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.     

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.     

Prognostic Implications of the Number of Retrieved Lymph Nodes of Patients with Rectal Cancer Treated with Preoperative Chemoradiotherapy

Background

The impact of the number of retrieved lymph nodes (LNs) on oncological outcomes in patients with rectal cancer remains unclear. This study was designed to evaluate the prognostic implications of the number of retrieved LNs in patients with rectal cancer receiving preoperative chemoradiotherapy (CRT).

Methods

The study cohort consisted of 859 patients with locally advanced (cT3-4 or cN+) mid to low rectal cancer that had been treated with preoperative CRT and radical resection between 2000 and 2009. Multivariate analysis and the Kaplan-Meier method were used to evaluate the influence of the number of retrieved LNs on disease-free survival (DFS).

Results

The median number of LNs retrieved from included patients was 13 (interquartile range [IQR] 9–17). Multivariate analysis confirmed the independent prognostic importance of the number of retrieved LNs on DFS (hazard ratio?=?0.97, 95 % confidence interval?=?0.95–0.99, p?=?0.029). The 3-year DFS rate in patients with yp stage II rectal cancer was associated with the total number of retrieved LNs.

Conclusions

DFS was associated with the number of LNs retrieved from patients with rectal cancer who received preoperative CRT, especially among patients with ypT3-4 N0 stage tumors. The oncological importance of the number of retrieved LNs should be considered when treating these patients.     

Predicting Pathological Response to Neoadjuvant Chemoradiotherapy in Locally Advanced Rectal Cancer Using 18FDG-PET/CT

Background

Pathologic complete response (pCR) after neoadjuvant chemoradiation (CRT) has been observed in 15?C30% of patients with locally advanced rectal cancer (LARC). The objective of this study was to determine whether PET/CT can predict pCR and disease-free survival in patients receiving CRT with LARC.

Methods

This is a retrospective review of patients with EUS-staged T3?CT4, N?+?rectal tumors treated with CRT, who underwent pre/post-treatment PET/CT from 2002?C2009. All patients were treated with CRT and surgical resection. Standardized uptake value (SUV) of each tumor was recorded. Logistic regression was used to analyze the association of pre-CRT SUV, post-CRT SUV, %SUV change, and time between CRT and surgery, compared with pCR. Kaplan?CMeier estimation evaluated significant predictors of survival.

Results

Seventy patients (age 62?years; 42M:28F) with preoperative stage T3 (n?=?61) and T4 (n?=?9) underwent pre- and post-CRT PET/CT followed by surgery. The pCR rate was 26%. Median pre-CRT SUV was 10.8, whereas the median post-CRT SUV was 4 (P?=?0.001). Patients with pCR had a lower median post-CRT SUV compared with those without (2.7 vs. 4.5, P?=?0.01). Median SUV decrease was 63% (7.5?C95.5%) and predicted pCR (P?=?0.002). Patients with a pCR had a greater time interval between CRT and surgery (median, 58 vs. 50?days) than those without (P?=?0.02). Patients with post-CRT SUV?P?=?0.03). Patients with SUV decrease ??63% had improved overall survival at median follow-up of 40?months than those without (P?=?0.006).

Conclusions

PET/CT can predict response to CRT in patients with LARC. Posttreatment SUV, %SUV decrease, and greater time from CRT to surgery correlate with pCR. Post-CRT, SUV?相似文献   

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.     

Impact of Circumferential Resection Margin Distance on Locoregional Recurrence and Survival after Chemoradiotherapy in Esophageal Squamous Cell Carcinoma

Background

Close circumferential resection margin (CRM) is an established predictor for locoregional recurrence (LR) in rectal cancer but remains controversial in esophageal malignancy. As yet, little is known about the significance of CRM after chemoradiotherapy (CRT), especially in squamous cell carcinoma (SCC). This study investigated the relationship between CRM distance and recurrence after neoadjuvant CRT in esophageal SCC patients.

Methods

Between 1997 and 2005, esophageal SCC patients who underwent surgery after neoadjuvant CRT and with pathology stage T3N0M0 and T3N1M0 (metastatic lymph nodes <2) were selected. CRM distance was reassessed and divided into three groups (group 1: CRM >1 mm, group 2: uninvolved CRM but <1 mm, group 3: CRM involved).

