Glucopeptide Superstructure Hydrogel Promotes Surgical Wound Healing Following Neoadjuvant Radiotherapy by Producing NO and Anticellular Senescence

Neoadjuvant radiotherapy, a preoperative intervention regimen for reducing the stage of primary tumors and surgical margins, has gained increasing attention in the past decade. However, radiation-induced skin damage during neoadjuvant radiotherapy exacerbates surgical injury, remarkably increasing the risk of refractory wounds and compromising the therapeutic effects. Radiation impedes wound healing by increasing the production of reactive oxygen species and inducing cell apoptosis and senescence. Here, a self-assembling peptide (R-peptide) and hyaluronic-acid (HA)-based and cordycepin-loaded superstructure hydrogel is prepared for surgical incision healing after neoadjuvant radiotherapy. Results show that i) R-peptide coassembles with HA to form biomimetic fiber bundle microstructure, in which R-peptide drives the assembly of single fiber through π-π stacking and other forces and HA, as a single fiber adhesive, facilitates bunching through electrostatic interactions. ii) The biomimetic superstructure contributes to the adhesion and proliferation of cells in the surgical wound. iii) Aldehyde-modified HA provides dynamic covalent binding sites for cordycepin to achieve responsive release, inhibiting radiation-induced cellular senescence. iv) Arginine in the peptides provides antioxidant capacity and a substrate for the endogenous production of nitric oxide to promote wound healing and angiogenesis of surgical wounds after neoadjuvant radiotherapy.

The Association of the Epidermal Growth Factor Receptor (EGFR) Immunoexpression With Prognostic Parameters in Adenocarcinoma Patients Receiving Neoadjuvant Treatment

The epidermal growth factor receptor (EGFR) expression is considered to play an essential role in the pathogenesis of colorectal adenocarcinoma. This study assessed the expression and predictive/prognostic value of EGFR expression in pre-op biopsy and post-op resection specimens in patients receiving neoadjuvant radiotherapy/neoadjuvant chemoradiotherapy (NRT/NCRT). Thirty-four consecutive patients were included in this study. The association between the prognostic features and EGFR immunohistochemical expression was analyzed in pre- (n=34) and post-treatment (n=22) tissue samples in cases with available tissue blocks. Of 34, 23 (67.6%) were men. The median age was 60.50 ± 10.69 (range, 31-84) years. EGFR expression was detected in 88.2% of biopsy specimens and in 91.2% of surgical specimens. There was only slight agreement between pre-op and post-op EGFR expression scores (kappa value 0.11). There was no significant correlation between pre-op and post-op EGFR expression scores (p>0.05). Although pre-op EGFR positivity and higher pre-op EGFR scores seemed to indicate a worse prognosis, this association between pre-op EGFR expression and overall survival (OS) or disease-specific survival (DSS) did not reach statistical significance (p>0.05). The only case with a post-op EGFR score of three who died of the disease experienced local recurrence and had distant metastasis. In conclusion, EGFR positivity in pre-op biopsy samples seems to be associated with shorter survival, and increased EGFR expression in post-treatment resection specimens predicts aggressive behavior in patients with rectal adenocarcinoma who received NRT/NCRT. However, due to the molecular heterogeneity, EGFR expression status should be evaluated in resection specimens rather than in pre-op biopsy samples for optimal prognosis prediction.

Revolutionizing the battle against locally advanced breast cancer: A comprehensive insight into neoadjuvant radiotherapy

Breast cancer (BC) constitutes one of the most pervasive malignancies affecting the female population. Despite progressive improvements in diagnostic and therapeutic technologies, leading to an increased detection of early stage BCs, locally advanced breast cancer (LABC) persists as a significant clinical challenge. Owing to its poor overall survival (OS) rate, elevated recurrence rate, and high potential for distant metastasis, LABC prominently impacts the comprehensive efficacy of BC treatments. Radiotherapy, encompassing preoperative, intraoperative, and postoperative modalities, is acknowledged as an effective strategy for mitigating BC metastasis and enhancing survival rates among patients. Nevertheless, the domain of preoperative neoadjuvant radiotherapy (NART) remains conspicuously underexplored in clinical studies. Available research suggests that NART can induce tumor volume reduction, provoke fibrotic changes in tumor and adjacent normal tissues, thereby mitigating intraoperative cancer propagation and enhancing the quality of life for LABC patients. This manuscript seeks to provide a review of contemporary research pertaining to LABC and its preoperative radiotherapy.

Evaluation of the Prognostic Value of Pretherapeutic Magnetic Resonance Imaging in Predicting Soft Tissue Sarcoma Radiation Response: A Retrospective Study from a Large Institutional Sarcoma Imaging Database

Background: RT-induced hyalinization/fibrosis was recently evidenced as a significant independent predictor for complete response to neoadjuvant radiotherapy (RT) and survival in patients with soft tissue sarcoma (STS). Purpose: Non-invasive predictive markers of histologic response after neoadjuvant RT of STS are expected. Materials and Methods: From May 2010 to April 2017, patients with a diagnosis of STS who underwent neoadjuvant RT for limb STS were retrieved from a single center prospective clinical imaging database. Tumor Apparent Diffusion Coefficients (ADC) and areas under the time-intensity perfusion curve (AUC) were compared with the histologic necrosis ratio, fibrosis, and cellularity in post-surgical specimens. Results: We retrieved 29 patients. The median ADC value was 134.3 × 10-3 mm2/s. ADC values positively correlated with the post-treatment tumor necrosis ratio (p = 0.013). Median ADC values were lower in patients with less than 50% necrosis and higher in those with more than 50% (120.3 × 10-3 mm2/s and 202.0 × 10-3 mm2/s, respectively (p = 0.020). ADC values higher than 161 × 10-3 mm2/s presented a 95% sensitivity and a 55% specificity for the identification of tumors with more than 50% tumor necrosis ratio. Tumor-to-muscle AUC ratios were associated with histologic fibrosis (p = 0.036). Conclusions: ADC and perfusion AUC correlated, respectively, with radiation-induced tumor necrosis and fibrosis.

Case report: The first case of concurrent breast myeloid sarcoma and borderline phyllodes tumor with malignant features

Background

Myeloid sarcoma (MS) is a rare hematological malignancy characterized by the formation of a solid mass of myeloblasts outside the bone marrow, such as in the lymph nodes, skin, or bone. MS may arise de novo or concurrently with acute myeloid leukemia (AML), myeloproliferative neoplasm (MPN), or myelodysplastic syndrome (MDS). MS accounts for less than 1% of extramedullary acute myeloid leukemia cases. Phyllodes tumors (PTs) are a rare fibroepithelial breast tumor that can be benign, malignant, or borderline, and account for less than 1% of all breast cancers.

Case presentation

We present a unique case of a 50-year-old woman with both breast MS and borderline PT with malignant features, which presented a diagnostic challenge. The patient initially presented with a mass in her right breast, and the initial fine-needle biopsy revealed the presence of immature myeloperoxidase (MPO)+ myeloid cells consistent with MS. Subsequent pathological analysis of tumor tissues after neoadjuvant radiotherapy and chemotherapy showed a borderline PT with malignant features. Following excision of the tumor, the patient experienced a local recurrence, which was also surgically removed. At 8 months post-surgery, the patient remains free of recurrence under close follow-up.

Conclusion

This case highlights the importance of considering the possibility of concurrent malignancies in the differential diagnosis of complex breast masses and underscores the challenges involved in diagnosing and managing such cases. Additionally, we also emphasize the value of neoadjuvant radiotherapy and chemotherapy in MS.

Long-term outcome of centrally located hepatocellular carcinoma treated by neoadjuvant radiotherapy and radical resection: a propensity score matched study

Objective

Centrally located hepatocellular carcinoma (HCC) typically presents challenges in surgical intervention and is associated with a bleak prognosis. In order to address this pressing issue, it is imperative to identify a comprehensive treatment approach, such as neoadjuvant radiotherapy (neoRT), that can enhance the prognosis of patients diagnosed with centrally located HCC.

Methods

Patients who had surgical resections for HCC between March 2015 and December 2020 were included in the study. Patients were assigned to either the neoRT combined with liver resection (neoRT+LR) group or the liver resection alone (LR) group. The study employed propensity-score analysis and Cox proportional-hazards regression models as research methodologies. Using the Kaplan-Meier method, overall survival (OS) and disease-free survival (DFS) were estimated in patients.

Results

During the study, 162 patients were enrolled, with 41 receiving neoRT+LR and 121 receiving LR. The duration of the median follow-up period was 45 months. The 1-year, 3-year, and 5-year OS rates were 95, 70, and 70% for patients in the neoRT+LR group, and 82, 64, and 54% for patients in the LR group, respectively. The 1-year, 3-year, 5-year DFS rates were 71, 53, and 37% for patients in the neoRT+LR group, and 52, 38, and 34% for patients in the LR group, respectively. A successful matching of 37 patients was achieved through propensity-score analysis. OS and DFS after matching analysis was statistically different between the two groups ( P=0.0099, P=0.034, respectively). neoRT was an independent prognostic factor for OS and DFS [hazard ratio (HR)=0.47, 95% CI: 0.24-0.93; HR=0.56, 95% CI: 0.34-0.92, respectively]. According to matching analysis, there were no statistically significant differences observed in terms of baseline characteristics, surgical safety, and complications between the groups.

Conclusion

Liver resection and neoRT can be advantageous for patients with centrally located HCC.

