|
1
|
Kim HJ, Choi GS, Cho SH, Kang MK, Park JS, Park SY, Kang BW, Kim JG. Sequential Lateral Lymphatic Metastasis Shows Similar Oncologic Outcomes to Upward Spread in Advanced Rectal Cancer After Preoperative Chemoradiotherapy. Dis Colon Rectum 2024; 67:359-368. [PMID: 37962146 DOI: 10.1097/dcr.0000000000002989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
BACKGROUND Whether lateral pelvic node metastasis should be considered as a regional or systemic disease is a long-standing debate. Although previous Japanese studies have considered it to be locoregional disease, Western countries consider it a systemic disease and do not perform lateral pelvic node dissection after preoperative chemoradiotherapy. OBJECTIVE To evaluate whether lateral pelvic node metastasis is a systemic or regional disease that is amenable to curative resection. DESIGN Retrospective analysis of a prospectively collected database. SETTING This study was conducted at a tertiary cancer center. PATIENTS There were 616 consecutive patients who underwent curative total mesorectal excision alone or with lateral pelvic node dissection after preoperative chemoradiotherapy for locally advanced rectal cancer between 2011 and 2019. MAIN OUTCOME MEASURES Three-year disease-free and overall survival. RESULTS A total of 360 patients underwent total mesorectal excision, and 160 patients underwent total mesorectal excision with lateral pelvic node dissection. There was no difference in the 3-year disease-free survival (DFS; p = 0.844) or overall survival rates ( p = 0.921) between the groups. Patients with lateral pelvic node metastasis showed DFS similar to those with perirectal lymph node metastasis in the total mesorectal excision group. In a subgroup analysis, patients with internal iliac pelvic node metastasis showed a disease-free survival comparable to those with perirectal node involvement, and patients with other lateral pelvic node metastasis showed a DFS similar to those with intermediate node involvement. In the lateral pelvic node dissection group, the lateral pelvic node metastatic rate was 32.5%. On multivariate analysis, fewer than 8 of the unilateral harvested lateral pelvic nodes and advanced ypT stage were significantly associated with poor disease-free survival. LIMITATION The retrospective design. CONCLUSIONS Lateral lymphatic metastasis showed oncologic outcomes similar to those of upward spread, especially perirectal lymph nodes metastasis. Large cohort studies with long-term follow-up are required to confirm these results. See Video Abstract . LAS METSTASIS LINFTICAS SECUENCIALES LATERALES MUESTRAN RESULTADOS ONCOLGICOS SIMILARES EN LA PROPAGACIN ASCENDENTE DEL CNCER RECTAL AVANZADO DESPUS DE LA RADIOQUIMIOTERAPIA PREOPERATORIA ANTECEDENTES:Es un debate muy antiguo si las metástasis en los ganglios pélvicos laterales deben considerarse una enfermedad regional o sistémica. Si bien estudios japoneses anteriores las consideran como una enfermedad locorregional, en los países de occidente se las considera como una enfermedad sistémica por la cual no se realiza disección de ganglios pélvicos laterales después de una radioquimioterapia preoperatoria.OBJETIVOS:Evaluar si la metástasis en los ganglios pélvicos laterales se consideran como enfermedad sistémica o enfermedad regional susceptible de resección curativa.DISEÑO:Análisis retrospectivo de una base de datos recopilada prospectivamente.AJUSTE:Este estudio se realizó en un centro oncológico terciario.PACIENTES:616 pacientes consecutivos se sometieron a excisión total del mesorrecto curativa sola o con disección de los ganglios pélvicos laterales después de radioquimioterapia preoperatoria en casos de cáncer de recto localmente avanzado entre 2011 y 2019.PRINCIPALES MEDIDAS DE RESULTADO:Sobrevida global y libre de enfermedad a 3 años.RESULTADOS:Un total de 360 pacientes se sometieron a excisión total del mesorrecto y 160 pacientes se sometieron a excisión total del mesorrecto con disección de ganglios pélvicos laterales.No hubo diferencias en la sobrevida libre de enfermedad a 3 años (p = 0,844) ni en las tasas de sobrevida general (p = 0,921) entre los grupos. Los pacientes con metástasis en los ganglios pélvicos laterales mostraron una sobrevida libre de enfermedad similar a aquellos con metástasis en los ganglios linfáticos perirrectales que se encontraban en el grupo de excisión total del mesorrecto.En el análisis de subgrupos, los pacientes con metástasis en los ganglios pélvicos ilíacos internos mostraron una sobrevida libre de enfermedad comparable a aquellos con afección de los ganglios perirrectales y los pacientes con otras metástasis en los ganglios pélvicos laterales mostraron una sobrevida libre de enfermedad similar a aquellos con afección de los ganglios intermedios.En el grupo de disección de los ganglios pélvicos laterales, la tasa de metástasis en dichos ganglios fué del 32,5%. En el análisis multivariado, < de 8 ganglios pélvicos laterales resecados unilateralmente y el estadio ypT avanzado se asociaron significativamente con una menor sobrevida libre de enfermedad.LIMITACIÓN:El diseño retrospectivo del estudio.CONCLUSIONES:Las metástasis linfáticas laterales mostraron resultados oncológicos similares a la diseminación ascendente, especialmente las metástasis en los ganglios linfáticos perirrectales. Se requieren grandes estudios de cohortes con seguimiento a largo plazo para confirmar estos resultados. (Traducción-Dr. Xavier Delgadillo ).
Collapse
Affiliation(s)
- Hye Jin Kim
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Gyu-Seog Choi
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Seung Hyun Cho
- Department of Radiology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Min Kyu Kang
- Department of Radiation Oncology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jun Seok Park
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Soo Yeun Park
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Byung Woog Kang
- Department of Hematology and Oncology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jong Gwang Kim
- Department of Hematology and Oncology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| |
Collapse
|
|
2
|
Xu Z, Valente MA, Sklow B, Liska D, Gorgun E, Kessler H, Rosen DR, Steele SR. Impact of Total Neoadjuvant Therapy on Postoperative Outcomes After Proctectomy for Rectal Cancer. Dis Colon Rectum 2023; 66:1022-1028. [PMID: 36538720 DOI: 10.1097/dcr.0000000000002555] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Total neoadjuvant therapy is an alternative to neoadjuvant chemoradiation alone for rectal cancer and has the benefits of more completion of planned therapy, increased downstaging, earlier treatment of micrometastases, and assessment of chemosensitivity; however, it may increase surgical complications, especially with increased radiation-to-surgery interval. OBJECTIVE The study aimed to determine the impact of total neoadjuvant therapy on postoperative complications compared with neoadjuvant chemoradiation alone. DESIGN Retrospective cohort study. SETTINGS Single tertiary referral center. PATIENTS The patient included was a stage II/III rectal cancer patient who underwent total neoadjuvant therapy or long-course neoadjuvant chemoradiation followed by surgical resection from 2018-2020. MAIN OUTCOME MEASURES The main outcome measures included severe postoperative complications (Clavien-Dindo grade ≥3). RESULTS Of 181 patients, 86 (47.5%) underwent total neoadjuvant therapy and 95 (52.5%) underwent neoadjuvant chemoradiation. There was no difference in severe postoperative complications or any complications. There was also no difference in the rate of complete total mesorectal excision or negative circumferential margin. Total neoadjuvant therapy had a mean operative time of 355.5 minutes and estimated blood loss of 263.6 mL compared with 326.7 minutes and 297.5 mL in the neoadjuvant chemoradiation group. Total neoadjuvant therapy patients had a lower mean lymph node yield than neoadjuvant chemoradiation patients. On multivariable analysis, total neoadjuvant therapy was associated with increased operative time (OR, 1.19; p < 0.001) and estimated blood loss (OR, 1.22; p < 0.001) and decreased lymph node yield (OR, 0.67; p < 0.001). There was no difference in severe complications or any complications. LIMITATIONS Selection bias uncontrolled by modeling. CONCLUSIONS We found no difference in risk of postoperative complications between patients who received total neoadjuvant therapy vs neoadjuvant chemoradiation. Total neoadjuvant therapy patients had longer operations and greater estimated blood loss. This may be a reflection of increased operative difficulty because of increased radiation-to-surgery interval and/or the effects of chemotherapy; however, the absolute differences were small and, therefore, should be interpreted cautiously. See Video Abstract at http://links.lww.com/DCR/C44 . IMPACTO DE LA TERAPIA NEOADYUVANTE TOTAL EN LOS RESULTADOS POSOPERATORIOS DESPUS DE UNA PROCTECTOMA POR CNCER DE RECTO ANTECEDENTES:La terapia neoadyuvante total es una alternativa a la quimiorradiación neoadyuvante sola para el cáncer de recto y tiene los beneficios de una mayor finalización de la terapia planificada, mayor reducción del estadiage, tratamiento más temprano de las micrometástasis y evaluación de la quimiosensibilidad; sin embargo, puede aumentar las complicaciones quirúrgicas, especialmente con un mayor intervalo entre la radiación y la cirugía.OBJETIVO:Determinar el impacto de la terapia neoadyuvante total sobre las complicaciones posoperatorias en comparación con la quimiorradiación neoadyuvante sola.DISEÑO:Estudio de cohorte retrospectivo.ENTORNO CLINICO:Centro único de referencia terciario.PACIENTES:Paciente con cáncer de recto en estadio II/III que se sometieron a terapia neoadyuvante total o quimiorradiación neoadyuvante de larga duración seguida de resección quirúrgica entre 2018 y 2020.PRINCIPALES MEDIDAS DE RESULTADO:Complicaciones postoperatorias graves (grado de Clavien-Dindo ≥3).RESULTADOS:De 181 pacientes, 86 (47,5%) se sometieron a terapia neoadyuvante total y 95 (52,5%) se sometieron a quimiorradioterapia neoadyuvante. No hubo diferencia en las complicaciones postoperatorias graves o cualquier otra complicación. Tampoco hubo diferencia en la tasa de escisión mesorrectal total completa o margen circunferencial negativo. La terapia neoadyuvante total tuvo un tiempo operatorio promedio de 355,5 minutos y una pérdida de sangre estimada de 263,6 ml en comparación con 326,7 minutos y 297,5 ml en el grupo de quimiorradiación neoadyuvante. Los pacientes con terapia neoadyuvante total tuvieron una media de ganglios linfáticos más bajo en comparación con los pacientes con quimiorradioterapia neoadyuvante. En el análisis multivariable, la terapia neoadyuvante total se asoció con un mayor tiempo operatorio (OR = 1,19, p < 0,001) y pérdida de sangre estimada (OR = 1,22, p < 0,001) y menor cantidad los ganglios linfáticos (OR = 0,67, p < 0,001). No hubo diferencia en las complicaciones graves o cualquier complicación.LIMITACIONES:Sesgo de selección no controlado por modelado.CONCLUSIONES:No encontramos diferencias en el riesgo de complicaciones postoperatorias entre los pacientes que recibieron terapia neoadyuvante total versus quimiorradiación neoadyuvante. Los pacientes con terapia neoadyuvante total tuvieron operaciones más prolongadas y una mayor pérdida de sangre estimada. Esto puede ser un reflejo de una mayor dificultad quirúrgica como resultado de un mayor intervalo entre la radiación y la cirugía y/o los efectos de la quimioterapia; sin embargo, las diferencias absolutas fueron pequeñas y, por lo tanto, deben interpretarse con cautela. Consulte Video Resumen en http://links.lww.com/DCR/C44 . (Traducción- Dr. Francisco M. Abarca-Rendon ).