Results

The cohort comprised 145 male and 6 female patients with mean age of 57 years. There were 74, 51, and 26 patients in group 1, 2, and 3, respectively. With median follow-up period of 50 months, LR developed in 30.5% of patients. Both group 2 and group 3 had significantly higher LR than group 1 (37 and 42% vs. 21%, P < 0.05). Meanwhile, mean time from operation to recurrence was also significantly shorter in group 2 and group 3 than in group 1 (267 and 269 days versus 402 days, P < 0.05). Five-year disease-specific survival (DSS) was highest in group 1 (40%). Despite the similarity in LR, 5-year DSS significantly differed between group 2 and group 3 (22 vs. 7%, P < 0.05). The higher rate of distant recurrence (DR) and concomitant LR + DR in group 3 accounted for the survival difference.

Conclusion

In ypT3 esophageal SCC patients, CRM distance provides useful information for risk stratification in cancer recurrence and survival.     

Outcome Standards for an Organ Preservation Strategy in Stage II and III Rectal Adenocarcinoma after Neoadjuvant Chemoradiation

Background

Neoadjuvant chemoradiotherapy is the standard of care for patients with locally advanced mid and distal rectal cancer. Tumor regression is variable, and this study was designed to evaluate the pathological response and impact on long-term disease control in responders and nonresponders.

Methods

A total of 303 consecutive patients with cStage II and III mid and distal rectal adenocarcinoma were identified. The mean age was 64 years and 63% were men. Patients received neoadjuvant chemoradiotherapy (45 Gy) with a continuous infusion of 5-fluorouracil. Total mesorectal excision (TME) was performed after an interval of 6–8 weeks. Tumors were stratified as responders (ypT0 or ypT1) and nonresponders (≥ypT3). All ypT2 were separately categorized.

Results

Tumors of 84 patients were classified as responders (27.5%) versus nonresponders in 144 patients (47.5%). Pathological tumor stage was ypT2 in 75 patients (25%). After a median follow-up of 55 months, the 5-year cancer-specific survival rate was 98% and the disease-free survival rate was 91% in responders versus 82% (P < 0.0025) and 60% (P < 0.0001), respectively, for the nonresponders.

Conclusions

After neoadjuvant chemoradiotherapy and TME surgery for locally advanced rectal cancer and complete or near-complete pathological tumor response oncological outcome is very good. These results set the standards for a rectum-sparing strategy.     

Long-Term Outcome of Patients with Complete Pathologic Response after Neoadjuvant Chemoradiation for cT3 Rectal Cancer: Implications for Local Excision Surgical Strategies

Background

Neoadjuvant chemoradiotherapy (CRT) followed by radical surgery including total mesorectal excision (TME) is standard treatment in patients with locally advanced rectal cancer. Emerging data indicate that patients with complete pathologic response (ypCR) after CRT have favorable outcome, suggesting the possibility of less invasive surgical treatment. We analyzed long-term outcome of cT3 rectal cancer treated by neoadjuvant CRT in relation to ypCR and type of surgery.

Methods

The study population comprised 139 patients (93 men, 46 women; median age 62 years) with cT3N0–1M0 mid and distal rectal adenocarcinoma treated by CRT and surgery (110 TME and 29 local excision) at our institution between 1996 and 2008. At pathology, ypCR was defined as no residual cancer cells in the primary tumor.

Results

Tumors of 42 patients (30.2%) were classified as ypCR. After a median follow-up of 55.4 months, comparing patients with ypCR to patients with no ypCR, 5-year disease-specific survival was 95.8% versus 78.0% (P = 0.004), and 5-year disease-free survival was 90.1% vs. 64.0% (P = 0.004). In patients with ypCR, no statistically significant outcome difference was observed between TME and local excision. In patients treated by local excision, comparing patients with ypCR to patients with no ypCR, 5-year disease-free survival was 100% vs. 65.5% (P = 0.024), and 5-year local recurrence-free survival was 92.9% vs. 66.7% (P = 0.047).

