Neoadjuvant chemoradiation treatment followed by surgery for esophageal cancer: there is much more than the mandard tumor regression score

Objective: Tumor regression grading (TRG) systems categorize residual tumor volume on the primary tumor after neoadjuvant treatment. Aim was to evaluate the impact of Mandard TRG, residual tumor depth (ypT) and residual lymph node status (ypN) and extent (ELNI) i.e. intracapsular versus extracapsular involvement on overall (OS) and disease-free survival (DFS) in esophageal carcinoma.

Methods: Between 2005 and 2014, 344 patients receiving R0-esophagectomy after neoadjuvant chemoradiation therapy (nCRT) were selected. Mandard TRG, ypTN and ELNI were prospectively recorded.

Results: Mandard TRG1 was found in 110 (32%); TRG2 in 120 (35%); TRG3 in 53 (15%); TRG4 in 54 (16%) and TRG5 in 7 (2%) patients. Both OS and DFS showed no significant difference between TRG1 and 2 (p?=?0.059 and 0.105, respectively). Therefore, TRG1/2 was classified together as ‘major response’, TRG3/4 as ‘minor response’ and TRG5 as ‘no response’. Multivariate analysis showed two independent prognosticators for OS (tumor regression response (TRR) and number of positive lymph nodes) and three independent prognosticators for DFS (TRR, ypT and ELNI).

Conclusion: After nCRT followed by surgery for esophageal carcinoma, number of residual positive lymph nodes as well as TRR are prognosticators for OS. Minor TRR, ypT and extracapsular lymph node invasion are prognosticators for recurrence.     

Neoplastic Mesorectal Microfoci (MMF) following Neoadjuvant Chemoradiotherapy: Clinical and Prognostic Implications

Background Neoplastic microfoci have frequently been found in the mesorectum, with poor outcome. In this study, incidence and clinical significance of mesorectal microfoci (MMF) were analyzed in patients operated on for rectal cancer following neoadjuvant chemoradiation. Methods A case series of 68 patients with extraperitoneal rectal cancer treated with neoadjuvant chemoradiation and surgery (including total mesorectal excision) were investigated for presence of neoplastic MMF. Results MMF were found in 26 cases (38.2%). Increasing incidence of microfoci was statistically related to pathologic involvement of the bowel wall (P = 0.0006), Mandard’s tumor regression grading (P = 0.0006), and pathologic neoplastic mesorectal involvement (P < 0.00001). None of the nine patients with complete tumor disappearance displayed both microfoci and lymph node metastasis. Only one local recurrence developed in a patient with multiple MMF. One out of nine pT0 or TRG1 patients (11.1%) had distant metastases compared with 15 out of 59 pT1–4 or TRG2–5 (25.4%, P = 0.70). Conclusions A remarkable incidence of MMF was found following chemoradiation. However, when this therapy induced complete regression of primary tumor (pT0–TRG1), we found that node metastases and neoplastic MMF also disappeared. These features should be confirmed to assess the impact of these microfoci in treatment decision making in rectal cancers.     

Neoplastic Mesorectal Microfoci (MMF) Following Neoadjuvant Chemoradiotherapy: Clinical and Prognostic Implications

Background Neoplastic microfoci have frequently been found in the mesorectum, with poor outcome. In this study, incidence and clinical significance of mesorectal microfoci (MMF) were analyzed in patients operated upon for rectal cancer following neoadjuvant chemoradiation.Methods A case series of 68 patients with extraperitoneal rectal cancer, treated with neoadjuvant chemoradiation and surgery (including total mesorectal excision), was investigated for the presence of neoplastic MMF.Results Mesorectal microfoci were found in 26 cases (38.2%). Increasing incidence of microfoci was statistically related to pathologic involvement of bowel wall (P = 0.0006), Mandard’s tumor regression grading (P = 0.0006) and pathologic neoplastic mesorectal involvement (P < 0.00001). None of the nine patients with complete tumor disappearance displayed both microfoci and lymph node metastasis. Only one local recurrence developed in a patient with multiple MMF. Out of 9 pT0 or TRG1 patients, 1 (11.1%) had distant metastases, compared to 15 out of 59 pT1–4 or TRG2–5 (25.4%, P = 0.70).Conclusions A remarkable incidence of MMF was found following chemoradiation. However, when this therapy induces complete regression of primary tumor (pT0–TRG1), node metastases and neoplastic MMF could also disappear, as shown in our cases. These features should be confirmed because they could significantly impact the treatment decision-making of rectal cancers.     

