Management of tumor volume changes during preoperative radiotherapy for extremity soft tissue sarcoma: a new strategy of adaptive radiotherapy

BACKGROUND

Using adaptive radiotherapy (ART), to determine objective clinical criteria that identify extremity soft tissue sarcoma (ESTS) patients requiring adaptation of their preoperative radiotherapy (RT) plan.

PATIENTS AND METHODS

We included 17 patients with a lower extremity ESTS treated between 2019 and 2021 with preoperative RT, using helicoidal intensity-modulated RT (IMRT) tomotherapy, before surgical resection. We collected clinical, tumor parameters and treatment data. Repositioning was ascertained by daily Megavoltage computed tomography (MVCT) imaging. Using the PreciseART technology we retrospectively manually delineated at least one MVCT for each patient per week and recorded volume and dosimetric parameters. A greater than 5% change between target volume and planned target volume (PTV) dosimetric coverage from the initial planning CT scan to at least one MVCT was defined as clinically significant.

RESULTS

All 17 patients experienced significant tumor volume changes during treatment; 7 tumors grew (41%) and 10 shrank (59%). Three patients (18%), all undifferentiated pleomorphic sarcomas (UPS) with increased volume changes, experienced significant reductions in tumor dose coverage. Seven patients required a plan adaptation, as determined by practical criteria applied in our departmental practice. Among these patients, only one ultimately experienced a significant change in PTV coverage. Three patients had a PTV decrease of coverage. Among them, 2 did not receive plan adaptation according our criteria. None of the patients with decreased tumor volumes had reduced target volume coverage. Monitoring volume variations by estimating gross tumor volume (GTV) on MVCT, in addition to axial and sagittal linear tumor dimensions, appeared to be most effective for detecting reductions in PTV coverage throughout treatment.

CONCLUSIONS

Variations in ESTS volume are evident during preoperative RT, but significant dosimetric variations are rare. Specific attention should be paid to grade 2-3 UPSs during the first 2 weeks of treatment. In the absence of dedicated software in routine clinical practice, monitoring of tumor volume changes by estimating GTV may represent a useful strategy for identifying patients whose treatment needs to be replanned.

Dynamic Nomogram for Predicting Long-Term Survival in Terms of Preoperative and Postoperative Radiotherapy Benefits for Advanced Gastric Cancer

Studies on the prognostic significance of preoperative radiotherapy (PERT) and postoperative radiotherapy (PORT) in patients with advanced gastric cancer (GC) remain elusive. The aim of the study was to evaluate the survival advantage of preoperative and postoperative radiotherapy and construct a dynamic nomogram model to provide customized prediction of the probability of prognostic events for advanced GC patients. We collected clinical records from 2010 to 2015 from the Surveillance, Epidemiology, and End Results (SEER) database with a specific target for stage II-IV GC patients treated with PERT or PORT. We used the least absolute shrinkage and selection operator (LASSO) regression model to identify factors that contribute to the overall survival (OS) of GC patients. The dynamic nomogram infographic was constructed based on the prognostic factors of tumor-specific survival. Out of the 3215 total patients (2271 [70.6%] male; median age, 61 [SD = 12] years), 1204 were in the PERT group and 2011 in the PORT group. Receiving PORT was associated with a survival advantage over PERT for stage II GC patients (HR = 0.791, 95% CI= 0.712-0.879, p < 0.001). The 1-, 3-, and 5-year OS rates were 89.9%, 63.8%, and 53.8% in the PORT group, whereas the corresponding rates were significantly lower in the PERT group (86.4%, 57.1%, and 44.3%, respectively, all p < 0.05). The survival prediction model demonstrated that patients aged > 65 years, with an advanced cancer development stage and tumor size >3 were independent risk factors for poor prognosis (all HR > 1, p < 0.05). In this study, a dynamic nomogram was established based on the LASSO model to provide a statistical basis for the clinical characteristics and predictive factors of advanced GC in a large population. PORT demonstrated significantly better treatment advantages than PERT for stage II GC patients.

Case report: Pathological complete response to perioperative treatment of radiotherapy combined with angiogenesis inhibitor in a patient with pleomorphic liposarcoma

Background

Liposarcomas (LPS) are mesenchymal malignancies with four principal subtypes presenting distinct molecular and clinical features. Pleomorphic liposarcoma (PLPS) is one of the rarest and most aggressive subtypes of LPS. Surgical resection is currently a preferred curative approach for localized PLPS. However, the prognosis of unresectable PLPS is extremely poor, and there is no standard treatment.

Case presentation

A 59-year-old Chinese woman was diagnosed with unresectable PLPS. The case was discussed and managed by specialists from a multidisciplinary team at Fudan Zhongshan Hospital. Preoperative radiotherapy (RT) of intensity-modulated radiation therapy (IMRT) at 50 Gy/25 Fx concurrently with the angiogenesis inhibitor anlotinib (8 mg, days 1-14, every 3 weeks) was prescribed to the patient. The dosage of anlotinib was increased to 10 mg after RT. After 6 months of treatment, the tumor had significantly shrunk and was successfully resected. Examination of the surgical specimens showed a pathological complete response (pCR). Until the latest follow-up (April 2022), no recurrence was observed, and disease-free survival has exceeded 14 months.

Conclusion

This case sheds light on the probability that perioperative RT combined with an angiogenesis inhibitor can be effectively used in PLPS, which is resistant to chemotherapy and usually considered to have a poor prognosis. Further studies with randomized controlled clinical trials will improve our knowledge of this preoperative treatment strategy.

Association of MicroRNA-652 Expression with Radiation Response of Colorectal Cancer: A Study from Rectal Cancer Patients in a Swedish Trial of Preoperative Radiotherapy

BACKGROUND

Radiotherapy is a standard adjuvant therapy in patients with progressive rectal cancer, but many patients are resistant to radiotherapy, leading to poor prognosis. Our study identified microRNA-652 (miR-652) value on radiotherapy response and outcome in rectal cancer patients.

METHODS

miR-652 expression was determined by qPCR in primary rectal cancer from 48 patients with and 53 patients without radiotherapy. The association of miR-652 with biological factors and the prognosis was examined. The biological function of miR-652 was identified through TCGA and GEPIA database searches. Two human colon cancer cell lines (HCT116 p53+/+ and p53-/-) were used for in vitro study. The molecular interactions of miR-652 and tumor suppressor genes were studied through a computational approach.

RESULTS

In RT patients, miR-652 expression was significantly decreased in cancers when compared to non-radiotherapy cases (P = 0.002). High miR-652 expression in non-RT patients was with increased apoptosis marker (P = 0.036), ATM (P = 0.010), and DNp73 expression (P = 0.009). High miR-652 expression was related to worse disease-free survival of non-radiotherapy patients, independent of gender, age, tumor stage, and differentiation (P = 0.028; HR = 7.398, 95% CI 0.217-3.786). The biological functional analysis further identified the prognostic value and potential relationship of miR-652 with apoptosis in rectal cancer. miR-652 expression in cancers was negatively related to WRAP53 expression (P = 0.022). After miR-652 inhibition, the estimation of reactive oxygen species, caspase activity, and apoptosis in HCT116 p53+/+ cells was significantly increased compared with HCT116 p53-/- cells after radiation. The results of the molecular docking analysis show that the miR652-CTNNBL1 and miR652-TP53 were highly stable.

CONCLUSION

Our findings suggest the potential value of miR-652 expression as a marker for the prediction of radiation response and clinical outcome in rectal cancer patients.

Preoperative Radio(Chemo)Therapy in Breast Cancer: Time to Switch the Perspective?

AIM

Radiation therapy represents, together with surgery and systemic treatment, the triad on which the current management of patients with breast cancer is based, achieving high control and survival rates. In recent years we have witnessed a (r)evolution in the conception of breast cancer treatment. The classic scheme of surgery followed by systemic treatment and radiotherapy is being subverted and it is becoming more and more frequent to propose the primary administration of systemic treatment before surgery, seeking to maximize its effect and favoring not only the performance of more conservative surgeries but also, in selected cases, increasing the rates of disease-free survival and overall survival. Radiotherapy is also evolving toward a change in perspective: considering preoperative primary administration of radiotherapy may be useful in selected groups. Advances in radiobiological knowledge, together with technological improvements that are constantly being incorporated into clinical practice, support the administration of increasingly reliable, precise, and effective radiotherapy, as well as its safe combination with antitumor drugs or immunotherapy in the primary preoperative context. In this paper, we present a narrative review of the usefulness of preoperative radiotherapy for breast cancer patients and the possibilities for its combination with other therapies.

Constructing and Validating a Prognosis Predictive Nomogram for Cancer-Specific Survival in Rectal Cancer Patients Receiving Preoperative Radiotherapy

Background A predictive tool is required to identify the cancer-specific survival in rectal cancer (RC) patients who have opted to receive preoperative radiotherapy.Methods A database containing the data on RC patients' records of Surveillance, Epidemiology, and End Results (SEER) receiving surgery during 2000-2014 was selected. All patients received neoadjuvant radiotherapy (NR). The correlation of clinicopathological parameters was analyzed using the Chi-square test and the survival risk factors were analyzed using the Cox proportional hazards analysis (univariate and multivariate). Finally, the nomogram was developed and validated to visually represent an accurate prediction of the probability of 3- and 5-year cancer-specific survival (CSS) based on the screened variables of the cohort.Results 11,499 rectal cancer patients were included in our cohort. Patients' records were randomly allocated to either the development or validation cohorts based on an equal ratio (1:1). Performing the multivariate Cox regression analysis incorporating these variables in the development cohort determined 11 independent prognostic factors. Statistically significant differences were recorded among subgroups using log-rank tests, which confirmed the appropriateness and acceptability of factor stratifications. Then, the nomogram was constructed and its concordance index (C-index) values in the development cohort (0.720) and validation cohort (0.717) were evaluated to be higher (P<0.05) than those of the AJCC stage (0.631 and 0.633 respectively). Also, the 3-year AUC values of this nomogram were higher than those of the AJCC stage in both the development cohort (0.746 vs. 0.631) and the validation cohort (0.745 vs. 0.640). Using DCA curves, the predictive potential of the currently developed nomogram outperformed the conventional AJCC staging system.Conclusion The nomogram model might be a more reliable tool to predict prognosis accurately in rectal cancer patients receiving preoperative radiotherapy.