Conclusions

With retrospective analysis limitations, our data confirm favorable long-term outcome of cT3 rectal cancer with ypCR after CRT and warrant clinical trials exploring local excision surgical strategies.     

Selective Lateral Pelvic Lymph Node Dissection in Patients with Advanced Low Rectal Cancer Treated with Preoperative Chemoradiotherapy Based on Pretreatment Imaging

Background

The significance of lateral pelvic lymph node (LPLN) metastasis in advanced low rectal cancer treated with preoperative chemoradiotherapy (CRT) remains unclear. The objective of this study was to evaluate the outcomes of selective LPLN dissection (LPLD) based on the pretreatment imaging in patients with advanced low rectal cancer treated with preoperative CRT.

Methods

We reviewed 127 consecutive patients with clinical stage II–III low rectal cancer below the peritoneal reflection who underwent preoperative CRT and curative resection. LPLD was performed in patients with suspected LPLN metastasis based on MDCT or MRI before CRT (LPLD group, N = 38), and only total mesorectal excision (TME) was performed in patients without suspected LPLN metastasis (TME group, N = 89). Clinical characteristics and the oncological outcome were compared between groups.

Results

The median tumor-to-anal verge distance was 40 mm in both groups. The median maximum long-axis LPLN diameter before CRT was 0 mm in the TME group and 10.5 mm in the LPLD group. Pathological LPLN metastasis was confirmed in 25 patients (66 %) in the LPLD group. Local recurrence at LPLN developed in 3 patients (3.4 %) in the TME group and in none (0 %) of the LPLD group. Multivariate analysis showed that only ypN was an independent prognostic factor for relapse-free survival (RFS), but LPLN metastasis was not associated with poor RFS.

Conclusions

The incidence of LPLN metastasis is high even after preoperative CRT, and LPLD might improve local control and survival of patients with LPLN metastasis in advanced low rectal cancer treated with preoperative CRT.     

Oncologically Safe Distal Resection Margins in Rectal Cancer Patients Treated with Chemoradiotherapy

Introduction

Although current guidelines recommend distal resection margins (DRM) of 2?C5?cm in rectal cancer operation, smaller margins may be safe. We therefore assessed the impact of distal margins on outcomes in patients with rectal cancer treated with neoadjuvant chemoradiotherapy (CRT) followed by radical resection or resection followed by adjuvant CRT.

Materials and methods

This study involved 376 patients who underwent sphincter-saving resection for rectal adenocarcinoma and pre- or postoperative CRT between 2000 and 2006. DRMs were measured on pinned fixed specimens. We excluded patients who did not complete planned CRT and those with stage IV disease. A retrospective cross-sectional analysis was performed.

Results

No significant differences in local recurrence (9.8 versus 7.3?%; P?=?0.324) and systemic recurrence (16.4 versus 18.7?%; P?=?0.731) were observed in patients with DRMs of ??5 and >5?mm, respectively. Moreover, in each DRM category, there were no differences in local and systemic recurrence rates between patients who received pre- or postoperative CRT. DRM did not affect overall survival (P?=?0.880) or 5-year survival rate (80.3 versus76.8?%; P?=?0.340).

Conclusion

A distal margin of at least 5?mm with negative resection margin on frozen section does not reduce oncological safety in rectal cancer patients who receive pre- or postoperative CRT.     

Transanal endoscopic microsurgery for rectal tumors: experience at Korea’s National Cancer Center

Background

Transanal endoscopic microsurgery (TEM) is a minimally invasive alternative to transanal excision, enabling complete local excision of selected benign or malignant rectal tumors. This study aimed to determine the surgical and oncologic results for rectal tumors excised by TEM.

Methods

From November 2001 to October 2007, 45 patients underwent TEM for excision of adenoma (13 patients), carcinoid tumor (6 patients), and carcinoma (26 patients). The patients included 27 men and 18 women with a median age of 52 years (range, 22–72 years).

