Evaluation of the frequency and pattern of local recurrence following intersphincteric resection for ultra-low rectal cancer

IntroductionAbdomino-perineal resection has been the standard treatment for rectal tumors located ⩽5 cm from the anal verge. Recently, intersphincteric resection became a valid option which preserves the bowel continuity with better functional outcome.AimIs to evaluate the oncological and functional outcome alongside the associated surgical morbidity in patients with T1-3 rectal cancer, who underwent intersphincteric resection (ISR).Patients & methodsBetween the years 2006 and 2011, 55 patients with invasive rectal adenocarcinoma, T1-3 lesions, located 2–5 cm from the anal verge underwent ISR with total mesorectal excision. When inevitable, complete. ISR was performed, otherwise partial ISR was done. All T3 patients underwent total meso-rectal excision (TME) while some had lateral lymph node dissection (LND) with concomitant pelvic autonomic nerve preservation (PANP).ResultsAmong the 55 patients, 21 (38.1%) patients were T1-2 and 34 (61.9%) patients were T3. The tumor location range was 0–5 cm from the anal verge (median 2.3 cm). Partial or complete ISR was done for 35 (63.6%) and 20 (36.4%), respectively. Patients were followed for a median of 1.5 years (range 1–4.6 years). The 3 year local recurrence and distant metastasis free rates were 85.2% and 85.6%, respectively. All the 3 local recurrences occurred in T3 patients group, and had positive circumferential resection margins. Overall 3-year disease-free survival was 82.6%; while the overall 3-year survival was 88.7%.ConclusionIntersphincteric resection with TME does not affect the local recurrence or overall survival rate in early rectal cancer T1-2 & 3, with preservation of bowel continuity and better life quality.     

The reliability of lymph-node staging in rectal cancer after preoperative chemoradiotherapy

AimsTo determine the prognostic significance of the nodal stage and number of nodes recovered in the surgical specimen after preoperative synchronous chemoradiation (SCRT) and surgery for locally advanced or unresectable rectal cancer.Materials and MethodsOne hundred and eighty-two consecutive patients with locally advanced or unresectable (T3/T4) rectal carcinomas were entered on a prospective database and treated in this department with preoperative chemoradiation, followed 6–12 weeks later by surgical resection. Most patients received chemotherapy in the form of low-dose folinic acid and 5-fluorouracil (5-FU) 350 mg/m² via a 60-min infusion on days 1–5 and 29–33 of a course of pelvic radiotherapy delivered at a dose of 45 Gy in 25 fractions over 33 days to a planned volume. After resection, patients with a positive circumferential margin (≤1 mm), extranodal deposits or Dukes' C histology received adjuvant 5-FU-based-chemotherapy (n = 40).ResultsAfter SCRT, 161 patients underwent resection. Twenty-one patients remained unresectable or refused an exenterative operation. Median follow-up is 36 months. Down-staging was achieved in most patients, with 19 having a complete pathological response (pT0). The median number of lymph nodes recovered for all patients was five (range 0–21). The 3-year survival rate for node-positive patients is 47%, for node-negative patients with less than three lymph nodes recovered is 62% and for node-negative patients with three or more lymph nodes recovered is 70%. Compared with node-positive patients, simple regression models revealed a reduced hazard ratio (HR) of 0.72 (0.36–1.43) for node-negative patients with less than three nodes recovered and 0.48 (0.26–0.89) for node-negative patients with three or more lymph nodes recovered. In a multivariate model, including nodal status, excision status, age and sex only positive excision margins significantly predicted a poor outcome: HR = 3.05 (1.55–5.97).ConclusionsThe number of nodes found after preoperative chemoradiation is a significant prognostic factor by univariate analysis. In this study, patients with node-negative histology, and at least three nodes recovered, had better long-term survival than patients in whom two or less nodes were recovered or with positive nodes. This effect was attenuated by the inclusion of excision status in multivariate models.     

