RESUMEN
A major advance has been made in the management of rectal cancer, with the emergence in 2021 of total neoadjuvant treatment. The main publications from the RAPIDO and PRODIGE-23 trials reported a significant improvement in progression-free survival and the pathological complete response rate. The aim of this review is to synthesize recent data on neoadjuvant treatment of rectal cancer, to explain the long-term results of the RAPIDO and PRODIGE-23 trials, and to put them into perspective, considering current advances in de-escalation strategies. The update of the 5-year survival data from the RAPIDO trial highlights an increased risk of loco-regional relapse, with 11.7% of relapses in the experimental group and 8.1% in the control group, while the update of the PRODIGE-23 trial confirms the benefits of this treatment regimen, with a significant improvement in overall survival. In addition, the results of the OPRA and PROPSPECT trials confirm the benefit of total neoadjuvant treatment with induction chemotherapy, as well as the possibility of surgical de-escalation in the OPRA trial and radiotherapy in the PROSPECT trial. The challenge for the future is to identify patients who require total neoadjuvant treatment with the aim of curative surgery to obtain a cure without local or distant relapse, and those for whom therapeutic de-escalation can be envisaged.
Asunto(s)
Adenocarcinoma , Terapia Neoadyuvante , Recurrencia Local de Neoplasia , Neoplasias del Recto , Humanos , Neoplasias del Recto/terapia , Neoplasias del Recto/patología , Neoplasias del Recto/mortalidad , Adenocarcinoma/terapia , Adenocarcinoma/patología , Adenocarcinoma/mortalidad , Recurrencia Local de Neoplasia/terapia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Quimioterapia de Inducción , Supervivencia sin Progresión , Fluorouracilo/administración & dosificación , Fluorouracilo/uso terapéutico , Capecitabina/administración & dosificación , Ensayos Clínicos Controlados Aleatorios como Asunto , Leucovorina/administración & dosificación , Leucovorina/uso terapéutico , Compuestos Organoplatinos/administración & dosificación , Compuestos Organoplatinos/uso terapéuticoRESUMEN
INTRODUCTION: MRI plays a key role in the preoperative staging of rectal cancers and choice of neoadjuvant radiochemotherapy. Yet, the acquisition and interpretation of rectum magnetic resonance imaging (MRI) turn out to be unequal, impacting patients'care. The present study aims at evaluating the quality of the acquisition of technical parameters of the rectal MRI performed by comparing them according to the various guidelines. METHODS: The medical MRI reports of all consecutive patients with locally advanced rectal cancer treated in a curative intent, by preoperative RCT and completion surgery were retrospectively reviewed over two periods (January 2010-December 2014 and January 2018 and December 2020) according to international 2012 and 2016 ESGAR and 2017 SAR MRI recommendation reports. RESULTS: During the first period (69 MRI performed), 58% of these MRI abided by the recommendations and 75% of essential criteria could be found in 25.5% of MRI reportings. During the second period (73 MRI performed), the protocol used by 6.8% of MR images abided by the 2016 Society of Gastrointestinal and Abdominal Radiology (ESGAR) recommendations and 39.7% abided by the Society of Abdominal Radiology (SAR) recommendations. 75% of essential criteria could be found in 52.3% of MRI reportings and 90% of essential criteria could be found in 6.2% of MRI reportings. DISCUSSION: In an era of increasing individualized patient care and conservative treatment focused on tumour response and prognostic factors, the present study showed that compliance to MRI protocols and reporting guidelines needs improving to upgrade patient care.
Asunto(s)
Neoplasias del Recto , Humanos , Estudios Retrospectivos , Estadificación de Neoplasias , Neoplasias del Recto/diagnóstico por imagen , Neoplasias del Recto/terapia , Neoplasias del Recto/patología , Recto/diagnóstico por imagen , Recto/cirugía , Imagen por Resonancia Magnética/métodosRESUMEN
With the establishment of total mesorectal excision for the treatment of rectal cancer, local recurrence rates have significantly decreased. The addition of preoperative external beam irradiation further reduces this risk to less than 6%. As the local treatment becomes successful and more widely used, the associated treatment-related toxicity is becoming clinically important. If 4 to 6% of the patients are to benefit from neo-adjuvant therapy before total mesorectal excision, the acute and the long-term toxicity burden must be reasonable. With the introduction of better-quality imaging for tumour visualization and treatment planning, a new-targeted radiation treatment was introduced with high dose rate endorectal brachytherapy. The treatment concept was tested in phase I and II studies first in the preoperative setting, then as a boost after external beam radiation therapy as a dose escalation study to achieve higher tumour local control in a radical treatment setting with no surgery. High dose rate endorectal brachytherapy is safe and effective in achieving high tumour regression rate and was well tolerated. It is presently explored in a phase III dose escalation study in the non-operative management of patients with operable rectal cancer.
