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Custers PA, Beets GL, Bach SP, Blomqvist LK, Figueiredo N, Gollub MJ, Martling A, Melenhorst J, Ortega CD, Perez RO, Smith JJ, Lambregts DMJ, Beets-Tan RGH, Maas M. An International Expert-Based Consensus on the Definition of a Clinical Near-Complete Response After Neoadjuvant (Chemo)radiotherapy for Rectal Cancer. Dis Colon Rectum 2024; 67:782-795. [PMID: 38701503 DOI: 10.1097/dcr.0000000000003209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
BACKGROUND A variety of definitions for a clinical near-complete response after neoadjuvant (chemo) radiotherapy for rectal cancer are currently used. This variety leads to inconsistency in clinical practice, long-term outcome, and trial enrollment. OBJECTIVE The aim of this study was to reach expert-based consensus on the definition of a clinical near-complete response after (chemo) radiotherapy. DESIGN A modified Delphi process, including a systematic review, 3 surveys, and 2 meetings, was performed with an international expert panel consisting of 7 surgeons and 4 radiologists. The surveys consisted of individual features, statements, and feature combinations (endoscopy, T2-weighted MRI, and diffusion-weighted MRI). SETTING The modified Delphi process was performed in an online setting; all 3 surveys were completed online by the expert panel, and both meetings were hosted online. MAIN OUTCOME MEASURES The main outcome was to reach consensus (80% or more agreement). RESULTS The expert panel reached consensus on a 3-tier categorization of the near-complete response category based on the likelihood of the response to evolve into a clinical complete response after a longer waiting interval. The panelists agreed that a near-complete response is a temporary entity only to be used in the first 6 months after (chemo)radiotherapy. Furthermore, consensus was reached that the lymph node status should be considered when deciding on a near-complete response and that biopsies are not always needed when a near-complete response is found. No consensus was reached on whether primary staging characteristics have to be taken into account when deciding on a near-complete response. LIMITATIONS This 3-tier subcategorization is expert-based; therefore, there is no supporting evidence for this subcategorization. Also, it is unclear whether this subcategorization can be generalized into clinical practice. CONCLUSIONS Consensus was reached on the use of a 3-tier categorization of a near-complete response, which can be helpful in daily practice as guidance for treatment and to inform patients with a near-complete response on the likelihood of successful organ preservation. See Video Abstract. UN CONSENSO INTERNACIONAL BASADO EN EXPERTOS ACERCA DE LA DEFINICIN DE UNA RESPUESTA CLNICA CASI COMPLETA DESPUS DE QUIMIORADIOTERAPIA NEOADYUVANTE CONTRA EL CNCER DE RECTO ANTECEDENTES:Actualmente, se utilizan una variedad de definiciones para una respuesta clínica casi completa después de quimioradioterapia neoadyuvante contra el cáncer de recto. Esta variedad resulta en inconsistencia en la práctica clínica, los resultados a largo plazo y la inscripción en ensayos.OBJETIVO:El objetivo de este estudio fue llegar a un consenso de expertos sobre la definición de una respuesta clínica casi completa después de quimioradioterapia.DISEÑO:Se realizó un proceso Delphi modificado que incluyó una revisión sistemática, 3 encuestas y 2 reuniones con un panel internacional de expertos compuesto por siete cirujanos y 4 radiólogos. Las encuestas consistieron en características individuales, declaraciones y combinaciones de características (endoscopía, T2W-MRI y DWI).AJUSTE:El proceso Delphi modificado se realizó en un entorno en línea; el panel de expertos completó las tres encuestas en línea y ambas reuniones se realizaron en línea.PRINCIPALES MEDIDAS DE RESULTADO:El resultado principal fue llegar a un consenso (≥80% de acuerdo).RESULTADOS:El panel de expertos llegó a un consenso sobre una categorización de tres niveles de la categoría de respuesta casi completa basada en la probabilidad de que la respuesta evolucione hacia una respuesta clínica completa después de un intervalo de espera más largo. Los panelistas coincidieron en que una respuesta casi completa es una entidad temporal que sólo debe utilizarse en los primeros 6 meses después de la quimioradioterapia. Además, se llegó a un consenso en que se debe considerar el estado de los nódulos linfáticos al decidir sobre una respuesta casi completa y que no siempre se necesitan biopsias cuando se encuentra una respuesta casi completa. No se llegó a un consenso sobre si se deben tener en cuenta las características primarias de estadificación al decidir una respuesta casi completa.LIMITACIONES:Esta subcategorización de 3 niveles está basada en expertos; por lo tanto, no hay evidencia que respalde esta subcategorización. Además, no está claro si esta subcategorización puede generalizarse a la práctica clínica.CONCLUSIONES:Se alcanzó consenso sobre el uso de una categorización de 3 niveles de una respuesta casi completa que puede ser útil en la práctica diaria como guía para el tratamiento y para informar a los pacientes con una respuesta casi completa sobre la probabilidad de una preservación exitosa del órgano. (Traducción - Dr. Aurian Garcia Gonzalez).
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Affiliation(s)
- Petra A Custers
- Department of Surgery, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, the Netherlands
- GROW School for Oncology and Developmental Reproduction, Maastricht University, Maastricht, the Netherlands
| | - Geerard L Beets
- Department of Surgery, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, the Netherlands
- GROW School for Oncology and Developmental Reproduction, Maastricht University, Maastricht, the Netherlands
| | - Simon P Bach
- Department of Surgery, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Lennart K Blomqvist
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Nuno Figueiredo
- Department of Surgery, Hospital Lusiadas Lisboa, Lisbon, Portugal
| | - Marc J Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York
| | - Anna Martling
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Pelvic Cancer, Division of Coloproctology, Karolinska University Hospital, Stockholm, Sweden
| | - Jarno Melenhorst
- GROW School for Oncology and Developmental Reproduction, Maastricht University, Maastricht, the Netherlands
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Cinthia D Ortega
- Department of Radiology, University of São Paulo School of Medicine, São Paulo, Brazil
- Department of Radiology and Diagnostic Imaging, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Rodrigo O Perez
- Division of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - J Joshua Smith
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York
| | - Doenja M J Lambregts
- GROW School for Oncology and Developmental Reproduction, Maastricht University, Maastricht, the Netherlands
- Department of Radiology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Regina G H Beets-Tan
- GROW School for Oncology and Developmental Reproduction, Maastricht University, Maastricht, the Netherlands
- Department of Radiology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Monique Maas
- GROW School for Oncology and Developmental Reproduction, Maastricht University, Maastricht, the Netherlands
- Department of Radiology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, the Netherlands
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Vailati BB, Cerdán-Santacruz C, São Julião GP, Corbi LE, Perez RO. RAPIDO: Condolences. Dis Colon Rectum 2024; 67:e206. [PMID: 38064238 DOI: 10.1097/dcr.0000000000003179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Affiliation(s)
- Bruna B Vailati
- Angelita and Joaquim Gama Institute, São Paulo, Brazil
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil
- Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | | | - Guilherme P São Julião
- Angelita and Joaquim Gama Institute, São Paulo, Brazil
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil
- Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Leonardo Ervolino Corbi
- Angelita and Joaquim Gama Institute, São Paulo, Brazil
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil
- Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Rodrigo O Perez
- Angelita and Joaquim Gama Institute, São Paulo, Brazil
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil
- Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
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Vailati BB, Cerdán-Santacruz C, Julião GPS, Corbi L, Perez RO. RAPIDO: Rest in Peace. Dis Colon Rectum 2024; 67:e125. [PMID: 37889955 DOI: 10.1097/dcr.0000000000003141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/29/2023]
Affiliation(s)
- Bruna B Vailati
- Angelita and Joaquim Gama Institute, São Paulo, Brazil
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil
- Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | | | - Guilherme P São Julião
- Angelita and Joaquim Gama Institute, São Paulo, Brazil
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil
- Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Leonardo Corbi
- Angelita and Joaquim Gama Institute, São Paulo, Brazil
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil
- Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Rodrigo O Perez
- Angelita and Joaquim Gama Institute, São Paulo, Brazil
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil
- Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
- Hospital de la Princesa, Madrid, Spain
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Vailati BB, Cerdán-Santacruz C, São Julião GP, Corbi L, Perez RO. Local Recurrence in Rectal Cancer: Small Absolute Numbers in a BIG Problem. Dis Colon Rectum 2024; 67:e127. [PMID: 37889960 DOI: 10.1097/dcr.0000000000003139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/29/2023]
Affiliation(s)
- Bruna B Vailati
- Angelita and Joaquim Gama Institute, São Paulo, Brazil
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil
- Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | | | - Guilherme P São Julião
- Angelita and Joaquim Gama Institute, São Paulo, Brazil
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil
- Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Leonardo Corbi
- Angelita and Joaquim Gama Institute, São Paulo, Brazil
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil
- Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Rodrigo O Perez
- Angelita and Joaquim Gama Institute, São Paulo, Brazil
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil
- Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
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El Sissy C, Kirilovsky A, Lagorce Pagès C, Marliot F, Custers PA, Dizdarevic E, Sroussi M, Castillo-Martin M, Haicheur N, Dermani M, Loche N, Buttard B, Musina AM, Anitei MG, van den Berg JG, Broeks A, Iseas S, Coraglio M, Loria FS, Romero A, Laurent-Puig P, de Reyniès A, Fernandez LM, Karoui M, Tougeron D, Vaccaro CA, Santino JP, Poulsen LØ, Lindebjerg J, O'Connor JM, Scripcariu V, Dimofte MG, Gérard JP, Chalabi M, Figueiredo N, Perez RO, Habr-Gama A, Galon J, Hansen TF, Jensen LH, Beets G, Zeitoun G, Pagès F. International Validation of the Immunoscore Biopsy in Patients With Rectal Cancer Managed by a Watch-and-Wait Strategy. J Clin Oncol 2024; 42:70-80. [PMID: 37788410 PMCID: PMC10730081 DOI: 10.1200/jco.23.00586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 07/06/2023] [Accepted: 07/24/2023] [Indexed: 10/05/2023] Open
Abstract
PURPOSE No biomarker capable of improving selection and monitoring of patients with rectal cancer managed by watch-and-wait (W&W) strategy is currently available. Prognostic performance of the Immunoscore biopsy (ISB) was recently suggested in a preliminary study. METHODS This international validation study included 249 patients with clinical complete response (cCR) managed by W&W strategy. Intratumoral CD3+ and CD8+ T cells were quantified on pretreatment rectal biopsies by digital pathology and converted to ISB. The primary end point was time to recurrence (TTR; the time from the end of neoadjuvant treatment to the date of local regrowth or distant metastasis). Associations between ISB and outcomes were analyzed by stratified Cox regression adjusted for confounders. Immune status of tumor-draining lymph nodes (n = 161) of 17 additional patients treated by neoadjuvant chemoradiotherapy and surgery was investigated by 3'RNA-Seq and immunofluorescence. RESULTS Recurrence-free rates at 5 years were 91.3% (82.4%-100.0%), 62.5% (53.2%-73.3%), and 53.1% (42.4%-66.5%) with ISB High, ISB Intermediate, and ISB Low, respectively (hazard ratio [HR; Low v High], 6.51; 95% CI, 1.99 to 21.28; log-rank P = .0004). ISB was also significantly associated with disease-free survival (log-rank P = .0002), and predicted both local regrowth and distant metastasis. In multivariate analysis, ISB was independent of patient age, sex, tumor location, cT stage (T, primary tumor; c, clinical), cN stage (N, regional lymph node; c, clinical), and was the strongest predictor for TTR (HR [ISB High v Low], 6.93; 95% CI, 2.08 to 23.15; P = .0017). The addition of ISB to a clinical-based model significantly improved the prediction of recurrence. Finally, B-cell proliferation and memory in draining lymph nodes was evidenced in the draining lymph nodes of patients with cCR. CONCLUSION The ISB is validated as a biomarker to predict both local regrowth and distant metastasis, with a gradual scaling of the risk of pejorative outcome.
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Affiliation(s)
- Carine El Sissy
- INSERM, Laboratory of Integrative Cancer Immunology, Paris, France
- Equipe Labellisée Ligue Contre le Cancer, Paris, France
- Cordeliers Research Center, Sorbonne University, University Paris Cité, Paris, France
- Immunomonitoring Platform, Laboratory of Immunology, Assistance Publique-Hôpitaux de Paris (AP-HP), Georges Pompidou European Hospital, Paris, France
| | - Amos Kirilovsky
- INSERM, Laboratory of Integrative Cancer Immunology, Paris, France
- Equipe Labellisée Ligue Contre le Cancer, Paris, France
- Cordeliers Research Center, Sorbonne University, University Paris Cité, Paris, France
- Immunomonitoring Platform, Laboratory of Immunology, Assistance Publique-Hôpitaux de Paris (AP-HP), Georges Pompidou European Hospital, Paris, France
| | - Christine Lagorce Pagès
- INSERM, Laboratory of Integrative Cancer Immunology, Paris, France
- Equipe Labellisée Ligue Contre le Cancer, Paris, France
- Cordeliers Research Center, Sorbonne University, University Paris Cité, Paris, France
- Immunomonitoring Platform, Laboratory of Immunology, Assistance Publique-Hôpitaux de Paris (AP-HP), Georges Pompidou European Hospital, Paris, France
- Department of Pathology, AP-HP, Georges Pompidou European Hospital, Paris, France
| | - Florence Marliot
- INSERM, Laboratory of Integrative Cancer Immunology, Paris, France
- Equipe Labellisée Ligue Contre le Cancer, Paris, France
- Cordeliers Research Center, Sorbonne University, University Paris Cité, Paris, France
- Immunomonitoring Platform, Laboratory of Immunology, Assistance Publique-Hôpitaux de Paris (AP-HP), Georges Pompidou European Hospital, Paris, France
| | - Petra A. Custers
- Department of Surgery, Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, the Netherlands
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
| | - Edina Dizdarevic
- Department of Oncology, Danish Colorectal Cancer Center South, University Hospital of Southern Denmark, Vejle, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Marine Sroussi
- Cordeliers Research Center, Sorbonne University, INSERM, University Paris Cité, SIRIC CARPEM, Paris, France
- Chemistry Biology Innovation Institute, BioChimie Laboratory, ESPCI, UMR8231 CNRS, University PSL, Paris, France
| | | | - Nacilla Haicheur
- INSERM, Laboratory of Integrative Cancer Immunology, Paris, France
- Equipe Labellisée Ligue Contre le Cancer, Paris, France
- Cordeliers Research Center, Sorbonne University, University Paris Cité, Paris, France
- Immunomonitoring Platform, Laboratory of Immunology, Assistance Publique-Hôpitaux de Paris (AP-HP), Georges Pompidou European Hospital, Paris, France
| | - Mohamed Dermani
- INSERM, Laboratory of Integrative Cancer Immunology, Paris, France
- Equipe Labellisée Ligue Contre le Cancer, Paris, France
- Cordeliers Research Center, Sorbonne University, University Paris Cité, Paris, France
- Immunomonitoring Platform, Laboratory of Immunology, Assistance Publique-Hôpitaux de Paris (AP-HP), Georges Pompidou European Hospital, Paris, France
| | - Nicolas Loche
- INSERM, Laboratory of Integrative Cancer Immunology, Paris, France
- Equipe Labellisée Ligue Contre le Cancer, Paris, France
- Cordeliers Research Center, Sorbonne University, University Paris Cité, Paris, France
- Immunomonitoring Platform, Laboratory of Immunology, Assistance Publique-Hôpitaux de Paris (AP-HP), Georges Pompidou European Hospital, Paris, France
| | - Bénedicte Buttard
- INSERM, Laboratory of Integrative Cancer Immunology, Paris, France
- Equipe Labellisée Ligue Contre le Cancer, Paris, France
- Cordeliers Research Center, Sorbonne University, University Paris Cité, Paris, France
| | - Ana Maria Musina
- Department of Surgical Oncology, Regional Institute of Oncology (IRO), Iasi, Romania
- “Grigore T. Popa” University of Medicine and Pharmacy, Iasi, Romania
| | - Maria Gabriela Anitei
- “Grigore T. Popa” University of Medicine and Pharmacy, Iasi, Romania
- Surgical Oncology Unit, Regional Institute of Oncology, Iasi, Romania
| | - José G. van den Berg
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Annegien Broeks
- Core Facility Molecular Pathology and Biobanking, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Soledad Iseas
- Oncology Unit, Gastroenterology Hospital Carlos Bonorino Udaondo, Buenos Aires, Argentina
| | - Mariana Coraglio
- Oncology Unit, Gastroenterology Hospital Carlos Bonorino Udaondo, Buenos Aires, Argentina
| | - Fernando Sanchez Loria
- GI Clinical Oncology and GI Surgical Oncology, Instituto Alexander Fleming, Buenos Aires, Argentina
| | - Alfredo Romero
- Department of Clinical Oncology, British Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Pierre Laurent-Puig
- Cordeliers Research Center, Sorbonne University, University Paris Cité, INSERM UMR1138, Paris, France
- Department of Biology, Cancer Institute Paris CARPEM, AP-HP, Georges Pompidou European Hospital, Paris, France
| | - Aurélien de Reyniès
- Cordeliers Research Center, University Paris Cité, INSERM UMRS1138, Paris, France
- AP-HP, SeqOIA Genomic Medicine Laboratory—IT Platform, Paris, France
| | - Laura M. Fernandez
- Colorectal Surgery, Digestive Department, Champalimaud Foundation, Lisbon, Portugal
| | - Mehdi Karoui
- Department of Digestive and Oncologic Surgery, AP-HP, Georges Pompidou European Hospital, Paris, France
| | - David Tougeron
- Department of Hepato-Gastro-Enterology and Nutritional Assistance, University Hospital of Poitiers, Poitiers, France
| | - Carlos A. Vaccaro
- Department of General Surgery, Hospital Italiano, Buenos Aires, Argentina
| | - Juan P. Santino
- Department of General Surgery, Hospital Italiano, Buenos Aires, Argentina
| | - Laurids Østergaard Poulsen
- Department of Oncology, Danish Colorectal Cancer Center South, University Hospital of Southern Denmark, Vejle, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Jan Lindebjerg
- Department of Oncology, Danish Colorectal Cancer Center South, University Hospital of Southern Denmark, Vejle, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Juan Manuel O'Connor
- GI Clinical Oncology and GI Surgical Oncology, Instituto Alexander Fleming, Buenos Aires, Argentina
| | - Viorel Scripcariu
- “Grigore T. Popa” University of Medicine and Pharmacy, Iasi, Romania
- Surgical Oncology Unit, Regional Institute of Oncology, Iasi, Romania
| | - Mihail-Gabriel Dimofte
- Department of Surgical Oncology, Regional Institute of Oncology (IRO), Iasi, Romania
- “Grigore T. Popa” University of Medicine and Pharmacy, Iasi, Romania
| | | | - Myriam Chalabi
- Department of Gastrointestinal Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Nuno Figueiredo
- Colorectal Surgery, Digestive Department, Champalimaud Foundation, Lisbon, Portugal
| | - Rodrigo O. Perez
- Division of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
- Department of Surgical Oncology, Beneficencia Portuguesa Hospital, São Paulo, Brazil
- Angelita and Joaquim Gama Institute, São Paulo, Brazil
| | - Angelita Habr-Gama
- Division of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
- Department of Surgical Oncology, Beneficencia Portuguesa Hospital, São Paulo, Brazil
- Angelita and Joaquim Gama Institute, São Paulo, Brazil
| | - Jérôme Galon
- INSERM, Laboratory of Integrative Cancer Immunology, Paris, France
- Equipe Labellisée Ligue Contre le Cancer, Paris, France
- Cordeliers Research Center, Sorbonne University, University Paris Cité, Paris, France
| | - Torben Frøstrup Hansen
- Department of Oncology, Danish Colorectal Cancer Center South, University Hospital of Southern Denmark, Vejle, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Lars Henrik Jensen
- Department of Oncology, Danish Colorectal Cancer Center South, University Hospital of Southern Denmark, Vejle, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Geerard Beets
- Department of Surgery, Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, the Netherlands
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
| | - Guy Zeitoun
- INSERM, Laboratory of Integrative Cancer Immunology, Paris, France
- Equipe Labellisée Ligue Contre le Cancer, Paris, France
- Cordeliers Research Center, Sorbonne University, University Paris Cité, Paris, France
- Immunomonitoring Platform, Laboratory of Immunology, Assistance Publique-Hôpitaux de Paris (AP-HP), Georges Pompidou European Hospital, Paris, France
| | - Franck Pagès
- INSERM, Laboratory of Integrative Cancer Immunology, Paris, France
- Equipe Labellisée Ligue Contre le Cancer, Paris, France
- Cordeliers Research Center, Sorbonne University, University Paris Cité, Paris, France
- Immunomonitoring Platform, Laboratory of Immunology, Assistance Publique-Hôpitaux de Paris (AP-HP), Georges Pompidou European Hospital, Paris, France
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Greijdanus NG, Wienholts K, Ubels S, Talboom K, Hannink G, Wolthuis A, de Lacy FB, Lefevre JH, Solomon M, Frasson M, Rotholtz N, Denost Q, Perez RO, Konishi T, Panis Y, Rutegård M, Hompes R, Rosman C, van Workum F, Tanis PJ, de Wilt JHW. Stoma-free survival after anastomotic leak following rectal cancer resection: worldwide cohort of 2470 patients. Br J Surg 2023; 110:1863-1876. [PMID: 37819790 PMCID: PMC10638542 DOI: 10.1093/bjs/znad311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/01/2023] [Accepted: 09/09/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND The optimal treatment of anastomotic leak after rectal cancer resection is unclear. This worldwide cohort study aimed to provide an overview of four treatment strategies applied. METHODS Patients from 216 centres and 45 countries with anastomotic leak after rectal cancer resection between 2014 and 2018 were included. Treatment was categorized as salvage surgery, faecal diversion with passive or active (vacuum) drainage, and no primary/secondary faecal diversion. The primary outcome was 1-year stoma-free survival. In addition, passive and active drainage were compared using propensity score matching (2 : 1). RESULTS Of 2470 evaluable patients, 388 (16.0 per cent) underwent salvage surgery, 1524 (62.0 per cent) passive drainage, 278 (11.0 per cent) active drainage, and 280 (11.0 per cent) had no faecal diversion. One-year stoma-free survival rates were 13.7, 48.3, 48.2, and 65.4 per cent respectively. Propensity score matching resulted in 556 patients with passive and 278 with active drainage. There was no statistically significant difference between these groups in 1-year stoma-free survival (OR 0.95, 95 per cent c.i. 0.66 to 1.33), with a risk difference of -1.1 (95 per cent c.i. -9.0 to 7.0) per cent. After active drainage, more patients required secondary salvage surgery (OR 2.32, 1.49 to 3.59), prolonged hospital admission (an additional 6 (95 per cent c.i. 2 to 10) days), and ICU admission (OR 1.41, 1.02 to 1.94). Mean duration of leak healing did not differ significantly (an additional 12 (-28 to 52) days). CONCLUSION Primary salvage surgery or omission of faecal diversion likely correspond to the most severe and least severe leaks respectively. In patients with diverted leaks, stoma-free survival did not differ statistically between passive and active drainage, although the increased risk of secondary salvage surgery and ICU admission suggests residual confounding.
