Preoperative chemoradiation for rectal cancer: results of multimodality management and analysis of prognostic factors

BACKGROUND: Our goals were to examine the impact of neoadjuvant chemoradiation for rectal cancer on surgical outcomes and to determine prognostic factors predicting improved survival. METHODS: Retrospective cohort of 56 male and 44 female patients. RESULTS: After preoperative chemoradiation, 73% of patients had sphincter-preserving surgery. The 5-year disease-free (DFS) and overall survival rates were 77% and 81%, respectively. Twenty-five percent of patients showed a complete pathologic response. T-level downstaging and pathologic T stage did not correlate with recurrence or survival rates. Pathologic nodal stage was associated with a significant difference in recurrence rates (N(0) 19%, N1 20%, and N2 75%, P = .038) and DFS (N0/N1 vs. N2, 79% vs. 25%, P = .002). CONCLUSION: Neoadjuvant chemoradiation resulted in a high rate of sphincter preservation. Complete pathologic responses after surgery were frequent and although pathologic T stage after surgery did not affect recurrence rates, pathologic nodal response was associated with improved recurrence and survival rates.     

Patterns of residual disease after preoperative chemoradiation in ultrasound T3 rectal carcinoma

Background: Rectal carcinoma tends to recur locally, with invasion of adjacent organs and significant pelvic pain. Both radiation therapy alone and combined chemoradiation have been used in an attempt to decrease the local recurrence rate and thereby improve survival. Although preoperative chemoradiation can clinically downstage rectal tumors, the pathologic extent of the residual disease has not been studied. Methods: Thirty-seven patients with T3 rectal cancer diagnosed by transrectal ultrasonography (uT3) received 45 Gy with continuous infusion 5-fluorouracil (300 mg/m²/day). Proctoscopy with mucosal/submucosal biopsy was performed in patients (16 of 37) posttreatment and before definitive surgery. Results: Microscopic evaluation of the 37 resected specimens showed a 30% (11 patients) pathologic complete remission rate. The pattern of residual disease in the remaining 26 patients showed that nine (25%) had microscopic residual tumor without evidence of mucosal involvement. Of the 14 patients with a negative proctoscopic evaluation and biopsy only, five (36%) had no residual tumor on final pathology. Conclusions: After chemoradiation, the pathologic presentation of rectal cancer may be altered, making endoscopic procedures and mucosal/submucosal biopsies unreliable in detection of residual disease. Despite the relatively good pathologic complete remission rate noted in this study, all patients undergoing chemoradiation for uT3 rectal carcinomas need definitive surgical resection to confirm a complete clinical remission. Presented at the 46th Annual Cancer Symposium of the Society of Surgical Oncology, Los Angeles, California, March 18–21, 1993.     

Complementary use of local excision and transanal endoscopic microsurgery for rectal cancer after neoadjuvant chemoradiation

Background Neoadjuvant therapies have significantly improved local control and survival of patients with rectal cancer. Nevertheless, although a complete pathologic response can be achieved in 30% of cases, a transabdominal surgical resection is always required. This study aimed, for the first time, to test in the literature the feasibility of local excision combined with transanal endoscopic microsurgery (TEM) as a surgical option for patients treated with neoadjuvant chemoradiation. Methods Between July 1997 and December 2002, 30 patients with rectal cancer affected by an extraperitoneal tumor entered a protocol consisting of neoadjuvant chemoradiation followed by surgery. The surgical treatment, consisting of open surgery, local excision, or TEM, was planned according to the patient’s clinical response after chemoradiation and distance from the anal verge. Results A significant clinical downstaging was observed in eight patients. Five of these patients underwent TEM, and three had local excision. Consequently, open surgery was performed for 22 patients. Histology showed six cases of complete pathologic response: three in the open surgery group and three in the transanal excision group. After a mean follow-up period of 47 months, the disease-free survival rate was 77% in the open surgery group and 100% in TEM or local excision group. Conclusions The findings suggest the complementary feasibility of TEM and local excision after neoadjuvant chemoradiation. However, randomized trials are needed to confirm the oncologic safety of this approach.     

