RESUMO
Neoadjuvant therapy in patients with locally advanced rectal cancer (LARC) has achieved good pathologic complete response (pCR) rates, potentially eliminating the need for surgical intervention. This study investigated preoperative methods for predicting pCR after neoadjuvant short-course radiotherapy (SCRT) combined with immunochemotherapy. Methods: Treatment-naïve patients with histologically confirmed LARC were enrolled from February 2023 to July 2023. Before surgery, the patients received neoadjuvant SCRT followed by 2 cycles of capecitabine and oxaliplatin plus camrelizumab. 68Ga-labeled fibroblast activation protein inhibitor ([68Ga]Ga-FAPI-04) PET/MRI, [18F]FDG PET/CT, and contrast-enhanced MRI were performed before treatment initiation and before surgery in each patient. PET and MRI features and the size and number of lesions were also collected from each scan. Each parameter's sensitivity, specificity, and diagnostic cutoff were derived via receiver-operating-characteristic curve analysis. Results: Twenty eligible patients (13 men, 7 women; mean age, 60.2 y) were enrolled and completed the entire trial, and all patients had proficient mismatch repair or microsatellite-stable LARC. A postoperative pCR was achieved in 9 patients (45.0%). In the visual evaluation, both [68Ga]Ga-FAPI-04 PET/MRI and [18F]FDG PET/CT were limited to forecasting pCR. Contrast-enhanced MRI had a low sensitivity of 55.56% to predict pCR. In the quantitative evaluation, [68Ga]Ga-FAPI-04 change in SULpeak percentage, where SULpeak is SUVpeak standardized by lean body mass, had the largest area under the curve (0.929) with high specificity (sensitivity, 77.78%; specificity, 100.0%; cutoff, 63.92%). Conclusion: [68Ga]Ga-FAPI-04 PET/MRI is a promising imaging modality for predicting pCR after SCRT combined with immunochemotherapy. The SULpeak decrease exceeding 63.92% may provide valuable guidance in selecting patients who can forgo surgery after neoadjuvant therapy.
Assuntos
Meios de Contraste , Fluordesoxiglucose F18 , Imageamento por Ressonância Magnética , Neoplasias Retais , Humanos , Neoplasias Retais/diagnóstico por imagem , Neoplasias Retais/terapia , Neoplasias Retais/patologia , Feminino , Masculino , Pessoa de Meia-Idade , Idoso , Meios de Contraste/química , Tomografia por Emissão de Pósitrons , Resultado do Tratamento , Terapia Neoadjuvante , Adulto , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada , Resposta Patológica Completa , QuinolinasRESUMO
BACKGROUND: With the increasing application of neoadjuvant therapy in rectal adenocarcinoma, there remain many controversies in clinical practical applications. Preoperative radiotherapy (PR) can limit the surgical plane and potentially affect the quality of surgical treatment. This study aimed to investigate the potential impact of PR on the surgical quality of rectal adenocarcinoma. METHODS: This retrospective study analyzed the clinicopathological data from 6,585 AJCC stage I-III rectal adenocarcinoma in the Surveillance, Epidemiology, and End Results (SEER) database from 2010 to 2015. Kaplan-Meier survival analysis and multivariate Cox proportional were used to assess the impact of PR on survival. Propensity score matching (PSM) was employed to balance the baseline covariates between the PR and non-PR groups and to compare postoperative pathological differences. RESULTS: After PSM, PR did not improve overall survival (OS) in stages I (p = 0.33), II (p = 0.37), and III (p = 0.14) patients. Multivariate Cox analysis indicated that PR was not an independent prognostic factor for patients. Restricted cubic spline (RCS) analysis demonstrated a nonlinear negative correlation between OS hazard ratios and both circumferential resection margin (CRM) and lymph node evaluation (LNE). Compared to the non-PR group, patients in the PR group had lower tumor deposits (TD) (p < 0.001), positive CRM (p = 0.191), and perineural invasion (PNI) (p = 0.001). CONCLUSION: PR is not an independent prognostic factor for rectal adenocarcinoma patients. However, PR can reduce the likelihood of TD, CRM, and PNI, thereby potentially influencing the quality of surgery.