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Affiliation(s)
- Nynke G Greijdanus
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Kiedo Wienholts
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Treatment and Quality of Life, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
| | - Sander Ubels
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Kevin Talboom
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Treatment and Quality of Life, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
| | - Gerjon Hannink
- Department of Medical Imaging, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | | | - F Borja de Lacy
- Gastrointestinal Surgery Department, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Jérémie H Lefevre
- Department of Digestive Surgery, Sorbonne Université, AP-HP, Hôpital Saint Antoine, Paris, France
| | - Michael Solomon
- Department of Surgery, University of Sydney Central Clinical School, Camperdown, New South Wales, Australia
| | - Matteo Frasson
- Department of Surgery, Valencia University Hospital La Fe, Valencia, Spain
| | | | - Quentin Denost
- Bordeaux Colorectal Institute, Clinique Tivoli, Bordeaux, France
| | - Rodrigo O Perez
- Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Tsuyoshi Konishi
- Department of Colon and Rectal Surgery, University of Texas MD Anderson Cancer Center, Anderson, Texas, USA
| | - Yves Panis
- Colorectal Surgery Centre, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly Seine, France
| | - Martin Rutegård
- Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
- Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden
| | - Roel Hompes
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Treatment and Quality of Life, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Frans van Workum
- Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Treatment and Quality of Life, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
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Greijdanus NG, Wienholts K, Ubels S, Talboom K, Hannink G, Wolthuis A, de Lacy FB, Lefevre JH, Solomon M, Frasson M, Rotholtz N, Denost Q, Perez RO, Konishi T, Panis Y, Rutegård M, Hompes R, Rosman C, van Workum F, Tanis PJ, de Wilt JH. Stoma-free Survival After Rectal Cancer Resection With Anastomotic Leakage: Development and Validation of a Prediction Model in a Large International Cohort. Ann Surg 2023; 278:772-780. [PMID: 37498208 PMCID: PMC10549897 DOI: 10.1097/sla.0000000000006043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
OBJECTIVE To develop and validate a prediction model (STOMA score) for 1-year stoma-free survival in patients with rectal cancer (RC) with anastomotic leakage (AL). BACKGROUND AL after RC resection often results in a permanent stoma. METHODS This international retrospective cohort study (TENTACLE-Rectum) encompassed 216 participating centres and included patients who developed AL after RC surgery between 2014 and 2018. Clinically relevant predictors for 1-year stoma-free survival were included in uni and multivariable logistic regression models. The STOMA score was developed and internally validated in a cohort of patients operated between 2014 and 2017, with subsequent temporal validation in a 2018 cohort. The discriminative power and calibration of the models' performance were evaluated. RESULTS This study included 2499 patients with AL, 1954 in the development cohort and 545 in the validation cohort. Baseline characteristics were comparable. One-year stoma-free survival was 45.0% in the development cohort and 43.7% in the validation cohort. The following predictors were included in the STOMA score: sex, age, American Society of Anestesiologist classification, body mass index, clinical M-disease, neoadjuvant therapy, abdominal and transanal approach, primary defunctioning stoma, multivisceral resection, clinical setting in which AL was diagnosed, postoperative day of AL diagnosis, abdominal contamination, anastomotic defect circumference, bowel wall ischemia, anastomotic fistula, retraction, and reactivation leakage. The STOMA score showed good discrimination and calibration (c-index: 0.71, 95% CI: 0.66-0.76). CONCLUSIONS The STOMA score consists of 18 clinically relevant factors and estimates the individual risk for 1-year stoma-free survival in patients with AL after RC surgery, which may improve patient counseling and give guidance when analyzing the efficacy of different treatment strategies in future studies.
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Affiliation(s)
- Nynke G. Greijdanus
- Department of Surgery, Radboud university medical centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Kiedo Wienholts
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
- Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Sander Ubels
- Department of Surgery, Radboud university medical centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Kevin Talboom
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
- Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Gerjon Hannink
- Department of Medical Imaging, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | | | - Francisco B. de Lacy
- Department of Gastrointestinal Surgery, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Jérémie H. Lefevre
- Department of Digestive Surgery, Sorbonne Université, AP-HP, Hôpital Saint Antoine, Paris, France
| | - Michael Solomon
- Department of Surgery, University of Sydney Central Clinical School, Camperdown, New South Wales, Australia
| | - Matteo Frasson
- Department of Surgery, Valencia University Hospital La Fe, Valencia, Spain
| | | | - Quentin Denost
- Bordeaux Colorectal Institute, Clinique Tivoli, Bordeaux, France
| | - Rodrigo O. Perez
- Department of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Tsuyoshi Konishi
- Department of Colon and Rectal Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Yves Panis
- Department of Colorectal Surgery, Colorectal Surgery Center, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly Seine, France
| | - Martin Rutegård
- Department of Surgery, Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
- Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden
| | - Roel Hompes
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
- Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud university medical centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Frans van Workum
- Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Pieter J. Tanis
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
- Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Johannes H.W. de Wilt
- Department of Surgery, Radboud university medical centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
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Fernandez LM, São Julião GP, Renehan AG, Beets GL, Papoila AL, Vailati BB, Kranenbarg EMK, Roodvoets AGH, Figueiredo NL, Van De Velde CJH, Habr-Gama A, Perez RO. Rectal Cancer and Organ-Preservation: Safety First, Then the King. Dis Colon Rectum 2023; 66:e1054-e1055. [PMID: 37493212 DOI: 10.1097/dcr.0000000000003020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Affiliation(s)
- Laura M Fernandez
- Colorectal Surgery, Digestive Department, Champalimaud Foundation, Lisbon, Portugal
| | - Guilherme P São Julião
- Angelita and Joaquim Gama Institute, São Paulo, Brazil, Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Andrew G Renehan
- Manchester Cancer Research Centre, National Institute of Health and Research Manchester Biomedical Research Centre, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, United Kingdom, Colorectal and Peritoneal Oncology Centre, The Christie National Health Service Foundation Trust, Manchester, United Kingdom
| | - Geerard L Beets
- Department of Surgery, Netherlands Cancer institute, Amsterdam, The Netherlands, GROW School for Oncology and Developmental Biology, Maastricht University, The Netherlands
| | - Ana L Papoila
- NOVA Medical School, Faculdade de Ciências Médicas (NMS|FCM), Lisbon, Portugal
| | - Bruna B Vailati
- Angelita and Joaquim Gama Institute, São Paulo, Brazil, Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | | | - Annet G H Roodvoets
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Nuno L Figueiredo
- Colorectal Surgery, Digestive Department, Champalimaud Foundation, Lisbon, Portugal, Colorectal Surgery, Hospital Lusiadas, Lisbon, Portugal
| | - Cornelis J H Van De Velde
- Department of Surgery, Netherlands Cancer institute, Amsterdam, The Netherlands, Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Angelita Habr-Gama
- Angelita and Joaquim Gama Institute, São Paulo, Brazil, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Rodrigo O Perez
- Colorectal Surgery Division, Angelita and Joaquim Gama Institute, São Paulo, Brazil, Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil, Colorectal Surgery Division, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil, Ludwig Institute for Cancer Research, São Paulo Branch, Brazil
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Temmink SJD, Peeters KCMJ, Renehan AG, Pares O, Perez RO, Nilsson PJ. Author response to: Comment on: Outcomes following watch and wait of a clinical complete response in rectal cancer after neoadjuvant treatment: comparison of patients with and without complete response at first reassessment in the International Watch & Wait Database (IWWD). Br J Surg 2023; 110:1242. [PMID: 37348060 PMCID: PMC10416698 DOI: 10.1093/bjs/znad186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 05/28/2023] [Indexed: 06/24/2023]
Affiliation(s)
- Sofieke J D Temmink
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Koen C M J Peeters
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Andrew G Renehan
- Manchester Cancer Research Centre, National Institute of Health Research Manchester Biomedical Research Centre, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, UK
- Colorectal and Peritoneal Oncology Centre, The Christie National Health Service Foundation Trust, Manchester, UK
| | - Oriol Pares
- Department of Radiation Oncology, Champalimaud Foundation, Lisboa, Portugal
| | - Rodrigo O Perez
- Department of Colorectal Surgery, Angelita and Joaquim Gama Institute, São Paulo, Brazil
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil; Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
- Ludwig Institute for Cancer Research, São Paulo Branch, São Paulo, Brazil
| | - Per J Nilsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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10
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Perez RO, Cerdán-Santacruz C, São Julião GP. Near-complete response following neoadjuvant therapy in rectal cancer: resect now? Br J Surg 2023:7190717. [PMID: 37279948 DOI: 10.1093/bjs/znad166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 05/12/2023] [Indexed: 06/08/2023]
Affiliation(s)
- Rodrigo O Perez
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil
- Division of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | | | - Guilherme P São Julião
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil
- Division of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
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Temmink SJD, Peeters KCMJ, Bahadoer RR, Kranenbarg EMK, Roodvoets AGH, Melenhorst J, Burger JWA, Wolthuis A, Renehan AG, Figueiredo NL, Pares O, Martling A, Perez RO, Beets GL, van de Velde CJH, Nilsson PJ. Watch and wait after neoadjuvant treatment in rectal cancer: comparison of outcomes in patients with and without a complete response at first reassessment in the International Watch & Wait Database (IWWD). Br J Surg 2023; 110:676-684. [PMID: 36972213 PMCID: PMC10364523 DOI: 10.1093/bjs/znad051] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 01/13/2023] [Accepted: 02/05/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND In rectal cancer, watch and wait for patients with a cCR after neoadjuvant treatment has an established evidence base. However, there is a lack of consensus on the definition and management of a near-cCR. This study aimed to compare outcomes in patients who achieved a cCR at first reassessment versus later reassessment. METHODS This registry study included patients from the International Watch & Wait Database. Patients were categorized as having a cCR at first reassessment or at later reassessment (that is near-cCR at first reassessment) based on MRI and endoscopy. Organ preservation, distant metastasis-free survival, and overall survival rates were calculated. Subgroup analyses were done for near-cCR groups based on the response evaluation according to modality. RESULTS A total of 1010 patients were identified. At first reassessment, 608 patients had a cCR; 402 had a cCR at later reassessment. Median follow-up was 2.6 years for patients with a cCR at first reassessment and 2.9 years for those with a cCR at later reassessment. The 2-year organ preservation rate was 77.8 (95 per cent c.i. 74.2 to 81.5) and 79.3 (75.1 to 83.7) per cent respectively (P = 0.499). Similarly, no differences were found between groups in distant metastasis-free survival or overall survival rate. Subgroup analyses showed a higher organ preservation rate in the group with a near-cCR categorized exclusively by MRI. CONCLUSION Oncological outcomes for patients with a cCR at later reassessment are no worse than those of patients with a cCR at first reassessment.
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Affiliation(s)
- Sofieke J D Temmink
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Koen C M J Peeters
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Renu R Bahadoer
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | | | - Annet G H Roodvoets
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Jarno Melenhorst
- Department of Surgery, Maastricht Universitair Medisch Centrum+, Maastricht, the Netherlands
| | | | - Albert Wolthuis
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Andrew G Renehan
- Manchester Cancer Research Centre, National Institute for Health Research Manchester Biomedical Research Centre, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, UK
- Colorectal and Peritoneal Oncology Centre, Christie National Health Service Foundation Trust, Manchester, UK
| | | | - Oriol Pares
- Department of Radiation Oncology, Champalimaud Foundation, Lisbon, Portugal
| | - Anna Martling
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Rodrigo O Perez
- Department of Colorectal Surgery, Angelita and Joaquim Gama Institute, São Paulo, Brazil
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil
- Colorectal Surgery Division, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
- Ludwig Institute for Cancer Research, São Paulo Branch, São Paulo, Brazil
| | - Geerard L Beets
- Department of Surgery, Netherlands Cancer Institute—Antoni van Leeuwenhoek, Amsterdam, the Netherlands
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands
| | | | - Per J Nilsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Cerdán-Santacruz C, Vailati BB, São Julião GP, Habr-Gama A, Perez RO. Local tumor regrowth after clinical complete response following neoadjuvant therapy for rectal cancer: what happens when organ preservation falls short. Tech Coloproctol 2023; 27:1-9. [PMID: 35986804 DOI: 10.1007/s10151-022-02654-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 06/09/2022] [Indexed: 01/12/2023]
Abstract
Organ preservation strategies, especially watch and wait, after neoadjuvant treatment in locally advanced rectal cancer, have become topics that generate significant interest, for both patients and clinicians. The obvious advantage of these strategies is the avoidance of surgery with its associated risks and functional consequences. Over time, it has become evident that these strategies offer acceptable safety in oncological terms and, in most patients, allows preservation of the rectum without harming patients in terms of distant metastasis or survival. However, there is a small group of patients in whom the tumor returns after an initially diagnosed clinical complete response; patients with local tumor regrowth. The main threat in these patients is not simply local disease, which can be successfully managed in most cases, but the possible effects it may have on distant metastases. The pathophysiology of the phenomenon of local tumor regrowth is not well known and, therefore, strategies to minimize possible impact on survival are not well defined. Our aim is to review key issues in this subgroup that pose a substantial threat to the safety and viability of organ-preserving and watch-and-wait strategies. We also explore possible pathophysiologic explanations and future directions and perspectives that may improve both local and systemic disease control.
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Affiliation(s)
- C Cerdán-Santacruz
- Colorectal Surgery, Hospital Universitario de la Princesa, Madrid, Spain
| | - B B Vailati
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil
- Division of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
- Angelita and Joaquim Gama Institute, Praça Amadeu Amaral 47, con. 111, São Paulo, 01327-904, Brazil
| | - G P São Julião
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil
- Division of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
- Angelita and Joaquim Gama Institute, Praça Amadeu Amaral 47, con. 111, São Paulo, 01327-904, Brazil
| | - A Habr-Gama
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil
- Division of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
- Angelita and Joaquim Gama Institute, Praça Amadeu Amaral 47, con. 111, São Paulo, 01327-904, Brazil
| | - R O Perez
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil.
- Division of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil.
- Angelita and Joaquim Gama Institute, Praça Amadeu Amaral 47, con. 111, São Paulo, 01327-904, Brazil.
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Fernandez LM, São Julião GP, Renehan AG, Beets GL, Papoila AL, Vailati BB, Bahadoer RR, Kranenbarg EMK, Roodvoets AGH, Figueiredo NL, Van De Velde CJH, Habr-Gama A, Perez RO. The Risk of Distant Metastases in Patients With Clinical Complete Response Managed by Watch and Wait After Neoadjuvant Therapy for Rectal Cancer: The Influence of Local Regrowth in the International Watch and Wait Database. Dis Colon Rectum 2023; 66:41-49. [PMID: 36515514 DOI: 10.1097/dcr.0000000000002494] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Nearly 30% of patients with rectal cancer develop local regrowth after initial clinical complete response managed by watch and wait. These patients might be at higher risk for distant metastases. OBJECTIVE This study aimed to investigate risk factors for distant metastases using time-dependent analyses. DESIGN Data from an international watch and wait database were retrospectively reviewed. Cox regression analysis was used to determine risk factors for worse distant metastases-free survival. Conditional survival modeling was used to investigate the impact of risk factors on the development of distant metastases. SETTING Retrospective, multicenter database. PATIENTS A total of 793 patients (47 institutions) with rectal cancer and clinical complete response to neoadjuvant treatment from the International Watch & Wait Database were included. MAIN OUTCOME MEASURES Distant metastases-free survival. RESULTS Of the 793 patients managed with watch and wait (median follow-up 55.2 mo)' 85 patients (10.7%) had distant metastases. Fifty-one of 85 patients (60%) had local regrowth at any time. Local regrowth was an independent factor associated with worse distant metastases-free survival in the multivariable model. Using conditional estimates, patients with local regrowth without distant metastases for 5 years (from decision to watch and wait) remained at higher risk for development of distant metastases for 1 subsequent year compared to patients without local regrowth (5-year conditional distant metastases-free survival 94.9% vs 98.4%). LIMITATIONS Lack of information on adjuvant chemotherapy, salvage surgery for local regrowth, and heterogeneity of individual surveillance/follow-up strategies used may have affected results. CONCLUSIONS In patients with clinical complete response managed by watch and wait, development of local regrowth at any time is a risk factor for distant metastases. The risk of distant metastases remains higher for 5 years after development of local regrowth. See Video Abstract at http://links.lww.com/DCR/C53. EL RIESGO DE METSTASIS A DISTANCIA EN PACIENTES CON RESPUESTA CLNICA COMPLETA MANEJADA POR WATCH AND WAIT DESPUS DE LA TERAPIA NEOADYUVANTE PARA EL CNCER DE RECTO LA INFLUENCIA DEL NUEVO CRECIMIENTO LOCAL EN LA BASE DE DATOS INTERNACIONAL WATCH AND WAIT ANTECEDENTES:Casi el 30 % de los pacientes con cáncer de recto desarrollan un nuevo crecimiento local después de la respuesta clínica completa inicial manejada por watch and wait. Estos pacientes podrían tener un mayor riesgo de metástasis a distancia.OBJETIVO:Investigar los factores de riesgo de metástasis a distancia mediante análisis dependientes del tiempo.DISEÑO:Se revisó retrospectivamente los datos de la base de datos internacional de Watch and Wait. Se utilizó el análisis de regresión de Cox para determinar los factores de riesgo de peor sobrevida libre de metástasis a distancia. Se utilizó un modelo de sobrevida condicional para investigar el impacto de los factores de riesgo en el desarrollo de metástasis a distancia. El tiempo transcurrido hasta el evento se calculó utilizando la fecha de decisión para watch and wait y la fecha del nuevo crecimiento local para el diagnóstico de metástasis a distancia.ESCENARIOBase de datos multicéntrica retrospectiva.PACIENTES:Se incluyeron un total de 793 pacientes (47 instituciones) con cáncer de recto y respuesta clínica completa al tratamiento neoadyuvante de la base de datos internacional de Watch and Wait.PRINCIPALES MEDIDAS DE RESULTADO:Desarrollo de metástasis a distancia.RESULTADOS:De los 793 pacientes tratados con watch and wait (mediana de seguimiento de 55,2 meses), 85 (10,7%) tenían metástasis a distancia. 51 de 85 (60%) tuvieron recrecimiento local en algún momento. El recrecimiento local fue un factor independiente asociado a una peor supervivencia libre de metástasis a distancia en el modelo multivariable. Además, al usar estimaciones condicionales, los pacientes con recrecimiento local sin metástasis a distancia durante 5 años (desde la decisión de watch and wait) permanecieron en mayor riesgo de desarrollar metástasis a distancia durante un año subsiguiente en comparación con los pacientes sin recrecimiento local (sobrevida libre de metástasis a distancia a 5 años: recrecimiento local 94,9% frente a no recrecimiento local 98,4%).LIMITACIONES:La falta de información relacionada con el uso de quimioterapia adyuvante, las características específicas de la cirugía de rescate para el nuevo crecimient o local y la heterogeneidad de las estrategias individuales de vigilancia/seguimiento utilizadas pueden haber afectado los resultados observados.CONCLUSIONES:En pacientes con respuesta clínica completa manejados por Watch and Wait, el desarrollo de recrecimiento local en cualquier momento es un factor de riesgo para metástasis a distancia. El riesgo de metástasis a distancia sigue siendo mayor durante 5 años después del desarrollo de un nuevo crecimiento local. Consulte Video Resumen en http://links.lww.com/DCR/C53. (Traducción-Dr. Felipe Bellolio).