Collapse
Affiliation(s)
- Zhaomin Xu
- Department of Colorectal Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | | | | | | | | | | | | | | |
Collapse
|
|
3
|
He L, Xiao J, Zheng P, Zhong L, Peng Q. Lymph node regression grading of locally advanced rectal cancer treated with neoadjuvant chemoradiotherapy. World J Gastrointest Oncol 2022; 14:1429-1445. [PMID: 36160739 PMCID: PMC9412927 DOI: 10.4251/wjgo.v14.i8.1429] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/30/2022] [Accepted: 07/06/2022] [Indexed: 02/05/2023] Open
Abstract
Neoadjuvant chemoradiotherapy (nCRT) and total rectal mesenteric excision are the main standards of treatment for locally advanced rectal cancer (LARC). Lymph node regression grade (LRG) is an indicator of prognosis and response to preoperative nCRT based on postsurgical metastatic lymph node pathology. Common histopathological findings in metastatic lymph nodes after nCRT include necrosis, hemorrhage, nodular fibrosis, foamy histiocytes, cystic cell reactions, areas of hyalinosis, residual cancer cells, and pools of mucin. A number of LRG systems designed to classify the amount of lymph node regression after nCRT is mainly concerned with the relationship between residual cancer cells and regressive fibrosis and with estimating the number of lymph nodes existing with residual cancer cells. LRG offers significant prognostic information, and in most cases, LRG after nCRT correlates with patient outcomes. In this review, we describe the systematic classification of LRG after nCRT, patient prognosis, the correlation with tumor regression grade, and the typical histopathological findings of lymph nodes. This work may serve as a reference to help predict the clinical complete response and determine lymph node regression in patients based on preservation strategies, allowing for the formulation of more accurate treatment strategies for LARC patients, which has important clinical significance and scientific value.
Collapse
Affiliation(s)
- Lei He
- School of Medicine, University of Electronic Science and Technology of China, Chengdu 611731, Sichuan Province, China
| | - Juan Xiao
- School of Medicine, University of Electronic Science and Technology of China, Chengdu 611731, Sichuan Province, China
| | - Ping Zheng
- Department of Pathology, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610041, Sichuan Province, China
| | - Lei Zhong
- Personalized Drug Therapy Key Laboratory of Sichuan Province, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, Chengdu 610072, Sichuan Province, China
| | - Qian Peng
- Radiation Therapy Center, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610041, Sichuan Province, China
| |
Collapse
|
|
4
|
Mei SW, Liu Z, Wang Z, Pei W, Wei FZ, Chen JN, Wang ZJ, Shen HY, Li J, Zhao FQ, Wang XS, Liu Q. Impact factors of lymph node retrieval on survival in locally advanced rectal cancer with neoadjuvant therapy. World J Clin Cases 2020; 8:6229-6242. [PMID: 33392304 PMCID: PMC7760431 DOI: 10.12998/wjcc.v8.i24.6229] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 10/20/2020] [Accepted: 11/04/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Conventional clinical guidelines recommend that at least 12 lymph nodes should be removed during radical rectal cancer surgery to achieve accurate staging. The current application of neoadjuvant therapy has changed the number of lymph node dissection. AIM To investigate factors affecting the number of lymph nodes dissected after neoadjuvant chemoradiotherapy in locally advanced rectal cancer and to evaluate the relationship of the total number of retrieved lymph nodes (TLN) with disease-free survival (DFS) and overall survival (OS). METHODS A total of 231 patients with locally advanced rectal cancer from 2015 to 2017 were included in this study. According to the American Joint Committee on Cancer (AJCC)/Union for International Cancer Control (UICC) tumor-node-metastasis (TNM) classification system and the NCCN guidelines for rectal cancer, the patients were divided into two groups: group A (TLN ≥ 12, n = 177) and group B (TLN < 12, n = 54). Factors influencing lymph node retrieval were analyzed by univariate and binary logistic regression analysis. DFS and OS were evaluated by Kaplan-Meier curves and Cox regression models. RESULTS The median number of lymph nodes dissected was 18 (range, 12-45) in group A and 8 (range, 2-11) in group B. The lymph node ratio (number of positive lymph nodes/total number of lymph nodes) (P = 0.039) and the interval between neoadjuvant therapy and radical surgery (P = 0.002) were independent factors of the TLN. However,TLN was not associated with sex, age, ASA score, clinical T or N stage, pathological T stage, tumor response grade (Dworak), downstaging, pathological complete response, radiotherapy dose, preoperative concurrent chemotherapy regimen, tumor distance from anal verge, multivisceral resection, preoperative carcinoembryonic antigen level, perineural invasion, intravascular tumor embolus or degree of differentiation. The pathological T stage (P < 0.001) and TLN (P < 0.001) were independent factors of DFS, and pathological T stage (P = 0.011) and perineural invasion (P = 0.002) were independent factors of OS. In addition, the risk of distant recurrence was greater for TLN < 12 (P = 0.009). CONCLUSION A shorter interval to surgery after neoadjuvant chemoradiotherapy for rectal cancer under indications may cause increased number of lymph nodes harvested. Tumor shrinkage and more extensive lymph node retrieval may lead to a more favorable prognosis.
Collapse
Affiliation(s)
- Shi-Wen Mei
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Zheng Liu
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Zheng Wang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Wei Pei
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Fang-Ze Wei
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Jia-Nan Chen
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Zhi-Jie Wang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Hai-Yu Shen
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Juan Li
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Fu-Qiang Zhao
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Xi-Shan Wang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Qian Liu
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| |
Collapse
|
|
5
|
Tan L, Liu ZL, Ma Z, He Z, Tang LH, Liu YL, Xiao JW. Prognostic impact of at least 12 lymph nodes after neoadjuvant therapy in rectal cancer: A meta-analysis. World J Gastrointest Oncol 2020; 12:1443-1455. [PMID: 33362914 PMCID: PMC7739152 DOI: 10.4251/wjgo.v12.i12.1443] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/28/2020] [Accepted: 10/20/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The number of dissected lymph nodes (LNs) in rectal cancer after neoadjuvant therapy has a controversial effect on the prognosis.
AIM To investigate the prognostic impact of the number of LN dissected in rectal cancer patients after neoadjuvant therapy.
METHODS We performed a systematic review and searched PubMed, Embase (Ovid), MEDLINE (Ovid), Web of Science, and Cochrane Library from January 1, 2000 until January 1, 2020. Two reviewers examined all the publications independently and extracted the relevant data. Articles were eligible for inclusion if they compared the number of LNs in rectal cancer specimens resected after neoadjuvant treatment (LNs ≥ 12 vs LNs < 12). The primary endpoints were the overall survival (OS) and disease-free survival (DFS).
RESULTS Nine articles were included in the meta-analyses. Statistical analysis revealed a statistically significant difference in OS [hazard ratio (HR) = 0.76, 95% confidence interval (CI): 0.66-0.88, I2 = 12.2%, P = 0.336], DFS (HR = 0.76, 95%CI: 0.63-0.92, I2 = 68.4%, P = 0.013), and distant recurrence (DR) (HR = 0.63, 95%CI: 0.48-0.93, I2 = 30.5%, P = 0.237) between the LNs ≥ 12 and LNs < 12 groups, but local recurrence (HR = 0.67, 95%CI: 0.38-1.16, I2 = 0%, P = 0.348) showed no statistical difference. Moreover, subgroup analysis of LN negative patients revealed a statistically significant difference in DFS (HR = 0.67, 95%CI: 0.52-0.88, I2 = 0%, P = 0.565) between the LNs ≥ 12 and LNs < 12 groups.
CONCLUSION Although neoadjuvant therapy reduces LN production in rectal cancer, our data indicate that dissecting at least 12 LNs after neoadjuvant therapy may improve the patients’ OS, DFS, and DR.
Collapse
Affiliation(s)
- Ling Tan
- Department of Gastrointestinal Surgery, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu 610500, Sichuan Province, China
| | - Zi-Lin Liu
- Department of Gastrointestinal Surgery, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu 610500, Sichuan Province, China
| | - Zhou Ma
- Department of Gastrointestinal Surgery, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu 610500, Sichuan Province, China
| | - Zhou He
- Department of Gastrointestinal Surgery, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu 610500, Sichuan Province, China
| | - Lin-Han Tang
- Department of Gastrointestinal Surgery, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu 610500, Sichuan Province, China
| | - Yi-Lei Liu
- Department of Gastrointestinal Surgery, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu 610500, Sichuan Province, China
| | - Jiang-Wei Xiao
- Department of Gastrointestinal Surgery, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu 610500, Sichuan Province, China
| |
Collapse
|
|
6
|
Feng S, Yan P, Zhang Q, Li Z, Li C, Geng Y, Wang L, Zhao X, Yang Z, Cai H, Wang X. Induction chemotherapy followed by neoadjuvant chemoradiotherapy and surgery for patients with locally advanced rectal cancer: a systematic review and meta-analysis. Int J Colorectal Dis 2020; 35:1355-1369. [PMID: 32488419 DOI: 10.1007/s00384-020-03621-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/14/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Controversy persists about whether additional induction chemotherapy (ICT) before neoadjuvant chemoradiation (NCRT) yields improved oncological outcomes. We performed a systematic review and meta-analysis to compare ICT+ NCRT+ surgery(S) with NCRT+ S in patients with locally advanced rectal cancer (LARC). METHODS We searched the PubMed, EMBASE, Cochrane Library, and China Biology Medicine (CBM) databases. The data were analyzed with Stata version 12.0 software. RESULTS We identified 9 relevant trials that enrolled 1538 patients. We detected no significant difference in the 5-year overall survival (OS) (OR 1.50, 95% CI 0.48-4.64), disease-free survival (DFS) (OR 1.03, 95% CI 0.73-1.46), local recurrence (LR) (OR 0.80, 95% CI 0.45-1.43), and distant metastasis (DM) rates (OR 1.03, 95% CI 0.55-1.93) between patients who did and did not receive ICT. The addition of ICT before NCRT had a similar pathological complete response rate compared to NCRT (OR 1.26, 95% CI 0.90-1.77). Our findings suggest that between the ICT + NCRT+S and NCRT+S groups, ICT improved the incidence of grade 3 to 4 toxicity effects (OR 4.81, 95% CI 2.38-9.37), but between the ICT + NCRT+S and NCRT+S+ adjuvant chemotherapy (ACT) groups, ICT might reduce toxicity (OR 0.19, 95% CI 0.08-0.50). ICT had no significant impact on surgical complications (OR 0.97, 95% CI 0.63-1.51). CONCLUSIONS The addition of ICT before NCRT seemingly shows no survival benefit on patients with LARC, and might increase the toxicity.
