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Radiation therapy (RT) is one of main methods of comprehensive treatment of esophageal cancer (EC). It plays a dual role in the immune system and can activate systemic immune response. However, the effect of tumor cytotoxicity induced by RT is limited, and it can induce abscopal effect in combination with immunotherapy (IT). A number of clinical studies have shown the effect and great potential of immune checkpoint inhibitors (ICIs), such as PD-1/L1 antibodies in advanced EC. Besides, RT and ICIs exert a synergistic effect. Currently, multiple ongoing studies related to concurrent radiochemotherapy combined with IT is expected to determine the efficacy of this comprehensive treatment in EC and elucidate the efficiency and cost-effectiveness.
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Objective To systematically evaluate the efficacy and safety between neoadjuvant therapy followed by radical surgery and definite chemoradiotherapy in the treatment of Ⅰ B2-Ⅱ B cervical cancer.Methods A computerized search was performed in PubMed,Embase,Cochrane Library,Web of Science,CBM,Wanfang Data,CNKI and VIP to collect controlled clinical trials related to neoadjuvant therapy followed by radical surgery versus definite chemoradiotherapy in the treatment of ⅠB2-ⅡB cervical cancer.The meta-analysis of survival data and adverse events was performed by Review Manager 5.3 software.Results Nine controlled clinical trials involving 3 914 patients were included in this meta-analysis.There were no significant differences in overall survival (HR =0.83,P =0.31) and progression-free survival (HR=O.85,P=0.57) between two groups.Compared with patients receiving definite chemoradiotherapy,those in the neoadjuvant therapy group had a significantly lower risk of irradiation enteritis (RR=0.27,P=0.03),whereas no significant difference was observed in the risk of irradiation cystitis (RR=0.30,P=0.34) and grade ≥ 3 neutropenia (RR=0.77,P=0.46) between two groups.Conclusion In the treatment of locally advanced ⅠB2-Ⅱ B cervical cancer,two modalities show similar survival benefits.Although the neoadjuvant therapy group yields a lower incidence of irradiation enteritis,the incidence rates of irradiation cystitis and grade ≥3 neutropenia do not significantly differ between two groups.Neoadjuvant therapy followed by radical surgery is not superior to the standard therapeutic regime.
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Objective To screen predictors for the prognosis of patients with inoperable locally advanced esophageal squamous carcinoma (LAESC) who are undergoing concurrent radiochemotherapy and establish a preliminary scoring system. Methods The data of 75 patients with inoperable LAESC who were undergoing intensity-modulated radiation therapy and concurrent chemotherapy were collected and analyzed to determine whether the prognosis was associated with medical history,vital signs,and the results of routine blood test and liver and kidney functions test before and at the end of radiochemotherapy. The prediction efficacy of the model was assessed using the receiver-operating characteristic curve. The degree of fitting was tested using the Hosmer-Lemeshow goodness-of-fit test. Results Seventy-five patients with LAESC were included. The univariate analysis indicated that the prognosis of the patients with LAESC who were undergoing concurrent radiochemotherapy was associated with weight loss of more than 5％,poor dietary habit,and significant decrease in white blood cell count (P = 0.047,0.074,and 0.074). The multivariate Cox model was conducted,and a scoring system for prediction of prognosis was established. The scores were 1.5 for weight loss of more than 5％,1.0 for poor dietary habit,and 1.0 for a significant decrease in white blood cell count (more than 2.0×109/L). A total score of more than 2.25 indicated a high mortality risk,with a sensitivity of 0.559 and a specificity of 0.805. Conclusion The simple and practical scoring system for prediction of prognosis of patients with LAESC in this study could generally predict the mortality risk of patients with inoperable LAESC who are undergoing concurrent radiochemotherapy.