Asunto(s)
Braquiterapia , Neoplasias del Recto , Braquiterapia/efectos adversos , Braquiterapia/métodos , Terapia Combinada , Humanos , Neoplasias del Recto/patología , Neoplasias del Recto/radioterapia , Neoplasias del Recto/cirugíaRESUMEN
Standard care for rectal cancers relies on both tumor (location relative to the sphincter, T and N stage, sphincter involvement) and patients characteristics. Radical surgery (total mesorectal excision) following short-course radiotherapy (RT) or standard chemo-radiotherapy, associated with induction or consolidation chemotherapy (total neoadjuvant treatment), remains the cornerstone of locally advanced rectal cancer (T3cd, T4 and/or N+) treatment. Nevertheless, for early stages, this radical resection could be avoided in favor of conservative approaches combining RT (external, contact, brachytherapy) with or without chemotherapy (concurrent, induction or consolidative), or even be limited, for good responders, to a local excision with view of organ-preservation strategies. This conservative approach could also be offered selectively to patients with complete clinical response after the induction sequence, irrespective of initial tumor characteristics. The Watch and Wait strategy relies on clinical, endoscopic and radiological evaluations, as well as sustained surveillance. Ongoing studies aim to improve response rates, either with chemotherapy intensification, or RT boost dose escalation with brachytherapy or contact-therapy.
Asunto(s)
Quimioradioterapia , Neoplasias del Recto , Humanos , Terapia Neoadyuvante , Recurrencia Local de Neoplasia , Preservación de Órganos , Neoplasias del Recto/patología , Neoplasias del Recto/radioterapia , Resultado del Tratamiento , Espera VigilanteRESUMEN
Rectal cancer is a common disease of the elderly. Current treatment recommendations are established for young subjects in good general health condition, without taking into account the frailty, comorbidities and polymedications inherent in patients over 75 years old. For locally advanced lower and middle rectal cancers (T3, T4 or N+), these are based on variations of regimens including neoadjuvant chemoradiotherapy, surgery of the rectum with total removal of the mesorectum, and a possibility of adjuvant chemotherapy. This restrictive treatment presents a problem of compliance and is not without adverse effects. Treatment by short exclusive radiotherapy or chemoradiotherapy with close monitoring according to the Watch and Wait strategy can be proposed to fragile patients not eligible for surgery, even if there is a non-negligible risk of recurrence.
Asunto(s)
Neoplasias del Recto , Anciano , Quimioradioterapia , Humanos , Terapia Neoadyuvante , Recurrencia Local de Neoplasia , Neoplasias del Recto/radioterapia , Recto/cirugía , Resultado del TratamientoRESUMEN
We present the updated recommendations of the French society of oncological radiotherapy for rectal cancer radiotherapy. The standard treatment for locally advanced rectal cancer consists in chemoradiotherapy followed by radical surgery with total mesorectal resection and adjuvant chemotherapy according to nodal status. Although this strategy efficiently reduced local recurrences rates below 5% in expert centres, functional sequelae could not be avoided resulting in 20 to 30% morbidity rates. The early introduction of neoadjuvant chemotherapy has proven beneficial in recent trials, in terms of recurrence free and metastasis free survivals. Complete pathological responses were obtained in 15% of tumours treated by chemoradiation, even reaching up to 30% of tumours when neoadjuvant chemotherapy is associated to chemoradiotherapy. These good results question the relevance of systematic radical surgery in good responders. Personalized therapeutic strategies are now possible by improved imaging modalities with circumferential margin assessed by magnetic resonance imaging, by intensity modulated radiotherapy and by refining surgical techniques, and contribute to morbidity reduction. Keeping the same objectives, ongoing trials are now evaluating therapeutic de-escalation strategies, in particular rectal preservation for good responders after neoadjuvant treatment, or radiotherapy omission in selected cases (Greccar 12, Opera, Norad).