Assuntos
Adenocarcinoma , Estadiamento de Neoplasias , Neoplasias Retais , Humanos , Neoplasias Retais/patologia , Neoplasias Retais/cirurgia , Neoplasias Retais/radioterapia , Neoplasias Retais/mortalidade , Adenocarcinoma/patologia , Adenocarcinoma/cirurgia , Adenocarcinoma/radioterapia , Adenocarcinoma/mortalidade , Masculino , Feminino , Estudos Retrospectivos , Pessoa de Meia-Idade , Idoso , Programa de SEER , Terapia Neoadjuvante , Cuidados Pré-Operatórios/métodos , Pontuação de Propensão , Radioterapia Adjuvante , AdultoRESUMO
PURPOSE: This study aimed to use propensity score matching (PSM) to explore the long-term outcomes and failure patterns in locally advanced rectal cancer (LARC) patients with positive versus negative lateral pelvic lymph node (LPLN). MATERIALS AND METHODS: Patients with LARC were retrospectively divided into LPLN-positive and LPLN-negative groups. Clinical characteristics were compared between the groups using the chi-square test. PSM was applied to balance these differences. Progression-free survival (PFS) and overall survival (OS), and local-regional recurrence (LRR) and distant metastasis (DM) rates were compared between the groups using the Kaplan-Meier method and log-rank tests. RESULTS: A total of 651 LARC patients were included, 160 (24.6%) of whom had positive LPLN and 491 (75.4%) had negative LPLN. Before PSM, the LPLN-positive group had higher rates of lower location (53.1% vs. 43.0%, P = 0.025), T4 stage (37.5% vs. 23.2%, P = 0.002), mesorectal fascia (MRF)-positive (53.9% vs. 35.4%, P < 0.001) and extramural venous invasion (EMVI)-positive (51.2% vs. 27.2%, P < 0.001) disease than the LPLN-negative group. After PSM, there were 114 patients for each group along with the balanced clinical factors, and both groups had comparable surgery, pathologic complete response (pCR), and ypN stage rates. The median follow-up was 45.9 months, 3-year OS (88.3% vs. 92.1%, P = 0.276) and LRR (5.7% vs. 2.8%, P = 0.172) rates were comparable between LPLN-positive and LPLN-negative groups. Meanwhile, despite no statistical difference, 3-year PFS (78.8% vs. 85.9%, P = 0.065) and DM (20.4% vs. 13.3%, P = 0.061) rates slightly differed between the groups. 45 patients were diagnosed with DM, 11 (39.3%) LPLN-positive and 3 (17.6%) LPLN-negative patients were diagnosed with oligometastases (P = 0.109). CONCLUSIONS: Our study indicates that for LPLN-positive patients, there is a tendency of worse PFS and DM than LPLN-negative patients, and for this group patients, large samples are needed to further confirm our conclusion.
Assuntos
Quimiorradioterapia , Linfonodos , Metástase Linfática , Pontuação de Propensão , Neoplasias Retais , Humanos , Neoplasias Retais/patologia , Neoplasias Retais/terapia , Neoplasias Retais/mortalidade , Masculino , Feminino , Pessoa de Meia-Idade , Estudos Retrospectivos , Idoso , Linfonodos/patologia , Pelve , Adulto , Recidiva Local de Neoplasia/patologia , Recidiva Local de Neoplasia/terapia , Taxa de Sobrevida , PrognósticoRESUMO
BACKGROUND: It is accepted that tumor stage and size can influence response to neoadjuvant therapy in locally advanced rectal cancer (LARC). Studies on organ preservation to date have included a wide variety of size and TNM stage tumors. The aim of this study was to report tumor response based on each relevant TNM stage and tumor size. METHODS: Patients treated with LARC from 2014 to 2021 with cT2-3NxM0 tumors who received neoadjuvant chemoradiotherapy with or without induction chemotherapy were included. Tumors were staged and tumor size calculated on pelvic MRI at the time of diagnosis (cTNM). Tumor size was based on the largest dimension taken on the longest axis of each tumor. Clinical response was defined on the basis of post-treatment pelvic MRI and pathological response following surgery, when performed. Statistical analysis was performed using IBM SPSS Statistics™, version 20. Data from 432 patients were analyzed as follows: cT2N0 (n = 51), cT2N+ (n = 36), cT3N0 (n = 76), cT3N+ (n = 270). RESULTS: The rate of complete or near-complete response (cCR or nCR) varied from 77% in cT2N0 ≤ 3 cm to 20% in cT3N+ > 4 cm. Organ preservation without recurrence at 2 years was achieved in 86% of patients with cT2N0, 50% in cT2N+, 39% in cT3N0, and 12% in cT3N+. CONCLUSION: There is significant variation in tumor response according to tumor stage and size. Tumor response appears inversely proportional to increasing TNM stage and tumor size. This data can support both refinement of selective patient recruitment to organ preservation programs and shared decision-making.
Assuntos
Tomada de Decisão Compartilhada , Imageamento por Ressonância Magnética , Terapia Neoadjuvante , Estadiamento de Neoplasias , Neoplasias Retais , Carga Tumoral , Humanos , Neoplasias Retais/patologia , Neoplasias Retais/terapia , Neoplasias Retais/diagnóstico por imagem , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Terapia Neoadjuvante/métodos , Resultado do Tratamento , Adulto , Estudos Retrospectivos , Quimiorradioterapia Adjuvante , Tratamentos com Preservação do Órgão/métodos , Protectomia/métodos , Idoso de 80 Anos ou maisRESUMO
OBJECTIVE: Our objective was to evaluate the predictive factors and metastatic time for liver and lung metastasis in locally advanced rectal cancer (RC) patients. METHODS: Univariate and multivariate analysis were performed to identify risk factors and prognostic factors for liver metastasis and lung metastasis in RC. Survival probabilities were calculated using the Kaplan-Meier model and compared using the log-rank test between groups. The probability of time-to-event occurrence was calculated using the random survival forest model. Finally, the SEER database was used to verify our findings. RESULTS: Our results indicated that pathological T stage and pathological N stage were independent predictive factors for liver metastasis. Furthermore, CEA level, pathological T stage, and tumor deposit were independent predictive factors for lung metastasis. Based on the results of a multivariate Cox analysis, we categorized patients with liver and lung metastasis into three groups based on their scores. The results revealed that patients with higher scores had a higher probability of experiencing metastasis. For liver metastasis, Groups 1, 2, and 3 all exhibited higher occurrence rates within the first 24 months. However, for lung metastasis, Group 4 showed the highest occurrence rate at the 12th month, while Groups 5 and 6 exhibited the highest occurrence rates at the 15th month. CONCLUSIONS: In summary, we developed predictive models to determine the likelihood of liver and lung metastasis in RC patients. It is crucial to implement a more intensive surveillance program for patients with unfavorable risk profiles in order to facilitate early detection of metastasis.
