AB059. 188. The effect of extending the interval between the end of long-course chemoradiation and total mesorectal excision on pathological, surgical and oncologic outcomes in patients with rectal cancer: a systematic review and meta-analysis (original) (raw)
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Diseases of The Colon & Rectum, 2003
PURPOSE: Preoperative chemoradiation reduces tumor size and nodal metastasis in patients with rectal cancer. Tumor downstaging has been associated with an increased probability of a sphincter-saving procedure and with improved local control. However, pathologic complete response to chemoradiation has not been correlated with local control and patient survival. We studied the prognostic value of pathologic complete response to preoperative chemoradiation in rectal cancer patients. METHODS: We have prospectively followed up 168 consecutive patients with ultrasound Stages II (46) and III (122) rectal cancer treated by preoperative chemoradiation followed by radical resection with mesorectal excision; 161 had a curative resection. Recurrence and survival were compared with tumor characteristics and pathologic complete response. Average follow-up was 37 months. RESULTS: Tumor downstaging occurred in 97 (58 percent) patients, including 21 (13 percent) patients who had a pathologic complete response. None of the clinical or pathologic variables was associated with pathologic complete response. The estimated 5-year rate of local recurrence was 5 percent; of distant metastasis, 14 percent. None of the patients with pathologic complete response has developed disease recurrence. We found no difference in survival among patients with pathologic Stages I, II, or III tumors. CONCLUSIONS: A pathologic complete response to preoperative chemoradiation is associated with improved local control and patient survival. For patients without pathologic complete response, the pathology stage does not have prognostic significance.
Research Square (Research Square), 2023
Purpose: We aimed to determine the long-term oncologic outcome for patients with rectal cancer treated with preoperative Chemoradiotherapy (CRT) followed by total mesorectal excision (TME). In addition, we attempted to identify prognostic factors and the oncologic signi cance of a pathological complete response (pCR) on the patient's oncologic outcome. Materials and Methods: Between February 1993 and January 2019, a prospectively maintained database of 357 consecutive patients with locally advanced (cT3-4 or any N1-2) primary rectal adenocarcinoma who received preoperative CRT followed by curative TME at our institute was analyzed. Results: With a median follow-up of 72 (23-295) months, local recurrence occurred in 21 (5.9%) patients. The 5-, 10-, and 15-year locoregional free survival rates were 92.7%, 91.3%, and 91.3%, respectively. The median time to pelvic recurrence was 28 (12-103) months. Pathologic complete response was reported in 41 (11.6%) patients, and no patient with pCR developed local recurrence. Advanced pathologic T stage, pathologic nodal stage, and circumferential resection margin involvement were signi cantly poor prognostic factors for these patients. Conclusion: Neoadjuvant radiochemotherapy for rectal cancer signi cantly improved the down-staging and sphincter preservation rates of low-lying rectal carcinomas. However, some patients will continue to recur after 5 years of follow-up.
The American Journal of Surgery, 2006
BACKGROUND: Neoadjuvant chemoradiation is increasingly utilized for rectal cancer, with resection typically six weeks after completion of radiotherapy. We observed that further delay after radiotherapy led to increased downsizing. We performed this retrospective analysis to evaluate the safety of this approach. METHODS: A retrospective review was performed of 48 patients with distal or midrectal cancer who were operated on eight weeks or less after chemoradiation ended (Group 1, n=16), and more than eight weeks later (Group 2, n=32). We looked at the effect of delaying surgery on intraoperative blood loss, operative and hospital duration, postoperative complications, readmissions, and mortality. RESULTS: The median interval between radiation and operation was seven weeks in Group 1 and eleven weeks in Group 2. There was no significant difference between the two groups in terms of intraoperative blood loss, postoperative complications, or readmissions. Length of operation and length of stay were slightly longer. CONCLUSIONS: Delaying surgery after neoadjuvant treatment is safe, with morbidity and mortality similar to that with surgery less than eight weeks after chemoradiation.
World journal of surgical oncology, 2017
There are only two prospective, randomized studies comparing preoperative long-term chemoradiotherapy and postoperative chemoradiotherapy in locally advanced rectal cancer (LARC); however, conflicting results in terms of locoregional recurrence (LR) and survival rates have been reported. This prospective study aims to compare the effects of preoperative versus postoperative chemoradiotherapy on recurrence and survival rates in LARC patients. From January 2003 to January 2016, a total of 336 eligible patients who were clinically diagnosed with LARC (T3-T4 tm or node-positive disease) were prospectively assigned into preoperative chemoradiotherapy (n = 177) and postoperative chemoradiotherapy (n = 159) groups. The preoperative treatment consisted of 50.4 Gy total dose of radiotherapy (delivered in fractions of 1.8 Gy) and concomitant two cycles chemotherapy of 5-fluorouracil and leucovorin. The patients in the preoperative group underwent curative total mesorectal excision (TME) follo...
