|
1
|
Wang C, Huang T, Wang X. Efficacy and safety of transanal endoscopic microsurgery for early rectal cancer: a meta-analysis. Front Oncol 2025; 15:1545547. [PMID: 39995839 PMCID: PMC11847824 DOI: 10.3389/fonc.2025.1545547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2024] [Accepted: 01/17/2025] [Indexed: 02/26/2025] Open
Abstract
Background The gold standard for the treatment of rectal cancer is radical surgery with total mesorectal excision (TME). As one of the alternatives to radical surgery, local resection has been proposed for the treatment of early rectal cancer. The purpose of this article was to evaluate the safety and efficacy of transanal endoscopic microsurgery (TEM) in the treatment of early rectal cancer. Methods By searching the PubMed, Cochrane Library, Web of Science, and China National Knowledge Infrastructure databases, we selected all articles on TEM for early rectal cancer. Two researchers independently completed the entire process from screening, inclusion to data extraction and performed statistical analysis using RevMan 5.3. The primary outcomes included basic patient characteristics, overall survival rate, disease-free survival rate, disease-specific survival rate, recurrence rate, and complication rate and type. Results A total of 33 articles were included in this meta-analysis. The results showed that the overall survival rate was 100% for T0 stage, 98.1% for Tis (carcinoma in situ) stage, and 80.2% for early stage rectal cancer patients (83.9% for T1 and 72.4% for T2). The weighted overall survival rate was 94% (RD = 0.94, 95% CI = 0.93-0.95, I 2 = 80%, P < 0.00001) for all stage patients, the weighted disease-free survival rate was 91% (RD = 0.91, 95% CI = 0.90-0.93, I 2 = 83%, P < 0.00001), and the disease-specific survival rate was 97% (RD = 0.97, 95% CI = 0.96-0.98, I 2 = 63%, P < 0.00001). The recurrence rate was 0.5% for T0 stage, 1.9% for Tis stage, and 11.9% for early stage rectal cancer patients (8.1% for T1 and 19.7% for T2). The weighted recurrence rate was 7% (RD = 0.07, 95% CI = 0.06-0.08, I 2 = 69%, P < 0.00001) for all stage patients. The weighted complications rate was 11% (RD = 0.11, 95% CI = 0.10-0.12, I 2 = 66%, P < 0.00001) for all stage patients, with Clavien-Dindo grade I accounting for 77.7%, Clavien-Dindo grade II accounting for 8%, and Clavien-Dindo grade III accounting for 14.3%. Conclusion The results showed that TEM has a high postoperative survival rate, low recurrence rate, and low complication rate in the T0 stage, Tis stage, and T1 stage, indicating its good safety and efficacy. For the treatment of T2 stage, TEM has a lower overall survival rate and a higher recurrence rate. Our meta-analysis results suggest that TEM alone is not recommended as a curative treatment for T2 stage; on the contrary, TME is more frequently recommended.
Collapse
Affiliation(s)
- Chunqiang Wang
- Affiliated Xiaoshan Hospital, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Tianye Huang
- The First Medical University of Shandong Affiliated Linyi Hospital, Linyi, Shandong, China
| | - Xuebing Wang
- The First Medical University of Shandong Affiliated Taian Hospital, Taian, Shandong, China
| |
Collapse
|
|
2
|
Liu YX, Yang XR, Peng LQ, Li ZH. A management of patients achieving clinical complete response after neoadjuvant therapy and perspectives: on locally advanced rectal cancer. Front Oncol 2025; 14:1450994. [PMID: 39845322 PMCID: PMC11750660 DOI: 10.3389/fonc.2024.1450994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Accepted: 12/10/2024] [Indexed: 01/24/2025] Open
Abstract
Neoadjuvant chemoradiotherapy (nCRT) followed by total mesorectal excision (TME) and selective use of adjuvant chemotherapy is currently considered the standard of care for locally advanced rectal cancer (LARC). Despite this, the concept of organ preservation is gradually challenging this approach. The management of complete clinical remission (cCR) lacks international consensus, leading scholars to develop their own perspectives based on well-designed studies and long-term data from large multicenter cohorts. To ensure appropriate treatment, this review focuses on the choice of neoadjuvant therapy, criteria for defining cCR, and treatment strategies for patients who achieve cCR after neoadjuvant therapy. By providing guidance on the accurate management of LARC patients after cCR, this review aims to prevent over- or under-treatment.
Collapse
Affiliation(s)
| | | | | | - Zhuo-Hong Li
- Department of Oncology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| |
Collapse
|
|
3
|
Chen N, Li CL, Wang L, Yao YF, Peng YF, Zhan TC, Zhao J, Wu AW. Local excision for middle-low rectal cancer after neoadjuvant chemoradiation: A retrospective study from a single tertiary center. World J Gastrointest Oncol 2024; 16:4614-4624. [PMID: 39678786 PMCID: PMC11577377 DOI: 10.4251/wjgo.v16.i12.4614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2024] [Revised: 08/13/2024] [Accepted: 09/05/2024] [Indexed: 11/12/2024] Open
Abstract
BACKGROUND Rectal cancer has become one of the leading malignancies threatening people's health. For locally advanced rectal cancer (LARC), the comprehensive strategy combining neoadjuvant chemoradiotherapy (NCRT), total mesorectal excision (TME), and adjuvant chemotherapy has emerged as a standard treatment regimen, leading to favorable local control and long-term survival. However, in recent years, an increasing attention has been paid on the exploration of organ preservation strategies, aiming to enhance quality of life while maintaining optimal oncological treatment outcomes. Local excision (LE), compared with low anterior resection (LAR) or abdominal-perineal resection (APR) was introduced dating back to 1970's. LE has historically been linked to a heightened risk of recurrence compared to TME, potentially due to occult lymph node metastasis and intraluminal recurrence. Recent evidence has demonstrated that LE might be an alternative approach, instead of LAR or APR, in cases with favorable tumor regression after NCRT with potentially better quality of life. Therefore, a retrospective analysis of clinicopathological data from mid-low LARC patients who underwent LE after NCRT was conducted, aiming to evaluate the treatment's efficacy, safety, and oncologic prognosis. AIM To explore the safety, efficacy, and long-term prognosis of LE in patients with mid-low rectal cancer who had a good response to NCRT. METHODS Patients with LE between 2012 to 2021 were retrospectively collected from the rectal cancer database from Gastro-intestinal Ward III in Peking University Cancer Hospital. The clinicopathological features, postoperative complications, and long-term prognosis of these patients were analyzed. The Kaplan-Meier method was used to create cancer-specific survival curve, and the log-rank test was used to compare the differences regarding outcomes. RESULTS A total of 33 patients were included in this study. The median interval between NCRT and surgery was 25.4 (range: 8.7-164.4) weeks. The median operation time was 57 (20.0-137.0) minutes. The initial clinical T staging (cT): 9 (27.3%) patients were cT2, 19 (57.6%) patients were cT3, and 5 (15.2%) patients were cT4; The initial N staging (cN): 8 patients (24.2%) were cN negative, 25 patients (75.8%) were cN positive; The initial M stage (cM): 2 patients (6.1%) had distant metastasis (ycM1), 31 (93.9%) patients had no distant metastasis (cM0). The pathological results: 18 (54.5%) patients were pathological T0 stage (ypT0), 6 (18.2%) patients were ypT1, 7 (21.2%) patients were ypT2, and 2 (6.1%) patients were ypT3. For 9 cT2 patients, 5 (5/9, 55.6%) had a postoperative pathological result of ypT0. For 19 cT3 patients, 11 (57.9%) patients were ypT0, and 2 (40%) were ypT0 in 5 cT4 patients. The most common complication was chronic perineal pain (71.4%, 5/7), followed by bleeding (43%, 3/7), stenosis (14.3%, 1/7), and fecal incontinence (14.3%, 1/7). The median follow-up time was 42.0 (4.0-93.5) months. For 31 patients with cM0, the 5-year disease-free survival (DFS) rate, 5-year local recurrence-free survival (LRFS) rate, and 5-year overall survival (OS) rate were 88.4%, 96.7%, and 92.9%, respectively. There were significant differences between the ycT groups concerning either DFS (P = 0.042) or OS (P = 0.002) in the Kaplan-Meier analysis. The LRFS curve of ycT ≤ T1 patients was better than that of ycT ≥ T2 patients, and the P value was very close to 0.05 (P = 0.070). The DFS curve of patients with ypT ≤ T1 was better than that of patients with ypT ≥ T2, but the P value was not statistically significant (P = 0.560). There was a significant difference between the ypT groups concerning OS (P = 0.014) in the Kaplan-Meier analysis. The LRFS curve of ypT ≤ T1 patients was better than that of ypT ≥ T2 patients, and the P value was very close to 0.05 (P = 0.070). Two patients with initial cM1 were alive at the last follow-up. CONCLUSION LE for rectal cancer with significant tumor regression after NCRT can obtain better safety, efficiency, and oncological outcome. Minimally invasive or nonsurgical treatment with patient participation in decision-making can be performed for highly selected patients. Further investigation from multiple centers will bring better understanding of potential advantages regarding local resection.
Collapse
Affiliation(s)
- Nan Chen
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Gastrointestinal Center, Unit III, Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Chang-Long Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Gastrointestinal Center, Unit III, Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Lin Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Gastrointestinal Center, Unit III, Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Yun-Feng Yao
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Gastrointestinal Center, Unit III, Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Yi-Fan Peng
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Gastrointestinal Center, Unit III, Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Tian-Cheng Zhan
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Gastrointestinal Center, Unit III, Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Jun Zhao
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Gastrointestinal Center, Unit III, Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Ai-Wen Wu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Gastrointestinal Center, Unit III, Peking University Cancer Hospital and Institute, Beijing 100142, China
| |
Collapse
|
|
4
|
Cai Y, Jiang L, Ju H, Zhu Y, Liu Z. Therapeutic strategies for ypT1 rectal cancer after neoadjuvant chemoradiotherapy: a retrospective cohort study. Int J Colorectal Dis 2024; 39:189. [PMID: 39592493 PMCID: PMC11599329 DOI: 10.1007/s00384-024-04764-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/14/2024] [Indexed: 11/28/2024]
Abstract
PURPOSE The optimal treatment of ypT1 rectal cancer after neoadjuvant chemoradiotherapy (nCRT) remains controversial. This study aimed to determine whether local excision is non-inferior to radical surgery and whether adjuvant chemotherapy (ACT) would improve survival in patients with ypT1 rectal cancer after nCRT. METHODS We enrolled 1212 and 91 patients with ypT1 rectal cancer underwent nCRT followed by radical surgery from the SEER database (2004-2018) and the Zhejiang Cancer Hospital (ZJCH) (2010-2022), respectively. Another 62 patients underwent LE were also identified from SEER registries. Propensity score matching was performed to balance baseline characteristics between patients in different treatment groups. RESULTS Regional nodal metastasis was histopathologically detected in 257 patients (20.7%) within the SEER cohort, showing a significant association with poor cancer-specific survival (CSS) and overall survival (OS). Consistent findings were also observed in the ZJCH cohort. After 1:1 propensity score matching (60 pairs), no significant differences were observed between the extended resection and local excision groups in CSS (hazard ratio [HR] 0.88, P = 0.785) and OS (HR 0.81, P = 0.450). Patients with regional nodal metastases were more likely to receive ACT, while no apparent survival benefit was observed with additional ACT after PSM adjusting (187 pairs). Notwithstanding, for individuals younger than 50 years, ACT might provide a survival benefit in CSS (HR 0.25, P = 0.033) and OS (HR 0.30, P = 0.022). CONCLUSION Although patients with ypT1 rectal cancer have a non-negligible risk for nodal metastasis, oncologic outcomes of local excision following nCRT seem to be comparable to radical surgery. ACT could not effectively improve prognosis in patients with ypT1 tumors, except for those younger than 50 years of age.
Collapse
Affiliation(s)
- Yibo Cai
- Department of Colorectal Surgery, Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, 1 Banshan E. Road, Hangzhou, Zhejiang, 310022, China
| | - Lai Jiang
- Department of Colorectal Surgery, Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, 1 Banshan E. Road, Hangzhou, Zhejiang, 310022, China
| | - Haixing Ju
- Department of Colorectal Surgery, Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, 1 Banshan E. Road, Hangzhou, Zhejiang, 310022, China
| | - Yuping Zhu
- Department of Colorectal Surgery, Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, 1 Banshan E. Road, Hangzhou, Zhejiang, 310022, China
| | - Zhuo Liu
- Department of Colorectal Surgery, Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, 1 Banshan E. Road, Hangzhou, Zhejiang, 310022, China.
| |
Collapse
|
|
5
|
Binda C, Secco M, Tuccillo L, Coluccio C, Liverani E, Jung CFM, Fabbri C, Gibiino G. Early Rectal Cancer and Local Excision: A Narrative Review. J Clin Med 2024; 13:2292. [PMID: 38673565 PMCID: PMC11051053 DOI: 10.3390/jcm13082292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/03/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024] Open
Abstract
A rise in the incidence of early rectal cancer consequent to bowel-screening programs around the world and an increase in the incidence in young adults has led to a growing interest in organ-sparing treatment options. The rectum, being the most distal portion of the large intestine, is a fertile ground for local excision techniques performed with endoscopic or surgical techniques. Moreover, the advancement in endoscopic optical evaluation and the better definition of imaging techniques allow for a more precise local staging of early rectal cancer. Although the local treatment of early rectal cancer seems promising, in clinical practice, a significant number of patients who could benefit from local excision techniques undergo total mesorectal excision (TME) as the first approach. All relevant prospective clinical trials were identified through a computer-assisted search of the PubMed, EMBASE, and Medline databases until January 2024. This review is dedicated to endoscopic and surgical local excision in the treatment of early rectal cancer and highlights its possible role in current and future clinical practice, taking into account surgical completion techniques and chemoradiotherapy.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, 47121 Forlì, Italy; (C.B.); (M.S.); (L.T.); (C.C.); (E.L.); (C.F.M.J.); (G.G.)
| | | |
Collapse
|
|
6
|
Yu G, Chi H, Zhao G, Wang Y. Tumor regression and safe distance of distal margin after neoadjuvant therapy for rectal cancer. Front Oncol 2024; 14:1375334. [PMID: 38638858 PMCID: PMC11024319 DOI: 10.3389/fonc.2024.1375334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 03/15/2024] [Indexed: 04/20/2024] Open
Abstract
Neoadjuvant therapy has been widely employed in the treatment of rectal cancer, demonstrating its utility in reducing tumor volume, downstaging tumors, and improving patient prognosis. It has become the standard preoperative treatment modality for locally advanced rectal cancer. However, the efficacy of neoadjuvant therapy varies significantly among patients, with notable differences in tumor regression outcomes. In some cases, patients exhibit substantial tumor regression, even achieving pathological complete response. The assessment of tumor regression outcomes holds crucial significance for determining surgical approaches and establishing safe margins. Nonetheless, current research on tumor regression patterns remains limited, and there is considerable controversy surrounding the determination of a safe margin after neoadjuvant therapy. In light of these factors, this study aims to summarize the primary patterns of tumor regression observed following neoadjuvant therapy for rectal cancer, categorizing them into three types: tumor shrinkage, tumor fragmentation, and mucinous lake formation. Furthermore, a comparison will be made between gross and microscopic tumor regression, highlighting the asynchronous nature of regression in the two contexts. Additionally, this study will analyze the safety of non-surgical treatment in patients who achieve complete clinical response, elucidating the necessity of surgical intervention. Lastly, the study will investigate the optimal range for safe surgical resection margins and explore the concept of a safe margin distance post-neoadjuvant therapy.