Collapse
Affiliation(s)
- Shuangwu Feng
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Peijing Yan
- Department of Clinical Research Management, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Qiuning Zhang
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, 730000, China
- Lanzhou Heavy Ions Hospital, Lanzhou, 730000, China
| | - Zheng Li
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, 730000, China
| | - Chengcheng Li
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Yichao Geng
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Lina Wang
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Xueshan Zhao
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Zhen Yang
- School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730000, China
| | - Hongyi Cai
- Department of Radiation Oncology, Gansu Province People's Hospital, Lanzhou, 730000, China
| | - Xiaohu Wang
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China.
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, 730000, China.
- Lanzhou Heavy Ions Hospital, Lanzhou, 730000, China.
| |
Collapse
|
|
7
|
Degiuli M, Arolfo S, Evangelista A, Lorenzon L, Reddavid R, Staudacher C, De Nardi P, Rosati R, Elmore U, Coco C, Rizzo G, Belluco C, Forlin M, Milone M, De Palma GD, Rega D, Delrio P, Guerrieri M, Ortenzi M, Muratore A, Marsanic P, Restivo A, Deidda S, Zuin M, Pucciarelli S, De Luca R, Persiani R, Biondi A, Roviello F, Marrelli D, Sgroi G, Turati L, Morino M. Number of lymph nodes assessed has no prognostic impact in node-negative rectal cancers after neoadjuvant therapy. Results of the "Italian Society of Surgical Oncology (S.I.C.O.) Colorectal Cancer Network" (SICO-CCN) multicentre collaborative study. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2018; 44:1233-1240. [PMID: 29705284 DOI: 10.1016/j.ejso.2018.04.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 03/12/2018] [Accepted: 04/05/2018] [Indexed: 02/08/2023]
Abstract
INTRODUCTION We retrospectively investigated the impact of number or complete absence of nodes retrieved on survival of patients with rectal cancer (RC) treated with neoadjuvant radiation-therapy (NAT). METHODS All patients with RC treated with NAT followed by curative surgery from 2000 to 2014 in 14 Italian referral Centres for Colorectal Surgery were enrolled. Information about number of nodes harvested, node ratio, type of radiation therapy schedule and tumour stage were recorded. Impact of number or complete absence of nodes retrieved on overall survival (OS) and on cumulative incidence of death for disease (CIDD) was assessed and factors influencing node yield were investigated. RESULTS In total, 1407 patients were included. Mean number of nodes retrieved was 12.9, while no lymph nodes were found in only 32 patients (2%, ypNnull). Definite nodal stage was ypN0 in 1001 patients (71%) and ypN+ in 372 patients (27%). In multivariable analysis ypNnull patients showed worse OS and CIDD compared to both ypN0 and ypN+. In ypN0 patients, number of nodes assessed, stratified in 4 groups (<5, 5-10, 11-15 and > 15), did not significantly influence OS and CIDD. Long-course radiation schedule and early T stages negatively affected node assessment. CONCLUSION Complete absence of nodes assessed was associated with worse prognosis compared to node-negative and node-positive patients. In node-negative patients number of nodes was not associated to OS and CIDD. Based on data from this large population of irradiated RC, number of nodes assessed has no prognostic impact in node-negative patients.
Collapse
Affiliation(s)
- Maurizio Degiuli
- University of Torino, School of Medicine, Department of Oncology, Digestive Surgery and Surgical Oncology, San Luigi University Hospital, Orbassano, Torino, Italy.
| | - Simone Arolfo
- Digestive and Oncological Surgery, Center for Minimal Invasive Surgery, Department of Surgical Sciences, Molinette Hospital and University of Torino School of Medicine, Italy
| | - Andrea Evangelista
- AOU Città della Salute e della Scienza University Hospital, Unit of Clinical Epidemiology and CPO, Torino, Italy
| | - Laura Lorenzon
- Division of General Surgery, Fondazione Policlinico Universitario A Gemelli, Universita' Cattolica del Sacro Cuore, Rome, Italy
| | - Rossella Reddavid
- University of Torino, School of Medicine, Department of Oncology, Digestive Surgery and Surgical Oncology, San Luigi University Hospital, Orbassano, Torino, Italy
| | | | - Paola De Nardi
- Division of Gastrointestinal Surgery, San Raffaele Hospital, Milan, Italy
| | - Riccardo Rosati
- Division of Gastrointestinal Surgery, San Raffaele Hospital, Milan, Italy
| | - Ugo Elmore
- Division of Gastrointestinal Surgery, San Raffaele Hospital, Milan, Italy
| | - Claudio Coco
- Polo Apparato Digerente e Sistema Endocrino-Metabolico - Area Chirurgica Addominale, Fondazione Policlinico Universitario "Agostino Gemelli" - Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gianluca Rizzo
- Polo Apparato Digerente e Sistema Endocrino-Metabolico - Area Chirurgica Addominale, Fondazione Policlinico Universitario "Agostino Gemelli" - Università Cattolica del Sacro Cuore, Rome, Italy
| | - Claudio Belluco
- Department of Surgical Oncology, CRO-IRCCS, National Cancer Institute, Aviano, Italy
| | - Marco Forlin
- Department of Surgical Oncology, CRO-IRCCS, National Cancer Institute, Aviano, Italy
| | - Marco Milone
- Advanced Biomedical Sciences Department, "Federico II" University, AOU "Federico II", Naples Italy
| | | | - Daniela Rega
- Colorectal Surgical Oncology, National Cancer Institute - IRCCS - G. Pascale Foundation, Napoli, Italy
| | - Paolo Delrio
- Colorectal Surgical Oncology, National Cancer Institute - IRCCS - G. Pascale Foundation, Napoli, Italy
| | - Mario Guerrieri
- Clinica Chirurgica, Azienda Ospedaliero-Universitaria Torrette di Ancona, Italy
| | - Monica Ortenzi
- Clinica Chirurgica, Azienda Ospedaliero-Universitaria Torrette di Ancona, Italy
| | - Andrea Muratore
- Division of General Surgery, E. Agnelli Hospital, Pinerolo (Torino), Italy
| | - Patrizia Marsanic
- Division of General Surgery, E. Agnelli Hospital, Pinerolo (Torino), Italy
| | - Angelo Restivo
- Colorectal Surgery, A.O.U. Cagliari, Department of Surgical Science, University of Cagliari, Italy
| | - Simona Deidda
- Colorectal Surgery, A.O.U. Cagliari, Department of Surgical Science, University of Cagliari, Italy
| | - Matteo Zuin
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Italy
| | - Salvatore Pucciarelli
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Italy
| | - Raffaele De Luca
- National Cancer Institute, Research Centre, Giovanni Paolo II, Surgery Unit, Bari, Italy
| | - Roberto Persiani
- Division of General Surgery, Fondazione Policlinico Universitario A Gemelli, Universita' Cattolica del Sacro Cuore, Rome, Italy
| | - Alberto Biondi
- Division of General Surgery, Fondazione Policlinico Universitario A Gemelli, Universita' Cattolica del Sacro Cuore, Rome, Italy
| | - Franco Roviello
- Department of General Surgery, Azienda Ospedaliero-Universitaria Senese, Nuovo Policlinico Le Scotte, Siena, Italy
| | - Daniele Marrelli
- Department of General Surgery, Azienda Ospedaliero-Universitaria Senese, Nuovo Policlinico Le Scotte, Siena, Italy
| | - Giovanni Sgroi
- Surgical Oncology, Ospedale Treviglio - ASST Bergamo Ovest Piazza Meneguzzo, 1 - 24047 Treviglio (BG), Italy
| | - Luca Turati
- Surgical Oncology, Ospedale Treviglio - ASST Bergamo Ovest Piazza Meneguzzo, 1 - 24047 Treviglio (BG), Italy
| | - Mario Morino
- Digestive and Oncological Surgery, Center for Minimal Invasive Surgery, Department of Surgical Sciences, Molinette Hospital and University of Torino School of Medicine, Italy
| |
Collapse
|
|
8
|
Allaix ME, Giraudo G, Ferrarese A, Arezzo A, Rebecchi F, Morino M. 10-Year Oncologic Outcomes After Laparoscopic or Open Total Mesorectal Excision for Rectal Cancer. World J Surg 2017; 40:3052-3062. [PMID: 27417110 DOI: 10.1007/s00268-016-3631-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Only few studies have compared laparoscopic total mesorectal excision (LTME) and open total mesorectal excision (OTME) for rectal cancer with follow-up longer than 5 years. The aim of this study was to compare 10-year oncologic outcomes after LTME and OTME for nonmetastatic rectal cancer. METHODS We conducted a retrospective analysis of a prospective database of rectal cancer patients undergoing LTME or OTME. Statistical analyses were performed on an ''intention-to-treat'' basis and by actual treatment. Overall survival (OS) and disease-free survival (DFS) were compared by using the Kaplan-Meier method. A multivariable analysis was performed to identify predictors of poor survival. RESULTS Between April 1994 and August 2005, a total of 153 LTME patients and 154 OTME patients were included. Similarly, 10-year OS and DFS after LTME and OTME were observed: 76.8 versus 70.6 % (P = 0.138) and 69.1 versus 67.6 % (P = 0.508), respectively. Conversion to OTME did not adversely affect OS and DFS. Stage-by-stage comparison showed no significant differences between LTME and OTME. No significant differences were observed in local recurrence rates after LTME and OTME (6.5 vs. 7.8 %, P = 0.837). Median time until local recurrence was 24.5 (range, 12-56) months after LTME and 22 (6-64) months after OTME (P = 0.777). Poor tumor differentiation, lymphovascular invasion, and a lymph node ratio of 0.25 or more were the independent predictors of poorer OS and DFS. CONCLUSION This retrospective study with long follow-up did not show significant differences between the two groups in OS and DFS.
