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Patterns of failure and survival for nonoperative treatment of stage c0 distal rectal cancer following neoadjuvant chemoradiation therapy

  • 2006 SSAT Annual Meeting
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Neoadjuvant chemoradiation therapy (CRT) is the preferred treatment option for distal rectal cancer. Complete pathological response after CRT has led to the proposal of nonoperative approach as an alternative treatment for highly selected patients with complete clinical response. However, patterns of failure following this strategy remains undetermined. Three hundred sixty-one patients with distal rectal cancer were managed by neoadjuvant CRT including 5-FU, leucovorin, and 5040 cGy. Tumor response assessment was performed at 8 weeks following CRT. Patients with complete clinical response were not immediately operated on and were closely followed. One hundred twenty-two patients were considered to have complete clinical response after the first tumor response assessment. Of these, only 99 patients sustained complete clinical response for at least 12 months and were considered stage c0 (27.4%) and managed nonoperatively. Mean follow-up was 59.9 months. There were 13 (13.1%) recurrences: 5 (5%) endorectal, 7 (7.1%) systemic, and 1 (1%) combined recurrence. All 5 isolated endorectal recurrences were salvaged. Mean recurrence interval was 52 months for local failure and 29.5 months for systemic failure. There were five cancer-related deaths after systemic recurrences. Overall and disease-free 5-year survivals were 93% and 85%. Even though surgery remains the standard treatment for rectal cancer, nonoperative treatment after complete clinical response following neoadjuvant CRT may be safe and associated with good survival rates in a highly selected group of patients. Survival in these patients is significantly affected by systemic failure. Exclusive local failure occurs late after CRT completion and is frequently amenable to salvage therapy.

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References

  1. Nelson H, Petrelli N, Carlin A, Couture J, Fleshman J, Guillem J, et al. Guidelines 2000 for colon and rectal cancer surgery. J Natl Cancer Inst 2001;93:583–596.

    Article  PubMed  CAS  Google Scholar 

  2. Tjandra JJ, Kilkenny JW, Buie WD, Hyman N, Simmang C, Anthony T, et al. Practice parameters for the management of rectal cancer (revised). Dis Colon Rectum 2005;48:411–423.

    Article  PubMed  Google Scholar 

  3. Madbouly KM, Remzi FH, Erkek BA, Senagore AJ, Baeslach CM, Khandwala F, et al. Recurrence after transanal excision of T1 rectal cancer: Should we be concerned? Dis Colon Rectum 2005;48:711–719; discussion 719–721.

    Article  PubMed  Google Scholar 

  4. Petersen S, Hellmich G, von Mildenstein K, Porse G, Ludwig K. Is surgery-only the adequate treatment approach for T2N0 rectal cancer? J Surg Oncol 2006; 93:350–354.

    Article  PubMed  Google Scholar 

  5. Sauer R, Becker H, Hohenberger W, Rodel C, Wittekind C, Fietkau R, et al. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 2004;351:1731–1740.

    Article  PubMed  CAS  Google Scholar 

  6. Kapiteijn E, Marijnen CA, Nagtegaal ID, Putter H, Steup WH, Wiggers T, et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med 2001;345:638–646.

    Article  PubMed  CAS  Google Scholar 

  7. Janjan NA, Khoo VS, Abbruzzese J, Pazdur R, Dubrow R, Cleary KR, et al. Tumor downstaging and sphincter preservation with preoperative chemoradiation in locally advanced rectal cancer: The M.D. Anderson Cancer Center experience. Int J Radiat Oncol Biol Phys 1999;44: 1027–1038.

    Article  PubMed  CAS  Google Scholar 

  8. Habr-Gama A, Perez RO, Kiss DR, Rawet V, Scanavini A, Santinho PM, et al. Preoperative chemoradiation therapy for low rectal cancer. Impact on downstaging and sphincter-saving operations. Hepatogastroenterology 2004;51: 1703–1707.

    PubMed  Google Scholar 

  9. Medich D, McGinty J, Parda D, Karlovits S, Davis C, Caushaj P, et al. Preoperative chemoradiotherapy and radical surgery for locally advanced distal rectal adenocarcinoma: Pathologic findings and clinical implications. Dis Colon Rectum 2001;44:1123–1128.

    Article  PubMed  CAS  Google Scholar 

  10. Habr-Gama A, de Souza PM, Ribeiro U Jr, Nadalin W, Gansl R, Sousa AH Jr., et al. Low rectal cancer: Impact of radiation and chemotherapy on surgical treatment. Dis Colon Rectum 1998;41:1087–1096.

    Article  PubMed  CAS  Google Scholar 

  11. Guillem JG, Chessin DB, Cohen AM, Shia J, Mazumdar M, Enker W, et al. Long-term oncologic outcome following preoperative combined modality therapy and total mesorectal excision of locally advanced rectal cancer. Ann Surg 2005; 241:829–836; discussion 836–838.