Collapse
Affiliation(s)
- Guilin Yu
- Department of General Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, China
| | - Huanyu Chi
- Department of General Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, China
- The Second Clinical College, Dalian Medical University, Dalian, China
| | - Guohua Zhao
- Department of General Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, China
| | - Yue Wang
- Department of General Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, China
| |
Collapse
|
|
7
|
Klimkowski R, Krzyzkowiak J, Pilonis ND, Bujko K, Kaminski MF. Endoscopic resection of residual rectal neoplasia after definitive chemoradiotherapy for rectal cancer. Best Pract Res Clin Gastroenterol 2024; 68:101896. [PMID: 38522889 DOI: 10.1016/j.bpg.2024.101896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 02/21/2024] [Accepted: 02/25/2024] [Indexed: 03/26/2024]
Abstract
The conventional approach to treating locally advanced rectal cancer, commonly defined as cT3 or cT4 primary tumors or with nodal metastases, involves chemoradiation (CRT) followed by surgical resection. There is a growing recognition of the potential for nonsurgical management following CRT or total neoadjuvant therapy (TNT), which allows for organ preservation. "Watch and wait" strategy may be considered if complete clinical response is achieved. In cases when adenoma or superficial cancer is present, a novel approach known as "salvage endoscopic resection of the residual disease" is emerging as a viable nonsurgical option for carefully selected patients. This review discusses available evidence and future potential for endoscopic management of residual neoplasia after oncological treatment of rectal cancer.
Collapse
Affiliation(s)
- Robert Klimkowski
- Department of Gastroenterological Oncology, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland; Department of Gastroenterology, Hepatology and Oncology, Medical Center for Postgraduate Education, Warsaw, Poland.
| | - Jakub Krzyzkowiak
- Department of Gastroenterological Oncology, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Nastazja Dagny Pilonis
- Department of Gastroenterological Oncology, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland; Department of Gastroenterology, Hepatology and Oncology, Medical Center for Postgraduate Education, Warsaw, Poland; Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway; Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, Gdansk, Poland
| | - Krzysztof Bujko
- Department of Radiotherapy I, National Research Institute of Oncology, Warsaw, Poland
| | - Michal F Kaminski
- Department of Gastroenterological Oncology, M. Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland; Department of Gastroenterology, Hepatology and Oncology, Medical Center for Postgraduate Education, Warsaw, Poland; Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway; Department of Surgical Oncology Medical University of Gdansk, Gdansk, Poland
| |
Collapse
|
|
8
|
Stefanou AJ, Dessureault S, Sanchez J, Felder S. Clinical Tools for Rectal Cancer Response Assessment following Neoadjuvant Treatment in the Era of Organ Preservation. Cancers (Basel) 2023; 15:5535. [PMID: 38067239 PMCID: PMC10705332 DOI: 10.3390/cancers15235535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 11/04/2023] [Accepted: 11/10/2023] [Indexed: 09/16/2024] Open
Abstract
Local tumor response evaluation following neoadjuvant treatment(s) in rectal adenocarcinoma requires a multi-modality approach including physical and endoscopic evaluations, rectal protocoled MRI, and cross-sectional imaging. Clinical tumor response exists on a spectrum from complete clinical response (cCR), defined as the absence of clinical evidence of residual tumor, to near-complete response (nCR), which assumes a significant reduction in tumor burden but with increased uncertainty of residual microscopic disease, to incomplete clinical response (iCR), which incorporates all responses less than nCR that is not progressive disease. This article aims to review the clinical tools currently routinely available to evaluate treatment response and offers a potential management approach based on the extent of local tumor response.
Collapse
Affiliation(s)
| | | | | | - Seth Felder
- Clinical and Pathologic Response to Therapy in Gastrointestinal Oncology, Moffitt Cancer Center, 12902 Magnolia Dr., Tampa, FL 33612, USA; (A.J.S.); (S.D.); (J.S.)
| |
Collapse
|
|
9
|
Chen L, Liu X, Zhang W, Qin S, Wang Y, Lin J, Chen Q, Liu G. The predictive value of tumor volume reduction ratio on three-dimensional endorectal ultrasound for tumor response to chemoradiotherapy for locally advanced rectal cancer. ANNALS OF TRANSLATIONAL MEDICINE 2022; 10:666. [PMID: 35845508 PMCID: PMC9279805 DOI: 10.21037/atm-22-2418] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 06/08/2022] [Indexed: 01/04/2023]
Abstract
Background Preoperative chemoradiotherapy remains part of the standard treatment for patients with locally advanced rectal cancer. Subsequent treatment individualization requires accurate prediction of tumor response to chemoradiotherapy. Three-dimensional endorectal ultrasound (3D-ERUS) can automatically capture and store the images of the rectal wall and rectal cancer with high resolution. In this study, we aimed to assess the correlation and predictive value between tumor volume changes measured on 3D-ERUS and the histopathological tumor response after chemoradiotherapy for patients with locally advanced rectal cancer. Methods A total of 54 patients with locally advanced rectal cancer who underwent chemoradiotherapy and had complete 3D-ERUS data pre-and post-chemoradiotherapy were enrolled in the study. The tumor volume pre-and post-chemoradiotherapy was measured manually on 3D-ERUS, and the tumor volume reduction ratio was calculated. The histopathological tumor regression grade (TRG) was used to assess tumor response. The differences in volumetry parameters were compared between groups with varying tumor response. The diagnostic efficacy of the tumor volume reduction ratio was evaluated by the receiver operating characteristic (ROC) curve. Results The mean age of all patients was 55.19±12.46 years. The relative proportions of TRG 0–3 were 29.6% (16/54), 16.6% (9/54), 50% (27/54), and 3.8% (2/54), respectively. The median tumor volumes post-chemoradiotherapy in good responders (TRG 0–1, median tumor volume =3.26 cm3) and the complete response group (TRG 0, median tumor volume =2.61 cm3) were smaller than those in poor responders (TRG 2–3, median tumor volume =5.43 cm3) and the partial response group (TRG 1–3, median tumor volume =4.00 cm3), while tumor volume reduction ratios were higher than those of poor responders (79.32% vs. 59.67%) and the partial response group (82.22% vs. 61.64%), with significant differences (all P values <0.05). The ROC curves showed that the cut-off values of the tumor volume reduction ratio to predict good responders and complete response were 67.77% and 72.02%, respectively. The corresponding areas under the curve in the prediction of good responders and complete response were 0.830 and 0.829, respectively. Conclusions The tumor volume reduction ratio measured on 3D-ERUS might be a helpful indicator for tumor response in patients with locally advanced rectal cancer.
Collapse
Affiliation(s)
- Limei Chen
- Department of Medical Ultrasonics, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaoyin Liu
- Department of Medical Ultrasonics, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wenjing Zhang
- Department of Medical Ultrasonics, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Si Qin
- Department of Medical Ultrasonics, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yimin Wang
- Department of Medical Ultrasonics, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jing Lin
- Department of Medical Ultrasonics, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qiu Chen
- Department of Medical Ultrasonics, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Guangjian Liu
- Department of Medical Ultrasonics, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| |
Collapse
|
|
10
|
Neoadjuvant and Adjuvant Therapy for Local Excision of Rectal Cancer. SEMINARS IN COLON AND RECTAL SURGERY 2022. [DOI: 10.1016/j.scrs.2022.100900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
|
11
|
Perez RO, Julião GPS, Vailati BB. Transanal Local Excision of Rectal Cancer after Neoadjuvant Chemoradiation: Is There a Place for It or Should Be Avoided at All Costs? Clin Colon Rectal Surg 2022; 35:122-128. [PMID: 35237107 PMCID: PMC8885162 DOI: 10.1055/s-0041-1742112] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Tumor response to neoadjuvant chemoradiation (nCRT) with tumor downsizing and downstaging has significantly impacted the number of patients considered to be appropriate candidates for transanal local excision (TLE). Some patients may harbor small residual lesions, restricted to the bowel wall. These patients, who exhibit major response ("near-complete") by digital rectal examination, endoscopic assessment, and radiological assessment may be considered for this approach. Although TLE is associated with minimal postoperative morbidity, a few clinical consequences and oncological outcomes must be evaluated in advance and with caution. In the setting of nCRT, a higher risk for clinically relevant wound dehiscences leading to a considerable risk for readmission for pain management has been observed. Worse anorectal function (still better than after total mesorectal excision [TME]), worsening in the quality of TME specimen, and higher rates of abdominal resections (in cases requiring completion TME) have been reported. The exuberant scar observed in the area of TLE also represents a challenging finding during follow-up of these patients. Local excision should be probably restricted for patients with primary tumors located at or below the level of the anorectal ring (magnetic resonance defined). These patients are otherwise candidates for abdominal perineal resections or ultra-low anterior resections with coloanal anastomosis frequently requiring definitive stomas or considerably poor anorectal function.
Collapse
Affiliation(s)
- Rodrigo Oliva Perez
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil,Division of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil,Address for correspondence Rodrigo Oliva Perez, MD, PhD Department of Surgical Oncology, Hospital Beneficencia PortuguesaSão Paulo 01323-001Brazil
| | - Guilherme Pagin São Julião
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil,Division of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Bruna Borba Vailati
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil,Division of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| |
Collapse
|
|
12
|
Tang J, Zhang Y, Zhang D, Zhang C, Jin K, Ji D, Peng W, Feng Y, Sun Y. Total Mesorectal Excision vs. Transanal Endoscopic Microsurgery Followed by Radiotherapy for T2N0M0 Distal Rectal Cancer: A Multicenter Randomized Trial. Front Surg 2022; 9:812343. [PMID: 35178428 PMCID: PMC8844472 DOI: 10.3389/fsurg.2022.812343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 01/10/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction Transanal endoscopic microsurgery (TEM) is an organ-preserving treatment alternative for patients with early rectal cancer. However, TEM alone is associated with greater risk of local recurrence and inferior survival in comparison with total meso-rectal excision (TME). As an important adjuvant therapy, radiotherapy can effectively reduce the local recurrence rate of rectal cancer. This study aimed to investigate whether TEM followed by radiotherapy can be a valid alternative to TME in T2N0M0 distal rectal cancer treatment. Methods We plan to recruit 168 participants meeting established inclusion criteria. Following informed consent, participants will randomly receive treatment protocols of TEM followed by radiotherapy (a total dose of 45–50.4 Gy given in 25–28 factions) or TME. Depending on post-operative pathology, the participants will receive either long-term follow-up or further treatment. The primary endpoint of this trial is 3-year local recurrence rate. The secondary end points include 3-year disease-free survival rate, 3-year overall survival rate, 3-year mortality rate, post-operative quality of life, post-operative safety index, intraoperative evaluation index and post-operative short-term evaluation index. Discussion This trial is the first prospective randomized trial to investigate the rectum preserving treatment by using transanal local excision followed by radiotherapy. Clinical trial registration The trial was prospectively registered at ClinicalTrials.gov NCT04098471 on September 20, 2019.
Collapse
|
|
13
|
Whelan S, Burneikis D, Kalady MF. Rectal cancer: Maximizing local control and minimizing toxicity. J Surg Oncol 2021; 125:46-54. [PMID: 34897711 DOI: 10.1002/jso.26743] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 10/11/2021] [Indexed: 12/31/2022]
Abstract
Adoption of multimodality treatment approach for rectal cancer has resulted in significant improvements in oncologic outcomes. The roles of chemotherapy, radiation, and surgery in rectal cancer treatment are continuously evolving with the goal of achieving the best possible oncologic and functional outcome while minimizing treatment toxicity. The aim of this review is to summarize the most recent trials focusing on organ-sparing treatment strategies and the optimal selection of patients for neoadjuvant radiation therapy.
Collapse
Affiliation(s)
- Sean Whelan
- Department of Surgery, Division of Colon and Rectal Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Dominykas Burneikis
- Department of Surgery, Division of Colon and Rectal Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Matthew F Kalady
- Department of Surgery, Division of Colon and Rectal Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| |
Collapse
|
|
14
|
Naiderman D, Tufare AL, Trinchero LB, Rossi F, Dolan M, Cano DM, Fagalde RL, Jury GL. Transanal Minimally-Invasive Surgery (TAMIS): Experience with No Closure of the Rectal Defect. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1055/s-0041-1735642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Abstract
Background In transanal minimally-invasive surgery (TAMIS), the closure of the rectal defect is controversial, and endoluminal suture is one of the most challenging aspects. The goal of the present study is to evaluate the short- and medium-term complications of a consecutive series of patients with extraperitoneal rectal injuries who underwent TAMIS without closure of the rectal defect.
Materials and Methods A prospective, longitudinal, descriptive study conducted between August 2013 and July 2019 in which all patients with extraperitoneal rectal lesions, who were operated on using the TAMIS technique, were consecutively included. The lesions were: benign lesions ≥ 3 cm; neuroendocrine tumors ≤ 2 cm; adenocarcinomas in stage T1N0; and adenocarcinomas in stage T2N0, with high surgical risk, or with the patients reluctant to undergo radical surgery, and others with doubts about complete remission after the neoadjuvant therapy. Bleeding, infectious complications, rectal stenosis, perforations, and death were evaluated.
Results A total of 35 patients were treated using TAMIS without closure of the defect. The average size of the lesions was of 3.68 ± 2.1 cm (95% confidence interval [95%CI]: 0.7 cm to 9 cm), their average distance from the anal margin was of 5.7 ± 1.48 cm, and the average operative time was of 39.2 ± 20.5 minutes, with a minimum postoperative follow-up of 1 year. As for the pathologies, they were: 15 adenomas; 3 carcinoid tumors; and 17 adenocarcinomas. In all cases, the rectal defect was left open.The overall morbidity was of 14.2%. Two patients (grade II in the Clavien-Dindo classification) were readmitted for pain treatment, and three patients (grade III in the Clavien-Dindo classification) were assisted due to postoperative bleeding, one of whom required reoperation.