Treatment strategies for patients with stage IV rectal cancer: a report from the Swedish Rectal Cancer Registry

BackgroundThe optimal treatment strategy for patients with stage IV rectal cancer is unclear. The aim of the present study was to describe trends and compare the different treatment strategies for this group of patients at a national level and over time.MethodsData from 2758 rectal cancer patients with (stage IV) and 13,420 without metastases (stage I–III) were available from the Swedish Rectal Cancer Registry between January 1995 and December 2006.ResultsPatients with stage IV disease increased from 15% to 19% between 1995 and 2006 (p < 0.001) and the frequency of patients not operated on increased from 13% to 26% (p < 0.001). Postoperative 30 day mortality after bowel resection was 2% and after exploratory laparotomy 9%. Median survival for stage IV patients after bowel resection was 16.3 months, exploratory laparotomy 6.1 months and for patients having no surgery 4.6 months. Over time survival was improved for patients aged 60–69 years, irrespective of the treatment given. An increased risk of death was associated with: age >80 years, operation at a local hospital, treatment in earlier time periods, not receiving preoperative radio- or chemotherapy and not having a bowel resection.ConclusionsIn the latest time period survival was improved for rectal cancer patients in stage IV despite the great increase in non-operated patients. Patients aged >80 years should be carefully assessed and staged before surgery. The survival advantage for stage IV rectal cancer patients who underwent primary tumour resection is probably due to selection to more favourable cases.     

Diagnosis and operation for locally recurrent rectal cancer

Local recurrence of rectal cancer following abdominoperineal resection is rarely amenable to limited resection. Six patients with deeply invading recurrent lesions had pelvic exenteration combined with sacral resection. This procedure seems a reasonable treatment for palliation and the chance of cure in selected patients. In order to select good candidates for this extensive procedure, carcinoembryonic antigen (CEA) assays and the diagnosis of locally recurrent tumor with pelvic computed tomography (CT) were evaluated. CEA assay is valuable for diagnosing most recurrent rectal cancers, but it is inadequate for early detection. A high CEA level often indicates extrapelvic tumor spread. CT examination is very valuable for the early detection and localization of recurrence in relation to pelvic structures.     

Hyaluronic acid spacer in focal prostate reirradiation: A single centre experience

PurposeThe optimal management of locally recurrent prostate cancer after curative radiotherapy is still unknown. In this study, we evaluated the preliminary results of reirradiation using stereotactic body radiotherapy for locally recurrent prostate cancer after initial definitive local radiotherapy.Materials and methodsBetween April 2016 and February 2019, 11 patients with recurrent disease at the previously irradiated prostate were treated. Local recurrence was detected by radiological with or without functional imaging modalities including prostate multiparametric/pelvic MRI or positron-emission tomography–computerised tomography with (⁶⁸Ga)-labelled prostate-specific membrane antigen performed after rising prostate specific antigen serum level during follow-up. All patients received stereotactic body radiotherapy to the recurrent nodule to a total dose of 30 Gy in five fractions. Hyaluronic acid spacer was injected between prostate and rectum in seven patients to decrease the rectal dose. Acute toxicity was evaluated by using Common Terminology Criteria for Adverse Events version 4.0, and late toxicity was evaluated by using Radiation Therapy Oncology Group/European Organisation for Research and Treatment of Cancer late radiation morbidity scoring schema.ResultsAt the diagnosis, the median age was 64 years, and the mean prostate specific antigen serum concentration was 17.7 ng/mL. The median interval time between local recurrence and initial definitive radiotherapy was 63 months. Mean prostate specific antigen concentration nadir value during follow-up was 0.43 ng/mL. With a median follow up of 19 months, three patients developed either local or distant relapse. One patient had grade 3 acute rectal toxicity, and one patient had grade 2 late urinary toxicity. We did not observe any acute or late toxicity due to hyaluronic acid spacer injection.ConclusionReirradiation after local recurrence following initial definitive radiotherapy together with hyaluronic acid spacer use seems to be effective and safe.     

Diagnostic accuracy and value of magnetic resonance imaging (MRI) in planning exenterative pelvic surgery for advanced colorectal cancer