Asunto(s)
Radioterapia de Intensidad Modulada/métodos , Neoplasias del Recto/radioterapia , Quimioradioterapia , Quimioterapia Adyuvante , Francia , Humanos , Terapia Neoadyuvante , Recurrencia Local de Neoplasia/prevención & control , Tratamientos Conservadores del Órgano/métodos , Órganos en Riesgo/diagnóstico por imagen , Posicionamiento del Paciente , Oncología por Radiación , Dosificación Radioterapéutica , Radioterapia Guiada por Imagen , Neoplasias del Recto/diagnóstico por imagen , Neoplasias del Recto/patología , Neoplasias del Recto/terapia , Recto/cirugía , Carga TumoralRESUMEN
Standard treatment consisting of chemoradiotherapy followed by radical surgery with total mesorectal excision, results in good oncologic local control but high morbidity and poor functional results. Since chemoradiotherapy results in 15% pathological complete response, even reaching up to 30% in case of association with neoadjuvant chemotherapy, radical surgery has been recently debated for good responders. Therefore, a de-escalation strategy, by omitting radical surgery in good responders, has recently been developed with two different options: a watch and wait strategy, requiring an accurate clinical and radiological definition of complete response and a local excision strategy including patients with sub-complete response. Ongoing trials focus on response optimization by chemotherapy intensification or radiotherapy dose escalation. However, many questions are still to be answered regarding definition of complete response, follow-up strategy, morbidity of salvage surgery in case of recurrence as well as long-term oncological and functionnal results.
Asunto(s)
Terapia Neoadyuvante/métodos , Tratamientos Conservadores del Órgano , Neoplasias del Recto/terapia , Antineoplásicos/administración & dosificación , Quimioradioterapia , Quimioterapia Adyuvante/estadística & datos numéricos , Humanos , Terapia Neoadyuvante/estadística & datos numéricos , Recurrencia Local de Neoplasia/cirugía , Dosificación Radioterapéutica , Recto/cirugía , Terapia Recuperativa , Espera VigilanteRESUMEN
The standard of care for patients with locally advanced rectal cancer has recently changed and is now based on the concept of total neoadjuvant therapy with the association of radiotherapy and systemic chemotherapy before radical surgery. The addition of noeadjuvant systemic chemotherapy before or after radiotherapy during preoperative course significantly decreased the risk of distant metastases and prolonged disease-free survival after surgery. The risk of recurrence varies among patients and the standard management associating chemotherapy, radiotherapy and surgery may expose many patients to overtreatment and can negatively affect quality of life. In this setting, several ongoing trials evaluate the possibility of less aggressive individually tailored approach based on omission of one of three treatments. In particular, NORAD and PROSPECT trials evaluate whether irradiation could be safely omitted in patients who are good responders to induction chemotherapy and have locally advanced primarily resectable tumor with large predictive circumferential resection margin. In the other hand, the total neoadjuvant therapy had significantly improved the pathological complete response rate, up to 30%, leading the concept of non-operative management and organ-preserving strategies. The phase III GRECCAR 12 study has therefore evaluated the potential benefit of intensification of neoadjuvant chemotherapy whereas OPERA and MORPHEUS trials assessed radiotherapy dose escalation by contact X-ray or brachytherapy for organ-preserving strategies. To date, total neoadjuvant therapy following by radical surgery remains the standard of care but probably less aggressive approach with omission of radiotherapy or surgery will become a new standard in selected patients in next future.