Collapse
Affiliation(s)
- Marco E Allaix
- Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Torino, Italy.
| | - Giuseppe Giraudo
- Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Torino, Italy
| | - Alessia Ferrarese
- Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Torino, Italy
| | - Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Torino, Italy
| | - Fabrizio Rebecchi
- Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Torino, Italy
| | - Mario Morino
- Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Torino, Italy
| |
Collapse
|
|
9
|
Lymph node yield after rectal resection in patients treated with neoadjuvant radiation for rectal cancer: A systematic review and meta-analysis. Eur J Cancer 2016; 72:84-94. [PMID: 28027520 DOI: 10.1016/j.ejca.2016.10.031] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 10/05/2016] [Accepted: 10/19/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND The lymph node status represents a major prognostic factor in colorectal cancer. However, it was demonstrated that neoadjuvant chemoradiotherapy (CRT) decreases the numbers of lymph nodes in the specimen. Several studies describe less than 12 lymph nodes in the resected specimen of rectal cancer patients after neoadjuvant radiation. This meta-analysis quantifies the influence of neoadjuvant CRT or radiotherapy (RT) only on the lymph node yield in rectal cancer patients. METHODS We performed a systematic review and searched PubMed, EMBASE and the Cochrane Library without any language restriction from 1st of January 1980 until 31st March 2015. Two reviewers examined all publications independently and extracted the relevant data if the study assessed lymph node counts or positive lymph node yields of patients who received neoadjuvant treatment compared with patients who did not receive neoadjuvant treatment. Meta-analyses were conducted to quantify the mean difference in lymph node yield. RESULTS A total of 34 articles (including 37 datasets) were included in the meta-analyses. Neoadjuvant CRT resulted in a mean reduction of 3.9 lymph nodes (95% confidence interval [CI] 3.7-4.1) and an average reduction in harvested positive lymph nodes of 0.7 (95% CI 0.2-1.2) compared with patients who received no neoadjuvant therapy. Individuals who received neoadjuvant RT had, in average, 2.1 lymph node less (95% CI 1.7-2.5) resected compared with their counterparts who received no neoadjuvant treatment. CONCLUSIONS Neoadjuvant CRT or RT only in rectal cancer patients leads to a decrease in lymph node harvest of approximately four and two lymph nodes, respectively. We therefore stress the importance of intensifying all efforts from involved subspecialities (i.e. surgeons and pathologists) to reach the benchmark harvest of 12 resected lymph nodes according to current guidelines.
Collapse
|
|
10
|
Raoof M, Nelson RA, Nfonsam VN, Warneke J, Krouse RS. Prognostic significance of lymph node yield in ypN0 rectal cancer. Br J Surg 2016; 103:1731-1737. [PMID: 27507796 DOI: 10.1002/bjs.10218] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 04/24/2016] [Accepted: 04/25/2016] [Indexed: 01/15/2023]
Abstract
BACKGROUND Neoadjuvant radiation therapy for locally advanced rectal adenocarcinoma decreases lymph node yield. This study investigated the association between survival and number of lymph nodes evaluated in patients with pathologically negative nodes after neoadjuvant therapy. METHODS Patients with locally advanced rectal adenocarcinoma who underwent neoadjuvant therapy and had pathologically negative lymph nodes were included from the Surveillance, Epidemiology, and End Results (SEER) database over a 7-year interval (January 2004 to December 2010). Systematic dichotomization for optimal cut-off point identification was performed using statistical modelling. RESULTS A total of 3995 patients met the inclusion criteria. The majority had T3 (66·7 per cent) and moderately differentiated (71·5 per cent) tumours. The median number of lymph nodes retrieved was 12 (i.q.r. 7-16). An optimal cut-off of nine lymph nodes was identified. Increasing age (P < 0·001), increasing T category (T4 versus T1, P < 0·001; T3 versus T1, P = 0·010), response to neoadjuvant therapy (P < 0·001) and number of nodes evaluated (P < 0·001) were significant factors for overall survival in univariable analysis. After adjustment in the multivariable model, the group with nine or more nodes examined had significantly better overall survival (hazard ratio (HR) 0·76, 95 per cent c.i. 0·65 to 0·88, P < 0·001; 5-year survival 83·2 versus 78·0 per cent) and cancer-specific survival (HR 0·76, 0·64 to 0·92, P = 0·004; 5-year survival 87·9 versus 85·1 per cent) than the group with one to eight nodes examined. CONCLUSION Overall and cancer-specific survival were worse where fewer than nine lymph nodes were identified after neoadjuvant therapy for locally advanced rectal cancer.
Collapse
Affiliation(s)
- M Raoof
- Department of Surgery, City of Hope National Medical Center, Duarte, California.
| | - R A Nelson
- Department of Biostatistics, City of Hope National Medical Center, Duarte, California
| | - V N Nfonsam
- Department of Surgery, University of Arizona, Tucson, Arizona, USA
| | - J Warneke
- Department of Surgery, University of Arizona, Tucson, Arizona, USA
| | - R S Krouse
- Department of Surgery, University of Arizona, Tucson, Arizona, USA.,Southern Arizona Veterans Affairs Health Care System, Tucson, Arizona, USA
| |
Collapse
|
|
11
|
Zhou D, Ye M, Bai Y, Rong L, Hou Y. Prognostic value of lymph node ratio in survival of patients with locally advanced rectal cancer. Can J Surg 2015; 58:237-44. [PMID: 26022151 DOI: 10.1503/cjs.001515] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The lymph node ratio (LNR) has been shown to be an important prognostic factor in patients with gastric, breast, pancreatic and colorectal cancer. We investigated the prognostic impact of the LNR in addition to TNM classification in patients with locally advanced rectal cancer. METHODS We retrospectively analyzed patients who underwent curative resection for locally advanced rectal cancer between July 2005 and December 2010. We determined the LNR cutoff value using a receiver operating characteristic curve. The Kaplan-Meier method was used to estimate survival curves, while Cox regression analyses were used to evaluate the relationship between LNR and survival. RESULTS We included 180 patients aged 28-83 years with median follow-up of 41.8 months. The median number of lymph nodes examined and lymph nodes involved were 11.5 and 4, respectively, and the median LNR was 0.366. An LNR of 0.19 (19%) was the cutoff point to separate patients with regard to median overall survival. Median overall survival was 64.2 months for patients with an LNR of 0, 59.1 for an LNR of 0.19 or less and 37.6 for an LNR greater than 0.19 (p = 0.004). The median disease-free survival was 32.9 months for patients with an LNR of 0, 30.4 for an LNR of 0.19 or less and 17.8 for an LNR greater than 0.19 (p = 0.002). CONCLUSION Our results suggest that LNR should be considered an additional prognostic factor in patients with locally advanced rectal cancer.
Collapse
Affiliation(s)
- Di Zhou
- The Department of Radiation Oncology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ming Ye
- The Department of Radiation Oncology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yongrui Bai
- The Department of Radiation Oncology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ling Rong
- The Department of Radiation Oncology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yanli Hou
- The Department of Radiation Oncology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| |
Collapse
|
|
12
|
Habr-Gama A, Perez RO. Immediate surgery or clinical follow-up after a complete clinical response? Recent Results Cancer Res 2014; 203:203-10. [PMID: 25103007 DOI: 10.1007/978-3-319-08060-4_14] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Neoadjuvant chemoradiation (CRT) is considered as one of the preferred treatment strategies for patients with locally advanced rectal cancer. This treatment strategy may lead to significant tumor regression, ultimately leading to complete pathological response in up to 42% of patients. Assessment of tumor response following CRT and before radical surgery may identify patients with complete clinical response that could be managed non operatively with strict follow-up (Watch & Wait Strategy).
Collapse
Affiliation(s)
- Angelita Habr-Gama
- University of São Paulo School of Medicine, Rua Manoel da Nóbrega 1564, São Paulo, SP, 04001-005, Brazil,
| | | |
Collapse
|
|
13
|
Wasserberg N. Interval to surgery after neoadjuvant treatment for colorectal cancer. World J Gastroenterol 2014; 20:4256-4262. [PMID: 24764663 PMCID: PMC3989961 DOI: 10.3748/wjg.v20.i15.4256] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Revised: 11/11/2013] [Accepted: 01/14/2014] [Indexed: 02/06/2023] Open
Abstract
The current standard treatment of low-lying locally advanced rectal cancer consists of chemoradiation followed by radical surgery. The interval between chemoradiation and surgery varied for many years until the 1999 Lyon R90-01 trial which compared the effects of a short (2-wk) and long (6-wk) interval. Results showed a better clinical tumor response (71.7% vs 53.1%) and higher rate of positive and pathologic tumor regression (26% vs 10.3%) after the longer interval. Accordingly, a 6-wk interval between chemoradiation and surgery was set to balance the oncological results with the surgical complexity. However, several recent retrospective studies reported that prolonging the interval beyond 8 or even 12 wk may lead to significantly higher rates of tumor downstaging and pathologic complete response. This in turn, according to some reports, may improve overall and disease-free survival, without increasing the surgical difficulty or complications. This work reviews the data on the effect of different intervals, derived mostly from retrospective analyses using a wide variation of treatment protocols. Prospective randomized trials are currently ongoing.
Collapse
|
|
14
|
Glimelius B. Optimal Time Intervals between Pre-Operative Radiotherapy or Chemoradiotherapy and Surgery in Rectal Cancer? Front Oncol 2014; 4:50. [PMID: 24778990 PMCID: PMC3985002 DOI: 10.3389/fonc.2014.00050] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 03/02/2014] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND In rectal cancer therapy, radiotherapy or chemoradiotherapy (RT/CRT) is extensively used pre-operatively to (i) decrease local recurrence risks, (ii) allow radical surgery in non-resectable tumors, and (iii) increase the chances of sphincter-saving surgery or (iv) organ-preservation. There is a growing interest among clinicians and scientists to prolong the interval from the RT/CRT to surgery to achieve maximal tumor regression and to diminish complications during surgery. METHODS The pros and cons of delaying surgery depending upon the aim of the pre-operative RT/CRT are critically evaluated. RESULTS Depending upon the clinical situation, the need for a time interval prior to surgery to allow tumor regression varies. In the first and most common situation (i), no regression is needed and any delay beyond what is needed for the acute radiation reaction in surrounding tissues to wash out can potentially only be deleterious. After short-course RT (5Gyx5) with immediate surgery, the ideal time between the last radiation fraction is 2-5 days, since a slightly longer interval appears to increase surgical complications. A delay beyond 4 weeks appears safe; it results in tumor regression including pathologic complete responses, but is not yet fully evaluated concerning oncologic outcome. Surgical complications do not appear to be influenced by the CRT-surgery interval within reasonable limits (about 4-12 weeks), but this has not been sufficiently explored. Maximum tumor regression may not be seen in rectal adenocarcinomas until after several months; thus, a longer than usual delay may be of benefit in well responding tumors if limited or no surgery is planned, as in (iii) or (iv), otherwise not. CONCLUSION A longer time interval after CRT is undoubtedly of benefit in some clinical situations but may be counterproductive in most situations. After short-course RT, long-term results from the clinical trials are not yet available to routinely recommend an interval longer than 2-5 days, unless the tumor is non-resectable at diagnosis.