A Modified NAR Scoring Model Incorporating Immune Infiltration Characteristics to Better Predict Long-Term Survival Following Neoadjuvant Radiotherapy in Rectal Cancer

(1) Background: The neoadjuvant rectal (NAR) score has been developed as a prognostic tool for survival in locally advanced rectal cancer (LARC). However, the NAR score only incorporates weighted cT, ypT, and ypN categories. This long-term follow-up study aims to modify a novel prognostic scoring model and identify a short-term endpoint for survival. (2) Methods: The prognostic factors for overall survival (OS) were explored through univariate and multivariate analyses. Based on Cox regression modeling, nomogram plots were constructed. Area under the curve (AUC) and concordance indices were used to evaluate the performance of the nomogram. Receiver operating characteristic (ROC) analysis was conducted to compare the efficiency of the nomogram with other prognostic factors. (3) Results: After a long-term follow-up, the 5-year OS was 67.1%. The mean NAR score was 20.4 ± 16.3. Multivariate analysis indicated that CD8+ T-cell, lymphovascular invasion, and the NAR score were independent predictors of OS. The modified NAR scoring model, incorporating immune infiltration characteristics, exhibited a high C-index of 0.739 for 5-year OS, significantly outperforming any individual factor. Moreover, the predictive value of the nomogram was superior to the AJCC stage and pathological complete regression at 3-year, 5-year, and 10-year time points, respectively. Over time, the model's predictions of long-term survival remained consistent and improved in accuracy. (4) Conclusions: The modified NAR scoring model, incorporating immune infiltration characteristics, demonstrates high accuracy and consistency in predicting OS.

Neoadjuvant intensity modulated radiotherapy for a single and small (≤5 cm) hepatitis B virus-related hepatocellular carcinoma predicted to have high risks of microvascular invasion: a randomized clinical trial

BACKGROUND

The presence of microvascular invasion (MVI) significantly impairs postoperative long-term survival of patients with hepatocellular carcinoma (HCC). The role of neoadjuvant radiotherapy (RT) in treating patients with an early-stage HCC predicted to have high risks of MVI remains to be explored.

MATERIALS AND METHODS

Consecutive patients with a resectable single and small (≤5 cm) hepatitis B virus-related HCC predicted to have high risks of MVI were randomized 1:1 to receive either neoadjuvant intensity modulated radiation therapy (18 Gy with fractionated doses of 3 Gy) followed by surgery 4 weeks later or upfront surgery. The primary endpoint was disease-free survival (DFS). The secondary outcomes included overall survival (OS), objective response rate, RT-related toxicity and surgical complications.

RESULTS

There were 30 patients randomized to each of the two groups. In the neoadjuvant RT group, three patients violated the study protocol, with two having upfront hepatectomy and one radiofrequency ablation after RT. The objective response rate after RT was 25.0% (7/28), but 2 patients suffered from grade 3 liver toxicity. The median follow-up was 68 months (interquartile range, 58-70 months) in the neoadjuvant RT group, and 68 months (interquartile range, 62-75 months) in the upfront surgery group. On intention-to-treat analysis, the median DFS and median OS were not reached in both the 2 arms. The 1-year, 2-year, 3-year and 5-year DFS rates for the neoadjuvant RT group were 86.7%, 76.7%, 60.0% and 56.3%, versus 90.0%, 66.7%, 52.8% and 45.7% in the upfront surgery group ( P =0.448), respectively. The corresponding OS rates were 96.7%, 86.7%, 83.3% and 72.7%, versus 100.0%, 93.3%, 79.6% and 60.7% ( P = 0.399).

CONCLUSION AND RELEVANCE

For patients with a resectable single and small hepatitis B virus-related HCC predicted to have high risks of MVI, neoadjuvant RT gave a promising response rate with a mild toxicity. Nevertheless, the neoadjuvant RT yielded similar long-term DFS and OS rates compared with patients who underwent upfront surgery.

The Conditioning of Adjuvant Chemotherapy for Stage II and III Rectal Cancer Determined by Postoperative Pathological Characteristics in Romania

The management of locally advanced rectal cancer (LARC) suffered changes thanks to the development of improved surgical procedures, radiation delivery, and chemotherapy. Although treatment options improved individually, the optimal order is still debated. Neoadjuvant chemo-radiotherapy followed by total mesorectal excision (TME) has been the "golden standard" for locally advanced rectal cancer. There is no common ground in international guidelines on the indications of adjuvant chemotherapy (ADJCHT), with differences between the American, European, and Japanese guidelines. This paper studies the preferences of Romanian oncologists in prescribing ADJCHT. We conducted a single-institution, retrospective study of all nonmetastatic, ECOG 0-1 LARC patients staged II-III who underwent TME and were admitted to the Oncology or Radiotherapy Department of Colțea Clinical Hospital, Bucharest between January 2017 and March 2021. A total of 186 patients were included in the study. A positive correlation was found between ADJCHT and each of the following: (y)pT > 2, (y)pN > 0, and the presence of perineural invasion (PNI+). A strong positive correlation was found between ADJCHT and the presence of at least one risk factor: (y)pT > 2, (y)pN > 0, PNI+, lymphovascular invasion, positive margins, or tumor grade > 1. Tumor downstaging decreased the risk of metastases in the first 2 years and was associated with the use of neoadjuvant radiotherapy, while adding neoadjuvant chemotherapy increased the chance of nodal downstaging. ADJCHT practice for LARC in Romania follows either NCCN or ESMO guidelines, at the discretion of the oncologist, due to the lack of national guideline.

Integra® Dermal Regeneration Matrix: A Versatile Solution for Complex Soft Tissue Sarcoma Reconstruction in the Hand

This case report describes the successful use of Integra® (Integra LifeSciences Corporation, Plainsboro, New Jersey, United States), an artificial skin substitute, for the reconstruction of soft tissue defects following soft tissue sarcoma resection. We present a case of a 75-year-old female presented with a progressively enlarging lesion on her right hand. Imaging revealed tumor involvement in the extensor tendons and adjacent to the index finger tendon. A percutaneous biopsy confirmed an undifferentiated pleomorphic sarcoma. The patient underwent neoadjuvant radiotherapy followed by wide excision of the tumor. Integra® dermal regeneration matrix was utilized to cover the exposed bone during the surgical procedure. This allowed for wound closure and provided a favorable environment for tissue regeneration and subsequent split-thickness skin graft. Complete wound healing was obtained. Regular follow-up examinations showed no evidence of local recurrence or secondary lesions after one year. The successful use of Integra®, in this case, demonstrates its efficacy as a reconstructive option for complex hand sarcomas. It offers immediate wound coverage and promotes tissue regeneration, thereby avoiding the need for more extensive treatment modalities with associated donor-site morbidity. The utilization of Integra® resulted in high patient satisfaction and excellent recovery. This case highlights the importance of utilizing innovative techniques and materials in achieving optimal outcomes in challenging hand sarcoma reconstructions.

The Prognostic Relevance of MRI Characteristics in Myxofibrosarcoma Patients Treated with Neoadjuvant Radiotherapy

To improve local control, neoadjuvant radiotherapy (nRT) followed by surgery is the standard of care in myxofibrosarcoma (MFS) because of its infiltrative growth pattern. Nevertheless, local recurrence rates are high. Data on prognostic factors for poor clinical outcomes are lacking. This retrospective study thus investigates the prognostic relevance of magnetic resonance imaging (MRI) characteristics before and after nRT in 40 MFS patients, as well as their association with disease-free survival (DFS) and overall survival (OS). A vascular pedicle, defined as extra-tumoral vessels at the tumor periphery, was observed in 12 patients (30.0%) pre-nRT and remained present post-nRT in all cases. Patients with a vascular pedicle had worse DFS (HR 5.85; 95% CI 1.56-21.90; p = 0.009) and OS (HR 9.58; 95% CI 1.91-48.00; p = 0.006). An infiltrative growth pattern, referred to as a tail sign, was observed in 22 patients (55.0%) pre-nRT and in 19 patients (47.5%) post-nRT, and was associated with worse DFS post-nRT (HR 6.99; 95% CI 1.39-35.35; p = 0.019). The percentage of tumor necrosis estimated by MRI was increased post-nRT, but was not associated with survival outcomes. The presence of a tail sign or vascular pedicle on MRI could support the identification of patients at risk for poor clinical outcomes after nRT.

Forecasting Individual Patients' Best Time for Surgery in Colon-Rectal Cancer by Tumor Regression during and after Neoadjuvant Radiochemotherapy

The standard treatment of locally advanced rectal cancer is neoadjuvant chemoradiotherapy before surgery. For those patients experiencing a complete clinical response after the treatment, a watch-and-wait strategy with close monitoring may be practicable. In this respect, the identification of biomarkers of the response to therapy is extremely important. Many mathematical models have been developed or used to describe tumor growth, such as Gompertz's Law and the Logistic Law. Here we show that the parameters of those macroscopic growth laws, obtained by fitting the tumor evolution during and immediately after therapy, are a useful tool for evaluating the best time for surgery in this type of cancer. A limited number of experimental observations of the tumor volume regression, during and after the neoadjuvant doses, permits a reliable evaluation of a specific patient response (partial or complete recovery) for a later time, and one can evaluate a modification of the scheduled treatment, following a watch-and-wait approach or an early or late surgery. Neoadjuvant chemoradiotherapy effects can be quantitatively described by applying Gompertz's Law and the Logistic Law to estimate tumor growth by monitoring patients at regular intervals. We show a quantitative difference in macroscopic parameters between partial and complete response patients, reliable for estimating the treatment effects and best time for surgery.

Clinical Benefits of Neoadjuvant Radiotherapy on the Postoperative Recurrence of Centrally Located Hepatocellular Carcinoma: A Real-World Evidence Based on Phase II Clinical Trial

Objective

Although surgical resection is one of the most effective way to treat liver cancer, its efficacy and safety in treatment of centrally located hepatocellular carcinoma (HCC) remains elusive. Therefore, it is very important to find a comprehensive treatment mode, such as radical resection combined with neoadjuvant radiotherapy (neoRT).