Asunto(s)
Terapia Neoadyuvante/métodos , Medicina de Precisión/métodos , Neoplasias del Recto/terapia , Quimioterapia Adyuvante/métodos , Ensayos Clínicos Fase III como Asunto , Supervivencia sin Enfermedad , Esquema de Medicación , Humanos , Quimioterapia de Inducción , Márgenes de Escisión , Recurrencia Local de Neoplasia/prevención & control , Tratamientos Conservadores del Órgano/métodos , Cuidados Posoperatorios , Cuidados Preoperatorios , Calidad de Vida , Dosificación Radioterapéutica , Radioterapia Adyuvante , Neoplasias del Recto/patología , Nivel de AtenciónRESUMEN
The management of patients with locally advanced rectal cancer has improved significantly in the past few years with preoperative radiotherapy (RT) and total mesorectal excision. The rate of local recurrence is now around 5 % while the risk of metastatic recurrence has not been reduced which is about 30 %. The benefit of adjuvant chemotherapy remains questionable apart from patients with ypN+tumor after preoperative chemoradiotherapy (CRT) for whom FOLFOX is an option. In recent years, several therapeutic trials have evaluated the benefit of extending the time between the end of RT and surgery and/or the benefit of neoadjuvant chemotherapy, administered as induction (before RT) or in consolidation (after RT and before surgery). The first results of two positive phase 3 trials, PRODIGE 23 and RAPIDO, have been reported in 2020. The two regimens evaluated in these trials are markedly different but have shown that neoadjuvant chemotherapy significantly reduces the risk of distant metastasis. Current developments largely related to a de-escalation of therapy: organ conservation according to a "Watch and Wait" strategy or local resection of the scar, administration of neoadjuvant chemotherapy without RT. These therapeutic strategies have not yet been validated but should be in the news tomorrow. The purpose of this review is to present recent data reported in patients with locally advanced rectal cancer.
Asunto(s)
Terapia Neoadyuvante/métodos , Recurrencia Local de Neoplasia/prevención & control , Neoplasias del Recto/tratamiento farmacológico , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Quimioradioterapia , Quimioterapia Adyuvante/métodos , Ensayos Clínicos Fase III como Asunto , Femenino , Fluorouracilo/uso terapéutico , Humanos , Leucovorina/uso terapéutico , Masculino , Persona de Mediana Edad , Tratamientos Conservadores del Órgano , Compuestos Organoplatinos/uso terapéutico , Neoplasias del Recto/patología , Neoplasias del Recto/radioterapia , Neoplasias del Recto/cirugía , Factores de TiempoRESUMEN
The Papillon experience and the Lyon R96-02 trial have shown that contact X-ray brachytherapy of 50kV is efficient and safe to achieve long term local control and organ preservation for cT1 and early cT2-3 rectal cancers. The OPERA trial, using the Papillon 50™ machine, brings further support to this preservation strategy for selected T2T3ab lesions. Future trials using a contact X-ray boost will try to consolidate and enlarge its place in organ preservation for rectal cancers.
Asunto(s)
Braquiterapia/métodos , Tratamientos Conservadores del Órgano/métodos , Ensayos Clínicos Controlados Aleatorios como Asunto , Neoplasias del Recto/radioterapia , Braquiterapia/instrumentación , Braquiterapia/tendencias , Diseño de Equipo , Predicción , Humanos , Tratamientos Conservadores del Órgano/instrumentación , Tratamientos Conservadores del Órgano/tendencias , Neoplasias del Recto/patología , Factores de Tiempo , Rayos XRESUMEN
PURPOSE: The small bowel is a main dose-limiting organ in pelvic radiotherapy in the patients with rectal cancer. Conventionally, pelvic radiotherapy of patients with rectal cancer is performed in the prone position. MATERIAL AND METHODS: Thirty-nine patients underwent CT planning scan in the treatment position (20 patients in prone position group and 19 patients in supine position group). After radiation treatment planning optimization, the volumes of the irradiated small intestines were investigated. RESULTS: The volume of irradiated small bowel was higher in the supine position (mean difference; 36,274 cm3). However, it was not statistically significant (P value=0.187) CONCLUSION: Supine position could be accepted for the patients undergoing preoperative rectal cancer chemo-radiation.