Assuntos
Neoplasias Hepáticas , Neoplasias Pulmonares , Estadiamento de Neoplasias , Neoplasias Retais , Programa de SEER , Humanos , Neoplasias Retais/patologia , Neoplasias Retais/terapia , Masculino , Feminino , Pessoa de Meia-Idade , Neoplasias Pulmonares/patologia , Neoplasias Pulmonares/terapia , Idoso , Fatores de Risco , Neoplasias Hepáticas/secundário , Neoplasias Hepáticas/terapia , Adulto , Modelos de Riscos Proporcionais , Prognóstico , Estimativa de Kaplan-Meier , Análise Multivariada , Seguimentos , Fatores de Tempo , Estudos RetrospectivosRESUMO
The anatomical dimensions and the shape of the pelvis influence surgical difficulty for rectal cancer. Compared to conventional laparoscopic surgery, robot-assisted surgery is expected to improve surgical outcomes due to the multi-joint movement of its surgical instruments. The aim of this study was to investigate the impact of pelvic anatomical indicators on short-term outcomes of patients with rectal cancer. A retrospective analysis was conducted using data from 129 patients with rectal cancer who underwent conventional laparoscopic low anterior resection (L-LAR) or robot-assisted low anterior resection (R-LAR) with total mesorectal excision or tumor-specific mesorectal excision between January 2014 and December 2022. The transverse diameter of the lesser pelvis and the sacral promontory angle were used as indicators of pelvic anatomy. The sacral promontory angle was not associated with age and sex while the pelvic width was smaller in male than in female. The pelvic width did not affect postoperative complications in both L-LAR and R-LAR. In contrast, postoperative urinary dysfunction occurred more frequently in patients with a small sacral promontory angle (p = 0.005) in L-LAR although there was no impact on short-term outcomes in R-LAR. Multivariate analysis demonstrated that a small sacral promontory angle was an independent predictive factor for urinary dysfunction (p = 0.032). Sharp angulation of the sacral promontory was a risk factor for UD after L-LAR. Robot-assisted surgery could overcome anatomical difficulties and reduce the incidence of UD.
Assuntos
Laparoscopia , Pelve , Complicações Pós-Operatórias , Neoplasias Retais , Procedimentos Cirúrgicos Robóticos , Humanos , Procedimentos Cirúrgicos Robóticos/métodos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Neoplasias Retais/cirurgia , Neoplasias Retais/patologia , Laparoscopia/métodos , Masculino , Feminino , Pelve/anatomia & histologia , Estudos Retrospectivos , Pessoa de Meia-Idade , Idoso , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/epidemiologia , Adulto , Resultado do Tratamento , Transtornos Urinários/etiologia , Idoso de 80 Anos ou mais , Sacro/cirurgiaRESUMO
The treatment mode for patients with low rectal cancer (LRC) is still mainly surgical treatment. With the advancement of medical technology, the current surgical mode is more inclined towards super minimally invasive surgery (SMIS) that preserves organs and functions. SMIS belongs to organ preservation surgery, including non-full thickness and full-thickness resection under digestive endoscopy, laparoscopic or robotic full-thickness resection, and transanal minimally invasive surgery, which can cover all stages of TNM staging. The paper elaborates on the importance of preoperative accurate diagnosis and risk stratification in selecting appropriate SMIS methods, the new progress of imaging technology in accurately predicting lymph node metastasis, providing preoperative TNM staging and risk stratification, and guiding SMIS treatment. Finally, the paper introduces the SMIS surgical options for the treatment of LRC that have been developed and are currently in the clinical research stage, with the aim of maximizing the quality of life for LRC patients.
Assuntos
Laparoscopia , Procedimentos Cirúrgicos Minimamente Invasivos , Neoplasias Retais , Humanos , Neoplasias Retais/cirurgia , Laparoscopia/métodos , Qualidade de Vida , Estadiamento de Neoplasias , Metástase Linfática , Procedimentos Cirúrgicos Robóticos/métodosRESUMO
Objective: To investigate the efficacy of Da Vinci robotic transanal minimally invasive surgery (R-TAMIS) for rectal neoplasms. Methods: The patients of rectal neoplasms who underwent R-TAMIS and were regularly followed up at the First Medical Center of Chinese PLA General Hospital from January 2021 to January 2024 were retropectively selected. Follow-up visits were conducted at 1, 2, and 4 weeks postoperatively, and then every 3 months until January 20, 2024. The perioperative situation, postoperative histopathological results, and follow-up status of the patients were observed. Results: A total of 17 patients were included, including 10 males and 7 females, aged 35-80 (59±13) years. Eleven patients underwent surgery using the da Vinci® Si robot, while 6 patients underwent surgery using the da Vinci® Xi robot. The height of the resected tumor from the anal verge [M (Q1, Q3)] was 3.5 (3.0, 3.8) cm. The total operative time was 55.0 (50.0, 55.0) minutes, the platform installation time was 32.5 (30.0, 35.0) minutes. The actual surgical operation time was 22.5 (20.0, 27.5) minutes. Intraoperative blood loss was 9.2 (5.0, 10.0) ml. The postoperative hospital stay was 3.2 (3.0, 3.8) days. The total treatment cost was (29 447±4 765) yuan. Two patients who achieved clinical complete remission after neoadjuvant chemoradiotherapy experienced incision dehiscence one week postoperatively, which was resolved after four weeks of rectal irrigation therapy. All surgical specimens were intact, and all resection margins were negative. A total of 44(31,73) weeks were followed up, without local recurrence or distant metastasis. Conclusion: Da Vinci robotic transanal minimally invasive local resection may be a safe and feasible treatment option for rectal neoplasms.