Methods

The centrally located HCC patients who underwent radical resection from July 2015 to April 2021 were enrolled. According to whether the neoRT was implemented or not, these patients were allocated into neoadjuvant radiotherapy combined with liver resection (neoRT+LR) and liver resection alone (LR) group. The research method used propensity-score analysis and Cox proportional-hazards regression models. We generated an E-value to assess the sensitivity to unmeasured confounding. This study is a real-world, retrospective study based on phase II clinical trial.

Results

A total of 168 patients were enrolled, including 38 patients treating with neoRT+LR and 130 patients with LR. The 1-, 3-, 5-year disease free survival (DFS) rates were 74%, 55% and 39% in the neoRT+LR group, and 44%, 28%, and 24% in the LR group, respectively. Neoadjuvant radiotherapy was an independent prognostic factor for postoperative recurrence ([HR]0.42, 95% CI [0.25, 0.69]). There was significant association between neoRT+LR and longer disease-free survival (Match, [HR] 0.43, 95% CI [0.24, 0.76]; GenMatch, [HR] 0.32, 95% CI [0.23, 0.43]; Adjusted for propensity score, [HR] 0.41, 95% CI [0.23, 0.73]; Inverse probability weighting, [HR] 0.38, 95% CI [0.22, 0.65], respectively). DFS before and after matching analysis was statistically different in two groups (p-value=0.005, p-value=0.0024, respectively). Neoadjuvant radiotherapy can significantly reduce the postoperative early recurrence (p-value <0.05). E-value analysis suggested robustness to unmeasured confounding.

Conclusion

Liver resection combined with neoadjuvant radiotherapy was effective and safe for treatment of centrally located HCC patients, which improved the prognosis of patients and reduced the incidence of early recurrence.

Case report and literature review: Conversion surgery for initially unresectable huge retroperitoneal liposarcoma after preoperative radiotherapy

Background

Retroperitoneal liposarcoma (RPLS) is a rare malignancy that is notorious for recurrence. Surgical resection with clean margin is the current treatment of choice. However, owing to the large retroperitoneal space, RPLSs often grow to significant sizes before being diagnosed. Neoadjuvant and adjuvant therapies have potentials to improve long term treatment outcome.

Case presentation

A 55-year-old Han Chinese male presented to the general surgery department with a one-year history of abdominal fullness and a one-week history of palpable right inguinal mass. At first, he was diagnosed with incarcerated inguinal hernia. However, abdominal computer tomography (CT) and biopsy confirmed his final diagnosis to be retroperitoneal well-differentiated liposarcoma, cT2bN0M0, stage IIb. The tumor, which measured 44.5cm in maximum diameter, was too large for primary surgical resection. Neoadjuvant radiotherapy with 70 Gy in 35 fractions was delivered to the tumor, which shrunk the target volume from 6300 cc to 4800 cc, as observed in the middle of the radiotherapy course. The right testicular mass also received 70Gy/35Fx. Conversion surgery was performed after radiotherapy. Unfortunately, due to residual tumor, adjuvant chemotherapy consisting of AIM (ifosfamide, Mesna, and doxorubicin) and MAID (Mesna, doxorubincin, ifosfamide, and dacarbazine) regimens were administered sequentially. Afterward, debulking surgery was conducted, plus another 18 cycles of ifosfamide monotherapy when residual tumor was still seen on CT. Since the completion of ifosfamide chemotherapy, the patient has been cancer free with no evidence of tumor recurrence for more than 26 months.

Conclusion

Despite conflicting evidence in the literature, our case supports the use of high dose neoadjuvant radiotherapy and adjuvant chemotherapy in treating large, unresectable RPLSs. It also highlights the importance of using individualized, multidisciplinary approach in achieving cure for large, unresectable rare tumors.

Neoadjuvant radiotherapy plus single-incision thoracoscopic surgery in the treatment of type B3 thymomas

Background

Although minimally invasive surgery is the standard treatment for thymomas, minimally invasive thymectomy is difficult for patients with type B3 thymomas, especially for giant or aggressive lesions. These tumors are frequently treated with radical radiation therapy or surgery plus adjuvant radiotherapy. Few studies, however, have tested the efficacy of neoadjuvant radiotherapy prior to thoracoscopic surgery.

Methods

Patients with type B3 thymomas >5 cm or with infiltrates into vital organs on CT-guided puncture biopsy who underwent neoadjuvant radiotherapy followed by single-incision minimally invasive thymectomy from March 2016 to July 2020 were retrospectively evaluated. Reduction ratios, TNM stage changes according to WHO stage criteria, resectability, long-term survival, and the response in terms of RECIST v1.1 criteria achieved by preoperative RT were analyzed.

Results

The 11 patients who underwent neoadjuvant radiotherapy plus minimally invasive thymectomy included five men and six women, of mean age 49.5 years. Four patients had myasthenia gravis. Neoadjuvant radiotherapy consisted of 50 Gy in 25 fractions, with all patients showing varying degrees of lesion reduction after radiotherapy. Surgery was performed about 1 month after neoadjuvant radiotherapy, with none of these patients having severe radiation pneumonitis. All patients underwent radical resection of the tumor and adjacent tissue, with none experiencing tumor seeding or rupture during surgery. The median postoperative hospital stay was 3 days (range: 2-6 days) and the frequency of additional regular analgesics (including those for wound pain and neuralgia) was 2.5 times per person. On follow-up, one patient experienced pleural metastasis and one experienced pulmonary metastasis, with the other nine patients showing no evidence of tumor recurrence.

Conclusion

Neoadjuvant radiotherapy followed by minimally invasive surgery was a safe and efficacious procedure for the treatment of type B3 thymomas, with less postoperative pain and faster recovery. This strategy, of tumor shrinkage prior to surgery, may make possible the easier removal of type B3 thymomas by single-incision thoracoscopy.

Correlation of radiological and histopathological response after neoadjuvant radiotherapy in soft tissue sarcoma

BACKGROUND

The aim of this study was to assess the association between radiological and histopathological response after neoadjuvant radiotherapy (nRT) in soft tissue sarcoma (STS), as well as the prognostic value of the different response evaluation methods on the oncological outcome.

METHODS

A retrospective cohort of patients with localized STS of the extremity and trunk wall, treated with nRT followed by resection were included. The radiological response was assessed by RECIST 1.1 (RECIST) and MR-adapted Choi (Choi), histopathologic response was evaluated according to the EORTC-STBSG recommendations. Oncological outcome parameters of interest were local recurrence-free survival (LRFS), disease metastases-free survival (DMFS), and overall survival (OS).

RESULTS

For 107 patients, complete pre- and postoperative pathology and imaging datasets were available. Most tumors were high-grade (77%) and the most common histological subtypes were undifferentiated pleomorphic sarcoma/not otherwise specified (UPS/NOS, 40%), myxoid liposarcoma (MLS, 21%) and myxofibrosarcoma (MFS, 16%). When comparing RECIST to Choi, the response was differently categorized in 58%, with a higher response rate (CR + PR) with Choi. Radiological responders showed a significant lower median percentage of viable cells (RECIST p = .050, Choi p = .015) and necrosis (RECIST p < .001), and a higher median percentage of fibrosis (RECIST p = .005, Choi p = .008), compared to radiological non-responders (SD + PD). RECIST, Choi, fibrosis, and viable cells were not significantly associated with altered oncological outcome, more necrosis was associated with poorer OS (p = .038).

CONCLUSION

RECIST, Choi and the EORTC-STBSG response score show incongruent results in response evaluation. The radiological response was significantly correlated with a lower percentage of viable cells and necrosis, but a higher percentage of fibrosis. Apart from necrosis, radiological nor other histopathological parameters were associated with oncologic outcomes.

Diffusion-Weighted MRI in the Evaluation of Early-Stage Breast Cancer Treated with a Short Preoperative Radiotherapy: Preliminary Results

Objective

To assess tumor response with diffusion-weighted MRI (DW-MRI) after a short preoperative radiotherapy in early-stage breast cancer (BCa).

Materials and Methods

This was a prospective, single-center pilot study. 3T-MRI were performed before and after radiotherapy. The longest diameter (LD) and the apparent diffusion coefficient (ADC) value of a region of interest (ROI) of the tumors were recorded. Histopathology and immunohistochemistry, including the Ki-67 index of the core biopsy and of the surgical specimen, were the reference standards.

Results

Nineteen patients with 22 early-stage BCa were included. The mean ROI ADC value was 1.093 ± 0.278 × 10^-3 mm²/s before radiotherapy and 1.490 ± 0.429 × 10^-3 mm²/s (p-value < 0.001) after radiotherapy. The Ki-67 index was 9.2 ± 9.1% at the percutaneous biopsy before radiotherapy and 4.9 ± 7.5% (p-value = 0.005) after radiotherapy at the surgical specimen. After neoadjuvant radiotherapy, a 4.7% decrease in LD and a 36.3% increase in ROI-ADC of the tumors were measured at MRI and a 46.7% decrease in Ki-67 index was observed at histology of the surgical specimen in comparison with the percutaneous core biopsy.

Conclusion

In early-stage BCa, a significant increase in ROI-ADC at DWI and a significant decrease in Ki-67 index were observed after a short preoperative radiotherapy, suggesting early tumor response.