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Affiliation(s)
- Laura M Fernandez
- Colorectal Surgery, Digestive Department, Champalimaud Foundation, Lisbon, Portugal
| | - Guilherme P São Julião
- Colorectal Surgery Division, Angelita and Joaquim Gama Institute, São Paulo, Brazil
- Department of Surgical Oncology, Colorectal Surgery Division, Hospital Beneficencia Portuguesa, São Paulo, Brazil
- Colorectal Surgery Division, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Andrew G Renehan
- Manchester Cancer Research Centre, National Institute of Health and Research Manchester Biomedical Research Centre, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, United Kingdom
- Colorectal and Peritoneal Oncology Centre, The Christie National Health Service Foundation Trust, Manchester, United Kingdom
| | - Geerard L Beets
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
- GROW School for Oncology and Developmental Biology, Maastricht University, the Netherlands
| | - Ana L Papoila
- NOVA Medical School, Faculdade de Ciências Médicas (NMS|FCM), Lisbon, Portugal
| | - Bruna B Vailati
- Colorectal Surgery Division, Angelita and Joaquim Gama Institute, São Paulo, Brazil
- Department of Surgical Oncology, Colorectal Surgery Division, Hospital Beneficencia Portuguesa, São Paulo, Brazil
- Colorectal Surgery Division, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Renu R Bahadoer
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Annet G H Roodvoets
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Nuno L Figueiredo
- Colorectal Surgery, Digestive Department, Champalimaud Foundation, Lisbon, Portugal
- Colorectal Surgery, Hospital Lusiadas, Lisbon, Portugal
| | - Cornelis J H Van De Velde
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Angelita Habr-Gama
- Colorectal Surgery Division, Angelita and Joaquim Gama Institute, São Paulo, Brazil
- Colorectal Surgery Division, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
- University of São Paulo School of Medicine, São Paulo, Brazil
| | - Rodrigo O Perez
- Colorectal Surgery Division, Angelita and Joaquim Gama Institute, São Paulo, Brazil
- Department of Surgical Oncology, Colorectal Surgery Division, Hospital Beneficencia Portuguesa, São Paulo, Brazil
- Colorectal Surgery Division, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
- Ludwig Institute for Cancer Research, São Paulo Branch, Brazil
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Zaborowski AM, Adamina AAM, Aigner F, d'Allens L, Allmer C, Álvarez A, Anula R, Andric M, Bach SAS, Bala M, Barussaud M, Bausys A, Beggs A, Bellolio F, Bennett MR, Berdinskikh A, Bevan V, Biondo S, Bislenghi G, Bludau M, Brouwer N, Brown C, Bruns C, Buchanan DD, Buchwald P, Burger JW, Burlov N, Campanelli M, Capdepont M, Carvello M, Chew HH, Christoforidis D, Clark D, Climent M, Collinson R, Cologne KG, Contreras T, Croner R, Daniels IR, Dapri G, Davies J, Delrio P, Denost Q, Deutsch M, Dias A, D’Hoore A, Drozdov E, Duek D, Dunlop M, Dziki A, Edmundson A, Efetov S, El-Hussuna A, Elliot B, Emile S, Espin E, Evans M, Faes S, Faiz O, Figueiredo N, Fleming F, Foppa C, Fowler G, Frasson M, Forgan T, Frizelle F, Gadaev S, Gellona J, Glyn T, Goran B, Greenwood E, Guren MG, Guillon S, Gutlic I, Hahnloser D, Hampel H, Hanly A, Hasegawa H, Iversen LH, Hill A, Hill J, Hoch J, Hompes R, Hurtado L, Iaquinandi F, Imbrasaite U, Islam R, Jafari MD, Salido AJ, Jiménez-Toscano M, Kanemitsu Y, Karachun A, Karimuddin AA, Keller DS, Kelly J, Kennelly R, Khrykov G, Kocian P, Koh C, Kok N, Knight KA, Knol J, Kontovounisios C, Korner H, Krivokapic Z, Kronberger I, Kroon HM, Kryzauskas M, Kural S, Kusters M, Lakkis Z, Lankov T, Larson D, Lázár G, Lee KY, Lee SH, Lefèvre JH, Lepisto A, Lieu C, Loi L, Lynch C, Maillou-Martinaud H, Maroli A, Martin S, Martling A, Matzel KE, Mayol J, McDermott F, Meurette G, Millan M, Mitteregger M, Moiseenko A, Monson JRT, Morarasu S, Moritani K, Möslein G, Munini M, Nahas C, Nahas S, Negoi I, Novikova A, Ocares M, Okabayashi K, Olkina A, Oñate-Ocaña L, Otero J, Ozen C, Pace U, Julião GPS, Panaiotti L, Panis Y, Papamichael D, Patel S, Uriburu JCP, Peng SL, Pera M, Perez RO, Petrov A, Pfeffer F, Phang TP, Poskus T, Pringle H, Proud D, Raguz I, Rama N, Rasheed S, Raval MJ, Rega D, Reissfelder C, Meneses JCR, Ris F, Riss S, Rodriguez-Zentner H, Roxburgh CS, Saklani A, Sammour T, Saraste D, Schneider M, Seishima R, Sekulic A, Seppala T, Sheahan K, Shlomina A, Sigismondo G, Singnomklao T, Siragusa L, Smart N, Solis-Peña A, Spinelli A, Staiger RD, Stamos MJ, Steele S, Tan KK, Tanis PJ, Tekkis P, Teklay B, Tengku S, Tsarkov P, Turina M, Ulrich A, Vailati BB, van Harten M, Verhoef C, Warrier S, Wexner S, de Wilt H, Weinberg BA, Wells C, Wolthuis A, Xynos E, You N, Zakharenko A, Zeballos J, Zhou J, Winter DC. Impact of microsatellite status in early-onset colonic cancer. Br J Surg 2022; 109:632-636. [PMID: 35522613 DOI: 10.1093/bjs/znac108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 03/04/2022] [Accepted: 03/11/2022] [Indexed: 11/14/2022]
Abstract
BACKGROUND The molecular profile of early-onset colonic cancer is undefined. This study evaluated clinicopathological features and oncological outcomes of young patients with colonic cancer according to microsatellite status. METHODS Anonymized data from an international collaboration were analysed. Criteria for inclusion were patients younger than 50 years diagnosed with stage I-III colonic cancer that was surgically resected. Clinicopathological features, microsatellite status, and disease-specific outcomes were evaluated. RESULTS A total of 650 patients fulfilled the criteria for inclusion. Microsatellite instability (MSI) was identified in 170 (26.2 per cent), whereas 480 had microsatellite-stable (MSS) tumours (relative risk of MSI 2.5 compared with older patients). MSI was associated with a family history of colorectal cancer and lesions in the proximal colon. The proportions with pathological node-positive disease (45.9 versus 45.6 per cent; P = 1.000) and tumour budding (20.3 versus 20.5 per cent; P = 1.000) were similar in the two groups. Patients with MSI tumours were more likely to have BRAF (22.5 versus 6.9 per cent; P < 0.001) and KRAS (40.0 versus 24.2 per cent; P = 0.006) mutations, and a hereditary cancer syndrome (30.0 versus 5.0 per cent; P < 0.001; relative risk 6). Five-year disease-free survival rates in the MSI group were 95.0, 92.0, and 80.0 per cent for patients with stage I, II, and III tumours, compared with 88.0, 88.0, and 65.0 per cent in the MSS group (P = 0.753, P = 0.487, and P = 0.105 respectively). CONCLUSION Patients with early-onset colonic cancer have a high risk of MSI and defined genetic conditions. Those with MSI tumours have more adverse pathology (budding, KRAS/BRAF mutations, and nodal metastases) than older patients with MSI cancers.
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Pages F, El Sissy C, Kirilovsky A, Custers P, Dizdarevic E, Lagorce C, Castillo-Martin M, van den Berg J, Iseas S, Sanchez Loria F, Gerard JP, Dimofte G, Perez RO, Habr-Gama A, Figueiredo N, Hansen T, Chalabi M, Galon J, Beets G, Zeitoun G. International validation of the Immunoscore-biopsy (IS B) to guide selection and monitoring of patients treated with watch-and-wait (WW) strategy for rectal cancer. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.3517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
3517 Background: The WW strategy for patients with rectal cancer who achieved a clinical complete response (cCR) after neoadjuvant therapy (nT) allows to avoid major resection and the associated morbidity and mortality. Standardized criteria to select and monitor WW patients, including biomarkers predicting recurrence after nT, are lacking. The prognostic impact of the immune infiltrate in colorectal cancers is now demonstrated and has been implemented into clinics through the Immunoscore, the first standardized digital-pathology-based assay, recommended by academic institutions. We evidenced that an Immunoscore adapted to biopsies (ISB) performed at diagnosis, predicts the response to nT and the risk of recurrence after nT. Its clinical utility was suggested in a test cohort of WW patients (El Sissy et al., Clin Cancer Res 2020). The aim of this study was to confirm the ability of the ISB to predict clinical outcomes, improve patients’ eligibility for the WW strategy, and optimize a follow-up schedule. Methods: A total of 304 WW patients from 10 centers across 7 countries were included. Tumor biopsies before treatment were immunostained for CD3+ and CD8+ T-cells and converted to ISB using the pre-defined cut-off. The primary endpoint was time-to-recurrence (TTR). Secondary endpoint was disease-free-survival (DFS). As immune response originates in draining lymph nodes, signs of immune activation were carried out in lymph nodes of additional patients managed by radical surgery with complete pathological response (pCR; n = 12) or non-pCR (n = 12) by 3' RNA-Seq and immunofluorescence technologies. Results: High-ISB patients presented with the lowest risk of recurrence after WW. 5-year recurrence-free rates were 97% (92%-100%), 61% (49%-76%), and 56% (44%-73%) with ISB High, Intermediate, and Low, respectively (HR [Low-vs-High] = 14.3, 95% CI 1.8-100). In patients with cCR after nT (n = 209), High-ISB showed a significant association with prolonged TTR and DFS (Logrank P = 0.005 and P = 0.006, respectively). When ISB was evaluated as a continuous variable, the risk of recurrence was increasing along with decreasing ISB (Wald tests, all P < 0.005). In multivariate analyses, ISB was independent of age, sex, location, and cTNM stage and was the single parameter correlated with TTR (HR [ISB High-vs-Low] = 0.08, 95% CI 0.01-0.6; P = 0.015) and DFS (P = 0.013). Unlike for patients with cCR, no difference according to ISB was observed for those with incomplete response (n = 41) or treated with brachytherapy (n = 34). Finally, intranodal signs of T-cell and B-cell activation were only evidenced in patients with pCR. Conclusions: ISB provides a reliable biomarker to predict clinical outcomes, improve eligibility, and optimize patients’ follow-up. Intranodal T-cell and B-cell activation further supports the immune benefit of both organ and lymph node preservation.
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Affiliation(s)
- Franck Pages
- Department of Immunology, Hôpital Européen Georges Pompidou, University of Paris, Paris, France
| | - Carine El Sissy
- Department of Immunology, Hôpital Européen Georges Pompidou, University of Paris, Paris, France
| | - Amos Kirilovsky
- Department of Immunology, Hôpital Européen Georges Pompidou, University of Paris, Paris, France
| | - Petra Custers
- Department of Surgery, Netherlands Cancer Institute,Antoni van Leeuwenhoek, Amsterdam, Netherlands
| | - Edina Dizdarevic
- Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle, Denmark
| | - Christine Lagorce
- Department of Pathology, Hôpital Européen Georges Pompidou, University of Paris, Paris, France
| | - Mireia Castillo-Martin
- Service of Pathology, Champalimaud Foundation Biobank (CFB)/Champalimaud Centre for the Unknown/Champalimaud Foundation, Lisbon, Portugal
| | | | - Soledad Iseas
- Oncology Unit, Gastroenterology Hospital, Dr. Carlos Bonorino Udaondo, Ciudad Autónoma De Buenos Aires, Argentina
| | - Fernando Sanchez Loria
- GI Clinical Oncology & GI Surgical Oncology, Instituto Alexander Fleming, Buenos Aires, Argentina
| | - Jean-Pierre Gerard
- Department of Radiation Oncology, Centre Antoine Lacassagne, Côte d'Azur University, Nice, France
| | - Gabriel Dimofte
- Department of Surgery, Grigore T. Popa University of Medicine and Pharmacy; Department of Surgery, Regional Institute of Oncology, Iasi, Romania
| | - Rodrigo O Perez
- Department of Colorectal Surgery, Insituto Angelita and Joaquim Gama, São Paulo, Brazil
| | - Angelita Habr-Gama
- Department of Colorectal Surgery, Angelita and Joaquim Gama Institute; Hospital Alemão Oswaldo Cruz; University of São Paulo School of Medicine, São Paulo, Brazil
| | - Nuno Figueiredo
- Colorectal Surgery, Digestive Department, Champalimaud Foundation; Colorectal Surgery, Lusiadas Hospital Lisboa, Lisbon, Portugal
| | - Torben Hansen
- Department of Oncology, Vejle Hospital, University of Southern Denmark; Danish Colorectal Cancer Center South, Vejle University Hospital; Institute of Regional Health Research, University of Southern Denmark, Vejle, Denmark
| | - Myriam Chalabi
- Gastrointestinal Oncology, Netherlands Cancer Institute; Molecular Oncology and Immunology, Netherlands Cancer Institute; Medical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Jerome Galon
- INSERM UMRS1138, Immunology and Cancer Department, Cordeliers Research Center, Paris, France
| | - Geerard Beets
- Department of Surgery, Netherlands Cancer Institute,Antoni van Leeuwenhoek, Amsterdam, Netherlands
| | - Guy Zeitoun
- Department of Immunology, Hôpital Européen Georges Pompidou, University of Paris, Paris, France
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Lambregts DMJ, Bogveradze N, Blomqvist LK, Fokas E, Garcia-Aguilar J, Glimelius B, Gollub MJ, Konishi T, Marijnen CAM, Nagtegaal ID, Nilsson PJ, Perez RO, Snaebjornsson P, Taylor SA, Tolan DJM, Valentini V, West NP, Wolthuis A, Lahaye MJ, Maas M, Beets GL, Beets-Tan RGH. Current controversies in TNM for the radiological staging of rectal cancer and how to deal with them: results of a global online survey and multidisciplinary expert consensus. Eur Radiol 2022; 32:4991-5003. [PMID: 35254485 PMCID: PMC9213337 DOI: 10.1007/s00330-022-08591-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/22/2021] [Accepted: 01/13/2022] [Indexed: 12/17/2022]
Abstract
Abstract
Objectives
To identify the main problem areas in the applicability of the current TNM staging system (8th ed.) for the radiological staging and reporting of rectal cancer and provide practice recommendations on how to handle them.
Methods
A global case-based online survey was conducted including 41 image-based rectal cancer cases focusing on various items included in the TNM system. Cases reaching < 80% agreement among survey respondents were identified as problem areas and discussed among an international expert panel, including 5 radiologists, 6 colorectal surgeons, 4 radiation oncologists, and 3 pathologists.
Results
Three hundred twenty-one respondents (from 32 countries) completed the survey. Sixteen problem areas were identified, related to cT staging in low-rectal cancers, definitions for cT4b and cM1a disease, definitions for mesorectal fascia (MRF) involvement, evaluation of lymph nodes versus tumor deposits, and staging of lateral lymph nodes. The expert panel recommended strategies on how to handle these, including advice on cT-stage categorization in case of involvement of different layers of the anal canal, specifications on which structures to include in the definition of cT4b disease, how to define MRF involvement by the primary tumor and other tumor-bearing structures, how to differentiate and report lymph nodes and tumor deposits on MRI, and how to anatomically localize and stage lateral lymph nodes.
Conclusions
The recommendations derived from this global survey and expert panel discussion may serve as a practice guide and support tool for radiologists (and other clinicians) involved in the staging of rectal cancer and may contribute to improved consistency in radiological staging and reporting.
Key Points
• Via a case-based online survey (incl. 321 respondents from 32 countries), we identified 16 problem areas related to the applicability of the TNM staging system for the radiological staging and reporting of rectal cancer.
• A multidisciplinary panel of experts recommended strategies on how to handle these problem areas, including advice on cT-stage categorization in case of involvement of different layers of the anal canal, specifications on which structures to include in the definition of cT4b disease, how to define mesorectal fascia involvement by the primary tumor and other tumor-bearing structures, how to differentiate and report lymph nodes and tumor deposits on MRI, and how to anatomically localize and stage lateral lymph nodes.
• These recommendations may serve as a practice guide and support tool for radiologists (and other clinicians) involved in the staging of rectal cancer and may contribute to improved consistency in radiological staging and reporting.
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Affiliation(s)
- Doenja M J Lambregts
- Department of Radiology, The Netherlands Cancer Institute, P.O. Box 90203, 1006 BE, Amsterdam, The Netherlands.
| | - Nino Bogveradze
- Department of Radiology, The Netherlands Cancer Institute, P.O. Box 90203, 1006 BE, Amsterdam, The Netherlands
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
- Department of Radiology, American Hospital Tbilisi, Tbilisi, Georgia
| | - Lennart K Blomqvist
- Department of Imaging and Physiology, Karolinska University Hospital, Stockholm, Sweden
| | - Emmanouil Fokas
- Department of Radiooncology, University Hospital, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
- Frankfurt Cancer Institute (FCI), University Hospital, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Julio Garcia-Aguilar
- Department of Surgery, Colorectal Service, Benno C. Schmidt Chair in Surgical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Bengt Glimelius
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Marc J Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tsuyoshi Konishi
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Corrie A M Marijnen
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Iris D Nagtegaal
- Department of Pathology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Per J Nilsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Division of Coloproctology, Pelvic Cancer Center, Karolinska University Hospital, Stockholm, Sweden
| | - Rodrigo O Perez
- Hospital Alemão Oswaldo Cruz & Hospital Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | - Petur Snaebjornsson
- Department of Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Stuart A Taylor
- Centre for Medical Imaging, University College London Hospital, London, UK
| | - Damian J M Tolan
- Department of Radiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Vincenzo Valentini
- Department of Bioimaging, Radiation Oncology and Hematology, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica S. Cuore, Rome, Italy
| | - Nicholas P West
- Pathology & Data Analytics, Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - Albert Wolthuis
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Max J Lahaye
- Department of Radiology, The Netherlands Cancer Institute, P.O. Box 90203, 1006 BE, Amsterdam, The Netherlands
| | - Monique Maas
- Department of Radiology, The Netherlands Cancer Institute, P.O. Box 90203, 1006 BE, Amsterdam, The Netherlands
| | - Geerard L Beets
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
- Department of Surgery, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Regina G H Beets-Tan
- Department of Radiology, The Netherlands Cancer Institute, P.O. Box 90203, 1006 BE, Amsterdam, The Netherlands.
