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01-06-2004 | Original Contribution

Neoadjuvant Therapy for Rectal Cancer: Histologic Response of the Primary Tumor Predicts Nodal Status

Authors: Thomas E. Read, M.D., Jose E. Andujar, M.D., Philip F. Caushaj, M.D., Douglas R. Johnston, B.A., David W. Dietz, M.D., Robert J. Myerson, M.D., Ph.D., James W. Fleshman, M.D., Elisa H. Birnbaum, M.D., Matthew G. Mutch, M.D., Ira J. Kodner, M.D.

Published in: Diseases of the Colon & Rectum | Issue 6/2004

PURPOSE:

This study was designed to compare histologic T and N stages in patients with rectal adenocarcinoma undergoing various neoadjuvant radiotherapy regimens and proctectomy, in an attempt to determine if final histologic stage of the mural tumor predicts nodal status.

METHODS:

Data were collected from computerized databases at two institutions on 649 consecutive patients who underwent neoadjuvant radiotherapy or chemoradiotherapy and proctectomy for primary adenocarcinoma of the rectum from 1990 to 2002.

RESULTS:

Five patients were excluded because of incomplete pathology data sets, leaving a study population of 644. Patients underwent neoadjuvant radiotherapy alone (2,000 cGy in 5 fractions, n = 191; or 4,500 cGy in 25 fractions, n = 259) or chemoradiation (4,500 cGy in 25 fractions with concurrent 5-fluorouracil, n = 194). Histologic stage of the remaining mural tumor (ypT) correlated with nodal status (ypN). Lymph nodes harboring metastatic tumor were found in 1 of 42 (2 percent) ypT0 patients, 2 of 45 (4 percent) ypT1 patients, 43 of 186 (23 percent) ypT2 patients, 158 of 338 (47 percent) ypT3 patients, and 16 of 33 (48 percent) ypT4 patients (P < 0.001, chi-squared test). The probability of finding ypN+ disease was 3 of 87 (3 percent) in patients with ypT0-1 residual primary tumors vs. 220 of 557 (39 percent) in patients with ypT2-4 residual primary tumors (P < 0.0001; Fisher’s exact test).

CONCLUSIONS:

Nodal metastases are rare in patients whose mural tumor burden shrinks to ypT0-1 after neoadjuvant radiotherapy. If transanal excision is offered to select patients with distal rectal cancer, it is reasonable to select those who have an excellent clinical response to neoadjuvant therapy for transanal excision, and then reserve proctectomy for patients proven to have residual ypT2-4 disease.

Holm, T, Singnomklao, T, Rutqvist, LE, Cedermark, B 1996Adjuvant preoperative radiotherapy in patients with rectal carcinoma. Adverse effects during long term follow-up of two randomized trialsCancer7896876

Karanjia, ND, Corder, AP, Bearn, P, Heald, RJ 1994Leakage from stapled low anastomosis after total mesorectal excision for carcinoma of the rectumBr J Surg8112246

Bailey, HR, Huval, WV, Max, E, Smith, KW, Butts, DR, Zamora, LF 1992Local excision of carcinoma of the rectum for cureSurgery11155561

Killingback, M 1992Local excision of carcinoma of the rectum: indicationsWorld J Surg1643746

Minsky, BD 1997Results of local excision followed by postoperative radiation therapy for rectal cancerRadiat Oncol Investig524651

Taylor, RH, Hay, JH, Larsson, SN 1998Transanal local excision of selected low rectal cancersAm J Surg1753603

Steele, GD,Jr, Herndon, JE, Bleday, R, et al. 1999Sphincter-sparing treatment for distal rectal adenocarcinomaAnn Surg Oncol643341

Bleday, R, Breen, E, Jessup, JM, Burgess, A, Sentovich, SM, Steele, G,Jr 1997Prospective evaluation of local excision for small rectal cancersDis Colon Rectum4038892

Fortunato, L, Ahmad, NR, Yeung, RS, et al. 1995Long-term follow-up of local excision and radiation therapy for invasive rectal cancerDis Colon Rectum3811939

10.

Paty, PB, Nash, GM, Baron, P, et al. 2002Long-term results of local excision for rectal cancerAnn Surg2365229

11.

Mellgren, A, Sirivongs, P, Rothenberger, DA, Madoff, RD, Garcia-Aguilar, J 2000Is local excision adequate therapy for early rectal cancer?Dis Colon Rectum43106471

12.