Collapse
Affiliation(s)
- Bengt Glimelius
- Department of Radiology, Oncology and Radiation Science, Uppsala University , Uppsala , Sweden
| |
Collapse
|
|
15
|
Nadoshan JJ, Omranipour R, Beiki O, Zendedel K, Alibakhshi A, Mahmoodzadeh H. Prognostic value of lymph node ratios in node positive rectal cancer treated with preoperative chemoradiation. Asian Pac J Cancer Prev 2014; 14:3769-72. [PMID: 23886180 DOI: 10.7314/apjcp.2013.14.6.3769] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To investigate the impact of the lymph node ratio (LNR) on the prognosis of patients with locally advanced rectal cancer undergoing pre-operative chemoradiation. METHODS Clinicopathologic and follow up data of 128 patients with stage III rectal cancer who underwent curative resection from 1996 to 2007 were reviewed. The patients were divided into two groups according to the lymph node ratio: LNR ≤ 0.2 (n=28), and >0.2 (n=100). Kaplan-Meier and the Cox proportional hazard regression models were used to evaluate the prognostic effects according to LNR. RESULTS Median numbers of lymph nodes examined and lymph nodes involved by tumour were 10.3 (range 2-28) and 5.8 (range 1-25), respectively, and the median LNR was 0.5 (range, 0-1.6). The 5-year survival rate significantly differed by LNR (≤ 0.2, 69%; >0.2, 19%; Log-rank p value < 0.001). LNR was also a significant prognostic factor of survival adjusted for age, sex, post-operative chemotherapy, total number of examined lymph nodes, metastasis and local recurrence (≤ 0.2, HR=1; >0.2, HR=4.8, 95%CI=2.1-11.1) and a significant predictor of local recurrence and distant metastasis during follow-up independently of total number of examined lymph node. CONCLUSIONS Total number of examined lymph nodes and LNR were significant prognostic factors for survival in patients with stage III rectal cancer undergoing pre-operative chemoradiotherapy.
Collapse
Affiliation(s)
- Jamal Jafari Nadoshan
- Department of Surgical Oncology, Cancer Institute, Tehran University of Medical Science, Tehran, Iran
| | | | | | | | | | | |
Collapse
|
|
16
|
Scabini S, Montecucco F, Nencioni A, Zoppoli G, Sartini M, Rimini E, Massobrio A, De Marini L, Poggi A, Boaretto R, Romairone E, Ballestrero A, Ferrando V. The effect of preoperative chemoradiotherapy on lymph nodes harvested in TME for rectal cancer. World J Surg Oncol 2013; 11:292. [PMID: 24246069 PMCID: PMC3879099 DOI: 10.1186/1477-7819-11-292] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Accepted: 06/27/2013] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Adequate lymph nodes resection in rectal cancer is important for staging and local control. This retrospective analysis single center study evaluated the effect of neoadjuvant chemoradiation on the number of lymph nodes in rectal carcinoma, considering some clinicopathological parameters. METHODS A total of 111 patients undergone total mesorectal excision for rectal adenocarcinoma from July 2005 to May 2012 in our center were included. No patient underwent any prior pelvic surgery or radiotherapy. Chemoradiotherapy was indicated in patients with rectal cancer stage II or III before chemoradiation. RESULTS One-hundred and eleven patients were considered. The mean age was 67.6 yrs (range 36 - 84, SD 10.8). Fifty (45.0%) received neoadjuvant therapy before resection. The mean number of removed lymph nodes was 13.6 (range 0-39, SD 7.3). In the patients who received neoadjuvant therapy the number of nodes detected was lower (11.5, SD 6.5 vs. 15.3, SD 7.5, p = 0.006). 37.4% of patients with preoperative chemoradiotherapy had 12 or more lymph nodes in the specimen compared to the 63.6% of those who had surgery at the first step (p: 0.006).Other factors associated in univariate analysis with lower lymph nodes yield included stage (p 0.005) and grade (p 0.0003) of the tumour. Age, sex, tumor site, type of operation, surgeons and pathologists did not weight upon the number of the removed lymph nodes. CONCLUSION In TME surgery for rectal cancer, preoperative CRT results into a reduction of lymph nodes yield in univariate analisys and linear regression.
Collapse
Affiliation(s)
- Stefano Scabini
- Oncologic Surgery and Implantable Systems Unit, Department of Emergency, IRCCS San Martino IST, Genoa, Italy
- Salita della Madonnetta 20/10, 16136 Genoa, Italy
| | - Fabrizio Montecucco
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa School of Medicine. IRCCS Azienda Ospedaliera Universitaria San Martino–IST Istituto Nazionale per la Ricerca sul Cancro, Genoa, Italy
| | - Alessio Nencioni
- Oncologic Unit, Department of Internal Medicine (DiMI), University of Genoa, Genoa, Italy
| | - Gabriele Zoppoli
- Oncologic Unit, Department of Internal Medicine (DiMI), University of Genoa, Genoa, Italy
| | - Marina Sartini
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Edoardo Rimini
- Oncologic Surgery and Implantable Systems Unit, Department of Emergency, IRCCS San Martino IST, Genoa, Italy
| | - Andrea Massobrio
- Oncologic Surgery and Implantable Systems Unit, Department of Emergency, IRCCS San Martino IST, Genoa, Italy
| | - Luisito De Marini
- Oncologic Surgery and Implantable Systems Unit, Department of Emergency, IRCCS San Martino IST, Genoa, Italy
| | - Alessandro Poggi
- Oncologic Molecular and Angiogenesis Unit, IRCCS San Martino IST, Genoa, Italy
| | - Roberto Boaretto
- Oncologic Surgery and Implantable Systems Unit, Department of Emergency, IRCCS San Martino IST, Genoa, Italy
| | - Emanuele Romairone
- Oncologic Surgery and Implantable Systems Unit, Department of Emergency, IRCCS San Martino IST, Genoa, Italy
| | - Alberto Ballestrero
- Oncologic Unit, Department of Internal Medicine (DiMI), University of Genoa, Genoa, Italy
| | - Valter Ferrando
- Oncologic Surgery and Implantable Systems Unit, Department of Emergency, IRCCS San Martino IST, Genoa, Italy
| |
Collapse
|
|
17
|
Sclafani F, Cunningham D. Non-operative management for locally advanced rectal cancer: critical review and future perspective. COLORECTAL CANCER 2013. [DOI: 10.2217/crc.13.33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
SUMMARY Over the last few decades we have observed important advances in diagnostic imaging, surgery, pathology and multimodal treatments for rectal cancer, as well as increased efforts to reduce treatment-related toxicities and preserve quality of life for curatively treated patients. Neoadjuvant short-course radiotherapy and long-course chemoradiotherapy followed by total mesorectal excision remain widely accepted as the standard of care for patients with locally advanced rectal cancer. However, a carefully selected group of patients achieving a complete response to neoadjuvant chemoradiotherapy may be spared the effects of surgery and achieve satisfactory oncologic outcomes with a ‘wait-and-see’ strategy. Although supported by the results of previous studies, this intriguing paradigm shift needs prospective evaluation within a clinical trial setting and a more accurate prediction and assessment of response by means of tumor biomarkers and diagnostic imaging.
Collapse
Affiliation(s)
- Francesco Sclafani
- Department of Medicine, The Royal Marsden NHS Foundation Trust, Sutton, Surrey, SM2 5PT, UK
| | - David Cunningham
- Department of Medicine, The Royal Marsden NHS Foundation Trust, Sutton, Surrey, SM2 5PT, UK
| |
Collapse
|
|
18
|
La Torre M, Mazzuca F, Ferri M, Mari FS, Botticelli A, Pilozzi E, Lorenzon L, Osti MF, Marchetti P, Enrici RM, Ziparo V. The importance of lymph node retrieval and lymph node ratio following preoperative chemoradiation of rectal cancer. Colorectal Dis 2013; 15:e382-8. [PMID: 23581854 DOI: 10.1111/codi.12242] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Accepted: 02/05/2013] [Indexed: 12/13/2022]
Abstract
AIM Preoperative chemoradiation (CRT) for rectal cancer decreases the number of examined lymph nodes (NELN) found in the resected specimen. However, the prognostic role of lymph node evaluation including overall numbers and the lymph node ratio (LNR) in patients having preoperative CRT have not yet been defined. The study has assessed the influence of CRT on the NELN and on lymph node number and LNR on the survival of patients with rectal cancer. METHOD Between 2003 and 2011, 508 patients with nonmetastatic rectal cancer underwent mesorectal excision. Of these 123 (24.2%) received preoperative CRT. Univariate and multivariate analysis was performed to define the role of NELN and LNR as prognostic indicators of survival. RESULTS Neoadjuvant CRT significantly reduced the NELN (P < 0.0001). Disease-free survival (DFS) and overall survival (OS) of patients with fewer or more than 12 nodes retrieved did not differ statistically. Node-negative patients with six or fewer lymph nodes were significantly associated with a poor DFS and OS on univariate analysis (P = 0.03 and P = 0.03). LNR significantly influenced the DFS and OS on multivariate analysis [DFS, P = 0.0473, hazard ratio (HR) 2.4980, 95% confidence interval (CI) 1.2631-9.4097; OS, P = 0.0419, HR 1.1820, 95% CI 1.1812-10,710]. CONCLUSION The cut-off of 12 lymph nodes does not influence survival and should not be considered for cancer-specific prediction of patients having neoadjuvant CRT. In contrast LNR is an independent prognostic predictor of DFS and OS in such patients.
Collapse
Affiliation(s)
- M La Torre
- Surgical Department of Clinical Sciences, Faculty of Medicine and Psychology, Biomedical Technologies and Translational Medicine 'La Sapienza', Sant'Andrea Hospital, University of Rome 'La Sapienza', Rome, Italy.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
19
|
|
|
20
|
Awwad GEH, Tou SIH, Rieger NA. Prognostic significance of lymph node yield after long-course preoperative radiotherapy in patients with rectal cancer: a systematic review. Colorectal Dis 2013; 15:394-403. [PMID: 22958550 DOI: 10.1111/codi.12011] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM A literature review was performed to elucidate whether long-course preoperative radiotherapy for patients with rectal cancer affects lymph node yield, and whether this influences prognosis. METHOD Cochrane Database, PubMed/MEDLINE, Scopus, Web of Knowledge, Embase and CINAHL databases and reference lists from published journal articles published between 1 January 1990 and 30 June 2011 were searched. Studies examining lymph node yield and prognosis were selected for review. RESULTS One thousand and twenty-nine articles were found, of which 11 met the inclusion criteria. None was a randomized controlled trial and all were cohort studies. Four studies showed that long-course preoperative radiotherapy reduced lymph node yield; however only one demonstrated a statistically significant survival benefit in patients with higher lymph node yields. Five-year survival was 48% in patients with fewer than and 69% in those with more than 11 lymph nodes identified in the operative specimen (P = 0.04). CONCLUSION Whilst long-course preoperative radiotherapy appears to reduce lymph node yield in patients with rectal cancer, no causal relationship between lymph node yield and survival can be established in this group of patients.