Assuntos
Procedimentos Cirúrgicos Minimamente Invasivos , Neoplasias Retais , Procedimentos Cirúrgicos Robóticos , Humanos , Neoplasias Retais/cirurgia , Masculino , Pessoa de Meia-Idade , Feminino , Procedimentos Cirúrgicos Robóticos/métodos , Idoso , Adulto , Idoso de 80 Anos ou mais , Canal Anal/cirurgia , Duração da Cirurgia , Cirurgia Endoscópica Transanal/métodos , Resultado do Tratamento , Tempo de InternaçãoRESUMO
BACKGROUND: Robotic three-dimensional magnified visual effects and field of view stabilization have enabled precise surgical operations. Intracorporeal anastomosis in right-sided colorectal cancer surgery is expected to shorten operation times, avoid paralytic ileus, and shorten wound lengths; however, there are few reports of intracorporeal anvil fixation for intestinal anastomosis in left-sided colorectal cancer surgery. Herein, we introduce a simple, novel procedure for using robotic purse-string suture (RPSS) in intracorporeal anastomosis with the double-stapling technique in rectal and sigmoid cancer surgery and report short-term outcomes. METHODS: From September 2022 to April 2024, 105 consecutive patients underwent robotic surgery with double-stapling technique anastomosis for rectal or sigmoid colon cancer at our institution. Their data were retrospectively analyzed. Intracorporeal anastomosis with the double-stapling technique using RPSS was performed in 26 patients (the RPSS group), while the double-stapling technique anastomosis with extracorporeal anvil fixation was performed in 79 patients (the EC group). A 1:1 propensity score-matched analysis was performed (matching criteria: sex, age, body mass index (BMI), tumor location and tumor size) using a caliper 0.3. In the RPSS group, after tumor-specific or total mesorectal excision, specimens were extracted from the umbilical wound with simultaneous anvil placement in the body cavity. The oral colonic stump was robotically excised and robotically circumferentially stitched with 3-0 Prolene in all layers. After anvil insertion into the stump, the bowel wall of the colon was completely sewn onto the central rod of the anvil. Reconstructions were anastomosed using the double-stapling technique. RESULTS: The matched cohort contained 23 patients in each group. The RPSS group had significantly less bleeding than the EC group (p = 0.038). Super-low anterior resection (SLAR) in the RPSS group had shorter total operative times than those in the EC group (p = 0.045). The RPSS group experienced no perioperative complications greater than Clavien-Dindo grade III or any anastomosis-related complications. CONCLUSIONS: The RPSS technique can be performed safely without any anastomosis-related complications and reduces the total operative times in SLAR and blood loss through total robotic surgery. This may be a useful modality for robotic colorectal surgery.
Assuntos
Anastomose Cirúrgica , Pontuação de Propensão , Procedimentos Cirúrgicos Robóticos , Técnicas de Sutura , Humanos , Procedimentos Cirúrgicos Robóticos/métodos , Masculino , Anastomose Cirúrgica/métodos , Feminino , Idoso , Estudos Retrospectivos , Pessoa de Meia-Idade , Técnicas de Sutura/instrumentação , Grampeamento Cirúrgico/métodos , Neoplasias Retais/cirurgia , Neoplasias do Colo Sigmoide/cirurgia , Colo Sigmoide/cirurgiaRESUMO
BACKGROUND: Radiotherapy reduces local recurrence in locally advanced rectal cancer, but may cause harm in patients who do not experience recurrence. The aim was to investigate the impact of radiotherapy on long-term quality of life after curative treatment for rectal cancer, i.e. in patients without a recurrence during the follow-up. METHODS: All patients operated on for rectal cancer in Norway under 75 years of age between 30 September 2007 and 1 October 2020 were identified using the Cancer Registry of Norway. Exclusion criteria were distant metastasis, recurrence and dementia. The primary outcome measure was the Gastrointestinal Quality of Life Index. Secondary outcome measures included the 36-item Short Form Survey. Inverse probability weights based on a multiple logistic regression model were used to balance prechosen covariates between the radiotherapy and no radiotherapy groups when assessing differences in outcomes. RESULTS: Of 5014 invited patients, 2142 (43%) eligible patients answered the questionnaires. Of these 762 (36%) were treated with neoadjuvant radiotherapy plus surgery and 1380 (64%) with surgery alone. The mean follow-up time was 6.4 and 7.4 years respectively. After propensity score matching, the Gastrointestinal Quality of Life Index differed significantly between irradiated and non-irradiated patients ((mean(s.d.), mean score 103.8(19.4) versus 110.8(19.6) respectively, mean difference: -6.96 (95% c.i. -8.72 to -5.19); P < 0.001). Among patients without a stoma the mean difference was -8.1 points, whereas it was -5.7 for patients with a stoma. The radiotherapy group also scored significantly lower in 7 of 8 36-item Short Form Survey domains compared with the surgery alone group. CONCLUSION: Long-term quality of life was significantly lower in patients without a recurrence during the follow-up who received radiotherapy compared with patients who did not. These findings warrant a critical re-evaluation of the use of radiotherapy both in traditional neoadjuvant treatment and in modern organ-preserving treatment regimens.