Garcia-Aguilar, J, Mellgren, A, Sirivongs, P, Buie, D, Madoff, RD, Rothenberger, DA 2000Local excision of rectal cancer without adjuvant therapy: a word of cautionAnn Surg23134551

13.

Friel, CM, Cromwell, JW, Marra, C, Madoff, RD, Rothenberger, DA, Garcia-Aguilar, J 2002Salvage radical surgery after failed local excision for early rectal cancerDis Colon Rectum458759

14.

Garcia-Aguilar, J, Pollack, J, Lee, SH, et al. 2002Accuracy of endorectal ultrasonography in preoperative staging of rectal tumorsDis Colon Rectum451015

15.

Brown, G, Radcliffe, AG, Newcombe, RG, Dallimore, NS, Bourne, MW, Williams, GT 2003Preoperative assessment of prognostic factors in rectal cancer using high-resolution magnetic resonance imagingBr J Surg9035564

16.

Minsky, BD, Rich, T, Recht, A, Harvey, W, Mies, C 1989Selection criteria for local excision with or without adjuvant radiation therapy for rectal cancerCancer6314219

17.

Brodsky, JT, Richard, GK, Cohen, AM, Minsky, BD 1992Variables correlated with the risk of lymph node metastasis in early rectal cancerCancer693226

18.

Morson, BC 1966Factors influencing the prognosis of early cancer of the rectumProc R Soc Med596078

19.

Sitzler, PJ, Seow-Choen, F, Ho, YH, Leong, AP 1997Lymph node involvement and tumor depth in rectal cancers: an analysis of 805 patientsDis Colon Rectum4014726

20.

Schell, SR, Zlotecki, RA, Mendenhall, WM, Marsh, RW, Vauthey, JN, Copeland, EM,3rd 2002Transanal excision of locally advanced rectal cancers downstaged using neoadjuvant chemoradiotherapyJ Am Coll Surg19458491

21.

Ruo, L, Guillem, JG, Minsky, BD, Quan, SH, Paty, PB, Cohen, AM 2002Preoperative radiation with or without chemotherapy and full-thickness transanal excision for selected T2 and T3 distal rectal cancersInt J Colorectal Dis17548

22.

Kim, CJ, Yeatman, TJ, Coppola, D, et al. 2001Local excision of T2 and T3 rectal cancers after downstaging chemoradiationAnn Surg2343528

23.

Medich, D, McGinty, J, Parda, D, et al. 2001Preoperative chemoradiotherapy and radical surgery for locally advanced distal rectal adenocarcinoma: pathologic findings and clinical implicationsDis Colon Rectum4411238

24.

Aumock, A, Birnbaum, EH, Fleshman, JW, et al. 2001Treatment of rectal adenocarcinoma with endocavitary and external beam radiotherapy: results for 199 patients with localized tumorsInt J Radiat Oncol Biol Phys5136370

25.

Fleshman, JW, Myerson, RJ 1997Adjuvant radiation therapy for adenocarcinoma of the rectumSurg Clin North Am771525

26.

Myerson, RJ, Michalski, JM, King, ML, et al. 1995Adjuvant radiation therapy for rectal carcinoma: predictors of outcomeInt J Radiat Oncol Biol Phys324150

27.

Myerson, RJ, Zusag, TW, Kodner, IJ, et al. 1992Adjunctive radiation therapy for rectal carcinomaAm J Clin Oncol1510211

28.

Read, TE, Ogunbiyi, OA, Fleshman, JW, et al. 2001Neoadjuvant external beam radiation and proctectomy for adenocarcinoma of the rectumDis Colon Rectum44177889

29.

Read, TE, McNevin, MS, Gross, EK, et al. 2001Neoadjuvant therapy for adenocarcinoma of the rectum: tumor response and acute toxicityDis Colon Rectum4451322

30.

American Joint Committee on Cancer. AJCC cancer staging manual. 5th ed. Philadelphia: Lippincott-Raven, 1997

31.

Valentini, V, Coco, C, Picciocchi, A, et al. 2002Does downstaging predict improved outcome after preoperative chemoradiation for extraperitoneal locally advanced rectal cancer? A long-term analysis of 165 patientsInt J Radiat Oncol Biol Phys5366474

32.

Read, TE, Myerson, RJ, Fleshman, JW, et al. 2002Surgeon specialty is associated with outcome in rectal cancer treatmentDis Colon Rectum4590414

33.