Clinical implications of acellular mucin pools in resected rectal cancer with pathological complete response to neoadjuvant chemoradiation1

Aim Approximately 20% of rectal cancers treated with neoadjuvant chemoradiation achieve a pathological complete response (pCR), which is associated with an improved oncological outcome. However, in a proportion of patients with a pCR, acellular pools of mucin are present in the surgical specimen. The aim of this study was to evaluate the clinical implications of acellular mucin pools in patients with rectal adenocarcinoma achieving a pCR after neoadjuvant chemoradiation followed by proctectomy. Method A single‐centre colorectal cancer database was searched for patients with clinical Stage II and Stage III rectal adenocarcinoma who achieved a pCR (i.e. ypT0N0M0) after neoadjuvant chemoradiation followed by proctectomy between 1997 and 2007. Patients were categorized according to the presence or absence of acellular mucin pools in the resected specimen, and groups were compared. Patient demographics, tumour and treatment characteristics, and oncological outcomes were recorded. Primary outcomes were 3‐year local and distant recurrences, and disease‐free and overall survivals. Results Two hundred and fifty‐eight patients with clinical Stage II or Stage III rectal adenocarcinoma were treated by neoadjuvant chemoradiation. Fifty‐eight of these patients had a 58 pCR. Eleven of the 58 patients with a pCR had acellular mucin pools in the surgical specimen. The median follow up was 40 months. The groups were statistically similar with respect to demographics, chemoradiation regimens, distance of tumour from the anal verge, clinical stage and surgical procedure. No patient had local recurrence. Patients with acellular mucin pools had increased distant recurrence (21%vs 5%), decreased disease‐free survival (79%vs 95%) and decreased overall survival (83%vs 95%) rates, although none of these differences was statistically significant. Conclusion The presence of acellular mucin pools in a proctectomy specimen with a pCR does not affect local recurrence, but may suggest a more aggressive tumour biology.     

Local excision for ypT2 rectal cancer--much ado about something.

BACKGROUND: The role of local excision for pT2 distal rectal cancer has been challenged because of the observation of high rates of lymph node metastases and local failure. However, neoadjuvant chemoradiation therapy (CRT) has led to increased local disease control and significant tumor downstaging, possibly decreasing rates of lymph node metastases. In this setting, a possible role for local excision of ypT2 has been suggested. METHODS: A total of 401 patients with distal rectal cancer underwent neoadjuvant CRT. Tumor response assessment was performed after at least 8 weeks from CRT completion. One hundred and twelve patients with complete clinical response were not immediately operated on and were excluded from the study, and 289 patients with incomplete clinical response were managed by radical surgery. Patients with final pathological stage ypT2 were analyzed to determine the risk of unfavorable pathological features that could represent unacceptable risk for local failure after local excision. RESULTS: Eighty-eight (30%) patients had ypT2 rectal cancer. Final ypT status was not associated with pretreatment radiological staging (p = 0.62). ypT status was significantly associated with the risk of lymph node metastases, risk of perineural and vascular invasion, and recurrence (p = 0.001). Lymph node metastases were present in 19% of patients with ypT2 rectal cancer. The risk of lymph node metastases in ypT2 was associated with the presence of perineural invasion (47% vs 4%; p = <0.001), vascular invasion (59% vs 6%; p < 0.001), and decreased mean interval CRT surgery (12 vs 18 weeks; p < 0.001), but not with mean tumor size (3.2 vs 3.1 cm; p = 0.8). Disease-free and overall survival rates were significantly better for patients with ypT2N0 (p = 0.02 and 0.006, respectively). Fifty-five (63%) patients with ypT2 had at least one unfavorable pathological feature for local excision (lymph node metastases, vascular or perineural invasion, mucinous type or tumor size >3 cm). CONCLUSION: Lymph node metastases were present in 19% of patients with ypT2 and were significantly associated with poor overall and disease-free survival rates. The risk of lymph node metastases could not be predicted by radiological staging or tumor size. Radical surgery should be considered the standard treatment option for ypT2 rectal cancer after CRT.     

