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Abstract Background: Colorectal cancer is one of the most common types of cancer and is associated with a high lethality rate. Treatment is multidisciplinary, and neoadjuvant chemoradiation is recommended in locally advanced rectal cancer. About 15% of patients answer favorably to neoadjuvant chemoradiation, so it is important to determine the predictors of response. Objective: To review the results of studies that analyzes the predictors of complete pathological response to neoadjuvant chemoradiation in patients with locally advanced rectal cancer. Search methods: We searched for eligible articles in data bases Pubmed and Scopus, between the 12th and the 20th of March 2020. The following key words were used: "predictors of response", "chemoradiation" and "locally advanced rectal cancer". Selection criteria: Inclusion criteria: Studies including patients with locally advanced rectal cancer, patients receiving neoadjuvant chemoradiation as treatment, studies including predictors of response to neodjuvant chemoradiation, overall survival as an outcome and regarding language restrictions, only articles in English were accepted, only studies published until the 31st of December 2019 were accepted. Main results: Fourteen studies fulfilled the inclusion criteria. Thirteen are cohort studies and one is a clinical trial. Four groups of predictors were defined: blood markers, tumors, histopathological and patients' characteristics. Author's conclusions: During the analysis of the articles, there were several predictors identified as potential candidates for clinical practice, such as high pre neoadjuvant chemoradiation Carcinoembryonic Antigen levels and small post neoadjuvant chemoradiation tumor size. Nevertheless, it is difficult to make definitive conclusions about the most reliable predictors. That is why it is crucial to initiate further studies with standardized cut-off values and a methodology homogenization.
Resumo Introdução: O cancro colorretal é um dos cancros mais prevalentes em Portugal e tem associada uma alta taxa de letalidade. Atualmente, o tratamento é multidisciplinar, e a quimioradioterapia neoadjuvante está indicada no Cancro do Reto Localmente Avançado. Sabe-se que cerca de 15% dos doentes responde favoravelmente à quimioradioterapia neoadjuvante, sendo por isso importante determinar quais os preditores de resposta a este tipo de tratamento. Objetivo: Rever os resultados dos estudos que analisam os preditores de resposta completa à quimioradioterapia em pacientes com Cancro do Reto Localmente Avançado. Métodos de pesquisa: Pesquisamos artigos elegíveis nos bancos de dados Pubmed e Scopus, desde o dia 12 a 20 de Março de 2020. Foram utilizadas as seguintes palavras chave: "preditores de resposta", "quimioradioterapia neoadjuvante" e "Cancro do Reto Localmente Avançado". Critérios de seleção: Critérios de inclusão: Estudos que incluam pacientes com Cancro do Reto Localmente Avançad, pacientes sujeitos a quimioradioterapia neoadjuvante, preditores de resposta à quimioradioterapia, que avaliem a sobrevivência como outcome, escritos em inglês e publicados até dia 31 de Dezembro de 2019. Resultados principais: Catorze estudos preencheram os critérios de inclusão. De todos os artigos, treze são Cohort e um é Clinical Trial. Foram definidos quatro grupos de preditores: marcadores de sangue e caraterísticas do tumor, histopatológicas e dos pacientes. Conclusões dos autores: Durante a análise dos artigos, foram identificados vários preditores como potenciais candidates para a prática clínica, tais como o valor elevado de antigénio carcinoembrionário pré- quimioradioneoaajuvância e tamanho reduzido. Contudo, é arriscado elaborar conclusões concretas relativamente aos preditores mais confiáveis. Por isso, é crucial iniciar novos estudos com valores de cut-off estandardizados e métodos com maior homogeneidade.
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Humans , Male , Female , Rectal Neoplasms , Chancre/drug therapy , Neoadjuvant Therapy , Treatment Outcome , Chemoradiotherapy, Adjuvant , ForecastingABSTRACT
Aims: Vitamin C plays a role in chemoprevention in cancer treatment, and Vitamin C modulates many regulators of inflammation in in vitro studies. The aim of this study is to assess the effect of Vitamin C supplementation with neoadjuvant chemoradiation in esophageal adenocarcinoma on the nuclear factor-kappa B (NF-κB) and associated cytokines. Materials and Methods: A total of 20 patients undergoing multimodal treatment for esophageal adenocarcinoma were randomized to receive Vitamin C (1000 mg/day) orally for 4 weeks or no supplementation. Pre- and post-Vitamin C endoscopic biopsies were used for the study of NF-κB activity and cytokine analysis. Results: NF-κB activity along with cytokines was activated in the cancer tissue pretreatment. Down-regulation in NF-κB activity was observed in 25% of cases, two from the Vitamin C arm posttreatment. There was a significant reduction in cytokines levels in the cancer group, and this effect was more pronounced in the Vitamin C group (P < 0.05). Conclusions: Vitamin C supplementation had a mild protective effect in modulating of regulators of inflammation and carcinogenesis. Further studies with larger numbers of endpoints are needed to evaluate its effect on modulation of chemoradiation responses.