PurposeTo assess the diagnostic accuracy of magnetic resonance imaging (MRI) in detecting colorectal tumour invasion according to seven intrapelvic compartments for planning exenterative pelvic surgery.MethodSixty-three consecutive patients underwent preoperative MRI planning for exenterative surgery, defined as operative excision beyond conventional mesenteric planes for locally advanced (n = 23) and recurrent (n = 41) pelvic colorectal cancer. The institutional research committee approved of the study and waived the need for a consent form as the images were retrospectively assessed. Two radiologists reported tumour invasion for each of seven anatomic surgical resection compartments, blinded to histopathology and the intraoperative findings. Sensitivity, specificity and predictive values were calculated for the seven intrapelvic compartments. Cox regression analysis was used to calculate the risk of death and recurrence. Overall interobserver agreement was assessed using Cohen’s Kappa coefficient (k).ResultsThe sensitivity of MRI was ?93.3% in all but the lateral compartment where it was 89.3%. Specificity for the posterior (82.2%) and anterior compartments below the peritoneal reflection (86.4%) was lower compared to the other compartments. Agreement between the two radiologists was found to be good or very good for all compartments (k > 0.72). An MRI diagnosis of tumour invasion in the anterior compartment above the peritoneal reflection was associated with a poorer survival (p = 0.012).ConclusionMRI is accurate in predicting the extent of colorectal tumour within the pelvis and therefore can be used to determine the type of surgery required for curative resection. It should always be used to stage patients with advanced colorectal pelvic cancer.     

Chimioradiothérapie de rattrapage à visée curative de rechutes pelviennes isolées de cancers du col utérin

PurposeEvaluation of the results of salvage radiation therapy with curative intent in the treatment of recurrent cervical carcinoma.Patients and methodsFourteen patients with a recurrence of a cervical cancer were treated in our department between 1982 and 2009. Five patients had a pelvic relapse, four a vaginal relapse and five a pelvic lymph node relapse. Four patients had first a surgical resection of the relapse, which was incomplete in two patients. All patients had pelvic radiotherapy with a median dose of 55 Gy in conventional fractionation. Concurrent chemotherapy was administered to 12 patients. A vaginal brachytherapy with a median dose of 20 Gy was performed in addition in 3 patients. The median follow-up was 39 months.ResultsSafety of radiation therapy was correct with 29% of grade 3 acute or intestinal toxicity. Tumor control was observed in 10 patients (71%). Four patients presented a locoregional tumor progression. At the time of analysis, three patients had died from their cancer. From the date of relapse, the rate of overall survival at 2 and 5 year was respectively 84% and 74%. Three patients (21%) had severe late effects.ConclusionIn our experience, chemoradiotherapy can achieve a high rate of remission in patients with isolated pelvic recurrence of cervical cancer. This treatment is feasible only if the patient had not received radiation therapy before or if the relapse is out of the previously irradiated volume.     

Prediction of pathologic staging with magnetic resonance imaging after preoperative chemoradiotherapy in rectal cancer: Pooled analysis of KROG 10-01 and 11-02

Background and purposeThe reported overall accuracy of MRI in predicting the pathologic stage of nonirradiated rectal cancer is high. However, the role of MRI in restaging rectal tumors after neoadjuvant CRT is contentious. Thus, we evaluate the accuracy of restaging magnetic resonance imaging (MRI) for rectal cancer patients who receive preoperative chemoradiotherapy (CRT).Methods and materialsWe analyzed 150 patients with locally advanced rectal cancer (T3–4N0–2) who had received preoperative CRT. Pre-CRT MRI was performed for local tumor and nodal staging. All patients underwent restaging MRI followed by total mesorectal excision after the end of radiotherapy. The primary endpoint of the present study was to estimate the accuracy of post-CRT MRI as compared with pathologic staging.ResultsPathologic T classification matched the post-CRT MRI findings in 97 (64.7%) of 150 patients. 36 (24.0%) of 150 patients were overstaged in T classification, and the concordance degree was moderate (k = 0.33, p < 0.01). Pathologic N classification matched the post-CRI MRI findings in 85 (56.6%) of 150 patients. 54 (36.0%) of 150 patients were overstaged in N classification. 26 patients achieved downstaging (ycT0–2N0) on restaging MRI after CRT. 23 (88.5%) of 26 patients who had been downstaged on MRI after CRT were confirmed on the pathological staging, and the concordance degree was good (k = 0.72, p < 0.01).ConclusionsRestaging MRI has low accuracy for the prediction of the pathologic T and N classifications in rectal cancer patients who received preoperative CRT. The diagnostic accuracy of restaging MRI is relatively high in rectal cancer patients who achieved clinical downstaging after CRT.     