Assuntos
Qualidade de Vida , Neoplasias Retais , Sistema de Registros , Humanos , Neoplasias Retais/radioterapia , Neoplasias Retais/cirurgia , Neoplasias Retais/patologia , Masculino , Feminino , Pessoa de Meia-Idade , Noruega , Idoso , Sobreviventes de Câncer/psicologia , Sobreviventes de Câncer/estatística & dados numéricos , Recidiva Local de Neoplasia , Inquéritos e Questionários , Estudos de Coortes , Terapia Neoadjuvante , Adulto , Pontuação de PropensãoRESUMO
Importance: Patients with locally advanced rectal cancer and persistent lymph node metastases (PLNM) after neoadjuvant treatment are at high risk of developing locoregional and distant metastasis, yet optimal postsurgical treatment of these patients is limited. Objective: To analyze the association of PLNM with pretreatment clinical parameters, intensity of neoadjuvant treatment, and long-term oncological outcomes. Design, Setting, and Participants: This cohort study is a post-hoc analysis of 3 randomized clinical trials (Surgical Oncology Working Group of Germany [CAO], Radiological Oncology Working Group of Germany [ARO], and Working Group for Internal Oncology in the German Cancer Society [AIO]) conducted in Germany in 1994, 2004, and 2012 that included 1948 patients with locally advanced rectal cancer recruited between February 1995 and January 2018. Statistical analysis was conducted between September 2023 and February 2024. Exposures: Receiving preoperative fluorouracil-based chemoradiotherapy (CRT, comprising the preoperative group of CAO/ARO/AIO-94 and the control group of CAO/ARO/AIO-04), fluorouracil-based CRT plus oxaliplatin (experimental group of CAO/ARO/AIO-04), or total neoadjuvant treatment (TNT) with fluorouracil-based CRT plus oxaliplatin with induction or consolidation leucovorin calcium (folinic acid), fluorouracil, and oxaliplatin chemotherapy within the CAO/ARO/AIO-12 trial. Main Outcome and Measures: The associations of PLNM with clinical parameters, intensity of neoadjuvant treatment, and cumulative incidences of LR, DM, and overall survival were assessed. Results: A total of 1888 patients (1333 male participants [70.6%]; median [range] age, 62 [19-84] years) with locally advanced rectal adenocarcinoma (clinical tumor stage 3 to 4 and/or clinically node-positive) treated within 3 consecutive clinical trials were analyzed. A total of 522 (29%) experienced PLNM; 378 had lymph node stage (ypN) 1 (20%) after neoadjuvant treatment (ypN) 1 (20%), and 174 had ypN2 (9%). Age, clinical T-stage, N-stage, grading, carcinoembryonic antigen levels, and time interval from completion of CRT to surgery were significantly associated with PLNM, whereas sex and tumor location were not. The percentage of patients with ypN2 stage was almost halved after TNT (18 of 293 patients [6%]) compared with patients treated with fluorouracil-based CRT (114 of 1009 patients [11.3%]; χ26 = 16.693; P = .01). After a median (IQR) follow-up of 54 (37-62) months, 5-year overall survival was 86.1% (95% CI, 83.9%-88.4%) for ypN0, 74.0% (95% CI, 83.9%-88.4%) for ypN1, and 43% for ypN2 (95% CI, 35.4%-52.2%) (P < .001). The 5-year cumulative incidences of locoregional and distant metastases were, respectively, 3% (95% CI, 2.1%-4.2%) and 20% (95% CI, 18%-23%) for ypN0, 6% (95% CI, 3.4%-8.8%) and 40% (95% CI, 34%-46%) for ypN1, and 19% (95% CI, 13%-26%) and 72% (95% CI, 63%-79%) for ypN2 (both P < .001). Conclusions and Relevance: In this cohort study, PLNM unmasked an unfavorable phenotype of rectal cancer at high risk for treatment failure. More aggressive adjuvant treatment might be considered; however, risk-adapted surveillance strategies and early recurrence-directed surgery, if feasible, are important strategies in this group of patients with CRT- and/or chemotherapy-resistant disease.
Assuntos
Metástase Linfática , Terapia Neoadjuvante , Neoplasias Retais , Humanos , Neoplasias Retais/patologia , Neoplasias Retais/terapia , Masculino , Feminino , Terapia Neoadjuvante/métodos , Pessoa de Meia-Idade , Idoso , Adulto , Estudos de Coortes , Alemanha/epidemiologia , Quimiorradioterapia/métodos , Fluoruracila/uso terapêutico , Fluoruracila/administração & dosagemRESUMO
STUDY OBJECTIVE: Advanced rectal cancer is a common cause of perineal pain and research on the use of radiofrequency therapy for the treatment of this pain is limited. In the present study, we aimed to compare the effectiveness and safety of conventional radiofrequency (CRF) and high-voltage long-term pulsed radiofrequency (H-PRF) of radiofrequency therapy in the management of perineal pain in advanced rectal cancer. DESIGN: Randomized, Double-Blind Controlled Trial. SETTING: Sichuan Cancer Hospital & Institute and Yanjiang District People's Hospital in Sichuan, China. PARTICIPANTS: A total of 72 patients with advanced rectal cancer experiencing perineal pain who were accepted for radiofrequency treatment. INTERVENTIONS: Patients were assigned randomly (1:1) assigned to either the group CRF or H-PRF in a double-blind trial. MEASUREMENTS AND MAIN RESULTS: The primary focus was on assessing perineal pain using numeric rating scales (NRS) scores at various time points. Secondary outcomes included the duration of maintaining a sitting position, depression scores, sleep quality, consumption of Oral Morphine Equivalent and Pregabalin, and the incidence of perineal numbness. A total of 57 patients (28 patients in the group CRF and 29 patients in the group H-PRF) were investigated. At all observation time points postoperatively, both groups of patients exhibited significant reductions in pain, enhancements in depression, improvements in sleep quality, and increased duration of sitting compared to their baseline measurements (P<0.05). During the 3 months and 6 months follow-up period, the group CRF exhibited significant reduction in pain, improvement in depression, sleep quality, and increased the time of keeping a sitting position compared with the group H-PRF (P<0.05). The consumption of oral morphine equivalent and Pregabalin as well as the incidence of perineal numbness were not significantly different between groups (P > 0.05). CONCLUSION: Our results demonstrate that application of CRF and H-PRF in ganglion impar to reduce perineal pain and improve the quality of life of patients with advanced rectal cancer is safe and effective. However, the long-term effect of CRF is better compared with that of H-PRF. TRIAL REGISTRATION: https://www.chictr.org.cn/ (ChiCTR2200061800) on 02/07/2022. This study adheres to CONSORT guidelines.