The Long and the Short of it: the Role of Short-course Radiotherapy in the Neoadjuvant Management of Rectal Cancer

Total mesorectal excision is the cornerstone of treatment for rectal cancer. Multiple randomised trials have shown a reduction in local recurrence rates with the addition of preoperative radiotherapy, either as a 1-week hypofractionated short-course (SCRT) or a conventionally fractionated long-course (LCRT) schedule with concurrent chemotherapy. There is also increasing interest in the addition of neoadjuvant chemotherapy to radiotherapy with the aim of improving disease-free survival. The relative use of SCRT and LCRT varies considerably across the world. This is reflected in, and is probably driven in part by, disparity between international guideline recommendations. In addition, different approaches to treatment may exist both between and within countries, with variation related to patient, disease and treatment centre and financial factors. In this review, we will specifically focus on the use of SCRT for the treatment of rectal cancer. We will discuss the literature base and current guidelines, highlighting the challenges and controversies in clinical application of this evidence. We will also discuss potential future applications of SCRT, including its role in optimisation and intensification of treatment for rectal cancer.

Preoperative radiotherapy for rectal cancer: A bibliometric analysis of the 100 most-cited research articles

Background and Aims

Preoperative long-course radio-chemotherapy (LC-RCHT) or preoperative short-course radiotherapy (SC-RT) are widely used in the treatment of locally advanced rectal cancer (LARC). This study aimed to evaluate the 100 most-cited research articles focused on preoperative radiotherapy for rectal cancer to reveal existing academic trends and the direction of therapeutic research.

Materials and Methods

This was a retrospective study based on publicly accessible data. The Web of Science database was used to identify the 100 most-cited articles.

Results

The median values for total citation and average citation per year (CPY) were 240.50 (range, 150-3787) and 17.32 (5.03-222.76), respectively. Randomized (median: 24.88 vs 13.32, P = 0.001) and funded (median: 27.33 vs 14.73, P = 0.002) studies had more CPY than those with opposite characteristics. No significant difference was found between studies using SC-RT and LC-RCHT, in terms of average CPY (median: 15.27 for SC-RT vs 18.36 for LC-RCHT, P = 0.303). In terms of the primary aim of the investigation, studies investigating non-operative treatment strategies had higher CPY than those investigating other subcategories (p = 0.029).

Conclusion

Randomized studies, funded studies, and studies investigating non-operative treatment were associated with more CPY. There remains equal interest in preoperative SC-RT and LC-RCHT for rectal cancer.

Effects of Preoperative Radiotherapy on Long-Term Bowel Function in Patients With Rectal Cancer Treated With Anterior Resection: A Systematic Review and Meta-analysis

Background: Anterior resection is a common surgical approach used in rectal cancer surgery; however, this procedure is known to cause bowel injury and dysfunction. Neoadjuvant therapy is widely used in patients with locally advanced rectal cancer. In this study, we determined the effect of preoperative radiotherapy on long-term bowel function in patients who underwent anterior resection for treatment of rectal cancer. Methods: We performed a comprehensive literature search of the PubMed, Embase, Web of Science, and the Cochrane Library databases. A random-effects model was used in the meta-analysis by the Review Manager software, version 5.3. Results: This systematic review and meta-analysis included 12 studies, which used low anterior resection syndrome score with a total of 2349 patients. Based on them, we concluded that low anterior resection syndrome was significantly more common in the preoperative radiotherapy group (odds ratio 3.59, 95% confidence interval 2.68-4.81, P < .00001) and that major low anterior resection syndrome also occurred significantly more frequently in the preoperative radiotherapy group (odds ratio 3.28, 95% confidence interval 2.05-5.26, P < .00001). Subgroup analyses of long-course radiation, total mesorectal excision, and non-metastatic tumors were performed, and the results met the conclusions of the primary outcomes. Conclusions: Preoperative radiotherapy negatively affects long-term bowel function in patients who undergo anterior resection for rectal cancer.

Impact of Preoperative vs Postoperative Radiotherapy on Overall Survival of Locally Advanced Breast Cancer Patients

Background

The treatment for locally advanced breast cancer (LABC) is a severe clinical problem. The postoperative radiotherapy is a conventional treatment method for patients with LABC, whereas the effect of preoperative radiotherapy on outcome of LABC remains controversial. This study aimed to examine and compare the overall survival (OS) in patients with LABC who underwent preoperative radiotherapy or postoperative radiotherapy.

Methods

This retrospective cohort study included 41,618 patients with LABC from the National Cancer Database (NCDB) between 2010 and 2014. We collected patients’ demographic, clinicopathologic, treatment and survival information. Propensity score was used to match patients underwent pre-operative radiotherapy with those who underwent post-operative radiotherapy. Cox proportional hazard regression model was performed to access the association between variables and OS. Log-rank test was conducted to evaluate the difference in OS between groups.

Results

The estimated median follow-up of all included participants was 69.6 months (IQR: 42.84-60.22); 70.1 months (IQR: 46.85-79.97) for postoperative radiotherapy, 68.5 (IQR: 41.13-78.23) for preoperative radiotherapy, and 67.5 (IQR: 25.92-70.99) for no radiotherapy. The 5-year survival rate was 80.01% (79.56-80.47) for LABC patients who received postoperative radiotherapy, 64.08% (57.55-71.34) for preoperative radiotherapy, and 59.67% (58.60-60.77) for no radiotherapy. Compared with no radiation, patients receiving postoperative radiotherapy had a 38% lower risk of mortality (HR=0.62, 95%CI: 0.60-0.65, p<0.001), whereas those who received preoperative radiotherapy had no significant survival benefit (HR=0.88, 95%CI: 0.70-1.11, p=0.282). Propensity score matched analysis indicated that patients treated with preoperative radiotherapy had similar outcomes as those treated with postoperative radiotherapy (AHR=1.23, 95%CI: 0.88-1.72, p=0.218). Further analysis showed that in C0 (HR=1.45, 95%CI: 1.01-2.07, p=0.044) and G1-2 (AHR=1.74, 95%CI: 1.59-5.96, p=0.001) subgroup, patients receiving preoperative radiotherapy showed a worse OS than those who received postoperative radiotherapy.

Conclusions

Patients with LABC underwent postoperative radiotherapy had improved overall survival, whereas no significant survival benefit was observed in patients receiving preoperative radiotherapy. Preoperative radiotherapy did not present a better survival than postoperative radiotherapy for LABC patients.

Effectiveness of Postoperative or Preoperative Radiotherapy on Prognosis in Patients with Stage II Resectable Non-Small Cell Lung Cancer: A Retrospective Study Based on the SEER Database

Background and Objectives: The research on the therapeutic effect of preoperative radiotherapy (PRRT) for patients with early non-small cell lung cancer (NSCLC) is still insufficient, and the impact of postoperative radiotherapy (PORT) on the prognosis of patients with early NSCLC remains controversial. We conducted this study to investigate the effect of PORT and PRRT on prognosis for these patients. Materials and Methods: In total, 3640 patients with stage II NSCLC who underwent a lobectomy or pneumonectomy were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. Multivariate regression was adopted to identify the independent influence of PORT or PRRT on patients’ prognosis. Subgroup analysis of survival was performed in patients with different combinations of key clinical features. We also used Kaplan-Meier analysis and competitive risk analysis to explore to which extent PORT or PRRT impacted the overall survival and cumulative mortality. Results: PORT was an independent risk factor of NSCLC-specific death among patients with N0 stage (HR, 1.648; 95% CI, 1.309–2.075, p < 0.001) and in N1 stage with <3 positive lymph nodes (HR, 2.698; 95% CI, 1.910–3.812, p < 0.001) in multivariate analysis. Findings from subgroup analysis for the risk of NSCLC-specific death, competitive risk analysis of NSCLC-specific cumulative mortality, and overall survival analysis also demonstrated PORT was detrimental to patients in these two subgroups above (p < 0.05). However, in patients with N1 stage with ≥3 positive lymph nodes, PORT may help prolong median survival. PRRT was an independent risk factor for NSCLC-specific death in multivariate analysis of patients with N0 stage (HR, 1.790; 95% CI, 1.201–2.668, p = 0.004), and significantly decreased overall survival in these patients (p < 0.001). Conclusion: PORT is associated with worse survival outcome and better cumulative mortality of stage II patients of NSCLC with N0 disease or N1 disease (<3 nodes), while PRRT is associated with reduced prognosis in patients with N0 stage. On the other hand, PORT may help to improve the prognosis of patients with N1 stage who have three or more lymph node metastases. Hence, PORT and PRRT should not be recommended for patients with N0 stage. However, in patients with “high volume” N1 stage, PORT might improve oncological outcomes.

The Correlation Between Survival Benefit of Preoperative Radiotherapy and Pretreatment Carcinoembryonic Antigen Level in Locally Advanced Rectal Cancer

Background

Preoperative radiotherapy followed by radical surgery is the standard treatment for locally advanced rectal cancer; however, its long-term survival benefit remains controversial. This study aimed to determine the relationship between pretreatment carcinoembryonic antigen (CEA) levels and the long-term prognosis of preoperative radiotherapy in locally advanced rectal cancer (LARC) patients.

Methods

Data of LARC patients who underwent surgery between 2011 and 2015 were identified from the Surveillance, Epidemiology, and End Results (SEER) database, and patients were accordingly divided into surgery (S) group and radiotherapy followed by surgery (RT+S) group. The primary outcomes were cancer-specific survival (CSS) and cancer-specific mortality (CSM). CSS was evaluated using Kaplan-Meier analysis, while CSM was evaluated using a competitive risk model. Subgroup analysis was also conducted, which was stratified by pretreatment CEA levels.