Collapse
Affiliation(s)
- G E H Awwad
- Department of General Surgery, Royal Adelaide Hospital, Adelaide, SA, Australia.
| | | | | |
Collapse
|
|
21
|
Sloothaak DAM, Geijsen DE, van Leersum NJ, Punt CJA, Buskens CJ, Bemelman WA, Tanis PJ. Optimal time interval between neoadjuvant chemoradiotherapy and surgery for rectal cancer. Br J Surg 2013; 100:933-9. [PMID: 23536485 DOI: 10.1002/bjs.9112] [Citation(s) in RCA: 204] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2013] [Indexed: 12/16/2022]
Abstract
BACKGROUND Neoadjuvant chemoradiotherapy (CRT) has been proven to increase local control in rectal cancer, but the optimal interval between CRT and surgery is still unclear. The purpose of this study was to analyse the influence of variations in clinical practice regarding timing of surgery on pathological response at a population level. METHODS All evaluable patients who underwent preoperative CRT for rectal cancer between 2009 and 2011 were selected from the Dutch Surgical Colorectal Audit. The interval between radiotherapy and surgery was calculated from the start of radiotherapy. The primary endpoint was pathological complete response (pCR; pathological status after chemoradiotherapy (yp) T0 N0). RESULTS A total of 1593 patients were included. The median interval between radiotherapy and surgery was 14 (range 6-85, interquartile range 12-16) weeks. Outcome measures were calculated for intervals of less than 13 weeks (312 patients), 13-14 weeks (511 patients), 15-16 weeks (406 patients) and more than 16 weeks (364 patients). Age, tumour location and R0 resection rate were distributed equally between the four groups; significant differences were found for clinical tumour category (cT4: 17·3, 18·4, 24·5 and 26·6 per cent respectively; P = 0·010) and clinical metastasis category (cM1: 4·4, 4·8, 8·9 and 14·9 per cent respectively; P < 0·001). Resection 15-16 weeks after the start of CRT resulted in the highest pCR rate (18·0 per cent; P = 0·013), with an independent association (hazard ratio 1·63, 95 per cent confidence interval 1·20 to 2·23). Results for secondary endpoints in the group with an interval of 15-16 weeks were: tumour downstaging, 55·2 per cent (P = 0·165); nodal downstaging, 58·6 per cent (P = 0·036); and (near)-complete response, 23·2 per cent (P = 0·124). CONCLUSION Delaying surgery until the 15th or 16th week after the start of CRT (10-11 weeks from the end of CRT) seemed to result in the highest chance of a pCR.
Collapse
Affiliation(s)
- D A M Sloothaak
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | | | | | | | | | | | | | | |
Collapse
|
|
22
|
Ahn YJ, Kwon HY, Park YA, Sohn SK, Lee KY. Contributing factors on lymph node yield after surgery for mid-low rectal cancer. Yonsei Med J 2013; 54:389-395. [PMID: 23364972 PMCID: PMC3575998 DOI: 10.3349/ymj.2013.54.2.389] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Revised: 04/15/2012] [Accepted: 04/18/2012] [Indexed: 01/27/2023] Open
Abstract
PURPOSE The purpose of the present study was to evaluate the contributing factors to the lymph node status as well as to define the impact of preoperative concurrent chemoradiotherapy (CCRT) on the number of lymph nodes retrieved in mid-low rectal cancer. MATERIALS AND METHODS We retrospectively analyzed 277 patients who underwent curative surgical resection for mid-low rectal cancer between 1998 and 2007. Eighty-two patients received long course preoperative CCRT followed by surgery. RESULTS A mean of 13.12±9.28 lymph nodes was retrieved. In a univariate analysis, distance from the anal verge, pT stage, pN stage, lymphovascular invasion, preoperative CCRT had significant influence on the number of lymph nodes retrieved. In a multivariate model, patients in the CCRT group had fewer retrieved lymph nodes than the non-CCRT group (p<0.001). Both univariate and multivariate analyses showed that the ypN0 group had fewer retrieved lymph nodes than the ypN1-2 group (p=0.027) in the CCRT group. CONCLUSION Preoperative CCRT was an independent risk factor for failure to harvest an appropriate number of lymph nodes, and node-negative patients who received CCRT had fewer lymph nodes harvested.
Collapse
Affiliation(s)
- Young Jae Ahn
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Youn Kwon
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon Ah Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Kook Sohn
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kang Young Lee
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| |
Collapse
|
|
23
|
Allaix ME, Arezzo A, Cassoni P, Mistrangelo M, Giraudo G, Morino M. Metastatic lymph node ratio as a prognostic factor after laparoscopic total mesorectal excision for extraperitoneal rectal cancer. Surg Endosc 2012; 27:1957-67. [DOI: 10.1007/s00464-012-2694-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Accepted: 10/23/2012] [Indexed: 12/11/2022]
|
|
24
|
Shanmugan S, Arrangoiz R, Nitzkorski JR, Yu JQ, Li T, Cooper H, Konski A, Farma JM, Sigurdson ER. Predicting pathological response to neoadjuvant chemoradiotherapy in locally advanced rectal cancer using 18FDG-PET/CT. Ann Surg Oncol 2012; 19:2178-85. [PMID: 22395978 DOI: 10.1245/s10434-012-2248-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Indexed: 12/16/2022]
Abstract
BACKGROUND Pathologic complete response (pCR) after neoadjuvant chemoradiation (CRT) has been observed in 15-30% of patients with locally advanced rectal cancer (LARC). The objective of this study was to determine whether PET/CT can predict pCR and disease-free survival in patients receiving CRT with LARC. METHODS This is a retrospective review of patients with EUS-staged T3-T4, N+rectal tumors treated with CRT, who underwent pre/post-treatment PET/CT from 2002-2009. All patients were treated with CRT and surgical resection. Standardized uptake value (SUV) of each tumor was recorded. Logistic regression was used to analyze the association of pre-CRT SUV, post-CRT SUV, %SUV change, and time between CRT and surgery, compared with pCR. Kaplan-Meier estimation evaluated significant predictors of survival. RESULTS Seventy patients (age 62 years; 42M:28F) with preoperative stage T3 (n=61) and T4 (n=9) underwent pre- and post-CRT PET/CT followed by surgery. The pCR rate was 26%. Median pre-CRT SUV was 10.8, whereas the median post-CRT SUV was 4 (P=0.001). Patients with pCR had a lower median post-CRT SUV compared with those without (2.7 vs. 4.5, P=0.01). Median SUV decrease was 63% (7.5-95.5%) and predicted pCR (P=0.002). Patients with a pCR had a greater time interval between CRT and surgery (median, 58 vs. 50 days) than those without (P=0.02). Patients with post-CRT SUV<4 had a lower recurrence compared with those without (P=0.03). Patients with SUV decrease≥63% had improved overall survival at median follow-up of 40 months than those without (P=0.006). CONCLUSIONS PET/CT can predict response to CRT in patients with LARC. Posttreatment SUV, %SUV decrease, and greater time from CRT to surgery correlate with pCR. Post-CRT, SUV<4, and SUV decrease≥63% were predictive of recurrence-free and overall survival.
Collapse
|
|
25
|
Optimal lymph node harvest in rectal cancer (UICC stages II and III) after preoperative 5-FU-based radiochemotherapy. Acetone compression is a new and highly efficient method. Am J Surg Pathol 2012; 36:202-13. [PMID: 22251939 DOI: 10.1097/pas.0b013e31823fa35b] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Preoperative 5-fluorouracil-based radiochemotherapy (RCT), followed by total mesorectal excision, is accepted as standard therapy in rectal cancers (UICC stages II and III). The accurate evaluation of ypN status after RCT with valuable lymph node (LN) harvest is essential for postoperative risk-adapted treatment decisions. Actual numbers of assessed LNs and validity of ypN status vary extensively depending on the methods used. MATERIAL AND METHODS This prospective study validates the acetone compression (AC), whole mesorectal compartment embedding (WME), and fat clearance (FC) methods for LN retrieval in n=257 rectal cancer specimens obtained from 2 high-volume surgical centers. For optimal LN retrieval, the AC method (n=161 specimens: 52 cases with RCT, 109 cases without RCT) was compared with the WME (n=64 cases, with RCT) and FC methods (n=32 cases: 17 cases with RCT, 15 cases without RCT). The efficacy of LN retrieval, costs involved, and molecular diagnostics were measured. RESULTS Using the AC method, 41 LNs (mean; range 14 to 86 LNs) were detectable in total mesorectal excision specimens after RCT and 44 LNs (mean; range 9 to 78 LNs) in cases without RCT. The LN yield after RCT obtained by using the AC method was equivalent to that of the WME method (mean 32 LNs/specimen; range 12 to 81 LNs) but demonstrated a better time and cost-efficacy. In addition, the AC method facilitated assessment of any tumor deposits, including perineural invasion, and did not hamper molecular analyses. The AC method increased LN retrieval 4- to-6-fold as compared with the literature and 2-fold compared with manual dissection after the FC method. DISCUSSION The AC method is the method of choice for accurate LN staging in locally advanced rectal cancer, especially after preoperative RCT, and is well suited for routine gastrointestinal pathology workup.
Collapse
|
|
26
|
Scabini S, Ferrando V. Number of lymph nodes after neoadjuvant therapy for rectal cancer: How many are needed? World J Gastrointest Surg 2012; 4:32-5. [PMID: 22408716 PMCID: PMC3297665 DOI: 10.4240/wjgs.v4.i2.32] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2011] [Revised: 10/24/2011] [Accepted: 11/10/2011] [Indexed: 02/06/2023] Open
Abstract
Dear readers,
In the February 2012 issue of the World J Gastrointest Surg (4(2):32-35) Scabini and Ferrando published an editorial entitled “Number of lymph nodes after neoadjuvant therapy for rectal cancer: how many are needed?”.It has been brought to our attention that segments of the editorial are identical or closely resemble the essential parts of the discussion of the original article “Preoperative chemoradiotherapy does not necessarily reduce lymph node retrieval in rectal cancer specimens ¨C Results from a prospective evaluation with extensive pathological work-up” that was published in the Journal of Gastrointestinal Surgery in 2009. Given the striking similarities of the two works, the World J Gastrointest Surg has decided to retract the editorial by Scabini and Ferrando.