Asunto(s)
Intestino Delgado/efectos de la radiación , Órganos en Riesgo , Posicionamiento del Paciente/métodos , Posición Prona , Neoplasias del Recto/radioterapia , Posición Supina , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Terapia Neoadyuvante , Pelvis/diagnóstico por imagen , Dosificación Radioterapéutica , Planificación de la Radioterapia Asistida por Computador , Tomografía Computarizada por Rayos XRESUMEN
PURPOSE: Platelet volume has been shown to prognostic value in patients with colorectal cancer. However, the changes of other platelet-associated biomarkers in rectal cancer patients, before and after the neoadjuvant chemoradiation therapy (NACRT), remain unclear. In this study, we investigated the prognostic value of platelet-associated biomarkers in rectal cancer patients with NACRT. PATIENTS AND METHODS: A total of 75 patients with locally advanced (T3-4 or N+) rectal cancer (LARC) cancer were selected and followed up from the Affiliated Cancer Hospital of Zhengzhou University between June 2013 and September 2016. The data of platelet-associated biomarkers, including the platelet count, platelet to lymphocyte ratio (PLR), lymphocyte to monocyte ratio (LMR), mean platelet volume (MPV), and platelet distribution width (PDW) both pre- and post- NACRT, were collected. The associations between these platelet-associated biomarkers and the overall survival (OS), as well as disease-free survival (DFS) of patients, were analysed. Patients were divided into groups with high or low values of the platelet-associated biomarkers, and the outcomes were compared by using Cox regression and Kaplan-Meier analysis. RESULTS: We found that pre-PLR (HR: 4.104; 95%CI: 1.411-11.421; P=0.009) and pre-LMR (HR: 0.384; 95%CI: 0.124-1.185; P=0.066) could predict the OS in LARC patients after NACRT by multivariate Cox regression analysis, a cut-off value of pre-PLR>7.02 and pre-LMR ≤7.10 could be used as independent prognostic factors for OS by Kaplan-Meier method. The pre-MPV value could be used as an independent prognostic factor for DFS by Kaplan-Meier analysis (P=0.037). Moreover, post-CEA was correlated with OS and DFS in LARC patients with NACRT. CONCLUSION: In LARC patients with NACRT, the pre-PLR and pre-LMR are independent prognostic factors for OS, while pre-MPV has predictive value for DFS.
Asunto(s)
Plaquetas , Quimioradioterapia/métodos , Terapia Neoadyuvante/métodos , Neoplasias del Recto/sangre , Neoplasias del Recto/terapia , Adulto , Anciano , Biomarcadores/sangre , Supervivencia sin Enfermedad , Femenino , Humanos , Estimación de Kaplan-Meier , Recuento de Linfocitos , Masculino , Volúmen Plaquetario Medio , Persona de Mediana Edad , Monocitos , Recuento de Plaquetas , Pronóstico , Modelos de Riesgos Proporcionales , Neoplasias del Recto/mortalidad , Neoplasias del Recto/patología , Estudios RetrospectivosRESUMEN
PURPOSE: A proportion of 10 to 30% of patients treated by chemoradiotherapy followed by total mesorectal excision surgery for a locally advanced rectal cancer can achieve a complete pathological response. We aimed to identify predictive factors associated with complete pathological response or no response and to assess the impact of each response on survival rates. PATIENTS AND METHODS: Patients treated with long course chemoradiotherapy for locally advanced and/or node positive rectal cancer from 2010 to 2016 were retrospectively reviewed. Statistical analysis was carried out to determine predictors of tumor regression and treatment outcomes. RESULTS: Records were available on 70 patients. In the univariate analysis, clinical factors associated with complete tumor response were tumor mobility in digital rectal examination (P=0.047), a limited parietal invasion (P=0.001), clinically negative lymph node (P<0.001) and a circumferential extent greater than 50% (P=0.001). On the other hand, a T4 classification and an endoscopic tumor size greater than 6cm were associated with no response to treatment (P=0.049 and P=0.017 respectively). On multivariate analysis, T2 clinical classification and N0 statement before treatment were independent predictive factors of pathologic complete response (P<0.001 and P=0.001) and a delayed surgery after 12 weeks was associated with no response to treatment (P=0.001). CONCLUSION: The identification of predictive factors of histological response may help clinicians to predict the prognosis and to propose organ preservation for good responders.
Asunto(s)
Quimioradioterapia Adyuvante , Terapia Neoadyuvante/métodos , Neoplasias del Recto/patología , Neoplasias del Recto/terapia , Adulto , Anciano , Anciano de 80 o más Años , Análisis de Varianza , Antimetabolitos Antineoplásicos/administración & dosificación , Capecitabina/administración & dosificación , Tacto Rectal , Femenino , Humanos , Ganglios Linfáticos/patología , Masculino , Persona de Mediana Edad , Neoplasias del Recto/mortalidad , Recto/cirugía , Estudios Retrospectivos , Tasa de Supervivencia , Resultado del Tratamiento , Carga TumoralRESUMEN
Despite being a standard of care in several cancers, sentinel lymph node (SLN) is not widespread in digestive cancers. European guidelines do not recommend its use for any digestive cancers. Particularity of the lymphatic vessel, intimately linked to blood vessel, may explain part of this phenomenon. Nevertheless, more indication could arise in the near future with the early diagnosis of tumor induced by cancer screening. Ruling out the lymphatic invasion could allow preserving the organ currently resected because of risk of lymph node positivity. This procedure is well studied in early gastric cancer in Korea and Japan. Several study have demonstrated that, a dual-tracer (isotopic and dye) allows to accurately identify the SLN. A randomized phase 3 trial is currently active in Korea to evaluate the oncological results of the procedure. Similar indication could arise for T1 tumor of the low-rectum, but currently available data are insufficient to recommend its use outside of a study. SLN may also be used to detect aberrant lymphatic drainage (rectum, ileum) but have been tested so far only in a few dozen of patients. Finally, SLN is disappointing in colon cancer, due to its low sensitivity and the absence of modification of the surgical procedure induced.