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Background: The objective of this study was to determine whether [18F]-fluorodeoxyglucose-positron emission tomography-computed tomography (FDG-PET CT) scan could predict the pathological response in carcinoma rectum patients after surgery in patients receiving neoadjuvant concurrent chemoradiotherapy (NACCRT). Setting and Design: A prospective study was carried out from March 2015 to March 2017; 39 patients of histopathologically proven, locally advanced, potentially operable, of adenocarcinoma rectum were included in the study. Methods: Patients had a pretreatment FDG-PET-CT scan and repeat scan after 6–8 weeks of NACCRT. The change in mean maximum standardized uptake value ([%Δ SUVmax]) was compared with the tumor regression grade (TRG) in the postoperative histology. TRG of 1 and 2 was deemed responders and 3–5 was nonresponders. Statistical Analysis: Chi-square test, one-way ANOVA, and receiver operating characteristics curve analysis were used. All analyses were done using SPSS 17.0 version. Results: In 61.5% responders receiving NACCRT, the SUV fell from 10.91 ± 3.70 to 4.14 ± 1.73, respectively, while in 38.5% nonresponders, SUV fell from 11.65 ± 2.66 to 4.23 ± 1.3. SUV Δ% was 63.03 ± 10.17 in nonresponders and 61.32 ± 11.81 in responders with a nonsignificant P = 0.646. The P value did not reach a statistical significance as far as reduction in SUV values pre- and post-NACCRT is concerned in both responders as well as nonresponders. Conclusion: Hence, we concluded that assessment with FDG PET CT scan in carcinoma rectum patients' postneoadjuvant treatment cannot be the only imaging modality or assessing the response and postoperative histopathology remains the gold standard.
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PURPOSE: The predictive role of obesity on pathologic complete response (pCR) after neoadjuvant chemoradiation (nCRT) in rectal cancer remains controversial. This study aimed to evaluate the association between obesity and pathologic response in patients with rectal cancer following nCRT. METHODS: A total of 320 patients with primary rectal cancer who underwent curative resection after nCRT between January 2010 and September 2014 were enrolled in this study. Obesity was defined as body mass index of ≥25 kg/m2. Clinicopathologic characteristics were analyzed to identify independent predictive factors for pCR. RESULTS: Among the included patients, 23.4% (n = 75) were obese, and 14.7% (n = 47) showed pCR. Baseline characteristics were generally similar between obese and nonobese patients, except that women (P = 0.001) and cT2 tumors (P = 0.001) were more common in the obese group. Multivariate logistic regression analysis revealed that obesity (odds ratio [OR] = 2.051; 95% confidence interval [CI], 1.009–4.168), cT2 (OR, 3.614; 95% CI, 1.166–11.202), and pretreatment carcinoembryonic antigen <5 ng/mL (OR, 2.921; 95% CI, 1.365–6.253) were independent predictors for pCR. Obesity was not associated with disease-free survival or local recurrence-free survival. CONCLUSION: Obesity was an independent predictive factor for pCR following nCRT in rectal cancer, but was not associated with recurrence. Further studies are needed to clarify the association between obesity and prognosis of rectal cancer after nCRT.
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Female , Humans , Body Mass Index , Carcinoembryonic Antigen , Disease-Free Survival , Logistic Models , Obesity , Polymerase Chain Reaction , Prognosis , Rectal Neoplasms , RecurrenceABSTRACT
Objective@#To evaluate the value of different sequences magnetic resonance imaging (MRI) in rectal cancer re-staging after neoadjuvant chemoradiation therapy (NCRT).@*Methods@#The clinical data of 117 patients with rectal cancer who underwent NCRT before surgery operation in Peking University cancer hospital from January 2016 to December 2018 were retrospectively analyzed. Among 117 patients, 101 patients underwent MRI scanning before and after NCRT, and 16 patient underwent MRI scanning after NCRT; T2 weighted imaging (T2WI) and diffusion weighted imaging (DWI) scanning were performed in all patients, and dynamic contrast enhancement (DCE) scanning was performed in 96 patients. T2WI, T2WI combined with DWI, T2WI combined with DCE were used for T re-staging of rectal cancer after NCRT respectively, and the results of which were compared with those of pathology after operation.@*Results@#The sensitivity of diagnosis of ypT0-2 rectal cancer after NCRT using T2WI combined with DWI, T2WI combined with DCE respectively was significantly higher than that using T2WI: 52.7% (29/55) and 30.4% (14/46) vs. 10.9% (6/55), and there was statistical difference (P<0.05). The accuracy rate and specificity of diagnosis of ypT3 and ypT4 rectal cancer after NCRT using T2WI combined with DWI were significantly higher than that using T2WI, with an accuracy rate of 60.7% (71/117) vs. 47.0%(55/117) and 92.3% (108/117) vs. 80.3% (94/117), and a specificity of 55.9% (33/59) vs. 23.7% (14/59) and 92.9% (105/113) vs. 80.5% (91/113), and there were statistical differences (P<0.05). The accuracy rate of down-staging after NCRT using T2WI combined with DWI was significantly higher than that using T2WI: 72.3% (73/101) vs. 58.4% (59/101), and there was statistical difference (P<0.05); there was no significant difference in accuracy rate between using T2WI and using T2WI combined with DWI and between using T2WI combined with DWI and using T2WI combined with DCE (P > 0.05).@*Conclusions@#T2WI combined with DWI is superior to T2WI in re-staging of rectal cancer after NCRT.
