectal specimen (85% vs 84%), anastomotic leak (9% vs 7%), organ/space infection (9% vs 5%), readmission (19% vs 21%), and reoperation (8% vs 9%), respectively (all p > 0.05). CONCLUSIONS In patients with clinical stage 2 or 3 rectal cancer, total neoadjuvant therapy with either induction chemotherapy and chemoradiation or short-course radiotherapy followed by consolidative chemotherapy were associated with similar perioperative morbidity and complete response rates.
Collapse
Affiliation(s)
- Amber M Moyer
- Department of Surgery, University of Colorado Denver School of Medicine, 12631 E. 17Th Ave., C313, Aurora, CO, 80045, USA
| | - Jon D Vogel
- Department of Surgery, University of Colorado Denver School of Medicine, 12631 E. 17Th Ave., C313, Aurora, CO, 80045, USA
| | - Samuel H Lai
- Department of Surgery, University of Colorado Denver School of Medicine, 12631 E. 17Th Ave., C313, Aurora, CO, 80045, USA
| | - Hyun Kim
- Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Re-I Chin
- Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Marina Moskalenko
- Department of Surgery, University of Colorado Denver School of Medicine, 12631 E. 17Th Ave., C313, Aurora, CO, 80045, USA
| | - Jeffrey R Olsen
- Department of Surgery, University of Colorado Denver School of Medicine, 12631 E. 17Th Ave., C313, Aurora, CO, 80045, USA
| | - Elisa H Birnbaum
- Department of Surgery, University of Colorado Denver School of Medicine, 12631 E. 17Th Ave., C313, Aurora, CO, 80045, USA
| | - Matthew L Silviera
- Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Matthew G Mutch
- Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Brandon C Chapman
- Department of Surgery, University of Colorado Denver School of Medicine, 12631 E. 17Th Ave., C313, Aurora, CO, 80045, USA.
| |
Collapse
|
4
|
Zhang X, Ma S, Guo Y, Luo Y, Li L. Total neoadjuvant therapy versus standard therapy in locally advanced rectal cancer: A systematic review and meta-analysis of 15 trials. PLoS One 2022; 17:e0276599. [PMID: 36331947 PMCID: PMC9635708 DOI: 10.1371/journal.pone.0276599] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 10/11/2022] [Indexed: 11/06/2022] Open
Abstract
Background Neoadjuvant chemoradiotherapy (nCRT) before total mesorectal excision (TME) and followed systemic chemotherapy is widely accepted as the standard therapy for locally advanced rectal cancer (LARC). This meta-analysis was to evaluate the current evidence regarding nCRT in combination with induction or consolidation chemotherapy for rectal cancer in terms of oncological outcomes. Methods A systematic search of medical databases (PubMed, EMBASE and Cochrane Library) was conducted up to the end of July 1, 2021. This meta-analysis was performed to evaluate the efficacy of TNT in terms of pathological complete remission (pCR), nCRT or surgical complications, R0 resection, local recurrence, distant metastasis, disease-free survival (DFS) and overall survival (OS) in LARC. Results Eight nRCTs and 7 RCTs, including 3579 patients were included in the meta-analysis. The rate of pCR was significantly higher in the TNT group than in the nCRT group, (OR 1.85, 95% CI 1.39–2.46, p < 0.0001), DFS (HR 0.80, 95% CI 0.69–0.92, p = 0.001), OS (HR 0.75, 95% CI 0.62–0.89, p = 0.002), nCRT complications (OR 1.05, 95% CI 0.77–1.44, p = 0.75), surgical complications (OR 1.02, 95% CI 0.83–1.26, p = 0.83), local recurrence (OR 1.82, 95% CI 0.95–3.49, p = 0.07), distant metastasis (OR 0.77, 95% CI 0.58–1.03, p = 0.08) did not differ significantly between the TNT and nCRT groups. Conclusion TNT appears to have advantages over standard therapy for LARC in terms of pCR, R0 resection, DFS, and OS, with comparable nCRT and postoperative complications, and no increase in local recurrence and distant metastasis.