Conclusion The TAMIS technique without closure of the rectal defect yields good results, and present a high feasibility and low complication rate.
Collapse
Affiliation(s)
- Diego Naiderman
- Coloproctology Sector, Hospital Interzonal General de Agudos “Dr. Oscar E. Alende” (HIGA), Mar del Plata, Buenos Aires, Argentina
- Centro de Estudios Digestivos, Mar del Plata, Buenos Aires, Argentina
- Clínica Pueyrredón, Mar del Plata, Buenos Aires, Argentina
| | - Ana Laura Tufare
- Universidad Nacional de Mar del Plata, Mar del Plata, Buenos Aires, Argentina
| | | | - Fernando Rossi
- Clínica Pueyrredón, Mar del Plata, Buenos Aires, Argentina
| | - Martín Dolan
- Centro de Estudios Digestivos, Mar del Plata, Buenos Aires, Argentina
| | - Diego Martín Cano
- Coloproctology Sector, Hospital Interzonal General de Agudos “Dr. Oscar E. Alende” (HIGA), Mar del Plata, Buenos Aires, Argentina
| | | | | |
Collapse
|
|
15
|
Long-term outcomes of transanal endoscopic microsurgery for clinical complete response after neoadjuvant treatment in T2-3 rectal cancer. Surg Endosc 2021; 36:2906-2913. [PMID: 34231071 DOI: 10.1007/s00464-021-08583-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 06/02/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Organ sparing by the transanal endoscopic microsurgery (TEM) procedure is a treatment for patients with locally advanced rectal cancer after chemoradiotherapy (CRT) and complete clinical response (cCR). AIMS To assess the surgical and long-term oncological outcomes of TEM for the treatment in T2-3 rectal cancer after CRT and cCR. METHODS This study was a retrospective review of a prospective database of patients with rectal cancer who underwent TEM after CRT and cCR from April 2011 to March 2020. RESULTS 52 patients underwent TEM during a period of 9 years. This group of patients included 27 females and 25 males. The median age was 62 (32-86) years, lesion size was 2.5 (1-4) cm, and lesion distance from the anal verge 7.3 (4-10) cm. Median operative time was 79.5 (25-120) min and hospital stay was 1 day (14 h-4 days). Morbidity rate was 13.5% and reoperation rate due to major complications was 3.8%. Final histological findings confirmed 34 (65.4%) patients with ypT0, 7 (13.5%), 6 (11.5%), and 5 (9.6%) patients with carcinoma ypT1, ypT2, and ypT3, respectively. After a median follow-up period of 86 (5-107) months, 1 (2.4%) patient had local recurrences and 3 (7.3%) distant metastases. The 5-year disease-free survival was 91.7% and 5-year overall survival 89.5%. CONCLUSION Our experience has shown significant rates of ypT0 and ypT1 associated with excellent long-term results. Performing TEM to treat T2-3N0 rectal cancer after CRT and cCR appears to be an oncologically safe and effective procedure.
Collapse
|
|
16
|
Pang X, Gao Y, Yi H, Liu H, Liu S, Zheng J. Associations between clinical characteristics and tumor response to neoadjuvant chemoradiotherapy in rectal cancer. Cancer Med 2021; 10:4832-4843. [PMID: 34128335 PMCID: PMC8290248 DOI: 10.1002/cam4.4051] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/16/2021] [Accepted: 05/17/2021] [Indexed: 12/11/2022] Open
Abstract
Following standard neoadjuvant chemoradiotherapy and total mesorectal excision, some patients with locally advanced rectal cancer achieve good response (pathological T0-2N0), while others show nonresponse (pathological T3-4N0 or node-positive). To date, the clinicopathological predictors of good response and the necessity of adjuvant chemotherapy treatment (ACT) in good responders remain unclear. In this retrospective study, clinicopathological characteristics were surveyed to investigate the correlation with good response; furthermore, a propensity score matching (PSM) model was designed to balance the confounding factors between good responders treated with ACT or observation. A total of 2255 patients were enrolled, including 1069 good responders and 1186 nonresponders. The results of the survival analysis showed a good response predicted a better 3-year prognosis (p < 0.001). The logistic regression analysis showed less advanced T and N stages (T3 vs. T4; N0 vs. N1-2), more neoadjuvant chemotherapy (nCT) cycles (≥4 vs. 1-3), and delayed surgery (≥8 weeks vs. <8 weeks) were independent predictors of a good response (p < 0.05). Especially, patients treated with both more nCT cycles and a delay in surgery included the greatest number of good responders (p < 0.001). For good responders, after PSM (1:3), 235 observation cases were matched to 705 ACT cases. As compared with observation, ACT had no greater impact on prognosis analysis (p > 0.05). In conclusion, more cycles of nCT and a delay in surgery predicted a better response, and the delivery of ACT might be omitted in good responders.
Collapse
Affiliation(s)
- Xiaolin Pang
- Department of Radiation Oncology, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Yuanhong Gao
- Department of Radiation Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Hanchen Yi
- Department of Radiation Oncology, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Hailing Liu
- Department of Pathology, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Shuai Liu
- Department of Radiation Oncology, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Jian Zheng
- Department of Radiation Oncology, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, People's Republic of China
| |
Collapse
|
|
17
|
Deschner BW, VanderWalde NA, Grothey A, Shibata D. Evolution and Current Status of the Multidisciplinary Management of Locally Advanced Rectal Cancer. JCO Oncol Pract 2021; 17:383-402. [PMID: 33881906 DOI: 10.1200/op.20.00885] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
The management of locally advanced rectal cancer has grown in both complexity and quality since the first proctectomy. What once was a malignancy with a fairly consistent treatment algorithm for decades, a recent paradigm shift in the care of these patients has led to a more personalized, multidisciplinary approach with variations in timing, sequence, duration, and potential exclusion of multimodality therapies. This review summarizes the most important evidence behind these developing overarching concepts to provide a context for this paradigm shift.
Collapse
Affiliation(s)
- Benjamin W Deschner
- Division of Surgical Oncology, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Noam A VanderWalde
- Radiation Oncology and Medical Oncology, West Cancer Center and Research Institute, Memphis, TN
| | - Axel Grothey
- Radiation Oncology and Medical Oncology, West Cancer Center and Research Institute, Memphis, TN
| | - David Shibata
- Division of Surgical Oncology, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| |
Collapse
|
|
18
|
Transanal minimally invasive surgery (TAMIS) for local excision of selected rectal neoplasms: efficacy and outcomes in the first 11 patients. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1016/j.jcol.2014.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AbstractDisposable single-port surgery devices have been used for transanal minimally invasive surgery (TAMIS) with benefits, when compared to local resection and transanal endoscopic microsurgery (TEM).
Objective To show outcomes and details of the technique.
Method A series of patients with indication for local resection of rectal tumors were submitted to surgery using the TAMIS platform.
Results Eleven patients have been submitted to TAMIS. Distance from anal verge was from 1.5 to 8 cm and maximum tumor diameter was 6 cm. Initial diagnosis of adenoma was the most frequent indication for resection. One partial dehiscence was the only complication seen. Minimal setup time, low cost and the possibility of using regular laparoscopic instruments make TAMIS a good option for transanal resection. The results of this technique are encouraging, concerning the feasibility, maneuverability, upfront cost, setup time, resectability and complication rate. Because of its simplicity and similarity with conventional laparoscopic surgery, it can be learned easily. Although at the present time the appropriate use of local excision is still under debate, TAMIS is a technique that still expects a lot of growing and much remains to be learned.
Collapse
|
|
19
|
Shao K, Zheng R, Li A, Li X, Xu B. Clinical predictors of pathological good response in locally advanced rectal cancer. Radiat Oncol 2021; 16:10. [PMID: 33436026 PMCID: PMC7805032 DOI: 10.1186/s13014-020-01741-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 12/26/2020] [Indexed: 01/10/2023] Open
Abstract
Purpose The aim of this study was to identify the clinical predictors of pathological good response (PGR) after neoadjuvant chemoradiotherapy (nCRT) in locally advanced rectal cancer (LARC) to clarify the indications for local excision. Methods and materials A total of 173 patients with LARC (cT3–4/N +) who were treated with nCRT followed by surgery were enrolled in our retrospective study. Patients were categorized into two groups according to the different tumor responses of surgical pathology. Stage ypT0–1N0 was defined as the group with PGR, and stage ypT2–4N0/ypTanyN + was the defined as the pathological poor response (PPR) group, and the potential predictors were compared. Results Of 173 patients, PGR was achieved in 57 patients (32.95%). The distance from the inferior margin of the tumor to the anal verge, cT classification, pretreatment carcinoembryonic antigen (CEA) and the interval from the end of radiation to surgery were correlated with pathological response. In the multivariate analysis, the distance from anal verge < 5 cm (OR = 0.443, p = 0.019), pretreatment CEA < 5 ng/mL (OR = 0.412, p = 0.015) and the interval from the end of radiation to surgery ≥ 84 days (OR = 2.652, p = 0.005) were independent predictors of PGR. Conclusions The distance from the inferior margin of the tumor to the anal verge, pretreatment CEA and the interval from the end of radiation to surgery were significant predictors of PGR in LARC. A prospective study is needed to further validate these results in the future.
Collapse
Affiliation(s)
- Kongfeng Shao
- Department of Radiation Oncology, Fujian Medical University Union Hospital, No.29 Xinquan Road, Gulou District, Fuzhou, 350001, People's Republic of China.,School of Clinical Medicine, Fujian Medical University, Fuzhou, People's Republic of China.,College of Union Clinical Medicine, Fujian Medical University, Fuzhou, People's Republic of China
| | - Rong Zheng
- Department of Radiation Oncology, Fujian Medical University Union Hospital, No.29 Xinquan Road, Gulou District, Fuzhou, 350001, People's Republic of China.,College of Union Clinical Medicine, Fujian Medical University, Fuzhou, People's Republic of China
| | - Anchuan Li
- Department of Radiation Oncology, Fujian Medical University Union Hospital, No.29 Xinquan Road, Gulou District, Fuzhou, 350001, People's Republic of China.,School of Clinical Medicine, Fujian Medical University, Fuzhou, People's Republic of China.,College of Union Clinical Medicine, Fujian Medical University, Fuzhou, People's Republic of China
| | - Xiaobo Li
- Department of Radiation Oncology, Fujian Medical University Union Hospital, No.29 Xinquan Road, Gulou District, Fuzhou, 350001, People's Republic of China.,College of Medical Technology and Engineering, Fujian Medical University, Fuzhou, People's Republic of China.,School of Clinical Medicine, Fujian Medical University, Fuzhou, People's Republic of China.,College of Union Clinical Medicine, Fujian Medical University, Fuzhou, People's Republic of China
| | - Benhua Xu
- Department of Radiation Oncology, Fujian Medical University Union Hospital, No.29 Xinquan Road, Gulou District, Fuzhou, 350001, People's Republic of China. .,College of Medical Technology and Engineering, Fujian Medical University, Fuzhou, People's Republic of China. .,School of Clinical Medicine, Fujian Medical University, Fuzhou, People's Republic of China. .,College of Union Clinical Medicine, Fujian Medical University, Fuzhou, People's Republic of China.
| |
Collapse
|
|
20
|
Bae H, Seo N, Han K, Koom WS, Kim MJ, Kim NK, Lim JS. MR prediction of pathologic complete response and early-stage rectal cancer after neoadjuvant chemoradiation in patients with clinical T1/T2 rectal cancer for organ saving strategy. Medicine (Baltimore) 2020; 99:e22746. [PMID: 33080736 PMCID: PMC7571887 DOI: 10.1097/md.0000000000022746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
To evaluate the ability of magnetic resonance imaging (MRI) to predict pathologic complete response (pCR) after neoadjuvant chemoradiation therapy (CRT) in patients with clinical T1/T2 rectal cancer to indicate candidates for organ-saving strategies.Between 2012 and 2016, 38 patients with clinical T1/T2 rectal cancer received neoadjuvant CRT. Radiologic complete response (rCR) was assigned when dense fibrotic tissue without tumor signal intensity was observed on post-CRT MRI. Surgical pathologic assessment was used to evaluate tumor regression. The association between rCR and the mural extent of the primary tumor, pCR, and pathologic T stage were analyzed.In rCR patients, the pCR rate was higher; the odds of achieving pCR were 8.00 times higher than for non-rCR patients (P = .02). rCR patients were also more likely to have early-stage cancer than non-rCR patients (P = 0.01). Patients with partial extent of the primary tumor on post-CRT MRI were more likely to be diagnosed with early-stage cancer than those with transmural extent (P = .01).rCR indicated by post-CRT MRI can be used as a supportive factor to predict pCR after neoadjuvant CRT in patients with clinical T1/T2 rectal cancer and can guide management decisions around organ-saving treatments.
Collapse
Affiliation(s)
- Heejin Bae
- Department of Radiology and Research Institute of Radiological Science
| | - Nieun Seo
- Department of Radiology and Research Institute of Radiological Science
| | - Kyunghwa Han
- Department of Radiology and Research Institute of Radiological Science
| | | | - Myeong-Jin Kim
- Department of Radiology and Research Institute of Radiological Science
| | - Nam Kyu Kim
- Division of Colorectal Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joon Seok Lim
- Department of Radiology and Research Institute of Radiological Science
| |
Collapse
|
|
21
|
Peltrini R, Sacco M, Luglio G, Bucci L. Local excision following chemoradiotherapy in T2-T3 rectal cancer: current status and critical appraisal. Updates Surg 2020; 72:29-37. [PMID: 31621033 DOI: 10.1007/s13304-019-00689-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 10/10/2019] [Indexed: 12/18/2022]
Abstract
Local excision following chemoradiotherapy in rectal cancer is an organ-preserving procedure which aims at reducing morbidity and functional disorders associated with total mesorectal excision (TME) in selected patients. Although TME after chemoradiotherapy remains the gold standard for locally advanced mid and low rectal cancer, in the last years multicenter research trials have offered encouraging oncologic results which have allowed to preserve the rectum in patients with a pathologic complete response after chemoradiotherapy. A review of the available literature on this topic was conducted to define the state of the art of this conservative approach and to focus on the most controversial aspects concerning local excision performed after chemoradiotherapy, in particular tumor scatter and lymph node status, completion and salvage surgery, morbidity and quality of life. The analysis of these topics should be considered, in trial setting or in current practice, for their clinical implications. Oncologic outcomes of recent trials are encouraging for part of the patients presenting T2 rectal cancer; however, TME still remains the standard treatment in clinical practice. In such cases, local excision should include a surgical safety margin of at least 1 cm from the resection margin to achieve a true negative margin from residual tumor cells. The selection of the patients should be carefully performed and their consensus extremely detailed because TME is necessary in about 30% of cases. Failing that, morbidity and quality of life are negatively affected. However, about half of these patients refuse radical surgery (45%), thus undergoing only palliative care.