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands.
- Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark.
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Zaborowski AM, Abdile A, Adamina M, Aigner F, d'Allens L, Allmer C, Álvarez A, Anula R, Andric M, Atallah S, Bach S, Bala M, Barussaud M, Bausys A, Beggs A, Bellolio F, Bennett MR, Berdinskikh A, Bevan V, Biondo S, Bislenghi G, Bludau M, Brouwer N, Brown C, Bruns C, Buchanan DD, Buchwald P, Burger JWA, Burlov N, Campanelli M, Capdepont M, Carvello M, Chew HH, Christoforidis D, Clark D, Climent M, Collinson R, Cologne KG, Contreras T, Croner R, Daniels IR, Dapri G, Davies J, Delrio P, Denost Q, Deutsch M, Dias A, D'Hoore A, Drozdov E, Duek D, Dunlop M, Dziki A, Edmundson A, Efetov S, El-Hussuna A, Elliot B, Emile S, Espin E, Evans M, Faes S, Faiz O, Figueiredo N, Fleming F, Foppa C, Fowler G, Frasson M, Forgan T, Frizelle F, Gadaev S, Gellona J, Glyn T, Goran B, Greenwood E, Guren MG, Guillon S, Gutlic I, Hahnloser D, Hampel H, Hanly A, Hasegawa H, Iversen LH, Hill A, Hill J, Hoch J, Hompes R, Hurtado L, Iaquinandi F, Imbrasaite U, Islam R, Jafari MD, Salido AJ, Jiménez Toscano M, Kanemitsu Y, Karachun A, Karimuddin AA, Keller DS, Kelly J, Kennelly R, Khrykov G, Kocian P, Koh C, Kok N, Knight KA, Knol J, Kontovounisios C, Korner H, Krivokapic Z, Kronberger I, Kroon HM, Kryzauskas M, Kural S, Kusters M, Lakkis Z, Lankov T, Larson D, Lázár G, Lee KY, Lee SH, Lefèvre JH, Lepisto A, Lieu C, Loi L, Lynch C, Maillou-Martinaud H, Maroli A, Martin S, Martling A, Matzel KE, Mayol J, McDermott F, Meurette G, Millan M, Mitteregger M, Moiseenko A, Monson JRT, Morarasu S, Moritani K, Möslein G, Munini M, Nahas C, Nahas S, Negoi I, Novikova A, Ocares M, Okabayashi K, Olkina A, Oñate-Ocaña L, Otero J, Ozen C, Pace U, Julião GPS, Panaiotti L, Panis Y, Papamichael D, Patel S, Uriburu JCP, Peng SL, Pera M, Perez RO, Petrov A, Pfeffer F, Phang TP, Poskus T, Pringle H, Proud D, Raguz I, Rama N, Rasheed S, Raval MJ, Rega D, Reissfelder C, Meneses JCR, Ris F, Riss S, Rodriguez-Zentner H, Roxburgh CS, Saklani A, Sammour T, Saraste D, Schneider M, Seishima R, Sekulic A, Seppala T, Sheahan K, Shlomina A, Sigismondo G, Singnomklao T, Siragusa L, Smart N, Solis-Peña A, Spinelli A, Staiger RD, Stamos MJ, Steele S, Tan KK, Tanis PJ, Tekkis P, Teklay B, Tengku S, Tsarkov P, Turina M, Ulrich A, Vailati BB, van Harten M, Verhoef C, Warrier S, Wexner S, de Wilt H, Weinberg BA, Wells C, Wolthuis A, Xynos E, You N, Zakharenko A, Zeballos J, Zhou J, Winter DC. Microsatellite instability in young patients with rectal cancer: molecular findings and treatment response. Br J Surg 2022; 109:251-255. [PMID: 35030243 DOI: 10.1093/bjs/znab437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 11/22/2021] [Indexed: 12/27/2022]
Abstract
In this study of 400 patients with early-onset rectal cancer, 12.5 per cent demonstrated microsatellite instability (MSI). MSI was associated with a reduced likelihood of nodal positivity, an increased rate of pathological complete response, and improved disease-specific survival.
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18
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Fernandez LM, Figueiredo N, Habr-Gama A, São Julião GP, Vieira P, Vailati BB, Nasir I, Parés O, Santiago I, Castillo-Martin M, Carvalho C, Parvaiz A, Perez RO. cT2N0 Distal Rectal Cancer: Do Not Believe in Fairy Tales. Dis Colon Rectum 2022; 65:e22. [PMID: 34775408 DOI: 10.1097/dcr.0000000000002307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
| | - Nuno Figueiredo
- University of São Paulo School of Medicine, Colorectal Surgery Division, Sao Paulo - Brazil
| | - Angelita Habr-Gama
- Angelita & Joaquim Gama Institute, Sao Paulo - Brazil
- University of São Paulo School of Medicine, Colorectal Surgery Division, Sao Paulo - Brazil
| | | | | | | | | | | | | | | | | | | | - Rodrigo O Perez
- Angelita & Joaquim Gama Institute, Sao Paulo - Brazil
- University of São Paulo School of Medicine, Colorectal Surgery Division, Sao Paulo - Brazil
- Ludwig Institute for Cancer Research São Paulo Branch, Sao Paulo - Brazil Hospital Lusiadas, Lisbon, Portugal
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19
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Bahadoer RR, Peeters KCMJ, Beets GL, Figueiredo NL, Bastiaannet E, Vahrmeijer A, Temmink SJD, Meershoek-Klein Kranenbarg WME, Roodvoets AGH, Habr-Gama A, Perez RO, van de Velde CJH, Hilling DE. Watch and wait after a clinical complete response in rectal cancer patients younger than 50 years. Br J Surg 2021; 109:114-120. [PMID: 34738104 DOI: 10.1093/bjs/znab372] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 09/21/2021] [Accepted: 09/23/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Young-onset rectal cancer, in patients less than 50 years, is expected to increase in the coming years. A watch-and-wait strategy is nowadays increasingly practised in patients with a clinical complete response (cCR) after neoadjuvant treatment. Nevertheless, there may be reluctance to offer organ preservation treatment to young patients owing to a potentially higher oncological risk. This study compared patients aged less than 50 years with those aged 50 years or more to identify possible differences in oncological outcomes of watch and wait. METHODS The study analysed data from patients with a cCR after neoadjuvant therapy in whom surgery was omitted, registered in the retrospective-prospective, multicentre International Watch & Wait Database (IWWD). RESULTS In the IWWD, 1552 patients met the inclusion criteria, of whom 199 (12.8 per cent) were aged less than 50 years. Patients younger than 50 years had a higher T category of disease at diagnosis (P = 0.011). The disease-specific survival rate at 3 years was 98 (95 per cent c.i. 93 to 99) per cent in this group, compared with 97 (95 to 98) per cent in patients aged over 50 years (hazard ratio (HR) 1.67, 95 per cent c.i. 0.76 to 3.64; P = 0.199). The cumulative probability of local regrowth at 3 years was 24 (95 per cent c.i. 18 to 31) per cent in patients less than 50 years and 26 (23 to 29) per cent among those aged 50 years or more (HR 1.09, 0.79 to 1.49; P = 0.603). Both groups had a cumulative probability of distant metastases of 10 per cent at 3 years (HR 1.00, 0.62 to 1.62; P = 0.998). CONCLUSION There is no additional oncological risk in young patients compared with their older counterparts when following a watch-and-wait strategy after a cCR. In light of a shared decision-making process, watch and wait should be also be discussed with young patients who have a cCR after neoadjuvant treatment.
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Affiliation(s)
- Renu R Bahadoer
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Koen C M J Peeters
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Geerard L Beets
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands.,GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands
| | - Nuno L Figueiredo
- Digestive Unit, Champalimaud Foundation, Lisbon, Portugal.,Colorectal Surgery, Hospital Lusíadas, Lisbon, Portugal
| | - Esther Bastiaannet
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands.,Department of Medical Oncology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Alexander Vahrmeijer
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | | | | | - Annet G H Roodvoets
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | | | | | | | - Denise E Hilling
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands.,Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, University Medical Centre Rotterdam, Rotterdam, the Netherlands
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Zaborowski AM, Abdile A, Adamina M, Aigner F, d'Allens L, Allmer C, Álvarez A, Anula R, Andric M, Atallah S, Bach S, Bala M, Barussaud M, Bausys A, Bebington B, Beggs A, Bellolio F, Bennett MR, Berdinskikh A, Bevan V, Biondo S, Bislenghi G, Bludau M, Boutall A, Brouwer N, Brown C, Bruns C, Buchanan DD, Buchwald P, Burger JWA, Burlov N, Campanelli M, Capdepont M, Carvello M, Chew HH, Christoforidis D, Clark D, Climent M, Cologne KG, Contreras T, Croner R, Daniels IR, Dapri G, Davies J, Delrio P, Denost Q, Deutsch M, Dias A, D'Hoore A, Drozdov E, Duek D, Dunlop M, Dziki A, Edmundson A, Efetov S, El-Hussuna A, Elliot B, Emile S, Espin E, Evans M, Faes S, Faiz O, Fleming F, Foppa C, Fowler G, Frasson M, Figueiredo N, Forgan T, Frizelle F, Gadaev S, Gellona J, Glyn T, Gong J, Goran B, Greenwood E, Guren MG, Guillon S, Gutlic I, Hahnloser D, Hampel H, Hanly A, Hasegawa H, Iversen LH, Hill A, Hill J, Hoch J, Hoffmeister M, Hompes R, Hurtado L, Iaquinandi F, Imbrasaite U, Islam R, Jafari MD, Kanemitsu Y, Karachun A, Karimuddin AA, Keller DS, Kelly J, Kennelly R, Khrykov G, Kocian P, Koh C, Kok N, Knight KA, Knol J, Kontovounisios C, Korner H, Krivokapic Z, Kronberger I, Kroon HM, Kryzauskas M, Kural S, Kusters M, Lakkis Z, Lankov T, Larson D, Lázár G, Lee KY, Lee SH, Lefèvre JH, Lepisto A, Lieu C, Loi L, Lynch C, Maillou-Martinaud H, Maroli A, Martin S, Martling A, Matzel KE, Mayol J, McDermott F, Meurette G, Millan M, Mitteregger M, Moiseenko A, Monson JRT, Morarasu S, Moritani K, Möslein G, Munini M, Nahas C, Nahas S, Negoi I, Novikova A, Ocares M, Okabayashi K, Olkina A, Oñate-Ocaña L, Otero J, Ozen C, Pace U, São Julião GP, Panaiotti L, Panis Y, Papamichael D, Park J, Patel S, Patrón Uriburu JC, Pera M, Perez RO, Petrov A, Pfeffer F, Phang PT, Poskus T, Pringle H, Proud D, Raguz I, Rama N, Rasheed S, Raval MJ, Rega D, Reissfelder C, Reyes Meneses JC, Ris F, Riss S, Rodriguez-Zentner H, Roxburgh CS, Saklani A, Salido AJ, Sammour T, Saraste D, Schneider M, Seishima R, Sekulic A, Seppala T, Sheahan K, Shine R, Shlomina A, Sica GS, Singnomklao T, Siragusa L, Smart N, Solis A, Spinelli A, Staiger RD, Stamos MJ, Steele S, Sunderland M, Tan KK, Tanis PJ, Tekkis P, Teklay B, Tengku S, Jiménez-Toscano M, Tsarkov P, Turina M, Ulrich A, Vailati BB, van Harten M, Verhoef C, Warrier S, Wexner S, de Wilt H, Weinberg BA, Wells C, Wolthuis A, Xynos E, You N, Zakharenko A, Zeballos J, Winter DC. Characteristics of Early-Onset vs Late-Onset Colorectal Cancer: A Review. JAMA Surg 2021; 156:865-874. [PMID: 34190968 DOI: 10.1001/jamasurg.2021.2380] [Citation(s) in RCA: 89] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance The incidence of early-onset colorectal cancer (younger than 50 years) is rising globally, the reasons for which are unclear. It appears to represent a unique disease process with different clinical, pathological, and molecular characteristics compared with late-onset colorectal cancer. Data on oncological outcomes are limited, and sensitivity to conventional neoadjuvant and adjuvant therapy regimens appear to be unknown. The purpose of this review is to summarize the available literature on early-onset colorectal cancer. Observations Within the next decade, it is estimated that 1 in 10 colon cancers and 1 in 4 rectal cancers will be diagnosed in adults younger than 50 years. Potential risk factors include a Westernized diet, obesity, antibiotic usage, and alterations in the gut microbiome. Although genetic predisposition plays a role, most cases are sporadic. The full spectrum of germline and somatic sequence variations implicated remains unknown. Younger patients typically present with descending colonic or rectal cancer, advanced disease stage, and unfavorable histopathological features. Despite being more likely to receive neoadjuvant and adjuvant therapy, patients with early-onset disease demonstrate comparable oncological outcomes with their older counterparts. Conclusions and Relevance The clinicopathological features, underlying molecular profiles, and drivers of early-onset colorectal cancer differ from those of late-onset disease. Standardized, age-specific preventive, screening, diagnostic, and therapeutic strategies are required to optimize outcomes.
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Affiliation(s)
| | - Ahmed Abdile
- Department of Surgery, Middlemore Hospital, Auckland, New Zealand
| | - Michel Adamina
- Department of Surgery, Cantonal Hospital, Winterthur, Switzerland
| | - Felix Aigner
- Department of Surgery, Barmherzige Brüder Krankenhaus Graz, Graz, Austria
| | - Laura d'Allens
- Department of Surgery, Cantonal Hospital, Winterthur, Switzerland
| | - Caterina Allmer
- Department of Surgery, Barmherzige Brüder Krankenhaus Graz, Graz, Austria
| | - Andrea Álvarez
- Department of Surgery, Bellvitge University Hospital, Barcelona, Spain
| | - Rocio Anula
- Department of Surgery, Instituto de Investigación Sanitaria San Carlos, Universidad Complutense de Madrid, Hospital Clínico San Carlos, Madrid, Spain
| | - Mihailo Andric
- Department of Surgery, University Hospital Magdeburg, Magdeburg, Germany
| | - Sam Atallah
- Department of Colorectal Surgery, AdventHealth, Orlando, Florida
| | - Simon Bach
- Department of Surgery, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Miklosh Bala
- Department of Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Marie Barussaud
- Department of Surgery, University Hospital Poitiers, Poitiers, France
| | - Augustinas Bausys
- Department of Surgery, National Cancer Institute, Vilnius, Lithuania
| | - Brendan Bebington
- Department of Surgery, Wits Donald Gordon Medical Centre, Johannesburg, South Africa
| | - Andrew Beggs
- Department of Surgery, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Felipe Bellolio
- Department of Digestive Surgery, Faculty of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | | | - Anton Berdinskikh
- Department of Surgery, St-Petersburg Clinical Scientific and Practical Centre, St Petersburg, Russia
| | - Vicki Bevan
- Department of Surgery, Morriston Hospital, Swansea, Wales, United Kingdom
| | - Sebastiano Biondo
- Department of Surgery, Bellvitge University Hospital, Barcelona, Spain
| | | | - Marc Bludau
- Department of Surgery, University Hospital Cologne, Cologne, Germany
| | - Adam Boutall
- Department of Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Nelleke Brouwer
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Carl Brown
- Department of Surgery, St Paul's Hospital, the University of British Columbia, Vancouver, British Columbia, Canada
| | - Christiane Bruns
- Department of Surgery, University Hospital Cologne, Cologne, Germany
| | - Daniel D Buchanan
- Department of Clinical Pathology, the University of Melbourne, Victorian Comprehensive Cancer Centre, Melbourne, Australia
| | - Pamela Buchwald
- Department of Surgery, Skåne University Hospital, Malmö, Sweden
| | | | - Nikita Burlov
- Department of Surgery, Leningrad Regional Clinical Oncology Dispensary, Leningrad, Russia
| | | | - Maylis Capdepont
- Department of Surgery, Bordeaux University Hospital, Bordeaux, France
| | - Michele Carvello
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Hwee-Hoon Chew
- Division of Colorectal Surgery, University Surgical Cluster, National University Health System, Singapore, Singapore
| | | | - David Clark
- Department of Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Marta Climent
- Department of Surgery, Bellvitge University Hospital, Barcelona, Spain
| | - Kyle G Cologne
- Department of Surgery, Keck Hospital, University of Southern California, Los Angeles
| | - Tomas Contreras
- Department of Surgery, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Roland Croner
- Department of Surgery, University Hospital Magdeburg, Magdeburg, Germany
| | - Ian R Daniels
- Department of Surgery, Royal Devon and Exeter Hospital, Exeter, United Kingdom
| | - Giovanni Dapri
- Department of Surgery, St-Pierre University Hospital, Brussels, Belgium
| | - Justin Davies
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Paolo Delrio
- Colorectal Surgical Oncology, Abdominal Oncology Department, Istituto Nazionale per lo Studio e la Cura dei Tumori, "Fondazione G. Pascale" IRCSS, Naples, Italy
| | - Quentin Denost
- Department of Surgery, Bordeaux University Hospital, Bordeaux, France
| | - Michael Deutsch
- Department of Surgery, Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Andre Dias
- Department of Surgery, Institute of Cancer of São Paulo, São Paulo, Brazil
| | | | - Evgeniy Drozdov
- Department of Surgery, Siberian State Medical University, Tomsk, Russia
| | - Daniel Duek
- Department of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Malcolm Dunlop
- Department of Surgery, Western General Hospital, Edinburgh, United Kingdom
| | - Adam Dziki
- Department of Surgery, Military Medical Academy University Teaching Hospital, Łódź, Poland
| | - Aleksandra Edmundson
- Department of Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Sergey Efetov
- Department of Surgery, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Alaa El-Hussuna
- Department of Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Brodie Elliot
- Department of Surgery, Whangarei Hospital, Whangarei, New Zealand
| | - Sameh Emile
- Department of Surgery, Mansoura University Hospital, Mansoura, Egypt
| | - Eloy Espin
- Colorectal Surgery Unit, General Surgery Service, Hospital Vall de Hebron, Barcelona, Spain
| | - Martyn Evans
- Department of Surgery, Morriston Hospital, Swansea, Wales, United Kingdom
| | - Seraina Faes
- Department of Visceral Surgery, University Hospital Lausanne, Lausanne, Switzerland
| | - Omar Faiz
- Department of Surgery, St Mark's Hospital, London, United Kingdom
| | - Fergal Fleming
- Department of Surgery, University of Rochester, New York
| | - Caterina Foppa
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - George Fowler
- Department of Surgery, Royal Devon and Exeter Hospital, Exeter, United Kingdom
| | - Matteo Frasson
- Department of Surgery, University Hospital La Fe, Valencia, Spain
| | - Nuno Figueiredo
- Department of Surgery, Champalimaud Clinical Centre, Lisbon, Portugal
| | - Tim Forgan
- Department of Surgery, Tygerberg Academic Hospital, Cape Town, South Africa
| | - Frank Frizelle
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Shamil Gadaev
- Fourth Coloproctology Department, St Petersburg Oncology Center, St Petersburg, Russia
| | - Jose Gellona
- Department of Colorectal Surgery, Clínica Santa María, Santiago, Chile
- Department of Colorectal Surgery, Hospital Militar de Santiago, Le Reina, Chile
| | - Tamara Glyn
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Jianping Gong
- Department of Surgery, Tongji Hospital, Wuhan, China
| | - Barisic Goran
- Department of Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Emma Greenwood
- Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | | | - Stephanie Guillon
- Department of Surgery, Bordeaux University Hospital, Bordeaux, France
| | - Ida Gutlic
- Department of Surgery, Skåne University Hospital, Malmö, Sweden
| | - Dieter Hahnloser
- Department of Visceral Surgery, University Hospital Lausanne, Lausanne, Switzerland
| | - Heather Hampel
- Division of Human Genetics, The Ohio State University Comprehensive Cancer Center, Columbus
| | - Ann Hanly
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - Hirotoshi Hasegawa
- Department of Surgery, Tokyo Dental College Ichikawa General Hospital, Chiba, Japan
| | | | - Andrew Hill
- Department of Surgery, Middlemore Hospital, Auckland, New Zealand
| | - James Hill
- Department of Surgery, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Jiri Hoch
- Department of Surgery, Motol University Hospital, Prague, Czech Republic
| | | | - Roel Hompes
- Department of Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Luis Hurtado
- Department of Surgery, University Hospital La Fe, Valencia, Spain
| | | | | | - Rumana Islam
- Department of Surgery, Austin Hospital, Melbourne, Australia
| | | | - Yukihide Kanemitsu
- Department of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Aleksei Karachun
- Surgical Department of Abdominal Oncology, N. N. Petrov National Medical Research Centre of Oncology, St Petersburg, Russia
| | - Ahmer A Karimuddin
- Department of Surgery, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Deborah S Keller
- Division of Colorectal Surgery, Department of Surgery, University of California at Davis Medical Center, Sacramento
| | - Justin Kelly
- Advent Health Colorectal Surgery, Orlando, Florida
| | - Rory Kennelly
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - Gleb Khrykov