Collapse
Affiliation(s)
- Xiping Zhang
- Department of General Surgery, Qinan Hospital, Tianshui, China
| | - Shujie Ma
- Department of General Surgery, People’s Hospital of Gannan, Hezuo, China
| | - Yinyin Guo
- Department of Pharmacy, Lanzhou University Second Hospital, Lanzhou, China
| | - Yang Luo
- Department of Neurology, The First Hospital of Lanzhou University, Lanzhou, China
| | - Laiyuan Li
- Department of Anorectal Surgery, Gansu Provincial Hospital, Lanzhou, China
- * E-mail:
| |
Collapse
|
5
|
Ma Z, Tan L, Liu ZL, Xiao JW. Total neoadjuvant therapy or standard chemoradiotherapy for locally advanced rectal cancer: A systematic review and meta-analysis. Front Surg 2022; 9:911538. [PMID: 36090336 PMCID: PMC9458916 DOI: 10.3389/fsurg.2022.911538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 08/10/2022] [Indexed: 11/29/2022] Open
Abstract
Background and Aim The effectiveness of total neoadjuvant therapy (TNT) on patients with locally advanced rectal cancer (LARC) is controversy. This study aims to compare the prognostic value of TNT with standard neoadjuvant chemoradiotherapy (CRT) for LARC. Methods We searched databases (Embase [Ovid], Medline [Ovid], PubMed, Cochrane Library, and Web of Science) for articles published between January 1, 2000, and March 10, 2022. Studies on evaluating the effects of TNT and standard CRT on the prognosis of LARC were included. The primary outcomes were overall survival (OS) and disease-free survival (DFS). Results 19 primary studies, involving 10 randomized controlled trials, 3 prospective studies and 6 retrospective studies, with data on 5,074 patients treated for LARC were included in the meta-analysis. Statistical analyses revealed that, compared with standard CRT, TNT significantly improved OS (hazard ratio [HR]=0.77, 95% confidence interval [CI]=0.65–0.90, I2 = 30%, P = 0.17), DFS (HR = 0.85, 95% CI = 0.74–0.97, I² = 11%, P = 0.35), distant metastases-free survival (DMFS, HR = 0.76, 95% CI = 0.65–0.90, I² = 0%, P = 0.50), pathological complete response rate (pCR, OR = 1.89, 95% CI = 1.61–2.22, I² = 0%, P = 0.47), and R0 resection rate (OR = 1.33, 95% CI = 1.07–1.67, I² = 16%, P = 0.28), but local recurrence-free survival (LRFS, HR = 1.12, 95% CI = 0.90–1.39, I² = 4%, P = 0.37). Conclusions Comprehensive literature research shows that TNT showed excellent short-term efficacy in terms of pCR and R0 resection rate while also improved the long-term outcomes of OS, DFS and DMFS, might become a new standard of treatment in patients with LARC. Even so, more studies and longer follow-up were still warranted.
Collapse
Affiliation(s)
- Zhou Ma
- Department of Gastrointestinal Surgery, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
- Department of Gastrointestinal Surgery, BaZhong Central Hospital, Bazhong, China
| | - Ling Tan
- Department of Urology, People's Hospital Affiliated to Chongqing Three Gorges Medical College, Chongqing, China
| | - Zi-lin Liu
- Department of Gastrointestinal Surgery, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Jiang-wei Xiao
- Department of Gastrointestinal Surgery, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
- Correspondence: Jiang-wei Xiao
| |
Collapse
|
6
|
Kim JK, Marco MR, Roxburgh CSD, Chen CT, Cercek A, Strombom P, Temple LKF, Nash GM, Guillem JG, Paty PB, Yaeger R, Stadler ZK, Gonen M, Segal NH, Reidy DL, Varghese A, Shia J, Vakiani E, Wu AJ, Romesser PB, Crane CH, Gollub MJ, Saltz L, Smith JJ, Weiser MR, Patil S, Garcia-Aguilar J. Survival After Induction Chemotherapy and Chemoradiation Versus Chemoradiation and Adjuvant Chemotherapy for Locally Advanced Rectal Cancer. Oncologist 2022; 27:380-388. [PMID: 35278070 PMCID: PMC9074984 DOI: 10.1093/oncolo/oyac025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 12/07/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Total neoadjuvant therapy (TNT) improves tumor response in locally advanced rectal cancer (LARC) patients compared to neoadjuvant chemoradiotherapy alone. The effect of TNT on patient survival has not been fully investigated. MATERIALS AND METHODS This was a retrospective case series of patients with LARC at a comprehensive cancer center. Three hundred and eleven patients received chemoradiotherapy (chemoRT) as the sole neoadjuvant treatment and planned adjuvant chemotherapy, and 313 received TNT (induction fluorouracil and oxaliplatin-based chemotherapy followed by chemoradiotherapy in the neoadjuvant setting). These patients then underwent total mesorectal excision or were entered in a watch-and-wait protocol. The proportion of patients with complete response (CR) after neoadjuvant therapy (defined as pathological CR or clinical CR sustained for 2 years) was compared by the χ2 test. Disease-free survival (DFS), local recurrence-free survival, distant metastasis-free survival, and overall survival were assessed by Kaplan-Meier analysis and log-rank test. Cox regression models were used to further evaluate DFS. RESULTS The rate of CR was 20% for chemoRT and 27% for TNT (P=.05). DFS, local recurrence-free survival, metastasis-free survival, and overall survival were no different. Disease-free survival was not associated with the type of neoadjuvant treatment (hazard ratio [HR] 1.3; 95% confidence interval [CI] 0.93-1.80; P = .12). CONCLUSIONS Although TNT does not prolong survival than neoadjuvant chemoradiotherapy plus intended postoperative chemotherapy, the higher response rate associated with TNT may create opportunities to preserve the rectum in more patients with LARC.