Collapse
Affiliation(s)
- Roberto Peltrini
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy.
| | - Michele Sacco
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Gaetano Luglio
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Luigi Bucci
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy
| |
Collapse
|
|
22
|
Arsoniadis EG, Finlayson E, Potenti F. Is there a role for specialized geriatric centers in treating geriatric cancer patients? Eur J Surg Oncol 2020; 46:383-386. [PMID: 32005554 DOI: 10.1016/j.ejso.2019.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 10/21/2019] [Accepted: 12/13/2019] [Indexed: 11/26/2022] Open
Abstract
As the population with colorectal cancer ages, the tailored approach required to manage older patients becomes all the more important for all providers and institutions treating colorectal cancer to adopt and improve the outcomes and well-being of this important and increasingly prevalent population. Joint guidelines from the American College of Surgeons and American Geriatric Association should be followed. Older cancer patients undergoing colorectal cancer surgery should be referred to centers with expertise in minimally invasive surgery. Likewise, older rectal cancer patients should be referred to centers with expertise in treating rectal cancer.
Collapse
Affiliation(s)
- Elliot G Arsoniadis
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA; Institute for Health Informatics, University of Minnesota, Minneapolis, MN, USA.
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Fabio Potenti
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
| |
Collapse
|
|
23
|
Sevak S, Gregoir T, Wolthuis A, Albert M. How can we utilize local excision to help, not harm, geriatric patients with rectal cancer? Eur J Surg Oncol 2020; 46:344-348. [PMID: 31983488 DOI: 10.1016/j.ejso.2019.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 09/12/2019] [Accepted: 12/13/2019] [Indexed: 01/24/2023] Open
Abstract
A majority of the morbidity and mortality burden of rectal cancer is distributed within the geriatric age group. Current surgical and medical treatment modalities pose significant challenges in treating complications specifically in the already pre-disposed senior population with baseline dysfunction. This chapter reviews the work-up, management, current data and oncologic outcomes of treating rectal cancer in the senior adult.
Collapse
Affiliation(s)
- Shruti Sevak
- Center for Colon and Rectal Surgery, AdventHealth, Orlando, FL, USA.
| | - Tine Gregoir
- Department of Abdominal Surgery, University Hospital Leuven, Herestraat 48, 3000, Leuven, Belgium
| | - Albert Wolthuis
- Department of Abdominal Surgery, University Hospital Leuven, Herestraat 48, 3000, Leuven, Belgium
| | - Matthew Albert
- Center for Colon and Rectal Surgery, AdventHealth, Orlando, FL, USA
| |
Collapse
|
|
24
|
Peterson CY, Blank J, Ludwig K. Colorectal Cancer in Elderly Patients: Considerations in Treatment and Management. PRINCIPLES AND PRACTICE OF GERIATRIC SURGERY 2020:903-929. [DOI: 10.1007/978-3-319-47771-8_59] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
|
|
25
|
Montroni I, Ugolini G, Audisio RA. Principles of Cancer Surgery in Older Adults. GERIATRIC ONCOLOGY 2020:825-844. [DOI: 10.1007/978-3-319-57415-8_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
|
|
26
|
Stijns RCH, de Graaf EJR, Punt CJA, Nagtegaal ID, Nuyttens JJME, van Meerten E, Tanis PJ, de Hingh IHJT, van der Schelling GP, Acherman Y, Leijtens JWA, Bremers AJA, Beets GL, Hoff C, Verhoef C, Marijnen CAM, de Wilt JHW. Long-term Oncological and Functional Outcomes of Chemoradiotherapy Followed by Organ-Sparing Transanal Endoscopic Microsurgery for Distal Rectal Cancer: The CARTS Study. JAMA Surg 2019; 154:47-54. [PMID: 30304338 DOI: 10.1001/jamasurg.2018.3752] [Citation(s) in RCA: 168] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Importance Treatment of rectal cancer is shifting toward organ preservation aiming to reduce surgery-related morbidity. Short-term outcomes of organ-preserving strategies are promising, but long-term outcomes are scarce in the literature. Objective To explore long-term oncological outcomes and health-related quality of life (HRQL) in patients with cT1-3N0M0 rectal cancer who underwent neoadjuvant chemoradiotherapy (CRT) followed by transanal endoscopic microsurgery (TEM). Design, Setting, and Participants In this multicenter phase II feasibility study, patients with cT1-3N0M0 rectal cancer admitted to referral centers for rectal cancer throughout the Netherlands between February 2011 and September 2012 were prospectively included. These patients were to be treated with neoadjuvant CRT followed by TEM in case of good response. An intensive follow-up scheme was used to detect local recurrences and/or distant metastases. Data from validated HRQL questionnaires and low anterior resection syndrome questionnaires were collected. Data were analyzed from February 2011 to April 2017. Main Outcomes and Measures The primary study outcome of the study was the number of ypT0-1 specimens by performing TEM. Secondary outcome parameters were locoregional recurrences and HRQL. Results Of the 55 included patients, 30 (55%) were male, and the mean (SD) age was 64 (39-82) years. Patients were followed up for a median (interquartile range) period of 53 (39-57) months. Two patients (4%) died during CRT, 1 (2%) stopped CRT, and 1 (2%) was lost to follow-up. Following CRT, 47 patients (85%) underwent TEM, of whom 35 (74%) were successfully treated with local excision alone. Total mesorectal excision was performed in 16 patients (4 with inadequate responses, 8 with completion after TEM, and 4 with salvage for local recurrence). The actuarial 5-year local recurrence rate was 7.7%, with 5-year disease-free and overall survival rates of 81.6% and 82.8%, respectively. Health-related quality of life during follow-up was equal to baseline, with improved emotional well-being in patients treated with local excision (mean score at baseline, 72.0; 95% CI, 67.1-80.1; mean score at follow-up, 86.9; 95% CI, 79.2-94.7; P = .001). Major, minor, and no low anterior resection syndrome was experienced in 50%, 28%, and 22%, respectively, of patients with successful organ preservation. Conclusions and Relevance In early-stage rectal cancer (cT1-3N0M0), CRT enables organ preservation with additional TEM surgery in approximately two-thirds of patients with good long-term oncological outcome and HRQL. This multimodality treatment triggers a certain degree of bowel dysfunction, and one-third of patients still undergo radical surgery and are overtreated by CRT.
Collapse
Affiliation(s)
- Rutger C H Stijns
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Eelco J R de Graaf
- Department of Surgery, IJsselland Hospital, Capelle aan de Ijssel, the Netherlands
| | - Cornelis J A Punt
- Department of Medical Oncology, Academic Medical Centre, Amsterdam, the Netherlands
| | - Iris D Nagtegaal
- Department of Pathology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Joost J M E Nuyttens
- Department of Radiation Oncology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Esther van Meerten
- Department of Oncology, Erasmus Medical Centre Cancer Institute, Rotterdam, the Netherlands
| | - Pieter J Tanis
- Department of Surgery, Academic Medical Centre, Amsterdam, the Netherlands
| | | | | | - Yair Acherman
- Department of Surgery, Medical Centre Slotervaart, Amsterdam, the Netherlands
| | | | - Andreas J A Bremers
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Geerard L Beets
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Christiaan Hoff
- Department of Surgery, Medical Centre Leeuwarden, Leeuwarden, the Netherlands
| | - Cornelis Verhoef
- Department of Surgical Oncology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Corrie A M Marijnen
- Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands
| | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | | |
Collapse
|
|
27
|
Ortega CD, Perez RO. Role of magnetic resonance imaging in organ-preserving strategies for the management of patients with rectal cancer. Insights Imaging 2019; 10:59. [PMID: 31147789 PMCID: PMC6542937 DOI: 10.1186/s13244-019-0742-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 04/05/2019] [Indexed: 02/06/2023] Open
Abstract
Total mesorectal excision has been the most effective treatment strategy adopted to reduce local recurrence rates among patients with rectal cancer. The morbidity associated with this radical surgical procedure led surgeons to challenge the standard therapy particularly when dealing with superficial lesions or good responders after neoadjuvant radiotherapy, to which radical surgery may be considered overtreatment. In this subset of patients, less invasive procedures in an organ-preserving strategy may result in good oncological and functional outcomes. In order to tailor the most appropriate treatment option, accurate baseline staging and reassessment of tumor response are relevant. MRI is the most robust tool for the precise selection of patients that are candidates for organ preservation; therefore, radiologists must be familiar with the criteria used to guide the management of these patients. The purpose of this article is to review the relevant features that radiologists should know in order to provide valuable information during the multidisciplinary discussion and ultimate management decision.
Collapse
Affiliation(s)
- Cinthia D Ortega
- School of Medicine, Radiology Department, University of São Paulo, Travessa da Rua Dr. Ovídio Pires de Campos, 75, São Paulo, 05403-010, Brazil.
| | - Rodrigo O Perez
- Angelita & Joaquim Gama Institute, São Paulo, Brazil.,School of Medicine, Colorectal Surgery Division, University of São Paulo, São Paulo, Brazil.,Ludwig Institute for Cancer Research São Paulo Branch, São Paulo, Brazil
| |
Collapse
|
|
28
|
Lee JL, Lim SB, Yu CS, Park IJ, Yoon YS, Kim CW, Park SH, Lee JS, Hong YS, Kim SY, Kim JE, Kim JH, Park JH, Kim J, Han M. Local excision in mid-to-low rectal cancer patients who revealed clinically total or near-total regression after preoperative chemoradiotherapy; a proposed trial. BMC Cancer 2019; 19:404. [PMID: 31035949 PMCID: PMC6489182 DOI: 10.1186/s12885-019-5581-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 04/04/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Preoperative chemoradiotherapy (pre-CRT) followed by total mesorectal excision (TME) is currently a standard therapy for locally advanced mid-to-low rectal cancer. Less aggressive, organ-preserving option such as local excision (LE) or watchful wait can alternatively be used for patients who respond well to pre-CRT. High-resolution rectal magnetic resonance imaging (MRI) is one of the most useful methods to assess pre-CRT response, and the MERCURY group has shown that the MR tumor regression grade (mrTRG) correlated with the pathologic TRG. The aim of this study is to compare postoperative complication and oncologic outcomes between LE and TME in mid-to-low rectal cancer patients whose tumors are mrTRG grade 1 (radiological complete remission) or 2 (predominant fibrosis; near-complete remission) after pre-CRT. METHODS A prospective, double-arm, randomized, open-labeled, single center, clinical trial will be conducted in patients with mid-to-low rectal cancer whose tumors are mrTRG 1/2 after pre-CRT at the Asan Medical Center, Seoul, Korea, after approval from the Institution Review Board. Patient medical records will be de-identified using a serial number to protect personal information. Inclusion criteria will include rectal adenocarcinoma with an inferior border < 8 cm from the anal verge, mrTRG 1/2, age > 20, and provision of informed consent. Postoperative complications will be assessed by Clavien-Dindo Classification Grade. Oncologic and functional outcomes will be collected and risk factors related to these outcomes will be investigated. DISCUSSION We believed that the rate of postoperative complication of LE will be comparable to that of TME in mid-to-low advanced rectal cancer patients with a favorable response after pre-CRT. TRIAL REGISTRATION KCT0002579 ( https://cris.nih.go.kr ) Dec-2017.
Collapse
Affiliation(s)
- Jong Lyul Lee
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505 Korea
| | - Seok-Byung Lim
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505 Korea
| | - Chang Sik Yu
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505 Korea
| | - In Ja Park
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505 Korea
| | - Yong Sik Yoon
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505 Korea
| | - Chan Wook Kim
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505 Korea
| | - Seong Ho Park
- Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505 Korea
| | - Jong Seok Lee
- Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505 Korea
| | - Yong Sang Hong
- Department of Medical Oncology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505 Korea
| | - Sun Young Kim
- Department of Medical Oncology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505 Korea
| | - Jeong Eun Kim
- Department of Medical Oncology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505 Korea
| | - Jong Hoon Kim
- Department of Radiation Oncology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505 Korea
| | - Jin-hong Park
- Department of Radiation Oncology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505 Korea
| | - Jihun Kim
- Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505 Korea
| | - Minkyu Han
- Department of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505 Korea
| |
Collapse
|
|
29
|
Current Surgical Strategies in the Management of Rectal Cancer. CURRENT COLORECTAL CANCER REPORTS 2019. [DOI: 10.1007/s11888-019-00428-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
|
30
|
Jeong SA, Park IJ, Hong SM, Bong JW, Choi HY, Seo JH, Kim HE, Lim SB, Yu CS, Kim JC. Does total regression of primary rectal cancer after preoperative chemoradiotherapy represent "no tumor" status? Ann Surg Treat Res 2019; 96:78-85. [PMID: 30746355 PMCID: PMC6358592 DOI: 10.4174/astr.2019.96.2.78] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 06/15/2018] [Accepted: 07/12/2018] [Indexed: 01/04/2023] Open
Abstract
Purpose Insistence that total regression of primary tumor would not represent long-term oncologic outcomes has been raised. Therefore, this study aimed to evaluate the outcomes of these patients after preoperative chemoradiotherapy (PCRT) and radical surgery and to evaluate the associated risk factors. Methods We included 189 patients with rectal cancer who showed total regression of the primary tumor after PCRT, followed by radical resection, between 2001 and 2012. Recurrence-free survival (RFS) was calculated using the Kaplan-Meier method, and the results were compared with 77 patients with Tis rectal cancer who received only radical resection. Factors associated with RFS were evaluated using Cox regression analysis. Results Sphincter-saving resection was performed for 146 patients (77.2%). Adjuvant chemotherapy was administered to 168 patients (88.9%). During the follow-up period, recurrence occurred in 17 patients (9%). The 5-year RFS was 91.3%, which was significantly lower than that of patients with Tis rectal cancer without PCRT (P = 0.005). In univariate analysis, preoperative CEA and histologic differentiation were associated with RFS. However, no factors were found to be associated with RFS. Conclusion RFS was lower in patients with total regression of primary rectal cancer after PCRT than in those with Tis rectal cancer without PCRT, and it would not be considered as the same entity with early rectal cancer or "disappeared tumor" status.