The correlation between tumour regression grade and lymph node status after chemoradiation in rectal cancer

Objective  To determine the correlation between tumour response to preoperative RCTX and lymph node status, an established parameter of clinical outcome.
Method  After IRB approval, 86 consecutive rectal cancer patients who received preoperative RCTX were identified. Fifty seven were males. Mean age 62 years. Preoperative staging by ultrasound was available in 60 patients. Radiotherapy consisted of (40–60 g) and chemotherapy of 5-FU infusion (1500 mg/m² week), assessed using Dworak's system.
Results  Tumour response according to Tumor regression grade (TRG) were: TRG 0: 8 (9.3%); TRG 1: 15 (17.4%); TRG 2: 14 (16.2%); TRG 3: 31 (36%); TRG 4: 18 (20%). Eighteen patients had tumour stage 0 (20.9%); while 8 (9.2%), 28 (32.1%), 30 (34.5%) and three had tumours stages 1, 2, 3 and 4 respectively. Evaluation of nodal status revealed no involvement in 65 patients (N0), and positive nodes in 21 (14 N1, 7 N2). Response to RCTX was significantly associated with node stage, hence individuals without node involvement (N0) had 66% of positive tumour response (TRG 4), while individuals with node metastasis had less response to RCTX (TRG 0, 1 and 2) 35% N1 and 14% for N2 ( P  =   0.007). Node status was independently associated to poor response to preoperative RCTX, even after adjusting for tumour stage, age and gender (OR 0.02, 95% CI 0.0009–0.67).
Conclusion  Tumour shrinkage by preoperative RCTX appears to correlate with lymph node metastasis suggesting that neoadjuvant RCTX may have a positive impact in overall patient survival.     

What is the Incidence of Metastatic Lymph Node Involvement After Significant Pathologic Response of Primary Tumor Following Neoadjuvant Treatment for Locally Advanced Rectal Cancer?

Background

In locally advanced rectal cancer (LARC) patients, major response to neoadjuvant radiotherapy (NR) has been associated with favorable long-term outcomes. Positive pathologic nodal status was recently proven to be associated with poor prognosis even after total regression of primary tumor (ypT0). The aim of this study was to evaluate the rate of lymph node (LN) involvement in patients with complete (ypT0) or major (TRG1: very few viable tumor cells) response.

Methods

Included were patients with complete or major response after radiotherapy followed by surgery and histological examination of the whole specimen.

Results

From 1996 to 2010, 245 patients with LARC were treated by NR. We collected clinical data for 53 patients (21.6 %) with ypT0 (n = 26, 49 %) or TRG1 (n = 27, 51 %) response. Sphincter-preserving surgery was performed in 40 patients (75 %). Overall, nine patients (16.9 %) presented LN involvement: 2 (7.7 %) in the ypT0 group and 7 (25.9 %) in the TRG1 group (NS). Patients with ypT3 tumors had significantly more invaded LN than patients with ypT1–T2 tumors (6 of 13 [46 %] vs 1 of 14 [7 %], p = .032). After median follow-up of 30 months (range, 1–160 months), 5-year disease-free and overall survivals were 88.2 and 89.0 %, respectively.

