Retrospective Study
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Oncol. Sep 15, 2016; 8(9): 695-706
Published online Sep 15, 2016. doi: 10.4251/wjgo.v8.i9.695
Delaying surgery after neoadjuvant chemoradiotherapy improves prognosis of rectal cancer
Mehmet Mihmanlı, Esin Kabul Gürbulak, İsmail Ethem Akgün, Mustafa Fevzi Celayir, Pınar Yazıcı, Deniz Tunçel, Tuba Tülin Bek, Ayhan Öz, Sinan Ömeroğlu
Mehmet Mihmanlı, Esin Kabul Gürbulak, İsmail Ethem Akgün, Mustafa Fevzi Celayir, Pınar Yazıcı, Ayhan Öz, Sinan Ömeroğlu, Department of General Surgery, Şişli Etfal Training and Research Hospital, Şişli 34371, Istanbul, Turkey
Deniz Tunçel, Department of Pathology, Şişli Etfal Training and Research Hospital, Şişli 34371, Istanbul, Turkey
Tuba Tülin Bek, Department of Radiation Oncology, Şişli Etfal Training and Research Hospital, Şişli 34371, Istanbul, Turkey
Author contributions: Mihmanlı M, Kabul Gürbulak E and Akgün İE contributed equally to this work; Mihmanlı M and Kabul Gürbulak E collected and analyzed the data, and drafted the manuscript; Akgün İE provided analytical oversight; Kabul Gürbulak E designed and supervised the study; Celayir MF, Yazıcı P and Tunçel D revised the manuscript for important intellectual content; Bek TT, Öz A and Ömeroğlu S offered technical or material support; Mihmanlı M and Kabul Gürbulak E provided administrative support; all authors have read and approved the final version to be published.
Institutional review board statement: The clinical study entitled “Delaying surgery after neoadjuvant chemoradiotherapy improves prognosis of rectal cancer” is acceptable for clinical research and approved by the Ethical Committee of Sisli Hamidiye Etfal Training and Research Hospital.
Informed consent statement: Informed written consent was obtained from all study participants, or their legal guardian for being included in the study.
Conflict-of-interest statement: Mehmet Mihmanlı, Esin Kabul Gürbulak, İsmail Ethem Akgün, Mustafa Fevzi Celayir, Pınar Yazıcı, Deniz Tunçel, Tuna Tülin Bek, Ayhan Öz and Sinan Ömeroğlu declare that they have no conflicts of interest.
Data sharing statement: Technical appendix, statistical code and dataset available from the corresponding author at (ekabul@gmail.com). Participants gave informed consent for data sharing. No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Esin Kabul Gürbulak, MD, Department of General Surgery, Şişli Etfal Training and Research Hospital, Halaskargazi Cad, Etfal Sk, Şişli 34371, Istanbul, Turkey. ekabul@gmail.com
Telephone: +90-212-3735000 Fax: +90-212-2240772
Received: May 3, 2016
Peer-review started: May 3, 2016
First decision: June 6, 2016
Revised: June 17, 2016
Accepted: July 14, 2016
Article in press: July 18, 2016
Published online: September 15, 2016
Abstract
AIM

To investigate the prognostic effect of a delayed interval between neoadjuvant chemoradiotherapy (CRT) and surgery in locally advanced rectal cancer.

METHODS

We evaluated 87 patients with locally advanced mid- or distal rectal cancer undergoing total mesorectal excision following an interval period after neoadjuvant CRT at Şişli Hamidiye Etfal Training and Research Hospital, Istanbul between January 2009 and January 2014. Patients were divided into two groups according to the interval before surgery: < 8 wk (group I) and ≥ 8 wk (group II). Data related to patients, cancer characteristics and pathological examination were collected and analyzed.

RESULTS

When the distribution of timing between group I (n = 45) and group II (n = 42) was viewed, comparison of interval periods (median ± SD) of groups showed a significant difference of as 5 ± 1.28 wk in group I and 10.1 ± 2.2 wk in group II (P < 0.001). The median follow-up period for all patients was 34.5 (9.9-81) mo. group II had significantly higher rates of pathological complete response (pCR) than group I had (19% vs 8.9%, P = 0.002). Rate of tumor regression grade (TRG) poor response was 44.4% in group I and 9.5% in group II (P < 0.002). A poor pathological response was associated with worse disease-free survival (P = 0.009). The interval time did not show any association with local recurrence (P = 0.79).

CONCLUSION

Delaying the neoadjuvant CRT-surgery interval may provide nodal down-staging, improve pCR rate, and decrease the rate of TRG poor response.

Keywords: Rectal carcinoma, Pathological tumor response, Neoadjuvant chemoradiotherapy, Interval timing, Tumor down-staging

Core tip: Delaying the neoadjuvant chemoradiotherapy (CRT)-surgery interval for treatment of locally advanced rectal carcinoma may improve pathological complete response rates by providing nodal down-staging, as well as decreasing the rate of tumor regression grade (TRG) poor response. TRG may be an important predictive factor for disease-free survival. Extending the interval between CRT and surgery may improve the survival through tumor down-staging without increasing the rate of surgical complications.