Results

A total of 2,760 patients were eligible for this study, including 350 (12.7%) patients in the S group and 2,410 (87.3%) in the RT+S group. There were no significant differences in the CSS and CSM rates at 1, 3, and 4 years between the S and RT+S groups before and after PSM (all p > 0.05). Pretreatment CEA levels were independently associated with CSS and CSM after adjusting for age, sex, stage, pathological factors, and treatment factors (all p < 0.05). Subgroup analysis showed that preoperative radiotherapy would benefit patients with elevated CEA in terms of CSS and CSM (both p < 0.05) but not those patients with normal CEA (both p > 0.05). Further analysis showed that preoperative radiotherapy was an independent protective factor for CSS and CSM in patients with elevated CEA levels (both p < 0.05).

Conclusions

Pretreatment CEA level may be considered a potential biomarker to screen LACR patients who would benefit from preoperative radiotherapy in terms of long-term prognosis.

Neoadjuvant Modified Short-Course Radiotherapy Followed by Delayed Surgery for Locally Advanced Rectal Cancer

Simple Summary

Both short- and long-course neoadjuvant radiotherapy (NA-RT) followed by surgery have been adopted as standard treatments for locally advanced rectal cancer (LARC). We hypothesized that a modified short-course radiotherapy (mSC-RT) using an accelerated hyperfractionated regimen, with a dose of 2.5 Gy twice daily up to a total dose of 25 Gy in 10 fractions, can provide a favorable therapeutic ratio in comparison with the conventional regimens. Ninety-seven consecutive LARC patients undergoing mSC-RT followed by delayed surgery were analyzed in this retrospective study. Additionally, potential prognostic factors for overall survival (OS) were also assessed. The results showed that mSC-RT followed by delayed surgery achieved equivalent anti-tumor efficacy and acute toxicity that were comparable with long- and short-course NA-RT, respectively. A neutrophil-to-lymphocyte ratio (NLR) ≥ 1.83 was independently associated with poor OS in LARC patients receiving mSC-RT. Thus, mSC-RT can be a promising alternative to both standard long- and short-course NA-RT regimens.

Abstract

This study aimed to assess the clinical outcomes and predictive factors of neoadjuvant modified short-course radiotherapy (mSC-RT) for locally advanced rectal cancer (LARC). Data from 97 patients undergoing mSC-RT followed by radical surgery for LARC were retrospectively analyzed. A 2.5 Gy dose twice daily up to a total dose of 25 Gy in 10 fractions was administered through mSC-RT, and this was delivered with oral chemotherapy in 95 (97.9%) patients. Radical surgery was performed 6 (range, 3–13) weeks after mSC-RT. The median follow-up among surviving patients was 43 (8–86) months. All patients completed neoadjuvant radiotherapy with no acute toxicity grade ≥ 3. Three- and five-year local control rates were 96.3% and 96.3%, respectively. Three- and five-year overall survival (OS) rates were 92.7% and 79.8%, respectively. Univariate analyses revealed that poor OS was associated with no concurrent administration of capecitabine, C-reactive-protein-to-albumin ratio ≥ 0.053, carcinoembryonic antigen ≥ 3.4 ng/mL, and neutrophil-to-lymphocyte ratio (NLR) ≥ 1.83 (P = 0.045, 0.001, 0.041, and 0.001, respectively). Multivariate analyses indicated that NLR ≥ 1.83 was independently associated with poor OS (p = 0.018). mSC-RT followed by delayed surgery for LARC was deemed feasible and resulted in good clinical outcomes, whereas poor OS was associated with high NLR.

Preoperative Short-Course Radiotherapy and Surgery versus Surgery Alone for Patients with Rectal Cancer: A Propensity Score-Matched Analysis at 18-Year Follow-Up

A significant problem for long-term rectal cancer survivors may be the late toxicity of radiotherapy. It creates the possible risk of developing second primary malignancy and a theoretical decrease in overall survival. This study aimed to assess the influence of short-course preoperative radiotherapy in patients with locally advanced rectal cancer on overall survival, local recurrence rate, and second malignancy at 18-year follow-up. The rectal cancer trial was conducted in a single tertiary center between February 1992 and June 2006. A total of 389 patients with locally advanced rectal cancer (cT2-cT4, cN0/+, cM0) were included in the study. Preoperative radiotherapy was conducted in 148 patients and 241 patients underwent surgery alone. The propensity-matched group consisted of 105 patients operated on after radiotherapy and 105 controls. The number of local recurrences was 7 (6.7%) in the preoperative radiotherapy group and 22 (21%) in the surgery alone group (p = 0.016). The 18-year survival analysis showed no survival benefit in the preoperative radiotherapy group (38% versus 48%, p = 0.107) but improved recurrence-free survival (81% versus 58%, p = 0.001). The preoperative short-course radiotherapy significantly decreases the risk of local recurrence in locally advanced rectal cancer and may improve recurrence-free survival without an increased risk of second primary malignancy.

Identification of Patients with Locally Advanced Rectal Cancer in Whom Preoperative Radiotherapy Can Be Omitted: A Multicenter Retrospective Study at Yokohama Clinical Oncology Group (YCOG1307)

Objectives:

The present study aimed to identify patients with locally advanced rectal cancer in whom preoperative radiotherapy (RT) can be omitted.

Methods:

This study was a retrospective multi-institutional study for patients with pathological stage II and III rectal cancer who underwent surgery without preoperative therapy between January 2008 and December 2012. Clinicopathological factors were examined by univariate and multivariate analyses to clarify independent risk factors of local recurrence (LR).

Results:

The 5-year cumulative local recurrence rate (LRR) of 815 patients was 11.2%. Independent predictive factors of LR were determined by a multivariate analysis to be a tumor location of <10 cm from the anal verge, a tumor diameter of ≥50 mm, undifferentiated histological type, and advanced T-N substage (T3N+ or T4Nany). In lower rectal cancer located <10 cm from the anal verge (n = 510), the 5-year cumulative LRR of patients without any remaining three factors was 4.4%, with one factor was 13.0%, with two factors was 22.2%, and with all three factors was 41.6%.

Conclusions:

Preoperative RT may be omitted in patients with lower rectal cancer with no risk factors. However, in addition to the present risk factors, we need to further examine the extramural vascular invasion (EMVI) status and circumferential resection margin (CRM) using magnetic resonance imaging (MRI) findings.

The trial was registered with UMIN Clinical Trails Registry, number 000006039.

Preoperative Radiotherapy Is Associated With Significant Survival Benefits for Patients With Gastric Signet Ring Cell Carcinoma: A SEER-Based Approach

Objective:

To explore the clinical and pathological features of gastric signet ring cell carcinoma, and evaluate the survival impact of preoperative radiotherapy on these patients.

Methods:

The Surveillance, Epidemiology, and End Results database was used to extract eligible patients from 2004 to 2015. The patients were divided into those with and without preoperative radiotherapy. The categorical variables were described by chi-square tests. The patients’ survival was compared between the 2 groups by Kaplan-Meier method with log-rank tests. Cox proportional hazard model was adopted to identify prognostic factors of cancer-specific survival.

Results:

Totally 4771 patients were recruited, of whom 218(4.6%) patients received preoperative radiotherapy, while 4553(95.4%) patients didn’t receive this treatment. Survival analysis of the entire cohort demonstrated that preoperative radiotherapy improved both cancer-specific survival and overall survival (p < 0.001) of the patients. Cox proportional hazard models identified age >60, tumor size >50 mm, TNM stage II-IV as independent risk factors for poor prognosis (HR > 1, p < 0.05). Notably, preoperative radiotherapy was identified as an independent protective factor for favorable prognosis (HR < 1, p < 0.05). Subgroup survival analysis showed that preoperative radiotherapy exerted significant survival benefits for the stages III and IV patients.

Conclusions:

In this population-based study, preoperative radiotherapy is associated with significant survival benefits for the patients with advanced gastric signet ring cell carcinoma. Hence preoperative radiotherapy is feasible for these patients.

Preoperative radiotherapy improves overall survival of pT4 pancreatic ductal adenocarcinoma patients after surgical resection

OBJECTIVE

The aim of delivering radiotherapy for pancreatic ductal adenocarcinoma patients was to sterilize vessel margin, increase R0 resection rate and delay local progression. Whether preoperative radiotherapy could prolong overall survival of surgical candidates remained unknown.

METHODS

Pancreatic ductal adenocarcinoma patients receiving radical resection from surveillance, epidemiology and end result database were enrolled. Propensity score matching was conducted to balance difference in baseline characteristics, and survival analyses were performed to compare overall survival between preoperative radiotherapy and upfront resection groups. Cox proportional hazard regression model and subgroup analyses were utilized to identify prognostic factors.

RESULTS

A total of 11 665 and 597 pancreatic ductal adenocarcinoma patients receiving upfront resection and preoperative radiotherapy followed by resection from 2004 to 2016 were identified, respectively, while baseline characteristics were distinct between groups. After propensity score matching, preoperative radiotherapy was not associated with better overall survival (upfront resection vs preoperative radiotherapy, 26 vs 27 months). Subgroup analyses showed that preoperative radiotherapy was a protective factor in pT4 (hazard ratio = 0.64, 95% confidence interval: 0.47-0.88) but a negative predictor in pT1 (hazard ratio = 1.79, 95% confidence interval: 1.08-2.97) patient populations. Survival analyses showed that preoperative radiotherapy improved overall survival of patients with pT4 stage (upfront resection vs preoperative radiotherapy, 19 vs 25 months) and involvement of celiac axis, superior mesenteric artery and aorta (upfront resection vs preoperative radiotherapy, 20 vs 27 months), while preoperative radiotherapy was associated with worse overall survival in patients with pT1 tumor (upfront resection vs preoperative radiotherapy, 39 vs 24 months).

CONCLUSION

Preoperative radiotherapy could improve survival of resected pancreatic ductal adenocarcinoma patients with pT4 stage or with celiac axis, superior mesenteric artery and aorta invasion.

Tumour response 3 months after neoadjuvant single-fraction radiotherapy for low-risk breast cancer

Introduction

Standard treatment for early-stage invasive breast cancer (bca) consists of breast-conserving surgery and several weeks of adjuvant radiotherapy (rt). Neoadjuvant single-fraction rt is a novel approach for early-stage bca. We sought to investigate the effect of delaying surgery after neoadjuvant rt with respect to the rate of pathologic response (pr).