Conclusions

There was a clear cutoff between patients with ypT0–T2 (3 of 40, 7.5 %) and ypT3 (6 of 13, 46 %) concerning the incidence of metastatic LN in patients achieving pathologic complete or major response after NR. In patients with good clinical response, local full-thickness resection of the residual tumor could be a first step, followed by standard rectal resection in cases of ypT3.     

Can Rectal Cancers With Pathologic T0 After Neoadjuvant Chemoradiation (ypT0) Be Treated by Transanal Excision Alone?

Background Patients with rectal cancer who have complete rectal wall tumor regression after neoadjuvant chemoradiation probably have eradication of tumor cells in the mesorectum as well, thus raising the possibility of transanal excision. Methods All pathology reports of all patients with locally advanced low and mid rectal cancer who underwent preoperative chemoradiation followed by radical resection from May 2000 to June 2004 were reviewed to evaluate the correlation between complete tumor response (ypT0) and nodal response. Results One hundred one consecutive patients had neoadjuvant chemoradiation followed by definitive operation. Four were excluded, leaving 64 men and 33 women (median age, 62 years). Fifty-three patients (55%) had mid rectal cancer, and 44 (45%) had low rectal cancer. Fifty-eight patients (60%) underwent low anterior resection, and 36 (37%) underwent abdominoperineal resection. In 17 patients (18%), no residual tumor cells were present within the rectal wall. One patient (6%) with ypT0 disease had positive lymph nodes. Conclusions No residual tumor in the rectal wall correlates with the absence of viable cancer cells in the mesorectal tissue (94%). Approximately 10% of T1 tumors have involved lymph nodes, and local excision is an accepted option. Transanal excision could probably be considered in a highly selected group of patients with a mural pathologic complete response to neoadjuvant therapy. This approach should be prospectively investigated, and strict selection guidelines should be used.     

Local Excision for ypT2 Rectal Cancer—Much Ado About Something

Background The role of local excision for pT2 distal rectal cancer has been challenged because of the observation of high rates of lymph node metastases and local failure. However, neoadjuvant chemoradiation therapy (CRT) has led to increased local disease control and significant tumor downstaging, possibly decreasing rates of lymph node metastases. In this setting, a possible role for local excision of ypT2 has been suggested. Methods A total of 401 patients with distal rectal cancer underwent neoadjuvant CRT. Tumor response assessment was performed after at least 8 weeks from CRT completion. One hundred and twelve patients with complete clinical response were not immediately operated on and were excluded from the study, and 289 patients with incomplete clinical response were managed by radical surgery. Patients with final pathological stage ypT2 were analyzed to determine the risk of unfavorable pathological features that could represent unacceptable risk for local failure after local excision. Results Eighty-eight (30%) patients had ypT2 rectal cancer. Final ypT status was not associated with pretreatment radiological staging (p = 0.62). ypT status was significantly associated with the risk of lymph node metastases, risk of perineural and vascular invasion, and recurrence (p = 0.001). Lymph node metastases were present in 19% of patients with ypT2 rectal cancer. The risk of lymph node metastases in ypT2 was associated with the presence of perineural invasion (47% vs 4%; p = <0.001), vascular invasion (59% vs 6%; p < 0.001), and decreased mean interval CRT surgery (12 vs 18 weeks; p < 0.001), but not with mean tumor size (3.2 vs 3.1 cm; p = 0.8). Disease-free and overall survival rates were significantly better for patients with ypT2N0 (p = 0.02 and 0.006, respectively). Fifty-five (63%) patients with ypT2 had at least one unfavorable pathological feature for local excision (lymph node metastases, vascular or perineural invasion, mucinous type or tumor size >3 cm). Conclusion Lymph node metastases were present in 19% of patients with ypT2 and were significantly associated with poor overall and disease-free survival rates. The risk of lymph node metastases could not be predicted by radiological staging or tumor size. Radical surgery should be considered the standard treatment option for ypT2 rectal cancer after CRT. Presented at the Plenary Session of the 48th Annual Meeting of The Society for Surgery of the Alimentary Tract, Washington, D.C., May 19–23, 2007.     

