Trends and outcome of neoadjuvant treatment for rectal cancer: A retrospective analysis and critical assessment of a 10-year prospective national registry on behalf of the Spanish Rectal Cancer Project

Abstract

Introduction: Preoperative treatment and adequate surgery increase local control in rectal cancer. However, modalities and indications for neoadjuvant treatment may be controversial. Aim of this study was to assess the trends of preoperative treatment and outcomes in patients with rectal cancer included in the Rectal Cancer Registry of the Spanish Associations of Surgeons. Method: This is a STROBE-compliant retrospective analysis of a prospective database. All patients operated on with curative intention included in the Rectal Cancer Registry were included. Analyses were performed to compare the use of neoadjuvant/adjuvant treatment in three timeframes: I)2006e2009; II) 2010e2013; III)2014e2017. Survival analyses were run for 3-year survival in timeframes I-II. Results: Out of 14,391 patients,8871 (61.6%) received neoadjuvant treatment. Long-course chemo/ radiotherapy was the most used approach (79.9%), followed by short-course radiotherapy ± chemotherapy (7.6%). The use of neoadjuvant treatment for cancer of the upper third (15-11 cm) increased over time (31.5%vs 34.5%vs 38.6%,p ¼ 0.0018). The complete regression rate slightly increased over time (15.6% vs 16% vs 18.5%; p ¼ 0.0093); the proportion of patients with involved circumferential resection margins (CRM) went down from 8.2% to 7.3%and 5.5% (p ¼ 0.0004). Neoadjuvant treatment significantly decreased positive CRM in lower third tumors (OR 0.71, 0.59e0.87, Cochrane-Mantel-Haenszel P ¼ 0.0008). Most ypN0 patients also received adjuvant therapy. In MR-defined stage III patients, preoperative treatment was associated with significantly longer local-recurrence-free survival (p < 0.0001), and cancer-specific survival (p < 0.0001). The survival benefit was smaller in upper third cancers. Conclusion:There was an increasing trend and a potential overuse of neoadjuvant treatment in cancer of the upper rectum. Most ypN0 patients received postoperative treatment. Involvement of CRM in lower third tumors was reduced after neoadjuvant treatment. Stage III and MRcN þ benefited the most.

Endorectal Ultrasound and Magnetic Resonance Imaging for Rectal Cancer Staging: A Modern Multimodality Approach

“…Moreover, our results demonstrated a good concordance (82%) between multimodal imaging findings and pathological results against 63-69% reported in the literature [22,27,40]. As a consequence, we observed a lower number of overstaged patients (9.8%), in contrast to average reported rates ranging from 15% to 24% [25,[45][46][47][48][49][50]. Moreover, the percentage of understaged patients was 8.2% in our study population, while it ranged from 12 to 24% in previous studies [22,25,40].…”

Role of 18F-PET-CT to Predict Pathological Response After Neoadjuvant Treatment of Rectal Cancer

“…There are several studied that have investigated the predictive value of 18 F -FDG PET-CT in the LARC and in recurrent rectal cancer, and more are likely to be produced using collaborative, international research platforms [18][19][20][21][22][23][24][25][26][27]. However, these studies have some limits mainly due to the methodological heterogeneity secondary to their multicentric nature in terms of preoperative studies, chemoradiotherapy, patients' characteristics and PET study method (timing, technique and analysis of images).…”

Toxicities and outcomes of neoadjuvant treatment in elderly patients with locally advanced rectal cancer: a scoping review protocol

“…Neoadjuvant long-course chemoradiation is associated with improved local control and reduced toxicity compared with postoperative chemoradiation. 13 14 National Comprehensive Cancer Network guidelines recommended preoperative concurrent chemoradiotherapy as a standard of care for stage 2/3 locally advanced rectal cancer. 15 Clinical trials (FFCD 92-03 and EORTC 22921) showed significant improvement in the complete pathological response and local control rate staging with preoperative concurrent chemoradiotherapy compared with preoperative radiotherapy alone.…”