Results

The median tumor distance from the anal verge was 7 cm (range, 3–15 cm), and the median tumor size was 17 mm (range, 2–60 mm). There was no procedure-related morbidity or mortality. However, one patient with rectal carcinoma died of lung cancer during the follow-up period. Of 13 patients with adenomas, 1 patient (7.7%, 1/13) experienced local recurrence 5 months after surgery. No recurrence occurred for six patients with carcinoid tumors. Histologic examination of the carcinomas showed pathologic tumor (pT) stage 0 (ypT0) in 2 patients, pT1 in 17 patients (including ypT1 in 1 patient), pT2 in 6 patients, and pT3 in 1 patient. Immediate salvage surgery was performed for five patients (19%, 5/26). During a median follow-up period of 37 months (range, 5–72 months), one patient (3.8%, 1/26) experienced local recurrence. The overall and disease-free 5-year survival rates for patients with carcinoma were 96.2% and 88.5%, respectively.

Conclusions

The TEM procedure is a safe and appropriate surgical treatment option for benign rectal tumors. With strict patient selection, it is oncologically safe for early-stage rectal carcinomas.     

Neoadjuvant Concurrent Chemoradiotherapy for Locally Advanced Esophageal Cancer in a Single High-Volume Center

Background

Neoadjuvant chemoradiotherapy (CRT) is now considered the standard of care by many centers in the treatment of both squamous cell carcinoma (SCC) and adenocarcinoma of the esophagus. This study evaluates the effectiveness of a neoadjuvant CRT protocol, as regards pathological complete response (pCR) rate and long-term survival.

Methods

From 2003 to 2011, at Upper G.I. Surgery Division of Verona University, 155 consecutive patients with locally advanced esophageal cancers (90 SCC, 65 adenocarcinoma) were treated with a single protocol of neoadjuvant CRT (docetaxel, cisplatin, and 5-fluorouracil with 50.4 Gy of concurrent radiotherapy). Response to CRT was evaluated through percentage of pathological complete response (pCR or ypT0N0), overall (OS) and disease-related survival (DRS), and pattern of relapse.

Results

One hundred thirty-one patients (84.5 %) underwent surgery. Radical resection (R0) was achieved in 123 patients (79.3 %), and pCR in 65 (41.9 %). Postoperative mortality was 0.7 % (one case). Five-year OS and DRS were respectively 43 and 49 % in the entire cohort, 52 and 59 % in R0 cases, and 72 and 81 % in pCR cases. Survival did not significantly differ between SCC and adenocarcinoma, except for pCR cases. Forty-nine patients suffered from relapse, which was mainly systemic in adenocarcinoma. Only three out of 26 pCR patients with previous adenocarcinoma developed relapse, always systemic.

Conclusions

This study suggests that patients treated with the present protocol achieve good survival and high pCR rate. Further research is necessary to evaluate whether surgery on demand is feasible in selected patients, such as pCR patients with adenocarcinoma.     

Pulmonary resection after chemoradiotherapy for advanced non-small cell lung cancer: the impact of presurgical radiation therapy

Purpose

Chemoradiation therapy (CRT) is recommended as standard care for stage III non-small cell lung cancer (NSCLC), but some patients experience local recurrence after the treatment. Surgical resection after CRT involves high surgical risk, but is expected to increase the curability. This study was performed to investigate the impact of presurgical CRT on the postoperative outcome, focusing especially on the effect of radiation therapy.

Methods

Twenty-six patients with stage III (N2 or T3-4) NSCLC underwent pulmonary resection after CRT. A radiation dose up to 40–70 Gy was given with concurrent chemotherapy. The morbidity, mortality and survival after surgical resection were examined.

Results

Lung resection was performed as lobectomy (73 %) or pneumonectomy (19 %). Postoperative complications occurred in 12 patients (morbidity 46.1 %). The overall 5-year survival of the entire cohort was 69.7 %. The factors associated with favorable long-term survival included a pathological complete response (CR) and mediastinal node negative condition after CRT, and microscopic complete resection.

Conclusion

Surgical resection for stage III patients after CRT may provide a survival benefit with acceptable morbidity. The surgical morbidity may be increased by prior radiation therapy, thus, surgeons should be familiar with the available countermeasures to reduce the surgical risk.     

Transanal Endoscopic Microsurgery vs. Laparoscopic Total Mesorectal Excision for T2N0 Rectal Cancer

Objective

The aim was to compare transanal endoscopic microsurgery (TEM) and laparoscopic resection (LR) in terms of short-term and oncologic outcomes in patients with a preoperatively diagnosed T2N0 extraperitoneal rectal cancer.