Collapse
Affiliation(s)
- Jin K Kim
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michael R Marco
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Chin-Tung Chen
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrea Cercek
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Paul Strombom
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Larissa K F Temple
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Garrett M Nash
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jose G Guillem
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Philip B Paty
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Rona Yaeger
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Zsofia K Stadler
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mithat Gonen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Neil H Segal
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Diane L Reidy
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anna Varghese
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jinru Shia
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Efsevia Vakiani
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Abraham J Wu
- Department of Radiation Oncology, 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
| | - Christopher H Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Marc J Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Leonard Saltz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - J Joshua Smith
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Martin R Weiser
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sujata Patil
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Julio Garcia-Aguilar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| |
Collapse
|
7
|
Park IJ. Watch and wait strategies for rectal cancer A systematic review. PRECISION AND FUTURE MEDICINE 2021. [DOI: 10.23838/pfm.2021.00177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
|
8
|
Kong JC, Soucisse M, Michael M, Tie J, Ngan SY, Leong T, McCormick J, Warrier SK, Heriot AG. Total Neoadjuvant Therapy in Locally Advanced Rectal Cancer: A Systematic Review and Metaanalysis of Oncological and Operative Outcomes. Ann Surg Oncol 2021; 28:7476-7486. [PMID: 33891203 DOI: 10.1245/s10434-021-09837-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 02/24/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Total neoadjuvant therapy in rectal cancer refers to the administration of chemoradiotherapy plus chemotherapy before surgery. Recent studies have shown improved pathological complete response and disease-free survival with this approach. However, survival benefits remain unproven. Our objective is to present a metaanalysis of oncological outcomes of total neoadjuvant therapy in locally advanced rectal cancer. PATIENTS AND METHODS A comprehensive search was performed on PubMed, Medline, and Google Scholars. Studies comparing total neoadjuvant therapy with standard neoadjuvant chemoradiotherapy were included. Data extracted from the individual studies were pooled and a metaanalysis performed. The outcomes of interest are the rate of complete pathological response, nodal response, resection margin, anal preservation, anastomotic leak, local recurrence, distant recurrence, disease-free survival, and overall survival. RESULTS There were 15 comparative studies with 2437 patients in the neoadjuvant chemoradiotherapy group and 2284 in the total neoadjuvant therapy group. The pooled complete pathological response was 22.3% in the total neoadjuvant therapy group, compared with 14.2% in the standard neoadjuvant chemoradiotherapy group (p < 0.001). Even though there was no difference in local recurrence rate, there was a significantly lower rate of distant recurrence (OR 0.81, p = 0.02), and better 3-year disease-free survival (70.6% vs. 65.3%, respectively, p < 0.001) and overall survival (84.9% vs. 82.3%, respectively, p = 0.006), favoring the total neoadjuvant therapy group. Due to significant heterogeneity in the study protocols, there remains uncertainty on the ideal chemotherapy/radiotherapy sequence. CONCLUSIONS This study provides supporting evidence on the favorable immediate and intermediate oncological outcomes with the use of total neoadjuvant therapy for locally advanced rectal cancer.