Applying post-neoadjuvant pathologic stage as prognostic tool in esophageal squamous cell carcinoma

BACKGROUND

It is still uncertain whether the newly released eighth American Joint Committee on Cancer (AJCC) post-neoadjuvant pathologic (yp) tumor-node-metastasis (TNM) stage for esophageal carcinoma can perform well regarding patient stratification. The current study aimed to assess the prognostication ability of the eighth AJCC ypTNM staging system and attempted to explore how to facilitate the staging system for more effective evaluation of prognosis.

MATERIALS AND METHODS

A total of 486 patients treated with neoadjuvant radiotherapy/chemoradiotherapy (nRT/CRT) were enrolled. ypN stage was reclassified by recursive partitioning. Prognostic performance, monotonicity, homogeneity, and discriminatory of yp and modified yp (myp) staging systems were assessed by time-dependent receiver operating characteristic (ROC), linear trend log-rank test, likelihood ratio χ2 test, Harrell's c statistic, and Akaike information criterion (AIC).

RESULTS

The ypT stage, ypN stage, and pathologic response were significant prognostic factors of overall survival. Survival was not discriminated well using the eighth AJCC ypN stage and ypTNM stage. Recursive partitioning reclassified mypN0-N2 as metastasis in 0, 1-2, and ≥3 regional lymph nodes. Applying the ypT stage, mypN stage, and pathologic response to construct the myp staging system, the myp stage performed better in time-dependent ROC, linear trend log-rank test, likelihood ratio χ2 test, Harrell's c statistic, and AIC.

CONCLUSIONS

The eighth AJCC ypTNM staging system performed well in differentiating prognosis to some extent. By reclassifying the ypN stage and enrolling pathologic response as a staging element, the myp staging system holds significant potential for prognostic discrimination.

Intensity modulated radiotherapy might be effective for locally advanced esophageal carcinosarcoma: A single center's experience and review of literature

Esophageal carcinosarcoma is a rare type of esophageal cancer; however, few studies have investigated the effects of radiotherapy in locally advanced patients. This study aimed to report experience of the safety and efficacy of intensity-modulated radiotherapy for locally advanced esophageal carcinosarcoma and review the literature. By searching the institutional database between January 2010 and December 2020, along with the literature review, 25 patients were eligible for the study. The clinical and radiologic information of all patients with esophageal carcinosarcoma who underwent radiotherapy were collected. Survival outcomes were calculated using Kaplan-Meier plots. In our series, 5 patients were in the curative/neoadjuvant radiotherapy group and 10 patients were in the adjuvant group. Most tumors were protruding (n = 10, 66.7%). All patients underwent intensity-modulated radiotherapy. In the curative/neoadjuvant radiotherapy group, 2 patients underwent concurrent chemoradiotherapy before surgery, and the other three received radiotherapy alone as the initial treatment. The median follow-up time was 43.1 months. All patients showed a partial response at the efficacy evaluation. The median time of overall survival and progression-free survival were 40.2 months (95% confidence interval [CI], 13.1-67.3 months) and 19.0 months (95% CI, 13.9 months-24.1 months) for the entire cohort, but were not reached for curative/neoadjuvant radiotherapy group. Overall survival (hazard ratio [HR] 0.81, 95% CI, 0.15-4.43; P = .805) and progression-free survival (HR 1.68, 95% CI, 0.35-8.19; P = .514) did not differ significantly between the 2 groups. When considering the literature review data in the final analysis, overall survival (HR 0.84, 95% CI, 0.25-2.81; P = .779) and progression-free survival (HR, 0.68; 95% CI, 0.26-1.76; P = .425) were also not different between the 2 groups. Treatment based on intensity-modulated radiotherapy with neoadjuvant or curative intent may be an option for patients with unresectable esophageal carcinosarcoma. Further research with a larger sample size is needed to validate the reliability.

Neoadjuvant chemoradiotherapy, chemotherapy, and radiotherapy do not significantly increase the incidence of anastomotic leakage after esophageal cancer surgery: a meta-analysis

This study investigated whether neoadjuvant therapies, such as neoadjuvant chemoradiotherapy (NCRT), neoadjuvant chemotherapy (NCT), and neoadjuvant radiotherapy (NRT), would affect the incidence of anastomotic leakage (AL) after esophageal cancer surgery. Published randomized controlled trials were reviewed, and the incidence of AL after esophageal cancer was statistically analyzed in each study. Meta-analysis was performed using Revman and Stata software. A total of 17 randomized controlled trials with 2874 patients were reviewed showing that, in general, preoperative neoadjuvant therapies were not significant risk factors for AL after esophageal cancer surgery (relative risk [RR] = 0.82, 95% CI = 0.64-1.04). NCRT and NRT did not significantly increase the risk of postoperative AL in patients with esophageal cancer (RR = 0.81, 95% CI = 0.63-1.05; RR = 0.64, 95% CI = 0.14-2.97, respectively). Moreover, NCT has no significant correlation with the occurrence of AL (RR = 1.01, 95% CI = 0.57-1.80). NCRT, NCT, and NRT do not significantly increase the incidence of gastroesophageal AL after esophageal cancer surgery.

Neoadjuvant Stereotactic Radiotherapy for Brain Metastases: Systematic Review and Meta-Analysis of the Literature and Ongoing Clinical Trials

Simple Summary

The available treatment strategies for patients with brain metastases remain suboptimal, with current research focused on identifying therapies intended to improve patient outcomes while reducing the risk of treatment-related complications. Several studies have investigated the role of pre-operative neoadjuvant stereotactic radiotherapy, and have proposed it as a valid alternative to post-operative adjuvant stereotactic radiotherapy. The aim of our systematic review was to comprehensively analyze the current literature and ongoing clinical trials evaluating neoadjuvant stereotactic radiotherapy in patients with brain metastases, describing treatment protocols and related outcomes. Early evidence suggests that neoadjuvant stereotactic radiotherapy may offer rates of local control and overall survival comparable to those obtained with adjuvant postoperative SRS, but comparative studies are currently lacking. In addition, neoadjuvant stereotactic radiotherapy shows low rates of post-treatment radiation necrosis and leptomeningeal metastases. Ongoing clinical trials aim to evaluate long-term outcomes in large patient cohorts, with some focused on comparing neoadjuvant stereotactic radiotherapy to adjuvant stereotactic radiosurgery.

Abstract

Background: Brain metastases (BMs) carry a high morbidity and mortality burden. Neoadjuvant stereotactic radiotherapy (NaSRT) has shown promising results. We systematically reviewed the literature on NaSRT for BMs. Methods: PubMed, EMBASE, Scopus, Web-of-Science, Cochrane, and ClinicalTrial.gov were searched following the PRISMA guidelines to include studies and ongoing trials reporting NaSRT for BMs. Indications, protocols, and outcomes were analyzed using indirect random-effect meta-analyses. Results: We included 7 studies comprising 460 patients with 483 BMs, and 13 ongoing trials. Most BMs originated from non-small lung cell carcinoma (41.4%), breast cancer (18.7%) and melanoma (43.6%). Most patients had single-BM (69.8%) located supratentorial (77.8%). Patients were eligible if they had histologically-proven primary tumors and ≤4 synchronous BMs candidate for non-urgent surgery and radiation. Patients with primary tumors clinically responsive to radiotherapy, prior brain radiation, and leptomeningeal metastases were deemed non-eligible. Median planning target volume was 9.9 cm³ (range, 2.9–57.1), and NaSRT was delivered in 1-fraction (90.9%), 5-fraction (4.8%), or 3-fraction (4.3%), with a median biological effective dose of 39.6 Gy10 (range, 35.7–60). Most patients received piecemeal (76.3%) and gross-total (94%) resection after a median of 1-day (range, 1–10) post-NaSRT. Median follow-up was 19.2-months (range, 1–41.3). Actuarial post-treatment rates were 4% (95%CI: 2–6%) for symptomatic radiation necrosis, 15% (95%CI: 12–18%) and 47% (95%CI: 42–52%) for local and distant recurrences, 6% (95%CI: 3–8%) for leptomeningeal metastases, 81% (95%CI: 75–87%) and 59% (95%CI: 54–63%) for 1-year local tumor control and overall survival. Conclusion: NaSRT is effective and safe for BMs. Ongoing trials will provide high-level evidence on long-term post-treatment outcomes, further compared to adjuvant stereotactic radiotherapy.

Comparison of different neoadjuvant treatments for resectable locoregional esophageal cancer: A systematic review and network meta-analysis

PURPOSE

The best pattern of neoadjuvant therapy for resectable locoregional esophageal cancer has not been determined. Our study evaluated the efficacy and postoperative events of different treatments using the Bayesian network meta-analysis.

METHODS

We systematically tracked randomized clinical trials from the Medline, EMBASE, and Cochrane Library databases. The following treatments were included: neoadjuvant chemoradiation followed by surgery (NCRT + S), neoadjuvant chemotherapy followed by surgery (NCT + S), neoadjuvant radiotherapy followed by surgery (NRT + S), and surgery alone (S). The Revised Cochrane risk-of-bias tools were used to assess the quality of included trials. Overall survival (OS) and progression-free survival or disease-free survival (PFS/DFS) were assessed through hazard ratios (HR). Locoregional recurrence, distant metastasis, postoperative mortality, and postoperative morbidity were assessed through odds ratios (OR). These outcomes were compared between different treatments through Bayesian network meta-analysis.

RESULTS

Twenty trials with 4384 patients were included. Compared with S, only NCRT + S could significantly improve OS for patients with esophageal cancer (HR = 0.78, 95% confidence interval [CI] 0.68-0.88). NCRT + S and NCT + S significantly improved PFS/DFS compared with S (NCRT + S vs. S, HR = 0.72, 95% CI 0.63-0.81; NCT + S vs. S, HR = 0.81, 95% CI 0.69-0.97). NCRT + S significantly reduced both locoregional recurrence (OR = 0.67, 95% CI 0.51-0.88) and distant metastasis (OR = 0.63, 95% CI 0.45-0.90) compared with S. There were no differences in postoperative morbidity between the four treatments. However, NCRT + S also increased postoperative mortality compared with S (OR = 1.77, 95% CI 1.09-2.82) and NCT + S (OR = 1.96, 95% CI 1.11-3.51).