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Objective@#To understand the perceptions, attitudes and treatment selection of Chinese surgeons on the "watch and wait" strategy for rectal cancer patients after achieving a clinical complete response (cCR) following neoadjuvant chemoradiotherapy (nCRT).@*Methods@#A cross-sectional survey was used in this study. Selection of subjects: (1) Domestic public grade III A (provincial and prefecture-level) oncology hospitals or general hospitals possessing the radiotherapy department and the diagnosis and treatment qualifications for colorectal cancer. (2) Surgeons of deputy chief physician or above. Using the "Questionnaire Star" online survey platform to create a questionnaire about cognition, attitude and treatment choice of the "watch and wait" strategy after cCR following nCRT for rectal cancer. The questionnaire contained 32 questions, such as the basic information of doctor, the current status of rectal cancer surgery, the management of pathological complete remission (ypCR) after nCRT for rectal cancer, the selection of examination items for diagnosis of cCR, the selection of suitable people undergoing "watch and wait" approach, the nCRT mode for promotion of cCR, the choice of evaluation time point, the willingness to perform "watch and wait" approach and the treatment choice, and the risk and monitoring of "watch and wait" approach. A total of 116 questionnaires were sent to the respondents via WeChat between January 31 and February 19, 2019. Statistical analysis was performed using Fisher′s exact test for categorical variables.@*Results@#Forty-eight hospitals including 116 surgeons meeting criteria were enrolled, of whom 77 surgeons filled the questionnaire with a response rate of 66.4%. "Watch and wait" strategy was carried out in 76.6% (59/77) of surgeons. Seventy surgeons (90.9%) were aware of the ypCR rate of rectal cancer after preoperative nCRT and 49 surgeons (63.6%) knew the 3-year disease-free survival of patients with ypCR in their own hospitals. Fifty-five surgeons (71.4%) believed that patients with ypCR undergoing radical surgery met the treatment criteria and were not over-treated. Three most necessary examinations in diagnosing cCR were colonoscopy (96.1%, 74/77), digital rectal examination (DRE) (90.9%,70/77) and DWI-MRI (83.1%, 64/77). Responders preferred to consider a "watch and wait" strategy for patients with baseline characteristics as mrN0 (77.9%, 60/77), mrT2 (68.8%, 53/77) and well-differentiated adenocarcinoma (68.8%, 53/77). Sixty-six surgeons (85.7%) believed that long-term chemoradiotherapy (LCRT) with combination or without combination of induction and/or consolidation of the CapeOX regimen (capecitabine + oxaliplatin) should be the first choice as a neoadjuvant therapy to achieve cCR. Forty-one surgeons (53.2%) believed that a reasonable interval of judging cCR after nCRT should be ≥ 8 weeks. Forty-four surgeons (57.1%) routinely, or in most cases, informed patient the possibility of cCR and proposed to "watch and wait" strategy in the initial diagnosis of patients with non-metastatic rectal cancer. Thirteen surgeons (16.9%) would take the "watch and wait" strategy as the first choice after the patient having cCR. Fifty-two surgeons (67.5%) would be affected by the surgical method, that was to say, "watch and wait" approach would only be recommended to those patients who would achieve cCR and could not preserve the anus or underwent difficult anus-preservation surgery. Sixteen surgeons (20.8%) demonstrated that "watch and wait" strategy would not be recommended to patients with cCR regardless of whether the surgical procedure involved anal sphincter. Eleven surgeons (14.3%) believed that the main risk of "watch and wait" approach came from distant metastasis rather than local recurrence or regrowth. Twenty-nine of surgeons (37.7%) did not understand the difference between "local recurrence" and "local regrowth" during the period of "watch and wait". Twenty-six surgeons (33.8%) thought that the monitoring interval for the first 3 years of "watch and wait" strategy was 3 months, and the follow-up monitoring interval could be 6 months to 5 years. Surgeons from cancer specialist hospitals had higher approval rate, notification rate, and referral rate of "watch and wait" strategy than those from general hospitals. Thirty-one surgeons (42.5%) considered that the difficulty and concern of carrying out "watch and wait" approach in the future was the disease progress leading to medical disputes. Twenty-six surgeons (35.6%) demonstrated that their concern was lack of uniform evaluation standard for cCR.@*Conclusions@#Chinese surgeons seem to have inadequate knowledge of non-operative management for rectal cancer patients achieving cCR after nCRT and show relatively conservative attitudes toward the strategy. Chinese consensus needs to be formed to guide the non-operative management in selected patients. Chinese Watch & Wait Database (CWWD) is also needed to establish and provide more evidence for the use of alternative procedure after a cCR following nCRT.
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Neoadjuvant chemoradiation has been accepted as a standard of care for local advanced middle to low rectal cancer. Patients with clinical complete response (cCR) or near cCR following neoadjuvant chemoradiation may benefit from watch and wait strategy or organ-preserving surgery with good short- and long-term outcome and quality of life (QOL). Yet the criteria of cCR varies and cCR is not consistent with pCR. Therefore, the obstacle to the strategy lies on whether its failure can be salvaged and the complexity of follow-up. Available studies demonstrated that local recurrence or regrowth can be salvaged by surgery without compromising the survival. So, the key is appropriate follow-up schedule and timely salvage. The strategy has not drawn much attention until recently, and relevant studies go slowly because of low data availability, patient awareness, and peer acceptance. We still believe that more and more patients might benefit from this strategy, along with the increasing attention of QOL from the patients. That may be obtained through screening of the right patients and optimizing treatment modality, evaluation methods, and protocol of follow-up.