Assuntos
Períneo , Neoplasias Retais , Humanos , Método Duplo-Cego , Masculino , Feminino , Neoplasias Retais/cirurgia , Pessoa de Meia-Idade , Idoso , Tratamento por Radiofrequência Pulsada/métodos , Gânglios Simpáticos , Medição da Dor/métodos , Qualidade do Sono , AdultoRESUMO
BACKGROUND: In locally advanced rectal cancer (LARC), optimizing neoadjuvant strategies, including the addition of concurrent chemotherapy and dose escalation of radiotherapy, is essential to improve tumor regression and subsequent implementation of anal preservation strategies. Currently, dose escalation studies in rectal cancer have focused on the primary lesions. However, a common source of recurrence in LARC is the metastasis of cancer cells to the proximal lymph nodes. In our trial, we implement simultaneous integrated boost (SIB) to both primary lesions and positive lymph nodes in the experimental group based on magnetic resonance-guided adaptive radiotherapy (MRgART), which allows for more precise (and consequently intense) targeting while sparing neighboring healthy tissue. The objective of this study is to evaluate the efficacy and safety of MRgART dose escalation to both primary lesions and positive lymph nodes, in comparison with the conventional radiotherapy of long-course concurrent chemoradiotherapy (LCCRT) group, in the neoadjuvant treatment of LARC. METHODS: This is a multi-center, randomized, controlled phase III trial (NCT06246344). 128 patients with LARC (cT3-4/N+) will be enrolled. During LCCRT, patients will be randomized to receive either MRgART with SIB (60-65 Gy in 25-28 fractions to primary lesions and positive lymph nodes; 50-50.4 Gy in 25-28 fractions to the pelvis) or intensity-modulated radiotherapy (50-50.4 Gy in 25-28 fractions). Both groups will receive concurrent chemotherapy with capecitabine and consolidation chemotherapy of either two cycles of CAPEOX or three cycles of FOLFOX between radiotherapy and surgery. The primary endpoints are pathological complete response (pCR) rate and surgical difficulty, while the secondary endpoints are clinical complete response (cCR) rate, 3-year and 5-year disease-free survival (DFS) and overall survival (OS) rates, acute and late toxicity and quality of life. DISCUSSION: Since dose escalation of both primary lesions and positive nodes in LARC is rare, we propose conducting a phase III trial to evaluate the efficacy and safety of SIB for both primary lesions and positive nodes in LARC based on MRgART. TRIAL REGISTRATION: The study was registered at ClinicalTrials.gov with the Identifier: NCT06246344 (Registered 7th Feb 2024).
Assuntos
Terapia Neoadjuvante , Radioterapia Guiada por Imagem , Neoplasias Retais , Humanos , Neoplasias Retais/patologia , Neoplasias Retais/terapia , Neoplasias Retais/radioterapia , Terapia Neoadjuvante/métodos , Feminino , Adulto , Masculino , Pessoa de Meia-Idade , Idoso , Radioterapia Guiada por Imagem/métodos , Quimiorradioterapia , Imageamento por Ressonância Magnética , Radioterapia de Intensidade Modulada/métodos , Radioterapia de Intensidade Modulada/efeitos adversos , Linfonodos/patologia , Metástase Linfática/radioterapia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Adulto JovemRESUMO
Establishing predictive models for the pathological response and lymph node metastasis in locally advanced rectal cancer (LARC) treated with neoadjuvant chemoradiotherapy (nCRT) based on MRI radiomic features derived from the tumor and mesorectal compartment (MC). This study included 209 patients with LARC who underwent rectal MRI both before and after nCRT. The patients were divided into a training set (n = 146) and a test set (n = 63). Regions of interest (ROIs) for the tumor and MC were delineated on both pre- and post-nCRT MRI images. Radiomic features were extracted, and delta radiomic features were computed. The predictive endpoints were pathological complete response (pCR), pathological good response (pGR), and lymph node metastasis (LNM). Feature selection for various models involved sequentially removing features with a correlation coefficient > 0.9, and features with P-values ≥ 0.05 in univariate analysis, followed by LASSO regression on the remaining features. Logistic regression models were developed, and their performance was evaluated using the area under the receiver operating characteristic curve (AUC). Among the 209 LARC patients, the number of patients achieving pCR, pGR, and LNM were 44, 118, and 40, respectively. The optimal model for predicting each endpoint is the combined model that incorporates pre- and delta-radiomics features for both the tumor and MC. These models exhibited superior performance with AUC values of 0.874 (for pCR), 0.801 (for pGR), and 0.826 (for LNM), outperforming the MRI tumor regression grade (mrTRG) which yielded AUC values of 0.800, 0.715, and 0.603, respectively. The results demonstrate the potential utility of the tumor and MC radiomics features, in predicting treatment efficacy among LARC patients undergoing nCRT.