Neoadjuvant Therapy for Rectal Cancer Down-Stages the Tumor but Reduces Lymph Node Harvest Significantly

Purpose The impact of neoadjuvant therapy (NAT) for rectal cancer on lymph node yield is not well known. This study evaluates the impact of NAT on tumor regression and lymph node harvest.Methods The subjects were 40 patients with rectal cancer; 20 receiving high-dose, long-course neoadjuvant therapy, and 20 age- and sex-matched controls who did not receive neoadjuvant therapy. Tumor regression (TRG) was graded from 1 to 5 as: TRG1, no residual tumor cells; TRG2, occasional residual tumor cells with marked fibrosis; TRG3, marked fibrosis with scattered tumor cells or groups; TRG4, abundant cancer cells with little fibrosis; TRG5, no tumor regression. We also evaluated the number of lymph nodes retrieved from excised specimens, the size of the largest node, and the extent of lymph node involvement by the tumor.Result Tumor regression was seen in all patients; as TRG1 in 6 (30%), TRG2 in 2 (10%), TRG3 in 3 (15%), and TRG4 in 9 (45%). The median nodal harvest was 4 (range (0–12) in the NAT group vs 9 (range 1–19) in the control (P = 0.001). The median size of the largest lymph node was 5mm (range 2–12mm) in the NAT group vs 9mm (range 4–15mm) in the control group (P = 0.004). Tumor-positive nodes were identified in 4 of 17 of the NAT group patients and in 9 of the 20 controls (P = 0.308).Conclusion Although NAT down-stages rectal cancer, it results in a significantly low yield of lymph nodes, which are also significantly smaller than those in nonirradiated controls. Therefore, surgeons and histopathologists must ensure adequate sampling and accurate staging is done for patients with irradiated rectal cancer.This paper was presented at the British Society of Gastroenterology Meeting held in Glasgow in 2001, and published as an abstract in Gut 2001;(suppl)48:A57     

Pathologic evaluation of response to neoadjuvant therapy drives treatment changes and improves long‐term outcomes for breast cancer patients

Systemic therapy for breast cancer may be given before (neoadjuvant) or after (adjuvant) surgery. When neoadjuvant systemic therapy is given, response to treatment can be evaluated. However, some prognostic information (for example, pathologic tumor size pretreatment) is then lost and pathologic evaluation of breast specimens after neoadjuvant therapy is more difficult. Pathologic complete response (pCR), defined as no invasive disease in the breast (ypT0/is or ypT0) and no disease in all sampled lymph nodes (ypN0), identifies patients with a lower risk of recurrence or death compared to those with residual disease. Multidisciplinary collaboration, marking of the tumor site and any lymph node involvement pretreatment, and access to specimen imaging to facilitate correlation of gross and microscopic findings are critical for accurate determination of pCR. For HER2‐positive and triple negative tumors requiring systemic therapy, giving the treatment before surgery identifies a high‐risk group of patients that can receive additional adjuvant therapy after surgery if a pCR is not achieved. Recent clinical trials have demonstrated that this approach reduced recurrence risk. More than ever, pathologic evaluation of response to neoadjuvant systemic therapy directs treatment received after surgery. Using a single standardized protocol for sampling of the post‐neoadjuvant surgical specimen allows pathologists to ensure accurate determination of pCR or residual disease and quantify residual disease. Residual cancer burden (RCB) and AJCC stage provide complementary quantitative information about residual disease and prognosis.     

Pathologic Complete Response After Neoadjuvant Treatment for Rectal Cancer Decreases Distant Recurrence and Could Eradicate Local Recurrence

Background

The aim of this study was to evaluate the clinical implications of pathologic complete response (pCR) (i.e., T0N0M0) after neoadjuvant chemoradiation and radical surgery in patients with locally advanced rectal cancer.