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OBJECTIVE: To investigate the prognosis and quality of life of patients who underwent transanal local excision(LE) following neoadjuvant chemoradiation for mid-low rectal cancer.METHODS: Patients undergo neoadjuvant chemoradiaiton and transanal local excision from March 2011 to June 2016 in Gastrointestinal cancer center,Peking University Cancer Hospital were enrolled in this study. Data of 19 cases were retrospectively collected and analyzed. The primary end points were disease free survival,short-term(1 month)postoperative complications; and secondary endpoints were quality of life and anal function one year after the surgery.RESULTS: Median tumor diameter was 1.0(0.3-3.0)cm. 8(42.1%) cases located in the anterior wall,6 cases(31.6%) in the posterior wall,3 cases(15.8%) in the left wall,and 2 cases(10.5%) in the right wall. The median distance of the tumor from the anal verge was 4.0(1.5-12.0)cm. Postoperative pathology demonstrated that 12 cases(63.2%) ypT0,3 cases(15.8%) ypT1,4 cases(21.1%) ypT2;the median time interval between chemoradiotherapy and LE was 4.3(2.0-36.0)months;The median time of operation was 50(20-137)min,with median blood loss 10(0-50)ml and hospital stay 4(1-5)d. The recurrence rate was 21.1%(1 local recurrence, 2 lung metastasis, 1 pelvic metastasis) with a follow up of 30(2-62) months.TME group had worse quality of life and anal function following TME surgery(P<0.01) while LE group not. LE group has better quality of life(EORTC-C30) and anal function(Wexner) than TME group(P<0.01).CONCLUSION: For mid-low rectal cancer with good response(ycT0-2 N0) following neoadjuvant chemoradiation,local excision might be a safe and feasible treatment option with acceptable anal function anal function.
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Objective@#To explore the best surgical timing after neoadjuvant chemoradiation for advanced rectal cancer patients.@*Methods@#According to the time interval between neoadjuvant chemoradiation and surgery, 117 patients with advanced rectal cancer were divided into short interval group (≤7 weeks, n=54) and long interval group (>7 weeks, n=64). The endpoints included postoperative pathology, short-term efficacy, tumor recurrence and patient survival between the two groups.@*Results@#There were 8 cases PCR in short interval group and 20 cases in long interval group(P=0.415). There were 23 cases of T downgrade in short interval group and 40 cases in the long interval group, which has significant difference (P=0.039). There were 21 cases of N downgrade in short interval group and 38 cases in long interval group, which has significant different (P=0.033). The short-term group was effective in 28 cases, stable in 20 cases, and progressed in 5 cases. In short term efficacy comparison, the cases of complete response, stable disease and progressive disease in short interval group was 28 cases, 20 and 5, long interval group was 47 cases, 14 cases and 3 cases, which has no significant difference(P=0.068). The 3-year local recurrence rate of short interval group and long interval group was 17.0% and 4.7%, respectively, and the difference was statistically significant(P=0.029). The incidence of recurrence in 3 years of short interval group and long interval group was 64.2% and 79.7%, respectively, and the difference was not significant (P=0.061). The highest PCR rate was reached in the 10th and 11th week after neoadjuvant chemoradiotherapy. Of the 12 and 8 patients who underwent surgery, 3 (25.0%) and 2 (25.0%) achieved PCR, respectively.@*Conclusion@#PCR and local recurrence rate might be improved by time interval between neoadjuvant chemoradiation and surgery was more than 7 weeks.
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There are several progresses in colorectal cancer research from 2017 annual meeting of Chinese Society of Clinical Oncology (CSCO).(1) Phase Ⅲ multi-center trial FRESCO and TERRA study have showed domestic new drug Fruquintinib and Japanese oral combination anti-cancer drug TAS-102 significantly improved overall survival (OS) comparing to placebo in third-line metastatic colorectal cancer (mCRC) patients.(2) Preoperative neoadjuvant chemotherapy with mFOLFOXIRI and selective radiotherapy or concomitant boost neoadjuvant chemoradiotherapy (nCRT) followed by one cycle of XELOX,can improve short-term outcome for locally advanced rectal cancer,and clinical and pathological features can be used to predict complete response following nCRT.(3) In asymptomatic elderly population,the specificity of septin9 methylation detection in plasma cfDNA as colorectal cancer screening is low,but the probability of negative predictions as non-colorectal cancer is high.And integrated signature of the gut microbiome and metabolome serves as diagnostic biomarkers in patients with colorectal cancer.(4) Immunoscore system predicts prognosis after liver metastasectomy in colorectal metastases,and the immune signature difference between right and left colon cancer could explain the difference of targeted therapy.