Timothy M. Pawlik, MD, MPH, PhD
Editor-in-Chief, World Journal of Gastrointestinal Surgery
Collapse
Affiliation(s)
- Stefano Scabini
- Stefano Scabini, Valter Ferrando, Oncologic Surgical Unit, Haemato-Oncology Department, St. Martino Hospital, 16136 Genoa, Italy
| | | |
Collapse
|
|
27
|
Petrelli F, Borgonovo K, Barni S. The emerging issue of ratio of metastatic to resected lymph nodes in gastrointestinal cancers: An overview of literature. Eur J Surg Oncol 2011; 37:836-47. [DOI: 10.1016/j.ejso.2011.07.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2010] [Revised: 03/25/2011] [Accepted: 07/25/2011] [Indexed: 12/21/2022] Open
|
|
28
|
Tsai CJ, Crane CH, Skibber JM, Rodriguez-Bigas MA, Chang GJ, Feig BW, Eng C, Krishnan S, Maru DM, Das P. Number of lymph nodes examined and prognosis among pathologically lymph node-negative patients after preoperative chemoradiation therapy for rectal adenocarcinoma. Cancer 2011; 117:3713-22. [PMID: 21328329 DOI: 10.1002/cncr.25973] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Revised: 11/09/2010] [Accepted: 11/17/2010] [Indexed: 12/25/2022]
Abstract
BACKGROUND Preoperative chemoradiation for rectal cancer can decrease the number of evaluable lymph nodes. Hence, the prognostic role of lymph node evaluation in patients with rectal cancer who receive preoperative chemoradiation is unclear. The authors of this report evaluated the prognostic impact of the number of lymph nodes examined in patients with rectal cancer who had negative lymph nodes based on the pathologic extent of disease (ypN0) after they received preoperative chemoradiation. METHODS Between 1990 and 2004, 372 patients with nonmetastatic rectal adenocarcinoma received preoperative chemoradiation followed by mesorectal excision and had ypN0 disease. The median radiation dose was 45 gray, and 68% of patients received adjuvant chemotherapy. RESULTS Patients had a median of 7 lymph nodes examined after preoperative chemoradiation. Compared with patients who had ≤7 lymph nodes examined, patients who had >7 lymph nodes had higher 5-year rates of freedom from relapse (86% vs 72%; log-rank P = .005) and cancer-specific survival (95% vs 86%; log-rank P = .0004), but no significant difference was observed in the overall survival rate (87% vs 81%; log-rank P = .07). Multivariate Cox proportional models demonstrated that patients who had >7 lymph nodes examined had a significantly lower risk of relapse (hazard ratio [HR], 0.39; P = .003) and death from rectal cancer (HR, 0.45; P = .04) but a similar risk of all-cause mortality (HR, 0.75; 95% CI, 0.46-1.20; P = .23) compared with patients who had ≤7 lymph nodes examined. CONCLUSIONS The number of lymph nodes examined was associated independently with disease relapse and cancer-specific survival in patients with rectal cancer who had ypN0 disease after receiving preoperative chemoradiation. Hence, the authors concluded that the number of negative lymph nodes examined may be a prognostic factor in patients with rectal cancer who receive preoperative chemoradiation.
Collapse
Affiliation(s)
- Chiaojung Jillian Tsai
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
|
29
|
Habr-Gama A, Perez R, Proscurshim I, Gama-Rodrigues J. Complete clinical response after neoadjuvant chemoradiation for distal rectal cancer. Surg Oncol Clin N Am 2011; 19:829-45. [PMID: 20883957 DOI: 10.1016/j.soc.2010.08.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Multimodality treatment of rectal cancer, with the combination of radiation therapy, chemotherapy, and surgery has become the preferred approach to locally advanced rectal cancer. The use of neoadjuvant chemoradiation therapy (CRT) has resulted in reduced toxicity rates, significant tumor downsizing and downstaging, better chance of sphincter preservation, and improved functional results. A proportion of patients treated with neoadjuvant CRT may ultimately develop complete clinical response. Management of these patients with complete clinical response remains controversial and approaches including radical resection, transanal local excision, and observation alone without immediate surgery have been proposed. The use of strict selection criteria of patients after neoadjuvant CRT has resulted in excellent long-term results with no oncological compromise after observation alone in patients with complete clinical response. Recurrences are detectable by clinical assessment and frequently amenable to salvage procedures.
Collapse
Affiliation(s)
- Angelita Habr-Gama
- Angelita & Joaquim Gama Institute, and University of Sao Paulo, Av. Dr Enéas de Carvalho Aguiar 255, Sao Paulo, SP, Brazil.
| | | | | | | |
Collapse
|
|
30
|
Morcos B, Baker B, Al Masri M, Haddad H, Hashem S. Lymph node yield in rectal cancer surgery: effect of preoperative chemoradiotherapy. Eur J Surg Oncol 2010; 36:345-9. [PMID: 20071133 DOI: 10.1016/j.ejso.2009.12.006] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2009] [Revised: 12/14/2009] [Accepted: 12/22/2009] [Indexed: 02/06/2023] Open
Abstract
AIM Adequate lymph node resection in rectal cancer is important for staging and local control. This study aims to verify the effect of neoadjuvant chemoradiation, as well as some clinicopathological features, on the yield of lymph nodes in rectal carcinoma. METHODS Data on consecutive patients who had total mesorectal excision for rectal adenocarcinoma at a single cancer center between January 2003 and July 2008 were reviewed. No patient had any prior pelvic surgery or radiotherapy. Patients had neoadjuvant chemoradiotherapy if they were stage II or III. RESULTS A total of 116 patients were included. The mean age was 53 years (range 29-83). Fifty-nine patients (51%) received neoadjuvant therapy before resection. The mean number of lymph nodes removed was 18 (range 4-67) per specimen. There was less lymph node yield in patients who received neoadjuvant therapy (16 vs. 19, p = 0.008). Only 64% of patients who had preoperative therapy had 12 lymph nodes or more in the specimen as opposed to 88% of those who had surgery upfront (p = 0.003). Other factors associated with lower lymph node yield included: female sex (p = 0.03) and tumour location in the lower rectum (p = 0.002). Age, tumour stage and grade, type of operation and surgical delay did not affect the number of lymph nodes removed. CONCLUSION Preoperative chemoradiotherapy for rectal cancer results in reduction in lymph node yield. Female sex and lower rectal tumours are also associated with retrieval of fewer lymph nodes.
Collapse
Affiliation(s)
- B Morcos
- Department of Surgery and Surgical Oncology, King Hussein Cancer Center, Amman, Jordan.
| | | | | | | | | |
Collapse
|
|
31
|
Preoperative chemoradiotherapy does not necessarily reduce lymph node retrieval in rectal cancer specimens--results from a prospective evaluation with extensive pathological work-up. J Gastrointest Surg 2010; 14:96-103. [PMID: 19830503 PMCID: PMC2793396 DOI: 10.1007/s11605-009-1057-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2009] [Accepted: 09/22/2009] [Indexed: 01/31/2023]
Abstract
PURPOSE Preoperative chemoradiotherapy (CRT) is supposed not only to reduce lymph node metastases but also lymph node recovery in rectal cancer specimens. The objective of this prospective study was to determine the effects of chemoradiation on mesorectal lymph node retrieval under terms of a meticulous histopathological evaluation. METHODS Specimens from 64 consecutive patients with stage II/III rectal cancer receiving preoperative 5-FU-based CRT were investigated. All patients were treated within the German Rectal Cancer Trial CAO/ARO/AIO-04. After surgery (including quality assessed total mesorectal excision), extensive pathological diagnostics was performed with embedding and microscopic evaluation of the whole mesorectal soft tissue compartment. RESULTS A total number of 2,021 lymph nodes were recovered (31.6 per specimen) within pathological work-up. There was no significant correlation between the number of retrieved nodes and patient- as well as tumor-dependent parameters. Lymph node size constantly amounted for less than 0.5 cm. Twenty patients (31.3%) had persistent nodal metastases. A considerable incidence of residual micrometastatic involvement in lymph nodes <0.3 cm (in 9.4% of all patients) was detected by extensive pathologic work-up. CONCLUSION Reliable nodal staging with high numbers of detected nodes was feasible after neoadjuvant CRT. Micrometastases frequently occur in small lymph nodes detected by microscopic evaluation.
Collapse
|
|
32
|
Increasing the rates of complete response to neoadjuvant chemoradiotherapy for distal rectal cancer: results of a prospective study using additional chemotherapy during the resting period. Dis Colon Rectum 2009; 52:1927-34. [PMID: 19934911 DOI: 10.1007/dcr.0b013e3181ba14ed] [Citation(s) in RCA: 156] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Addition of chemotherapy in the resting period between radiotherapy completion and response assessment during neoadjuvant treatment for distal rectal cancer could potentially increase rates of complete tumor regression. The purpose of this study was to evaluate toxicity rates and the impact of an extended neoadjuvant chemoradiation regimen on complete response rates. METHODS Thirty-four consecutive patients with nonmetastatic distal rectal cancer were prospectively included. Patients were managed by 5,400 Gy of radiation and 5-fluorouracil/leucovorin-based chemotherapy given for three consecutive days every 21 days for six cycles (three cycles concomitant with radiotherapy). Tumor response assessment was performed at ten weeks from radiation completion. Patients with complete clinical response were strictly monitored and were not immediately operated on. Patients with incomplete clinical response were referred to surgery. RESULTS Twenty-nine patients had completed 12 months of follow-up and were included in this preliminary analysis. Twenty-eight (97%) successfully completed treatment. Fifteen of 16 patients had Grade III toxicities that were skin-related (93%). Median follow-up was 23 months. Fourteen patients (48%) were considered as complete clinical responders sustained for at least 12 months (median, 24 months) after chemoradiation completion by clinical assessment alone. An additional five patients (17%) were considered as complete responders with ypT0 results after full-thickness local excision. Overall, the complete response rate was 65%. CONCLUSIONS The addition of chemotherapy during the resting period after neoadjuvant chemoradiation is associated with acceptable toxicity and high tolerability rates. The considerably high rates of complete response in this preliminary series requires further follow-up, but they may provide valuable information for future prospective, randomized trials.