Materials and Methods

A single-center, prospectively maintained colorectal cancer database was queried for patients with primary cII and cIII rectal cancer staged by CT and ERUS/MRI undergoing long-course neoadjuvant chemoradiation followed by proctectomy with curative intent between 1997 and 2007. Patients were stratified into pCR and no-pCR groups and compared with respect to demographics, tumor and treatment characteristics, and oncologic outcomes. Outcomes evaluated were 5-year overall survival, disease-free survival, disease-specific mortality, local recurrence, and distant recurrence.

Results

The query returned 238 patients (73% male), with a median age of 57 years and median follow-up of 54 months. Of these, 58 patients achieved pCR. Patients with pCR vs no-pCR were statistically comparable with respect to demographics, chemoradiation regimens, tumor distance from anal verge, clinical stage, surgical procedures performed, and follow-up time. No patient with pCR had local recurrence. Overall survival and distant recurrence were also significantly improved for patients achieving pCR.

Conclusions

Achievement of pCR after neoadjuvant chemoradiation is associated with greatly improved cancer outcomes in locally advanced rectal cancer. Future studies should evaluate the relationship between increases in pCR rates and improvements in cancer outcomes in this population.     

pCR rates in patients with bilateral breast cancer after neoadjuvant anthracycline-taxane based-chemotherapy – A retrospective pooled analysis of individual patients data of four German neoadjuvant trials

PurposePatients with bilateral breast cancer (BBC) are usually excluded from participating in clinical trials and little is known about the response and outcome of BBC to neoadjuvant chemotherapy compared to unilateral BC (UBC).MethodsWe prospectively captured the information on patients with BBC in our database treated within four neoadjuvant chemotherapy trials and collected retrospectively the rate of pathological complete response (pCR) defined as ypT0 ypN0, ypT0/is ypN0, ypT0 ypNX, clinical and histologic parameters. Synchronous carcinoma in the contralateral breast was considered as the non-indicator lesion. Patients with UBC only treated within the same neoadjuvant trials performed the control group.ResultsFrom the 6727 patients treated within 4 German neoadjuvant trials 119 (1.8%) patients have been identified with the diagnosis of BBC. The pCR rate (ypT0 ypN0) was 12.6% in the non-indicator lesion group versus 10.9% the indicator lesion group versus 20.9% for patients with unilateral disease (p = 0.003). There were more advanced tumor stages and positive axillary lymph nodes in the indicator lesion than in the nonindicator lesion or in UBC. In 52.5% the molecular subtype was identical between indicator and non-indicator lesion with more triple negative and HER2 positive BC in the group of UBC. The disease free survival rate (DFS) was 25.8% for patients with UBC versus 39.6% for patients with BBC.ConclusionThe selection for the indicator lesion was based on tumor size, nodal status and inclusion criteria. Patients with BBC patients had a lower pCR rate and a lower DFS.     

Clinically-Staged T3N0 Rectal Cancer: Is Preoperative Chemoradiotherapy the Optimal Treatment?

Background

Preoperative chemoradiotherapy has been widely adopted as the standard of care for stage II–III rectal cancers. However, patients with T3N0 lesions had been shown to have a better prognosis than other categories of locally advanced tumor. Thus, neoadjuvant chemoradiation is likely to be overtreatment in this subgroup of patients. Nevertheless, the low accuracy rate of preoperative staging techniques for detection of node-negative tumors does not allow to check this hypothesis. We analyzed a group of patients with cT3N0 low rectal cancer who underwent neoadjuvant chemoradiotherapy with the purpose of evaluating the incidence of metastatic nodes in the resected specimens.

Methods

Between January 2002 and February 2008, 100 patients with low rectal cancer underwent clinical staging by means of endorectal ultrasound, computed tomography, positron emission tomography, and magnetic resonance imaging. All patients received preoperative 5-fluorouracil-based chemoradiotherapy and surgical resection with curative aim.

Results

Of 100 patients with locally advanced rectal cancer, 32 were clinically staged as T3N0M0. Pathological analysis showed the presence of lymph node metastases in nine patients (28%) (node-positive group). In the remaining 23 cases, clinical N stage was confirmed at pathology (node-negative group). Node-positive and node-negative groups differ only in the number of ypT3 tumors (P < .01).