Methods

Women 65 years of age or older with a new diagnosis of stage i luminal A bca were eligible for inclusion. A single 20 Gy dose to the primary breast tumour was given, followed by breast-conserving surgery 3 months later. The primary endpoint was the pr rate assessed by microscopic evaluation using the Miller-Payne system.

Results

To date, 10 patients have been successfully treated. Median age of the patients was 72 years (range: 65-84 years). In 8 patients, neoadjuvant rt resulted in a tumour pr with median residual cellularity of 3%. No immediate rt complications other than mild dermatitis were noted.

Conclusions

This study demonstrates a method for delivering single-fraction rt that can lead to a high level of pr in most patients. Continued accrual to this study and subsequent trials are needed to determine the feasibility, safety, and role of this novel technique in the management of early-stage bca.

Dose-time fractionation schedules of preoperative radiotherapy and timing to surgery for rectal cancer

Chemoradiotherapy (CRT) is extensively used prior to surgery for rectal cancer to provide significantly better local control, but the radiotherapy (RT), as the other component of CRT, has been subject to less interest than the drug component in recent years. With considerable developments in RT, the use of advanced techniques, such as intensity-modulated radiotherapy (IMRT) in rectal cancer, is garnering more attention nowadays. The radiation dose can be better conformed to the target volumes with possibilities for synchronous integrated boost without increased complications in normal tissue. Hopefully, both local recurrence and toxicities can be further reduced. Although those seem to be of interest, many issues remain unresolved. There is no international consensus regarding the radiation schedule for preoperative RT for rectal cancer. Moreover, an enormous disparity exists regarding the RT delivery. With the advent of IMRT, variations will likely increase. Moreover, time to surgery is also quite variable, as it depends upon the indication for RT/CRT in the clinical practices. In this review, we discuss the options and problems related to both the dose-time fractionation schedule and time to surgery; furthermore, it addresses the research questions that need answering in the future.

Prognostic value of nuclear FBI-1 in patients with rectal cancer with or without preoperative radiotherapy

Factor that binds to the inducer of short transcripts of the human immunodeficiency virus-1 (FBI-1) represents as a crucial gene regulator in colorectal cancer; however, the correlation between FBI-1 and preoperative radiotherapy (RT) in rectal cancer (RC) has not yet been reported. The aim was to detect FBI-1 expression in patients with RC with or without RT, by immunohistochemistry and quantitative polymerase chain reaction, and to analyze its association with clinicopathological features and response to RT. The results from immunohistochemistry analysis (n=139) and reverse transcription-quantitative polymerase chain reaction (n=55) demonstrated that FBI-1 was overexpressed in patients with RC, whether they had received preoperative RT or not. Subsequently, the association between FBI-1 expression, and the clinicopathological features and response to RT in patients with RC was analyzed. Cytoplasmic FBI-1 was upregulated in non-RT (n=77) and RT (n=62) groups (17.7 vs. 74.0%, P<0.001; 41.1 vs. 69.4%, P=0.002, respectively) of patients with RC compared with normal mucosa. However, nuclear FBI-1 was downregulated (75.8 vs. 22.1%, P<0.001; 83.9 vs. 35.5%, P<0.001, respectively) in both groups. RT had no significant effect on FBI-1 expression in RC tissues. Furthermore, nuclear FBI-1 was positively associated with tumor-node-metastasis stage and distant recurrence (P=0.003 and P=0.010, respectively). In patients with stage I, II or III RC, higher nuclear FBI-1 expression was associated with poorer disease-free survival [hazard ratio (HR)=1.934, 95% confidence interval (CI): 1.055-3.579, P=0.033] and overall survival (HR=2.174, 95% CI: 1.102-4.290, P=0.025), independently of sex, age, growth pattern, differentiation and RT. In addition, FBI-1 was positively correlated with numerous biological factors, including p73 [Spearman's correlation coefficient (r_s)=0.332, P=0.007], lysyl oxidase (r_s=0.234, P=0.043), Wrap53 (r_s=-0.425, P=0.0002) and peroxisome proliferator-activated receptor δ (r_s=-0.294, P=0.026). In conclusion, the present study demonstrated that nuclear FBI-1 was an independent prognostic factor in patients with RC and correlated with numerous biological factors, which indicated that it may have multiple roles in RC.

Sequential simulation computed tomography allows assessment of internal rectal movements during preoperative chemoradiotherapy in rectal cancer

Purposes

The purpose of this study was to assess the internal rectal movement and to determine the factors related to extensive internal rectal movement using sequential simulation computed tomography (CT) images.

Materials and Methods

From 2010 to 2015, 96 patients receiving long-course preoperative chemoradiotherapy were included in our retrospective study. The initial simulation CT (Isim-CT) and follow-up simulation CT (Fsim-CT) for a boost were registered according to the isocenters and bony structure. The rectums on Isim-CT and Fsim-CT were compared on four different axial planes as follows: (1) lower pubis symphysis (AX_VERYLOW), (2) upper pubis symphysis (AX_LOW), (3) superior rectum (AX_HIGH), and (4) middle of AX_LOW and AX_HIGH (AX_MID). The involved rectum in the planning target volume was evaluated. The maximal radial distances (MRD), the necessary radius from the end of Isim-CT rectum to cover entire Fsim-CT rectum, and the common area rate (CAR) of the rectum (CAR, (Isim-CT∩Fsim-CT)/(Isim-CT)) were measured. Linear regression tests for the MRDs and logistic regression tests for the CARs were conducted.

Results

The mean ± standard deviation (mm) of MRDs and CAR <80% for AX_VERYLOW, AX_LOW, AX_MID, and AX_HIGH were 2.3 ± 2.5 and 8.9%, 3.0 ± 3.7 and 17.4%, 4.0 ± 5.2 and 27.1%, and 4.1 ± 5.2 and 25%, respectively. For MRDs and CARs, a higher axial level (AX_VERYLOW/AX_MID-HIGH, P = 0.018 and P = 0.034, respectively), larger bladder volume (P = 0.054 and P = 0.017, respectively), smaller bowel gas extent (small/marked, P = 0.014 and P = 0.001, respectively), and increased bowel gas change (decrease/increase, both P < 0.001) in rectum were associated with extensive internal rectal movement in multivariate analyses.

Conclusions

As a result of following internal rectal movement through sequential simulation CT, the rectum above the pubis symphysis needs a larger margin, and bladder volume and bowel gas should be closely observed.

Hypofractionated radiotherapy in nine dogs with unresectable solitary lung adenocarcinoma

Although lung lobectomy is the most common treatment option for dogs with solitary lung tumors, surgery often cannot be performed at the time of diagnosis. In this retrospective, case series study, we described the effects of hypofractionated radiotherapy for tumor mass reduction in nine dogs with solitary lung adenocarcinoma that were later considered for surgical resection, and we assessed the tolerability of the radiation protocol. Tumors were deemed unresectable by the attending veterinarian. The dose prescription was 7.0-12.0 Gy/fraction in four to seven fractions, administered weekly for a total dose of 40-50 Gy. Treatment planning prioritized normal tissue dose constraints. The median interval between the last radiotherapy session and maximum tumor size reduction was 56 (range: 26-196) days, with six and three dogs exhibiting a partial response and stable disease, respectively. Although acute and late radiation-induced toxicity to the skin and/or lungs developed in all nine dogs, it was self-limiting or improved with short-term anti-inflammatory treatment. Tumor progression after initial size reduction was confirmed in three dogs at 62, 126, and 175 days, respectively, after the last radiotherapy session. Seven of the nine dogs underwent lobectomy a median of 68 days after radiotherapy when tumors were in partial response or stable disease or at the time of progression, and five received systemic chemotherapy concurrent with or after radiotherapy. These findings suggest that hypofractionated radiotherapy for canine solitary lung adenocarcinoma is useful when the tumor is large or when surgery cannot be performed immediately after diagnosis.

Value of radiotherapy in addition to esophagectomy for stage II and III thoracic esophageal squamous cell carcinoma: Analysis of surveillance, epidemiology, and end results database

To determine the value of radiotherapy in addition to esophagectomy for stage II and III TESCC. We searched the Surveillance, Epidemiology, and End Results (SEER) database for all cases of stage II‐III TESCC. Patients were grouped as those receiving pre‐ or postoperative radiotherapy plus esophagectomy and those receiving esophagectomy alone. Overall survival (OS) and cancer‐specific survival (CSS) were compared between the groups. Among the 3292 patients, multimodality treatments (pre‐ or postoperative radiotherapy plus surgery) were more effective than surgery alone (5‐year, OS: 17.3% vs 7.9%; P < 0.001; CSS: 51.8% vs 34.9%; P < 0.001). Among the patients receiving multimodality treatments, multivariate analyses revealed stage to be the most significant prognostic factor for OS (II vs III, HR, 0.726; P < 0.001), but the sequence of radiotherapy and surgery was only of the marginal significance (pre‐ vs postoperative, HR, 0.875; P = 0.093). Preoperative radiotherapy provided significantly better survival than postoperative radiotherapy in stage III disease (5‐year, OS: 13.0% vs 11.0%, P < 0.04; CSS: 49.2% vs 31.7%, P < 0.003), but not in stage II disease (5‐year OS: 23.5% vs 21.0%, P = 0.519; CSS: 62.0% vs 53.4%, P = 0.075). Radiotherapy in addition to esophagectomy provides better outcomes than esophagectomy alone for in stage II‐III TESCC. Preoperative radiotherapy followed by surgery appears to be the optimal treatment strategy in stage III TESCC.

Nomogram predicts survival benefit for non- metastatic esophageal cancer patients who underwent preoperative radiotherapy

Background

A prognostic model to predict the individual disease-specific survival (DSS) rates of non-metastatic esophageal cancer (nMEC) patients after preoperative radiotherapy (pRT) has not been established. In the current study, we aimed to establish a survival nomogram for nMEC patients after pRT.

Methods

We identified 2,424 nMEC patients who underwent pRT from the Surveillance, Epidemiology, and End Results database. Approximately, 80% (n=1,948) of the included patients were randomly selected and designated as training data set, and the remaining patients (n=476) were defined as external validation set. Nomogram was established by the training set and validated by the validation set.