Methods

We conducted a retrospective analysis of a prospective database. All patients with a preoperatively staged T2N0 extraperitoneal rectal adenocarcinoma were considered for LR. Patients refusing LR or medically unfit for LR were considered for TEM, which was associated with neoadjuvant RT in the last cases. Only patients with a minimum follow-up of 36?months were included.

Results

Seventy-eight patients were included. TEM was indicated or preferred in 43 patients; of these, 11 underwent neoadjuvant RT. Morbidity was significantly lower after TEM (p?<?0.001). The median follow-up was 70 (36?C140) months. A higher local recurrence rate was noted after TEM (26?%), compared to neoadjuvant RT + TEM (0?%) and LR (9?%) (p?=?0.070). Overall, 5-year survival rate was 76?% after TEM, 77.8?% after RT + TEM, and 96?% after LR, respectively (p?=?0.134).

Conclusions

While TEM alone may only be considered a palliative treatment, it might allow similar oncologic results to abdominal resection in responders to neoadjuvant RT. Large prospective randomized trials are awaited to confirm these findings.     

Factors Associated with Local–Regional Failure After Definitive Chemoradiation for Locally Advanced Esophageal Cancer

Background

Locally advanced esophageal cancer is often treated with a trimodality approach. While a substantial proportion of such patients initially achieve a clinical complete response (cCR) after chemoradiation, only a small proportion achieve durable control. We analyzed patients who reached cCR after definitive chemoradiation for esophageal cancer to identify clinical predictors of local disease recurrence.

Methods

We identified 141 patients who obtained initial cCR after definitive chemoradiation without surgery for esophageal cancer from 2002 through 2009. The initial response to treatment was assessed by endoscopic evaluation and biopsy results, with cCR defined as having no evidence of disease present. Patterns of failure were categorized as in-field (within the planned treatment volume [PTV]), outside the radiation treatment field, or both.

Results

At a median follow-up of 22 months (range, 6–87 months), 77 patients (55 %) had experienced disease recurrence (local or both). Of first failures, 32 (23 %) were outside the radiation field, followed by 30 (21 %) within the field, and 15 (11 %) were both. By multivariate analysis, in-field failure after cCR was associated with a pretreatment standardized uptake value on positron emission tomography of >10 (subhazard ratio [SHR] 3.31, p = 0.023) and poorly differentiated tumors (SHR 3.69, p = 0.031). All failures, in-field and out-of-field, correlated with non-Caucasian ethnicity (SHR 2.55, p = 0.001), N1 disease (SHR 2.05, p = 0.034), T3/T4 disease (SHR 3.56, p = 0.011), and older age (SHR 0.96, p = 0.008).

Conclusions

Our data suggest that selected clinical characteristics can be used to predict failure patterns after definitive chemoradiation. Such risk-assessment strategies can help individualize therapy.     

Prognostic Factors for Postoperative Morbidity and Tumour Response After Neoadjuvant Chemoradiation Followed by Resection for Rectal Cancer

Background and Purpose

In patients with locally advanced rectal cancer treated with neoadjuvant chemoradiation followed by rectal resection, postoperative morbidity is a significant clinical problem. Pathologic complete tumour response seems to give the best prognosis in the long term. Little is known about the factors that are associated with postoperative complications and pathologic complete response. The aim of this retrospective study was to identify and describe these factors.

Methods

Ninety-nine consecutive patients with locally advanced rectal cancer who underwent neoadjuvant chemoradiation (50 Gy and capecitabine) followed by surgery at our institute between January 2007 and May 2012 were identified. Postoperative complications were graded according to the Clavien-Dindo classification. Pathologic tumour response was categorized as complete response or no/partial response.

Results

Postoperative complications occurred in 68 patients (69 %) and grade 3–5 complications in 25 patients (25 %). The 30-day and 90-day mortality were 1 % (n?=?1) and 2 % (n?=?2), respectively. A young age (p?=?0.021) and a preoperative or postoperative blood transfusion (p?=?0.015) independently predicted complications. Intraoperative or postoperative blood transfusion (p?=?0.007) and ypT0-1 stage (p?=?0.037) were independent predictors for grade 3–5 complications. Complete response rate was 22 % (n?=?22); 4 % (n?=?4) of patients showed no response. No independent factors predicting complete response were found.