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Objective To investigate the clinical effect of induction chemotherapy plus concurrent radiochemotherapy in the treatment of locally advanced non-small cell lung cancer (NSCLC) through a meta-analysis.Methods CBM, CNKI, Cochrane Library, PubMed, and EMbase were searched for the articles on comparison between induction chemotherapy plus concurrent radiochemotherapy and concurrent radiochemotherapy for patients with locally advanced NSCLC.According to the inclusion and exclusion criteria, the data on short-term outcome and survival were collected.A Meta-analysis was performed to evaluate the clinical effect of induction chemotherapy followed by concurrent radiochemotherapy.Results A total of 5 articles were included, which involved 845 patients.The results showed that the short-term outcome and the 2-and 3-year survival rates were similar between patients receiving induction chemotherapy plus concurrent radiochemotherapy and those receiving concurrent radiochemotherapy ( OR=0.875, 95% CI 0.507-1.510, P=0.631;HR=0.770, 95% CI 0.515-1.151, P=0.203;HR=0.809, 95% CI 0.559-1.172, P=0.262), but the patients receiving induction chemotherapy plus concurrent radiochemotherapy showed a significantly higher incidence rate of grade ≥ 3 leukopenia than those receiving concurrent radiochemotherapy alone ( OR=0.637, 95% CI 0.435-0.931, P=0.020).Conclusions Induction chemotherapy plus concurrent radiochemotherapy shows no significant advantages over concurrent radiochemotherapy alone in the short-term outcome and 2-and 3-year survival rates, but it significantly increases myelosuppression.Since there are few studies involving a limited number of cases included in this analysis, more multicenter randomized trials are needed to provide more detailed data and further clarify the clinical value of induction chemotherapy plus concurrent radiochemotherapy.
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Objective To observe the primary clinical effect of concurrent radiochemotherapy for patients with nasal cavity natural killer (NK)/T cell lymphoma and to analyze the prognostic factors.Methods 31 primary untreated patients with stage Ⅱ nasal cavity NK/T cell lymphoma were enrolled for this study.All patients underwent concurrent radiochemotherapy with intensity-modulated radiotherapy technique + asparaginase based chemotherapeutic agents and adjuvant chemotherapy.Results The main toxicities were mouth mucocitis,myelosuppression and xerosmia at grade 1 or 2.31 patients achieved good clinical shortterm effect with high local complete remission rate at the 3rd month after radiotherapy [83.9 ％ (26/31)],and the 2-year overall survival rate was 77 ％.Univariate and multivariate analysis suggested IPI score and clinical short-term effect were the significant independent survival prognostic factors (P ＜ 0.05).Conclusions Concurrent radiochemotherapy for stage Ⅱ nasal cavity NK/T cell lymphoma can be well tolerated by patients with mild toxicities,and can improve both clinical short-term effect and overall survival by high local complete remission rate.IPI score and clinical short-term effect are the important survival prognostic factors.
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Objective To evaluate and compare the clinical outcomes of concurrent chemoradiotherapy with different radiation doses for esophageal carcinoma. Methods 78 cases of esophageal carcinoma receiving primary definitive treatment in our department between May 1 , 2005 to June 31 2007 were analyzed retrospectively. The patients with esophageal carcinoma were divided into high- ( > 50 Gy, median dose of 64 Gy) and low-dose (50 Gy) groups according to their prescription doses (n = 35, 43, respectively). Chemotherapy regimen consisted of cisplatin (75 mg/m2, d1) and 5-FU (500 ~ 600 mg/m2, D2 ~ 5) starting at days 1, 28, 49 and 70 after the beginning of radiotherapy with 2 ~ 4 cycles. The two groups were compared in terms of the early treatment outcomes, the side effects and survival rates. Results The 1,3 and 5-year survival rates for the high and low dose groups were 71.4%, 34.3%, 25.7%and 76.7%, 41.9%, 30.2%, respectively. The median survival time was 19 and 22 months respectively without statistical difference. The high dose group was more likely to have higher incidence rate of grade Ⅲ to Ⅳ myelosuppression in spite of the statistical difference. The high dose group had significantly higher incidence of esophagitis than did the low dose group (P=0.040). Conclusion For esophageal carcinoma with only indications of concurrent chemoradiotherapy, te low dose radiation (50 Gy) has comparable outcomes and less side effects compared with the high dose radiation (>50 Gy).