Asunto(s)
Neoplasias Gastrointestinales/patología , Metástasis Linfática/patología , Biopsia del Ganglio Linfático Centinela , HumanosRESUMEN
PURPOSE: To retrospectively evaluate the inter-observer agreement between a radiologist and a radiation oncologist and volume differences, in T2 and diffusion-weighted (DWI) MRI of gross tumor volume (GTV) delineation, in rectal cancer patients. MATERIALS AND METHODS: Two observers, a radiologist and a radiation oncologist, delineated GTVs of 50 patients on T2-weighted MRI (T2GTV) and echo planar DWI (DWIGTV). Observers agreement was assessed using DICE index, Bland-Altman analysis and intra-class correlation coefficient (ICC). Student's t-test was used for GTV comparison. RESULTS: Median T2GTV and DWIGTV were 17.09±14.12 cm3 (1.92-62.03) and 12.79±12.31 cm3 (1.23-62.25) for radiologist, and 16.82±13.66 cm3 (1.78-65.9) and 13.72±12.77 cm3 (1.29-69.75) for radiation oncologist. T2GTV were significantly larger compared to DWIGTV (P<0.001 and P<0.001, for both observers). Mean DICE index for T2GTV and DWIGTV were 0.80±0.07 and 0.77±0.06. The mean difference between the two observers were 0.26cm3 (95% CI: -5.36 to 5.88) and -1.13cm3 (95% CI: -5.70 to 3.44) for T2 and DWI volumes. The ICC for T2 volumes was 0.989 (95% CI: 0.981-0.994) (P<0.001) and 0.992 (95% CI: 0.986-0.996) (P<0.001) for DWI volumes. CONCLUSION: DWI resulted in smaller volumes delineation compared to T2-weighted MRI. Substantial and almost perfect agreements were reported for DWIGTV and T2GTV between radiologist and radiation oncologist. Due to the fact that DWI could be considered a simple technique for volume delineation for radiation oncologist, DWI could be used to improve quality in radiation planning for an accurate boost volume delineation when a dose escalation is investigated.
Asunto(s)
Imagen de Difusión por Resonancia Magnética , Neoplasias del Recto/diagnóstico por imagen , Neoplasias del Recto/patología , Carga Tumoral , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Variaciones Dependientes del Observador , Reproducibilidad de los Resultados , Estudios RetrospectivosRESUMEN
The impact of rectal cancer on patient quality of life has been investigated but no research has yet examined the impact of time perspective in the assessment of quality of life of rectal cancer patients. Our goal is to explore the links between quality of life and time perspective and the role of time perspective as a determinant of quality of life. Data were collected from 69 patients who completed a questionnaire comprising a specific measure of quality of life (FACT-C), a measure of time perspective (ZTPI), a measure of emotional distress (HADS) and a collection of socio-demographic and medical data. Regression analyses revealed that present fatalist, past positive and future time perspective predicted quality of life. Present fatalist time perspective seemed to have a deleterious impact on specific measure of rectal cancer quality of life. Present fatalist and future time perspective predicted a better emotional quality of life whereas past positive predicted a worse emotional quality of life. These results suggest the importance of considering time perspective as a determinant of psychological quality of life in order to improve the QoL of patients.
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Actitud Frente a la Salud , Calidad de Vida , Neoplasias del Recto/psicología , Anciano , Femenino , Humanos , Masculino , Neoplasias del Recto/cirugía , Factores de Tiempo , Percepción del TiempoRESUMEN
Rectal cancer is a common pathology in the elderly. The standard for advanced rectal tumors is a chemoradiotherapy regimen combined 50Gy with concomitant chemotherapy followed by a surgery. This treatment induces interruptions of chemoradiotherapy and toxicities G3-4 more important in people over 70 years of age. Hypofractionated radiotherapy 5×5Gy with surgery following week is an alternative. All retrospective studies on this fractionation report an excellent immediate and chronic tolerance. The randomized phase III NACRE trial, comparing these 2 radiotherapy, followed by surgery at 6-8 week, established a standard in the management of the elderly patients.