Conclusions

Our results indicate that immediate surgery for patients with cT3N0 rectal cancer represents an undertreatment risk in at least 28% of cases, making necessary the use of postoperative chemoradiotherapy. Preoperative chemoradiotherapy should be the therapy of choice on the grounds of the principle that overtreatment is less hazardous than undertreatment for cT3N0 rectal cancers.     

术前贝伐单抗联合卡培他滨及放疗在局部进展期直肠癌中的应用研究

【摘要】〓目的〓评价局部进展期直肠癌患者术前应用贝伐单抗联合卡培他滨化疗以及标准剂量放疗的效果和安全性。方法〓选择局部进展直肠癌患者应用卡培他滨825 mg/m2、2次/d,第1~14 d和22~35天;贝伐单抗5 mg/kg,放疗前第14 d,放疗后1、15、29 d;放疗50.4Gy分28次。放化疗7~9周后实施TME手术。结果〓纳入42例可评估患者,其中38例手术,18例(43%)临床T4和/或N2,平均相对强度>90%,97%照射。术前组10例(24%)发生3/4级腹泻,4例(10%)出现疼痛,而术后组的5例(13%)患者均出现3/4级疼痛、乏力和感染,4例(11%)因出现并发症再次手术。术后38例中肿瘤完全消退达T0 的有9例(9/38,23.7%);其中达T0N0 7例(7/38,18.4%)、T0N1 2例(5.3%)。结论〓本研究提示术前贝伐单抗联合卡培他滨和放疗在期望肿瘤衰退率方面是安全和有效的。     

Diffusion-Weighted MRI for Selection of Complete Responders After Chemoradiation for Locally Advanced Rectal Cancer: A Multicenter Study

Purpose  

In 10–24% of patients with rectal cancer who are treated with neoadjuvant chemoradiation, no residual tumor is found after surgery (ypT0). When accurately selected, these complete responders might be considered for less invasive treatments instead of standard surgery. So far, no imaging method has proven reliable. This study was designed to assess the accuracy of diffusion-weighted MRI (DWI) in addition to standard rectal MRI for selection of complete responders after chemoradiation.     

A Simplified Tumor Regression Grade Correlates with Survival in Locally Advanced Rectal Carcinoma Treated with Neoadjuvant Chemoradiotherapy

Background  Locally advanced rectal cancer is frequently treated with neoadjuvant chemoradiotherapy to reduce local recurrence and possibly improve survival. The tumor response to chemoradiotherapy is variable and may influence the prognosis after surgery. This study assessed tumor regression and its influence on survival in patients with rectal cancer treated with chemoradiotherapy followed by curative surgery. Methods  One hundred twenty-six patients with locally advanced rectal cancer (T3/T4 or N1/N2) were treated with chemoradiotherapy followed by total mesorectal excision. Patients received long-course radiotherapy (50 Gy in 25 fractions) in combination with 5-flourouracil over 5 weeks. By means of a standardized approach, tumor regression was graded in the resection specimen using a 3-point system related to tumor regression grade (TRG): complete or near-complete response (TRG1), partial response (TRG2), or no response (TRG3). Results  The 5-year disease-free survival was 72% (median follow-up 37 months), and 7% of patients had local recurrence. Chemoradiotherapy produced downstaging in 60% of patients; 21% of patients experienced TRG1. TRG1 correlated with a pathological T0/1 or N0 status. Five-year disease-free survival after chemoradiotherapy and surgery was significantly better in TRG1 patients (100%) compared with TRG2 (71%) and TRG3 (66%) (P = .01). Conclusion  Tumor regression grade measured on a 3-point system predicts outcome after chemoradiotherapy and surgery for locally advanced rectal cancer.     