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OBJECTIVE: We evaluated pseudoprogression (PsPD) following radiation therapy combined with concurrent temozolomide (TMZ), and we assessed pseudoresponse following anti-angiogenic therapy for patients with recurrent disease using the Response Assessment of the Neuro-Oncology Working Group. METHODS: Patients who were pathologically confirmed as having high-grade glioma received radiotherapy with concurrent TMZ followed by adjuvant TMZ. Bevacizumab (Avastin) with CPT-11 were used as a salvage option for cases of radiologic progression. Magnetic resonance imaging (MRI) was routinely performed 1 month after concurrent radiochemotherapy (CRT) and every 3 months thereafter. For cases treated with the bevacizumab-containing regimen for progressive disease, MRI was performed every 2 months. RESULTS: Of 55 patients, 21 (38%) showed radiologic progression within 4 weeks after CRT. Of these patients, 16 (29%) showed progression at second post-CRT MRI (etPD) and five (9%) showed improvement (PsPD). Seven of thirty-four initially non-progressed patients showed progression at the second post-CRT MRI (ltPD). No difference in survival was observed between the etPD and ltPD groups (p=0.595). Five (50%) of ten patients showed a radiological response after salvage bevacizumab therapy. Four of those patients exhibited rapid progression immediately after discontinuation of the drug (drug holiday). CONCLUSION: Twelve weeks following treatment could be the optimal timing to determine PsPD or true progression. MRI with gadolinium enhancement alone is not sufficient to characterize tumor response or growth. Clinical correlation with adequate follow-up duration and histopathologic validation may be helpful in discriminating PsPD from true progression.
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Humans , Chemoradiotherapy , Follow-Up Studies , Gadolinium , Glioma , Magnetic Resonance Imaging , Radiotherapy , BevacizumabABSTRACT
Multidisplinary treatment is the mordent means of local-regional gastric cancer therapy, and individualized treatment decisions are dependent on the patient's characteristics. Stage II patients previously treated with standard D2 resection should receive oral administration of S-1 or combination chemotherapy of XELOX. However, patients at stage IIIb or at a more advanced stage should receive combination treatment as priority. Concurrent radiochemotherapy was recommended to treat patients that had been operated by D0 or D1 resection. Perioperative chemotherapy is more reasonable than pure neoadjuvant chemotherapy. No evidence has verified that perioperative or neoadjuvant chemotherapy leads to better survival compared with postoperative adjuvant chemotherapy. The value of chemotherapy before operation is rest with the effect of downstaging and conversion of the unresectable tumor to a resectable one. Con-current radiochemotherapy prior to an operation needs further investigation to affirm its high efficacy of downstaging and conversion.
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Objective To evaluate the efficacy and side effects of extensive regional field radiotherapy concurrent with chemotherapy for locally advanced esophageal cancer.Methods Of the 101 patients with locally advanced esophageal cancer patients,44 patients were treated by involved field radiotherapy alone,29 patients treated by involved field radiotherapy combined with chemotherapy,and 28 patients received extensive regional field radiotherapy combined with chemotherapy,the total dose of radiotherapy was 60 Gy.The clinical target volume (CTV) of involved field included the gross tumor volume (GTV) plus a 0.8 cm lateral margin,the tumor plus a nominal 3-5 cm cephalad and caudal margin.Extensive regional field radiotherapy was delivered in two steps:the CTV included the CTV of the involved field plus elective nodal region in the first step;in the second step,the CTV definition was same with the CTV of the involved field.Synchronous chemotherapy regimens included TP and NP.Results 90.1％patients completed planned radiotherapy,all patients in the concurrent chemotherapy groups completed at least one cycle of chemotherapy.The follow-up rate was 99％.Twenty-four and 42 patients completed followed-up more than 24 months in the radiotherapy alone and concurrent chemoradiotherapy group,respectively.The median survival time of the involved field radiotherapy group,involved field chemoradiotherapy group and extensive regional field chemoradiotherapy group was 13,21 and 19 months,respectively;the 2-year overall survival (OS) rate was 15％,48％ and 46％,respectively for the three groups.The 2-year OS rate was improved significantly in the chemoradiotherapy group (x2 =6.83,P =0.033).Compared with radiotherapy alone group,the incidence of grade three or four bone marrow suppression was higher in the concurrent chemoradiotherapy group (53％: 0 ％,x2 =32.94,P =0.000),the remaining adverse events (acute radiation pneumonitis,acute radiation esophagitis,esophageal fibrosis,late radiation lung injury) had no significant intergroup differences (x2 =5.56,6.70,2.39,0.42,P =0.235,0.349,0.881,0.981).Conclusions Compared with radiotherapy alone,concurrent chemoradiotherapy can improve the survival rate for locally advanced esophageal cancer.The side effects of the extensive regional field radiotherapy combined with chemotherapy is well tolerated.But the efficacy of the extensive regional field radiotherapy combined with chemotherapy needs further research.