- Department of Surgery, Leningrad Regional Clinical Oncology Dispensary, Leningrad, Russia
| | - Peter Kocian
- Department of Surgery, Motol University Hospital, Prague, Czech Republic
| | - Cherry Koh
- Department of Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - Neils Kok
- Department of Surgery, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Joep Knol
- Department of Surgery, Ziekenhuis Oost-Limburg, Belgium
| | | | - Hartwig Korner
- Department of Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Zoran Krivokapic
- Department of Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | | | - Hidde Maarten Kroon
- Department of Surgery, University of Adelaide, Royal Adelaide Hospital, Adelaide, Australia
| | | | - Said Kural
- School of Medicine, Uludag University, Bursa, Turkey
| | - Miranda Kusters
- Department of Surgery, Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands
| | - Zaher Lakkis
- Department of Surgery, University Hospital Besançon, Besançon, France
| | - Timur Lankov
- Surgical Department of Abdominal Oncology, N. N. Petrov National Medical Research Centre of Oncology, St Petersburg, Russia
| | - Dave Larson
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - György Lázár
- Department of Surgery, University of Szeged, Szeged, Hungary
| | - Kai-Yin Lee
- Division of Colorectal Surgery, University Surgical Cluster, National University Health System, Singapore, Singapore
| | - Suk Hwan Lee
- Kyung Here University Hospital at Gangdong, Seoul, South Korea
| | - Jérémie H Lefèvre
- Sorbonne Université, Department of Digestive Surgery, Assistance Publique-Hôpitaux de Paris, Hôpital St Antoine, Paris, France
| | - Anna Lepisto
- Department of Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Christopher Lieu
- Division of Medical Oncology, University of Colorado Anschutz Medical Campus, Aurora
| | - Lynette Loi
- University of Glasgow, Glasgow, United Kingdom
| | - Craig Lynch
- Department of Surgery, St Vincent's Hospital, University of Melbourne, Melbourne, Australia
| | | | - Annalisa Maroli
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Sean Martin
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - Anna Martling
- Department of Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Klaus E Matzel
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Julio Mayol
- Department of Surgery, Instituto de Investigación Sanitaria San Carlos, Universidad Complutense de Madrid, Hospital Clínico San Carlos, Madrid, Spain
| | - Frank McDermott
- Department of Surgery, Royal Devon and Exeter Hospital, Exeter, United Kingdom
| | | | - Monica Millan
- Department of Surgery, La Fe University Hospital, Valencia, Spain
| | - Martin Mitteregger
- Department of Surgery, Barmherzige Brüder Krankenhaus Graz, Graz, Austria
| | - Andrei Moiseenko
- Surgical Department of Abdominal Oncology, N. N. Petrov National Medical Research Centre of Oncology, St Petersburg, Russia
| | - John R T Monson
- AdventHealth Medical Group Colorectal Surgery, AdventHealth, Orlando, Florida
| | - Stefan Morarasu
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - Konosuke Moritani
- Department of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Gabriela Möslein
- Department for Hereditary Tumors, Evangelisches Krankenhaus Bethesda, Duisburg, Germany
| | - Martino Munini
- Department of Surgery, Lugano Regional Hospital, Lugano, Switzerland
| | - Caio Nahas
- Department of Surgery, Institute of Cancer of São Paulo, São Paulo, Brazil
| | - Sergio Nahas
- Department of Surgery, Institute of Cancer of São Paulo, São Paulo, Brazil
| | - Ionut Negoi
- Department of Surgery, Emergency Hospital of Bucharest, Bucharest, Romania
| | - Anastasia Novikova
- Department of Surgery, Pavlov First St Petersburg State Medical University's Clinic, St Petersburg, Russia
| | - Misael Ocares
- Department of Surgery, University Hospital Concepción, Concepción, Chile
| | | | - Alexandra Olkina
- Surgical Department of Abdominal Oncology, N. N. Petrov National Medical Research Centre of Oncology, St Petersburg, Russia
| | - Luis Oñate-Ocaña
- Department of Surgery, National Cancer Institute, Mexico City, Mexico
| | - Jaime Otero
- Department of Surgery, Instituto de Investigación Sanitaria San Carlos, Universidad Complutense de Madrid, Hospital Clínico San Carlos, Madrid, Spain
| | - Cihan Ozen
- Department of Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Ugo Pace
- Colorectal Surgical Oncology, Abdominal Oncology Department, Istituto Nazionale per lo Studio e la Cura dei Tumori, "Fondazione G. Pascale" IRCSS, Naples, Italy
| | | | - Lidiia Panaiotti
- Surgical Department of Abdominal Oncology, N. N. Petrov National Medical Research Centre of Oncology, St Petersburg, Russia
| | - Yves Panis
- Department of Surgery, Beaujon Hospital, Paris, France
| | | | - Jason Park
- Department of Surgery, St Boniface General Hospital, Winnipeg, Manitoba, Canada
| | - Swati Patel
- Department of Gastroenterology, University of Colorado Anschutz Medical Campus, Aurora
| | | | - Miguel Pera
- Department of Surgery, Hospital del Mar, Barcelona, Spain
| | - Rodrigo O Perez
- Colorectal Surgery Division, Angelita and Joaquim Gama Institute, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Alexei Petrov
- Surgical Department of Abdominal Oncology, N. N. Petrov National Medical Research Centre of Oncology, St Petersburg, Russia
| | - Frank Pfeffer
- Department of Surgery, Haukeland University Hospital, Bergen, Norway
| | - P Terry Phang
- Department of Surgery, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Tomas Poskus
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Heather Pringle
- Department of Surgery, Royal Devon and Exeter Hospital, Exeter, United Kingdom
| | - David Proud
- Department of Surgery, Austin Hospital, Melbourne, Australia
| | - Ivana Raguz
- Department of Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Nuno Rama
- Department of Surgery, Centro Hospitalar de Leiria, Leiria, Portugal
| | - Shahnawaz Rasheed
- Department of Surgery, Royal Marsden Hospital, London, United Kingdom
| | - Manoj J Raval
- Department of Surgery, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Daniela Rega
- Colorectal Surgical Oncology, Abdominal Oncology Department, Istituto Nazionale per lo Studio e la Cura dei Tumori, "Fondazione G. Pascale" IRCSS, Naples, Italy
| | | | | | - Frederic Ris
- Department of Surgery, University Hospital Geneva, Geneva, Switzerland
| | - Stefan Riss
- Department of Surgery, Medical University Vienna, Vienna, Austria
| | | | - Campbell S Roxburgh
- Glasgow Royal Infirmary, Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom
| | | | | | - Tarik Sammour
- Department of Surgery, University of Adelaide, Royal Adelaide Hospital, Adelaide, Australia
| | - Deborah Saraste
- Department of Surgery, Stockholm South General Hospital, Stockholm, Sweden
| | - Martin Schneider
- Department of Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Ryo Seishima
- Department of Surgery, Keio University, Tokyo, Japan
| | | | - Toni Seppala
- Department of Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Kieran Sheahan
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - Rebecca Shine
- Department of Surgery, Austin Hospital, Melbourne, Australia
| | - Alexandra Shlomina
- Department of Surgery, Sechenov First Moscow State Medical University, Moscow, Russia
| | | | | | | | - Neil Smart
- Department of Surgery, Royal Devon and Exeter Hospital, Exeter, United Kingdom
| | - Alejandro Solis
- Colorectal Surgery Unit, General Surgery Service, Hospital Vall de Hebron, Barcelona, Spain
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Roxane D Staiger
- Department of Surgery, University Hospital Zurich, Zurich, Switzerland
| | | | - Scott Steele
- Department of Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Ker-Kan Tan
- Department of Surgery, School of Medicine, National University of Singapore, Singapore, Singapore
| | - Pieter J Tanis
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, The Netherlands
| | - Paris Tekkis
- Department of Surgery, Royal Marsden Hospital, London, United Kingdom
| | - Biniam Teklay
- Department of Surgery, Åbenrå Hospital, Åbenrå, Denmark
| | | | | | - Petr Tsarkov
- Department of Surgery, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Matthias Turina
- Department of Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Alexis Ulrich
- Department of Surgery, Lukas Hospital, Neuss, Germany
| | - Bruna B Vailati
- Department of Surgery, Angelita and Joaquim Gama Institute, São Paulo, Brazil
| | - Meike van Harten
- Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Cornelis Verhoef
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Satish Warrier
- Department of Surgery, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Steve Wexner
- Department of Surgery, Cleveland Clinic Florida, Weston
| | - Hans de Wilt
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Benjamin A Weinberg
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Cameron Wells
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | | | - Evangelos Xynos
- Department of Surgery, Creta Inter-Clinic Hospital, Heraklion, Crete, Greece
| | - Nancy You
- Department of Surgery, MD Anderson Cancer Center, Houston, Texas
| | - Alexander Zakharenko
- Department of Surgery, Pavlov First St Petersburg State Medical University's Clinic, St Petersburg, Russia
| | | | - Des C Winter
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
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Perez RO, Julião GPS, Proscurshim I, Sabbagh C, Grzona E, Lynn PB, Gama-Rodrigues J. Total mesorectal excision and sphincter preservation — the early steps of rectal cancer surgery. Journal of Coloproctology 2021. [DOI: 10.1016/j.jcol.2013.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
AbstractThe treatment of rectal cancer has evolved significantly over the last 100 years. Standardization of total mesorectal excision and the development of techniques for sphincter preservation have resulted in significant improvements in the management of this disease. Still, local disease control and functional outcomes of sphincter preserving procedures remain a relevant issue. In this historical paper, the oncological and functional outcomes of patients with rectal cancer treated between 1960 and 1971 by a pioneer woman surgeon using a sphincter preserving approach and a technique resembling total mesorectal excision performed at that time are reported. The results reflect one of the earliest steps of partial intersphincteric resection and total mesorectal excision with good oncological outcomes (2% local recurrence) and acceptable functional outcomes in a highly selected group of patients.
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Affiliation(s)
- Rodrigo O. Perez
- Colorectal Surgery Division, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | | | | | - Esteban Grzona
- Angelita & Joaquim Gama Institute, São Paulo, SP, Brazil
| | | | - Joaqim Gama-Rodrigues
- Angelita & Joaquim Gama Institute, São Paulo, SP, Brazil
- Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
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22
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Fernandez LM, São Julião GP, Figueiredo NL, Beets GL, van der Valk MJM, Bahadoer RR, Hilling DE, Meershoek-Klein Kranenbarg E, Roodvoets AGH, Renehan AG, van de Velde CJH, Habr-Gama A, Perez RO. Conditional recurrence-free survival of clinical complete responders managed by watch and wait after neoadjuvant chemoradiotherapy for rectal cancer in the International Watch & Wait Database: a retrospective, international, multicentre registry study. Lancet Oncol 2020; 22:43-50. [PMID: 33316218 DOI: 10.1016/s1470-2045(20)30557-x] [Citation(s) in RCA: 98] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/09/2020] [Accepted: 09/14/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Watch and wait is a novel management strategy in patients with rectal cancer who have a clinical complete response after neoadjuvant chemoradiotherapy. Surveillance of these patients is generally intensive, because local regrowth (with the potential for salvage) occurs in 25% of patients, and distant metastases occur in 10% of patients. It is unclear for how long these patients should be followed up. To address this issue, we did conditional survival modelling using the International Watch & Wait Database (IWWD), which is a large-scale registry of patients with a clinical complete response after neoadjuvant chemotherapy who have been managed by a watch-and-wait strategy. METHODS We did a retrospective, multicentre registry study using a dataset from the IWWD, which includes data from 47 clinics across 15 countries. We selected patients (aged ≥18 years) with rectal cancer who had a clinical complete response after neoadjuvant chemotherapy, and who were subsequently managed by a watch-and-wait strategy between Nov 25, 1991, and Dec 31, 2015. Patients who had not achieved a clinical complete response or who had undergone any surgical procedure were excluded. The criteria used for defining a clinical complete response and the specific surveillance strategies were at the discretion of each participating centre. We used conditional survival modelling to estimate the probability of patients remaining free of local regrowth or distant metastasis for an additional 2 years after sustaining a clinical complete response or being distant metastasis-free for 1, 3, and 5 years from the date of the decision to commence watch and wait. The primary outcomes were conditional local regrowth-free survival at 3 years, and conditional distant metastasis-free survival at 5 years. FINDINGS We identified 793 patients in the IWWD with clinical complete response who had been managed by a watch-and-wait strategy. Median follow-up was 55·2 months (IQR 36·0-75·6). The probability of remaining free from local regrowth for an additional 2 years if a patient had a sustained clinical complete response for 1 year was 88·1% (95% CI 85·8-90·9), for 3 years was 97·3% (95·2-98·6), and for 5 years was 98·6% (97·6-100·0). The probably of remaining free from distant metastasis for a further 2 years in patients who had a clinical complete response without distant metastasis for 1 year was 93·8% (92·3-95·9), for 3 years was 97·8% (96·6-99·3), and for 5 years was 96·6% (94·0-98·9). INTERPRETATION These results suggest that the intensity of active surveillance in patients with rectal cancer managed by a watch-and-wait approach could be reduced if they achieve and maintain a clinical complete response within the first 3 years of starting this approach. FUNDING European Registration of Cancer Care, financed by the European Society of Surgical Oncology, the Champalimaud Foundation Lisbon, the Bas Mulder Award, granted by the Alpe d'HuZes Foundation and the Dutch Cancer Society, the European Research Council Advanced Grant, and the National Institute of Health and Research Manchester Biomedical Research Centre.
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Affiliation(s)
- Laura M Fernandez
- Colorectal Surgery, Digestive Department, Champalimaud Foundation, Lisbon, Portugal
| | - Guilherme P São Julião
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil; Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Nuno L Figueiredo
- Colorectal Surgery, Digestive Department, Champalimaud Foundation, Lisbon, Portugal
| | - Geerard L Beets
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, Netherlands; GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, Netherlands
| | | | - Renu R Bahadoer
- Department of Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Denise E Hilling
- Department of Surgery, Leiden University Medical Center, Leiden, Netherlands; Department of Surgery, Erasmus MC, Rotterdam, Netherlands
| | | | - Annet G H Roodvoets
- Department of Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Andrew G Renehan
- Manchester Cancer Research Centre, National Institute of Health and Research, Manchester Biomedical Research Centre, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, UK; Colorectal and Peritoneal Oncology Centre, The Christie National Health Service Foundation Trust, Manchester, UK
| | | | - Angelita Habr-Gama
- Department of Colorectal Surgery, Angelita and Joaquim Gama Institute, São Paulo, Brazil; Hospital Alemão Oswaldo Cruz, São Paulo, Brazil; University of São Paulo School of Medicine, São Paulo, Brazil
| | - Rodrigo O Perez
- Department of Colorectal Surgery, Angelita and Joaquim Gama Institute, São Paulo, Brazil; Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil; Hospital Alemão Oswaldo Cruz, São Paulo, Brazil; Ludwig Institute for Cancer Research, São Paulo Branch, São Paulo, Brazil.
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Perez RO, São Julião GP. Rectal eversion for direct access to the distal resection margin: do we need another tool in the toolbox of rectal cancer surgery? Tech Coloproctol 2020; 24:989-990. [PMID: 32803499 DOI: 10.1007/s10151-020-02323-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/08/2020] [Indexed: 10/23/2022]
Affiliation(s)
- R O Perez
- Angelita and Joaquim Gama Institute, São Paulo, Brazil. .,São Paulo Branch, Ludwig Institute for Cancer Research, São Paulo, Brazil. .,Departamento de Cirurgia Oncológica, Hospital Beneficencia Portuguesa, São Paulo, Brazil. .,Hospital Alemão Oswaldo Cruz, São Paulo, Brazil.
| | - G P São Julião
- Angelita and Joaquim Gama Institute, São Paulo, Brazil.,Departamento de Cirurgia Oncológica, Hospital Beneficencia Portuguesa, São Paulo, Brazil.,Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
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24
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El Sissy C, Kirilovsky A, Van den Eynde M, Muşină AM, Anitei MG, Romero A, Marliot F, Junca A, Doyen J, Mlecnik B, Haicheur N, Fredriksen T, Lagorce C, Jouret-Mourin A, Leonard D, Bibeau F, Iseas S, Roca EL, Cabanne AM, Vaccaro CA, Santino JP, Huertas E, Tougeron D, Carvalho C, Figueiredo N, Perez RO, Habr-Gama A, Scripcariu V, Gerard JP, Galon J, Zeitoun G, Pagès F. A Diagnostic Biopsy-Adapted Immunoscore Predicts Response to Neoadjuvant Treatment and Selects Patients with Rectal Cancer Eligible for a Watch-and-Wait Strategy. Clin Cancer Res 2020; 26:5198-5207. [PMID: 32669377 DOI: 10.1158/1078-0432.ccr-20-0337] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 05/30/2020] [Accepted: 07/07/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE No biomarker to personalize treatment in locally advanced rectal cancer (LARC) is currently available. We assessed in LARC whether a diagnostic biopsy-adapted immunoscore (ISB) could predict response to neoadjuvant treatment (nT) and better define patients eligible to an organ preservation strategy ("Watch-and-Wait"). EXPERIMENTAL DESIGN Biopsies from two independent cohorts (n 1 = 131, n 2 = 118) of patients with LARC treated with nT followed by radical surgery were immunostained for CD3+ and CD8+ T cells and quantified by digital pathology to determine ISB. The expression of immune-related genes post-nT was investigated (n = 64 patients). Results were correlated with response to nT and disease-free survival (DFS). The ISB prognostic performance was further assessed in a multicentric cohort (n = 73 patients) treated by Watch-and-Wait. RESULTS ISB positively correlated with the degree of histologic response (P < 0.001) and gene expression levels for Th1 orientation and cytotoxic immune response, post-nT (P = 0.006). ISB high identified patients at lower risk of relapse or death compared with ISB low [HR, 0.21; 95% confidence interval (CI), 0.06-0.78; P = 0.009]. Prognostic performance of ISB for DFS was confirmed in a validation cohort. ISB was an independent parameter, more informative than pre- (P < 0.001) and post-nT (P < 0.05) imaging to predict DFS. ISB combined with imaging post-nT discriminated very good responders that could benefit from organ preservation strategy. In the "Watch-and-Wait" cohort (n = 73), no relapse was observed in patients with ISB high (23.3%). CONCLUSIONS ISB predicts response to nT and survival in patients with LARC treated by surgery. Its usefulness in the selection of patients eligible for a Watch-and-Wait strategy is strongly suggested.