CONCLUSION

NCRT + S is the most efficient neoadjuvant treatment for resectable locoregional esophageal cancer. However, NCRT + S increases the risk of postoperative mortality but not morbidity.

Predictive Factors of Long-Term Survival after Neoadjuvant Radiotherapy and Chemotherapy in High-Risk Breast Cancer

Simple Summary

This retrospective analysis reports on the treatment outcomes of women diagnosed with high-risk breast cancer treated with chemotherapy in combination with radiotherapy before the surgical removal of the tumor. It is well established that the lack of visible tumor cells in the pathological tumors analysis by the time of surgery (known as pathological complete response, pCR) is a factor that improves survival without the tumor reappearing in the body. However, it is unknown whether that is only true when giving systemic therapy or when pCR is achieved with the help of radiotherapy. We collected patient information and survival times to analyze the outcome in our patient group. We found that women with a pCR treated with chemotherapy in combination with radiotherapy can expect favorable long-term survival. This was true across different types of breast cancer and chemotherapy substances.

Abstract

Background: Neoadjuvant radiotherapy (naRT) in addition to neoadjuvant chemotherapy (naCT) has been used for locally advanced, inoperable breast cancer or to allow breast conserving surgery (BCS). Retrospective analyses suggest that naRT + naCT might result in an improvement in pathological complete response (pCR rate and disease-free survival). pCR is a surrogate parameter for improved event-free and overall survival (OS) and allows for the adaption of the post-neoadjuvant therapy regimens. However, it is not clear whether pCR achieved with the addition of naRT has the same prognostic value. Patients and methods: We performed a retrospective re-analysis of 356 patients (cT1-cT4/cN0-N+) treated with naRT and naCT with a long-term follow-up. Patients underwent naRT on the breast and regional lymph nodes combined with a boost to the primary tumor. Chemotherapy with different agents was given either sequentially or concomitantly to naRT. We used the Cox proportional hazard regression model to estimate the effect of pCR in our cohort in different subgroups as well as chemotherapy protocols. Clinical response markers correlating with OS were also analyzed. Results: For patients with median follow-ups of 20 years, 10 years, 15 years, 20 years, and 25 years, OS rates were 69.7%, 60.6%, 53.1%, and 45.1%, respectively. pCR was achieved in 31.1% of patients and associated with a significant improvement in OS (HR = 0.58; CI-95%: 0.41–0.80; p = 0.001). The prognostic impact of pCR was evident across breast cancer subtypes and chemotherapy regimens. Multivariate analysis showed that age, clinical tumor and nodal stage, chemotherapy, and pCR were prognostic for OS. Conclusion: NaCT and naRT prior to surgical resection achieve good long-term survival in high-risk breast cancer. pCR after naRT maintains its prognostic value in breast cancer subtypes and across different subgroups. pCR driven by naRT and naCT independently influences long-term survival.

Nomograms for Predicting Disease-Free Survival in Patients With Siewert Type II/III Adenocarcinoma of the Esophagogastric Junction Receiving Neoadjuvant Therapy and Radical Surgery

Objective

This study aimed to develop prognostic prediction models for patients with Siewert type II/III adenocarcinoma of the esophagogastric junction (AEG) who received neoadjuvant therapy (neoadjuvant chemoradiotherapy or neoadjuvant chemotherapy) and radical surgery. A baseline nomogram and a post-operative nomogram were constructed before neoadjuvant therapy and after surgery. The predictive performance of the constructed nomograms was internally validated and compared to the TNM staging system.

Materials and Methods

A total of 245 patients diagnosed with Siewert type II/III AEG and treated with neoadjuvant therapy followed by radical surgery at The Fourth Hospital of Hebei Medical University between January 2011 and December 2017 were enrolled. The variables before neoadjuvant therapy were defined as baseline factors, while the variables of baseline factors along with the variables of treatment and postoperative pathology were defined as post-operative factors. To construct the corresponding nomograms, independent predictors of baseline and post-operative factors were identified. The C-index and a time-dependent receiver operating characteristic curve were used to evaluate the model’s discrimination ability. The calibration ability of the model was determined by comparing the probability of predicted free-recurrence to the actual free-recurrence. Decision curve analysis (DCA) was used to determine the clinical usefulness of the nomogram.

Results

Among the baseline factors, age, cT stage, cN stage, Borrmann type, and staging laparoscopy were independent prognostic predictors. In contrast, among the post-operative factors, age, cN stage, staging laparoscopy, ypT stage, clinical response, number of positive lymph nodes, number of negative lymph nodes, laurén classification, and lymphatic, or perineural invasion (VELPI) were independent prognostic predictors. The two nomograms were constructed using the independent predictors of prognosis. The C-indexes for the baseline and post-operative nomograms were 0.690 (95% CI, 0.644-0.736) and 0.817 (95% CI, 0.782-0.853), respectively. The AUCs of the baseline nomogram at 3 and 5 years were both greater than cTNM (73.1 vs 58.8, 76.1 vs 55.7). Similarly, the AUCs of the post-operative nomogram were both greater than ypTNM (85.2 vs 69.1, 88.2 vs 71.3) at 3 and 5 years. The calibration curves indicated that both models had a high degree of calibration ability. By comparing the DCA at 3 and 5 years, we determined that the two nomograms constructed had better clinical utility than the TNM staging system.

Conclusions

The constructed nomograms have a more accurate predictive ability than the eighth edition TNM staging system, which can be useful for treatment selection and follow-up monitoring of patients.

Neoadjuvant concurrent chemoradiotherapy using infusional gemcitabine in locally advanced rectal cancer: A phase II trial

INTRODUCTION

Gemcitabine is a well-known radiosensitizer. Herein, we tested the efficacy and toxicity of preoperative concurrent infusional gemcitabine and radiotherapy in locally advanced rectal cancer.

PATIENTS AND METHODS

This was a phase II, single-arm trial. Eligible patients had a diagnosis of rectal adenocarcinoma with clinical stage T3-T4 and/or nodal involvement, age ≥18 years, and no prior chemotherapy or radiotherapy. Patients received preoperative radiation at a dose of 50.4-54 Gy over 28 days with concurrent infusional gemcitabine administered at a dose of 100 mg/m² over the course of 24 h weekly for 6 weeks. The primary endpoint was pathological complete response (pCR).

RESULTS

Forty patients were recruited. Only one patient did not complete therapy due to death. Eight patients did not undergo surgery, one died, two progressed to nonresectable disease, and five withdrew consent. Five patients progressed prior to surgery, with two having unresectable metastases and three having resectable liver metastases. One was found to have peritoneal metastasis during surgery. Out of the 32 patients who underwent surgery, seven achieved pCR at a rate of 20%. With a median follow-up of 30 months, four additional patients had a distant relapse (one had a subsequent local relapse). The 3-year event-free and overall survival rates were 70% and 85%, respectively. The commonest preoperative grade 3-4 toxicity included lymphopenia (50%), neutropenia (41%), anemia (15%), diarrhea (12%), abdominal pain (12%), and proctitis (8%).

CONCLUSION

Concurrent preoperative chemoradiotherapy using infusional gemcitabine for locally advanced rectal cancer achieved an encouraging degree of local control with manageable toxicity.

Lymph Node Yield in Gastrointestinal Cancer Surgery With or Without Prior Neoadjuvant Therapy: Protocol for a Systematic Review and Meta-analysis

BACKGROUND

Lymph node yield is the number of lymph nodes retrieved during oncological resection and histopathologically identified in the resection specimen. It is an important surrogate parameter for assessing the oncological radicality of the resection of gastrointestinal carcinomas, as well as a prognostic factor in these diseases. It remains unclear if and to what extent neoadjuvant chemotherapy, radiotherapy, or chemoradiotherapy, which have become established treatments for carcinoma of the esophagus, stomach, and rectum and are increasingly used in pancreatic carcinoma, affect the lymph node yield.

OBJECTIVE

This systematic review with meta-analysis is conducted with the aim of summarizing the available evidence regarding the lymph node yield, an oncological surrogate marker, in patients with gastrointestinal carcinomas undergoing surgery after neoadjuvant therapy compared to those undergoing surgery without neoadjuvant therapy.

METHODS

Randomized and nonrandomized studies comparing oncological resection of esophageal, stomach, pancreatic, and rectal carcinoma with and without prior neoadjuvant therapy are eligible for inclusion regardless of study design. Publications will be identified with a defined search strategy in 2 electronic databases: PubMed and Cochrane Library. The primary endpoint of the analysis is the number of lymph nodes identified in the resected specimen. Secondary endpoints include the number of harvested metastatic lymph nodes, operation time, postoperative complications, pathological TNM staging, and overall and recurrence-free survival time. Using suitable statistical methods, the endpoints between patients with and without neoadjuvant therapy, as well as in defined subgroups (neoadjuvant chemotherapy, radiotherapy, or chemoradiotherapy; and patients with esophageal, gastric, pancreatic, or rectal cancer), will be compared.

RESULTS

The literature search and data collection started in October 2021. Results are expected to be published in mid-2022.