Results

According to the results of the multivariate analysis, a nomogram combined with age at diagnosis, sex, tumor location, yp-T stage, yp metastatic lymph node ratio stage (yp-mLNRS), and grade was developed. The C-index of the model was significantly higher than that of yp-TNM staging system (0.62, 95% CI, 0.58 to 0.66 vs 0.55, 95% CI, 0.51 to 0.60; p<0.001). Calibration plots of the nomogram showed that the probability of DSS rates optimally corresponded to the survival rates were observed.

Conclusion

The proposed nomogram resulted in more reliable DSS prediction for nMEC patients in general population, regardless of the patient’s histological type. Upon validation, it will aid in individualized survival prediction and prove useful in clinical decision making in nMECs after pRT.

Preoperative radiotherapy in soft tissue sarcoma: from general guidelines to personalized medicine

This critical review aims to generate hypotheses when to adhere to guidelines and when it could be considered to individualize management of extremity soft tissue sarcomas.Based upon peer-reviewed publications using a PubMed search on the MeSH headings "soft tissue sarcoma" AND "preoperative radiotherapy", data were compiled. Titles and abstracts screened for data including "fraction size AND/OR total dose AND/OR overall treatment time", "chemotherapy", "targeted agents AND/OR tyrosine kinase inhibitors", were screened as well as their respective reference. Furthermore, new data presented in abstract form at international sarcoma meetings have been included as well as relevant clinical trial information available at the ClinicalTrials.gov website. Generally accepted guidelines suggest applying preoperative external beam radiotherapy (RT), conventionally fractionated in 25-28 fractions of 1.8-2 Gy to a total dose of 50-50.4 Gy in 5-6 weeks This regimen aims to increase the local control probability as compared to surgery alone. This regimen inflicts both acute and late toxicities. The reasons for and results of hypofractionated and/or reduced dose regimens are summarized and discussed. Finally, RT could be combined with conventional chemotherapy as well as targeted agents and data are summarized. Outside the setting of well-designed prospective clinical trials, the conventional 50 Gy in 5-6 weeks schedule should be considered as standard. However, in individual cases and based upon current and future studies alternative fraction size, total dose, overall treatment time and/or combination with chemotherapy or targeted agents may be considered in order to increase efficacy with reduced late morbidities.

The prognostic value of negative lymph node count for patients with gastric cancer who received preoperative radiotherapy

Negative lymph node (NLN) count provides accurate prognostic information in patients with gastric cancer. However, it is unclear whether NLN still has prognostic value for patients received preoperative radiotherapy. In this study, Surveillance, Epidemiology, and End Results Program (SEER)-registered gastric cancer patients were used for analysis. Clinicopathological characteristics and survival time were collected. Univariate and multivariate Cox proportional hazards models were used to assess the risk factors for survival. NLN count was validated as an independent prognostic factor in both univariate and mulivariate analysis (P < 0.001). X-tile plots identified 12 as the optimal cutoff value to divide the patients into high and low risk subsets in terms of survival rate. Nomogram based on cancer-specific survival was successfully established according to all significant factors. The C-index was 0.630 (95% CI: 0.605–0.655). Subgroup analysis showed that NLN count was a prognosis factor for patients with advanced gastric cancer (stage ypII and ypIII). In conclusion, our results firmly demonstrated that NLN count was an independent prognostic factor for patients with gastric cancer who received preoperative radiotherapy. It provides more accurate prognostic information especially for patients with advanced gastric cancer (stage ypII and ypIII). Nomograms based on cancer-specific survival could be recommended as practical models to evaluate prognosis.

Nomogram predicts survival benefit from preoperative radiotherapy for non-metastatic breast cancer: A SEER-based study

Background

To estimate survival in non-metastatic breast cancer patients who failed to achieve a pathological complete response (pCR) more effectively, we combined the clinicpathological characteristics after preoperative radiation therapy (pRT) and established a novel nomogram.

Materials and Methods

Using the Surveillance, Epidemiology, and End Results (SEER) database, we identified 2,545 non-metastatic breast cancer patients who underwent pRT between 1998 and 2013. Based on the registries of patients, the primary cohort divided into training set (n = 1,692) and validation set (n = 853). Nomograms were established by training set and validated by validation set.

Results

According to the multivariate analysis of training set, nomogram which combined age at diagnosed, marital status, location, grade, ER status, yp-T status, yp-N status and whether received breast conservation surgery (BCS) was developed. Calibration plots of the nomograms showed that the probability of DSS corresponded to actual observation closely. The C-index was 0.78 in validation set, which was significantly higher than that of yp-TNM staging system (0.75, p = 0.004).

Conclusions

The proposed nomogram resulted in more–reliable DSS prediction for non-metastatic breast cancer patients in general population, it would be helpful in individualized survival prediction and better treatment allocation after pRT.

Phase III randomized trial of preoperative concurrent chemoradiotherapy versus preoperative radiotherapy for patients with locally advanced head and neck squamous cell carcinoma

Purpose

To determine the role of preoperative concurrent chemoradiotherapy in the treatment of locally advanced head and neck squamous cell carcinoma (HNSCC).

Methods

A total of 222 patients with stage III/IVA-B HNSCC were randomly assigned to receive preoperative concurrent chemoradiotherapy (Pre-S CRT, weekly cisplatin 30mg/m²) or preoperative radiotherapy alone (Pre-S RT). Survival analysis was estimated by the Kaplan-Meier method and compared by the log-rank test.

Results

With a medial follow-up of 59 month, the 5-year overall survival (OS), progression-free survival (PFS), distant metastasis-free survival (DMFS) of Pre-S CRT v Pre-S RT group were 53.8% v 39.0% (hazard ratio [HR], 0.74, 95% CI, 0.50 to 1.10, P = 0.13), 53.2% v 38.7%, (HR, 0.69, 95% CI, 0.47 to 1.01, P =0.06), and 80.4% v 68.1% (HR, 0.53, 95% CI, 0.28 to 0.98, P = 0.04), respectively. In patients with larynx-hypopharynx primaries, the 5-year OS, PFS and DMFS of Pre-S CRT v Pre-S RT were 62.7% v 38.8% (HR, 0.59, 95% CI 0.35 to 1.02, P = 0.054), 63.1% v 39.9% (HR, 0.52; 95% CI 0.30 to 0.89, P = 0.03) and 86.2% v 63.3% (HR, 0.35, 95% CI 0.15 to 0.82, P = 0.01), respectively.

Conclusion

The addition of weekly cisplatin concurrent to preoperative RT does not improve OS, but improve DMFS in locally advanced HNSCC. However, in a subset of patients with the larynx-hypopharynx primaries, preoperative chemoradiotherapy has significantly improved PFS and DMFS, and has also provided a borderline benefit in OS in comparison with preoperative radiotherapy alone.

RBBP6 increases radioresistance and serves as a therapeutic target for preoperative radiotherapy in colorectal cancer

Radiotherapy (RT) can be used as preoperative treatment to downstage initially unresectable locally rectal carcinoma, but radioresistance and recurrence remain significant problems. Retinoblastoma binding protein 6 (RBBP6) has been implicated in the regulation of cell cycle, apoptosis and chemoresistance both in vitro and in vivo. The present study investigated whether the inhibition of RBBP6 expression would improve radiosensitivity in human colorectal cancer cells. After SW620 and HT29 cells were exposed to radiation, the levels of RBBP6 mRNA and protein increased over time in both cells. Moreover, a significant reduction in clonogenic survival and a decrease in cell viability in parallel with an obvious increase in cell apoptosis were demonstrated in irradiated RBBP6‐knockdown cells. Transfection with RBBP6 shRNA improved the levels of G2‐M phase arrest, which blocked the cells in a more radiosensitive period of the cell cycle. These observations indicated that cell cycle and apoptosis mechanisms may be connected with tumor cell survival following radiotherapy. In vivo, the tumor growth rate of nude mice in the RBBP6‐knockdown group was significantly slower than that in other groups. These results indicated that RBBP6 overexpression could resist colorectal cancer cells against radiation by regulating cell cycle and apoptosis pathways, and inhibition of RBBP6 could enhance radiosensitivity of human colorectal cancer.

Neoadjuvant radiotherapy provided survival benefit compared to adjuvant radiotherapy for hepatocellular carcinoma

BACKGROUND

This study compared the impact of neoadjuvant radiotherapy (RT) and adjuvant RT on survival for patients with hepatocellular carcinoma (HCC).

METHODS

Patients with HCC were identified from the Surveillance, Epidemiology and End Results (SEER) database. The Kaplan-Meier method and multivariate Cox regression analysis were used to compare the impact of neoadjuvant RT on survival with adjuvant RT. Subsequently, a propensity score-matched analysis was performed to confirm the result.

RESULTS

A total of 244 patients with HCC identified from the SEER database (2004-2014) received preoperative or post-operative radiation. A total of 151 patients received post-operative RT and 93 patients received preoperative RT. Preoperative RT had a clear superiority in terms of unadjusted overall survival and cancer-specific survival (P < 0.001 for log-rank test). After adjusting for confounding variables, hazard ratios (HRs) for all-cause (HR: 0.33; 95% CI: 0.19-0.53, P < 0.001) and cancer-specific (HR: 0.32; 95% CI: 0.19-0.53, P < 0.001) mortality risks in preoperative RT group were significantly lower than that of post-operative RT group. Subsequently, a propensity score-matched analysis was performed to confirm this result. Further univariate and multivariate survival analyses revealed that there was a persistent superiority of overall survival and cancer-specific survival in patients who received preoperative radiation than patients without RT.

CONCLUSION

We found that neoadjuvant RT was associated with improved long-term survival for patients with HCC versus adjuvant RT.

Results of a Single Surgical Team

Background

Surgery in combination with radiotherapy (RT) has become the standard of care for most soft tissue sarcomas. The choice between pre- and postoperative RT is controversial. Preoperative RT is associated with a 32–35% rate of major wound complications (MWC) and 16–25% rate of reoperation. The role of vascularized soft tissue “flaps” in reducing complications is unclear. We report the outcomes of patients treated with preoperative RT, resection, and flap reconstruction.