Conclusions

Neoadjuvant chemoradiation followed by rectal resection is associated with significant postoperative morbidity but minimal postoperative mortality. A complete response rate of 22 % was achieved.     

Paradigm-Shifting New Evidence for Treatment of Rectal Cancer

Background

Treatment of rectal cancer has dramatically evolved during the last three decades shifting toward a tailored approach based on preoperative staging and response to neoadjuvant combined modality therapy (CMT).

Methods

A literature search was performed using PubMed/Medline electronic databases.

Results

Selected patients with T1 N0 rectal cancer are best treated with local excision by transanal endoscopic microsurgery (TEM). Satisfactory results have been reported after CMT and TEM for the treatment of highly selected T2 N0 rectal cancers. CMT followed by rectal resection and total mesorectal excision is considered the standard of care for the treatment of locally advanced rectal cancer. However, a subset of stage II and III patients may not require neoadjuvant radiation treatment. Finally, there are mounting data supporting a “watch and wait” approach or local excision in patients with complete clinical response after neoadjuvant CMT.

Conclusions

Current evidence shows that selected T1 N0 rectal cancers can be managed by TEM alone, while locally advanced cancers should be treated by CMT followed by radical surgery. Studies are underway to identify patients that do not benefit from neoadjuvant radiation therapy. A non-operative approach in case of complete clinical response must be validated by large prospective studies.     

Clinicopathological outcomes of preoperative chemoradiotherapy using S-1 plus Irinotecan for T4 lower rectal cancer

Purpose

To investigate the clinicopathological outcomes of patients with T4 lower rectal cancer treated using preoperative chemoradiotherapy with S-1 plus Irinotecan.

Methods

Between 2005 and 2011, 35 patients with T4M0 lower rectal cancer, diagnosed initially as T4a in 12 and as T4b in 23, were treated with 45 Gy of radiotherapy concomitantly with S-1 plus Irinotecan. The median follow-up period was 50.6 months (range 2–123 months).

Results

A total of 32 patients (91.4 %) completed the radiotherapy and 26 (74.3 %) completed the full chemotherapy regimen. Radical surgery was then performed in 33 (94.3 %) of the 35 patients after the exclusion of two patients, who had macroscopic residual disease. The pathological diagnosis was downstaged from T4a to ypT0-3 in all 12 of those patients (100 %) and from T4b to ypT0-4a in 20 of those 23 patients (87.0 %). The tumor regression grade of 1a/1b/2/3 (complete response) was 10/8/15/2, respectively. In terms of long-term survival, the 5-year local relapse-free survival rate was 74.8 % and the recurrence-free survival rate was 52.0 %.

Conclusions

This regimen may result in favorable downstaging. Moreover, in this series, pathological evidence of involvement of adjacent organs was rare following preoperative chemoradiotherapy, in the patients with disease diagnosed as T4b at the initial staging.

     

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.     

Neoadjuvant chemo‐radiotherapy and rectal cancer: can the UK watch and wait with Brazil?

Objecive It has recently been reported that up to one‐third of patients with nonmetastatic distal rectal cancer managed with neoadjuvant chemoradiation therapy (CRT) had a complete clinical response (cCR) to treatment. In the selected cases, this has been used as the sole treatment. The aim of this study was to determine the frequency of complete pathological response for patients receiving CRT in one centre in the UK. Method Patients receiving 6 weeks of neoadjuvant CRT were identified using the two cancer audit databases in two different tertiary hospitals from January 2002 to November 2007. Pathology was reviewed and the histopathological response of the resected specimen to CRT was evaluated using the Mandard classification (1 = complete response, 5 = no response) Results One hundred and thirty‐two consecutive patients [median age 61 (range 44–86) years, 90 men] with nonmetastatic locally advanced rectal cancer received neoadjuvant chemo radiotherapy between 2002 and 2007 followed by resection of the tumour. Data were available from 129 patients.