新辅助治疗对低位直肠癌患者经腹会阴联合直肠切除术后会阴切口愈合的影响

目的探讨新辅助治疗对于低位直肠癌经腹会阴联合直肠切除术（APR）后会阴切口愈合的影响。方法回顾性分析北京协和医院基本外科2005年1月至2009年1月实施APR术的93例直肠癌患者的临床资料．其中29例行术前新辅助治疗（新辅助治疗组）．64例直接手术（直接手术组）。将会阴伤口愈合情况分为甲、乙、丙级。对比观察两组患者会阴切口愈合情况。结果新辅助治疗组29例术前行局部放疗（50Gv,25次／5周）并同步联合化疗,采用FOLFOX4方案（氟尿嘧啶、奥沙利铂）;APR术后会阴伤口甲级愈合18例（62．1％）,乙级愈合6例（20．7％）,丙级愈合5例（17．2％）：直接手术组会阴伤口甲级愈合41例（64．1％）,乙级愈合15例（23．4％）,丙级愈合8例（12．5％）;两组间伤口感染（丙级愈合）发生率差异无统计学意义（P=0．773）。结论术前新辅助治疗尤其是50Gv的长程放疗不增加APR术后会阴伤口的感染发生率。     

Outcomes in patients treated by laparoscopic resection of rectal carcinoma after neoadjuvant therapy for rectal cancer.

OBJECTIVE: We analyzed the effect of neoadjuvant chemo radiation on feasibility and outcomes in rectal cancer patients undergoing laparoscopic resection of the rectum. METHODS: This was a retrospective analysis of a consecutive series of laparoscopic resections for rectal cancer from 1998 to 2004 (N=60). RESULTS: Eight patients received preoperative chemoradiation therapy (neoadjuvant group) for rectal cancer and 52 patients did not (primary surgical group). The conversion rate was higher in the neoadjuvant group, but this did not reach statistical significance (3/8, 37% in the neoadjuvant group vs. 7/52, 13% in the primary surgical group, P=0.12). Operative time was longer in the neoadjuvant group (170+/-60 vs 228+/-70 min, P=0.03). Complication rates (3/52, 5.7% in the primary surgical vs. 0% in the neoadjuvant group, P=1.0), and a median number of resected lymph nodes (14.5 in the primary surgical vs. 16.0 in the neoadjuvant group, P=0.81) were similar between groups. CONCLUSION: Laparoscopic resection of rectal cancer in patients after preoperative chemoradiation treatment seems to be associated with a higher conversion rate and a longer duration of surgery. No change in mortality and morbidity was detected. We encourage further investigation of laparoscopic rectal surgery for treatment of rectal cancer.     

Preoperative chemoradiation and extended pelvic lymphadenectomy for rectal cancer: Two distinct principles

Extended pelvic lymphadenectomy (EPL) with total mesorectal excision (TME) has been reported to provide oncological benefit in lower rectal cancer in Japan. In Western countries EPL is not widely accepted because of frequent morbidity but instead preoperative chemoradiation (CRT) followed by TME has been established as a standard treatment for decreasing local recurrence. Recently, several studies have focused on the comparison between these two distinct therapeutic approaches in Western countries and Japan. A study comparing Dutch trial data and Japanese data revealed that EPL and RT are almost equivalent in decreasing local recurrence in lower rectal cancer as compared with TME alone. Considering that almost 45% survival can be achieved by EPL even in the presence of metastatic lateral lymph nodes (LLNs), EPL performed by experienced surgeons definitely contributes to decrease local recurrence. On the other hand, a randomized controlled trial in Japan that compared EPL with conventional TME following preoperative RT revealed that EPL is associated with a higher frequency of sexual and urinary dysfunction without oncological benefits in the presence of preoperative RT. On this point, preoperative CRT followed by conventional TME without EPL would be a better therapeutic approach in patients without evident metastatic LLNs. For future treatment, it would be desirable to have a narrower indication for EPL using full advantage of recent improvement in image diagnosis. Although objective comparison of these two principles between Japan and the West is difficult due to differences in patient groups, further studies would lead to the next great step towards future improvement in treating lower rectal cancer.     