Collapse
Affiliation(s)
- Seong-A Jeong
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In Ja Park
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Mo Hong
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jun Woo Bong
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hye Yoon Choi
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Hyun Seo
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyong Eun Kim
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seok-Byung Lim
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang Sik Yu
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Cheon Kim
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| |
Collapse
|
|
31
|
Kokelaar RF, Jones H, Beynon J, Evans ME, Harris DA. Meta-analysis of the prognostic value of CpG island methylator phenotype in rectal cancer. Int J Colorectal Dis 2018; 33:995-1000. [PMID: 29926233 PMCID: PMC6060825 DOI: 10.1007/s00384-018-3108-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/14/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE The pathological and prognostic importance of CpG island methylator phenotype (CIMP) in rectal cancer, as a sub-population of colorectal cancer, is unknown. A meta-analysis was preformed to estimate the prognostic significance of CIMP in rectal cancer. METHODS A systematic search was performed of PubMed, Embase, MEDLINE, PubMed Central, and Cochrane electronic databases for articles pertaining to CIMP and rectal cancer. Articles were analysed and data extracted according to PRISMA standards. RESULTS Six studies including 1529 patients were included in the analysis. Following dichotomisation, the prevalence of CIMP-positive tumours was 10 to 57%, with a median of 12.5%. Meta-analysis demonstrated the pooled odds ratio for all-cause death for CIMP-positive tumours vs CIMP-negative tumours was 1.24 (95% CI 0.88-1.74). Z test for overall effect was 1.21 (p = 0.23). Heterogeneity between the studies was low (X2 5.96, df 5, p = 0.31, I2 = 16%). A total of 15 different loci were used for assessing CIMP across the studies, with a median of 6.5 loci (range 5-8). CONCLUSIONS No significant association between CIMP and poor outcomes in rectal cancer was demonstrated. There was a high degree of heterogeneity in CIMP assessment methodologies and in study populations. Rectal cancer datasets were frequently not extractable from larger colorectal cohorts, limiting analysis.
Collapse
Affiliation(s)
- R F Kokelaar
- ABMU Singleton Hospital, Sketty Lane, Swansea, Wales, SA2 8QA, UK.
| | - H Jones
- ABMU Singleton Hospital, Sketty Lane, Swansea, Wales, SA2 8QA, UK
| | - J Beynon
- ABMU Singleton Hospital, Sketty Lane, Swansea, Wales, SA2 8QA, UK
| | - M E Evans
- ABMU Singleton Hospital, Sketty Lane, Swansea, Wales, SA2 8QA, UK
| | - D A Harris
- ABMU Singleton Hospital, Sketty Lane, Swansea, Wales, SA2 8QA, UK
| |
Collapse
|
|
32
|
Jang JK, Lee JL, Park SH, Park HJ, Park IJ, Kim JH, Choi SH, Kim J, Yu CS, Kim JC. Magnetic resonance tumour regression grade and pathological correlates in patients with rectal cancer. Br J Surg 2018; 105:1671-1679. [PMID: 29893988 DOI: 10.1002/bjs.10898] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 04/15/2018] [Accepted: 05/03/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Evidence to support the specific use of magnetic resonance tumour regression grade (mrTRG) is inadequate. The aim of this study was to investigate the pathological characteristics of mrTRG after chemoradiotherapy (CRT) for rectal cancer and the implications for surgery. METHODS Patients undergoing long-course CRT (45-50 Gy plus a booster dose of 4-6 Gy) for mid or low rectal cancer (cT3-4 or cN+ without metastasis) between 2011 and 2015 who had post-CRT rectal MRI before surgery were included retrospectively. Three board-certified experienced radiologists assessed mrTRG. mrTRG was correlated with pathological tumour regression grade (pTRG), ypT and ypN. In a subgroup of patients with mrTRG1-2 and no tumour spread (such as nodal metastasis) on MRI, the projected rate of completion total mesorectal excision (TME) if they underwent transanal excision (TAE) and had a ypT status of ypT2 or higher was estimated, and recurrence-free survival was calculated according to the operation (TME or TAE) that patients had actually received. RESULTS Some 439 patients (290 men and 149 women of mean(s.d.) age 62·2(11·4) years) were analysed. The accuracy of mrTRG1 for predicting pTRG1 was 61 per cent (40 of 66), and that for ypT1 or less was 74 per cent (49 of 66). For mrTRG2, these values were 22·3 per cent (25 of 112) and 36·6 per cent (41 of 112) respectively. Patients with mrTRG1 and mrTRG2 without tumour spread were ypN+ in 3 per cent (1 of 29) and 16 per cent (8 of 50) respectively. Assuming mrTRG1 or mrTRG1-2 with no tumour spread on post-CRT MRI as the criteria for TAE, the projected completion TME rate was 26 per cent (11 of 43) and 41·0 per cent (41 of 100) respectively. For the 100 patients with mrTRG1-2 and no tumour spread, recurrence-free survival did not differ significantly between TME (79 patients) and TAE (21) (adjusted hazard ratio 1·86, 95 per cent c.i. 0·42 to 8·18). CONCLUSION Patients with mrTRG1 without tumour spread may be suitable for TAE.
Collapse
Affiliation(s)
- J K Jang
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Centre, Seoul, South Korea
| | - J L Lee
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Centre, Seoul, South Korea
| | - S H Park
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Centre, Seoul, South Korea
| | - H J Park
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Centre, Seoul, South Korea
| | - I J Park
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Centre, Seoul, South Korea
| | - J H Kim
- Department of Radiation Oncology, University of Ulsan College of Medicine, Asan Medical Centre, Seoul, South Korea
| | - S H Choi
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Centre, Seoul, South Korea
| | - J Kim
- Department of Pathology, University of Ulsan College of Medicine, Asan Medical Centre, Seoul, South Korea
| | - C S Yu
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Centre, Seoul, South Korea
| | - J C Kim
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Centre, Seoul, South Korea
| |
Collapse
|
|
33
|
Xiao Y, Xu D, Ju H, Yang C, Wang L, Wang J, Hazle JD, Wang D. Application value of biplane transrectal ultrasonography plus ultrasonic elastosonography and contrast-enhanced ultrasonography in preoperative T staging after neoadjuvant chemoradiotherapy for rectal cancer. Eur J Radiol 2018; 104:20-25. [PMID: 29857861 DOI: 10.1016/j.ejrad.2018.04.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 03/05/2018] [Accepted: 04/25/2018] [Indexed: 01/15/2023]
Abstract
PURPOSE To determine the accuracy of biplane transrectal ultrasonography (TRUS) plus ultrasonic elastosonography (UE) and contrast-enhanced ultrasonography (CEUS) in preoperative T staging after neoadjuvant chemoradiotherapy for rectal cancer. MATERIALS AND METHODS Fifty-three patients with advanced lower rectal cancer were examined before and after neoadjuvant chemoradiotherapy with use of TRUS plus UE and CEUS and were diagnosed as having T stage disease. We compared ultrasonic T stages before and after neoadjuvant chemoradiotherapy and analyzed any changes. Also, with postoperative pathological stages as the gold standard, we compared ultrasonic and pathological T stages and determined their consistency by the kappa statistic. RESULTS For patients with rectal cancer, ultrasonic T stages were lower after neoadjuvant chemoradiotherapy than before, with a statistically significant difference (P < 0.05). The posttreatment downstaging rate was 39.6% (21/53). A total of 84.9% received correct staging with use of biplane TRUS plus UE and CEUS in the evaluation of preoperative T staging after neoadjuvant chemoradiotherapy for rectal cancer, which was highly consistent with that of pathological staging (κ = 0.768, P < 0.05). Its sensitivities were 80.0%, 50.0%, 75.0%, 96.3%, and 100% in the diagnoses of stages T0 to T4 rectal cancers, respectively; the specificities were 95.4%, 97.9%, 95.1%, 88.5%, and 100% at stages T0 to T4, respectively. CONCLUSION Biplane TRUS plus UE and CEUS can be used to accurately perform preoperative T staging in rectal cancer after neoadjuvant chemoradiotherapy; in addition, this procedure well reflects changes in depth of rectal cancer invasion into the intestinal wall before and after neoadjuvant chemoradiotherapy. It is of great value in clinically evaluating the efficacy of neoadjuvant chemoradiotherapy, in selecting therapeutic regimens, and in avoiding overtreatment.
Collapse
Affiliation(s)
- Ying Xiao
- Taizhou Municipal Hospital, Department of Ultrasound, Eastern Road of Zhongshan, Taizhou, China.
| | - Dong Xu
- Zhejiang Cancer Hospital, Department of Ultrasound, Eastern Road of Banshan, Hangzhou, China; University of Texas MD Anderson Cancer Center, Department of Imaging Physics, Division of Diagnostic Imaging, Houston, USA.
| | - Haixing Ju
- Zhejiang Cancer Hospital, Department of Colorectal Surgery, Eastern Road of Banshan, Hangzhou, China.
| | - Chen Yang
- Zhejiang Cancer Hospital, Department of Ultrasound, Eastern Road of Banshan, Hangzhou, China.
| | - Liping Wang
- Zhejiang Cancer Hospital, Department of Ultrasound, Eastern Road of Banshan, Hangzhou, China.
| | - Jinming Wang
- Taizhou Municipal Hospital, Department of Pharmacy, Eastern Road of Zhongshan, Taizhou, China.
| | - John D Hazle
- University of Texas MD Anderson Cancer Center, Department of Imaging Physics, Division of Diagnostic Imaging, Houston, USA.
| | - Dongguo Wang
- Taizhou Municipal Hospital, Department of Medical laboratory, Eastern Road of Zhongshan, Taizhou, China.
| |
Collapse
|
|
34
|
Model predicting the ypN0 status after good response to chemoradiotherapy in rectal cancer. Am J Surg 2018; 216:438-443. [PMID: 29656991 DOI: 10.1016/j.amjsurg.2018.03.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 03/14/2018] [Accepted: 03/29/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND The purpose of this study was to identify the predictive factors for ypN0 status in tumors with good pathologic response to chemoradiotherapy (CRT). METHODS A retrospective chart review was conducted on patients at two tertiary cancer center who underwent rectal resection after good response to CRT between 2000 and 2013. RESULTS No preoperative treatment (oxaliplatin use, radiotherapy boost of 5,4 Gy, delay CRT-surgery) impacted on the ypN status. In the multivariate analysis, only a ypT<3 (HR 7.5 [2,9-19.5]) was significant and no lymphovascular invasion (HR 8,9 [1.6-49.8]) was limited to significance.The best model predicting the ypN0 status used only the ypT status<3. The major part (92.2%) of patients with ypT0-2 tumors had no LN invasion. CONCLUSION The risk of lymph node involvement metastases was only 7.8% for the patients with an ypT0-2 status. A fullthickness transanal resection coud be the futur treatment of these patients.
Collapse
|
|
35
|
Total Mesorectal Excision Versus Local Excision After Preoperative Chemoradiotherapy in Rectal Cancer With Lymph Node Metastasis: A Propensity Score-Matched Analysis. Int J Radiat Oncol Biol Phys 2018; 101:630-639. [PMID: 29678529 DOI: 10.1016/j.ijrobp.2018.02.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 02/05/2018] [Accepted: 02/21/2018] [Indexed: 12/21/2022]
Abstract
PURPOSE To determine whether local excision (LE) outcomes were comparable to total mesorectal excision (TME) outcomes in node-positive (cN+) rectal cancer patients who were good responders. METHODS AND MATERIALS This retrospective study included clinical T2-3 and cN+ low rectal cancer patient who received preoperative chemoradiotherapy (PCRT) followed by TME or LE. Clinical stage T1 or T4 tumors, upper-to-middle rectal tumors (>7 cm from anal verge), and synchronous distant metastases were excluded. Lymph nodes ≥5 mm in size were defined as tumor-positive, and patients with metastatic lymph nodes >20 mm in size were excluded. Preoperative chemoradiotherapy comprised radiation (50-50.4 Gy/25-28 fractions over 5 weeks) with 2 cycles of 5-fluorouracil or oral capecitabine. Propensity scores were computed from tumor and patient variables and used for 1-to-1 matched analysis. Local recurrence-free survival, disease-free survival, and overall survival were compared between the 2 matched groups. RESULTS Between January 2007 and December 2013, 563 and 55 patients underwent TME and LE, respectively. The median follow-up period was 54 months. In propensity score-matched analysis, 48 patients were included in each group. No statistical differences were observed in 3-year local recurrence-free survival (97.9% vs 97.9%, P = .994), 3-year disease-free survival (91.5% vs 91.4%, P = .968), or 3-year OS (93.7% vs 97.9%, P = .809) between the TME and LE groups. CONCLUSIONS In clinical N+ rectal cancer patients, oncologic outcomes of PCRT followed by LE were comparable to those of TME; this finding might be applicable only to those patients with good response in the primary tumor and small lymph node metastases.
Collapse
|
|
36
|
Stijns RCH, Tromp MSR, Hugen N, de Wilt JHW. Advances in organ preserving strategies in rectal cancer patients. Eur J Surg Oncol 2017; 44:209-219. [PMID: 29275912 DOI: 10.1016/j.ejso.2017.11.024] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 10/23/2017] [Accepted: 11/19/2017] [Indexed: 02/06/2023] Open
Abstract
Treatment of rectal cancer patients has been subjected to change over the past thirty years. Total mesorectal excision is considered the cornerstone of rectal cancer treatment, but is also associated with significant morbidity resulting in an impaired quality of life. The addition of neoadjuvant chemoradiotherapy to surgery has shown to improve survival and local control and may lead to a partial or even complete response (CR). This raises questions regarding the necessity for subsequent radical surgery. After careful patient selection local excision and wait-and-see approaches are explored, aiming to improve quality of life without compromising oncological outcome. A multimodality diagnostic approach for optimal staging is crucial in determining the appropriate neoadjuvant treatment regimen. Adequate endoscopic restaging of rectal tumours after multimodality treatment will aid in selecting patients who are eligible for an organ preserving approach. The role and accuracy of imaging in the detection of the primary tumour, residual rectal cancer or local recurrence seems vital. Alternative neoadjuvant regimens are currently explored to increase the rate of clinical CRs, which may support organ preserving approaches. This review aims to generate insight into the advances in diagnostics and treatment modalities in all stages of rectal cancer and will highlight future studies that may support further implementation of organ preservation treatment in rectal cancer.