CONCLUSIONS

This meta-analysis will provide the most up-to-date and complete summary of the evidence on an association between neoadjuvant therapy and lymph node yield in gastrointestinal cancer surgery. The underlying hypothesis is that neoadjuvant therapy decreases the number and size of lymph nodes through lymphocyte depletion and radiation-induced fibrosis, thus leading to a lower possible lymph node yield. The findings of the meta-analysis will show if this hypothesis is supported by evidence.

TRIAL REGISTRATION

PROSPERO CRD218459; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021218459.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/35243.

Population-level utilisation of neoadjuvant radiotherapy for the treatment of rectal cancer

PURPOSE

International clinical guidelines recommend long- or short-course neoadjuvant radiotherapy for locally advanced rectal cancer. This study aims to examine variation in the use of neoadjuvant radiotherapy for rectal cancer and identify patient and hospital factors that underpin this variation.

METHODS AND MATERIALS

We conducted a retrospective, consecutive cohort study using statewide hospitalisation and radiotherapy data from New South Wales, Australia, 2013-2018. Included participants had a primary rectal adenocarcinoma and underwent surgical resection. Factors associated with the use or not of any neoadjuvant radiotherapy, and short versus long-course were explored using multilevel logistic regression models.

RESULTS

Of the 2912 people included in the study, 43% received neoadjuvant radiotherapy. There was significant variation in the use of neoadjuvant radiotherapy depending on geographic location. Abdominoperineal excision (odds ratio [OR] = 1.87, 95% confidence interval [CI] = 1.53-2.28) and having surgery in a public hospital (OR = 2.34, 95% CI = 1.92-2.87) were both predictors of use. Among those receiving neoadjuvant radiotherapy, 17% received short-course therapy, with short-course declining over the study period.

CONCLUSIONS

The use of neoadjuvant radiotherapy for rectal cancer is highly variable, with differences only partially explained by assessable patient-or hospital-level factors. Understanding neoadjuvant radiotherapy utilisation patterns may assist in identifying barriers and opportunities to improve adherence to clinical guidelines.

Prognostic nomogram for Siewert type II adenocarcinoma of the esophagogastric junction patients with and without neoadjuvant radiotherapy: a retrospective cohort study

OBJECTIVE

To compare the prognostic factors of Siewert type II AEG patients who had received neoadjuvant radiotherapy (nRT) versus those who did not receive nRT. Nomograms for outcome prediction were constructed for the two treatment modalities.

MATERIALS AND METHODS

Data for 1,745 Siewert II type AEG patients who underwent radical surgery between 2010 and 2015 were retrieved from SEER (Surveillance, Epidemiology, and End Results) database. Patients were assigned to neoadjuvant radiotherapy (nRT) and non-neoadjuvant radiotherapy (non-nRT) groups based on treatment modality. Independent prognostic predictors were used to develop nomograms. Concordance index (C-index), receiver operating characteristic (ROC), calibration curves, and decision curve analyses (DCA) were used to determine the performance and prognostic value of the nomograms. The predictive accuracy of nomograms was compared with the prognostic value of the Tumor-Node-Metastasis (TNM) staging system.

RESULTS

The results showed that age, lymph node rate (LNR), and the number of removed lymph nodes (RLN) were independent prognostic factors for CSS in the nRT group. Tumor size, tumor grade, T stage, LNR, and therapy type were independent prognosis factors for CSS in patients in the non-nRT group. The C-indices for the nomograms were 0.652 (95% CI, 0.614-0.690) and 0.663 (95% CI, 0.606-0.720) in the training and validation cohort, respectively, for the nRT group. C-indices for the nomogram in non-nRT group were 0.754 (95% CI, 0.723-0.785) and 0.747 (95% CI, 0.688-0.800) for the training and validation cohorts, respectively. C-indices and ROC curves showed good predictive value compared with the TNM staging system in both groups. C-indices, as well as the AUC values of the nomograms and the TNM staging system for both cohorts in the non-nRT group were higher compared with those in the nRT group. Analysis of the survival calibration curve revealed high consistency between actual versus predicted outcomes determined by the nomograms. Decision curve analyses revealed that the new models had higher prediction value and clinical significance compared with TNM staging system.

CONCLUSION

The established nomograms showed high prognostic value for Siewert type II AEG patients in both nRT and non-nRT groups. In addition, the nomogram and the TNM staging systems showed better prognostic performance for patients in the non-nRT group compared with patients in the nRT group.

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.

A blind randomized validated convolutional neural network for auto-segmentation of clinical target volume in rectal cancer patients receiving neoadjuvant radiotherapy

Background

Delineation of clinical target volume (CTV) for radiotherapy is a time‐consuming and labor‐intensive work. This study aims to propose a novel convolutional neural network (CNN)‐based model for fast auto‐segmentation of CTV. To evaluate its performance and clinical utility, a blind randomized validation method was used.

Methods

Our proposed model was based on the generally accepted U‐Net architecture using computed tomography slices with CTV contours delineated by experienced radiation clinicians from 135 rectal patients receiving neoadjuvant radiotherapy. The Dice similarity coefficient (DSC) and 95th percentile Hausdorff distance (95HD) were used to measure segmentation performance. The validated dataset of additional 20 patients for clinical evaluation by 10 experienced oncology clinicians from 7 centers was randomly and blindly divided into two groups for clinicians' scoring and Turing test, respectively. Second evaluation was performed with different randomization after 2 weeks.

Results

The mean DSC and 95HD values of the proposed model were 0.90 ± 0.02 and 8.11 ± 1.93 mm for CTV of rectal cancer patients, respectively. The average time for automatic segmentation in the validation groups was 15 s per patient. By clinicians' scoring, the AI model performed better than manually delineating, though the differences were not significant (Week 0: 2.59 vs. 2.52, p = 0.086; Week 2: 2.55 vs. 2.47, p = 0.115). Additionally, the mean positive rates in the Turing test were 40.5% in Week 0 and 45.2% in Week 2, which demonstrated the great intelligence of our model.

Conclusions

Our proposed model can be used clinically for assisting contouring of CTVs in rectal cancer patients receiving neoadjuvant radiotherapy, which improves the efficiency and consistency of radiation clinicians' work.

Outcomes and computed tomography radiomic features extraction in soft tissue sarcomas treated with neoadjuvant radiation therapy

Background

The aim of the study was to evaluate the management, toxicity and treatment responses of patients treated with neoadjuvant radiotherapy (NART) for soft tissue sarcomas (STS) and to analyse the potential of radiomic features extracted from computed tomography (CT) scans.

Materials and methods

This is a retrospective and exploratory study with patients treated between 2006 and 2019. Acute and chronic toxicities are evaluated. Local progression free survival (LPFS), distant progression free survival (DPFS) and overall survival (OS) are analysed. Radiomic features are obtained.

Results

A total of 25 patients were included. Median follow-up is 24 months. Complications in surgical wound healing were observed in 20% of patients, chronic fibrosis was documented as grade 1 (12%) and grade 2 (12%) without grade 3 events and chronic lymphedema as grade 1 (8%) and grade 2 (20%) without grade 3 events. Survival variables were LPFS 76%, DPFS 62% and OS 67.2% at 2-year follow-up. CT radiomics features were associated significantly with local control (GLCM-correlation), systemic control (HUmin, HUpeak, volume, GLCM-correlation and GLZLM-GLNU) and OS (GLZLM-SZE).

Conclusions

STS treated with NART in our centre associate with an OS and toxicity comparable to other series. CT radiomic features have a prognosis potential in STS risk stratification. The results of our study may serve as a motivation for future prospective studies with a greater number of patients.

Can Elevated Pretreatment Serum Carcinoembryonic Antigen Levels Serve as a Potential Biomarker Guiding Adjuvant Chemotherapy in Rectal Cancer Patients With ypTis-3N0 After Neoadjuvant Radiotherapy and Surgery?

Survival benefit of adjuvant chemotherapy (ACT) remained controversial in patients with stage II/III rectal cancer (RC) who received neoadjuvant therapy and surgery. This study aimed to investigate the guiding role of elevated pretreatment serum carcinoembryonic antigen (CEA) levels for receiving ACT in yield pathological Tis-3N0 (ypTis-3N0) RC patients after neoadjuvant radiotherapy and surgery. Between 2004 and 2015, 10,973 RC patients with ypTis-3N0 who received neoadjuvant radiotherapy and radical surgery were retrospectively analyzed using the Surveillance, Epidemiology, and End Results (SEER) database. Compared with CEA-normal group, elevated-CEA patients had worse 5-year CSS rate (90.1 vs 83.5%). The 5-year CSS rates were 86.3 and 87.4% for ypTis-3N0M0 patients with or without ACT, respectively. Patients receiving ACT had a comparable 5-year CSS rate compared to those who did not regardless of CEA levels in ypTis-3N0M0 RC patients (CEA elevation group: 76.4 vs. 83.5%, P = 0.305; CEA normal group: 90.0 vs. 90.1%, P = 0.943). Intriguingly, ypT3N0M0 RC patients with elevated CEA levels may benefit from ACT (5-year CSS: 69.1 vs. 82.9%, P = 0.045), while those with normal CEA levels did not (5-year CSS: 89.3 vs. 89.3%, P = 0.885). Multivariate Cox analysis demonstrated that ACT tended to be a protective factor in elevated-CEA ypT3N0M0 RC patients (HR = 0.633, 95% CI = 0.344–1.164, P = 0.141), while ACT was not associated with improved CSS in normal-CEA ypT3N0M0 RC patients (HR = 1.035, 95% CI = 0.487–2.202, P = 0.928). Elevated pretreatment serum CEA levels may serve as a promising biomarker guiding ACT in rectal cancer patients with ypT3N0M0.

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.