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Objective To compare the clinical effects of three-dimensional (3D) and two-dimensional (2D) laparoscopic surgeries for rectal cancer (RC) after neoadjuvant chemoradiation therapy (nCRT).Methods The retrospective cohort study was conducted.The clinicopathological data of 126 patients with RC who received laparoscopic surgery after nCRT in the Liaoning Cancer Hospital from January 2013 to January 2014 were collected.Of 126 patients,63 undergoing 3D laparoscopic surgery and 63 undergoing 2D laparoscopic surgery were respectively allocated into the 3D and 2D groups.Surgery was performed by the same doctors' team.Patients received surgery at 6-8 weeks after nCRT,and surgery followed the principle of total mesorectal excision.Observation indicators:(1) intra-and post-operative situations;(2) postoperative pathological examination;(3)follow-up and survival situations.Follow-up using outpatient examination and telephone interview was performed to detect local tumor recurrence and patients' survival up to January 2017.Patients received reexaminations once every 3 months within 1 year postoperatively and once every 6 months after 2-3 years postoperatively.Measurement data with normal distribution were represented as (x)±s and comparison between groups was analyzed using the t test.Comparisons of count data were analyzed using the chi-square test.Comparison of ordinal data was done by the nonparametric test.Survival curve was drawn using the Kaplan-Meier method.Survival was analyzed using the Logrank test.Results (1) Intra-and post-operative situations:all the patients underwent successful laparoscopic surgery for RC,without conversion to open surgery and perioperative death.Operation time,volume of intraoperative blood loss,time to anal exsufflation and number of patients with postoperative urinary dysfunction were (125±10)minutes,(54±23)mL,(44±5)hours,0 in the 3D group and (137±12)minutes,(62±20)mL,(46±5) hours,5 in the 2D group,respectively,with statistically significant differences between the 2 groups (t=5.777,2.038,2.575,x2 =7.138,P＜0.05).Number of patients with preserving anus,number of lymph node dissected,number of patients with anastomotic fistula and duration of hospital stay were 60,14.9±2.1,2,(9.5±0.8)days in the 3D group and 58,14.3± 1.7,4,(9.9±2.0)days in the 2D group,respectively,with no statistically significant difference between the 2 groups (x2 =0.133,t=1.606,x2 =0.175,t =1.329,P＞0.05).Two and 4 patients with anastomotic leakage in the 3D and 2D groups received defunctioning stoma,and finally anastomotic leakage healed,without anastomotic stenosis.Of 5 patients with urinary dysfunction in the 2D group,4 received indwelling catheter for 3 weeks and then can micturate autonomously after indwelling catheter removal,1 received indwelling catheter for 3 months and then can micturate autonomously after indwelling catheter removal,without suprapubic cystostomy.(2) Postoperative pathological examination:0 and 4 patients in the 3D and 2D groups had positive circumferential margin,with a statistically significant difference (x2=5.676,P＜0.05).One and 2 patients in the 3D and 2D groups had positive distal margin,with no statistically significant difference (x2 =1.606,P＞0.05).Number of patients with stage Ⅱ and Ⅲ of postoperative pathological staging were 30,33 in the 3D group and 32,31 in the 2D group,respectively,with no statistically significant difference between the 2 groups (x2=0.127,P＞0.05).(3) Follow-up and survival situations:126 patients were followed up for 36.0-48.0months,with a median time of 39.5 months.During the follow-up,0 and 3 patients in the 3D and 2D groups were complicated with local tumor recurrence,with a statistically significant difference between the 2 groups (x2 =4.232,P＜0.05).One-and 3-year overall survival rates were 98.4％,82.5％ in the 3D group and 96.8％,79.4％ in the 2D group,respectively,with no statistically significant difference between the 2 groups (x2 =0.206,P＞0.05).One-and 3-year disease-free survival rates were 92.7％,77.8％ in the 3D group and 90.5％,73.0％in the 2D group,respectively,with no statistically significant difference between the 2 groups (x2=0.421,P＞0.05).Conclusion Compared with 2D laparoscopic surgery,3D laparoscopic surgery for RC after nCRT is safe and feasible,it can also shorten operation time,reduce intraoperative bleeding,alleviate the influence of intestinal peristalsis function,protect pelvic nerves better and improve operation quality.
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Objective To investigate the effect of meticulousness of pathologists on the lymph node harvest after radical resection of invasive rectal carcinoma in paients following neoadjuvant chemoradiotherapy. Methods The clinical data of 191 patients with rectal cancer (stage I to III) undergoing radical excision after neoadjuvant chemoradiotherapy in Department of ColorectalSurgery, Changhai Hospital, Second Military Medical University from Jan. 2005 to Dec. 2014 were retrospectively analyzed. Since Jan. 2009 when multidisciplinary cooperation was carried out, pathologists and surgeons suggested that no less than 15 lymph nodes in single rectal specimen should be found by meticulousness of pathologists, according to which patients were divided into routine sampling group (n=46) and meticulousness group (n=145). The harvest number and positive rate of postoperative lymphnodes were compared between the two groups. Results The lymph node retrieval in the meticulousness group was significantly more than that in the routine sampling group (13.1 ± 4.9 vs 9.6 ± 4.0, P<0.01), and the percentage of patients with the lymph node harvest equaling or more than 12 was significantly increased (69.7% vs 33.3%, P<0.01). There were no significant differences in the positive node harvest number (1.8 ± 2.9 vs 1.9 ± 3.8, P=0.334) or positive rate of lymph nodes (50.0% vs 38.6%, P=0.172) between the two groups. The positive rate of tymph nodes of patients in T0, T1, T2, T3, and T4 stages in the two groups were 25. 0% (1/4) and 22.7% (5/22), 0.0% (0/1) and 33.3% (1/3), 9.1% (1/11) and 25. 0%(8/32), 70.0%(21/30) and 47.1%(40/85), and 0.0%(0/0) and 66. 7%(2/3), respectively. There were no significant differences in T stages between the two groups (X2=4.55, P=0.209). Conclusion The lymph node harvest number is increased by meticulousness of pathologists after multidisciplinary cooperation, while the positive node harvest number and positive rate of tymph nodes are not increased, suggesting that supplementary measures should be taken to obtainmore accurate lymph node status of patients with rectat cancer after neoadjuvant chemoradiotherapy.