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ObjectiveTo determine the maximal tolerated dose and the dose-limiting toxicity of hydroxycamptothecin (HCPT)concurrently combined with three-dimensional conformal radiotherapy (3DCRT) for unresectable or locally relapsed rectal cancer.Methods Twenty-two patients with rectal cancer were enrolled into phase Ⅰstudy between 2004 -2007. HCPT was intravenously administered concurrently with 3DCRT weekly,dose given from 6,8,10 mg/m2 or twice a week,dose given from 4,6,8,10 mg/m2,respectively.Total radiation dose of 50 Gy was delivered to the whole pelvis at a fraction of 2 Gy per day for 5 weeks,with 10 - 16 Gy subsequent boost to tumor area.Dose-limiting toxicities (DLT) were defined as grade 3 or higher non-hematologic toxicity or grade 4 hematologic toxicity.ResultsIn the twice a week group,DLTs of grade 3 diarrhea were observed in 2 patient treated at dose of 6 mg/m2.In the weekly group,DLTs of grade 3 diarrhea and radiation-induced dermatitis were observed in Ⅰ patient at dose of 8mg/m2,and were not observed in the next 3 patients at the same dose level.However,at dose of 10 mg/m2,2 patients had grade 3 diarrhea or nausea.The 5-year overall survival rate was 23％ and the median survival time was 18 months.ConclusionsHCPT given concurrently with 3DCRT is safe and tolerable for patients with unresectable or locally relapsed rectal cancer.Either 8 mg/m2 weekly or 4 mg/m2 twice a week can be recommended for further study.The dose-limiting toxicities are grade 3 diarrhea,nausea and radiation-induced dermatitis.
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Objective To evaluate clinical factors as predictors of radiation pneumonitis(RP)in advanced stage non-small cell lung cancer(NSCLC)patients treated with concurrent radiochemotherapy when gross tumor volume is 70 Gy. Methods Data of 84 patients with histologically proved NSCLC treated with 3DCRT or IMRT were collected. To evaluate the correlation between clinical parameters and radiation pneumonitis(RP). The clinical parameters were considered: pathological type, therapy agents, age,gender, stage, karnofsky performance status(KPS), smoking status, diabetes, chronic obstructive pulmonary disease(COPD). Results The occurrence of grade 1,2 RP was 63%, 33%, respectively. In univariate analysis, diabetes was significantly associated with RP of ≥ grade 1(x2 =4.03, P = 0.045)and ≥grade 2(x2 = 15.59 ,P =0.000). KPS was significantly associated with RP of ≥grade 1(x2 =3.98 ,P = 0.046)and ≥grade 2(x2 = 5.21, P = 0.023). In logistic multivariate analysis, diabetes was significantly associated with RP of ≥grade 1(x2 =5.50,P =0.019)and ≥grade 2(x2 = 12.92,P =0.000). KPS was significantly associated with RP of ≥ grade 1(x2 = 6.29, P = 0.012)and ≥ grade 2(x2 = 6.61, P =0.010). Conclusion The definite statistical significant risk factors of RP are diabetes and KPS.
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OBJECTIVE: Concurrent chemoradiation has improved survival of patients with cervical carcinoma. However, follow-up of randomized studies is relatively short and data on long term toxicity are scarce, as is information on their health-related quality of life. This study assesses and compares incidences of late side-effects among patients treated with radiotherapy or chemoradiation using two toxicity scoring systems, and investigates impact on health-related quality of life. METHODS: Between 1985 and 1993, 114 patients underwent radiotherapy (n=39) or chemoradiation (n=75) for stage IIA-IVB cervical carcinoma. Late side-effects were scored retrospectively by reviewing medical charts using standardised checklists, focusing on bladder- and intestinal side effects. Health-related quality of life was assessed once using the EORTC QLQ-C30. RESULTS: No significant differences in late treatment-related side-effects between radiotherapy and chemoradiation groups were found. Grade > or = 2 toxicity was found in 33% (bladder), and in 6% (bowel). Only 1.8% had both grade 3-4 toxicity. Bladder syndrome with high urinary frequency, urine incontinence and small bowel toxicity had a significant impact on health-related quality of life. CONCLUSION: Grade 2 are relatively frequent late side effects in curatively treated patients, but are not enhanced by the addition of chemotherapy. Their negative impact on health-related quality of life stresses the importance of new radiation techniques, aiming at reduction of these side effects.
