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Past
Extramural venous invasion (EMVI) is associated with a poor prognosis in patients with locally advanced rectal cancer.1 With evolving treatment paradigms for these patients, such as total neoadjvuant therapy (TNT) and watch-and-wait, it is imperative to understand the true impact of EMVI positivity at baseline and after neoadjuvant treatment.2,3 Accurate assessment of EMVI regression after neoadjuvant treatment can help inform selection of patients for treatment adjustments and can also help inform long-term prognosis.
Present
Our retrospective analysis of data from 175 patients with locally advanced rectal cancer treated with TNT followed by total mesorectal excision found that patients with EMVI on baseline magnetic resonance imaging (MRI) had shorter disease-free survival and shorter overall survival on average than patients without EMVI on baseline MRI.4 In exploratory analyses, regression of EMVI after TNT was positively associated with survival. We found considerable discordance between post-TNT MRI and surgical pathology in the assessment of EMVI regression. Our data suggest that post-TNT MRI should be interpreted with caution, as it appears to underestimate EMVI regression.
Future
Improving the accuracy of post-TNT assessment of EMVI will aid effective implementation of non-operative and other treatment deintensification strategies for rectal cancer. Future work may benefit from advanced analyses, such as artificial intelligence, to resolve some of the discrepancies between EMVI regression on post-TNT MRI and surgical pathology.5
References
Tan JJ, Carten RV, Babiker A, Abulafi M, Lord AC, Brown G. Prognostic importance of MRI-detected extramural venous invasion in rectal cancer: a literature review and systematic meta-analysis. Int J Radiat Oncol Biol Phys. 2021;111:385–94.
Cercek A, Roxburgh CSD, Strombom P, et al. Adoption of total neoadjuvant therapy for locally advanced rectal cancer. JAMA Oncol. 2018;4(6):e180071.
Vailati BB, São Julião GP, Habr-Gama A, Perez RO. Nonoperative management of rectal cancer: the watch and wait strategy. Surg Oncol Clin N Am. 2022;31(2):171–82.
Thompson HM, Bates DDB, Golia Pernicka J, et al. MRI assessment of extramural venous invasion before and after total neoadjuvant therapy for locally advanced rectal cancer and its association with disease-free and overall survival. Ann Surg Oncol. 2023. https://doi.org/10.1245/s10434-023-13225-9.
Zhao L, Liang M, Yang Y, Zhang H, Zhao X. Prediction of false-negative extramural venous invasion in patients with rectal cancer using multiple mathematical models of diffusion-weighted imaging. Eur J Radiol. 2021;139:109731.
Funding
The funding was provided by National Cancer Institute (Grant No. P30 CA008748).
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Hannah M. Thompson and Maria Widmar declare they have no conflicts of interest in relation to this manuscript.
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Thompson, H.M., Widmar, M. ASO Author Reflections: Understanding the Association between Extramural Venous Invasion and Survival in Rectal Cancer Patients. Ann Surg Oncol 30, 3966 (2023). https://doi.org/10.1245/s10434-023-13357-y
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DOI: https://doi.org/10.1245/s10434-023-13357-y