新辅助放疗在低位直肠癌中的应用

目的探讨新辅助放疗在低位局部进展期直肠癌中的疗效及其对保肛手术的意义。方法回顾性分析2000~2005年39例行新辅助放疗低位直肠癌病人的临床资料。结果肿瘤距肛缘3~7 cm,平均4.9 cm。放疗后21例(53.8%)排便困难、便血等症状得以改善。腹会阴联合切除14例,低位前切除术13例,Parks术8例,Hartm ann术4例。术后病理显示肿瘤完全消退(CR)3例,肿瘤部分缓解(PR)22例,无效(NR)14例,总有效率为64.1%(25/39)。保肛率为53.8%(21/39),其中放疗有效者(CR PR)保肛率为64%(16/25),无效者为35.7%%(5/14),两者间差异有显著性意义(P<0.01)。结论新辅助放疗对多数直肠癌病人有效,可以使肿瘤缩小、降低分期,并可提高低位直肠癌的保肛率。     

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....     

Preoperative chemoradiation in patients with resectable rectal cancer: Results on tumor response

Background There is no consensus about the role of preoperative radiotherapy (RT) and chemotherapy (CT) in patients with resectable cancer of the distal rectum. This study analyzed the local clinical and pathologic response in patients receiving preoperative RT/CT for rectal cancer. Methods Thirty-two consecutive patients with a palpable adenocarcinoma of the rectum received preoperative RT (45 Gy in 25 fractions over 5 weeks), plus continuous chemotherapy with doxifluridine and leucovorin or 5-fluorouracil by continuous intravenous infusion during RT. Surgery was performed 8 weeks later. The Wilcoxon andχ ² tests were used for data analysis. Results Twelve patients had mild gastrointestinal toxicity, only one of whom required interruption of therapy. The tumor shrank to 57.8% of its original size, and at the echoendoscopy (u) there was a 58.7% decrease of the maximum diameter (P<.001). Downstaging from uT3 and uT2 to <uT3 and <uT2, respectively, occurred in 41.6% of patients (P=.0020). Total and major regression of the tumor at the histopathologic examination occurred in 12.5% and 50% of patients. Conclusions Local response to preoperative RT/CT was highly satisfactory and allowed conservative surgery in 81% of patients. Optimization of the combined therapy could achieve even better results.     

Long-term results of preoperative chemoradiation for distal rectal cancer correlation between final stage and survival

Neoadjuvant chemoradiation treatment (CRT) has resulted in significant tumor downstaging and improved local disease control for distal rectal cancer. The purpose of the present study was to determine the correlation between final stage and survival in these patients regardless of initial disease stage. Two hundred sixty patients with distal (0-7 cm from anal verge) rectal adenocarcinoma considered resectable were treated by neoadjuvant CRT with 5-FU and leucovorin plus 5040 cGy. Patients with incomplete clinical response 8 weeks after CRT completion were treated by radical surgical resection. Patients with complete clinical response were managed by observation alone. Overall survival and diseasefree survival were compared according to Kaplan-Meier curves and log-rank tests according to final stage. Seventy-one patients (28%) showed complete clinical response (clinical stage 0). One hundred sixtynine patients showed incomplete clinical response and were treated with surgery. In 22 of these patients (9%), pathologic examination revealed pT0 N0 M0 (stage p0), 59 patients (22%) had stage I, 68 patients (26%) had stage II, and 40 patients (15%) had stage III disease. Overall survival rates were significantly higher in stage c0 (P = 0.01) compared with stage p0. Disease-free survival rate showed better results in stage c0, but the results were not significant. Five-year overall and disease-free survival rates were 97.7% and 84% (stage 0); 94% and 74% (stage I); 83% and 50% (stage II); and 56% and 28% (stage III), respectively. Cancer-related overall and disease-free survival may be correlated to final pathologic staging following neoadjuvant CRT for distal rectal cancer. Also, stage 0 is significantly associated with improved outcome. Presented at the Forty-Fifth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, Louisiana, May 15–19, 2004 (oral presentation).     