    Article  PubMed  Google Scholar 

  12. Habr-Gama A, Perez RO, Nadalin W, Sabbaga J, Ribeiro U Jr, Silva e Sousa AH Jr, et al. Operative versus nonoperative treatment for stage 0 distal rectal cancer following chemoradiation therapy: Long-term results. Ann Surg 2004;240:711–717; discussion 717–8.

    PubMed  Google Scholar 

  13. Habr-Gama A, Perez RO, Nadalin W, Nahas SC, Ribeiro U Jr, Silva E Jr, et al. Long-term results of preoperative chemoradiation for distal rectal cancer correlation between final stage and survival. J Gastrointest Surg 2005; 9:90–99; discussion 99–101.

    Article  PubMed  Google Scholar 

  14. Meyers MO, Tepper JE. Rectal cancer: Can we throw away the scalpel? Ann Surg Oncol 2005;12:95–97.

    Article  PubMed  Google Scholar 

  15. Hiotis SP, Weber SM, Cohen AM, Minsky BD, Paty PB, Guillem JG, et al. Assessing the predictive value of clinical complete response to neoadjuvant therapy for rectal cancer: An analysis of 488 patients. J Am Coll Surg 2002;194:131–135; discussion 135–136.

    Article  PubMed  Google Scholar 

  16. Stipa F, Zernecke A, Moore HG, Minsky BD, Wong WD, Weiser M, et al. Residual mesorectal lymph node involvement following neoadjuvant combined-modality therapy: Rationale for radical resection? Ann Surg Oncol 2004;11: 187–191.

    Article  PubMed  Google Scholar 

  17. Heald RJ, Ryall RD. Recurrence and survival after total mesorectal excision for rectal cancer. Lancet 1986;1:1479–1482.

    Article  PubMed  CAS  Google Scholar 

  18. Simunovic M, Sexton R, Rempel E, Moran BJ, Heald RJ. Optimal preoperative assessment and surgery for rectal cancer may greatly limit the need for radiotherapy. Br J Surg 2003;90:999–1003.

    Article  PubMed  CAS  Google Scholar 

  19. Colquhoun P, Wexner SD, Cohen A. Adjuvant therapy is valuable in the treatment of rectal cancer despite total mesorectal excision. J Surg Oncol 2003;83:133–139.

    Article  PubMed  Google Scholar 

  20. Nascimbeni R, Burgart LJ, Nivatvongs S, Larson DR. Risk of lymph node metastasis in T1 carcinoma of the colon and rectum. Dis Colon Rectum 2002;45:200–206.

    Article  PubMed  Google Scholar 

  21. Hahnloser D, Wolff BG, Larson DW, Ping J, Nivatvongs S. Immediate radical resection after local excision of rectal cancer: An oncologic compromise? Dis Colon Rectum 2005;48:429–437.

    Article  PubMed  Google Scholar 

  22. Floyd ND, Saclarides TJ. Transanal endoscopic microsurgical resection of pT1 rectal tumors. Dis Colon Rectum 2006; 49:164–168.

    Article  PubMed  Google Scholar 

  23. Perez RO, Habr-Gama A, Nishida Arazawa ST, Rawet V, Coelho Siqueira SA, Kiss DR, et al. Lymph node micrometastasis in stage II distal rectal cancer following neoadjuvant chemoradiation therapy. Int J Colorectal Dis 2005;20:434–439.

    Article  PubMed  Google Scholar 

  24. Andreola S, Leo E, Belli F, Gallino G, Sirizzotti G, Sampietro G. Adenocarcinoma of the lower third of the rectum: Metastases in lymph nodes smaller than 5 mm and occult micrometastases;preliminary results on early tumor recurrence. Ann Surg Oncol 2001;8:413–417.

    Article  PubMed  CAS  Google Scholar 

  25. Oberg A, Stenling R, Tavelin B, Lindmark G. Are lymph node micrometastases of any clinical significance in Dukes Stages A and B colorectal cancer? Dis Colon Rectum 1998; 41:1244–1249.

    Article  PubMed  CAS  Google Scholar 

  26. Moore HG, Gittleman AE, Minsky BD, Wong D, Paty PB, Weiser M, et al. Rate of pathologic complete response with increased interval between preoperative combined modality therapy and rectal cancer resection. Dis Colon Rectum 2004;47:279–286.

    Article  PubMed  Google Scholar 

  27. Deniaud-Alexandre E, Touboul E, Tiret E, Sezeur A, Houry S, Gallot D, et al. Results of definitive irradiation in a series of 305 epidermoid carcinomas of the anal canal. Int J Radiat Oncol Biol Phys 2003;56:1259–1273.