Total pelvic exenteration for primary and locally recurrent rectal cancer

Thirteen patients with advanced carcinoma of the lower colon and no evidence of extrapelvic metastasis were submitted to total pelvic exenteration with urinary diversion. The operative mortality rate was 7.7%. Determinate 5-year survival rate of 40% was achieved. Local recurrence of rectal cancer following abdominoperineal resection is rarely amenable to limited resection. Six patients with deeply invading recurrent lesions had pelvic exenteration combined with sacral resection. This procedure seems a reasonable treatment for palliation and the chance of cure in selected patients. CT examination of the pelvis is very valuable for the early detection and localization of recurrence.     

The effect of patient positioning (prone or supine) on the dose received by small bowel in pelvic radiotherapy in rectal cancer patients

PurposeThe small bowel is a main dose-limiting organ in pelvic radiotherapy in the patients with rectal cancer. Conventionally, pelvic radiotherapy of patients with rectal cancer is performed in the prone position.Material and MethodsThirty-nine patients underwent CT planning scan in the treatment position (20 patients in prone position group and 19 patients in supine position group). After radiation treatment planning optimization, the volumes of the irradiated small intestines were investigated.ResultsThe volume of irradiated small bowel was higher in the supine position (mean difference; 36,274 cm³). However, it was not statistically significant (P value = 0.187)ConclusionSupine position could be accepted for the patients undergoing preoperative rectal cancer chemo-radiation.     

Management of advanced pelvic cancer by exenteration.

AIM: To describe our results in managing locally advanced primary or recurrent pelvic malignancies. METHOD: Investigations included: clinical, laboratory, endoscopic (rectoscopy and colonoscopy) examinations, ultrasound scan, and CT scan or MRI of the abdomen and pelvis, to determine the extent of the pelvic malignancy. A careful explorative laparatomy of abdomen and pelvis was performed, followed by anterior, posterior or total pelvic exenteration. RESULTS: In the period June 1995-Jan 2002, 7 anterior, 2 posterior and 51 total pelvic exenterations were performed in 60 patients, distributed as follows: 28 for rectal cancer (12 primary, 16 recurrent), 20 for cervical cancer (9 primary, 11 recurrent) and 12 for other pelvic malignancies. The median survival time and overall 5-year survival rates were as follows: primary rectal cancer--50 months and 32%; recurrent rectal cancer--31 months and 17%; primary cervical cancer--46.4 months and 41% and recurrent cervical cancer--23.4 months and 16%. During the same period, 559 of our patients were treated for primary or recurrent rectal cancer by different types of straightforward resection. CONCLUSION: Pelvic exenteration is justifiable in cases of locally advanced primary and recurrent malignancies of rectum, cervical cancer and possibly in cases of other pelvic malignancies.     

Multimodal management of primary adenocarcinoma of the female urethra: About four cases

PurposeTo retrospectively analyse female patients treated for urethral adenocarcinoma, modalities of treatment and long-term outcomes.PatientsFour cases of primary female urethral adenocarcinoma were treated in the departments of urology and radiation-oncology at Georges-Pompidou and Necker hospitals (France) over a 7-year period.ResultsAll of them underwent surgery, with three presenting stage pT3-pT4 and one a positive cytology on inguinal node. Three patients received adjuvant cisplatin-based chemoradiotherapy up to 60 Gy, and one preoperative chemoradiotherapy at 45 Gy. Two recurrences were observed: one local relapse occurred at 9 months from the diagnosis and was treated by anterior pelvic exenteration followed by chemoradiotherapy, with no recurrence. One tumour relapsed both at the local level and on distant metastatic sites at 9 months from the diagnosis, and died 21 months after this progression. Median survival and progression-free survival are respectively 4.2 years and 13 months. Three patients are alive at 7, 4.5 and 3 years from diagnosis.ConclusionFemale urethral adenocarcinoma is a very rare entity and often present in locally advanced stages. Initial extensive surgery with pelvic exenteration should be considered, followed by chemoradiotherapy according to the surgical margins and lymph nodes involvement.     