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Objective To investigate the value of endorectal ultrasonography (ERUS) inpreoperative assessment of rectal cancer post neoadjuvant chemoradiation therapy.Methods From Jan.2016 to Dec.2016,90 rectal cancer patients who underwent preoperative neoadjuvant chemoradiation therapy and total mesorectal excision surgery in the Sixth Affiliated Hospital of Sun Yat-Sen University were retrospectively analyzed,and all patients underwent ERUS examination post neoadjuvant chemoradiation therapy.Of these,64 patients were evaluated by ERUS pre and post neoadjuvant chemoradiation therapy and 26 patients were evaluated only post neoadjuvant chemoradiation therapy.Wilcoxon rank sum test for paired sample was performed to compare the distance from inferior margin of tumor to anal margin,the length and thickness of the tumor pre and post neoadjuvant chemoradiation therapy respectively in rectal cancer.Taken pathologic findings as golden standard,the accuracy of T staging assessed by ERUS post neoadjuvant chemoradiation therapy was evaluated.Results Compared with pre neoadjuvant chemoradiation therapy,the distance from inferior margin of tumor to anal margin significantly increased after neoadjuvant chemoradiation therapy [(58.63±21.71) mm vs (51.68± 19.81) mm],and the length [(26.10± 10.07) mm vs (40.82±9.18) mm] and thickness [(9.73±2.50) mm vs (14.92±5.30) mm] of tumor also evidently decreased post neoadjuvant chemoradiation therapy,respectively (Z were 4.996,6.153 and 6.076,all P ＜ 0.01).The final pathological T stage was pathologic complete response (pCR) or pT0 in 15 patients,pT1 in 3 patients,pT2 in 30 patients and pT3 in 42 patients.The diagnostic accuracy of T staging of rectal cancer post neoadjuvant chemoradiation therapy for ERUS was uT0 82.2％ (74/90),uT1 96.7％ (87/90),uT2 66.7％ (60/90),uT3 67.8％ (61/90) and uT4 96.7％ (87/90),and the overall accuracy was 82.2％ (74/90).Conclusion ERUS could effectively record the morphological changes of rectal cancer pre and post neoadjuvant chemoradiation therapy,which may contribute to the re-evaluation of the distance from inferior tumor margin to anal margin and the range and depth of tumor involvement pre surgical resection.
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Objective:To discuss treatment of complete response cases after neoadjuvant radiotherapy in rectal cancer. Methods:This retrospective study analyzed clinical data of 84 rectal cancer cases with pre-operative neoadjuvant chemoradiotherapy in our hospital from January 2010 to Augnst 2014. Results:After neoadjuvant chemoradiotherapy, 33 patients presented clinically complete response at a rate of 39.3%. After post-operative pathologic examination, among clinically complete response cases, six cases exhibited patho-logically complete responses at a rate of 18.2%. No recurrence or disease progression occurred within 12-36 months of post-operative follow up. Conclusion:Neoadjuvant chemoradiotherapy can significantly lower tumor stage and promote clinically complete remission of some patients. However, for clinically complete remission cases, further radical surgery should be provided.
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Objective To explore the clinical effect of neoadjuvant chemo-radiation combined with thoracoscopic and laparoscopic three-incision esophagectomy for esophageal cancer.Methods The retrospective cohort study was conducted.The clinicopathological data of 111 esophageal cancer patients who underwent neoadjuvant chemo-radiation combined with thoracoscopic and laparoscopic three-incision esophagectomy in the Cancer Hospital of Chinese Academy of Medical Sciences between January 2010 and December 2016 were collected.Among 111 patients,68 with interval time between neoadjuvant chemo-radiation and thoracoscopic and laparoscopic three-incision esophagectomy ＜ 8 weeks were allocated into the ＜ 8 weeks group and 43 with interval time between neoadjuvant chemo-radiation and thoracoscopic and laparoscopic three-incision esophagectomy ≥8 weeks were allocated into the ≥8 weeks group.Patients underwent preoperative radiotherapy and chemotherapy with TP regimen,and then underwent selective thoracoscopic and laparoscopic three-incision esophagectomy.Observation indicators:(1) neoadjuvant chemo-radiation situations;(2) surgical and postoperative situations;(3) follow-up.Follow-up using outpatient examination and telephone interview was performed to detect postoperative survival of patients and tumor recurrence or metastasis up to March 2017.Measurement data with normal distribution were represented as (x)±s and comparison between groups was analyzed using the t test.Count data were analyzed using the chi-square test or Fisher exact probability.Comparison of ranked data was done by the nonparametric test.Results (1) Neoadjuvant chemo-radiation situations:all the patients underwent neoadjuvant chemo-radiation,without severe adverse reaction.Number of patients with complete remission based on oncopathology were 34 in the ＜8 weeks group and 15 in the ≥ 8 weeks group,with no statistically significant difference between the 2 groups (x2=2.441,P＞0.05).(2) Surgical and postoperative situations:all the patients underwent successful thoracoscopic and laparoscopic three-incision esophagectomy,with negative surgical margins.Operation time,volume of intraoperative blood loss,number of lymph node dissected,time of postoperative intrathoracic drainagetube removal,time of postoperative neck drainage-tube removal,hoarseness,upper gastrointestinal hemorrhage,anastomotic fistula,respiratory complication,pleural effusion and empyema,cardiovascular complication,incision abnormal healing,death within postoperative 30 days and duration of hospital stay were (354±103)minutes,(400± 76)mL,19±4,(11±4)days,(4.9±1.6)days,5,1,12,3,6,5,8,0,(19± 17) days in the ＜ 8 weeks group and (343±92) minutes,(392±51)mL,19±3,(12±6)days,(4.5±1.0)days,2,0,7,5,3,4,3,2,(18± 11) days in the ≥ 8 weeks group,respectively,with no statistically significant difference between the 2 groups (t =1.080,0.569,0.326,1.223,1.286,x2=0.029,0.035,1.114,0.000,0.000,0.246,t=0.315,P＞ 0.05).(3) Follow-up:90 of 111 patients were followed up for 3-82 months,with a median time of 25 months,including 55 in the ＜8 weeks group and 35 in the ≥8 weeks group.During follow-up,death and tumor recurrence were detected in 9,11 patients in the ＜8 weeks group and 6,11 patients in the ≥ 8 weeks group,respectively.Conclusion Neoadjuvant chemo-radiation combined with thoracoscopic and laparoscopic three-incision esophagectomy is safe and effective,and it doesn't increase the perioperative risks based on preoperative 8-week interval time.