Collapse
Affiliation(s)
- Rutger C H Stijns
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - Mike-Stephen R Tromp
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Niek Hugen
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| |
Collapse
|
|
37
|
São Julião GP, Celentano JP, Alexandre FA, Vailati BB. Local Excision and Endoscopic Resections for Early Rectal Cancer. Clin Colon Rectal Surg 2017; 30:313-323. [PMID: 29184466 DOI: 10.1055/s-0037-1606108] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Radical surgery is considered as the standard treatment for rectal cancer. Transanal local excision has been considered an interesting alternative for the management of selected patients with rectal cancers for many decades. Different approaches had been considered for local excision, from endoscopic submucosal dissection to resections using platforms, such as transanal endoscopic microsurgery or transanal minimally invasive surgery. Identifying the ideal candidate for this approach is crucial, as a local failure after local excision is associated with poor outcomes, even for an initial early rectal tumor. In this article, the diagnostic tools and criteria to select patients for local excision, the different modalities used, and the outcomes are discussed.
Collapse
|
|
38
|
São Julião GP, Habr-Gama A, Vailati BB, Aguilar PB, Sabbaga J, Araújo SEA, Mattacheo A, Alexandre FA, Fernandez LM, Gomes DB, Gama-Rodrigues J, Perez RO. Is neoadjuvant chemoradiation with dose-escalation and consolidation chemotherapy sufficient to increase surgery-free and distant metastases-free survival in baseline cT3 rectal cancer? Eur J Surg Oncol 2017; 44:93-99. [PMID: 29217398 DOI: 10.1016/j.ejso.2017.11.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 10/10/2017] [Accepted: 11/16/2017] [Indexed: 10/18/2022] Open
Abstract
Patients with cT3 rectal cancer are less likely to develop complete response to neoadjuvant chemoradiation (nCRT) and still face significant risk for systemic relapse. In this setting, radiation (RT) dose-escalation and consolidation chemotherapy in "extended" nCRT regimens have been suggested to improve primary tumor response and decrease the risks of systemic recurrences. For these reasons we compared surgery-free and distant-metastases free survival among cT3 patients undergoing standard or extended nCRT. METHODS Patients with distal and non-metastatic T3 rectal cancer managed by nCRT were retrospectively reviewed. Patients undergoing standard CRT (50.4 Gy and 2 cycles of 5FU-based chemotherapy) were compared to those undergoing extended CRT (54 Gy and 6 cycles of 5FU-based chemotherapy). Patients were assessed for tumor response at 8-10 weeks. Patients with complete clinical response (cCR) underwent organ-preservation strategy (Watch & Wait). Patients were referred to salvage surgery in the event of local recurrence during follow-up. Cox's logistic regression was performed to identify independent features associated with improved surgery-free survival after cCR and distant-metastases-free survival. RESULTS 155 patients underwent standard and 66 patients extended CRT. Patients undergoing extended CRT were more likely to harbor larger initial tumor size (p = 0.04), baseline nodal metastases (cN+; p < 0.001) and higher tumor location (p = 0.02). Cox-regression analysis revealed that the type of nCRT regimen was not independently associated with distinct surgery-free survival after cCR or distant-metastases-free survival (p > 0.05). CONCLUSIONS Dose-escalation and consolidation chemotherapy are insufficient to increase long-term surgery-free survival among cT3 rectal cancer patients and provides no advantage in distant metastases-free survival.
Collapse
Affiliation(s)
| | - Angelita Habr-Gama
- Angelita & Joaquim Gama Institute, Rua Manoel da Nobrega, 1564, Sao Paulo, SP, 04001-005, Brazil
| | - Bruna Borba Vailati
- Angelita & Joaquim Gama Institute, Rua Manoel da Nobrega, 1564, Sao Paulo, SP, 04001-005, Brazil
| | - Patricia Bailão Aguilar
- Hospital Alemão Oswaldo Cruz - Radiation Oncology, Rua Joao Juliao, 331, Sao Paulo, SP, 01323-020, Brazil
| | - Jorge Sabbaga
- Centro de Oncologia Molecular - Hospital Sirio-Libanês, Rua Dona Adma Jafet, 91, Sao Paulo, SP, 01308-050, Brazil
| | - Sérgio Eduardo Alonso Araújo
- University of São Paulo School of Medicine, Colorectal Surgery Division, Av. Dr. Arnaldo, 455, Sao Paulo, SP, 01246-903, Brazil; Hospital Israelita Albert Einstein, Av. Albert Einstein, 627, Sao Paulo, SP, 05652-900, Brazil
| | - Adrian Mattacheo
- Angelita & Joaquim Gama Institute, Rua Manoel da Nobrega, 1564, Sao Paulo, SP, 04001-005, Brazil
| | - Flavia Andrea Alexandre
- Angelita & Joaquim Gama Institute, Rua Manoel da Nobrega, 1564, Sao Paulo, SP, 04001-005, Brazil
| | - Laura Melina Fernandez
- Angelita & Joaquim Gama Institute, Rua Manoel da Nobrega, 1564, Sao Paulo, SP, 04001-005, Brazil
| | - Diogo Bugano Gomes
- Hospital Israelita Albert Einstein, Av. Albert Einstein, 627, Sao Paulo, SP, 05652-900, Brazil
| | - Joaquim Gama-Rodrigues
- Angelita & Joaquim Gama Institute, Rua Manoel da Nobrega, 1564, Sao Paulo, SP, 04001-005, Brazil
| | - Rodrigo Oliva Perez
- Angelita & Joaquim Gama Institute, Rua Manoel da Nobrega, 1564, Sao Paulo, SP, 04001-005, Brazil; University of São Paulo School of Medicine, Colorectal Surgery Division, Av. Dr. Arnaldo, 455, Sao Paulo, SP, 01246-903, Brazil; Ludwig Institute for Cancer Research São Paulo Branch, Rua Dona Adma Jafet, 91, Sao Paulo, SP, 01308-050, Brazil.
| |
Collapse
|
|
39
|
Sohn DK, Han KS, Kim BC, Hong CW, Chang HJ, Baek JY, Kim MJ, Park SC, Oh JH, Kim DY. Endoscopic assessment of tumor regression after preoperative chemoradiotherapy as a prognostic marker in locally advanced rectal cancer. Surg Oncol 2017; 26:453-459. [PMID: 29113665 DOI: 10.1016/j.suronc.2017.09.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 08/24/2017] [Accepted: 09/09/2017] [Indexed: 12/12/2022]
Abstract
PURPOSE This study was designed to evaluate tumor regression endoscopic criteria for predicting the post-chemoradiotherapy (CRT) prognosis of patients with locally advanced rectal cancer. MATERIAL AND METHODS A total of 425 patients with rectal cancer who received radical surgery after CRT were included in this study. All patients were divided into two groups according to post-CRT preoperative endoscopic findings: 1) good response (E-GR): scar, telangiectasia, or erythema; 2) minimal or no response (E-MR): nodules, ulcers, strictures, or remnant tumor. Cox proportional hazard models were used to analyze the effect of preoperative clinicopathological variables on disease-free survival (DFS) and overall survival (OS). RESULTS The independent prognostic factors for DFS were tumor location less than 5 cm from anal verge (hazard ratio [HR] 1.92, 95% confidence interval [CI] 1.27 to 2.88), pre-CRT carcinoembryonic antigen (CEA) > 5 ng/mL (HR 2.10, 95% CI 1.41 to 3.14), histologic high grade (HR 2.96, 95% CI 1.51 to 5.81), and E-GR (HR 0.26, 95% CI 0.08 to 0.83). The independent prognostic factors for OS were age over 65 years, tumor location, pre-CRT CEA, histologic grade, and E-GR (HR 0.13, 95% CI 0.02 to 0.99). CONCLUSIONS Post-CRT endoscopic findings were predictors of prognosis in patients with rectal cancer. If endoscopic findings are simultaneously used with certain preoperative prognostic factors, rectal cancer patients will potentially have more treatment options.
Collapse
Affiliation(s)
- Dae Kyung Sohn
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Kyung Su Han
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Byung Chang Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Chang Won Hong
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Hee Jin Chang
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Ji Yeon Baek
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Min Ju Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Sung Chan Park
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Jae Hwan Oh
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Dae Yong Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, South Korea.
| |
Collapse
|
|
40
|
Lorenzon L, Parini D, Rega D, Mellano A, Vigorita V, Biondi A, Jaminez-Rosellon R, Scheiterle M, Giannini I, Gallo G, Marino G, Turati L, Marsanic P, De Franco L, Marano L, De Luca R. Long-term outcomes in ypT0 rectal cancers: An international multi-centric investigation on behalf of Italian Society of Surgical Oncology Young Board (YSICO). EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2017; 43:1472-1480. [PMID: 28571778 DOI: 10.1016/j.ejso.2017.04.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 04/12/2017] [Accepted: 04/30/2017] [Indexed: 12/26/2022]
Abstract
AIM To investigate the outcome and pattern of survivals of rectal cancer patients presenting a complete or nearly complete tumor response after neo-adjuvant treatment. METHODS Young surgeons <40 years old affiliated to the Italian Society of Surgical Oncology (YSICO) from 13 referral centers for colorectal cancer treatment, were invited to participate a retrospective study. Records from patients treated from 2005 to 2015 with a pathological diagnosis of ypT0/ypTis were retrieved and pooled in a common data-base for statistical purposes. All clinical and pathological variables were reviewed. Univariate and multivariate analyses were conducted with the end-point of survivals. RESULTS Two hundreds and sixty-one patients were analyzed including 237 ypT0 and 24 ypTis. Nodal positive patients were 8.7%. More than sixty-six percent of the patients did not perform adjuvant chemotherapy, with a statistical difference comparing N0 versus N+ patients (66.8% vs 40.9%, p 0.02). Mean follow-up was of 47.6 months. Twenty-two relapses were observed, 91.6% at a distant site. The mean time to recurrence was of 35.3 months. On univariate analysis, the use of adjuvant chemotherapy correlated with better OS exclusively in ypT0N + patients and not in ypT0N0. Univariate and multivariate analyses documented nodal positivity as the only prognostic factor correlated with a worse OS. CONCLUSION Recurrences were mostly diagnosed at a distant site and within the third year of follow-up. Nodal positivity was the only variable independently correlated with a worse OS. Univariate analysis documented a benefit for the use of adjuvant chemotherapy treatment exclusively in ypT0N + rectal cancers.
Collapse
Affiliation(s)
- L Lorenzon
- Surgical and Medical Department of Translational Medicine, Sant'Andrea Hospital, Faculty of Medicine and Psychology, Sapienza University of Rome, Italy.
| | - D Parini
- General Surgery Unit, Santa Maria della Misericordia Hospital, Rovigo, Italy
| | - D Rega
- Colorectal Surgical Oncology, Istituto Nazionale per lo Studio e la Cura dei Tumori Fondazione Giovanni Pascale IRCCS, Naples, Italy
| | - A Mellano
- Surgical Oncology Unit, Candiolo Cancer Institute - IRCCS - Candiolo Cancer Institute - IRCCS, Turin, Italy
| | - V Vigorita
- Unit of Coloproctology, Department of General and Digestive Surgery, University Hospital Complex of Vigo Alvaro Conquieiro Hospital, Vigo, Spain
| | - A Biondi
- General Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli, Catholic University, Rome, Italy
| | | | - M Scheiterle
- Department of Medicine, Surgery and Neurosciences - Unit of General Surgery and Surgical Oncology, University of Siena, Italy
| | - I Giannini
- General Surgery Unit, Policlinico Bari, Italy
| | - G Gallo
- Coloproctology Unit, Santa Rita Clinic, Vercelli, Italy; Department of Medical and Surgical Sciences, University of Catanzaro, Italy
| | - G Marino
- Surgery Unit, IRCCS CROB Regional Oncologic Center, Rionero in Vulture, Potenza, Italy
| | - L Turati
- Surgical Oncology Unit, Treviglio Hospital, ASST Bergamo Ovest, Italy
| | - P Marsanic
- Surgical Oncology Unit, Candiolo Cancer Institute - IRCCS - Candiolo Cancer Institute - IRCCS, Turin, Italy
| | - L De Franco
- Department of Medicine, Surgery and Neurosciences - Unit of General Surgery and Surgical Oncology, University of Siena, Italy
| | - L Marano
- Multidisciplinary Robotic Surgery Unit, "San Matteo degli Infermi Hospital" - ASL Umbria 2, Spoleto, Perugia, Italy
| | - R De Luca
- Department of Surgical Oncology, National Cancer Research Centre, Istituto Tumori Giovanni Paolo II, Bari, Italy
| |
Collapse
|
|
41
|
São Julião GP, Habr-Gama A, Vailati BB, Araujo SEA, Fernandez LM, Perez RO. New Strategies in Rectal Cancer. Surg Clin North Am 2017; 97:587-604. [PMID: 28501249 DOI: 10.1016/j.suc.2017.01.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In recent years, our understanding of rectal cancer has improved, including how locally advanced disease responds to chemotherapy and radiation. This has led to new innovations and advances in the treatment of rectal cancer, which includes organ-preserving strategies for responsive disease, and minimally invasive approaces for the performance of total mesorectal excision/protectomyh for persistently advanced disease. This article discusses new strategies for rectal cancer therapy, including Watch and Wait, local excision, minimally invasive proctectomy, and transanal total mesorectal excision particularly in the setting of preoperative multimodality treatment.
Collapse
Affiliation(s)
- Guilherme Pagin São Julião
- Department of Colorectal Surgery, Angelita & Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo 04001, Brazil
| | - Angelita Habr-Gama
- Department of Colorectal Surgery, Angelita & Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo 04001, Brazil
| | - Bruna Borba Vailati
- Department of Colorectal Surgery, Angelita & Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo 04001, Brazil
| | - Sergio Eduardo Alonso Araujo
- Department of Colorectal Surgery, Hospital Israelita Albert Einstein, Avenida Albert Einstein 627, Suite 219, São Paulo 05652, Brazil
| | - Laura Melina Fernandez
- Department of Colorectal Surgery, Angelita & Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo 04001, Brazil
| | - Rodrigo Oliva Perez
- Department of Colorectal Surgery, Angelita & Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo 04001, Brazil.
| |
Collapse
|
|
42
|
Li N, Dou L, Zhang Y, Jin J, Wang G, Xiao Q, Li Y, Wang X, Ren H, Fang H, Wang W, Wang S, Liu Y, Song Y. Use of sequential endorectal US to predict the tumor response of preoperative chemoradiotherapy in rectal cancer. Gastrointest Endosc 2017; 85:669-674. [PMID: 27354104 DOI: 10.1016/j.gie.2016.06.042] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 06/12/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Accurate prediction of the response to preoperative chemoradiotherapy (CRT) potentially assists in the individualized selection of treatment. Endorectal US (ERUS) is widely used for the pretreatment staging of rectal cancer, but its use for preoperatively predicting the effects of CRT is not well evaluated because of the inflammation, necrosis, and fibrosis induced by CRT. This study assessed the value of sequential ERUS in predicting the efficacy of preoperative CRT for locally advanced rectal cancer. METHODS Forty-one patients with clinical stage II/III rectal adenocarcinoma were enrolled prospectively. Radiotherapy was delivered to the pelvis with concurrent chemotherapy of capecitabine and oxaliplatin. Total mesorectal excision was performed 6 to 8 weeks later. EUS measurements of primary tumor maximum diameter were performed before (ERUS1), during (ERUS2), and 6 to 8 weeks after (ERUS3) CRT, and the ratios of these were calculated. Correlations between ERUS values, tumor regression grade (TRG), T down-staging rate, and pathologic complete response (pCR) rate were assessed, and survival was analyzed. RESULTS There was no significant correlation between ERUS2/ERUS1 and TRG. The value of ERUS3/ERUS1 correlated with pCR rate and TRG but not T down-staging rate. An ERUS3 value of 6.3 mm and ERUS3/ERUS1 of 52% were used as the cut-off for predicting pCR, and patients were divided into good and poor prognosis groups. Although not statistically significant, 3-year recurrence and survival rates of the good prognosis group were better than those of the poor prognosis group. CONCLUSIONS Sequential ERUS may predict therapeutic efficacy of preoperative CRT for locally advanced rectal cancer. (Clinical trial registration number: NCT01582750.).