Collapse
Affiliation(s)
- Joseph C Kong
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia. .,Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia. .,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia.
| | - Mikael Soucisse
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Michael Michael
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia.,Division of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Jeanne Tie
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia.,Division of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Samuel Y Ngan
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia.,Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Trevor Leong
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia.,Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Jacob McCormick
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Satish K Warrier
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
| | - Alexander G Heriot
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
| |
Collapse
|
9
|
Induction chemotherapy followed by neoadjuvant chemoradiotherapy and surgery for patients with locally advanced rectal cancer: a systematic review and meta-analysis. Int J Colorectal Dis 2020; 35:1355-1369. [PMID: 32488419 DOI: 10.1007/s00384-020-03621-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/14/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Controversy persists about whether additional induction chemotherapy (ICT) before neoadjuvant chemoradiation (NCRT) yields improved oncological outcomes. We performed a systematic review and meta-analysis to compare ICT+ NCRT+ surgery(S) with NCRT+ S in patients with locally advanced rectal cancer (LARC). METHODS We searched the PubMed, EMBASE, Cochrane Library, and China Biology Medicine (CBM) databases. The data were analyzed with Stata version 12.0 software. RESULTS We identified 9 relevant trials that enrolled 1538 patients. We detected no significant difference in the 5-year overall survival (OS) (OR 1.50, 95% CI 0.48-4.64), disease-free survival (DFS) (OR 1.03, 95% CI 0.73-1.46), local recurrence (LR) (OR 0.80, 95% CI 0.45-1.43), and distant metastasis (DM) rates (OR 1.03, 95% CI 0.55-1.93) between patients who did and did not receive ICT. The addition of ICT before NCRT had a similar pathological complete response rate compared to NCRT (OR 1.26, 95% CI 0.90-1.77). Our findings suggest that between the ICT + NCRT+S and NCRT+S groups, ICT improved the incidence of grade 3 to 4 toxicity effects (OR 4.81, 95% CI 2.38-9.37), but between the ICT + NCRT+S and NCRT+S+ adjuvant chemotherapy (ACT) groups, ICT might reduce toxicity (OR 0.19, 95% CI 0.08-0.50). ICT had no significant impact on surgical complications (OR 0.97, 95% CI 0.63-1.51). CONCLUSIONS The addition of ICT before NCRT seemingly shows no survival benefit on patients with LARC, and might increase the toxicity.
Collapse
|
10
|
Total Neoadjuvant Therapy in Rectal Cancer: A Systematic Review and Meta-analysis of Treatment Outcomes. Ann Surg 2020; 271:440-448. [PMID: 31318794 DOI: 10.1097/sla.0000000000003471] [Citation(s) in RCA: 187] [Impact Index Per Article: 46.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The addition of induction chemotherapy to concomitant neoadjuvant chemoradiation in locally advanced rectal cancer could increase pathological downstaging and act on occult micrometastatic disease, leading ultimately to a better outcome. A systematic review was carried out of the existing literature on the treatment outcomes of total neoadjuvant therapy (TNT) on locally advanced rectal cancer. TNT was defined as chemotherapy using cycles of induction and/or consolidation in conjunction with standard chemoradiotherapy prior to surgery. METHODS A systematic search of PubMed, Embase, and the Cochrane Library was performed according to the PRISMA statement up until January 2019. The primary endpoints were complete pathologic response (pCR), disease-free survival, and overall survival rates. RESULTS A total of 28 studies (3 retrospective and 25 prospective for a total of 3579 patients) were included in the final analysis (n = 2688 treated with TNT and n = 891 with neoadjuvant chemoradiotherapy therapy). The pooled pCR rate was 22.4% (95% CI 19.4%-25.7%) in all patients treated with TNT (n = 27 studies with data available). In n = 10 comparative studies with data available, TNT was found to increase the odds of pCR by 39% (1.40, 95% CI 1.08-1.81, P = 0.01). CONCLUSIONS The addition of induction or consolidation chemotherapy to standard neoadjuvant chemoradiotherapy results in a higher pCR rate. Given that the comparative analysis was derived from few randomized publications, large confirmatory trials should be carried out before a strong recommendation is made in favor of TNT.