Patients and methods

122 treatment episodes involving 117 patients were retrospectively reviewed. All patients were treated with 50.4 Gy of external beam radiation. Surgery was performed at 4–8 weeks after completion of RT by the same combination of orthopedic oncology and plastic reconstructive surgeon. Defects were reconstructed with 64 free and 59 pedicled/local flaps.

Results

30 (25%) patients experienced a MWC and 17 (14%) required further surgery. 20% of complications were exclusively related to the donor site. There was complete or partial loss of three flaps. There was no difference in the rate of MWC or reoperation for complications with respect to age, sex, tumor site, previous unplanned excision, tumor grade, depth, and type of flap. Tumor size ≥8 cm was associated with a higher rate of reoperation (11/44 vs 6/78; P = 0.008) but the rate of MWC was not significant (16/44 vs 14/78; P = 0.066).

Conclusion

The use of soft tissue flaps is associated with a low rate of MWC and reoperation. Our results suggest that a high rate of flap usage may be required to observe a reduction in complication rates.

Impact of the number of resected lymph nodes on survival after preoperative radiotherapy for esophageal cancer

To assess the impact of the number of resected lymph nodes (RLNs) for survival in esophageal cancer (EC) patients treated with preoperative radiotherapy and cancer-directed surgery. The Surveillance Epidemiology and End Results (SEER) database was queried to identify EC patients treated from 1988 to 2012 who had complete data on the number of positive lymph nodes and number of RLNs. Kaplan–Meier survival analysis and Cox regression proportional hazard methods were used to determine factors that significantly impact cause-specific survival (CSS) and overall survival (OS). There were a total of 3,159 patients who received preoperative radiotherapy and cancer-directed surgery. The median number of RLNs was 10 in both patients who received and did not receive preoperative radiotherapy (P = 0.332). Cox regression univariate and multivariate analysis showed that RLN count was a significant prognostic factor for CSS and OS. Patients with 11–71 RLNs had better CSS (hazard ratio [HR] = 0.694, 95% confidence interval [CI]: 0.603–0.799, P < 0.001) and OS (HR = 0.724, 95% CI: 0.636–0.824, P < 0.001) than patients with 1–10 RLNs. The 5-year CSS rates were 39.1% and 44.8% in patients with 1–10 RLNs and 11–71 RLNs, respectively (P < 0.001). The 5-year OS rates were 33.7% and 39.9% in patients with 1–10 RLNs and 11–71 RLNs, respectively (P < 0.001). A higher number of RLNs was associated with better survival by tumor stage and nodal stage (all P < 0.05). RLN count is an independent prognostic factor in EC patients who undergo preoperative radiotherapy and cancer-directed surgery.

Optimal managements of stage IIIA (N2) non-small cell lung cancer patients: a population-based survival analysis

Background

This study aimed to investigate the optimal management of stage IIIA (cN2) non-small cell lung cancer (NSCLC) patients and determine potential predictive factors.

Methods

We extracted patients diagnosed as NSCLC stage IIIA (cN2) between 2004 and 2011 from Surveillance, Epidemiology, and End Results (SEER) database. Overall survival (OS) and lung cancer-specific survival (LCSS) were compared among patients given different clinical managements by Kaplan-Meier method. Other variables such as age, sex and tumor size were analyzed to explore the factors associated with outcomes.

Results

A total of 98,700 IIIA-cN2 NSCLC patients were identified from SEER database. Survival of patients treated with surgery was better than that of patients treated by radiotherapy alone (P<0.001). Radiation prior to surgery significantly improved the survival in comparison with surgery alone (P<0.001). In the subgroups of OS analysis, age >65 (P=0.902), adenocarcinoma (P=0.279), tumor size ≤3 cm (P=0.170), well differentiated (P=0.360) patients, preoperative radiotherapy improved survival insignificantly compared with surgery alone.

Conclusions

Preoperative radiation with surgery had the most encouraging survival outcomes in stage IIIA-cN2 NSCLC patients compared with radiation or surgery alone. No significant outcome improvement was shown between postoperative radiotherapy (PORT) and surgery alone.

What has preoperative radio(chemo)therapy brought to localized rectal cancer patients in terms of perioperative and long-term outcomes over the past decades? A systematic review and meta-analysis based on 41,121 patients

We asked what preoperative radiotherapy/chemoradiotherapy (PRT/PCRT) has brought to patients in terms of perioperative and long-term outcomes over the past decades. A systematic review and meta-analysis was conducted using PubMed, Embase and Web of Science databases. All original comparative studies published in English that were related to PRT/PCRT and surgical resection and which analyzed survival, postoperative and quality of life outcomes were included. Data synthesis and statistical analysis were carried out using Stata software. Data from 106 comparative studies based on 80 different trials enrolling 41,121 patients were included in our study. Based on our overall analyses, PRT/PCRT significantly improved patients' local recurrence-free survival (LRFS), but neither overall survival (OS) nor metastasis-free survival (MFS) showed improvement. In addition, PRT significantly increased the postoperative morbidity and mortality but PCRT did not have a significant effect. Furthermore, PRT/PCRT significantly increased the risk of postoperative wound complications but not anastomotic leakage and bowel obstruction. Our comprehensive subgroup analyses further supported the aforementioned results. Meanwhile, long-term anorectal symptoms (impaired squeeze pressures, use of pads, incontinence and urgency) and erectile dysfunction were also significantly increased in patients after PRT/PCRT. The benefits of PRT/PCRT as applied over the last several decades have not been sufficient to improve OS. Metastases of primary tumor and postoperative adverse effects were the two primary obstacles for an improved OS. In fact, the greatest advantage of PRT/PCRT is still local tumor control and a significantly improved LRFS.

The clinicopathologic relevance and prognostic value of tumor deposits and the applicability of N1c category in rectal cancer with preoperative radiotherapy

The clinicopathologic relevance and prognostic value of tumor deposits in colorectal cancer has been widely demonstrated. However, there are still debates in the prognostic value of tumor deposits and the applicability of N1c category in rectal cancer with preoperative radiotherapy. In this study, rectal cancer with preoperative radiotherapy followed by resection of primary tumors registered in Surveillance, Epidemiology and End Results (SEER) database from 2010-2012 were analyzed. There were 4,813 cases eligible for this study, and tumor deposits were found in 514 (10.7%) cases. The presence of tumor deposits was significantly associated with some aggressive characteristics, including poorer tumor differentiation, more advanced ypT category, ypN category and ypTNM stage, distant metastasis, elevated carcinoembryonic antigen, higher positive rates of circumferential resection margin and perineural invasion (all P < = 0.001). Tumor deposit was also an independent negative prognostic factor for cancer-specific survival in rectal cancer with preoperative radiotherapy (adjusted HR and 95% CI: 2.25 (1.51 - 3.35)). N1c category had significant worse survival compared with N0 category (adjusted HR and 95% CI: 2.41 (1.24 - 4.69)). In conclusion, tumor deposit was a significant and independent prognostic factor, and the N1c category by the 7th edition of AJCC/TNM staging system was applicable in rectal cancer with preoperative radiotherapy.

Special AT-rich sequence binding protein 1 expression correlates with response to preoperative radiotherapy and clinical outcome in rectal cancer

Our recent study showed the important role of special AT-rich sequence binding protein 1 (SATB1) in the progression of human rectal cancer. However, the value of SATB1 in response to radiotherapy (RT) for rectal cancer hasn't been reported so far. Here, SATB1 was determined using immunohistochemistry in normal mucosa, biopsy, primary cancer, and lymph node metastasis from 132 rectal cancer patients: 66 with and 66 without preoperative RT before surgery. The effect of SATB1 knockdown on radiosensitivity was assessed by proliferation-based assay and clonogenic assay. The results showed that SATB1 increased from normal mucosa to primary cancer, whereas it decreased from primary cancer to metastasis in non-RT patients. SATB1 decreased in primary cancers after RT. In RT patients, positive SATB1 was independently associated with decreased response to preoperative RT, early time to metastasis, and worse survival. SATB1 negatively correlated with ataxia telangiectasia mutated (ATM) and pRb2/p130, and positively with Ki-67 and Survivin in RT patients, and their potential interaction through different canonical pathways was identified in network ideogram. Taken together, our findings disclose for the first time that radiation decreases SATB1 expression and sensitizes cancer cells to confer clinical benefit of patients, suggesting that SATB1 is predictive of response to preoperative RT and clinical outcome in rectal cancer.

XRCC2 as a predictive biomarker for radioresistance in locally advanced rectal cancer patients undergoing preoperative radiotherapy

XRCC2 has been shown to increase the radioresistance of some cancers. Here, XRCC2 expression was investigated as a predictor of preoperative radiotherapy (PRT) treatment response in locally advanced rectal cancer (LARC). XRCC2 was found to be overexpressed in rectal cancer tissues resected from patients who underwent surgery without PRT. In addition, overall survival for LARC patients was improved in XRCC2-negative patients compared with XRCC2-positive patients after treatment with PRT (P < 0.001). XRCC2 expression was also associated with an increase in LARC radioresistance. Conversely, XRCC2-deficient cancer cells were more sensitive to irradiation in vitro, and a higher proportion of these cells underwent cell death induced by G2/M phase arrest and apoptosis. When XRCC2 was knocked down, the repair of DNA double-strand breaks caused by irradiation was impaired. Therefore, XRCC2 may increases LARC radioresistance by repairing DNA double-strand breaks and preventing cancer cell apoptosis. Moreover, the present data suggest that XRCC2 is a useful predictive biomarker of PRT treatment response in LARC patients. Thus, inhibition of XRCC2 expression or activity represents a potential therapeutic strategy for improving PRT response in LARC patients.