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Affiliation(s)
- Carine El Sissy
- Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Université de Paris, Faculté de santé, Paris, France.,Laboratory of Integrative Cancer Immunology, INSERM UMRS1138, Immunology and Cancer Department, Cordeliers Research Center, Paris, France
| | - Amos Kirilovsky
- Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Université de Paris, Faculté de santé, Paris, France.,Laboratory of Integrative Cancer Immunology, INSERM UMRS1138, Immunology and Cancer Department, Cordeliers Research Center, Paris, France
| | - Marc Van den Eynde
- Institut Roi Albert II, Department of Medical Oncology, Cliniques Universitaires St-Luc, Brussels, Belgium
| | - Ana-Maria Muşină
- University of Medicine and Pharmacy "Grigore T. Popa" Iaşi, Department of Surgical Oncology, Regional Institute of Oncology, Iaşi, Roumania
| | - Maria-Gabriela Anitei
- University of Medicine and Pharmacy "Grigore T. Popa" Iaşi, Department of Surgical Oncology, Regional Institute of Oncology, Iaşi, Roumania
| | - Alfredo Romero
- Hospital Britanico de Buenos Aires, Oncología Clínica, Buenos Aires, Argentina
| | - Florence Marliot
- Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Université de Paris, Faculté de santé, Paris, France.,Laboratory of Integrative Cancer Immunology, INSERM UMRS1138, Immunology and Cancer Department, Cordeliers Research Center, Paris, France
| | - Audelaure Junca
- CHU de Poitiers, Service D'hépato-Gastro-Entérologie et Assistance Nutritive, Poitiers, France
| | - Jérôme Doyen
- Centre Antoine Lacassagne, Radiation Oncology, University of Côte d'Azur, Nice, France
| | - Bernhard Mlecnik
- Laboratory of Integrative Cancer Immunology, INSERM UMRS1138, Immunology and Cancer Department, Cordeliers Research Center, Paris, France.,Inovarion, Paris, France
| | - Nacilla Haicheur
- Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Université de Paris, Faculté de santé, Paris, France
| | - Tessa Fredriksen
- Laboratory of Integrative Cancer Immunology, INSERM UMRS1138, Immunology and Cancer Department, Cordeliers Research Center, Paris, France
| | - Christine Lagorce
- Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Université de Paris, Faculté de santé, Paris, France.,Laboratory of Integrative Cancer Immunology, INSERM UMRS1138, Immunology and Cancer Department, Cordeliers Research Center, Paris, France
| | - Anne Jouret-Mourin
- Institut Roi Albert II, Department of Medical Oncology, Cliniques Universitaires St-Luc, Brussels, Belgium
| | - Daniel Leonard
- Institut Roi Albert II, Department of Medical Oncology, Cliniques Universitaires St-Luc, Brussels, Belgium
| | | | - Soledad Iseas
- Hospital Udaondo, Oncología Clínica, Buenos Aires, Argentina
| | - Enrique L Roca
- Hospital Udaondo, Oncología Clínica, Buenos Aires, Argentina
| | - Ana M Cabanne
- Hospital Udaondo, Oncología Clínica, Buenos Aires, Argentina
| | - Carlos A Vaccaro
- Department of General Surgery, Hospital Italiano, Buenos Aires, Argentina
| | - Juan P Santino
- Department of General Surgery, Hospital Italiano, Buenos Aires, Argentina
| | | | - David Tougeron
- CHU de Poitiers, Service D'hépato-Gastro-Entérologie et Assistance Nutritive, Poitiers, France
| | - Carlos Carvalho
- Digestive Department, Champalimaud Foundation, Lisbon, Portugal
| | - Nuno Figueiredo
- Digestive Department, Champalimaud Foundation, Lisbon, Portugal
| | | | | | - Viorel Scripcariu
- Institut Roi Albert II, Department of Medical Oncology, Cliniques Universitaires St-Luc, Brussels, Belgium
| | - Jean-Pierre Gerard
- CHU de Poitiers, Service D'hépato-Gastro-Entérologie et Assistance Nutritive, Poitiers, France
| | - Jérôme Galon
- Laboratory of Integrative Cancer Immunology, INSERM UMRS1138, Immunology and Cancer Department, Cordeliers Research Center, Paris, France
| | - Guy Zeitoun
- Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Université de Paris, Faculté de santé, Paris, France
| | - Franck Pagès
- Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Université de Paris, Faculté de santé, Paris, France. .,Laboratory of Integrative Cancer Immunology, INSERM UMRS1138, Immunology and Cancer Department, Cordeliers Research Center, Paris, France
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Abstract
Rectal cancer treatment has evolved during the past 40 years with the use of a standardized surgical technique for tumour resection: total mesorectal excision. A dramatic reduction in local recurrence rates and improved survival outcomes have been achieved as consequences of a better understanding of the surgical oncology of rectal cancer, and the advent of adjuvant and neoadjuvant treatments to compliment surgery have paved the way for a multidisciplinary approach to disease management. Further improvements in imaging techniques and the ability to identify prognostic factors such as tumour regression, extramural venous invasion and threatened margins have introduced the concept of decision-making based on preoperative staging information. Modern treatment strategies are underpinned by accurate high-resolution imaging guiding both neoadjuvant therapy and precision surgery, followed by meticulous pathological scrutiny identifying the important prognostic factors for adjuvant chemotherapy. Included in these strategies are organ-sparing approaches and watch-and-wait strategies in selected patients. These pathways rely on the close working of interlinked disciplines within a multidisciplinary team. Such multidisciplinary forums are becoming standard in the treatment of rectal cancer across the UK, Europe and, more recently, the USA. This Review examines the essential components of modern-day management of rectal cancer through a multidisciplinary team approach, providing information that is essential for any practising colorectal surgeon to guide the best patient care.
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Affiliation(s)
- Deborah S Keller
- Department of Surgery, New York-Presbyterian, Columbia University Medical Centre, New York, NY, USA
| | - Mariana Berho
- Department of Pathology and Laboratory Medicine, Cleveland Clinic Florida, Weston, Florida, USA
| | | | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - Manish Chand
- Wellcome EPSRC Centre for Interventional and Surgical Sciences (WEISS); University College London, London, UK.
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Abstract
Incorporation of new treatment modalities has significantly increased the complexity of the treatment and management of rectal cancer, including perioperative therapy for local advanced disease and organ preservation for those with response to the preoperative treatment. This review may help practitioners better understand the rationale and selection.
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Affiliation(s)
- Weijing Sun
- University of Kansas Medical Center, Department of Internal Medicine, Medical Oncology Division, Westwood, KS
| | - Raed Al-Rajabi
- University of Kansas Medical Center, Department of Internal Medicine, Medical Oncology Division, Westwood, KS
| | | | - Saquib Abbasi
- University of Kansas Medical Center, Department of Internal Medicine, Medical Oncology Division, Westwood, KS
| | - Ryan Ash
- University of Kansas Medical Center, Department of Radiology, Kansas City, KS
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Fernandez LM, Figueiredo N, Beets G, Valk MVD, Bahadoer R, Hilling D, Renehan A, Van De Velde CJH, Habr-Gama A, Perez RO. Conditional survival of patients with rectal cancer undergoing Watch and Wait: The risk of recurrence over time. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.4_suppl.30] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
30 Background: Patients with rectal cancer and complete clinical response (cCR) after neoadjuvant chemoradiation (nCRT) have been offered non-operative management (W&W). Risk factors for local regrowth (RG) include baseline cT and type of nCRT. However, the influence of risk factors for RG over time and the extent in time that patients need to be followed with the rectum in situ after a cCR are unknown. Objective: Analyze the risk of recurrence over time through conditional survival (cDFS/cLRFS) estimates for rectal cancer patients under W&W. Methods: Retrospective analysis of all patients from the largest multicenter database of patients managed non-operatively (International Watch and Wait Database–IWWD). Only patients with cCR after nCRT and W&W with a median of >3 years of follow-up were included. cDFS was used to investigate the evolution of recurrence-odds, as patients remain disease-free after nCRT. 2-year cDFS was estimated at “x” years after nCRT based on the formula cDFS2=DFS(x+2)/DFS(x). Results: 768 patients treated between 1991-2015 were included. Using cDFSestimates, the probability of remaining disease-free for 2 additional years once cCR was achieved and sustained for 1, 3, and 5 years, were 85%, 97%, and 95%, respectively. These contrast with the actuarial DFS for similar intervals of 70%, 68% and 65% respectively. Baseline cT was associated with the risk of RG at 1 year after a cCR (cT2 aLRFS 89% vs. cT3 82%; p=0.004). However, after sustaining a cCR for 1 year, baseline cT becomes irrelevant at 2 years (cLRFS; 94% vs. 90%; |d| 0.14). Also, total dose of RT (≤50 vs >50Gy) was associated with the risk of RG (aLRFS 76% vs 85%; p=0.03) at 1 year. Dose of RT becomes irrelevant (at 2 years; cLRFS 93% vs. 90%; |d| 0.10) once patients sustained a cCR for 1 year. Conclusions: Conditional survival estimates suggests that patients have significantly lower risks (≤5%) of developing late RG (at 5 years) after sustaining cCR for 3 years. A sustained cCR over time may be more relevant for long-term risk of RG than cT-stage or RT dose. The present data can have significant consequences for the recommendation of intensive surveillance after sustaining 3ys of cCR.
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Affiliation(s)
| | | | | | | | - Renu Bahadoer
- Leids Universitair Medisch Centrum, Leiden, Netherlands
| | | | - Andrew Renehan
- The Christie Hospital NHS Foundation Trust, Manchester, United Kingdom
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Bettoni F, Masotti C, Corrêa BR, Donnard E, Dos Santos FF, São Julião GP, Vailati BB, Habr-Gama A, Galante PAF, Perez RO, Camargo AA. The Effects of Neoadjuvant Chemoradiation in Locally Advanced Rectal Cancer-The Impact in Intratumoral Heterogeneity. Front Oncol 2019; 9:974. [PMID: 31612112 PMCID: PMC6776613 DOI: 10.3389/fonc.2019.00974] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 09/13/2019] [Indexed: 12/22/2022] Open
Abstract
Purpose: Intratumoral genetic heterogeneity (ITGH) is a common feature of solid tumors. However, little is known about the effect of neoadjuvant chemoradiation (nCRT) in ITGH of rectal tumors that exhibit poor response to nCRT. Here, we examined the impact of nCRT in the mutational profile and ITGH of rectal tumors and its adjacent irradiated normal mucosa in the setting of incomplete response to nCRT. Methods and Materials: To evaluate ITGH in rectal tumors, we analyzed whole-exome sequencing (WES) data from 79 tumors obtained from The Cancer Genome Atlas (TCGA). We also compared matched peripheral blood cells, irradiated normal rectal mucosa and pre and post-treatment tumor samples (PRE-T and POS-T) from one individual to examine the iatrogenic effects of nCRT. Finally, we performed WES of 7 PRE-T/POST-T matched samples to examine how nCRT affects ITGH. ITGH was assessed by quantifying subclonal mutations within individual tumors using the Mutant-Allele Tumor Heterogeneity score (MATH score). Results: Rectal tumors exhibit remarkable ITGH that is ultimately associated with disease stage (MATH score stage I/II 35.54 vs. stage III/IV 44.39, p = 0.047) and lymph node metastasis (MATH score N0 35.87 vs. N+ 45.79, p = 0.026). We also showed that nCRT does not seem to introduce detectable somatic mutations in the irradiated mucosa. Comparison of PRE-T and POST-T matched samples revealed a significant increase in ITGH in 5 out 7 patients and MATH scores were significantly higher after nCRT (median 41.7 vs. 28.8, p = 0.04). Finally, we were able to identify a subset of “enriched mutations” with significant changes in MAFs between PRE-T and POST-T samples. These “enriched mutations” were significantly more frequent in POST-T compared to PRE-T samples (92.9% vs. 7.1% p < 0.00001) and include mutations in genes associated with genetic instability and drug resistance in colorectal cancer, indicating the expansion of tumor cell subpopulations more prone to resist to nCRT. Conclusions: nCRT increases ITGH and may result in the expansion of resistant tumor cell populations in residual tumors. The risk of introducing relevant somatic mutations in the adjacent mucosa is minimal but non-responsive tumors may have potentially worse biological behavior when compared to their untreated counterparts. This was an exploratory study, and due to the limited number of samples analyzed, our results need to be validated in larger cohorts.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Anamaria A Camargo
- Hospital Sírio Libanês, São Paulo, Brazil.,Ludwig Institute for Cancer Research, São Paulo, Brazil
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Arezzo A, Lo Secco G, Passera R, Esposito L, Guerrieri M, Ortenzi M, Bujko K, Perez RO, Habr-Gama A, Stipa F, Picchio M, Restivo A, Zorcolo L, Coco C, Rizzo G, Mistrangelo M, Morino M. Individual participant data pooled-analysis of risk factors for recurrence after neoadjuvant radiotherapy and transanal local excision of rectal cancer: the PARTTLE study. Tech Coloproctol 2019; 23:831-842. [PMID: 31388861 DOI: 10.1007/s10151-019-02049-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 07/19/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND An organ-preserving strategy may be a valid alternative in the treatment of selected patients with rectal cancer after neoadjuvant radiotherapy. Preoperative assessment of the risk for tumor recurrence is a key component of surgical planning. The aim of the present study was to increase the current knowledge on the risk factors for tumor recurrence. METHODS The present study included individual participant data of published studies on rectal cancer surgery. The literature was reviewed according to according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Individual Participant Data checklist (PRISMA-IPD) guidelines. Series of patients, whose data were collected prospectively, having neoadjuvant radiotherapy followed by transanal local excision for rectal cancer were reviewed. Three independent series of univariate/multivariate binary logistic regression models were estimated for the risk of local, systemic and overall recurrence, respectively. RESULTS We identified 15 studies, and 7 centers provided individual data on 517 patients. The multivariate analysis showed higher local and overall recurrences for ypT3 stage (OR 4.79; 95% CI 2.25-10.16 and OR 6.43 95% CI 3.33-12.42), tumor size after radiotherapy > 10 mm (OR 5.86 95% CI 2.33-14.74 and OR 3.14 95% CI 1.68-5.87), and lack of combined chemotherapy (OR 3.68 95% CI 1.78-7.62 and OR 2.09 95% CI 1.10-3.97), while ypT3 was the only factor correlated with systemic recurrence (OR 5.93). The analysis of survival curves shows that the overall survival is associated with ypT and not with cT. CONCLUSIONS Local excision should be offered with caution after neoadjuvant chemoradiotherapy to selected patients with rectal cancers, who achieved a good response to neoadjuvant chemoradiotherapy.
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Affiliation(s)
- A Arezzo
- Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Turin, Italy.
| | - G Lo Secco
- Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Turin, Italy
| | - R Passera
- Department of Nuclear Medicine, San Giovanni Battista Hospital, University of Turin, Turin, Italy
| | - L Esposito
- Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Turin, Italy
| | - M Guerrieri
- Department of General Surgery, Università Politecnica delle Marche, Ancona, Italy
| | - M Ortenzi
- Department of General Surgery, Università Politecnica delle Marche, Ancona, Italy
| | - K Bujko
- Department of Radiotherapy, Maria Sklodowska-Curie Memorial Cancer Centre, Warsaw, Poland
| | - R O Perez
- Colorectal Surgery Division, University of São Paulo School of Medicine, São Paulo, Brazil
| | - A Habr-Gama
- Colorectal Surgery Division, University of São Paulo School of Medicine, São Paulo, Brazil
| | - F Stipa
- Department of Surgery, Azienda Ospedaliera San Giovanni-Addolorata, Rome, Italy
| | - M Picchio
- Department of Surgery, Azienda Ospedaliera San Giovanni-Addolorata, Rome, Italy
| | - A Restivo
- Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - L Zorcolo
- Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - C Coco
- Department of Surgical Sciences, Catholic University of Sacred Heart, Rome, Italy
| | - G Rizzo
- Department of Surgical Sciences, Catholic University of Sacred Heart, Rome, Italy
| | - M Mistrangelo
- Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Turin, Italy
| | - M Morino
- Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Turin, Italy
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30
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Ortega CD, Perez RO. Role of magnetic resonance imaging in organ-preserving strategies for the management of patients with rectal cancer. Insights Imaging 2019; 10:59. [PMID: 31147789 PMCID: PMC6542937 DOI: 10.1186/s13244-019-0742-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 04/05/2019] [Indexed: 02/06/2023] Open
Abstract
Total mesorectal excision has been the most effective treatment strategy adopted to reduce local recurrence rates among patients with rectal cancer. The morbidity associated with this radical surgical procedure led surgeons to challenge the standard therapy particularly when dealing with superficial lesions or good responders after neoadjuvant radiotherapy, to which radical surgery may be considered overtreatment. In this subset of patients, less invasive procedures in an organ-preserving strategy may result in good oncological and functional outcomes. In order to tailor the most appropriate treatment option, accurate baseline staging and reassessment of tumor response are relevant. MRI is the most robust tool for the precise selection of patients that are candidates for organ preservation; therefore, radiologists must be familiar with the criteria used to guide the management of these patients. The purpose of this article is to review the relevant features that radiologists should know in order to provide valuable information during the multidisciplinary discussion and ultimate management decision.
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Affiliation(s)
- Cinthia D Ortega
- School of Medicine, Radiology Department, University of São Paulo, Travessa da Rua Dr. Ovídio Pires de Campos, 75, São Paulo, 05403-010, Brazil.
| | - Rodrigo O Perez
- Angelita & Joaquim Gama Institute, São Paulo, Brazil.,School of Medicine, Colorectal Surgery Division, University of São Paulo, São Paulo, Brazil.,Ludwig Institute for Cancer Research São Paulo Branch, São Paulo, Brazil
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El Sissy C, Kirilovsky A, Van Den Eynde M, Romero A, Marliot F, Lagorce C, Bibeau F, Iseas IS, Roca EL, Vaccaro CA, Tougeron D, Carvalho CT, Figueiredo N, Perez RO, Habr Gama A, Scripcariu V, Gerard JP, Galon J, Zeitoun G, Pages F. The consensus Immunoscore adapted to biopsies in patients with locally advanced rectal cancer: Potential clinical significance for a “Watch and Wait” strategy. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.2628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
2628 Background: We investigated whether an adaptation to rectal biopsies of the recently validated consensus Immunoscore, could predict the response to neoadjuvant treatment and delineate clinical responders that could benefit from a “Watch and Wait” (W&W) strategy with acceptable outcomes. Methods: Initial biopsies from 273 patients with locally advanced rectal cancer (LARC) treated by neoadjuvant chemoradiotherapy (nCRT) followed by Total Mesorectal Excision (TME), were immunostained for CD3+ and cytotoxic CD8+ T cells and quantified by digital pathology to determine the Immunoscore within pre-treatment Biopsy (ISB). Expression level of 44 immune related genes post-neoadjuvant treatment was investigated by Nanostring technology (n = 64 patients). Results were correlated with response to neoadjuvant treatment, disease free survival (DFS) and time to recurrence (TTR). Prognostic performance of ISB was finally assessed in 73 LARC treated by W&W strategy. Results: ISB Low, Intermediate and High were respectively observed in 23.3, 50.4 and 26.3 % of the cohort. ISB was positively and significantly correlated with the response to nCRT, as evaluated by Dworak classification (P = .0034), ypTNM (P = .0003), down-staging (P = .0014), and neoadjuvant rectal (NAR) score, (P < .0001). ISB status was also positively associated with the degree of local immune activation post-neoadjuvant treatment. ISB High patients were at low risk of relapse, with 5-year DFS rates of 81.1 % (CI, 71.3-92.1 %) as compared to 57.8 % (CI, 45.9-72.9 %) in ISB low patients. In multivariate analysis, ISB was the only significant parameter at presentation associated with DFS (High vs Low: P = .001). Among W&W patients, significant difference was observed for TTR according to ISB status (High vs Low: P = .025). Conclusions: ISB could provide a reliable estimate of the response to nCRT and risk of recurrence in LARC patients' treated by TME or W&W strategy.