Collapse
|
11
|
Kim Y, Kim DY, Kim TH, Kim SY, Baek JY, Kim MJ, Chang HJ, Cha Y, Park SC, Oh JH. Patterns of failure in rectal cancer with positive circumferential resection margin after surgery following preoperative chemoradiation: a propensity score matching analysis. Br J Radiol 2018; 91:20180143. [PMID: 30129789 DOI: 10.1259/bjr.20180143] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE: To compare the patterns of failure between rectal cancer patients with negative and positive circumferential resection margin (CRM) after surgery following preoperative chemoradiation. METHODS: Of 944 stage II-III rectal cancer patients treated with radical surgery following preoperative chemoradiation, 74 patients (7.8%) showed positive CRM. Each 72 patients from negative and positive CRM groups were identified by propensity score matching and compared in terms of survival outcomes and patterns of failure. Local failure was defined as recurrence at the anastomosis site or adjacent to the mesorectal fascia. RESULTS: The median follow-up was 46 months (range, 4-155). No difference was observed in 5-year local recurrence-free survival (93.4% vs 89.6%, p = 0.442) in the negative and positive CRM groups. There was statistically significant difference in relapse-free survival (57.1% vs 39.1%, p = 0.042). Negative CRM group showed favorable outcomes than positive CRM in distant metastasis-free survival (59.4% vs 43.3%, p = 0.069) and overall survival (67.5% vs 55.8%, p = 0.186), but the difference was not statistically significant. As the initial failure pattern, there were 30 and 43 recurrences in the negative and positive CRM groups (local 6.6 and 7.3%, regional 12.8 and 14.4%, and distant 38.5 and 54.9%). Isolated local recurrence was identified in two with negative CRM and in none with positive CRM (p = 0.497). CONCLUSION: Distant metastasis was the major pattern of failure regardless of CRM involvement in rectal cancer patients treated with surgery following preoperative chemoradiation. It would be taken account of our finding on adjuvant treatment for the patient with positive CRM. ADVANCES IN KNOWLEDGE: Investigation of the patterns of failure in patients with CRM involvement after preoperative chemoradiation followed by surgery can be conducive to selecting the appropriate approach to additional treatment for them.
Collapse
Affiliation(s)
- Youngkyong Kim
- 1 Proton Therapy Center, National Cancer Center , Goyang , Republic of Korea
| | - Dae Yong Kim
- 1 Proton Therapy Center, National Cancer Center , Goyang , Republic of Korea.,2 Center for Colorectal Cancer, National Cancer Center , Goyang , Republic of Korea
| | - Tae Hyun Kim
- 1 Proton Therapy Center, National Cancer Center , Goyang , Republic of Korea
| | - Sun Young Kim
- 3 Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
| | - Ji Yeon Baek
- 2 Center for Colorectal Cancer, National Cancer Center , Goyang , Republic of Korea
| | - Min Ju Kim
- 2 Center for Colorectal Cancer, National Cancer Center , Goyang , Republic of Korea
| | - Hee Jin Chang
- 2 Center for Colorectal Cancer, National Cancer Center , Goyang , Republic of Korea
| | - Yongjun Cha
- 2 Center for Colorectal Cancer, National Cancer Center , Goyang , Republic of Korea
| | - Sung Chan Park
- 2 Center for Colorectal Cancer, National Cancer Center , Goyang , Republic of Korea
| | - Jae Hwan Oh
- 2 Center for Colorectal Cancer, National Cancer Center , Goyang , Republic of Korea
| |
Collapse
|
12
|
van Zoggel DMGI, Bosman SJ, Kusters M, Nieuwenhuijzen GAP, Cnossen JS, Creemers GJ, van Lijnschoten G, Rutten HJT. Preliminary results of a cohort study of induction chemotherapy-based treatment for locally recurrent rectal cancer. Br J Surg 2017; 105:447-452. [PMID: 29168556 DOI: 10.1002/bjs.10694] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 08/08/2017] [Accepted: 08/14/2017] [Indexed: 01/27/2023]
Abstract
BACKGROUND A significant number of patients treated for locally recurrent rectal cancer have local or systemic failure, especially after incomplete surgical resection. Neoadjuvant treatment regimens in patients who have already undergone preoperative (chemo)radiotherapy for the primary tumour are limited. The objective of the present study was to evaluate the influence of a neoadjuvant regimen incorporating induction chemotherapy (ICT) in patients with locally recurrent rectal cancer who had preoperative (chemo)radiotherapy for the primary cancer or an earlier local recurrence. METHODS Patients were treated with a sequential neoadjuvant regimen including three or four cycles of 5-fluorouracil and oxaliplatin-containing chemotherapy. When no progressive disease was found at evaluation, neoadjuvant treatment was continued with chemoradiation therapy (CRRT) using 30 Gy with concomitant capecitabine. If there was a response to ICT, the patient was advised to continue with systemic chemotherapy after CRRT as consolidation chemotherapy while waiting for resection. These patients were compared with patients who received CRRT alone in the same time interval. RESULTS Of 58 patients who had ICT, 32 (55 per cent) had surgery with clear resection margins, of whom ten (17 per cent) exhibited a pathological complete response (pCR). The remaining 26 patients had 23 R1 and three R2 resections. In 71 patients who received CRRT, a similar rate of R0 (35 patients) and R1 (36) resection was found (P = 0·506), but only three patients (4 per cent) had a pCR (P = 0·015). CONCLUSION The incorporation of ICT in neoadjuvant regimens for locally recurrent rectal cancer is a promising strategy.