Neoadjuvant Treatment Strategies for Locally Advanced Rectal Cancer

Improved surgical technique plus selective preoperative radiotherapy have decreased rectal cancer pelvic local recurrence from, historically, 25% down to about 5-10%. However, this improvement has not reduced distant metastatic relapse, which is the main cause of death and a key issue in rectal cancer management. The current standard is local pelvic treatment (surgery ± preoperative radiotherapy) followed by adjuvant chemotherapy, depending on resection histology. For circumferential resection margin (CRM)-threatened cancer on baseline magnetic resonance imaging, downstaging long-course preoperative chemoradiation (LCPCRT) is generally used. However, for non-CRM-threatened disease, varying approaches are currently adopted in the UK, including straight to surgery, short-course preoperative radiotherapy and LCPCRT. Clinical trials are investigating intensification of concurrent chemoradiation. There is also increasing interest in investigating preoperative neoadjuvant chemotherapy (NAC) as a way of exposing micro-metastatic disease to full-dose systemic chemotherapy as early as possible and potentially reducing metastatic relapse. Phase II trials suggest that this strategy is feasible, with promising histological response and low rates of tumour progression during NAC. Phase III trials are needed to determine the benefit of NAC when added to standard therapy and also to determine if it can be used instead of neoadjuvant radiotherapy-based schedules. Although several measures of neoadjuvant treatment response assessment based on imaging or pathology are promising predictive biomarkers for long-term survival, none has been validated in prospective phase III studies. The phase III setting will enable this, also providing translational opportunities to examine molecular predictors of response and survival.

Rectal cancer threatening or affecting the prostatic plane: is partial prostatectomy oncologically adequate? Results of a multicentre retrospective study

AIM

The management of rectal cancer threatening or affecting the prostatic plane is still under debate. The role of preoperative chemo radiotherapy and the extent of prostatectomy seem to be key points in the treatment of these tumours. The aim of the present study was to evaluate the pathological circumferential margin status and the local recurrence rate following different therapeutic options.

METHOD

A multicentre, retrospective study was conducted of patients with rectal cancer threatening or affecting the prostatic plane, but not the bladder, judged by magnetic resonance imaging (MRI). The use of preoperative chemoradiotherapy and the type of urologic resection were correlated with the status of the pathological circumferential resection margin (CRM) and local recurrence.

RESULTS

A consecutive series of 126 men with rectal cancer threatening (44) or affecting (82) the prostatic plane on preoperative staging and operated with local curative intent between 1998 and 2010 was analysed. In patients who did not have chemoradiotherapy but had a preoperative threatened anterior margin the CRM-positive rate was 25.0%. In patients who did not have preoperative chemoradiotherapy but did have an affected margin, the CRM-positive rate was 41.7%. When preoperative radiotherapy was given, the respective CRM infiltration rates were 7.1 and 20.7%. In patients having preoperative chemoradiotherapy followed by prostatic resection the rate of CRM positivity was 2.4%. Partial prostatectomy after preoperative chemoradiotherapy resulted in a free anterior CRM in all cases, but intra-operative urethral damage occurred in 36.4% of patients who underwent partial prostatectomy, resulting in a postoperative urinary fistula in 18.2% of patients.

CONCLUSION

Preoperative chemoradiation is mandatory in male patients with a threatened or affected anterior circumferential margin on preoperative MRI. In patients with preoperative prostatic infiltration, prostatic resection is necessary. In this group of patients partial prostatectomy seems to be oncologically safe.

Diffusion-weighted magnetic resonance imaging for prediction of tumor response to neoadjuvant chemoradiotherapy using irinotecan plus S-1 for rectal cancer

The purpose of this study was to investigate the clinical value of diffusion-weighted (DW) magnetic resonance imaging (MRI) as a predictor of tumor response in patients receiving neoadjuvant chemoradiotherapy (NA-CRT) for rectal cancer (RC) through measurement of the apparent diffusion coefficient (ADC) value in each tumor. Neoadjuvant radiotherapy with a total dose of 45 Gy in 25 fractions was performed in all 16 patients with RC, combined with irinotecan and S-1. MRI was performed before and after NA-CRT. Multiple factors were assessed to predict the pathological response to NA-CRT. The pathological response rate was determined in 9 patients (56.3%). Statistical analyses indicated that the ADC value prior to NA-CRT was significantly lower in patients with a better response to NA-CRT (P=0.023). A cut-off value of 0.750×10^-3 mm²/sec obtained by a receiver operating characteristic curve analysis indicated a sensitivity of 77.8% and specificity of 85.7% for pathological responders to NA-CRT. In addition, the patients with lower ADC values exhibited a greater pathological response to NA-CRT (P=0.041). In conclusion, the ADC value of MRI of RC patients treated with NA-CRT followed by surgery may provide valuable information to predict the response to NA-CRT.

Advances in radiotherapy delivery for rectal cancer: a European perspective

Preoperative chemoradiotherapy and radiotherapy with an integrated boost offer excellent local control rates in patients with rectal cancer. The introduction of intensity-modulated radiotherapy and image-guided radiotherapy has drastically improved the tolerance of these treatments. The new challenge is developing organ-preserving strategies and curative treatments for medically inoperable patients. Contact radiotherapy seems efficient for small tumors. Tumor hypoxia limits the success of radiotherapy for locally advanced cancers. Modulation of the L-arginine/iNOS pathway and implementation of hypoxia imaging in radiotherapy planning may overcome this hurdle.

Urinary and sexual dysfunction in women after resection with and without preoperative radiotherapy for rectal cancer: a population-based cross-sectional study

AIM

Knowledge of urinary and sexual dysfunction in women after rectal cancer treatment is limited. This study addresses this in relation to the use of preoperative radiotherapy, type of surgery and the presence of bowel dysfunction.

METHOD

All living female patients who underwent abdominoperineal excision (APE) or low anterior resection (LAR) for rectal cancer in Denmark between 2001 and 2007 were identified. Validated questionnaires (the ICIQ-FLUTS and the SVQ) on urinary and sexual function were completed by 516 (75%) and 482 (72%) recurrence-free patients in 2009.

RESULTS

Urgency and incontinence were reported by 77 and 63% of respondents, respectively. Vaginal dryness, dyspareunia and reduced vaginal dimensions occurred in 72, 53 and 29%, respectively, and 69% reported that they had little/no sexual desire. Preoperative radiotherapy was associated with voiding difficulties (OR = 1.63, 95% CI 1.09-2.44), reduced vaginal dimensions (OR = 4.77, 95% CI 1.97-11.55), dyspareunia (OR = 2.76, 95% CI 1.12-6.79), lack of desire (OR = 2.22, 95% CI 1.09-4.53) and reduced sexual activity (OR = 0.55, 95% CI 0.30-0.98). Patients undergoing APE had a higher risk of dyspareunia (OR = 2.61, 95% CI 1.00-6.85). Bowel dysfunction after LAR was associated with bladder storage difficulties (OR = 1.64, 95% CI 1.01-2.65), symptoms of incontinence (OR = 2.17, 95% CI 1.35-3.50), lack of sexual desire (OR = 2.69, 95% CI 1.21-5.98), sexual inactivity (OR = 0.48, 95% CI 0.24-0.96) and sexual dissatisfaction (OR = 0.40, 95% CI 0.20-0.82).

CONCLUSION

Urinary and sexual problems are common in women after treatment for rectal cancer. Preoperative radiotherapy interferes with several aspects of urinary and sexual functioning. Bowel dysfunction after LAR is associated with urinary dysfunction and a reduction in sexual desire, activity and satisfaction.

Limb-sparing surgery as an alternative for limb amputation in an invasive myxoid liposarcoma--case report

In medical practice, plastic surgeons confront with patients with sarcomas of the extremities that require a radical surgical approach. Knowing when to attempt limb-sparing surgery and when to give in to limb amputation is one of the most difficult decisions a surgeon can take. The correct approach and management of such cases ensure surgical success and the patient survival. In this paper, the case of a 56-year-old man, admitted in our clinic with a crush injury of the right calf and subsequent haematoma is presented. During haematoma drainage, the surgeon noticed abnormal tissue and performed an incisional biopsy. The patient was diagnosed with myxoid liposarcoma of the external compartment of the right calf. Limb amputation was proposed, but the patient refused. After the clinical examination, blood tests and diagnostic imaging, which allowed the correct evaluation of the case-tumor sizes and neighboring tissue reports, and preoperatory radiotherapy, limb sparing surgery, respectively primary tumor excision was decided to be performed. Negative margins could not be obtained by 3 successive resections or by adjuvant chemotherapy. The presented case supports the idea that limb-sparing surgery is only applicable to carefully selected patients with soft tissue sarcoma. In some cases, radical excision involving even mutilating amputations may provide a better oncologic and functional result.

Adjuvant chemotherapy for rectal cancer patients treated with preoperative (chemo)radiotherapy and total mesorectal excision: a Dutch Colorectal Cancer Group (DCCG) randomized phase III trial

BACKGROUND

The discussion on the role of adjuvant chemotherapy for rectal cancer patients treated according to current guidelines is still ongoing. A multicentre, randomized phase III trial, PROCTOR-SCRIPT, was conducted to compare adjuvant chemotherapy with observation for rectal cancer patients treated with preoperative (chemo)radiotherapy and total mesorectal excision (TME).

PATIENTS AND METHODS

The PROCTOR-SCRIPT trial recruited patients from 52 hospitals. Patients with histologically proven stage II or III rectal adenocarcinoma were randomly assigned (1:1) to observation or adjuvant chemotherapy after preoperative (chemo)radiotherapy and TME. Radiotherapy consisted of 5 × 5 Gy. Chemoradiotherapy consisted of 25 × 1.8-2 Gy combined with 5-FU-based chemotherapy. Adjuvant chemotherapy consisted of 5-FU/LV (PROCTOR) or eight courses capecitabine (SCRIPT). Randomization was based on permuted blocks of six, stratified according to centre, residual tumour, time between last irradiation and surgery, and preoperative treatment. The primary end point was overall survival.

RESULTS

Of 470 enrolled patients, 437 were eligible. The trial closed prematurely because of slow patient accrual. Patients were randomly assigned to observation (n = 221) or adjuvant chemotherapy (n = 216). After a median follow-up of 5.0 years, 5-year overall survival was 79.2% in the observation group and 80.4% in the chemotherapy group [hazard ratio (HR) 0.93, 95% confidence interval (CI) 0.62-1.39; P = 0.73]. The HR for disease-free survival was 0.80 (95% CI 0.60-1.07; P = 0.13). Five-year cumulative incidence for locoregional recurrences was 7.8% in both groups. Five-year cumulative incidence for distant recurrences was 38.5% and 34.7%, respectively (P = 0.39).