The effect of neoadjuvant chemoradiation therapy on the prognostic value of lymph nodes after rectal cancer surgery

Background

Neoadjuvant therapy may affect the prognostic impact of total lymph node harvests and lymph node positivity after surgery for rectal cancer.

Methods

We performed a retrospective review of 390 consecutive patients with histologically confirmed rectal cancer. Postoperative follow-up evaluation and survival were confirmed via medical record review. The impacts of lymph node positivity and total lymph node harvest on survival and recurrence are reflected as proportional hazard ratios (HRs).

Results

A total of 221 patients underwent neoadjuvant therapy, of whom 75 had positive nodes. Node-positive patients showed a significantly shorter survival time (HR, 2.89; P = .002) and time to local recurrence (HR, 6.36; P = .031) compared with patients without positive nodes. Survival and recurrence were not significantly different between patients with a total harvest of fewer than 12 nodes and patients with a higher lymph node harvest.

Conclusions

After neoadjuvant treatment and total mesorectal excision, lymph node positivity is associated with significantly shorter survival and time to local recurrence in rectal cancer patients, whereas absolute total lymph node harvests likely have little impact on prognosis.     

Laparoscopic versus robotic rectal resection for rectal cancer in a veteran population

Background

Robotic rectal cancer resection remains controversial. We compared the safety and efficacy of laparoscopic vs robotic rectal cancer resection in a high-risk Veterans Health Administration population.

Methods

Patients who underwent minimally invasive rectal cancer resection were identified from an institutional colorectal cancer database. Baseline characteristics and outcomes were compared between robotic and laparoscopic groups.

Results

The robotic group (n = 13) did not differ significantly from the laparoscopic group (n = 59) with respect to baseline characteristics except for a higher rate of previous abdominal surgery. Robotic patients had significantly lower tumors, more advanced disease, a higher rate of preoperative chemoradiation, and were more likely to undergo abdominoperineal resection. Robotic rectal resection was associated with longer operative time. There were no differences in blood loss, conversion rates, postoperative morbidity, lymph nodes harvested, margin positivity, or specimen quality between groups.

Conclusions

The robotic approach for rectal cancer resection is safe with similar postoperative and oncologic outcomes compared with laparoscopy.     

直肠癌新辅助治疗有效性与安全性的Meta分析

目的系统评价新辅助治疗在直肠癌中的治疗作用及其对术后并发症的影响。方法检索2010年5月前在PubMed．Ovid,WebofScience,Springer-Link,ElsevierScienceDirect等数据库已公开发表的比较直肠癌新辅助治疗与单纯手术或术后辅助治疗的随机对照试验（RCT）,并进行入选标准和质量评价．对符合标准的文献提取相关临床效应指标进行Meta分析。结果11篇RCT共7407例患者纳入分析．新辅助治疗组3685例,对照组为3722例。直肠癌新辅助治疗组局部复发率（OR=O．43,95％CI：0．37-0．50,P〈0．01）、远处转移率（OR=0．85,95％CI：0．76-0．95,P〈0．01）、5年生存率（RR=1．15,95％CI：1．04-1．28,P〈0．01）及保肛手术率（RR=I．48,95％CI：1．17-1．87,P〈0．01）均优于对照组,差异有统计学意义,但术后死亡率（DR=1．20,95％CI：0．68-2．13,P=0．53）及吻合口并发症发生率（OR=1．04,95％CI：0．73-1．48,P=0．84）的差异无统计学意义。结论直肠癌新辅助治疗有利于控制局部及远处复发．提高远期生存,未明显增加术后并发症的发生率。     