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Objective To explore the efficacy of high-resolution MRI in the prediction of tumor complete response after neoadjuvant chemoradiation therapy for T3 rectal cancer.Methods The clinical data of 108 patients with T3 rectal cancer who were admitted to Shanghai Cancer Center of Fudan University from 2010 to 2012 were retrospectively analyzed.The TNM stage of tumor,extramural depth of tumor invasion (mrT3 stage),involvement of mesorectum and rectal fascia,tumor diameter and distance from anal edge to lower edge of tumor were the main items of evaluation using the high-resolution MRI.A total of 108 patients underwent surgical resection of tumor after neoadjuvant chemoradiation therapy.The tumor complete response after neoadjuvant chemoradiation therapy was evaluated by tumor node metastasis (TNM) stage and tumor regression grade (TRG).The categorical data and multivariate analysis were done by the single factor analysis of variance (ANOVA) and Logistic regression analysis.Results The positive response rate of the T3a,T3b and T3c in the patients were 61.5％ (16/26),36.9％ (24/65) and 11.8％ (2/17) after neoadjuvant chemoradiation therapy,respectively.The mrT3,mrN and tumor diameter were the potential factors affecting response of neoadjuvant chemoradiation therapy by the univariate analysis of pathological restaging (x2 =50.474,30.985,8.318,P ＜ 0.05).The mrT3 was an independent risk factor affecting response of neoadjuvant chemoradiation therapy by the multivariate analysis of pathological restaging (OR =4.473,95 ％ confidence interval:2.003-9.991,P ＜ 0.05).There was no significant difference between the mrT3 stage,N stage,involvement of mesorectum and rectal fascia,tumor diameter and distance from anal edge to lower edge of tumor before therapy and the response after neoadjuvant chemoradiation therapy based on the tumor regression grade(TRG) (x2 =6.264,6.159,2.949,2.189,6.335,P ＞ 0.05).Conclusion The mrT3 in patients undergoing high-resolution MRI before neoadjuvant chemoradiation therapy could predict the tumor complete response after neoadjuvant chemoradiation therapy for T3 rectal cancer.
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BACKGROUND: Pancreatic cancer has an extremely poor prognosis and prolonged survival is achieved only by resection with macroscopic tumor clearance. There is a strong rationale for a neoadjuvant approach, since a relevant percentage of pancreatic cancer patients present with non‑metastatic but locally advanced disease. The objective of the present study was to assess the effect of neoadjuvant chemoradiation therapy (NACRT) on tumor response, down staging and resection, toxicity and any survival advantage. MATERIALS AND METHODS: A prospective pilot study was carried out from January 2009 to June 2011 in which 15 patients of locally advanced unresectable pancreatic cancer were included. All patients were treated with NACRT protocol with oral Capecitabine and 3D conformal radiotherapy (3DCRT) of 30 Gy in 10 fractions. The patients were restaged 3 to 4 weeks after the completion of NACRT and explored for resection. RESULTS: Out of 15 patients, fourteen were evaluable. Four patients underwent surgery, 5 had partial response but remained unresectable, 2 patients had stable disease and 3 had progressive disease. Most of the toxicities were slight and were in grade 1 to 2. None of the patients developed grade 3 or 4 gastrointestinal or hematological toxicity. The median survival was 15 months for resected patients and 8.6 months for unresected patients, respectively. The 2 year actuarial overall survival was 34.6%. CONCLUSION: All patients with locally unresectable pancreatic cancer should be offered chemoradiation therapy, in hopes of down staging the tumor for possible resection and achieving higher survival.
