Outcomes of Patients With Local Regrowth After Nonoperative Management of Rectal Cancer After Neoadjuvant Chemoradiotherapy

Cotti, Guilherme Cutait de Castro; Pandini, Rafael Vaz; Braghiroli, Oddone Freitas Melro; Nahas, Caio Sérgio Rizkallah; Bustamante-Lopez, Leonardo Alfonso; Marques, Carlos Frederico Sparapan; Imperiale, Antônio Rocco; Ribeiro, Ullysses; Salvajoli, Bernardo; Hoff, Paulo M.; Nahas, Sérgio Carlos

doi:10.1097/dcr.0000000000002197

Cited by 14 publications

(6 citation statements)

References 21 publications

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“…Notably, a watch-and-wait strategy is a valuable alternative for rectal resection in patients who were evaluated with a clinical complete response. Patients could undergo salvage surgical treatment for local regrowth with adequate pelvic control 22 . To achieve enhanced tumor regression, total neoadjuvant therapy (TNT), defined as delivering all planned chemotherapy before surgery, was developed.…”

Section: Discussionmentioning

confidence: 99%

Effect of interval between neoadjuvant chemoradiotherapy and surgery on oncological outcomes in poor responders with locally advanced rectal cancer: a retrospective cohort study

Luo

Yang

Zhang

et al. 2023

International Journal of Surgery

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Background: The optimal interval from completion of neoadjuvant chemoradiotherapy (CRT) to surgery in locally advanced rectal cancer remains controversial. It seems that delayed surgery is associated with an increase in pathological complete response rates. However, the prognostic effect of delayed surgery in poor responders is unclear. Materials and methods: Patients with locally advanced mid or distal rectal cancer undergoing neoadjuvant CRT followed by total mesorectal excision at a university teaching cancer center between June 2010 and December 2018 were retrospectively reviewed in this study. According to the tumor regression grade, poor responders (tumor regression grade 2–3) to neoadjuvant CRT were selected for analyses. Patients were divided into the longer interval group (greater than 8 weeks) and the shorter interval group (8 weeks or less) based on the wait time from completion of neoadjuvant CRT therapy to surgery. Results: among 916 eligible patients, 522 patients had a poor tumor response. There were 217 patients in the shorter interval group and 305 patients in the longer interval group. At the baseline, patients in the longer interval group were more likely to have a T3 stage and positive vascular invasion. Compared with patients in the shorter interval group, patients in the longer interval group had significantly worse overall survival and disease-free survival (DFS) (log-rank test, overall survival: P =0.004, DFS: P <0.001). The 3-year DFS rates were 75.6 and 63.1% in the shorter interval group and the longer interval group, respectively. In the multivariate analysis, delayed surgery was associated with an increased risk of mortality (hazard ratio: 2.003, 95% CI: 1.233–3.253, P =0.005) and recurrence (hazard ratio: 1.555, 95% CI: 1.121–2.156, P =0.008). Conclusion: Patients who had a poor tumor response should be identified by restaging MRI and receive radical surgery in time, without a prolonged interval.

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Section: Discussionmentioning

confidence: 99%

Effect of interval between neoadjuvant chemoradiotherapy and surgery on oncological outcomes in poor responders with locally advanced rectal cancer: a retrospective cohort study

Luo

Yang

Zhang

et al. 2023

International Journal of Surgery

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“…We thank the author for the thoughtful comments regarding our published article 1 and would like address these valuable insights.…”

Section: To the Editor—mentioning

confidence: 99%

The Authors Reply

Cotti

Bustamante-Lopez

Braghiroli

2022

Diseases of the Colon &Amp; Rectum

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To the Editor-We thank the author for the thoughtful comments regarding our published article 1 and would like address these valuable insights.1. Since the 1980s, mesorectal fascia involvement (MRFI) has been associated with local recurrence in rectal cancer, and the role of magnetic resonance imaging (MRI) in staging and decision-making has grown over the years. [2][3][4] However, MRI has limitations in predicting response to neoadjuvant therapy. Multivariate analysis was indeed performed and did not provide any additional information. Because of the small number of patients, results should be interpreted with caution. A recent study observed that restaging MRI overestimated circumferential resection margin when compared with pathologic examination in 30% of patients. 4 Moreover, there are no sufficient data looking at MRFI as a predictor of failure after organ preservation. 2. Although there was no association between MRFI and overall survival (OS) on univariate Kaplan-Meyer survival analysis (log rank 0.443), the question was pertinent, and we conducted a Cox regression analysis to assess whether MRFI could explain part of the risk. Nevertheless, MRFI was not independently associated with survival-β = −0.983 (0.265-3.646), p = 0.980. The proportion of patients with low-lying cT2N0M0at risk for an abdominoperineal resection treated with neoadjuvant therapy was 28.4% (19/67). The treatment decision was based on discussions in multidisciplinary meetings and with our patients. 4. We agree that organ-sparing strategies are a reality only possible for a minority of patients. However, with an accumulation of recent published data, we are finally able to answer important questions that will help in the treatment selection of patients who present with a complete or near-complete clinical response, addressing especially the risk of regrowths and failures.

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“…Although there are no studies comparing the merits of one surveillance regimen over another for patients with a cCR undergoing WW/OP, frequent reassessments are necessary to prevent delays in diagnosis and allow for salvage surgery when appropriate. [87][88][89][90][91] Systemic disease surveillance should not differ from current guidelines for colorectal cancer after surgical resection with curative intent. 92 In terms of LR, rectal and mesorectal regrowth occurs more frequently in the first 3 years after TNT, and the intensity of WW/OP surveillance is highest during this time frame.…”

Section: A Watch-and-wait Strategy Can Be Offered To Selected Patient...mentioning

confidence: 99%

Section: Certainty Of Evidencementioning

confidence: 99%

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Rectal Cancer 2023 Supplement

Langenfeld,

Davis,

Vogel

et al. 2023

Diseases of the Colon &Amp; Rectum

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he American Society of Colon and Rectal Surgeons (ASCRS) is dedicated to ensuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Clinical Practice Guidelines (CPG) Committee is composed of society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop CPG based on the best available evidence.Although not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician considering all the circumstances presented by the individual patient. STATEMENT OF THE PROBLEMColorectal cancer is the third most common cancer and the third most common cause of cancer-related deaths in the United States. 1 Approximately 30% of these cancers will originate in the rectum, and the American Cancer Society estimated a total of 44,850 new rectal cancer diagnoses in the United States for 2022. 2 Adenocarcinoma of the rectum is inherently complex. Surgery for rectal cancer is technically challenging and is associated with major alterations in GI, urinary, and sexual functions and with decreased quality of life. [3][4][5] The treatment of rectal cancer is also rapidly evolving, with new data emerging on a regular basis.In 2020, the ASCRS published its most recent CPG for rectal cancer. 6 This was a comprehensive assessment covering a wide spectrum of topics. Since then, there have been Earn continuing medical education (CME) credit online at cme.lww. com. This activity has been approved for AMA PRA category 1 credit.Funding/Support: None reported.

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Outcomes of Patients With Local Regrowth After Nonoperative Management of Rectal Cancer After Neoadjuvant Chemoradiotherapy

Cited by 14 publications

References 21 publications

Effect of interval between neoadjuvant chemoradiotherapy and surgery on oncological outcomes in poor responders with locally advanced rectal cancer: a retrospective cohort study

Effect of interval between neoadjuvant chemoradiotherapy and surgery on oncological outcomes in poor responders with locally advanced rectal cancer: a retrospective cohort study

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The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Rectal Cancer 2023 Supplement

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