Radiomics in the Setting of Neoadjuvant Radiotherapy: A New Approach for Tailored Treatment

Simple Summary

This review based on a literature search aims at showing the impact of Texture Analysis in the prediction of response to neoadjuvant radiotherapy and/or chemoradiotherapy. The manuscript explores radiomics approaches in different fields of neoadjuvant radiotherapy, including esophageal cancer, lung cancer, sarcoma and rectal cancer in order to shed a light in the setting of neoadjuvant radiotherapy that can be used to tailor the best subsequent therapeutical strategy.

Abstract

Introduction: Neoadjuvant radiotherapy is currently used mainly in locally advanced rectal cancer and sarcoma and in a subset of non-small cell lung cancer and esophageal cancer, whereas in other diseases it is under investigation. The evaluation of the efficacy of the induction strategy is made possible by performing imaging investigations before and after the neoadjuvant therapy and is usually challenging. In the last decade, texture analysis (TA) has been developed to help the radiologist to quantify and identify the parameters related to tumor heterogeneity, which cannot be appreciated by the naked eye. The aim of this narrative is to review the impact of TA on the prediction of response to neoadjuvant radiotherapy and or chemoradiotherapy. Materials and Methods: Key references were derived from a PubMed query. Hand searching and ClinicalTrials.gov were also used. Results: This paper contains a narrative report and a critical discussion of radiomics approaches in different fields of neoadjuvant radiotherapy, including esophageal cancer, lung cancer, sarcoma, and rectal cancer. Conclusions: Radiomics can shed a light on the setting of neoadjuvant therapies that can be used to tailor subsequent approaches or even to avoid surgery in the future. At the same, these results need to be validated in prospective and multicenter trials.

History and current situation of neoadjuvant treatment for locally advanced esophageal cancer

Esophageal cancer is one of the most commonly diagnosed malignant tumors, especially in north China. Surgery is one of the major treatments. However, for locally advanced cases, surgery alone does not achieve an ideal prognosis. As a result of rapid development in recent years, neoadjuvant chemotherapy, neoadjuvant radiotherapy or neoadjuvant chemoradiotherapy followed by surgery are becoming the “standard treatment pattern” for patients with locally advanced esophageal cancer, and an improvement in prognosis is evident. With the gradual application of immunotherapy in esophageal cancer, neoadjuvant immunotherapy has also shown an important role. This article mainly focuses on the history and current status of neoadjuvant treatment and its future role in the treatment of esophageal cancer.

IGF-1R depletion sensitizes colon cancer cell lines to radiotherapy

PURPOSE

Insulin like growth factor receptor 1 (IGF-1R) has been documented to play a key role in radiation response, thereby offering an attractive drug target to enhance tumor sensitivity to radiotherapy. Here, we investigated weather knockdown of IGF-1R can sensitize colorectal cancer (CRC) cell lines to radiation.

MATERIAL AND METHODS

Human colon carcinoma SW480 and HT-29 cells were transfected with specific small interference RNA (siRNA) to mediate IGF-1R depletion. The expression of IGF-1R mRNA and protein among transfected and untransfected cells was detected by Western blot analysis. Changes in cell proliferation and radiosensitivity were evaluated by the clonogenic survival assay. NVP-ADW742, an IGF-1R inhibitor, in combination with radiation was studied. RAD51, a measure for homologous recombination repair, and 53BP1, a maker for non-homologous end-joining (NHEJ), were determined by immunofluorescence for double-strand breaks (DSB) repair pathways. Cell cycle was also examined in the IGF-1R knockdown and IGF-1R-inhibited cells.

RESULTS

CRC cell lines were selectively sensitized to radiation after siRNA-mediated IGF-1R depletion. NVP-ADW742 efficiently increases cancer cell response to radiation. Furthermore, initial formation of RAD51 foci after IR, and 53BP1 foci were significantly reduced in IGF-1R-depleted or with IGF-1R Inhibitor CRC cell lines. Lastly, IGF-1R-depleted or with IGF-1R Inhibitor caused more G2 phase cell arrest.

CONCLUSION

Our findings demonstrate that depletion of IGF-1R lead to an increase in radiosensitivity in CRC.

Controversies in radiotherapy for pancreas cancer

The management of pancreatic adenocarcinoma remains an area of controversy and ongoing discovery. Despite advances in surgical and radiation techniques, as well as chemotherapeutic agents, outcomes of patients diagnosed with this devastating malignancy remain poor. This article aims to review the available literature evaluating the efficacy of adjuvant, neoadjuvant, and definitive radiation therapy. We will also highlight areas of ongoing research efforts being carried out to improve outcomes in this patient population.

Downregulation of miR-423-5p Contributes to the Radioresistance in Colorectal Cancer Cells

Resistance to radiotherapy is the main reason causing treatment failure in locally advanced rectal cancer. MicroRNAs (miRNAs) have been well demonstrated to regulate cancer development and progression. However, how miRNAs regulate radiotherapy resistance in colorectal cancer remains unknown. Herein, we established two human colorectal cancer cell lines resistant to radiotherapy, named HCT116-R and RKO-R, using the strategy of fractionated irradiation. The radioresistant phenotypical changes of the two cell lines were validated by cell viability assay, colony formation assay and apoptosis assay. The miRNA expression profilings of HCT116-R and RKO-R were determined using RNA-seq analyses, and further confirmed by quantitative real-time PCR. Multiple miRNAs, including miR-423-5p, miR-7-5p, miR-522-3p, miR-3184-3p, and miR-3529-3p, were identified with altered expression in both of the radiotherapy-resistant cells, compared to the parental cells. The downregulation of miR-423-5p was further validated in the rectal cancer tissues from radiotherapy-resistant patients. Silencing of miR-423-5p in parental HCT116 and RKO cells decreased the sensitivity to radiation treatment, and inhibited the radiation-induced apoptosis. In consistence, overexpression of miR-423-5p in HCT116-R and RKO-R cells partially rescued their sensitivity to radiotherapy, and promoted the radiation-induced apoptosis. Bcl-xL (Bcl-2-like protein 1) was predicted to be a potential target gene for miR-423-5p, and miR-423-5p/Bcl-xL axis could be a critical mediator of radiosensitivity in colorectal cancer cells. The current finding not only revealed a novel role of miR-423-5p in regulating the radiosensitivity in colorectal cancer, but also suggested miR-423-5p as a molecular candidate for combination therapy with radiation to treat colorectal cancer.

Overall Survival Benefit in Rectal Cancer After Neoadjuvant Radiotherapy and Adjuvant Chemotherapy: A Propensity-Matched Population-Based Study

Background

It is well known that neoadjuvant radiotherapy could reduce local recurrence followed by surgical resection. However, evidence about oncologic efficacy of radiotherapy and survival benefit of adjuvant chemotherapy after neoadjuvant radiotherapy is still lacking.

Methods

This retrospective propensity score-matched cohort study identified patients with pathologically confirmed rectal cancer and receiving surgery with curative intent from the Surveillance, Epidemiology, and End Results database from 2004 through 2014. Overall survival was compared using the stratified log-rank test. Multivariate Cox regression analysis was used for identifying risk factor and developing prediction nomogram.

Results

A total of 22,008 (11,004 for each group) propensity-matched patients were identified. In the context of receiving adjuvant chemotherapy after surgical resection, there was no significant difference in terms of overall survival between surgery alone group and neoadjuvant radiotherapy and surgery group, whether for stage I (log-rank test p = 0.467), stage II (log-rank test p = 0.310), or stage III (p = 0.994). In case of receiving a prior combination therapy of neoadjuvant radiotherapy and surgery, the following adjuvant chemotherapy could significantly improve overall survival for patients with stage I (log-rank test p <0.001), stage II (log-rank test p = 0.038), and stage III (log-rank test p = 0.014). Nomogram integrating clinicopathologic factors was developed to predict survival benefit associated with neoadjuvant radiotherapy. Calibration and ROC curves validated promising performance for the nomogram.

Conclusion

Patients with rectal cancer underwent neoadjuvant radiotherapy yield acceptable outcomes and are more likely to benefit from adjuvant chemotherapy in terms of overall survival. These data would be evidential for advocating consistency in guideline adherence to the use of adjuvant chemotherapy after neoadjuvant radiotherapy.

Malignant peripheral nerve sheath tumor in the nasopharynx and oropharynx: a case report

Malignant peripheral nerve sheath tumor (MPNST) in the nasopharynx and oropharynx has not been reported. A 3-year-old boy was referred to hospital after experiencing intermittent inspiratory dyspnea for 3 years. Preoperative imaging showed that the lymph nodes were clear. Therefore, neck lymph node dissection was not performed during the operation. This could have reduced the collateral damage. Complete excision and radiotherapy were performed because of the pathological diagnosis of MPNST. Because of the high location of the tumor, we chose the transoral approach instead of the cervical approach, avoiding tracheotomy, and we effectively improved the quality of life of the child. A mass in the nasopharynx and oropharynx was diagnosed pathologically as an MPNST after surgery. The patient’s inspiratory dyspnea was resolved. No recurrence was observed during a 3-year follow-up. After review of our case, we found that postoperative recovery in our patient was closely related to accurate preoperative imaging assessment, the choice of operation methods, thorough resection, and postoperative neoadjuvant radiotherapy. Prevertebral fascia acted as a barrier to surround the mass and prevented it from growing further toward the vertebral body, which was important for a good prognosis. Children undergoing tracheotomy often have long tube management and difficult extubation.

Sphincter-saving surgery for ultra-low rectal carcinoma initially indicated for abdominoperineal resection: Is it safe on a long-term follow-up?

BACKGROUND

Rate of abdominoperineal resection (APR) varies from countries and surgeons. Surgical impact of preoperative treatment for ultra-low rectal carcinoma (ULRC) initially indicated for APR is debated. We report the 10-year oncological results from a prospective controlled trial (GRECCAR 1) which evaluate the sphincter saving surgery (SSR).