新辅助治疗后腹腔镜直肠癌根治术的中短期疗效

目的：探讨中低位直肠癌患者在新辅助治疗后行腹腔镜手术的安全性、可行性。 方法：回顾性分析41例新辅助治疗后行腹腔镜手术的中低位直肠癌患者（观察组）与同期48例单纯腹腔镜手术（对照组）中低位直肠癌患者的临床资料。比较两组患者的手术相关指标、术后恢复情况及术后并发症发生率。 结果：两组患者术前条件具有可比性,两组均无手术相关死亡患者。观察组淋巴结清除数明显低于对照组（8.3 vs. 15.2,P<0.01）,其余手术相关指标、术后恢复情况以及术后并发症发生率两组间差异均无统计学意义（均P>0.05）。 结论：腹腔镜直肠癌根治术在行新辅助治疗后的中低位直肠癌患者中应用是安全、可行的。     

腹腔镜和开腹Dixon手术根治直肠癌的短期疗效对比

【摘要】〓目的〓比较腹腔镜和开腹Dixon手术根治直肠癌的疗效。方法〓84例直肠癌患者非随机分为腔镜组44例和开腹组40例,比较两组患者的淋巴结清扫数目、肿瘤距远端切缘的距离、手术所需时间、术中出血量、术后肛门排气时间、术后并发症发生情况、住院时间及住院总费用。结果〓腔镜组与开腹组的淋巴结活检数目分别为分别为12.91±3.58枚和14.33±3.38枚,肿瘤距远端切缘的距离分别为3.15±0.61cm和3.28±0.74 cm,两组相比较,差异均无统计学意义(P均>0.05)。腔镜组与开腹组的手术时间分别为191.75±23.06 min和154.80±12.99 min,术中出血量分别为132.63±35.73 mL和181.02±75.79 mL,肛门排气时间分别为 2.93±1.33天和4.70±1.39天,住院时间分别为11.38±2.00天和16.82±1.85天,住院总费用分别为3.69±0.30万元和3.03±0.37万元,两组相比较,差异均有统计学意义(P均<0.05)。腔镜组和开腹组并发症的发生率分别为9.1%和17.5%,两组比较,差异无统计学意义(P>0.05)。结论〓腹腔镜Dixon手术根治直肠癌的短期疗效优于开腹Dixon手术。     

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目的探讨将新辅助化放疗与全直肠系膜切除(TME)操作规范相结合能否进一步提高局部进展期低位直肠癌的治疗效果。方法2001年5月至2004年6月,将60例T3、T4期的低位直肠癌随机分为二组,给予放疗40～46Gy/20～23次,每周5次,每次2Gy。A组同时给予卡培他滨2500mg/(m2·d),分2次口服,服用14d休息7d;B组给予卡培他滨1250mg/(m2·d),分2次口服,从放疗开始连续服用至手术,放疗结束后休息6周进行手术。手术均按TME操作规范进行。结果全部病例按计划完成新辅助化放疗,其中9例肿瘤完全消失,未行手术。51例施行了根治性切除术,49例为保肛手术,2例为腹会阴切除术,故全组实际保留肛门率为96.67%(58/60)。病理结果显示8例肿瘤消失(T0)。总的肿瘤消失为17例,T2N011例,T3N019例,T2-3N113例,无T4期。总共43例(71.67%)达到降期(downstaging)。全组均获随访,随访时间6～38个月,中位24个月。随访中无局部复发,2例肺转移,总复发率3.33%,无死亡,无瘤生存和无复发生存率均为96.67%。新辅助化放疗的副反应发生率为28.67%,2例Ⅲ级均发生在手足综合征。结论新辅助治疗与TME操作规范相结合有效地达到肿瘤降期的目的,肿瘤缩小,切除率和肿瘤保肛率均明显增加,进一步降低了复发的风险,提高了长期生存的希望;副反应轻、安全、病人耐受好。