Optimal timing of surgery after neoadjuvant chemoradiation therapy in locally advanced rectal cancer

Abstract

PurposeThe optimal time between neoadjuvant chemoradiotherapy (CRT) and surgery for rectal cancer has been debated. This study evaluated the influence of this interval on oncological outcomes.MethodsWe compared postoperative complications, pathological downstaging, disease recurrence, and survival in patients with locally advanced rectal cancer who underwent surgical resection <8 weeks (group A, n = 105) to those who had surgery ≥8 weeks (group B, n = 48) after neoadjuvant CRT.ResultsOf 153 patients, 117 (76.5%) were male and 36 (23.5%) were female. Mean age was 57.8 years (range, 28 to 79 years). There was no difference in the rate of sphincter preserving surgery between the two groups (group A, 82.7% vs. group B, 77.6%; P = 0.509). The longer interval group had decreased postoperative complications, although statistical significance was not reached (group A, 28.8% vs. group B, 14.3%; P = 0.068). A total of 111 (group A, 75 [71.4%] and group B, 36 [75%]) patients were downstaged and 26 (group A, 17 [16.2%] and group B, 9 [18%]) achieved pathological complete response (pCR). There was no significant difference in the pCR rate (P = 0.817). The longer interval group experienced significant improvement in the nodal (N) downstaging rate (group A, 46.7% vs. group B, 66.7%; P = 0.024). The local recurrence (P = 0.279), distant recurrence (P = 0.427), disease-free survival (P = 0.967), and overall survival (P = 0.825) rates were not significantly different.ConclusionIt is worth delaying surgical resection for 8 weeks or more after completion of CRT as it is safe and is associated with higher nodal downstaging rates.

NEOADJUVANT THERAPY AND SURGERY FOR RECTAL CANCER. Comparative study between partial and complete pathological response

“…In our study, 10% of patients had metastatic lymph nodes in the group with total tumor remission, the same percentage found by Shwaartz et al (25) . In the present study, complete remission was considered the absence of viable tumor cells in the rectal wall in the surgical specimen, and were observed in 30 patients, representing 14% of the sample, as found by other authors Nyasavajjala et al (20) (10%), Jeong et al (15) (17%) and Garland et al (9) (11.4 %). However, this data was slightly lower than the best results, perhaps suggesting differences in the neoadjuvant treatment and especially in the interval between neoadjuvant therapy and surgery.…”

“…Similarly, Jeong et al (15) found no differences in survival, local recurrence, distant metastasis and tumor response rate, however they showed a better complete pathological response rate in the lymph nodes in the patients operated after 8 weeks of the completion of neoadjuvant therapy (66.7% vs 46.7%;…”

“…The key point is that the necrosis induced by radiotherapy appears to be time dependent, so a controlled postpone surgery would allow a potentiation of the effect, maximizing the benefits of neoadjuvant therapy (12,15) . At first, in 1999, François et al (8) through Trial Lyon R90-01, found a complete pathological response in 10.3% of the patients operated shortly time (2 weeks) after neoadjuvant therapy, and 26% with a longer interval (6 to 8 weeks).…”

Meta-analysis of the effect of extending the interval after long-course chemoradiotherapy before surgery in locally advanced rectal cancer

“…). A total of 26 publications, including four RCTs and 25 445 patients with rectal cancer were eligible for inclusion ( Table ). Twenty‐four of the 26 studies (22 650 patients) reported the primary endpoint of pCR based on the predefined wait interval and were included in the qualitative and quantitative analysis for this outcome variable; 15·9 per cent (1522 of 9551) and 11·3 per cent (1481 of 13 099) had achieved pCR in the extended and classical intervals respectively.…”

Preoperative Short-Course Radiotherapy Combined With Chemotherapy, Local Hyperthermia and Delayed Surgery in Treatment of Rectal Cancer: Phase Ii Trial

“…Возможно, что данная комбинация с увеличением интервала до хирур-гического лечения может сочетать в себе как удобст во для пациента и экономическую выгоду, характерные для короткого курса ЛТ, так и выраженную регрессию опу-холи, и локальный контроль, которые достигаются при пролонгированных курсах ХЛТ. Более того, увеличе-ние временнóго интервала до хирургического вмеша-тельства может решить проблему повышенного риска периоперационных осложнений, связанных с прове-дением короткого курса ЛТ [7,8]. Однако из-за отсутст-вия данных клинических исследований такой вариант до сих пор не рассматривался большинством специа-листов.…”