CONCLUSION

The PROCTOR-SCRIPT trial could not demonstrate a significant benefit of adjuvant chemotherapy with fluoropyrimidine monotherapy after preoperative (chemo)radiotherapy and TME on overall survival, disease-free survival, and recurrence rate. However, this trial did not complete planned accrual.

REGISTRATION NUMBER

Dutch Colorectal Cancer group, CKTO 2003-16, ISRCTN36266738.

Preoperative intensity modulated radiation therapy for retroperitoneal sarcoma

The use of intensity modulated radiation therapy (IMRT) has allowed for the administration of high doses to retroperitoneal sarcomas (RSTS) while limiting toxicity to adjacent organs. The purpose of our study is to assess the outcome and toxicities of patients with RSTS treated with neo-adjuvant external beam radiation (EBRT) therapy using IMRT. This is a retrospective study of 21 patients treated with preoperative IMRT for primary or recurrent RSTS between 2005 and 2011. Overall survival (OS) and local recurrence free survival (LRFS) were computed using the Kaplan-Meier method (log-rank test). Acute and chronic toxicities were assessed using the CTCAE v. 3 criteria. The actuarial 2 and 3-year OS was 66% for both and the 5-year OS was 51%. As for LRFS it was 57% at 2 and 3-year and 51% for the 5-year LRFS. Factors predictive for local control were microscopically negative margins (p = 0.022), a median tumor diameter <15 cm (p = 0.007) and pathology of liposarcoma (p = 0.021). Furthermore, patients treated for recurrent disease fared worse (p = 0.04) in local control than patients treated for primary disease. As for OS, patients treated for Grade 1 histology had a better outcome (p 5 0.05). EBRT was generally well tolerated. Acute gastrointestinal (GI) Grade 1 or 2 toxicities occurred in 33% of patients and one patient had unexplained post-radiation Grade 2 fever that resolved after tumor resection. As for chronic toxicities 24% of our patients presented Grade 1 GI toxicity and one patient presented Grade 3 small bowel stenosis not clearly due to radiation toxicity. Despite the location and volume of the tumors treated, preoperative IMRT was very well tolerated in our patients with retroperitoneal sarcoma. Unfortunately local recurrences remain common and dose escalation is to be considered.

Preoperative radiotherapy for rectal cancer: a comparative study of quality control adherence at two cancer hospitals in Spain and Poland

Background

We performed a clinical audit of preoperative rectal cancer treatment at two European radiotherapy centres (Poland and Spain). The aim was to independently verify adherence to a selection of indicators of treatment quality and to identify any notable inter-institutional differences.

Methods

A total of 162 patients, in Catalan Institute of Oncology (ICO) 68 and in Greater Poland Cancer Centre (GPCC) 94, diagnosed with locally advanced rectal cancer and treated with preoperative radiotherapy or radio-chemotherapy were included in retrospective study. A total of 7 quality control measures were evaluated: waiting time, multidisciplinary treatment approach, portal verification, in vivo dosimetry, informed consent, guidelines for diagnostics and therapy, and patient monitoring during treatment.

Results

Several differences were observed. Waiting time from pathomorphological diagnosis to initial consultation was 31 (ICO) vs. 8 (GPCC) days. Waiting time from the first visit to the beginning of the treatment was twice as long at the ICO. At the ICO, 82% of patient experienced treatment interruptions. The protocol for portal verification was the same at both institutions. In vivo dosimetry is not used for this treatment localization at the ICO. The ICO utilizes locally-developed guidelines for diagnostics and therapy, while the GPCC is currently developing its own guidelines.

Conclusions

An independent external clinical audit is an excellent approach to identifying and resolving deficiencies in quality control procedures. We identified several procedures amenable to improvement. Both institutions have since implemented changes to improve quality standards. We believe that all radiotherapy centres should perform a comprehensive clinical audit to identify and rectify deficiencies.

Prognosis of esophageal squamous cell carcinoma patients with preoperative radiotherapy: Comparison of different cancer staging systems

BACKGROUND

The 7th edition American Joint Committee on Cancer tumor-node-metastasis (AJCC TNM) staging system was published in 2010. Here we evaluate its predictive ability and compare the 6th and 7th editions of the AJCC TNM staging systems in esophageal squamous cell cancer (ESCC) with preoperative radiotherapy.

METHODS

A total of 296 esophageal squamous cell carcinoma patients receiving preoperative radiotherapy between 1980 and 2007 were included. Patients were staged using the 6th and 7th edition staging systems. Survival analyses were performed using Cox regression models. The homogeneity, discriminatory ability, and monotonicity of gradients of the two staging systems were compared using linear trend χ(2), likelihood ratio statistics, and Akaike information criterion calculation.

RESULTS

The overall five-year survival rate for the entire cohort was 27.1%. Female gender, length, "T," and "N," classifications according to the 7th edition staging system were the prognostic factors in univariate analyses. However, tumor histological grade and cancer location did not significantly influence patient survival. The 7th edition staging system has the highest linear trend χ(2)and likelihood ratio χ(2)scores. Compared to the 6th edition, the 7th edition staging system also has a smaller Akaike information criterion value, which represents the optimum prognostic stratification.

CONCLUSIONS

The strength of the 7th edition AJCC TNM staging system lies in the new descriptors for "T" and "N" classifications. However, we did not find cancer location to be a significant prognostic factor in our cohort. Overall, the 7th edition AJCC TNM staging system performed better than the previous edition.

Neoadjuvant short-course hyperfractionated accelerated radiotherapy (SC-HART) combined with S-1 for locally advanced rectal cancer

The purpose of this study was to examine the safety and feasibility of a novel protocol of neoadjuvant short-course hyperfractionated accelerated radiotherapy (SC-HART) combined with S-1 for locally advanced rectal cancer. A total of 56 patients with lower rectal cancer of cT3N1M0 (Stage III b) was treated with SC-HART followed by radical surgery, and were analyzed in the present study. SC-HART was performed with a dose of 2.5 Gy twice daily, with an interval of at least 6 hours between fractions, up to a total dose of 25 Gy (25 Gy in 10 fractions for 5 days) combined with S-1 for 10 days. Radical surgery was performed within three weeks following the end of the SC-HART. The median age was 64.6 (range, 39-85) years. The median follow-up term was 16.3 (range, 2-53) months. Of the 56 patients, 53 (94.4%) had no apparent adverse events before surgery; 55 (98.2%) completed the full course of neoadjuvant therapy, while one patient stopped chemotherapy because of Grade 3 gastrointestinal toxicity (CTCAE v.3). The sphincter preservation rate was 94.6%. Downstaging was observed in 45 patients (80.4%). Adjuvant chemotherapy was administered to 43 patients (76.8%). The local control rate, disease-free survival rate and disease-specific survival rate were 100%, 91.1% and 100%, respectively. To conclude, SC-HART combined with S-1 for locally advanced rectal cancer was well tolerated and produced good short-term outcomes. SC-HART therefore appeared to have a good feasibility for use in further clinical trials.

A comparison of dosimetric parameters between tomotherapy and three-dimensional conformal radiotherapy in rectal cancer

PURPOSE

Tomotherapy for intensity-modulated radiation has been demonstrated to reduce unnecessary irradiations to adjacent organs at risk (OARs). The purpose of this study was to compare the dosimetric parameters between Tomotherapy and three-dimensional conformal radiotherapy (3D-CRT) in rectal cancer patients.

MATERIALS AND METHODS

We redesigned three-dimensional conformal plans for 20 rectal cancer patients who had received short-course preoperative radiotherapy with Tomotherapy. The target coverage for 3D-CRT and Tomotherapy was evaluated with the following including the mean dose, V(nGy), D(min), D(max), radiation conformality index (RCI), and radical dose homogeneity index (rDHI).

RESULTS

The mean PTV dose for Tomotherapy is significantly higher than that observed for the 3D-CRT (p = 0.043). However, there is no significant difference in the V(23.25Gy), V(26.25Gy), V(27.5Gy), and RCI values between Tomotherapy and 3D-CRT. However, the average rDHI (p < 0.001) value for Tomotherapy was significantly lower than that reported for the 3D-CRT. Tomotherapy significantly lowered the mean level of irradiation doses to the bladder, small bowel, and femur heads as compared to 3D-CRT.

CONCLUSIONS

Tomotherapy could produce a favorable target coverage and significant dose reduction for the OARs at the expense of acceptable dose inhomogeneity of the PTV compared with 3D-CRT in rectal cancer patients.

Evaluation of short-course radiotherapy followed by neoadjuvant bevacizumab, capecitabine, and oxaliplatin and subsequent radical surgical treatment in primary stage IV rectal cancer

BACKGROUND

To evaluate the efficacy and tolerability of preoperative short-course radiotherapy followed by capecitabine and oxaliplatin treatment in combination with bevacizumab and subsequent radical surgical treatment of all tumor sites in patients with stage IV rectal cancer.

PATIENTS AND METHODS

Adults with primary metastasized rectal cancer were enrolled. They received radiotherapy (5 × 5 Gy) followed by bevacizumab (7.5 mg/kg, day 1) and oxaliplatin (130 mg/m(2), day 1) intravenously and capecitabine (1000 mg/m(2) twice daily orally, days 1-14) for up to six cycles. Surgery was carried out 6-8 weeks after the last bevacizumab dose. The percentage of radical surgical treatment, 2-year survival and recurrence rates, and treatment-related toxicity was evaluated.

RESULTS

Of 50 included patients, 42 (84%) had liver metastases, 5 (10%) lung metastases, and 3 (6%) both liver and lung metastases. Radical surgical treatment was possible in 36 (72%) patients. The 2-year overall survival rate was 80% [95% confidence interval (CI) 66.3%-90.0%]. The 2-year recurrence rate was 64% (95% CI 49.8%-84.5%). Toxic effects were tolerable. No treatment-related deaths occurred.

CONCLUSIONS

Radical surgical treatment of all tumor sites carried out after short-course radiotherapy, and bevacizumab-capecitabine-oxaliplatin combination therapy is a feasible and potentially curative approach in primary metastasized rectal cancer.