Impact of radiotherapy boost on pathological complete response in patients with locally advanced rectal cancer: A systematic review and meta-analysis

PurposeWe conducted a systematic review and meta-analysis to quantify the pathological complete response (pCR) rate after preoperative (chemo)radiation with doses of ⩾60 Gy in patients with locally advanced rectal cancer. Complete response is relevant since this could select a proportion of patients for which organ-preserving strategies might be possible. Furthermore, we investigated correlations between EQD2 dose and pCR-rate, toxicity or resectability, and additionally between pCR-rate and chemotherapy, boost-approach or surgical-interval.Methods and materialsPubMed, EMBASE and Cochrane libraries were searched with the terms ‘radiotherapy’, ‘boost’ and ‘rectal cancer’ and synonym terms. Studies delivering a preoperative dose of ⩾60 Gy were eligible for inclusion. Original English full texts that allowed intention-to-treat pCR-rate calculation were included. Study variables, including pCR, acute grade ⩾3 toxicity and resectability-rate, were extracted by two authors independently. Eligibility for meta-analysis was assessed by critical appraisal. Heterogeneity and pooled estimates were calculated for all three outcomes. Pearson correlation coefficients were calculated between the variables mentioned earlier.ResultsThe search identified 3377 original articles, of which 18 met our inclusion criteria (1106 patients). Fourteen studies were included for meta-analysis (487 patients treated with ⩾60 Gy). pCR-rate ranged between 0.0% and 44.4%. Toxicity ranged between 1.3% and 43.8% and resectability-rate between 34.0% and 100%. Pooled pCR-rate was 20.4% (95% CI 16.8–24.5%), with low heterogeneity (I² 0.0%, 95% CI 0.00–84.0%). Pooled acute grade ⩾3 toxicity was 10.3% (95% CI 5.4–18.6%) and pooled resectability-rate was 89.5% (95% CI 78.2–95.3%).ConclusionDose escalation above 60 Gy for locally advanced rectal cancer results in high pCR-rates and acceptable early toxicity. This observation needs to be further investigated within larger randomized controlled phase 3 trials in the future.     

Diagnostic accuracy and prognostic impact of restaging by magnetic resonance imaging after preoperative chemoradiotherapy in patients with rectal cancer

BackgroundThe prognostic role of restaging rectal magnetic resonance imaging (MRI) in patients with preoperative CRT has not been established. The goal of this study was to evaluate the diagnostic accuracy and prognostic role of radiological staging by rectal MRI after preoperative chemoradiation (CRT) in patients with rectal cancer.MethodsA total of 231 consecutive patients with rectal cancer who underwent preoperative CRT and radical resection from January 2008 to December 2009 were prospectively enrolled. The diagnostic accuracy and prognostic significance of post-CRT radiological staging by MRI was evaluated.ResultsThe sensitivity, specificity, positive predictive value, and negative predictive value of radiological diagnosis of good responders (ypTNM stage 0–I) were 32%, 90%, 65%, and 69%, respectively. The overall accuracy of MRI restating for good responders was 68%. The 5-year disease-free survival rates of patients with radiological and pathological TNM stage 0, stage I, and stage II–III were 100%, 94%, and 76%, respectively (P = 0.037), and 97%, 87%, and 73%, respectively (P = 0.007). On multivariate analysis, post-CRT radiological staging by MRI was an independent prognostic factor for disease-free survival.ConclusionRadiological staging by MRI after preoperative CRT may be an independent predictor of survival in patients with rectal cancer.     

Updated systematic review of the approach to pelvic exenteration for locally advanced primary rectal cancer

ObjectivesTo review the evidence regarding surgical advances in the management of primary locally advanced rectal cancer.BackgroundThe management of rectal cancer has evolved significantly in recent decades, with improved (neo)adjuvant treatment strategies and enhanced perioperative protocols. Centralization of care for complex, advanced cases has enabled surgeons in these units to undertake more ambitious surgical procedures.MethodsA Pubmed, Ovid, Embase and Cochrane database search was conducted according to the predetermined search strategy. The review protocol was prospectively registered with PROSPERO (CRD42021245582).Results14 studies were identified which reported on the outcomes of 3,188 patients who underwent pelvic exenteration (PE) for primary rectal cancer. 50% of patients had neoadjuvant radiotherapy. 24.2% underwent flap reconstruction, 9.4% required a bony resection and 34 patients underwent a major vascular excision. 73.9% achieved R0 resection, with 33.1% experiencing a major complication. Median length of hospital stay ranged from 13 to 19 days. 1.6% of patients died within 30 days of their operation. Five-year overall survival (OS) rates ranged 29%–78%.LimitationsThe studies included in our review were mostly single-centre observational studies published prior to the introduction of modern neoadjuvant treatment regimens. It was not possible to perform a meta-analysis on the basis that most were non-randomized, non-comparative studies.ConclusionsPelvic exenteration offers patients with locally advanced rectal cancer the chance of long-term survival with acceptable levels of morbidity. Increased experience facilitates more radical procedures, with the introduction of new platforms and/or reconstructive options.     