Asunto(s)
Hipofraccionamiento de la Dosis de Radiación , Neoplasias del Recto/radioterapia , Factores de Edad , Anciano , HumanosRESUMEN
Standard treatment consisting of chemoradiotherapy followed by radical surgery with total mesorectal excision, resulting in good oncologic local control but high morbidity and poor functional results. The same treatment applied to all patients presenting with low or mid T3-4 rectal tumors could result in overtreatment of small tumors. However, it remains insufficient (or unsatisfactory?) for locally advanced tumors regarding metastatic recurrence rate. Treatment is decided by a multidisciplinary board on the basis of initial staging, including MRI which allows for resection margin prediction and post-treatment response evaluation. The therapeutic strategy is changing towards upfront chemotherapy and therapeutic desescalation omitting radiotherapy or surgery in a rectal preservation strategy. Moreover, tumor response leads to new multidisciplinary board discussion and treatment adaptation.
Asunto(s)
Neoplasias del Recto/radioterapia , HumanosRESUMEN
Intensity-modulated radiation therapy is recommended in anal squamous cell carcinoma treatment and is increasingly used in rectal cancer. It adapts the dose to target volumes, with a high doses gradient. Intensity-modulated radiation therapy allows to reduce toxicity to critical normal structures and to consider dose-escalation studies or systemic treatment intensification. Image-guided radiation therapy is a warrant of quality for intensity-modulated radiation therapy, especially for successful delivery of the dose as planned. There is no recommended international or national anorectal cancer image-guided radiation therapy protocol currently available. Dose-escalation trials or expert opinions about intensity-modulated/image-guided radiation therapy good practice guidelines recommend daily volumetric imaging throughout the treatment or during the five first fractions and weekly thereafter as a minimum. Image-guided radiation therapy allows to reduce margins related to patient setup errors. Internal margin, related to the internal organ motion, needs to be adapted according to short- or long-course radiotherapy, gender, rectal location; it can be higher than current recommended planning target volume margins, particularly in the upper and anterior part of mesorectum, which has the most significant movement. Image-guided radiation therapy based on volumetric imaging allows to take target volume shrinkage into account and to develop adaptive strategies, in particular for mesorectum shrinkage during rectal cancer treatment. Lastly, the emergence of new image-guided radiation therapy technologies including MRI (which plays a major role in pelvic tumours assessment and diagnosis) opens up interesting perspectives for adaptive radiotherapy, taking into account both organs' movements and tumour shrinkage.
Asunto(s)
Neoplasias del Ano/diagnóstico por imagen , Neoplasias del Ano/radioterapia , Radioterapia Guiada por Imagen/métodos , Neoplasias del Recto/diagnóstico por imagen , Neoplasias del Recto/radioterapia , Humanos , Posicionamiento del Paciente , Radioterapia de Intensidad ModuladaRESUMEN
The prognosis of patients with rectal cancer and synchronous liver metastasis has improved thanks to chemotherapy and rectal and liver surgery progresses. However, there is no consensus about optimal management and practices remain heterogeneous. A curative treatment may be considered for 20 to 30% of patients with complete resection of metastasis and primary tumor after induction chemotherapy. To this end, a primary optimal evaluation by a multidisciplinary board including hepatic and colorectal surgeons is crucial. The therapeutic strategy associates chemotherapy, radiotherapy, hepatic and rectal surgery. The most threatening site guides the sequence of treatments. If hepatic resectability is uncertain, a "liver first" strategy associating induction chemotherapy and hepatic surgery is preferred. In non-resectable metastatic cases, chemotherapies with targeted therapies might lead to secondary resection for 30% of patients (conversion). This has changed our practice and triggers reconsidering resectability after chemotherapy. When metastases remain non-resectable, additional treatment focusing on primary tumor should control pelvic symptoms otherwise hardly impacting quality of life. Rectal surgery, short-course radiotherapy (5×5Gy), conformational long-course chemoradiotherapy or intensity-modulated radiation therapy with dose escalation are options discussed in this review.