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Humans , Checklist , Chemoradiotherapy , Follow-Up Studies , Incidence , Quality of Life , Retrospective Studies , Urinary BladderABSTRACT
Objective To decrease radiation induced toxicities especially mucostis in patients with locally advanced nasopharyngeal carcinoma( NPC ) who underwent concurrent radiochemotherapy, the maximum tolerated dose and dose limited toxicities of capecitabine combination with cisplatin were observed. Methods From Aug 2006 to Oct 2007, 24 patients with intensity modulated radiotherapy(IMRT) and concurrent chemotherapy with capecitabine and cisplatin for nasopharyngeal carcinoma(stages Ⅲ-Ⅳ) were enrolled in this study. There were four dose-level groups of Capecitabine[625-1250 mg/(m2 ·d) , d1-14]and fixed cisplatin dose[20 mg/(m ·d) ,d1-5) ]MRI and CT scan were used for evaluation of tumor shrinkage. Treatment related toxicities were evaluated according to the common toxicity criteria( NCI-CTC Version 3.0). Results The acute side-effects include Grade 3 or Grade 4 mucosal toxicity(lasting for at least 5 d) and Grade 3 or Grade 4 non-mucosal toxicity were evaluated. Group 625 mg/m2 and Group 825 mg/m2 had none, Group 1000 mg/m2 had 6 patients and Group 1250 mg/m2 had 3 patients for mucosal toxicity, which were the main dose-limited toxicity and relevant to the dose of capecitabine apparently( P < 0. 05 ). There was also a trend of increase by the dose level of capecitabine for other toxicities. The median follow-up time for all patients was 28. 5 months. The locoregional recurrence occurred in 2 patients and distant metastasis in 2 patients. Two-year overall survival rate and locoregional control rate were 100% and 91.7%, respectively.Complete response and partialresponse were found on MRI or CT scan in patients of 29. 2% at the end of treatment and 83. 3% after three months, respectively. Conclusions The combination regimen of capecitabine and cisplatin is safe and effective according to the preliminary result. Toxicities related to radiochemotherapy for NPC were significantly associated with the dose level of chemotherapy.
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Objective A phase Ⅰ study was conducted to determine the maximal tolerated dose (MTD) and the dose-limiting toxicity(DLT) of chemotherapy of oral doxifluridine(5-dFUR) and leucovorin with concurrent standard radiotherapy(RT) as adjuvant treatment in patients with rectal cancer. Methods Patients aged 18-75 years old, Karnofsky scored ≥70%, stage Ⅱ/Ⅲ rectal cancer after curative surgery were eligible. Total RT dose was delivered as DT 50 Gy in the fraction of 2.0 Gy per day for 5 weeks to the pelvic area. 5-dFUR was administered concurrently with radiotherapy in escalating doses, and oral leucovorin was The DLTs included grade 3 or grade 4 hematologic and nonhematologic toxicity. Results From Aug. 2005 the most common side effects although all neutropenia was less grade 3. The DLT was observed in 1 patient of RT. In the following 3 enrolled patients, one suffered grade 3 abdominal cramp pain, diarrhea, fatigue, nausea/vomit and grade 2 neutropinea and fever. Grade 3 diarrhea was also observed in all the additional 3 papatients didn't complete the scheduled concurrent chemoradiotherapy due to severe side effects,including 1 at grade 3 abdominal cramp pain,fatigue and nausea/vomit. Conclusions Diarrhea is the most common and severe side effect in this phase Ⅰ study. The MTD of doxifluridine, concurrently with RT and fixed dose of oral cramp pain is often accompanied with diarrhea and nauser/vomit when the dose of doxifluridine exceeds 550 mg/( m2 · d) or 900 mg/d,patients need to be observed carefully.