Assuntos
Metástase Linfática , Imageamento por Ressonância Magnética , Terapia Neoadjuvante , Neoplasias Retais , Humanos , Neoplasias Retais/terapia , Neoplasias Retais/diagnóstico por imagem , Neoplasias Retais/patologia , Terapia Neoadjuvante/métodos , Imageamento por Ressonância Magnética/métodos , Feminino , Masculino , Pessoa de Meia-Idade , Metástase Linfática/diagnóstico por imagem , Idoso , Adulto , Resultado do Tratamento , Curva ROC , Quimiorradioterapia/métodos , RadiômicaRESUMO
BACKGROUND: Liquid biopsy is a minimally invasive procedure investigating tumor mutations. METHODS: In our retrospective study, we investigated whether molecular therapy monitoring of patients receiving neoadjuvant radio(chemo)therapy on a daily routine is possible in 17 patients with locally advanced rectal cancer. Six patients received short-course radiotherapy (5 × 5 Gy) with subsequent surgery, six patients were treated according RAPIDO protocol with short-course radiotherapy followed by chemotherapy (FOLFOX4) and subsequent surgery and five patients received conventional neoadjuvant radiochemotherapy with 5-FU followed by surgery. Response was assessed by Dworak. Liquid biopsies were taken before and immediately after neoadjuvant radiotherapy to isolate and ultradeeply sequence cell free DNA with a panel of 127 genes. Somatic mutations were determined bioinformatically by comparison with normal DNA from leukocytes to distinguish them from germline variants or aging mutations. RESULTS: In 12 patients (71%) at least one somatic mutation was detected. In 8/12 patients a decrease and in 4/12 an increase or mixed response in ctDNA was seen. Statistical correlation between ctDNA analysis and clinical response could not be seen. CONCLUSION: ctDNA is responding to neoadjuvant therapy and liquid biopsy is easily integrated into a daily routine. As part of translational research this protocol leaves room for further investigations.
Assuntos
DNA Tumoral Circulante , Terapia Neoadjuvante , Neoplasias Retais , Humanos , Neoplasias Retais/terapia , Neoplasias Retais/genética , Neoplasias Retais/patologia , Terapia Neoadjuvante/métodos , Masculino , Feminino , Estudos Retrospectivos , Pessoa de Meia-Idade , DNA Tumoral Circulante/sangue , DNA Tumoral Circulante/genética , Idoso , Mutação , Adulto , Biomarcadores Tumorais/genética , Biópsia Líquida/métodosRESUMO
BACKGROUND: Information about the distribution characteristics and prognostic significance of lateral lymph nodes (LLNs) on primary computed tomography (CT) scan in rectal cancer patients is lacking. METHODS: Between January 2013 and December 2016, patients with pathologically proved rectal cancer and pretreatment abdominal enhanced CT in our department were screened. We firstly redivided LLNs into seven categories based on their locations. Then, the number and distribution of all measurable LLNs and the characteristics of the largest LLN in each lateral compartment were recorded. Furthermore, we investigated the long-term outcomes in patients with different LLN characteristics and LLN risk scoring. RESULTS: A total of 572 patients were enrolled in this study. About 80% of patients had measurable LLNs, and most patients developed measurable LLNs in the obturator cranial compartment. Lateral local recurrence (LLR) was observed in 20 patients, which accounted for 83.3% of the local recurrence (LR). Patients with the largest LLN short-axis diameter >10 mm had a poor prognosis, which was similar to that in patients with simultaneous distant metastasis (SDM). Patients with LLN risk scoring ≥2 had a worse prognosis than those with LLN risk scoring <2, while better than those with SDM. CONCLUSION: This study suggests that LLR is the main locoregional recurrence pattern. Most rectal cancer patients have measurable LLNs on primary CT scan. However, patients with enlarged LLNs <10 mm or LLN risk scoring <2 still have a significantly better prognosis than patients with SDM, which indicated the potential value of locoregional treatment for these LLNs.