METHODS

ULRC indicated for APR were included (n = 207). Randomization was between high-dose radiation (HDR, 45 + 18 Gy) and radiochemotherapy (RCT, 45 Gy + 5FU infusion). Surgical decision was based on tumour volume regression at surgery. SSR technique was standardized as mucosectomy (M) or partial (PISR)/complete (CISR) intersphincteric resection.

RESULTS

Overall SSR rate was 85% (72% ISR), postoperative morbidity 27%, with no mortality. There were no significant differences between the HDR and RCT groups: 10-year overall survival (OS10) 70.1% versus 69.4%, respectively, 10.2% local recurrence (9.2%/14.5%) and 27.6% metastases (32.4%/27.7%). OS and disease-free survival were significantly longer for SSR (72.2% and 60.1%, respectively) versus APR (54.7% and 38.3%). No difference in OS10 between surgical approaches (M 78.9%, PISR 75.5%, CISR 65.5%) or tumour location (low 64.8%, ultralow 76.7%).

CONCLUSION

GRECCAR 1 demonstrates the feasibility of safely changing an initial APR indication into an SSR procedure according to the preoperative treatment tumour response. Long-term oncologic follow-up validates this attitude.

Radiotherapy Scheme Effect on PD-L1 Expression for Locally Advanced Rectal Cancer

In locally advanced rectal cancer, radiotherapy (RT) followed by surgery have improved locoregional control, but distant recurrences remain frequent. Although checkpoint inhibitors have demonstrated objective response in several cancers, the clinical benefit of PD-1/PD-L1 blockade remains uncertain in rectal cancer. We collected data from biopsies and surgical specimens in 74 patients. The main objective was to evaluate the impact of neoadjuvant RT and fractionation on PD-L1 expression. Secondary objectives were to study the relation between PD-L1 expression and tumor regression grade (TRG), progression-free survival (PFS), overall survival (OS), and CD8 TILs infiltration. Median rates of cells expressing PD-L1 pre- and post-RT were 0.15 (range, 0-17) and 0.5 (range, 0-27.5), respectively (p = 0.0005). There was no effect of RT fractionation on PD-L1+ cell rates. We found no relation between CD8+ TILs infiltration and PD-L1 expression and no difference between high-PD-L1 or low-PD-L1 expression and TRG. High-to-high PD-L1 expression profile had none significant higher OS and PFS compared to all other groups (p = 0.06). Median OS and PFS were higher in biopsies with >0.08 PD-L1+ cells. High-to-high PD-L1 profile and ypT0-2 were significantly associated with higher OS and PFS. This study did not show the differential induction of PD-L1 expression according to fractionation.

Role of radiation therapy in node-negative esophageal cancer: A propensity-matched analysis

Background

This study investigated the prognostic impact of (neo‐)adjuvant radiation therapies in early stage esophageal cancer.

Methods

A retrospective analysis using the Surveillance, Epidemiology, and End Results (SEER) database was conducted from 2004 to 2016. Patients with pathologically staged T1‐4N0M0 esophageal cancer were divided into two treatment groups: (i) neoadjuvant radiotherapy followed by surgery; and (ii) upfront esophagectomy followed by adjuvant radiotherapy. Propensity scored match and Cox proportional hazards model were used to identify covariates associated with overall survival and cancer‐specific survival.

Results

There were 821 patients selected, of whom 588 (71.6%) received neoadjuvant radiotherapy and 233 (28.4%) received adjuvant radiotherapy. For the entire cohort, neoadjuvant radiotherapy was associated with a significantly benefit in five‐year survival outcomes compared with adjuvant radiotherapy (P < 0.01). After matching, the survival outcomes were still better for neoadjuvant radiotherapy than that of adjuvant treatment. Stratifying based on pathologic tumor status, neoadjuvant radiation was associated with improved CSS (five‐year survival 73.7% vs. 42.1%; P = 0.014) for localized (pT3‐4N0) disease. The Cox multivariate regression analysis revealed that the addition of neoadjuvant radiation for pT3‐4N0 diseases with tumor length ≥ 5 cm and squamous cell carcinoma, was a powerful prognostic factor for improved cancer‐specific survival (P < 0.01).

Conclusions

Compared with adjuvant radiotherapy, the addition of neoadjuvant radiation for pT3‐4N0 diseases has been associated with improved cancer‐specific survival in high‐risk patients. Studies on preoperative neoadjuvant therapies would be plausible in high‐risk esophageal cancer patients.

Neoadjuvant Radiotherapy-Related Wound Morbidity in Soft Tissue Sarcoma: Perspectives for Radioprotective Agents

Historically, patients with localized soft tissue sarcomas (STS) of the extremities would undergo limb amputation. It was subsequently determined that the addition of radiation therapy (RT) delivered prior to (neoadjuvant) or after (adjuvant) a limb-sparing surgical resection yielded equivalent survival outcomes to amputation in appropriate patients. Generally, neoadjuvant radiation offers decreased volume and dose of high-intensity radiation to normal tissue and increased chance of achieving negative surgical margins-but also increases wound healing complications when compared to adjuvant radiotherapy. This review elaborates on the current neoadjuvant/adjuvant RT approaches, wound healing complications in STS, and the potential application of novel radioprotective agents to minimize radiation-induced normal tissue toxicity.

Perioperative radiotherapy versus surgery alone for retroperitoneal sarcomas: a systematic review and meta-analysis

Background

There is no clear evidence on whether radiotherapy (RT) improves treatment result in patients with retroperitoneal sarcomas (RPS).

Methods

A systematic literature search was performed using PubMed, Scopus and CENTRAL databases. Data were retrieved from published comparatives studies in patients with RPS undergoing surgery alone or RT plus surgery. The primary endpoints were the 5-year OS and the median OS. The secondary endpoints were the recurrence-free survival (RFS) and the R0-resection rate. Continuous outcomes were calculated by means of weighted mean difference (WMD).

Results

Ten out of 374 articles were analyzed. The median OS and the 5-year survival were significantly increased in patients treated with RT and surgery, compared to patients treated with surgery alone (p < 0.00001, p < 0.001). Median RFS was significantly increased in patients treated with either preoperative (p < 0.001) or postoperative (p = 0.001) RT compared to patients that underwent surgery alone. Finally, median R0-resection rate was similar between the two groups (p = 0.56).

Conclusion

RT along with radical surgery could be the standard of care in at least a subgroup of patients with RPS.

Neutrophil-to-Lymphocyte Ratio in Rectal Cancer-Novel Biomarker of Tumor Immunogenicity During Radiotherapy or Confounding Variable?

The aim of this study was to investigate the predictive value of blood-derived makers of local and systemic inflammatory responses on early and long-term oncological outcomes. A retrospective analysis of patients with locally advanced rectal cancer treated with preoperative long-course 5-fluorouracil-based radiochemotherapy was performed. Differential blood counts before neoadjuvant treatment were extracted from the patients' electronic charts. Optimal cut-off values for neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and lymphocyte-to-monocyte ratio (LMR) were determined. Potential clinical and hematological prognostic factors for disease-free survival (DFS) were studied using uni- and multivariate analysis. A total of 220 patients were included in the analysis. Median follow-up was 67 months. Five-year DFS and overall survival (OS) were 70% and 85%, respectively. NLR with a cut-off value of 4.06 was identified as optimal to predict DFS events. In multivariate analysis, only tumor volume (HR 0.33, 95% CI (0.14-0.83), p = 0.017) and NLR (HR 0.3, 95% CI (0.11-0.81), p = 0.017) remained significant predictors of DFS. Patients with a good histological response (Dworak 3 and 4) to radiotherapy also had a lower NLR than patients with less pronounced tumor regression (3.0 vs. 4.2, p = 0.015). A strong correlation between primary tumor volume and NLR was seen (Pearson's r = 0.64, p < 0.001). Moreover, patients with T4 tumors had a significantly higher NLR than patients with T1-T3 tumors (6.6 vs. 3.3, p < 0.001). An elevated pretherapeutic NLR was associated with higher T stage, inferior DFS, and poor pathological response to neoadjuvant radiochemotherapy. A strong correlation between NLR and primary tumor volume was seen. This association is important for the interpretation of study results and for the design of translational studies which are warranted.

Gastric Lavage Malignant Cells (yGL) and Hypohemoglobinemia (yAnemia) as New Systems of Tumor Regression Grading and Prognostic Prediction for Gastric Cancer After Neoadjuvant Treatment

BACKGROUND/AIM

Although reckoned necessary for survival benefit, neoadjuvant chemotherapy (NAC) of gastric cancer (GC) patients has so far provided questionable results. Consequently, searching for new and clearer systems of response to NAC, post-NAC re-evaluation and prognostic prediction appears essential. The purpose of this study was to examine endogastric cytopathology and hemoglobin level count as new features, potentially useful for GC patients after NAC.

PATIENTS AND METHODS

Between April 2012 and October 2018, 21 of 116 patients with resectable GC received NAC and were investigated for the presence of free-floating malignant cells in their gastric lavage (yGL1) and the development of hypohemoglobinia (yAnemia).

RESULTS

yGL1 and yAnemia were found in 11 and 12 patients, respectively. yGL1 correlated with the traditional parameters of tumor regression (p=0.0424). Both yGL1 and yAnemia were found to be independent predictive factors of overall and progression-free survival (p≤0.0364).

CONCLUSION

In the light of our results, the yGL1 and yAnemia appear two promising, simple and interesting clinicopathological features which should always be examined for better clarifying GC patients' response to NAC.