Annals of Surgical Oncology
Background Local excision might represent an alternative to total mesorectal excision for patients with locally advanced rectal cancer who achieve a major or complete clinical response after neoadjuvant chemoradiotherapy. Methods Between August 2005 and July 2011, 63 patients with mid-low rectal adenocarcinoma who had a major/complete clinical response after neoadjuvant chemoradiotherapy were enrolled in a multicenter prospective phase 2 trial and underwent transanal full thickness local excision. The main endpoint of this study was to evaluate the 5- and 10-year overall, relapse-free, local, and distant relapse-free survival, which were calculated by applying the Kaplan–Meier method. The rate of patients with rectum preserved and without stoma were also calculated. Results Of 63 patients, 38 (60%) were male and 25 (40%) were female, with a median (range) age of 64 (25–82) years. At baseline, the following clinical stages were found: cT2, n = 21 (33.3%); cT3, n = 42 (66.6%), 39 (61....
International Journal of Radiation Oncology Biology Physics, 2001
Purpose: To assess the pelvic failure among patients with T3 rectal cancer treated with local excision after preoperative chemoradiation. Methods and Materials: Between January 1990 and June 2002, 431 patients with clinically staged T3 rectal cancer were treated with preoperative chemoradiation followed by surgical resection. Full-thickness local excision [Kraske (n ؍ 3) or a transanal excision (n ؍ 23)] was performed in 26 patients because of patient refusal of abdominoperineal resection (APR) (n ؍ 13), medical comorbidity (n ؍ 4), physician preference after a complete clinical response (n ؍ 6), and other reasons (n ؍ 3). All patients were treated with continuous-infusion 5-fluorouracil (5-FU) (300 mg/m 2 Monday to Friday) and concomitant pelvic radiation (45 Gy in 25 fractions with a 3-field belly board technique). Ten local-excision patients received a concomitant boost during the last week of therapy (1.5-Gy second daily fractions) for a total dose of 52.5 Gy. Similar preoperative treatment was followed by total mesorectal excision in 405 patients. Among the local-excision patients, the median tumor size was 3.5 cm (range, 0.5-7 cm). Well-differentiated or moderately-differentiated histology was present in all but 3 cases, and endoscopic ultrasound staging examination was performed in 25 of 26 patients. Based on CT findings, 1 patient was node positive. The median circumference involved by tumor was 33%, (20%-75%). The median distance from the anal verge was 3 cm (range, 1-8 cm). Results: The mean follow-up was 46 months (range, 5-109 months) in the local-excision group. In the localexcision group, 19 of 26 patients had only residual scarring noted on digital rectal examination and rigid proctoscopy before surgery. Fourteen patients (54%) had a complete histologic response to chemoradiation, 9 patients (35%) had microscopic residual disease, and 3 patients (12%) had gross residual disease. Two intrapelvic recurrences occurred at 76 and 20 months among the 26 patients treated with local excision (6% 5-year actuarial pelvic recurrence rate). This rate compared with an 8% 5-year actuarial pelvic recurrence rate among T3 patients treated with mesorectal excision and a 6% pelvic recurrence rate in the subgroup of mesorectal-excision patients with a complete clinical response to preoperative chemoradiation. One additional local-excision patient recurred in an inguinal lymph node after local excision and subsequently died of metastatic disease. A total of 2 local-excision patients died of metastatic rectal cancer. Actuarial overall survival at 5 years was 86% in the local-excision group compared with 81% among mesorectal-excision patients (p ؍ NS), and 85% in patients with a complete clinical response to chemoradiation followed by mesorectal excision by APR or LAR (p ؍ NS). Conclusions: In an experience stimulated by patient refusal of APR, highly selected patients who responded well to conventional external-beam radiotherapy (CXRT) were selected to undergo local excision. Most of these patients had pathologic complete response. Local control and survival rates are comparable to those achieved with chemoradiation followed by mesorectal excision. This strategy should be prospectively studied in a group of patients with low rectal cancer who have no clinical evidence of tumor after chemoradiation.