Collapse
Affiliation(s)
- Ning Li
- Department of Radiotherapy, Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Lizhou Dou
- Department of Endoscopy, Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yueming Zhang
- Department of Endoscopy, Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jing Jin
- Department of Radiotherapy, Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Guiqi Wang
- Department of Endoscopy, Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Qin Xiao
- First Chest Radiotherapy Department, Hunan Cancer Hospital, Hunan, China
| | - Yexiong Li
- Department of Radiotherapy, Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xin Wang
- Department of Radiotherapy, Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Hua Ren
- Department of Radiotherapy, Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Hui Fang
- Department of Radiotherapy, Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Weihu Wang
- Department of Radiotherapy, Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Shulian Wang
- Department of Radiotherapy, Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yueping Liu
- Department of Radiotherapy, Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yongwen Song
- Department of Radiotherapy, Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Beijing, China
| |
Collapse
|
|
43
|
Abstract
BACKGROUND Recent evidence shows that the majority of rectal cancers demonstrate occult tumor scatter after neoadjuvant chemoradiotherapy that can extend for several centimeters under adjacent normal-appearing mucosa beside the residual mucosal abnormality or scar. OBJECTIVE This systematic review aimed to determine all of the published selection criteria and technical descriptions for local excision to date with regard to this phenomenon. DATA SOURCES PubMed, MEDLINE, and Embase were searched using the following key words: rectal cancer, local excision, radiotherapy, and neoadjuvant. STUDY SELECTION Studies that assessed local excision of rectal cancer after neoadjuvant chemoradiotherapy were included. Duplicate series were excluded from final analysis. INTERVENTION All of the data points were tabulated and analyzed using Microsoft Excel. MAIN OUTCOME MEASURES Criteria for patient selection, surgical technique, clinical restaging, pathologic assessment, and indications for completion surgery were analyzed. RESULTS After exclusions, data from 25 studies that in total evaluated local excision in 1001 patients were included. Compared with the single accepted technique of total mesorectal excision, described techniques for local excision after neoadjuvant therapy demonstrate significant variability in many critical technical issues, such as marking/tattooing original tumor margins before neoadjuvant therapy, using pretreatment tumor size/stage as exclusion criteria, and specifically stating lateral excision margins. Where detailed, the majority of local recurrences occurred in patients with clear pathological margins, yet significant variation existed for pathological assessment and reporting, with few studies detailing R status and some not reporting margin status at all. Significant variability also existed for adverse tumor features that mandated completion surgery, and, importantly, many series describe patients refusing completion surgery where indicated. LIMITATIONS We were unable to perform meta-analysis because studies lacked sufficient methodologic homogeneity to synthesize. CONCLUSIONS The observations from this study prompt additional study, standardization of technique, and cautious use of local excision of rectal cancer in the setting of neoadjuvant chemoradiotherapy.
Collapse
|
|
44
|
[Colorectal cancer in the elderly. Surgical treatment, chemotherapy, and contribution from geriatrics]. Rev Esp Geriatr Gerontol 2017; 52:261-270. [PMID: 28126268 DOI: 10.1016/j.regg.2016.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 10/14/2016] [Indexed: 12/12/2022]
Abstract
Age is the biggest risk factor for colorectal cancer, with 70% of the cases in patients over 70 years old. For this reason, a review is presented on the surgical treatment and chemotherapy of cancer of colon and rectum in the elderly. A search was performed in PubMed, including words such as elderly, surgery, colorectal cancer, chemotherapy, radiotherapy, and oncogeriatrics, and review articles and originals on treatment of colorectal cancer in the elderly were selected. A narrative form was developed from the latest evidence with the results obtained on the treatment of this pathology. Although the treatment of colorectal cancer is standardised, a prior comprehensive geriatric assessment is required in the case of the elderly, before deciding the type of treatment in order to offer these robust elderly-standardised guidelines for the robust elderly and adapt them for use in fragile patients.
Collapse
|
|
45
|
Current Controversies in Transanal Surgery for Rectal Cancer. Surg Laparosc Endosc Percutan Tech 2016; 26:431-438. [DOI: 10.1097/sle.0000000000000357] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
|
46
|
A Systematic Review of Local Excision After Neoadjuvant Therapy for Rectal Cancer: Are ypT0 Tumors the Limit? Dis Colon Rectum 2016; 59:984-97. [PMID: 27602930 DOI: 10.1097/dcr.0000000000000613] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Neoadjuvant therapy reduces local recurrence after radical surgery for rectal cancer with complete pathological response in 15% to 25% of patients. Radical surgery is associated with significant morbidity that may be avoided by local excision in selected cases. OBJECTIVE This systematic review aimed to determine the oncological outcomes and morbidity of local excision after neoadjuvant therapy. DATA SOURCES Data sources included MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials databases. STUDY SELECTION A systematic search of the databases using validated terms for rectal cancer, neoadjuvant therapy, and local excision was conducted. INTERVENTIONS Neoadjuvant therapy and local excision were the included interventions. MAIN OUTCOME MEASURES Pooled local recurrence, median survival, and pooled morbidity were measured. RESULTS Twenty unique studies were included (14 cohort, 5 comparative cohort, and 1 randomized controlled trial), describing 1068 patients. Patient choice, prohibitive comorbidity, good clinical response, and early stage disease were the most frequent indications for local excision. Pretreatment T2 and T3 tumors accounted for 46.4% and 30.7% of cases. Long-course treatment was administered in all of the studies, except to a cohort of 64 patients who received short-course radiotherapy. Pooled complete clinical response was 45.8% (95% CI, 31.4%-60.5%), and pooled complete pathological response was 44.2% (95% CI, 36.4%-52.0%). Median follow-up was 54 months (range, 12-81 months). ypT0 tumors had a pooled local recurrence rate of 4.0% (95% CI, 1.9%-6.9%) and a median disease-free survival rate of 95.0% (95% CI, 87.4%-100%). Pooled local recurrence and median disease-free survival rates for ypT1 tumors or higher were 21.9% (95% CI, 15.9%-28.5%) and 68.0% (58.3%-69.0%). Pooled incidence of complications was 23.2% (95% CI, 15.7%-31.7%), with suture-line dehiscence reported in 9.9% (95% CI, 4.8%-16.7%). LIMITATIONS Limitations included study quality, high risk of selection bias and detection bias in study designs, and limited sample sizes. CONCLUSIONS Local excision after neoadjuvant therapy should only be considered a curative treatment if complete pathological response is obtained. Given the high rate of local recurrence among incomplete responders, future studies should focus on predicting patients who will achieve complete pathological response.
Collapse
|
|
47
|
Martens MH, Maas M, Heijnen LA, Lambregts DMJ, Leijtens JWA, Stassen LPS, Breukink SO, Hoff C, Belgers EJ, Melenhorst J, Jansen R, Buijsen J, Hoofwijk TGM, Beets-Tan RGH, Beets GL. Long-term Outcome of an Organ Preservation Program After Neoadjuvant Treatment for Rectal Cancer. J Natl Cancer Inst 2016; 108:djw171. [PMID: 27509881 DOI: 10.1093/jnci/djw171] [Citation(s) in RCA: 265] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 06/10/2016] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The aim of this study was to establish the oncological and functional results of organ preservation with a watch-and-wait approach (W&W) and selective transanal endoscopic microsurgery (TEM) in patients with a clinical complete or near-complete response (cCR) after neoadjuvant chemoradiation for rectal cancer. METHODS Between 2004 and 2014, organ preservation was offered if response assessment with digital rectal examination, endoscopy, and MRI showed (near) cCR. Watch-and-wait was offered for cCR, and two options were offered for near cCR: TEM or reassessment after three months. Follow-up included endoscopy and MRIs every three months during the first year, and every six months thereafter. Long-term outcome was assessed with Kaplan-Meier curves. Functional outcome was assessed with colostomy-free survival and Vaizey incontinence score (0 = perfect continence, 24 = totally incontinent). RESULTS One hundred patients were included, with median follow-up of 41.1 months. Sixty-one had cCR at initial response assessment. Thirty-nine had near cCR, of whom 24 developed cCR at the second assessment and 15 patients underwent TEM (9 ypT0, 1 ypT1, 5 ypT2). Fifteen patients developed a local regrowth (12 luminal, 3 nodal), all salvageable and within 25 months. Five patients developed metastases, and five patients died. Three-year overall survival was 96.6% (95% confidence interval [CI] = 89.9% to 98.9%), distant metastasis-free survival was 96.8% (95% CI = 90.4% to 99.0%), local regrowth-free survival was 84.6% (95% CI = 75.8% to 90.5%), and disease-free survival was 80.6% (95% CI = 70.9% to 87.4%). Colostomy-free survival was 94.8% (95% CI = 88.0% to 97.8%), with a good continence after watch-and-wait (Vaizey = 3.4, SD = 3.9) and moderate after TEM (Vaizey = 9.7, SD = 5.1). CONCLUSIONS Organ preservation appears oncologically safe for selected rectal cancer patients with a cCR or near cCR after neoadjuvant chemoradiation when applying strict selection criteria and frequent follow-up, including endoscopy and MRI. The low colostomy rate and the good long-term functional outcome warrant discussing this option with the patient as an alternative to major surgery.