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PURPOSE: This study reports the results of the use of preoperative concurrent radiochemotherapy (CRCT) for the treatment of locoregionally advanced esophageal cancer. MATERIALS AND METHODS: From 1998 through 2005, 61 patients with intrathoracic esophageal cancer at stages II-IVB (without distant organ metastasis and presumed to be respectable) received preoperative CRCT. CRCT consisted of radiotherapy (45 Gy /25 fractions /5 weeks) and FP chemotherapy (5-FU 1 g/m2/day, days 1-4 and 29-32, Cisplatin 60 mg/m2/day, days 1 and 29). An esophagectomy was planned in 4~6 weeks after the completion of CRCT. RESULTS: There were two treatment-related deaths. Among the 61 patients, 53 patients underwent surgery and 17 patients achieved a pathological complete response (pCR). The overall survival (OS) rates of all 61 patients at 2 and 5 years were 59.0% and 38.0%, respectively. The rates of OS and disease-free survival (DFS) of the surgically resected patients at 2 and 5 years were 61.6%, 40.1% and 53.3%, 41.8%, respectively. By univariate analysis, achieviement of pCR and a clinically uninvolved distant lymph node (cM0) were favorable prognostic factors for OS and DFS. There were 27 patients that experienced a relapse-a locoregional relapse occurred in 5 patients, a distant metastasis occurred in 12 patients and combined failure occurred in 10 patients. CONCLUSION: The results of the current study are favorable. pCR and an uninvolved distant lymph node were found to be favorable prognostic factors.
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Humans , Chemoradiotherapy , Cisplatin , Disease-Free Survival , Drug Therapy , Esophageal Neoplasms , Esophagectomy , Lymph Nodes , Neoplasm Metastasis , Polymerase Chain Reaction , Radiotherapy , Recurrence , Treatment OutcomeABSTRACT
Lung cancer remains the leading cause of cancer death in the worldwide.Approximately 45% of patients present with stage III disease.For patients with unresectable stage IIIA/B disease,Several clinical trials demonstrated concurrent chemoradiotherapy was superior to TRT alone and sequential chemoradiotherapy.Chemoradiotherapy is a standard treatment for unresectable locally advanced non-small cell lung cancer(NSCLC),Cisplatin-based chemotherapy with concurrent thoracic radiotherapy yields a 5-year survival rate of approximately 15% for patients with unresectable locally advanced NSCLC.Despite a substantial number of clinical trials,The most effective chemotherapy combination,the use of induction or consolidation chemotherapy in addition to the concurrent portion of therapy,and the optimal dose of chemotherapy with concurrent TRT have yet to be determined.In addition to evaluating optimal sequencing strategies of combined modality therapy,current investigations are also focusing on the integration of novel agents,including chemotherapeutic and targeted therapies.Currently ongoing trials involving novel approaches are reviewed here.
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PURPOSE: To report the early results of preopeartive concurrent radio-chemotherapy (CRCT) for treating rectal cancer. MATERIALS AND METHODS: From June 1999 to April 2002, 40 rectal cancer patients who either had lesions with a questionable resectability or were candidates for sphincter-sacrificing surgery received preoperative CRCT. Thirty-seven patients completed the planned CRCT course. 45 Gy by 1.8 Gy daily fraction over 5 weeks was delivered to the whole pelvis in the prone position. The chemotherapy regimens were oral UFT plus oral leucovorin (LV) in 12 patients, intravenous bolus 5-FU plus LV in 10 patients, and intravenous 5-FU alone in 15 patients (bolus infusion in 10, continuous infusion in 5). Surgery was planned in 4~6 weeks of the completion of the preoperative CRCT course, and surgery was attempted in 35 patients. RESULTS: The compliance to the current preoperative CRCT protocol was excellent, where 92.5% (37/40) completed the planned treatment. Among 35 patients, in whom surgery was attempted after excluding two patients with new metastatic lesions in the liver and the lung, sphincter-preservation was achieved in 22 patients (62.9%), while resection was abandoned during laparotomy in two patients (5.7%). Gross complete resection was performed in 30 patients, gross incomplete resection was performed in one patient, and no detailed information on the extent of surgery was available in two patients. Based on the surgical and pathological findings, the down-staging rate was 45.5% (15/33), and the complete resection rate with the negative resection margin 78.8% (26/33). During the CRCT course, grade 3~4 neutropenia developed in four patients (10.8%). Local recurrence after surgical resection developed in 12.1% (4/33), and distant metastases after the preoperative CRCT start developed in 21.6% (8/37). The overall 3-years survival rate was 87%. CONCLUSION: Preoperative CRCT in locally advanced rectal cancer is well tolerated and can lead to high resection rate, down-staging rate, sphincter preservation rate, however, longer term follow-up will be necessary to confirm these results.