Surgical treatment of locally recurrent rectal cancer.

BACKGROUND: The aim of our study was to analyse data of patients treated by salvage surgery for locally recurrent rectal cancer, with emphasis on the question whether salvage surgery is still worthwhile when adjuvant radiotherapy is no longer a treatment option. METHODS: Forty patients (19 males/21 females) treated by surgery with curative intent for locally recurrent rectal carcinoma were analysed. Local recurrence was defined as cancer recurrence within the lower pelvis. Salvage surgery included abdominoperineal resection, abdominosacral resection, exenteration (posterior or total) and local resection. Clinical and pathological factors were analysed to identify prognostic factors for survival. RESULTS: The median overall survival was 25 months (95% CI: 13-37 months) and 5-year survival was 28% (95% CI: 12-45%). The absence of symptoms at the time of recurrence, central localisation and the absence of microscopic involvement of surgical margins, but not additional radiotherapy, were found to be significant independent prognostic factors for better survival after salvage surgery. CONCLUSION: Salvage surgery, alone or in combination with radiotherapy, can achieve radical resection of locally recurrent rectal cancer and can result in long-term survival.     

Application of minimally invasive approaches to pelvic exenteration for locally advanced and locally recurrent pelvic malignancy - A narrative review of outcomes in an evolving field

IntroductionMinimally invasive surgical techniques are being successfully used to treat locally advanced and recurrent pelvic malignancy of colorectal origin. This review aims to describe the application of minimally invasive approaches to pelvic exenteration and compare current reported surgical outcomes.Methods and resultsA literature search was performed of PubMed, Google Scholar and EMBASE for studies on pelvic exenteration with locally advanced or recurrent rectal cancer utilising minimally invasive techniques. A total of 22 studies were reviewed, including four case reports describing novel approaches.DiscussionLaparoscopic, robotic and trans-anal total mesenteric excision (TaTME) aided pelvic exenteration methods have recently demonstrated low post-operative morbidity and mortality trends. Minimally invasive methods also have improved rates of R0 resection in modest cohort studies. Hybrid methods have also been proposed to overcome observed technical difficulties such as the narrow male pelvis and obese habitus. There is still limited data beyond case report and small cohort studies on challenging patient groups such as those with recurrent rectal cancer or bony involvement, as a consequence of patient selection for these novel approaches.ConclusionInternational, multicentre studies have provided the best opportunity to explore efficacy of these methods on a larger scale. Further research is required into patient selection, safety and long-term outcomes of these approaches within high volume centres practicing beyond the surgical learning curve.     

Comparative effectiveness of postoperative chemotherapy among older patients with non-metastatic rectal cancer treated with preoperative chemoradiotherapy

ObjectivePostoperative chemotherapy is standard following preoperative chemoradiation therapy (CRT) and curative resection for clinically staged II/III rectal cancer. Recent trials have questioned whether postoperative chemotherapy improves overall survival. The objective of the study was to evaluate the comparative effectiveness of postoperative chemotherapy following CRT or radiation therapy (RT) with specific attention to the impact of age on postoperative chemotherapy effectiveness.Materials and MethodsPatients treated with CRT or RT then resection of pathologically staged 0-III rectal cancer diagnosed from 2004 to 2009 were identified from the Surveillance, Epidemiology and End Results program-Medicare database. Propensity score weighted Cox proportional hazards models and Kaplan Meier methods were used to compare the effectiveness of 1) postoperative 5-fluorouracil (5-FU) or capecitabine to no treatment and 2) postoperative oxaliplatin + 5-FU/capecitabine to 5-FU/capecitabine alone on mortality. Results were stratified by age.ResultsWe identified 1316 patients; 49% received postoperative chemotherapy, 341 (52%) included oxaliplatin. After weighting, postoperative 5-FU/capecitabine alone was associated with decreased mortality in patients aged 66–74 (adjusted hazard ratio (aHR) = 0.46, 95% CI: 0.30, 0.72), corresponding to a 5-year risk difference of − 0.23, (95% CI: − 0.33, − 0.12). No further mortality reduction from adding oxaliplatin to 5-FU/capecitabine was seen in patients aged 66–74 (aHR = 1.57, 95% CI: 0.93, 2.65). No mortality reduction for 5-FU/capecitabine alone was observed among patients aged 75 + (aHR = 1.11, 95% CI: 0.76, 1.63).ConclusionsAmong patients < 75 years, postoperative 5-FU/capecitabine was associated with reduced mortality after preoperative CRT/RT and surgical resection; however, the addition of oxaliplatin was not associated with further mortality reduction. Decisions regarding postoperative chemotherapy after age 75 warrant consideration of individual patient risks and preferences, as benefits may be limited.     