    Article  PubMed  Google Scholar 

  28. Bonadeo FA, Vaccaro CA, Benati ML, Quintana GM, Garione XE, Telenta MT. Rectal cancer: Local recurrence after surgery without radiotherapy. Dis Colon Rectum 2001;44:374–379.

    Article  PubMed  CAS  Google Scholar 

  29. Luna-Perez P, Trejo-Valdivia B, Labastida S, Garcia-Alvarado S, Rodriguez DF, Delgado S. Prognostic factors in patients with locally advanced rectal adenocarcinoma treated with preoperative radiotherapy and surgery. World J Surg 1999;23:1069–1074; discussion 1075.

    Article  PubMed  CAS  Google Scholar 

  30. Coco C, Valentini V, Manno A, Mattana C, Verbo A, Cellini N, et al. Long-term results after neoadjuvant radio-chemotherapy for locally advanced resectable extraperitoneal rectal cancer. Dis Colon Rectum 2006;49:311–318.

    Article  PubMed  Google Scholar 

  31. Ruo L, Tickoo S, Klimstra DS, Minsky BD, Saltz L, Mazumdar M, et al. Long-term prognostic significance of extent of rectal cancer response to preoperative radiation and chemotherapy. Ann Surg 2002;236:75–81.

    Article  PubMed  Google Scholar 

  32. Garcia-Aguilar J, Hernandez de Anda E, Sirivongs P, Lee SH, Madoff RD, Rothenberger DA. A pathologic complete response to preoperative chemoradiation is associated with lower local recurrence and improved survival in rectal cancer patients treated by mesorectal excision. Dis Colon Rectum 2003;46:298–304.

    Article  PubMed  Google Scholar 

  33. Kraemer M, Wiratkapun S, Seow-Choen F, Ho YH, Eu KW, Nyam D. Stratifying risk factors for follow-up: A comparison of recurrent and nonrecurrent colorectal cancer. Dis Colon Rectum 2001;44:815–821.

    Article  PubMed  CAS  Google Scholar 

  34. Chmielarz A, Kryj M, Wloch J, Poltorak S, Sacher A, Lasek-Kryj M. Prognostic factors for the time of occurrence and dynamics of distant metastases and local recurrences after radical treatment in patients with rectal cancer. Med Sci Monit 2001;7:1263–1269.

    PubMed  CAS  Google Scholar 

  35. Kienle P, Koch M, Autschbach F, Benner A, Treiber M, Wannenmacher M, et al. Decreased detection rate of disseminated tumor cells of rectal cancer patients after preoperative chemoradiation: A first step towards a molecular surrogate marker for neoadjuvant treatment in colorectal cancer. Ann Surg 2003;238:324–330; discussion 330–331.

    PubMed  Google Scholar 

  36. Swayne LC, Goldenberg DM, Diehl WL, Macaulay RD, Derby LA, Trivino JZ. SPECT anti-CEA monoclonal antibody detection of occult colorectal carcinoma metastases. Clin Nucl Med 1991;16:849–852.

    Article  PubMed  CAS  Google Scholar 

  37. Chessin DB, Kiran RP, Akhurst T, Guillem JG. The emerging role of 18F-fluorodeoxyglucose positron emission tomography in the management of primary and recurrent rectal cancer. J Am Coll Surg 2005;201:948–956.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. From the Department of Gastroenterology, University of São Paulo School of Medicine, and Hospital Alemão Oswaldo Cruz (HAOC), São Paulo, Brazil

    Angelita Habr-Gama M.D., Ph.D., Rodrigo O. Perez M.D., Igor Proscurshim M.S., Fábio G. Campos M.D., Ph.D., Desiderio Kiss M.D., Ph.D. & Joaquim Gama-Rodrigues M.D., Ph.D.

  2. Department of Radiology, University of São Paulo School of Medicine, and Hospital Alemão Oswaldo Cruz (HAOC), São Paulo, Brazil

    Wladimir Nadalin M.D., Ph.D.

Authors
  1. Angelita Habr-Gama M.D., Ph.D.
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  2. Rodrigo O. Perez M.D.
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  3. Igor Proscurshim M.S.
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  4. Fábio G. Campos M.D., Ph.D.
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  5. Wladimir Nadalin M.D., Ph.D.
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  7. Joaquim Gama-Rodrigues M.D., Ph.D.
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Correspondence to Rodrigo O. Perez M.D..

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Habr-Gama, A., Perez, R.O., Proscurshim, I. et al. Patterns of failure and survival for nonoperative treatment of stage c0 distal rectal cancer following neoadjuvant chemoradiation therapy. J Gastrointest Surg 10, 1319–1329 (2006). https://doi.org/10.1016/j.gassur.2006.09.005

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  • DOI: https://doi.org/10.1016/j.gassur.2006.09.005

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