Assuntos
Linfonodos , Metástase Linfática , Recidiva Local de Neoplasia , Neoplasias Retais , Tomografia Computadorizada por Raios X , Humanos , Neoplasias Retais/patologia , Neoplasias Retais/diagnóstico por imagem , Neoplasias Retais/terapia , Neoplasias Retais/mortalidade , Masculino , Feminino , Pessoa de Meia-Idade , Linfonodos/patologia , Linfonodos/diagnóstico por imagem , Prognóstico , Idoso , Recidiva Local de Neoplasia/patologia , Estudos Transversais , Adulto , Idoso de 80 Anos ou mais , Estudos RetrospectivosRESUMO
Objective: To investigate the pattern of distribution of the circumferential fascia of the rectum and elucidate its clinical implications. Methods: In this descriptive study, we examined the gross anatomy of four male hemipelvic cadaveric specimens from the Department of Anatomy at Fujian Medical University and the histological features of 16 fresh postoperative specimens from patients who had undergone total mesorectal excision for rectal cancer at the Department of Colorectal Surgery, Union Hospital, Fujian Medical University, between January and December 2022. The resultant combination of gross anatomical and histological features was employed to assess the following areas: (1)the morphology of the anterior mesorectum and fascia at the peritoneal reflection; (2)the caudal attachment point of Denonvilliers' fascia; (3) the fusion area of the pelvic plexus and the pre-hypogastric fascia; (4)the lateral and posterior attachment edges of the rectosacral fascia; and (5) selected histological features. Results: Our findings were as follows. (1) At the peritoneal reflection, the anterior mesorectum forms a triangular fat pad with a dense fascial structure. The base of this pad extends anteriorly across the most caudal point of the peritoneal reflection, with Denonvilliers' fascia originating from the anterior side of the triangle, near the bladder side of the peritoneum craniad to the peritoneal reflection. (2) The caudal attachment of Denonvilliers' fascia is at the angle between the seminal vesicles, the ampulla of the vas deferens, and the prostate. It adheres tightly to the prostatic capsule and vascular bundles pass through its cephalic side. (3) The pre-hypogastric fascia transitions laterally to merge with Denonvilliers' fascia; its middle part being inseparable from the main body of the pelvic plexus, which gives rise to the nerves that innervate the rectum. (4) The rectosacral fascia is formed by fusion of the fascia propria with the pre-hypogastric fascia. The resultant fused fascia bifurcates into two leaves on the right side; the outer leaf being the pre-hypogastric fascia and the inner leaf the fascia propria. (5) Histologically, the peritoneal reflection zone shows cuboidal epithelium of the peritoneum at its lowest point with no detectable origin of Denonvilliers' fascia. The anterior side of the peritoneal reflection, from which Denonvilliers' fascia originates, has a dense double-layered fascial structure comprising thick collagen fiber (16/16). The fascia propria exhibits a thinner and looser collagen fiber structure and its origin varies between individuals, 13/16 originating together with Denonvilliers' fascia from the craniad side of the peritoneal reflection, and 3/16 originating separately from the most caudal point of the peritoneal reflection. The caudal edge of Denonvilliers' fascia has a double-layered fascial structure with multiple S100-stained areas. The posterior edge of the rectosacral fascia has a fused fascial structure, thick nerve fibers being clearly observable between collagen fibers originating from the pre-hypogastric fascia under high magnification. The lateral edge of the rectosacral fascia extends interiorly, maintains the integrity of the fascia propria. Conclusions: In this study, we investigated the pattern of distribution of the circumferential fascia of the rectum by cadaveric dissection and histological examination of postoperative specimens. We found that the anterior mesorectum forms a triangular fat pad that can serve as a reference for dissection anterior to Denonvilliers' fascia, by making incisions 1 cm above the peritoneal reflection. The region of fusion of Denonvilliers' fascia with the prostatic capsule on the caudal side is rich in neurovascular bundles, contradicting the traditional view of a retroprostatic plane. This finding supports the practice of cutting Denonvilliers' fascia 0.5 cm above the base of the seminal vesicles. The fusion of the fascia propria with the pre-hypogastric fascia posteriorly forms the rectosacral fascia, which bifurcates into two leaves on both sides of the rectum, the inner leaf being the fascia propria and the outer leaf the pre-hypogastric fascia. These transition anteriorly to become Denonvilliers' fascia and fuse densely with the main body of the pelvic plexus on both sides. These findings provide a theoretical foundation for protecting the pelvic plexus and hypogastric nerve by transecting Denonvilliers' fascia and then dissecting in a top-to-bottom direction (i.e., from anterior to caudal), ultimately leading to the transection of the pre-hypogastric fascia.
Assuntos
Fáscia , Neoplasias Retais , Reto , Humanos , Fáscia/anatomia & histologia , Masculino , Reto/anatomia & histologia , Neoplasias Retais/cirurgia , Neoplasias Retais/patologia , Peritônio/anatomia & histologia , Relevância ClínicaRESUMO
BACKGROUND: We aimed to evaluate outcomes of organ preservation by local excision (LE) compared to proctectomy following neoadjuvant therapy for rectal cancer. METHODS: This retrospective observational study using the National Cancer Database (NCDB) included patients with locally advanced non-metastatic rectal cancer (ypT0-1 tumors) treated with neoadjuvant therapy between 2004 and 2019. Outcomes of patients who underwent LE or proctectomy were compared. 1:1 propensity score matching including patient demographics, clinical and therapeutic factors was used to minimize selection bias. Main outcome was overall survival (OS). RESULTS: 11,256 of 318,548 patients were included, 526 (4.6%) of whom underwent LE. After matching, mean 5-year OS was similar between the groups (54.1 vs. 54.2 months; p = 0.881). Positive resection margins (1.2% vs. 0.6%; p = 0.45), pathologic T stage (p = 0.07), 30-day mortality (0.6% vs. 0.6%; p = 1), and 90-day mortality (1.5% vs. 1.2%; p = 0.75) were comparable between the groups. Length of stay (1 vs. 6 days; p < 0.001) and 30-day readmission rate (5.3% vs. 10.3%; p = 0.02) were lower in LE patients. Multivariate analysis of predictors of OS demonstrated male sex (HR 1.38, 95% CI 1.08-1.77; p = 0.009), higher Charlson score (HR 1.52, 95% CI 1.29-1.79; p < 0.001), poorly differentiated carcinoma (HR 1.61, 95% CI 1.08-2.39; p = 0.02), mucinous carcinoma (HR 3.53, 95% CI 1.72-7.24; p < 0.001), and pathological T1 (HR 1.45, 95% CI 1.14-1.84; p = 0.002) were independent predictors of increased mortality. LE did not correlate with worse OS (HR 0.91, 95% CI 0.42-1.97; p = 0.82). CONCLUSION: Our findings show no overall significant survival difference between LE and total mesorectal excision, including ypT1 tumors. Moreover, patients with poorly differentiated or mucinous adenocarcinomas generally had poorer outcomes, regardless of surgical method.