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Affiliation(s)
| | | | - Marc Van Den Eynde
- Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Alfredo Romero
- Hospital Britanico de Buenos Aires, Buenos Aires, Argentina
| | | | | | | | - Ilma Soledad Iseas
- Clinical Oncology Unit, Hospital Bonorino Udaondo, Buenos Aires, Argentina
| | - Enrique Luis Roca
- Clinical Oncology Unit, Hospital Bonorino Udaondo, Buenos Aires, Argentina
| | | | | | | | | | | | | | | | | | - Jerome Galon
- Laboratory of Integrative Cancer Immunology, INSERM, Paris, France
| | | | - Franck Pages
- INSERM, Laboratory of Integrative Cancer Immunology, Equipe Labellisée Ligue Contre le Cancer, Paris, France
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Chadi SA, Beets GL, Perez RO, Renehan AG. Watch-and-wait strategy in rectal cancer – Authors' reply. Lancet Gastroenterol Hepatol 2019; 4:97. [DOI: 10.1016/s2468-1253(18)30418-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 11/27/2018] [Indexed: 01/18/2023]
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Koyama FC, Lopes Ramos CM, Ledesma F, Alves VAF, Fernandes JM, Vailati BB, São Julião GP, Habr-Gama A, Gama-Rodrigues J, Perez RO, Camargo AA. Effect of Akt activation and experimental pharmacological inhibition on responses to neoadjuvant chemoradiotherapy in rectal cancer. Br J Surg 2018; 105:e192-e203. [PMID: 29341150 DOI: 10.1002/bjs.10695] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 08/13/2017] [Accepted: 08/14/2017] [Indexed: 01/18/2023]
Abstract
BACKGROUND Neoadjuvant chemoradiotherapy (CRT) is one of the preferred initial treatment strategies for locally advanced rectal cancer. Responses are variable, and most patients still require surgery. The aim of this study was to identify molecular mechanisms determining poor response to CRT. METHODS Global gene expression and pathway enrichment were assessed in pretreatment biopsies from patients with non-metastatic cT2-4 N0-2 rectal cancer within 7 cm of the anal verge. Downstream Akt activation was assessed in an independent set of pretreatment biopsies and in colorectal cancer cell lines using immunohistochemistry and western blot respectively. The radiosensitizing effects of the Akt inhibitor MK2206 were assessed using clonogenic assays and xenografts in immunodeficient mice. RESULTS A total of 350 differentially expressed genes were identified, of which 123 were upregulated and 199 downregulated in tumours from poor responders. Mitochondrial oxidative phosphorylation (P < 0·001) and phosphatidylinositol signalling pathways (P < 0·050) were identified as significantly enriched pathways among the set of differentially expressed genes. Deregulation of both pathways is known to result in Akt activation, and high immunoexpression of phosphorylated Akt S473 was observed among patients with a poor histological response (tumour regression grade 0-2) to CRT (75 per cent versus 48 per cent in those with a good or complete response; P = 0·016). Akt activation was also confirmed in the radioresistant cell line SW480, and a 50 per cent improvement in sensitivity to CRT was observed in vitro and in vivo when SW480 cells were exposed to the Akt inhibitor MK2206 in combination with radiation and 5-fluorouracil. CONCLUSION Akt activation is a key event in the response to CRT. Pharmacological inhibition of Akt activation may enhance the effects of CRT. Surgical relevance Organ preservation is an attractive alternative in rectal cancer management following neoadjuvant chemoradiotherapy (CRT) to avoid the morbidity of radical surgery. Molecular steps associated with tumour response to CRT may provide a useful tool for the identification of patients who are candidates for no immediate surgery. In this study, tumours resistant to CRT were more likely to have activation of specific genetic pathways that result in phosphorylated Akt (pAkt) activation. Pretreatment biopsy tissues with high immunoexpression of pAkt were more likely to exhibit a poor histological response to CRT. In addition, the introduction of a pAkt inhibitor to cancer cell lines in vitro and in vivo led to a significant improvement in sensitivity to CRT. Identification of pAkt-activated tumours may thus allow the identification of poor responders to CRT. In addition, the concomitant use of pAkt inhibitors to increase sensitivity to CRT in patients with rectal cancer may constitute an interesting strategy for increasing the chance of a complete response to treatment and organ preservation.
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Affiliation(s)
- F C Koyama
- Molecular Oncology Centre, Hospital Sírio Libanês, São Paulo, Brazil.,Ludwig Institute for Cancer Research, São Paulo, Brazil
| | - C M Lopes Ramos
- Molecular Oncology Centre, Hospital Sírio Libanês, São Paulo, Brazil
| | - F Ledesma
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - V A F Alves
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - J M Fernandes
- Molecular Oncology Centre, Hospital Sírio Libanês, São Paulo, Brazil
| | - B B Vailati
- Instituto Angelita and Joaquim Gama, São Paulo, Brazil
| | | | - A Habr-Gama
- Instituto Angelita and Joaquim Gama, São Paulo, Brazil.,Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - J Gama-Rodrigues
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - R O Perez
- Ludwig Institute for Cancer Research, São Paulo, Brazil.,Instituto Angelita and Joaquim Gama, São Paulo, Brazil.,Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.,Digestive Surgical Oncology Division, BP - A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | - A A Camargo
- Molecular Oncology Centre, Hospital Sírio Libanês, São Paulo, Brazil.,Ludwig Institute for Cancer Research, São Paulo, Brazil
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Affiliation(s)
- Angelita Habr-Gama
- Angelita & Joaquim Gama Institute, São Paulo, Brazil; University of São Paulo School of Medicine, São Paulo, Brazil
| | | | - Rodrigo O Perez
- Angelita & Joaquim Gama Institute, São Paulo, Brazil; Colorectal Surgery Division, University of São Paulo School of Medicine, São Paulo, Brazil; Ludwig Institute for Cancer Research, São Paulo, Brazil; Gastrointestinal Surgical Oncology Division, Beneficência Portuguesa de São Paulo, São Paulo, Brazil
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van der Valk MJM, Hilling DE, Bastiaannet E, Meershoek-Klein Kranenbarg E, Beets GL, Figueiredo NL, Habr-Gama A, Perez RO, Renehan AG, van de Velde CJH. Long-term outcomes of clinical complete responders after neoadjuvant treatment for rectal cancer in the International Watch & Wait Database (IWWD): an international multicentre registry study. Lancet 2018; 391:2537-2545. [PMID: 29976470 DOI: 10.1016/s0140-6736(18)31078-x] [Citation(s) in RCA: 569] [Impact Index Per Article: 94.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 05/06/2018] [Accepted: 05/08/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND The strategy of watch and wait (W&W) in patients with rectal cancer who achieve a complete clinical response (cCR) after neoadjuvant therapy is new and offers an opportunity for patients to avoid major resection surgery. However, evidence is based on small-to-moderate sized series from specialist centres. The International Watch & Wait Database (IWWD) aims to describe the outcome of the W&W strategy in a large-scale registry of pooled individual patient data. We report the results of a descriptive analysis after inclusion of more than 1000 patients in the registry. METHODS Participating centres entered data in the registry through an online, highly secured, and encrypted research data server. Data included baseline characteristics, neoadjuvant therapy, imaging protocols, incidence of local regrowth and distant metastasis, and survival status. All patients with rectal cancer in whom the standard of care (total mesorectal excision surgery) was omitted after neoadjuvant therapy were eligible to be included in the IWWD. For the present analysis, we only selected patients with no signs of residual tumour at reassessment (a cCR). We analysed the proportion of patients with local regrowth, proportion of patients with distant metastases, 5-year overall survival, and 5-year disease-specific survival. FINDINGS Between April 14, 2015, and June 30, 2017, we identified 1009 patients who received neoadjuvant treatment and were managed by W&W in the database from 47 participating institutes (15 countries). We included 880 (87%) patients with a cCR. Median follow-up time was 3·3 years (95% CI 3·1-3·6). The 2-year cumulative incidence of local regrowth was 25·2% (95% CI 22·2-28·5%), 88% of all local regrowth was diagnosed in the first 2 years, and 97% of local regrowth was located in the bowel wall. Distant metastasis were diagnosed in 71 (8%) of 880 patients. 5-year overall survival was 85% (95% CI 80·9-87·7%), and 5-year disease-specific survival was 94% (91-96%). INTERPRETATION This dataset has the largest series of patients with rectal cancer treated with a W&W approach, consisting of approximately 50% data from previous cohort series and 50% unpublished data. Local regrowth occurs mostly in the first 2 years and in the bowel wall, emphasising the importance of endoscopic surveillance to ensure the option of deferred curative surgery. Local unsalvageable disease after W&W was rare. FUNDING European Registration of Cancer Care financed by European Society of Surgical Oncology, Champalimaud Foundation Lisbon, Bas Mulder Award granted by the Alpe d'Huzes Foundation and Dutch Cancer Society, and European Research Council Advanced Grant.
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Affiliation(s)
- Maxime J M van der Valk
- Department of Surgery, Leiden University Medical Center, Leiden, Netherlands; Department of Surgery, Netherlands Cancer institute, Amsterdam, Netherlands
| | - Denise E Hilling
- Department of Surgery, Leiden University Medical Center, Leiden, Netherlands; Department of Surgery, Netherlands Cancer institute, Amsterdam, Netherlands
| | - Esther Bastiaannet
- Department of Surgery, Leiden University Medical Center, Leiden, Netherlands; Department of Medical Oncology, Leiden University Medical Center, Leiden, Netherlands
| | | | - Geerard L Beets
- Department of Surgery, Netherlands Cancer institute, Amsterdam, Netherlands; GROW School for Oncology and Developmental Biology, Maastricht University, Netherlands.
| | - Nuno L Figueiredo
- Colorectal Surgery, Digestive Department, Champalimaud Foundation, Lisbon, Portugal
| | - Angelita Habr-Gama
- Department of Colorectal Surgery, Angelita and Joaquim Gama Institute, São Paolo, Brazil
| | - Rodrigo O Perez
- Department of Colorectal Surgery, Angelita and Joaquim Gama Institute, São Paolo, Brazil
| | - Andrew G Renehan
- Manchester Cancer Research Centre, National Institute of Health and Research Manchester Biomedical Research Centre, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, UK; Colorectal and Peritoneal Oncology Centre, The Christie National Health Service Foundation Trust, Manchester, UK
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Battersby NJ, Perez RO, Baxter N, Moran B, Brown G. Session 4: Trying to augment response with chemotherapy: a triumph of hope over experience? Colorectal Dis 2018; 20 Suppl 1:100-102. [PMID: 29878682 DOI: 10.1111/codi.14089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
As part of an approach to improve tumour regression and increase the proportion of patients with complete clinical and radiological response, Dr Perez reviews the methods and evidence base for augmenting therapy and thus augmenting response rates preoperatively. Much of the data reviewed were in the context of patients undergoing a watch-and-wait approach for rectal cancer after initial treatment with chemoradiotherapy.
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Affiliation(s)
| | - R O Perez
- Angelita & Joaquim Gama Institute, São Paulo, Brazil.,Colorectal Surgery Division, University of São Paulo School of Medicine, São Paulo, Brazil.,Ludwig Institute for Cancer Research, São Paulo, Brazil.,Gastrointestinal Surgical Oncology Division, Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | - N Baxter
- University of Toronto, Toronto, ON, Canada
| | - B Moran
- North Hampshire Hospital, Basingstoke, UK
| | - G Brown
- The Royal Marsden NHS Foundation Trust, London, UK.,Gastrointestinal Cancer Imaging, Imperial College London, London, UK
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Abstract
The surgical management of rectal cancer has evolved from a disease without any possibility of cure in the early 1700s where surgical management consisted of the palliative drainage of disease related abscesses to the present day where surgical cure is not only possible but also possible with sphincter or even organ preservation. Prof Habr-Gama's lecture describes the evolution of the surgical management of rectal cancer and the current focus on organ preservation.
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Affiliation(s)
- R O Perez
- Angelita and Joaquim Gama Institute, São Paulo, Brazil.,Colorectal Surgery Division, School of Medicine, University of São Paulo, São Paulo, Brazil.,Ludwig Institute for Cancer Research, São Paulo, Brazil.,Gastrointestinal Surgical Oncology Division, Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | - A Habr-Gama
- Angelita and Joaquim Gama Institute, São Paulo, Brazil.,Colorectal Surgery Division, School of Medicine, University of São Paulo, São Paulo, Brazil
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Habr-Gama A, Perez RO. Contact Radiation Therapy for Achieving Organ Preservation in Rectal Cancer After Standard Neoadjuvant Chemoradiation: Looking for a Place in the Sun. Int J Radiat Oncol Biol Phys 2018; 100:574-576. [PMID: 29413272 DOI: 10.1016/j.ijrobp.2017.11.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 11/17/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Angelita Habr-Gama
- Angelita & Joaquim Gama Institute, São Paulo, Brazil; University of São Paulo School of Medicine, São Paulo, Brazil.
| | - Rodrigo O Perez
- Angelita & Joaquim Gama Institute, São Paulo, Brazil; Colorectal Surgery Division, University of São Paulo School of Medicine, São Paulo, Brazil; Ludwig Institute for Cancer Research, São Paulo, Brazil; Gastrointestinal Surgical Oncology Division, Beneficência Portuguesa de São Paulo, São Paulo, Brazil
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Masotti C, Bettoni F, Correa BR, Habr-Gama A, Gama-Rodrigues J, Viana M, Vailati BB, Juliao GPS, Fernandez LM, Galante PAF, Perez RO, Camargo AA. Abstract B62: Intratumoral genetic heterogeneity in rectal cancer and response to neoadjuvant chemoradiotherapy. Clin Cancer Res 2018. [DOI: 10.1158/1557-3265.tcm17-b62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Response to neoadjuvant chemoradiotherapy (nCRT) varies substantially among patients with locally advanced rectal cancer, but key determinants of treatment response are not fully understood. Intratumoral genetic heterogeneity (ITGH) is a common feature of solid tumors and has been proposed to drive disease progression and treatment response. Others and we have recently demonstrated that primary nontreated rectal tumors exhibit significant ITGH, but the effect of nCRT in shaping the clonal architecture of rectal cancer has not yet been addressed. In the present work, we further expanded the analysis of ITGH in rectal cancer by analyzing whole-exome sequencing (WES) and clinical data from 79 primary nontreated rectal cancers obtained from The Cancer Genome Atlas. We show that primary rectal tumors exhibit a remarkable variability in the degree of ITH. We also analyzed the effect of nCRT on ITGH and monitored tumor cell subpopulation dynamics after treatment through WES of paired tumor samples collected at diagnosis (pretreatment) and at surgery following nCRT (post-treatment) from seven patients. We show that treatment exposure does not introduce novel somatic mutations or significantly alter tissue genetic heterogeneity. Instead, nCRT acts as a potent selective pressure, shaping the mutational landscape of rectal tumors and allowing the selection and expansion of tumor cell subpopulations, which are more prone to resist nCRT. Our results shed light on the highly heterogeneous and dynamic mutational landscape of rectal tumors and indicate that ITGH may directly affect response to nCRT.
Citation Format: Cibele Masotti, Fabiana Bettoni, Bruna R. Correa, Angelita Habr-Gama, Joaquim Gama-Rodrigues, Maria Viana, Bruna B. Vailati, Guilherme P. Sao Juliao, Laura M. Fernandez, Pedro A. F. Galante, Rodrigo O. Perez, Anamaria A. Camargo. Intratumoral genetic heterogeneity in rectal cancer and response to neoadjuvant chemoradiotherapy [abstract]. In: Proceedings of the AACR International Conference held in cooperation with the Latin American Cooperative Oncology Group (LACOG) on Translational Cancer Medicine; May 4-6, 2017; São Paulo, Brazil. Philadelphia (PA): AACR; Clin Cancer Res 2018;24(1_Suppl):Abstract nr B62.
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Affiliation(s)
- Cibele Masotti
- 1Centro de Oncologia Molecular, Instituto de Ensino e Pesquisa do Hospital Sirio-Libanes, São Paulo, SP, Brazil,
| | - Fabiana Bettoni
- 1Centro de Oncologia Molecular, Instituto de Ensino e Pesquisa do Hospital Sirio-Libanes, São Paulo, SP, Brazil,
| | - Bruna R. Correa
- 1Centro de Oncologia Molecular, Instituto de Ensino e Pesquisa do Hospital Sirio-Libanes, São Paulo, SP, Brazil,
| | | | | | - Maria Viana
- 3CICAP, Pathology Division, São Paulo, SP, Brazil
| | | | | | | | - Pedro A. F. Galante
- 1Centro de Oncologia Molecular, Instituto de Ensino e Pesquisa do Hospital Sirio-Libanes, São Paulo, SP, Brazil,
| | | | - Anamaria A. Camargo
- 1Centro de Oncologia Molecular, Instituto de Ensino e Pesquisa do Hospital Sirio-Libanes, São Paulo, SP, Brazil,
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Koyama FC, Ramos CML, Fernandes JM, Ledesma FC, Alves VAF, Vailati FC, Habr-Gama A, Perez RO, Camargo AA. Abstract A53: Akt inhibitior MK2206 combination to neoadjuvant radiotherapy: Improving the rectal cancer treatment. Clin Cancer Res 2018. [DOI: 10.1158/1557-3265.tcm17-a53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Resistance to therapy is the major obstacle to a favorable outcome in cancer treatment. Neoadjuvant chemoradiotherapy (nCRT) can lead to complete tumor regression in a significant proportion of patients with rectal cancer (up to 40%). The possibility of avoiding radical surgery and its associated functional consequences for those who present complete response has become increasingly attractive, but approximately 60% of patients have only partial or no tumor remission after nCRT. In order to identify molecular mechanisms determining poor response to nCRT and to uncover optimized treatment strategies, we have conducted global gene expression analysis followed by pathway enrichment analysis in pretreatment biopsies from patients showing complete or poor clinical response to nCRT. We show that mitochondrial oxidative phosphorylation and phosphatidylinositol signaling pathways are consistently altered in rectal tumors comparatively. Both pathways have already been associated with resistance to radiation and chemotherapy in solid tumors and appear to converge on the activation of the Akt pathway in nonresponding tumors. To further address the role of Akt activation in response to nCRT, we evaluated by immunohistochemistry, Akt activation in an independent set of pretreatment biopsies from rectal cancer patients and observed not only high pAkt levels in those presenting poor response to nCRT but also that nuclear pAkt can also discriminate resistant tumors. We also evaluated the combination of an allosteric Akt-inhibitor MK2206 to chemoradiation in a radioresistant colorectal cancer cell line SW480 either in vitro and in vivo and observed an improvement of 50% of tumoricidal effect. Altogether, our results indicate that activation of the Akt pathway is a key event affecting response to nCRT and that combining chemoradiotherapy and Akt inhibitors such as MK2206 may significantly improve response rates to neoadjuvant therapy in rectal cancer.
Citation Format: Fernanda C. Koyama, Camila M. Lopes Ramos, Jennifer M. Fernandes, Fernanda C. Ledesma, Venancio A F Alves, Fernanda C. Vailati, Angelita Habr-Gama, Rodrigo O. Perez, Anamaria A. Camargo. Akt inhibitior MK2206 combination to neoadjuvant radiotherapy: Improving the rectal cancer treatment [abstract]. In: Proceedings of the AACR International Conference held in cooperation with the Latin American Cooperative Oncology Group (LACOG) on Translational Cancer Medicine; May 4-6, 2017; São Paulo, Brazil. Philadelphia (PA): AACR; Clin Cancer Res 2018;24(1_Suppl):Abstract nr A53.