Collapse
|
|
33
|
Habr-Gama A, Oliva Perez R. [The strategy "wait and watch" in patients with a cancer of bottom stocking rectum with a complete clinical answer after neoadjuvant radiochemotherapy]. ACTA ACUST UNITED AC 2009; 146:237-9. [PMID: 19682685 DOI: 10.1016/j.jchir.2009.07.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
|
34
|
Kim YW, Kim NK, Min BS, Lee KY, Sohn SK, Cho CH, Kim H, Keum KC, Ahn JB. The prognostic impact of the number of lymph nodes retrieved after neoadjuvant chemoradiotherapy with mesorectal excision for rectal cancer. J Surg Oncol 2009; 100:1-7. [PMID: 19418495 DOI: 10.1002/jso.21299] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND We aimed to assess factors associated with the number of nodes retrieved and the impact of the number of lymph nodes in rectal cancer patients who underwent neoadjuvant chemoradiation with radical surgery. METHODS A total of 258 patients were enrolled. Lymph nodes were retrieved from specimens using a manual dissection technique. RESULTS Of the 258 patients, nine patients had an absence of lymph nodes (ypNx), 150 patients had a node-negative status (ypN(-)) and 99 patients had node-positive disease (ypN(+)). An advanced ypT classification (ypT3,4) and larger tumor (>4 cm) were associated with an increased number of nodes retrieved. The pretreatment CEA level (>5 ng/ml) and ypN(+) classification were significant risk factors for cancer specific and recurrence free survival. There was no significant difference of oncological outcomes among ypNx patients and a subset of ypN(-) patients based on the number of nodes retrieved using three cutoff values (1-11, 12-25, and 25-65 nodes). CONCLUSIONS In a neoadjuvant setting, ypN(+) disease was an independent risk factor for oncological outcomes. An absence of nodes does not represent an inferior oncological outcome. The number of nodes does not seen to impact survival and recurrence in ypN(-) patients.
Collapse
Affiliation(s)
- Young-Wan Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | | | | | | | | | | | | | | | | |
Collapse
|
|
35
|
Doll D, Gertler R, Maak M, Friederichs J, Becker K, Geinitz H, Kriner M, Nekarda H, Siewert JR, Rosenberg R. Reduced lymph node yield in rectal carcinoma specimen after neoadjuvant radiochemotherapy has no prognostic relevance. World J Surg 2009; 33:340-7. [PMID: 19034566 DOI: 10.1007/s00268-008-9838-8] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND In colorectal surgery UICC/AJCC criteria require a yield of 12 or more locoregional lymph nodes for adequate staging. Neoadjuvant radiochemotherapy for rectal carcinoma reduces the number of lymph nodes in the resection specimen; the prognostic impact of this reduced lymph node yield has not been determined. METHODS One hundred two patients with uT3 rectal carcinoma who were receiving neoadjuvant radiochemotherapy were compared with 114 patients with uT3 rectal carcinoma who were receiving primary surgery followed by adjuvant radiochemotherapy. Total lymph node yield and number of tumor-positive lymph nodes were determined and correlated with survival. RESULTS After neoadjuvant radiochemotherapy both total lymph node yield (12.9 vs. 21.4, p < 0.0001) and number of tumor-positive lymph nodes (1.0 vs. 2.3, p = 0.014) were significantly lower than after primary surgery plus adjuvant radiochemotherapy. Reduced total lymph node yield in neoadjuvantly treated patients had no prognostic impact, with overall survival of patients with 12 or more lymph nodes the same as that of patients with less than 12 lymph nodes. Overall survival of neoadjuvantly treated patients was significantly influenced by the number of tumor-positive lymph nodes with 5-year-survival rates of 88, 63, and 39% for 0, 1-3, and more than 3 positive lymph nodes (p < 0.0001). CONCLUSION The UICC/AJCC criterion of a total lymph node yield of 12 or more should be revised for rectal carcinoma patients.
Collapse
Affiliation(s)
- Dietrich Doll
- Chirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaningerstrasse 22, 81675, Munich, Germany.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
|
36
|
Habr-Gama A, Perez RO. Non-operative management of rectal cancer after neoadjuvant chemoradiation. Br J Surg 2009; 96:125-7. [PMID: 19160360 DOI: 10.1002/bjs.6470] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
A problem of patient selection
Collapse
Affiliation(s)
- A Habr-Gama
- Emeritus Professor, University of São Paulo School of Medicine, São Paulo, Brazil.
| | | |
Collapse
|
|
37
|
Leibold T, Shia J, Ruo L, Minsky BD, Akhurst T, Gollub MJ, Ginsberg MS, Larson S, Riedel E, Wong WD, Guillem JG. Prognostic implications of the distribution of lymph node metastases in rectal cancer after neoadjuvant chemoradiotherapy. J Clin Oncol 2008; 26:2106-11. [PMID: 18362367 DOI: 10.1200/jco.2007.12.7704] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
PURPOSE After preoperative chemoradiotherapy of rectal cancer, the number of retrievable and metastatic lymph nodes is decreased. The current TNM classification is based on number and not location of lymph node metastases and may understage disease after chemoradiotherapy. The aim of this study was to examine the prognostic significance of location of involved lymph nodes in rectal cancer patients after preoperative chemoradiotherapy. PATIENTS AND METHODS We prospectively examined whole-mount specimens from 121 patients with uT3-4 and/or N+ rectal cancer who received preoperative chemoradiotherapy followed by resection. Location of involved lymph nodes was compared with median number of lymph nodes involved as well as presence of distant metastasis at presentation. RESULTS Lymph node metastases were detected in 37 patients (31%). Thirteen patients with lymph node involvement along major supplying vessels (proximal lymph node metastases) had a significantly higher rate of distant metastatic disease at time of surgery than patients without proximal lymph node involvement (P < .001); median number of lymph nodes involved was two for patients with proximal lymph node metastases and 1.5 for patients with mesorectal lymph node involvement alone. CONCLUSION Our data suggest that, after preoperative chemoradiotherapy, proximal lymph node involvement is associated with a high incidence of metastatic disease at time of surgery. Because the median number of involved lymph nodes is low after preoperative chemoradiotherapy, the TNM staging system may not provide an accurate assessment of metastatic disease. Therefore, the ypTNM staging system should incorporate distribution as well as number of lymph node metastases after preoperative chemoradiotherapy for rectal cancer.
Collapse
Affiliation(s)
- Tobias Leibold
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, Room C-1077, New York, NY 10021, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
38
|
Habr-Gama A, Perez RO, Proscurshim I, Rawet V, Pereira DD, Sousa AHS, Kiss D, Cecconello I. Absence of lymph nodes in the resected specimen after radical surgery for distal rectal cancer and neoadjuvant chemoradiation therapy: what does it mean? Dis Colon Rectum 2008; 51:277-83. [PMID: 18183463 DOI: 10.1007/s10350-007-9148-5] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE The number of retrieved lymph nodes during radical surgery has been considered of great importance to ensure adequate staging and radical resection. However, this finding may not be applicable after neoadjuvant therapy in which, not only is there a decrease in lymph nodes recovered, but also a subgroup of patients with absence of lymph nodes in the resected specimen. METHODS Patients with absence of lymph nodes were compared with patients with ypN0 disease and patients with ypN+ disease. RESULTS Thirty-two patients (11 percent) had absence of lymph nodes, 171 patients (61 percent) had ypN0 disease, and 78 patients (28 percent) had ypN+ disease. Patients with absence of lymph nodes had significantly lower ypT status (ypT0-1, 40 vs. 13 percent; P<0.001) and decreased risk of perineural invasion (6 vs. 21 percent; P=0.04) compared with ypN0 patients. Five-year disease-free survival (74 percent) was similar to patients with ypN0 (59 percent; P=0.2), and both were significantly better than patients with ypN+ disease (30 percent; P<0.001). CONCLUSIONS Absence of lymph nodes retrieved from the resected specimen is associated with favorable pathologic features (ypT and perineural invasion status) and good disease-free survival rates. In this setting, absence of retrieved lymph nodes may reflect improved response to neoadjuvant chemoradiation therapy rather than inappropriate or suboptimal oncologic radicality.
Collapse
Affiliation(s)
- Angelita Habr-Gama
- Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | | | | | | | | | | | | | | |
Collapse
|
|
39
|
Habr-Gama A, Perez RO, Proscurshim I, Nunes Dos Santos RM, Kiss D, Gama-Rodrigues J, Cecconello I. Interval between surgery and neoadjuvant chemoradiation therapy for distal rectal cancer: does delayed surgery have an impact on outcome? Int J Radiat Oncol Biol Phys 2008; 71:1181-8. [PMID: 18234443 DOI: 10.1016/j.ijrobp.2007.11.035] [Citation(s) in RCA: 151] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2007] [Revised: 11/03/2007] [Accepted: 11/06/2007] [Indexed: 12/15/2022]
Abstract
BACKGROUND The optimal interval between neoadjuvant chemoradiation therapy (CRT) and surgery in the treatment of patients with distal rectal cancer is controversial. The purpose of this study is to evaluate whether this interval has an impact on survival. METHODS AND MATERIALS Patients who underwent surgery after CRT were retrospectively reviewed. Patients with a sustained complete clinical response (cCR) 1 year after CRT were excluded from this study. Clinical and pathologic characteristics and overall and disease-free survival were compared between patients undergoing surgery 12 weeks or less from CRT and patients undergoing surgery longer than 12 weeks from CRT completion and between patients with a surgery delay caused by a suspected cCR and those with a delay for other reasons. RESULTS Two hundred fifty patients underwent surgery, and 48.4% had CRT-to-surgery intervals of 12 weeks or less. There were no statistical differences in overall survival (86% vs. 81.6%) or disease-free survival rates (56.5% and 58.9%) between patients according to interval (< or =12 vs. >12 weeks). Patients with intervals of 12 weeks or less had significantly higher rates of Stage III disease (34% vs. 20%; p = 0.009). The delay in surgery was caused by a suspected cCR in 23 patients (interval, 48 +/- 10.3 weeks). Five-year overall and disease-free survival rates for this subset were 84.9% and 51.6%, not significantly different compared with the remaining group (84%; p = 0.96 and 57.8%; p = 0.76, respectively). CONCLUSIONS Delay in surgery for the evaluation of tumor response after neoadjuvant CRT is safe and does not negatively affect survival. These results support the hypothesis that shorter intervals may interrupt ongoing tumor necrosis.
Collapse
|
|
40
|
Abstract
Patient safety and quality of care are inextricably linked. Surgery encompasses such a wide spectrum of diagnosis, treatment, postoperative care, and outpatient follow-up of so many illnesses that quality improvement and patient safety opportunities are numerous and potentially overwhelming. The study of error can be applied across all components of the care process, and offers many points of study to improve patient safety. A fundamental premise is that appropriate and safely delivered health care is less expensive. In our current climate, this emphasis on quality and safety will remain a high priority. Surgeon leadership at all levels is key to our professional viability.
Collapse
Affiliation(s)
- Michael H McCafferty
- Department of Surgery, Section of Colorectal Surgery, University of Louisville, 550 South Jackson Street, Louisville, Kentucky 40202, USA
| | | |
Collapse
|