Impact of primary tumour resection on survival of patients with colorectal cancer and synchronous metastases treated by chemotherapy: Results from the multicenter,randomised trial Fédération Francophone de Cancérologie Digestive 9601

ObjectiveTo assess the impact of primary tumour resection on overall survival (OS) of patients diagnosed with stage IV colorectal cancer (CRC).DesignAmong the 294 patients with non-resectable colorectal metastases enrolled in the Fédération Francophone de Cancérologie Digestive (FFCD) 9601 phase III trial, which compared different first-line single-agent chemotherapy regimens, 216 patients (73%) presented with synchronous metastases at study entry and constituted the present study population. Potential baseline prognostic variables including prior primary tumour resection were assessed by univariate and multivariate Cox analyses. Progression-free survival (PFS) and OS curves were compared with the logrank test.ResultsAmong the 216 patients with stage IV CRC (median follow-up, 33 months), 156 patients (72%) had undergone resection of their primary tumour prior to study entry. The resection and non-resection groups did not differ for baseline characteristics except for primary tumour location (rectum, 14% versus 35%; p = 0.0006). In multivariate analysis, resection of the primary was the strongest independent prognostic factor for PFS (hazard ratio (HR), 0.5; 95% confidence interval [CI], 0.4–0.8; p = 0.0002) and OS (HR, 0.4; CI, 0.3–0.6; p < 0.0001). Both median PFS (5.1 [4.6–5.6] versus 2.9 [2.2–4.1] months; p = 0.001) and OS (16.3 [13.7–19.2] versus 9.6 [7.4–12.5]; p < 0.0001) were significantly higher in the resection group. These differences in patient survival were maintained after exclusion of patients with rectal primary (n = 43).ConclusionResection of the primary tumour may be associated with longer PFS and OS in patients with stage IV CRC starting first-line, single-agent chemotherapy.     

Prognostic value of platelet-associated biomarkers in rectal cancer patients received neoadjuvant chemoradiation: A retrospective study

PurposePlatelet volume has been shown to prognostic value in patients with colorectal cancer. However, the changes of other platelet-associated biomarkers in rectal cancer patients, before and after the neoadjuvant chemoradiation therapy (NACRT), remain unclear. In this study, we investigated the prognostic value of platelet-associated biomarkers in rectal cancer patients with NACRT.Patients and methodsA total of 75 patients with locally advanced (T3–4 or N+) rectal cancer (LARC) cancer were selected and followed up from the Affiliated Cancer Hospital of Zhengzhou University between June 2013 and September 2016. The data of platelet-associated biomarkers, including the platelet count, platelet to lymphocyte ratio (PLR), lymphocyte to monocyte ratio (LMR), mean platelet volume (MPV), and platelet distribution width (PDW) both pre- and post- NACRT, were collected. The associations between these platelet-associated biomarkers and the overall survival (OS), as well as disease-free survival (DFS) of patients, were analysed. Patients were divided into groups with high or low values of the platelet-associated biomarkers, and the outcomes were compared by using Cox regression and Kaplan–Meier analysis.ResultsWe found that pre-PLR (HR: 4.104; 95%CI: 1.411–11.421; P = 0.009) and pre-LMR (HR: 0.384; 95%CI: 0.124–1.185; P = 0.066) could predict the OS in LARC patients after NACRT by multivariate Cox regression analysis, a cut-off value of pre-PLR > 7.02 and pre-LMR ≤ 7.10 could be used as independent prognostic factors for OS by Kaplan–Meier method. The pre-MPV value could be used as an independent prognostic factor for DFS by Kaplan–Meier analysis (P = 0.037). Moreover, post-CEA was correlated with OS and DFS in LARC patients with NACRT.ConclusionIn LARC patients with NACRT, the pre-PLR and pre-LMR are independent prognostic factors for OS, while pre-MPV has predictive value for DFS.