Collapse
Affiliation(s)
| | - S J Bosman
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - M Kusters
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands.,Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - J S Cnossen
- Department of Radiotherapy, Catharina Hospital, Eindhoven, The Netherlands
| | - G J Creemers
- Department of Medical Oncology, Catharina Hospital, Eindhoven, The Netherlands
| | | | - H J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands.,GROW School of Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| |
Collapse
|
13
|
Al-Sukhni E, Attwood K, Gabriel E, Nurkin SJ. Predictors of circumferential resection margin involvement in surgically resected rectal cancer: A retrospective review of 23,464 patients in the US National Cancer Database. Int J Surg 2016; 28:112-7. [PMID: 26906328 DOI: 10.1016/j.ijsu.2016.01.098] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Revised: 01/17/2016] [Accepted: 01/27/2016] [Indexed: 01/06/2023]
Abstract
INTRODUCTION The circumferential resection margin (CRM) is a key prognostic factor after rectal cancer resection. We sought to identify factors associated with CRM involvement (CRM+). METHODS A retrospective review was performed of the National Cancer Database, 2004-2011. Patients with rectal cancer who underwent radical resection and had a recorded CRM were included. Multivariable analysis of the association between clinicopathologic characteristics and CRM was performed. Tumor <1 mm from the cut margin defined CRM+. RESULTS AND DISCUSSION Of 23,464 eligible patients, 13.3% were CRM+. Factors associated with CRM+ were diagnosis later in the study period, lack of insurance, advanced stage, higher grade, undergoing APR, and receiving radiation. Nearly half of CRM+ patients did not receive neoadjuvant therapy. CRM+ patients who did not receive neoadjuvant therapy were more likely to be female, older, with more comorbidities, smaller tumors, earlier clinical stage, advanced pathologic stage, and CEA-negative disease compared to those who received it. CONCLUSIONS Factors associated with CRM+ include features of advanced disease, undergoing APR, and lack of health insurance. Half of CRM+ patients did not receive neoadjuvant treatment. These represent cases where CRM status may be modifiable with appropriate pre-operative selection and multidisciplinary management.
Collapse
Affiliation(s)
- Eisar Al-Sukhni
- Roswell Park Cancer Institute, Department of Surgical Oncology, Elm & Carlton Streets, Buffalo, NY, 14263, USA.
| | - Kristopher Attwood
- Roswell Park Cancer Institute, Department of Biostatistics, Elm & Carlton Streets, Buffalo, NY, 14263, USA
| | - Emmanuel Gabriel
- Roswell Park Cancer Institute, Department of Surgical Oncology, Elm & Carlton Streets, Buffalo, NY, 14263, USA
| | - Steven J Nurkin
- Roswell Park Cancer Institute, Department of Surgical Oncology, Elm & Carlton Streets, Buffalo, NY, 14263, USA
| |
Collapse
|
14
|
Akbar A, Bhatti ABH, Niazi SK, Syed AA, Khattak S, Raza SH, Kazmi AS. Impact of Time Interval Between Chemoradiation and Surgery on Pathological Complete Response and Survival in Rectal Cancer. Asian Pac J Cancer Prev 2016; 17:89-93. [PMID: 26838260 DOI: 10.7314/apjcp.2016.17.1.89] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Ali Akbar
- Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital Research Centre, Lahore, Pakistan E-mail :
| | | | | | | | | | | | | |
Collapse
|