Subject(s)
Aged , Antineoplastic Agents/administration & dosage , Chemoradiotherapy/methods , Deoxycytidine/administration & dosage , Deoxycytidine/analogs & derivatives , Feasibility Studies , Fluorouracil/administration & dosage , Fluorouracil/analogs & derivatives , Humans , Male , Middle Aged , Neoadjuvant Therapy/methods , Pancreatic Neoplasms/mortality , Pancreatic Neoplasms/therapy , Pilot Projects , Prospective Studies , Radiotherapy Planning, Computer-Assisted , Radiotherapy, Conformal , Tertiary Care CentersABSTRACT
Based on a review of the literature, this paper provides an update on surgical treatment of middle and low rectal cancer and discusses issues of debate surrounding that treatment. The main goal of the surgical treatment of rectal cancer is radical resection of the tumor and surrounding lymphatic tissue. Local excision of early rectal cancer can be another treatment option, in which the patient can avoid possible complications related to radical surgery. Neoadjuvant chemoradiation therapy (CRT) has been recommended for patients with cT3-4N0 or any T N+ rectal cancer because CRT shows better local control and less toxicity than adjuvant CRT. However, recent clinical trials showed promising results for local excision after neoadjuvant CRT in selected patients with low rectal cancer. In addition, the "wait and see" concept is another modality that has been reported for the management of tumors that show complete clinical remission after neoadjuvant CRT. Although radical surgery for middle and low rectal cancer is the cornerstone therapy, an ultralow anterior resection with or without intersphincteric resection (ISR) has become an alternative standard surgical method for selected patients. Many studies have reported on the oncological safety of the ISR, but few of them have addressed the issue the functional outcome. Furthermore, an abdominoperineal resection (APR) has problems with high rates of tumor perforations and positive circumferential resection margins, and those factors have contributed to its having a high rate of local recurrence and a poor survival rate for rectal cancer compared with sphincter-saving procedures. Recently, great efforts have been made to reduce these problems, and the total levator excision or the extended APR concept has emerged. Surgical management for low rectal cancer should aim to radically excise the tumor and to preserve as much of the sphincter function as possible by using multidisciplinary approaches. However, further prospective clinical trials are needed for tailored treatment of rectal cancer patients.
Subject(s)
Humans , Lymphoid Tissue , Rectal Neoplasms , Recurrence , Survival RateABSTRACT
PURPOSE: The aim of the study was to evaluate the efficacy and the toxicity of preoperative treatment with capecitabine in combination with radiation therapy (RT) in patients with locally-advanced, resectable rectal cancer. METHODS: Thirty-five patients with locally-advanced rectal cancer (cT3/4, N-/+) were treated with capecitabine (825 mg/m2, twice daily for 7 days/wk) and concomitant RT (50.4 Gy/28 fractions). Surgery was performed 6-8 wk after completion of the chemoradiation followed by 4-6 cycles of adjuvant capecitabine monotherapy (1,250 mg/m2, twice daily for 14 days every 3 wk). RESULTS: The chemoradiation program was completed in all but 2 patients, for whom both capecitabine and RT were interrupted for 2 wk because of grade-3 diarrhea. A R0 resection under the principle of total mesorectal excision (low anterior resection, 26; intersphincteric resection, 6; abdominoperineal resection, 2) was performed in all but one patient with a low anterior resection with positive circumferential margin (R1). Primary tumor and node downstaging occurred in 57% and 60% of patients, respectively. The overall rate of downstaging, including both the primary tumor and node, was 77% (27 patients). A pathological complete response of the primary tumor was achieved in 4 patients (11%). No patient had grade-4 toxicity, and the only grade-3 toxicity developed was diarrhea in 2 patients (6%) during chemoradiation. During a median follow-up of 38 mo, distant metastases developed in 4 patients (multiple lung metastases, 2; aortocaval nodal metastases, 2), and another 2 patients showed local recurrence. The three-year disease-free survival was 83%. CONCLUSION: This study suggests that preoperative capecitabine-based chemoradiation therapy is an effective and safe treatment modality for the tratment of locally-advanced, resectable rectal cancer.
Subject(s)
Humans , Capecitabine , Deoxycytidine , Diarrhea , Disease-Free Survival , Fluorouracil , Follow-Up Studies , Lung , Neoplasm Metastasis , Rectal Neoplasms , RecurrenceABSTRACT
PURPOSE: The effects of neoadjuvant chemoradiation therapy (NCRT) in cases of locally advanced rectal cancer include tumor downstaging with respect to a curative resection and a decreasing incidence of local recurrence. The aim of this study is to evaluate the oncologic results according to the tumor regression grade (TRG) after NCRT and radical surgical resection in cases of locally advanced rectal cancer. METHODS: From 1999 to 2003, 140 consecutive patients, who suffered from locally advanced rectal cancer (T3 or T4, or lymph node positive) were enrolled in this study. They all received neoadjuvant chemoradiation therapy and a radical resection. Chemotherapy was based on 5-fluorouracil (5-FU), and the total radiation dose was 5,040 cGy over 6 weeks. A radical surgical resection, including a total mesorectal excision, was done 6 to 8 weeks after the completion of NCRT. We classified patients into subgroups by using the TRG; then, we investigated the overall and the disease-free survival rates and the local recurrence and the distant metastasis rates. RESULTS: One hundred twenty-six (126, 90%) patients responded to radiation therapy. According to the TRG, the numbers of non- responders (Grade I, NR), partial responders (Grade II, PR), and patients who went into complete remission (Grade III, CR) were 14 (10%), 98 (70%), and 28 (20%), respectively. The overall survival (OS) and the disease-free survival (DFS) rates for 3 years (n=140) were 91.43% and 74.29%, and the rates for 5 years (n=117) were 81.20% and 67.52%, respectively. While there was no significant difference in the 3-year OS or DFS between the three groups stratified by TRG (P=0.1136, P=0.1215), the 5-year OS and DFS showed a statistical difference (P=0.0485, P=0.0458). Furthermore, the 3-year OS and DFS rates (P=0.0451, P=0.0458), as well as the 5-year OS and DFS rates (P=0.0139, P=0.0131) were significantly better for patients in the CR group than for the other patients. Still, no statistical significance differences existed between the CR group and the non-CR groups or between the TRG groups in terms of the local recurrence and the distant metastasis rates (P=0.447, P=0.271). CONCLUSIONS: Any tumor response group that shows complete Rremission after NCRT and radical surgical resection has an oncologic benefit in overall survival and disease- free survival in our study.