International Journal of Colorectal Disease, 2014
Background Low rectal cancer is conventionally managed with neoadjuvant chemoradiotherapy (CRT) followed by radical surgery (RS). In patients who refuse a stoma or are unfit for RS, an alternative approach may be the use of pre-op CRT and local excision (LE) where tumours are responsive. The aim of this systematic review is to determine whether differences exist in local recurrence (LR), overall survival (OS) and disease-free (DFS) survival between patients treated with CRT+LE and CRT+RS. Methods A literature search was performed using MEDLINE/ PubMed/Ovid databases and Google Scholar between 1946 and 2013. Studies comparing outcome following LE and RS post-CRT were included. A pooled analysis was carried out using the Mantel-Haenszel statistical (random effects) model to identify differences in LR, OS and DFS between CRT+LE and CRT+RS. Results Eight studies were suitable for pooled analyses of LR whereas five and four studies were analysed for OS and DFS, respectively. When RS was used as the reference group, LR rate was higher in the LE group. However, this was nonsignificant (odds ratio (OR) 1.29, confidence interval (CI) 0.72-2.31, p=0.40). Similarly, no difference was observed in 10-year OS (OR 0.96, CI 0.38-2.43, p=0.93) or 5-year DFS (OR 1.04, CI 0.61-1.76, p=0.89). There was evidence of publication bias in studies used for DFS. Subgroup analysis of above outcomes in T3/any N stage cancers showed no difference in LE versus RS. Conclusion In the current evidence synthesis, there was no statistical difference in the LR, OS and DFS rates observed between patients treated with LE and RS for rectal cancer post-CRT. LE post-CRT may represent a viable alternative to RS for some patients wishing to avoid RS. However, further randomised studies are required to confirm these results.
International Surgery Journal
Background: Colorectal cancer is a major cause of morbidity and mortality throughout the world. The incidence of rectal carcinoma is increasing in developing countries. Challenge in preoperative evaluation remains to identify patients who might benefit from neoadjuvant chemotherapy or chemoradiation (NACT/RT). The aim of this study was to study the correlation of final histopathology specimen (pathological tumor regression grade) with preoperative MRI (magnetic resonance tumor regression grade) (mrTRG).Method: This was a prospective observational analysis with operable rectal cancer of mid or distal rectum who underwent total mesorectal excision either upfront or following CT/RT. Preoperative MRI was done for local staging and also to assess response to neo-adjuvant CT/RT. Histo-pathological specimen was assessed for pathological tumor regression and correlation between mrTRG and pathological tumor regression grading (pTRG) analysed.Results: Out of 79 patients, 69 patients received ...
Preoperative chemoradiation may not always be needed for patients with T3 and T2N+ rectal cancer
Cancer, 2011
BACKGROUND: Preoperative chemoradiation is becoming the standard treatment for patients with locally advanced rectal cancer. However, since the introduction of total mesorectal excision (TME), local recurrence rates have been reduced significantly, and some patients can be spared from potentially toxic over treatment. The current study was designed to assess the factors that predict recurrence in an institutional series of patients with rectal cancer who had clinical T2 lymph node-positive (cT2Nþ) tumors or cT3N0/Nþ tumors and underwent radical surgery without receiving preoperative chemoradiation. METHODS: Between November 1997 and November 2008, the authors' multidisciplinary group preoperatively staged 398 patients with rectal cancer by using endorectal ultrasonography and/or magnetic resonance imaging. The analysis included 152 consecutive patients with cT2Nþ, cT3N0, or cT3Nþ rectal cancer who underwent TME without receiving preoperative chemoradiation. Macroscopic assessment of the mesorectal excision and circumferential resection margins were determined. Factors potentially related to local recurrence (LR), disease-free survival (DFS) and cancer-specific survival (CSS) were analyzed. RESULTS: After a median followup of 39 months, the 5-year actuarial LR, DFS, and CSS rates were 9.5%, 65.4%, and 77.8%, respectively, for the whole group. Threatened mesorectal fascia at preoperative staging was the only independent preoperative factor that predicted a higher risk for LR (P ¼ .007), shorter DFS (P ¼ .007), and shorter CSS (P ¼ .05). In particular, the 5-year LR rates for patients with and without preoperative threatened circumferential resection margins were 19.4% and 5.4%, respectively. CONCLUSIONS: The current results suggested that patients with rectal cancer clinically staged as T3N0/Nþ or T2Nþ with a free margin >2 mm from mesorectal fascia may undergo TME alone, avoiding over treatment with preoperative chemoradiation.