直肠癌新辅助治疗与手术间隔时间对降期疗效的影响

目的 探讨局部进展期直肠癌新辅助治疗与手术间隔时间对降期疗效的影响.方法 2003年5月-2008年12月为前期,T3/T4期直肠癌32例,新辅助治疗结束4～6周后手术;2009年1月-2010年12月为后期,T3/T4期直肠癌21例,新辅助治疗结束8周后手术.比较两组患者的术后Dworak分级、TNM分期和临床结局....     

Comparison of Magnetic Resonance Imaging and Histopathological Response to Chemoradiotherapy in Locally Advanced Rectal Cancer

Background

Magnetic resonance imaging (MRI) methods for chemoradiotherapy (CRT) response assessment of rectal cancer include posttreatment T staging (ymrT), tumor regression grading (mrTRG), volume reduction posttreatment, and modified RECIST measurement. We compared these methods in identifying good versus poor responders with the histopathological standards of T stage (ypT) and tumor regression grading (TRG).

Methods

A total of 86 patients underwent CRT in a prospective phase II trial for MRI-defined locally advanced rectal cancer. Two readers independently assessed MRIs for ymrT, mrTRG, volume change, and RECIST. Parameters for each case were categorized as good or poor response and analyzed against ypT and TRG by univariate logistic regression.

Results

A total of 83 patients had evaluable imaging, and 78 had final pathology (five did not undergo surgery). Of these, 34 patients had good response (ypT0-3a) and 44 had poor response (>ypT3a). Also, 27 patients had favorable pathologic TRG (predominant fibrosis) and 51 had unfavorable TRG (predominant tumor). Good mrTRG and ymr P?=?0.001) associated with favorable pathology odds ratio [OR]?=?16.11 (95?% confidence interval [95?% CI]: 3.36?C77.29) and 17.50 (95?% CI: 5.38?C56.89), respectively. RECIST measurements and volume reduction of >80?% showed an OR of 3.23 (95?% CI: 1.14?C9.17), 4.25 (95?% CI: 0.92?C15.45), respectively, for a good ypT score (P?=?0.028), but there was no association for histopathological TRG.

Conclusion

Favorable and unfavorable histopathology are predicted by both ymrT and mrTRG, and we recommend these parameters for post-treatment assessment of rectal cancers treated with CRT.     

中低位直肠癌新辅助放化疗后行经肛门局部切除19例疗效分析

目的 探讨中低位直肠癌新辅助放化疗后行经肛门局部切除的有效性和安全性。方法 回顾性分析2011年3月至2016年6月北京大学肿瘤医院胃肠肿瘤中心诊治的行新辅助放化疗并接受经肛门局部切除的19例中低位直肠癌病人的临床资料。主要的研究终点为：无病生存（disease free survival）、术后短期（1个月）并发症；次要研究终点为：术后1年的生活质量和肛门功能。结果 肿瘤直径为1.0（0.3~3.0）cm。8例（42.1%）肿瘤位于前壁，6例（31.6%）位于后壁，3例（15.8%）位于左侧壁，2例（10.5%）位于右侧壁；肿瘤距肛缘中位距离为4.0（1.5~12.0）cm；术后病理学检查示，ypT0 12例（63.2%）， ypT1 3例（15.8%），ypT2 4例（21.1%）。放化疗结束距手术的时间间隔为4.3（2.0~36.0）个月。局部切除手术时间为50（20~137）min，术中出血量为10（0~50）mL，术后住院时间为4（1~5）d。随访30（2~62）个月，1例局部复发，3例出现远处转移（1例腹盆腔和2例肺转移），肿瘤复发率为21.1%（4/19）。局部切除病例肛门功能评分术前和术后差异无统计学意义（P>0.05），而TME病例肛门功能评分术前和术后差异有统计学意义（P<0.05）。局部切除病例术后生活质量（EORTC QLQ-C30）和肛门功能（Wexner）评分低于同期TME手术组（P<0.01）。结论 中低位直肠癌新辅助放化疗后，ycT0~2N0病例行经肛门局部切除是一种安全可行的治疗选择，可获得较好的肛门功能保留和生活质量。