Outcome standards for an organ preservation strategy in stage II and III rectal adenocarcinoma after neoadjuvant chemoradiation.
ABSTRACT Neoadjuvant chemoradiotherapy is the standard of care for patients with locally advanced mid and distal rectal cancer. Tumor regression is variable, and this study was designed to evaluate the pathological response and impact on long-term disease control in responders and nonresponders.
A total of 303 consecutive patients with cStage II and III mid and distal rectal adenocarcinoma were identified. The mean age was 64 years and 63% were men. Patients received neoadjuvant chemoradiotherapy (45 Gy) with a continuous infusion of 5-fluorouracil. Total mesorectal excision (TME) was performed after an interval of 6-8 weeks. Tumors were stratified as responders (ypT0 or ypT1) and nonresponders (≥ypT3). All ypT2 were separately categorized.
Tumors of 84 patients were classified as responders (27.5%) versus nonresponders in 144 patients (47.5%). Pathological tumor stage was ypT2 in 75 patients (25%). After a median follow-up of 55 months, the 5-year cancer-specific survival rate was 98% and the disease-free survival rate was 91% in responders versus 82% (P < 0.0025) and 60% (P < 0.0001), respectively, for the nonresponders.
After neoadjuvant chemoradiotherapy and TME surgery for locally advanced rectal cancer and complete or near-complete pathological tumor response oncological outcome is very good. These results set the standards for a rectum-sparing strategy.
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ABSTRACT: This retrospective 12-year study evaluated the prognostic value of initial and postoperative staging of rectal tumors. Between 1985 and 1996, 297 patients were treated with preoperative radiotherapy (39 Gy in 13 fractions) and surgery for Stage T2-T4N0-N1M0 rectal adenocarcinoma. Pretreatment staging included a clinical examination and endorectal ultrasonography (EUS) since 1988. Clinical staging was performed by digital rectal examination and rigid proctoscopy. EUS was performed in 236 patients. Postoperative staging was performed by examination of the pathologic specimen. The median follow-up was 49 months. The overall 5-year survival rate was 67%, with a local failure rate of 9%. The rate of sphincter preservation was 65%. The clinical examination findings were strong prognostic factor for both cT stage (p < 0.001) and cN stage (p < 0.006) but had poor specificity for cN stage (only 25 lymph nodes detected). In both univariate and multivariate analyses, EUS had a statistically significant prognostic value for uT (p < 0.014) but not for uN (p < 0.47) stage. In contrast, pT and pN stages were strong prognostic factors (p < 0.001 and p < 0.001, respectively). Pretreatment staging, including clinical examination and EUS, seemed accurate enough to present a high prognostic value for the T stage. EUS was insufficient to stage lymph node involvement. Owing to its lack of specificity, uN stage was not a reliable prognostic factor. An improvement in N staging is necessary and essential. Despite downstaging, postoperative staging remained a very strong prognostic factor for both T and N stages.International Journal of Radiation OncologyBiologyPhysics 05/2005; 61(5):1371-7. · 4.52 Impact Factor
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ABSTRACT: Report overall long-term results of stage 0 rectal cancer following neoadjuvant chemoradiation and compare long-term results between operative and nonoperative treatment. Two-hundred sixty-five patients with distal rectal adenocarcinoma considered resectable were treated by neoadjuvant chemoradiation (CRT) with 5-FU, Leucovorin and 5040 cGy. Patients with incomplete clinical response were referred to radical surgical resection. Patients with incomplete clinical response treated by surgery resulting in stage p0 were compared to patients with complete clinical response treated by nonoperative treatment. Statistical analysis was performed using chi2, Student t test and Kaplan-Meier curves. Overall and disease-free 10-year survival rates were 97.7% and 84%. In 71 patients (26.8%) complete clinical response was observed following CRT (Observation group). Twenty-two patients (8.3%) showed incomplete clinical response and pT0N0M0 resected specimens (Resection group). There were no differences between patient's demographics and tumor's characteristics between groups. In the Resection group, 9 definitive colostomies and 7 diverting temporary ileostomies were performed. Mean follow-up was 57.3 months in Observation Group and 48 months in Resection Group. There were 3 systemic recurrences in each group and 2 endorectal recurrences in Observation Group. Two patients in the Resection group died of the disease. Five-year overall and disease-free survival rates were 88% and 83%, respectively, in Resection Group and 100% and 92% in Observation Group. Stage 0 rectal cancer disease is associated with excellent long-term results irrespective of treatment strategy. Surgical resection may not lead to improved outcome in this situation and may be associated with high rates of temporary or definitive stoma construction and unnecessary morbidity and mortality rates.Annals of Surgery 11/2004; 240(4):711-7; discussion 717-8. · 6.33 Impact Factor
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ABSTRACT: Given the improvement in oncologic outcome after the introduction of total mesorectal excision for the treatment of rectal cancer, the objective of the present study was to determine the frequency of identification and preservation of the pelvic autonomic nerves and to identify a possible link between postoperative micturition disturbances and the extent of the radical resection. Between March 1997 and December 2001, 150 patients with adenocarcinoma of the rectum (<or=16 cm from the anal verge) underwent surgery, with sphincter preservation in 112 cases (74.7 percent). Sixty-three patients (42 percent) were classified as American Society of Anesthesiologists Stage III and two (1.3 percent) as Stage IV. The number of cases with complete identification, partial identification, or nonidentification of the autonomic nerves (superior hypogastric plexus, hypogastric nerve, and inferior hypogastric plexus) was documented and correlated with micturition disturbances (need for a long-term urinary catheter). Urine volumes were measured by ultrasound before and after surgery. The pelvic autonomic nerves were identified completely in 108 patients (72 percent), partially in 16 (10.7 percent), and not at all in 26 (17.3 percent). After the initial phase of the study (n = 50 patients), complete identification was realized in 78 percent of cases. Multivariate analysis showed that of the predetermined parameters (learning curve for Group I vs. Groups II or III, gender, T stage, blood loss, curative surgery, and previous surgery), gender (P = 0.006), learning curve (P = 0.019), and depth of penetration of the rectal wall (T1/T2 vs. T3/T4; P = 0.028) exerted an independent influence on achievement of complete pelvic nerve identification. Sixteen patients (10.7 percent) were discharged from the hospital with a urinary catheter. Identification and preservation of the pelvic autonomic nerves was associated with low bladder dysfunction rates (4.5 vs. 38.5 percent; P < 0.001). In the evaluation of preoperative and postoperative bladder function, a urologic history and residual urine volume measurements by ultrasound were essential. The information obtained from urodynamic studies was of no relevance. Identification and preservation of the pelvic autonomic nerves was achieved in the majority of patients and led to the prevention of urinary dysfunction. Gender (P = 0.006), learning curve (P = 0.019), and T stage are independent parameters that influence outcome.Diseases of the Colon & Rectum 05/2003; 46(5):621-8. · 3.34 Impact Factor