Abstract
Purpose
This paper aimed to study the long term follow-up of patients with primary rectal adenocarcinoma receiving neoadjuvant chemoradiotherapy who obtained a pathological complete response (pCR) and identify factors predicting complete response.
Methods
Retrospective review of notes, histology, pre-operative full blood count and imaging of patients with primary rectal adenocarcinoma diagnosed in our institute from 2000 to 2012 from a prospectively maintained database were used. SPSS version 22.0 was used for statistical analysis.
Results
Three hundred eighty patients diagnosed with primary rectal adenocarcinoma were identified, 277 received neoadjuvant chemoradiotherapy followed by curative resection. Forty-six patients obtained a pCR (ypT0N0) with no local recurrence and two metastatic recurrences on follow-up. Patients with a pCR have a significantly improved overall survival and disease-free survival compared to a non-pCR (150.0 and 136.1 vs 77.5 and 84.7 months, p = 0.001). On univariate analysis, increased tumour height above anal verge, low lymph node yield, high pre-operative haemoglobin and a low neutrophil-lymphocyte ratio are significant factors identifying a pCR. Multivariable analysis of the above factors confirmed tumour height above anal verge as significant in obtaining a pCR.
Conclusion
Patients with rectal adenocarcinoma who develop a pCR following neoadjuvant chemoradiotherapy have improved overall and disease-free survival. We have identified distance from anal verge, low lymph node yield, high pre-operative haemoglobin and low neutrophil-lymphocyte ratio as significant predictors of developing a pCR.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Office of National Statistics, U.K. (2012) Cancer incidence and mortality in the United Kingdom, 2008–10, available at http://www.ons.gov.uk/ons/rel/cancer-unit/cancer-incidence-and-mortality/2008-2010/stb-cancer-incidence-and-mortality-in-the-united-kindom--2008-2010.html
Cancer Research, U.K. (2012) Bowel Cancer Incidence Statistics, 2007–2009, available at http://www.cancerresearchuk.org/cancer-info/cancerstats/types/bowel/incidence/uk-bowel-cancer-incidence-statistics
Sauer R et al (2004) Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 351(17):1731–1740
Glynne-Jones R, Hughes R (2012) Critical appraisal of the ‘wait and see’ approach in rectal cancer for clinical complete responders after chemoradiation. Br J Surg 99(7):897–909
National Institute of Clinical Excellence, N (2011) The diagnosis and management of colorectal cancer: full guideline
Maas M et al (2010) Long-term outcome in patients with a pathological complete response after chemoradiation for rectal cancer: a pooled analysis of individual patient data. Lancet Oncol 11(9):835–844
Garcia-Aguilar J et al (2012) A phase II trial of neoadjuvant chemoradiation and local excision for T2 N0 rectal cancer: preliminary results of the ACOSOG Z6041 trial. Ann Surg Oncol 19(2):384–391
Habr-Gama A et al (2006) Patterns of failure and survival for nonoperative treatment of stage c0 distal rectal cancer following neoadjuvant chemoradiation therapy. J Gastrointest Surg 10(10):1319–1328 discussion 1328-9
Smith JD et al (2012) Nonoperative management of rectal cancer with complete clinical response after neoadjuvant therapy. Ann Surg 256(6):965–972
Das P et al (2007) Predictors of tumor response and downstaging in patients who receive preoperative chemoradiation for rectal cancer. Cancer 109(9):1750–1755
de Campos-Lobato LF et al (2011) Pathologic complete response after neoadjuvant treatment for rectal cancer decreases distant recurrence and could eradicate local recurrence. Ann Surg Oncol 18(6):1590–1598
Lee JH et al (2015) The role of fibrinogen as a predictor in preoperative chemoradiation for rectal cancer. Ann Surg Oncol 22(1):209–215
de Campos-Lobato LF et al (2013) Less than 12 nodes in the surgical specimen after total mesorectal excision following neoadjuvant chemoradiation: it means more than you think! Ann Surg Oncol 20(11):3398–3406
Beppu N et al (2015) Pathologic evaluation of the response of mesorectal positive nodes to preoperative chemoradiotherapy in patients with rectal cancer. Surgery 157(4):743–751
Becker A et al (2000) Severe anemia is associated with poor tumor oxygenation in head and neck squamous cell carcinomas. Int J Radiat Oncol Biol Phys 46(2):459–466
Harrison LB et al (2002) Impact of tumor hypoxia and anemia on radiation therapy outcomes. Oncologist 7(6):492–508
Walter CJ et al (2013) Prevalence and significance of anaemia in patients receiving long-course neoadjuvant chemoradiotherapy for rectal carcinoma. Color Dis 15(1):52–56
Khan AA et al (2013) Association between pretreatment haemoglobin levels and morphometric characteristics of the tumour, response to neoadjuvant treatment and long-term outcomes in patients with locally advanced rectal cancers. Color Dis 15(10):1232–1237
Mallappa S et al (2013) Preoperative neutrophil to lymphocyte ratio >5 is a prognostic factor for recurrent colorectal cancer. Color Dis 15(3):323–328
Carruthers R et al (2012) Systemic inflammatory response is a predictor of outcome in patients undergoing preoperative chemoradiation for locally advanced rectal cancer. Color Dis 14(10):e701–e707
Kim IY, You SH, Kim YW (2014) Neutrophil-lymphocyte ratio predicts pathologic tumor response and survival after preoperative chemoradiation for rectal cancer. BMC Surg 14:94
Fridlender ZG, Albelda SM (2012) Tumor-associated neutrophils: friend or foe? Carcinogenesis 33(5):949–955
Mishalian I et al (2013) Tumor-associated neutrophils (TAN) develop pro-tumorigenic properties during tumor progression. Cancer Immunol Immunother 62(11):1745–1756
Choi CH et al (2012) Clinical predictive factors of pathologic tumor response after preoperative chemoradiotherapy in rectal cancer. Radiat Oncol J 30(3):99–107
Acknowledgements
The authors thank Mr. Dave Sharpe for maintaining and collating the evidence in the database, Dr. Jonathan Gillender for collecting the data of patients with complete response, and Leicester Specialist Colorectal Group for maintaining the overall database.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Rights and permissions
About this article
Cite this article
Runau, F., Collins, A., Fenech, G.A. et al. A single institution’s long-term follow-up of patients with pathological complete response in locally advanced rectal adenocarcinoma following neoadjuvant chemoradiotherapy. Int J Colorectal Dis 32, 341–348 (2017). https://doi.org/10.1007/s00384-016-2712-5
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00384-016-2712-5