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Affiliation(s)
| | | | | | | | - Venancio A F Alves
- 2Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil,
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Lopes-Ramos CM, Barros BP, Koyama FC, Carpinetti PA, Pezuk J, Doimo NTS, Habr-Gama A, Perez RO, Parmigiani RB. E2F1 somatic mutation within miRNA target site impairs gene regulation in colorectal cancer. PLoS One 2017; 12:e0181153. [PMID: 28704519 PMCID: PMC5509303 DOI: 10.1371/journal.pone.0181153] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Accepted: 06/27/2017] [Indexed: 01/06/2023] Open
Abstract
Background Genetic studies have largely concentrated on the impact of somatic mutations found in coding regions, and have neglected mutations outside of these. However, 3’ untranslated regions (3' UTR) mutations can also disrupt or create miRNA target sites, and trigger oncogene activation or tumor suppressor inactivation. Methods We used next-generation sequencing to widely screen for genetic alterations within predicted miRNA target sites of oncogenes associated with colorectal cancer, and evaluated the functional impact of a new somatic mutation. Target sequencing of 47 genes was performed for 29 primary colorectal tumor samples. For 71 independent samples, Sanger methodology was used to screen for E2F1 mutations in miRNA predicted target sites, and the functional impact of these mutations was evaluated by luciferase reporter assays. Results We identified germline and somatic alterations in E2F1. Of the 100 samples evaluated, 3 had germline alterations at the MIR205-5p target site, while one had a somatic mutation at MIR136-5p target site. E2F1 gene expression was similar between normal and tumor tissues bearing the germline alteration; however, expression was increased 4-fold in tumor tissue that harbored a somatic mutation compared to that in normal tissue. Luciferase reporter assays revealed both germline and somatic alterations increased E2F1 activity relative to wild-type E2F1. Conclusions We demonstrated that somatic mutation within E2F1:MIR136-5p target site impairs miRNA-mediated regulation and leads to increased gene activity. We conclude that somatic mutations that disrupt miRNA target sites have the potential to impact gene regulation, highlighting an important mechanism of oncogene activation.
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Affiliation(s)
| | - Bruna P. Barros
- Centro de Oncologia Molecular, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Fernanda C. Koyama
- Centro de Oncologia Molecular, Hospital Sírio-Libanês, São Paulo, Brazil
- Ludwig Institute for Cancer Research, São Paulo, Brazil
| | | | - Julia Pezuk
- Centro de Oncologia Molecular, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Nayara T. S. Doimo
- Centro de Oncologia Molecular, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Angelita Habr-Gama
- Angelita & Joaquim Gama Institute, São Paulo, Brazil
- University of São Paulo School of Medicine, São Paulo, Brazil
| | - Rodrigo O. Perez
- Ludwig Institute for Cancer Research, São Paulo, Brazil
- Angelita & Joaquim Gama Institute, São Paulo, Brazil
- University of São Paulo School of Medicine, São Paulo, Brazil
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Habr-Gama A, Julião GPS, Perez RO. Inferior Survival Rates After Chemoradiation for Rectal Cancer Without Surgery. JAMA Oncol 2017; 3:859. [PMID: 28448642 DOI: 10.1001/jamaoncol.2016.6618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | | | - Rodrigo O Perez
- Angelita & Joaquim Gama Institute, São Paulo/SP, Brazil2Colorectal Surgery Division, University of São Paulo School of Medicine, São Paulo/SP, Brazil3Ludwig Institute for Cancer Research São Paulo Branch, São Paulo/SP, Brazil
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São Julião GP, Ortega CD, Vailati BB, Habr-Gama A, Fernandez LM, Gama-Rodrigues J, Araujo SE, Perez RO. Magnetic resonance imaging following neoadjuvant chemoradiation and transanal endoscopic microsurgery for rectal cancer. Colorectal Dis 2017; 19:O196-O203. [PMID: 28436197 DOI: 10.1111/codi.13691] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 02/15/2017] [Indexed: 02/08/2023]
Abstract
AIM Full-thickness local excision after neoadjuvant chemoradiotherapy (CRT) for patients with rectal cancer and incomplete clinical response has been a treatment strategy for organ preservation. Follow-up of these patients is challenging since anatomic distortion and postoperative changes may be clinically indistinguishable from tumour recurrence. MRI may have a role in detecting recurrence. The aim of this study was to describe the MRI findings during follow-up in patients having local excision following CRT with and without local recurrence. METHOD The data were collected retrospectively from a single centre. Fifty-three patients with rectal cancer who had full-thickness local excision after neoadjuvant CRT and near-complete response were eligible for the study. Patients with local recurrence were treated by radical salvage surgery. The main outcome was local MRI assessment findings during follow-up. RESULTS Fifteen patients (five who developed local recurrence and 10 with no evidence of local recurrence) had MR images available for review and were included in the study. High signal intensity and thickening of the rectal wall were present in all patients with recurrent disease within the rectal wall. Overall, 80% of the patients with recurrence showed diffusion restriction. MRI mesorectal fascia status and circumferential resection margin showed agreement in all cases. A low signal intensity scar was seen in all patients without recurrent disease. CONCLUSION MRI shows high signal intensity and thickening of the rectal wall in recurrent disease in comparison to a low signal intensity fibrotic scar in non-recurrent disease. These findings may be useful in surveillance of these patients.
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Affiliation(s)
- G P São Julião
- Angelita and Joaquim Gama Institute, Sao Paulo, SP, Brazil.,Hospital Alemão Oswaldo Cruz, Sao Paulo, SP, Brazil
| | - C D Ortega
- Angelita and Joaquim Gama Institute, Sao Paulo, SP, Brazil.,School of Medicine, University of São Paulo, Sao Paulo, SP, Brazil
| | - B B Vailati
- Angelita and Joaquim Gama Institute, Sao Paulo, SP, Brazil.,Hospital Alemão Oswaldo Cruz, Sao Paulo, SP, Brazil
| | - A Habr-Gama
- Angelita and Joaquim Gama Institute, Sao Paulo, SP, Brazil.,Hospital Alemão Oswaldo Cruz, Sao Paulo, SP, Brazil.,School of Medicine, University of São Paulo, Sao Paulo, SP, Brazil
| | - L M Fernandez
- Angelita and Joaquim Gama Institute, Sao Paulo, SP, Brazil
| | - J Gama-Rodrigues
- Angelita and Joaquim Gama Institute, Sao Paulo, SP, Brazil.,Hospital Alemão Oswaldo Cruz, Sao Paulo, SP, Brazil.,School of Medicine, University of São Paulo, Sao Paulo, SP, Brazil
| | - S E Araujo
- Colorectal Surgery Division, School of Medicine, University of São Paulo, Sao Paulo, SP, Brazil
| | - R O Perez
- Angelita and Joaquim Gama Institute, Sao Paulo, SP, Brazil.,Hospital Alemão Oswaldo Cruz, Sao Paulo, SP, Brazil.,Colorectal Surgery Division, School of Medicine, University of São Paulo, Sao Paulo, SP, Brazil.,São Paulo Branch, Ludwig Institute for Cancer Research, Sao Paulo, SP, Brazil.,Surgical Oncology Division, BP - A Beneficência Portuguesa de São Paulo, Sao Paulo, SP, Brazil
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Habr-Gama A, Perez RO. No Surgery After Chemoradiation Is Not Equal to Nonoperative Management After Complete Clinical Response and Chemoradiation. J Clin Oncol 2016; 34:4051. [PMID: 27528720 DOI: 10.1200/jco.2016.67.9001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Angelita Habr-Gama
- Angelita Habr-Gama, Angelita & Joaquim Gama Institute, São Paulo, Brazil; and Rodrigo O. Perez, Angelita & Joaquim Gama Institute; University of São Paulo School of Medicine; and Ludwig Institute for Cancer Research São Paulo Branch, São Paulo, Brazil
| | - Rodrigo O Perez
- Angelita Habr-Gama, Angelita & Joaquim Gama Institute, São Paulo, Brazil; and Rodrigo O. Perez, Angelita & Joaquim Gama Institute; University of São Paulo School of Medicine; and Ludwig Institute for Cancer Research São Paulo Branch, São Paulo, Brazil
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Carpinetti P, Donnard E, Bettoni F, Asprino P, Koyama F, Rozanski A, Sabbaga J, Habr-Gama A, Parmigiani RB, Galante PAF, Perez RO, Camargo AA. The use of personalized biomarkers and liquid biopsies to monitor treatment response and disease recurrence in locally advanced rectal cancer after neoadjuvant chemoradiation. Oncotarget 2016; 6:38360-71. [PMID: 26451609 PMCID: PMC4742005 DOI: 10.18632/oncotarget.5256] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 09/24/2015] [Indexed: 12/18/2022] Open
Abstract
Neoadjuvant chemoradiotherapy (nCRT) followed by surgery is the mainstay treatment for locally advanced rectal cancer. Variable degrees of tumor regression are observed after nCRT and alternative treatment strategies, including close surveillance without immediate surgery, have been investigated to spare patients with complete tumor regression from potentially adverse outcomes of radical surgery. However, clinical and radiological assessment of response does not allow accurate identification of patients with complete response. In addition, surveillance for recurrence is similarly important for these patients, as early detection of recurrence allows salvage resections and adjuvant interventions. We report the use of liquid biopsies and personalized biomarkers for monitoring treatment response to nCRT and detecting residual disease and recurrence in patients with rectal cancer. We sequenced the whole-genome of four rectal tumors to identify patient-specific chromosomal rearrangements that were used to monitor circulating tumor DNA (ctDNA) in liquid biopsies collected at diagnosis and during nCRT and follow-up. We compared ctDNA levels to clinical, radiological and pathological response to nCRT. Our results indicate that personalized biomarkers and liquid biopsies may not be sensitive for the detection of microscopic residual disease. However, it can be efficiently used to monitor treatment response to nCRT and detect disease recurrence, preceding increases in CEA levels and radiological diagnosis. Similar good results were observed when assessing tumor response to systemic therapy and disease progression. Our study supports the use of personalized biomarkers and liquid biopsies to tailor the management of rectal cancer patients, however, replication in a larger cohort is necessary to introduce this strategy into clinical practice.
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Affiliation(s)
- Paola Carpinetti
- Ludwig Institute for Cancer Research, São Paulo, SP, Brazil.,Centro de Oncologia Molecular Hospital Sírio Libanês, São Paulo, SP, Brazil.,Programa de Pós Graduação em Bioquímica, Instituto de Química, Universidade de São Paulo, SP, Brazil
| | - Elisa Donnard
- Ludwig Institute for Cancer Research, São Paulo, SP, Brazil.,Centro de Oncologia Molecular Hospital Sírio Libanês, São Paulo, SP, Brazil.,Programa de Pós Graduação em Bioquímica, Instituto de Química, Universidade de São Paulo, SP, Brazil
| | - Fabiana Bettoni
- Centro de Oncologia Molecular Hospital Sírio Libanês, São Paulo, SP, Brazil
| | - Paula Asprino
- Centro de Oncologia Molecular Hospital Sírio Libanês, São Paulo, SP, Brazil
| | | | - Andrei Rozanski
- Centro de Oncologia Molecular Hospital Sírio Libanês, São Paulo, SP, Brazil
| | - Jorge Sabbaga
- Centro de Oncologia Clínica, Hospital Sírio Libanês, São Paulo, SP, Brazil
| | - Angelita Habr-Gama
- Angelita & Joaquim Gama Institute, São Paulo, SP, Brazil.,University of São Paulo, School of Medicine, São Paulo, SP, Brazil
| | | | - Pedro A F Galante
- Centro de Oncologia Molecular Hospital Sírio Libanês, São Paulo, SP, Brazil
| | - Rodrigo O Perez
- Ludwig Institute for Cancer Research, São Paulo, SP, Brazil.,Angelita & Joaquim Gama Institute, São Paulo, SP, Brazil.,University of São Paulo, School of Medicine, São Paulo, SP, Brazil
| | - Anamaria A Camargo
- Ludwig Institute for Cancer Research, São Paulo, SP, Brazil.,Centro de Oncologia Molecular Hospital Sírio Libanês, São Paulo, SP, Brazil
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dos Anjos DA, Habr-Gama A, Vailati BB, Rossi CB, Coturel AE, Perez RO, São Julião GP, de Sousa JB, Buchpiguel CA. 18F-FDG uptake by rectal cancer is similar in mucinous and nonmucinous histological subtypes. Ann Nucl Med 2016; 30:513-7. [DOI: 10.1007/s12149-016-1089-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 05/22/2016] [Indexed: 12/17/2022]
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Habr-Gama A, Perez RO, São Julião GP, Proscurshim I, Fernandez LM, Figueiredo MN, Gama-Rodrigues J, Buchpiguel CA. Consolidation chemotherapy during neoadjuvant chemoradiation (CRT) for distal rectal cancer leads to sustained decrease in tumor metabolism when compared to standard CRT regimen. Radiat Oncol 2016; 11:24. [PMID: 26911200 PMCID: PMC4766749 DOI: 10.1186/s13014-016-0598-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 02/04/2016] [Indexed: 02/07/2023] Open
Abstract
Background Neoadjuvant CRT may lead to significant tumor regression in patients with rectal cancer. Different CRT regimens with consolidation chemotherapy may lead to increased rates of complete tumor regression. The purpose of this study was to understand tumor metabolic activity following two different neoadjuvant CRT regimens using sequential PET/CT imaging in two different intervals following RT. Methods Patients with cT2-4 N0-2 M0 rectal cancer treated by standard CRT (54Gy and 2 cycles of 5FU-based chemotherapy) or extended CRT (54Gy and 6 cycles of 5FU-based chemotherapy) underwent sequential PET/CT imaging at baseline, 6 weeks and 12 weeks from radiation completion. Results 99 patients undergoing standard CRT were compared to 12 patients undergoing CRT with consolidation chemotherapy. Patients treated with consolidation CRT had increased rates of complete clinical or pathological response (66 % vs. 23 %; p < 0.001). SUVmax variation between baseline and 6 weeks (88 % vs. 63 %; p < 0.001) and between baseline and 12 weeks (90 % vs. 57 %; p < 0.001) were significantly more pronounced among patients undergoing extended CRT with consolidation chemotherapy. An increase in SUVmax between 6 and 12 weeks was observed in 51 % of patients undergoing standard and 18 % of patients undergoing consolidation CRT (p = 0.04). Conclusions Most of the reduction in tumor metabolism after neoadjuvant CRT occurs within the first 6 weeks from RT completion. In patients undergoing CRT with consolidation chemotherapy, tumors are less likely to regain metabolic activity between 6 and 12 weeks. Therefore, assessment of tumor response may be safely postponed to 12 weeks in patients undergoing extended CRT with consolidation chemotherapy. Trial registration NCT00254683
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Affiliation(s)
- Angelita Habr-Gama
- Angelita & Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo, SP, Brazil. .,University of São Paulo School of Medicine, São Paulo, Brazil.
| | - Rodrigo O Perez
- Angelita & Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo, SP, Brazil. .,University of São Paulo School of Medicine Colorectal Surgery Division, São Paulo, Brazil. .,Ludwig Institute for Cancer Research São Paulo Branch, São Paulo, Brazil.
| | | | - Igor Proscurshim
- Angelita & Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo, SP, Brazil.
| | - Laura M Fernandez
- Angelita & Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo, SP, Brazil.
| | - Marleny N Figueiredo
- Angelita & Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo, SP, Brazil.
| | - Joaquim Gama-Rodrigues
- Angelita & Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo, SP, Brazil. .,University of São Paulo School of Medicine, São Paulo, Brazil.
| | - Carlos A Buchpiguel
- University of São Paulo School of Medicine Nuclear Imaging Division, São Paulo, Brazil.
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Bettoni F, Donnard ER, Correa BRS, Asprino PF, Koyama FC, Felício NM, Hessel BH, Galante PAF, Camargo AA, Habr-Gama A, Perez RO. Abstract 05: Genetic heterogeneity in rectal cancer - Identification of subpopulations of tumor cells resistant to neoadjuvant CRT. Clin Cancer Res 2016. [DOI: 10.1158/1557-3265.pmsclingen15-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
One of the benefits of neoadjuvant chemotherapy and radiation therapy (CRT) for the management of rectal cancer is tumor downstaging that can ultimately lead to complete tumor regression (known as complete pathological response - pCR). In a previous study using PET/CT imaging to assess tumor response to CRT, 50% of rectal cancers showed a continuous decrease in metabolic activity (estimated by standard uptake value measurements) between 6 and 12 weeks from CRT completion. However the remaining 50% of the cases showed increased metabolic activity within that period. We reasoned that the increased metabolic activity observed in these later patients could be determined by the clonal expansion of a genetically distinct subpopulation of tumor cells resistant to CRT. To address this question we performed exome sequencing and mutation detection analysis on normal tissue, primary tumor and residual tumor from 7 patients with rectal cancer that exhibited an increase in metabolic activity after CRT. Overall, about 20Gb of unambiguously mapped sequences were generated for each sample resulting in an average fold-coverage of 30X. Captured sequences mapped to the reference human genome were then used for the detection of SNPs and non-synonymous somatic point mutations in all three samples from each patient. Approximately 30,000 single nucleotide variants (SNVs) were identified in each sample and most of these SNVs were common to all samples. As expected, the majority of these common inherited variants (96%) have already been described in dbSNP. To identify non-synonymous somatic mutations occurring in primary and residual tumor samples, we excluded those present in the normal sample and those already described as a known SNP in dbSNP resulting in a mean of 243 SNVs per patient. Noteworthy, a significant number of non-synonymous somatic mutations were exclusively found in the primary and residual tumor samples of each patient, 30 and 32 SNVs on average respectively, revealing a high degree of tumor genetic heterogeneity. Furthermore, we were able to identify non-synonymous somatic mutations that were presented in both samples (mean of 107 SNVs), and for these mutations we determined the mutant allele frequency (number of reads representing the mutation/total number of reads covering the mutated base) in the primary and the residual tumor. We then searched for mutations with significantly different allele frequencies in the two samples, as these mutations would likely represent genetically distinct subpopulations of tumor cells selected during CRT. We were able to identify, on average, 4 SNVs enriched in primary tumor and 37 SNVs enriched in residual tumor per patient. In conclusion, based on exome sequencing of rectal tumors that exhibit incomplete response to CRT and have increased tumor metabolism we were able to identify non-synonymous mutations that may be associated with specific mechanisms of resistance or sensitivity to CRT. Functional analysis of these mutations and mutated genes will be presented, providing new insights into the molecular events influencing response to neoadjuvant CRT in rectal cancer.
Citation Format: Fabiana Bettoni, Elisa R. Donnard, Bruna R. S. Correa, Paula F. Asprino, Fernanda C. Koyama, Natália M. Felício, Bruna H. Hessel, Pedro A. F. Galante, Anamaria A. Camargo, Angelita Habr-Gama, Rodrigo O. Perez. Genetic heterogeneity in rectal cancer - Identification of subpopulations of tumor cells resistant to neoadjuvant CRT. [abstract]. In: Proceedings of the AACR Precision Medicine Series: Integrating Clinical Genomics and Cancer Therapy; Jun 13-16, 2015; Salt Lake City, UT. Philadelphia (PA): AACR; Clin Cancer Res 2016;22(1_Suppl):Abstract nr 05.
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Habr-Gama A, Vianna MR, São Julião GP, Rawet V, Gama-Rodrigues J, Proscurshim I, Alves J, Fernandez LM, Perez RO. Management of adenomas within the area of rectal cancer that develop complete pathological response. Int J Colorectal Dis 2015; 30:1285-7. [PMID: 26243467 DOI: 10.1007/s00384-015-2326-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/26/2015] [Indexed: 02/04/2023]
Affiliation(s)
- Angelita Habr-Gama
- Angelita & Joaquim Gama Institute, R.Manoel da Nobrega 1564, Paraiso, Sao Paulo-SP, 04001-005, Brazil
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Abstract
Neoadjuvant chemoradiation (CRT) is considered one of the preferred treatment strategies for patients with locally advanced rectal cancer. This strategy may lead to significant tumor regression, ultimately leading to a complete pathologic response in up to 42% of patients. Assessment of tumor response following CRT and before radical surgery may identify patients with a complete clinical response who could possibly be managed nonoperatively with strict follow-up (watch-and-wait strategy). The present article deals with critical issues regarding appropriate selection of patients for this approach.
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Affiliation(s)
- Angelita Habr-Gama
- Angelita and Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, Paraiso, São Paulo 04001-005, Brazil; University of São Paulo School of Medicine, Rua Manoel da Nóbrega 1564, Paraiso, São Paulo 04001-005, Brazil.
| | | | - Rodrigo O Perez
- Angelita and Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, Paraiso, São Paulo 04001-005, Brazil; Colorectal Surgery Division, Department of Gastroenterology, University of São Paulo School of Medicine, Rua Manoel da Nóbrega 1564, Paraiso, São Paulo 04001-005, Brazil
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