Collapse
Affiliation(s)
- Milou H Martens
- Department of Surgery (MHM, LAH, LPSS, SOB, JM), Department of Radiology (MHM, MM, LAH, DMJL), GROW School for Oncology and Developmental Biology (MHM, LAH, JB, RGHBT, GLB), and Department of Medical Oncology (RJ), Maastricht University Medical Center, Maastricht, the Netherlands; Department of Surgery, Laurentius Hospital, Roermond, the Netherlands (JWAL); Department of Surgery, Medical Center Leeuwarden, Leeuwarden, the Netherlands (CH); Department of Surgery, Zuyderland Medical Center, Sittard-Geleen and Heerlen, the Netherlands (EJB, TGMH); Department of Radiotherapy, Maastro Radiation Clinic, Maastricht, the Netherlands (JB); Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands (MM, DMJL, RGHBT); Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands (GLB)
| | - Monique Maas
- Department of Surgery (MHM, LAH, LPSS, SOB, JM), Department of Radiology (MHM, MM, LAH, DMJL), GROW School for Oncology and Developmental Biology (MHM, LAH, JB, RGHBT, GLB), and Department of Medical Oncology (RJ), Maastricht University Medical Center, Maastricht, the Netherlands; Department of Surgery, Laurentius Hospital, Roermond, the Netherlands (JWAL); Department of Surgery, Medical Center Leeuwarden, Leeuwarden, the Netherlands (CH); Department of Surgery, Zuyderland Medical Center, Sittard-Geleen and Heerlen, the Netherlands (EJB, TGMH); Department of Radiotherapy, Maastro Radiation Clinic, Maastricht, the Netherlands (JB); Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands (MM, DMJL, RGHBT); Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands (GLB)
| | - Luc A Heijnen
- Department of Surgery (MHM, LAH, LPSS, SOB, JM), Department of Radiology (MHM, MM, LAH, DMJL), GROW School for Oncology and Developmental Biology (MHM, LAH, JB, RGHBT, GLB), and Department of Medical Oncology (RJ), Maastricht University Medical Center, Maastricht, the Netherlands; Department of Surgery, Laurentius Hospital, Roermond, the Netherlands (JWAL); Department of Surgery, Medical Center Leeuwarden, Leeuwarden, the Netherlands (CH); Department of Surgery, Zuyderland Medical Center, Sittard-Geleen and Heerlen, the Netherlands (EJB, TGMH); Department of Radiotherapy, Maastro Radiation Clinic, Maastricht, the Netherlands (JB); Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands (MM, DMJL, RGHBT); Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands (GLB)
| | - Doenja M J Lambregts
- Department of Surgery (MHM, LAH, LPSS, SOB, JM), Department of Radiology (MHM, MM, LAH, DMJL), GROW School for Oncology and Developmental Biology (MHM, LAH, JB, RGHBT, GLB), and Department of Medical Oncology (RJ), Maastricht University Medical Center, Maastricht, the Netherlands; Department of Surgery, Laurentius Hospital, Roermond, the Netherlands (JWAL); Department of Surgery, Medical Center Leeuwarden, Leeuwarden, the Netherlands (CH); Department of Surgery, Zuyderland Medical Center, Sittard-Geleen and Heerlen, the Netherlands (EJB, TGMH); Department of Radiotherapy, Maastro Radiation Clinic, Maastricht, the Netherlands (JB); Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands (MM, DMJL, RGHBT); Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands (GLB)
| | - Jeroen W A Leijtens
- Department of Surgery (MHM, LAH, LPSS, SOB, JM), Department of Radiology (MHM, MM, LAH, DMJL), GROW School for Oncology and Developmental Biology (MHM, LAH, JB, RGHBT, GLB), and Department of Medical Oncology (RJ), Maastricht University Medical Center, Maastricht, the Netherlands; Department of Surgery, Laurentius Hospital, Roermond, the Netherlands (JWAL); Department of Surgery, Medical Center Leeuwarden, Leeuwarden, the Netherlands (CH); Department of Surgery, Zuyderland Medical Center, Sittard-Geleen and Heerlen, the Netherlands (EJB, TGMH); Department of Radiotherapy, Maastro Radiation Clinic, Maastricht, the Netherlands (JB); Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands (MM, DMJL, RGHBT); Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands (GLB)
| | - Laurents P S Stassen
- Department of Surgery (MHM, LAH, LPSS, SOB, JM), Department of Radiology (MHM, MM, LAH, DMJL), GROW School for Oncology and Developmental Biology (MHM, LAH, JB, RGHBT, GLB), and Department of Medical Oncology (RJ), Maastricht University Medical Center, Maastricht, the Netherlands; Department of Surgery, Laurentius Hospital, Roermond, the Netherlands (JWAL); Department of Surgery, Medical Center Leeuwarden, Leeuwarden, the Netherlands (CH); Department of Surgery, Zuyderland Medical Center, Sittard-Geleen and Heerlen, the Netherlands (EJB, TGMH); Department of Radiotherapy, Maastro Radiation Clinic, Maastricht, the Netherlands (JB); Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands (MM, DMJL, RGHBT); Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands (GLB)
| | - Stephanie O Breukink
- Department of Surgery (MHM, LAH, LPSS, SOB, JM), Department of Radiology (MHM, MM, LAH, DMJL), GROW School for Oncology and Developmental Biology (MHM, LAH, JB, RGHBT, GLB), and Department of Medical Oncology (RJ), Maastricht University Medical Center, Maastricht, the Netherlands; Department of Surgery, Laurentius Hospital, Roermond, the Netherlands (JWAL); Department of Surgery, Medical Center Leeuwarden, Leeuwarden, the Netherlands (CH); Department of Surgery, Zuyderland Medical Center, Sittard-Geleen and Heerlen, the Netherlands (EJB, TGMH); Department of Radiotherapy, Maastro Radiation Clinic, Maastricht, the Netherlands (JB); Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands (MM, DMJL, RGHBT); Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands (GLB)
| | - Christiaan Hoff
- Department of Surgery (MHM, LAH, LPSS, SOB, JM), Department of Radiology (MHM, MM, LAH, DMJL), GROW School for Oncology and Developmental Biology (MHM, LAH, JB, RGHBT, GLB), and Department of Medical Oncology (RJ), Maastricht University Medical Center, Maastricht, the Netherlands; Department of Surgery, Laurentius Hospital, Roermond, the Netherlands (JWAL); Department of Surgery, Medical Center Leeuwarden, Leeuwarden, the Netherlands (CH); Department of Surgery, Zuyderland Medical Center, Sittard-Geleen and Heerlen, the Netherlands (EJB, TGMH); Department of Radiotherapy, Maastro Radiation Clinic, Maastricht, the Netherlands (JB); Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands (MM, DMJL, RGHBT); Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands (GLB)
| | - Eric J Belgers
- Department of Surgery (MHM, LAH, LPSS, SOB, JM), Department of Radiology (MHM, MM, LAH, DMJL), GROW School for Oncology and Developmental Biology (MHM, LAH, JB, RGHBT, GLB), and Department of Medical Oncology (RJ), Maastricht University Medical Center, Maastricht, the Netherlands; Department of Surgery, Laurentius Hospital, Roermond, the Netherlands (JWAL); Department of Surgery, Medical Center Leeuwarden, Leeuwarden, the Netherlands (CH); Department of Surgery, Zuyderland Medical Center, Sittard-Geleen and Heerlen, the Netherlands (EJB, TGMH); Department of Radiotherapy, Maastro Radiation Clinic, Maastricht, the Netherlands (JB); Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands (MM, DMJL, RGHBT); Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands (GLB)
| | - Jarno Melenhorst
- Department of Surgery (MHM, LAH, LPSS, SOB, JM), Department of Radiology (MHM, MM, LAH, DMJL), GROW School for Oncology and Developmental Biology (MHM, LAH, JB, RGHBT, GLB), and Department of Medical Oncology (RJ), Maastricht University Medical Center, Maastricht, the Netherlands; Department of Surgery, Laurentius Hospital, Roermond, the Netherlands (JWAL); Department of Surgery, Medical Center Leeuwarden, Leeuwarden, the Netherlands (CH); Department of Surgery, Zuyderland Medical Center, Sittard-Geleen and Heerlen, the Netherlands (EJB, TGMH); Department of Radiotherapy, Maastro Radiation Clinic, Maastricht, the Netherlands (JB); Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands (MM, DMJL, RGHBT); Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands (GLB)
| | - Rob Jansen
- Department of Surgery (MHM, LAH, LPSS, SOB, JM), Department of Radiology (MHM, MM, LAH, DMJL), GROW School for Oncology and Developmental Biology (MHM, LAH, JB, RGHBT, GLB), and Department of Medical Oncology (RJ), Maastricht University Medical Center, Maastricht, the Netherlands; Department of Surgery, Laurentius Hospital, Roermond, the Netherlands (JWAL); Department of Surgery, Medical Center Leeuwarden, Leeuwarden, the Netherlands (CH); Department of Surgery, Zuyderland Medical Center, Sittard-Geleen and Heerlen, the Netherlands (EJB, TGMH); Department of Radiotherapy, Maastro Radiation Clinic, Maastricht, the Netherlands (JB); Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands (MM, DMJL, RGHBT); Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands (GLB)
| | - Jeroen Buijsen
- Department of Surgery (MHM, LAH, LPSS, SOB, JM), Department of Radiology (MHM, MM, LAH, DMJL), GROW School for Oncology and Developmental Biology (MHM, LAH, JB, RGHBT, GLB), and Department of Medical Oncology (RJ), Maastricht University Medical Center, Maastricht, the Netherlands; Department of Surgery, Laurentius Hospital, Roermond, the Netherlands (JWAL); Department of Surgery, Medical Center Leeuwarden, Leeuwarden, the Netherlands (CH); Department of Surgery, Zuyderland Medical Center, Sittard-Geleen and Heerlen, the Netherlands (EJB, TGMH); Department of Radiotherapy, Maastro Radiation Clinic, Maastricht, the Netherlands (JB); Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands (MM, DMJL, RGHBT); Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands (GLB)
| | - Ton G M Hoofwijk
- Department of Surgery (MHM, LAH, LPSS, SOB, JM), Department of Radiology (MHM, MM, LAH, DMJL), GROW School for Oncology and Developmental Biology (MHM, LAH, JB, RGHBT, GLB), and Department of Medical Oncology (RJ), Maastricht University Medical Center, Maastricht, the Netherlands; Department of Surgery, Laurentius Hospital, Roermond, the Netherlands (JWAL); Department of Surgery, Medical Center Leeuwarden, Leeuwarden, the Netherlands (CH); Department of Surgery, Zuyderland Medical Center, Sittard-Geleen and Heerlen, the Netherlands (EJB, TGMH); Department of Radiotherapy, Maastro Radiation Clinic, Maastricht, the Netherlands (JB); Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands (MM, DMJL, RGHBT); Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands (GLB)
| | - Regina G H Beets-Tan
- Department of Surgery (MHM, LAH, LPSS, SOB, JM), Department of Radiology (MHM, MM, LAH, DMJL), GROW School for Oncology and Developmental Biology (MHM, LAH, JB, RGHBT, GLB), and Department of Medical Oncology (RJ), Maastricht University Medical Center, Maastricht, the Netherlands; Department of Surgery, Laurentius Hospital, Roermond, the Netherlands (JWAL); Department of Surgery, Medical Center Leeuwarden, Leeuwarden, the Netherlands (CH); Department of Surgery, Zuyderland Medical Center, Sittard-Geleen and Heerlen, the Netherlands (EJB, TGMH); Department of Radiotherapy, Maastro Radiation Clinic, Maastricht, the Netherlands (JB); Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands (MM, DMJL, RGHBT); Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands (GLB)
| | - Geerard L Beets
- Department of Surgery (MHM, LAH, LPSS, SOB, JM), Department of Radiology (MHM, MM, LAH, DMJL), GROW School for Oncology and Developmental Biology (MHM, LAH, JB, RGHBT, GLB), and Department of Medical Oncology (RJ), Maastricht University Medical Center, Maastricht, the Netherlands; Department of Surgery, Laurentius Hospital, Roermond, the Netherlands (JWAL); Department of Surgery, Medical Center Leeuwarden, Leeuwarden, the Netherlands (CH); Department of Surgery, Zuyderland Medical Center, Sittard-Geleen and Heerlen, the Netherlands (EJB, TGMH); Department of Radiotherapy, Maastro Radiation Clinic, Maastricht, the Netherlands (JB); Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands (MM, DMJL, RGHBT); Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands (GLB)
| |
Collapse
|
|
48
|
Abstract
BACKGROUND Treatment of early stage rectal cancer has excellent oncological results. To reduce treatment-related mortality and morbidity and improve functional results, a focus on local resections is increasingly important. OBJECTIVE The purpose of this study was to compare outcomes after transanal endoscopic microsurgery and total mesorectal excision for early stage rectal cancer (T1 + T2) in Norway. DESIGN This was an observational study based on prospective data from the Norwegian Colorectal Cancer Registry. SETTINGS The study was conducted as a national, population-based study. PATIENTS All 543 patients with T1 and 1593 patients with T2 rectal cancer without distant metastases that was treated by transanal endoscopic microsurgery or total mesorectal excision without radiochemotherapy during 2000-2009 were included. MAIN OUTCOME MEASURES The primary outcomes were 5-year relative survival and 5-year local recurrence rate. RESULTS Among 543 patients with T1 cancer, the 5-year overall survival rate was 65.3% after transanal endoscopic microsurgery versus 81.5% after total mesorectal excision (p = 0.012). Adjusted for age and sex there was no excess mortality for transanal endoscopic microsurgery (HR = 1.28 (95% CI, 0.8-1.9); p = 0.22). The 5-year relative survival rate was 96.8% after transanal endoscopic microsurgery versus 98.2% after total mesorectal excision (p = 0.603), and the 5-year local recurrence rate was 14.5% versus 1.4% (p < 0.001). Among 1593 patients with T2 cancer, 5-year overall survival was 42.1% versus 76.1% (p < 0.001), 5-year relative survival was 65.4% versus 93.9% (p < 0.001), and 5 year local recurrence rate was 11.4% versus 4.4% in the 2 groups. LIMITATIONS The study is limited by its observational design and that the 2 groups were different according to patient and tumor characteristics. Another limitation was the low number of transanal endoscopic microsurgery procedures. CONCLUSIONS Transanal endoscopic microsurgery had comparable 5-year relative survival to total mesorectal excision in T1 rectal cancer but inferior 5-year relative survival in T2 rectal cancer. Transanal endoscopic microsurgery was associated with higher local recurrence rates for both T1 and T2 tumors.
Collapse
|
|
49
|
Rocha JJRD, Bernardes MVAA, Feitosa MR, Perazzoli C, Machado VF, Peria FM, Oliveira HFD, Feres O. Transanal endoscopic operation for rectal cancer after neoadjuvant therapy. Acta Cir Bras 2016; 31 Suppl 1:29-33. [PMID: 27142902 DOI: 10.1590/s0102-86502016001300007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
PURPOSE In this paper we report the oncological outcomes from clinical series of patients with rectal cancer submitted to local excision after neoadjuvant therapy and discuss the indications for local excision in partial clinical responders. METHODS We analysed a prospective database of 39 patients submitted to a transanal endoscopic operation for rectal cancer after neoadjuvant chemoradiation between 2006 and 2015, comparing clinical and pathological variables, perioperative complications, recurrence rate and overall survival. RESULTS We obtained 15.4% ypT0, 17.9% ypT1, 35.9% ypT2 and 28.2% ypT3. After a median follow-up of 24 months, tumoral recurrence was observed in 4 patients, one of them with isolated pulmonary metastasis. R0 resection was achieved in 79.5%, and postoperative complications were observed in 30.2% patients and no perioperative mortality occur. Compromise surgical margins do not affect recurrence rate, and 94.9% of patients are alive nowadays. CONCLUSION Local excision could be associated with low recurrence rate and good overall survival. Short hospitalization time and low level of serious complications observed could be an interesting option for patients who would not tolerate a radical procedure or for those who declined a total mesorectal excision. A strict long-term follow-up must be warranted to detect early tumoral recurrence.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Omar Feres
- Ribeirão Preto Medical School, University of São Paulo, Brazil
| |
Collapse
|
|
50
|
Stage-Dependent Frequency of Lymph Node Metastases in Patients With Rectal Carcinoma After Preoperative Chemoradiation: Results from the CAO/ARO/AIO-94 Trial and From a Comparative Prospective Evaluation With Extensive Pathological Workup. Dis Colon Rectum 2016; 59:377-85. [PMID: 27050599 DOI: 10.1097/dcr.0000000000000570] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND For patients with ycT1/2 rectal carcinomas after neoadjuvant chemoradiotherapy, local excision instead of radical surgery has increasingly been discussed as a way to avoid postoperative morbidity associated with radical surgery. OBJECTIVE The purpose of this study was to determine the incidence of lymph node metastases in total mesorectal excision specimens with ypT0, ypT1/2, and ypT3/4 rectal cancers. DESIGN This is a prospective and retrospective cohort study. SETTINGS This study was conducted in tertiary referral hospitals that are part of the German Rectal Cancer Study Group. PATIENTS A total of 479 patients with stage II and III rectal cancers treated within phase III trials of the German Rectal Cancer Study Group were evaluated. Specimens from 81 patients treated in the Working Group of Surgical Oncology/Working Group of Radiation Oncology/Working Group of Medical Oncology of the Germany Cancer Society (CAO/ARO/AIO-04) trial were prospectively studied with extensive microscopic screening of the entire mesorectum. The frequency and localization of nodal metastases were specified and compared with those of 398 patients having received neoadjuvant chemoradiation within the CAO/ARO/AIO-94 trial. MAIN OUTCOME MEASURES Frequency and localization of mesorectal lymph node metastases in patients with ypT0, ypT1/2, or ypT3/4 cancer were measured. RESULTS A mean number of 28.0 ± 13.7 nodes were detected per specimen within the prospective group. A total of 25% of patients in the ypT1/2 group had nodal metastases compared with 40% in the ypT3/4 group. Patients with node-positive ypT1/2 had a mean number of 2.2 metastases, and 55% of these metastases were located far from the primary lesion in the proximal mesorectum. Within the CAO/ARO/AIO-94 cohort (n = 398), 19% of patients with ypT1/2 (ypT1 = 22%; ypT2 = 18%) had ypN+ status compared with 43% with ypT3/4 cancers (ypT3 = 40%; ypT4 = 73%). LIMITATIONS Low numbers of patients with ypT0 limited the evaluation of nodal metastases in pathologic complete responders. CONCLUSIONS Even in good responders (ypT1/2), >20% of rectal carcinomas still harbored residual lymph node metastases. Local excision for patients with ycT1/2 rectal cancers would, thus, miss metastases in a considerable percentage and might involve the risk of significant undertreatment in a number of patients.
Collapse
|