Swedish Rectal Cancer Trial1997Improved survival with preoperative radiotherapy in resectable rectal cancerN Engl J Med3369807

34.

Kapiteijn, E, Marijnen, CA, Nagtegaal, ID, et al. 2001Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancerN Engl J Med34563846

35.

Ruo, L, Tickoo, S, Klimstra, DS, et al. 2002Long-term prognostic significance of extent of rectal cancer response to preoperative radiation and chemotherapyAnn Surg2367581

36.

Garcia-Aguilar, J, Hernandez De Anda, E, Sirivongs, P, Lee, SH, Madoff, RD, Rothenberger, DA 2003A pathologic complete response to preoperative chemoradiation is associated with lower local recurrence and improved survival in rectal cancer patients treated by mesorectal excisionDis Colon Rectum46298304

37.

Hiotis, SP, Weber, SM, Cohen, AM, et al. 2002Assessing the predictive value of clinical complete response to neoadjuvant therapy for rectal cancer: an analysis of 488 patientsJ Am Coll Surg1941315

38.

Fleshman, JW, Myerson, RJ, Fry, RD, Kodner, IJ 1992Accuracy of transrectal ultrasound in predicting pathologic stage of rectal cancer before and after preoperative radiation therapyDis Colon Rectum358239

39.

Guillem, JG, Puig-La Calle, J,Jr, Akhurst, T, et al. 2000Prospective assessment of primary rectal cancer response to preoperative radiation and chemotherapy using 18-fluorodeoxyglucose positron emission tomographyDis Colon Rectum431824

40.

Singh, AK, Myerson, RJ, Birnbaum, EH, et al. 2000Outcome of patients with rectal adenocarcinoma and localized pelvic non-nodal metastatic fociDis Colon Rectum43121721

41.

Wichmann, MW, Muller, C, Meyer, G, et al. 2002Effect of preoperative radiochemotherapy on lymph node retrieval after resection of rectal cancerArch Surg13720610

42.

Janjan, NA, Khoo, VS, Abbruzzese, J, et al. 1999Tumor downstaging and sphincter preservation with preoperative chemoradiation in locally advanced rectal cancer: the M. D. Anderson Cancer Center experienceInt J Radiat Oncol Biol Phys44102738

43.

Minsky, BD, Cohen, AM, Enker, WE, et al. 1997Preoperative 5-FU, low-dose leucovorin, and radiation therapy for locally advanced and unresectable rectal cancerInt J Radiat Oncol Biol Phys3728995

44.

Videtic, GM, Fisher, BJ, Perera, FE, et al. 1998Preoperative radiation with concurrent 5-fluorouracil continuous infusion for locally advanced unresectable rectal cancerInt J Radiat Oncol Biol Phys4231924

45.

Habr-Gama, A, Souza, PM, Ribeiro, UJ, et al. 1998Low rectal cancer: impact of radiation and chemotherapy on surgical treatmentDis Colon Rectum41108796

46.

Hyams, DM, Mamounas, EP, Petrelli, N, et al. 1997A clinical trial to evaluate the worth of preoperative multimodality therapy in patients with operable carcinoma of the rectum: a progress report of National Surgical Adjuvant Breast and Bowel Project Protocol R-03Dis Colon Rectum401319

47.

Marsh, RD, Chu, NM, Vauthey, JN, et al. 1996Preoperative treatment of patients with locally advanced unresectable rectal adenocarcinoma utilizing continuous chronobiologically shaped 5-fluorouracil infusion and radiation therapyCancer7821725

48.

Valentini, V, Coco, C, Cellini, N, et al. 1998Preoperative chemoradiation for extraperitoneal T3 rectal cancer: acute toxicity, tumor response, and sphincter preservationInt J Radiat Oncol Biol Phys40106775

49.

Chan, A, Wong, A, Langevin, J, Khoo, R 1993Preoperative concurrent 5-fluorouracil infusion, mitomycin C and pelvic radiation therapy in tethered and fixed rectal carcinomaInt J Radiat Oncol Biol Phys257919

Title: Neoadjuvant Therapy for Rectal Cancer: Histologic Response of the Primary Tumor Predicts Nodal Status
Authors: Thomas E. Read, M.D.
Jose E. Andujar, M.D.
Philip F. Caushaj, M.D.
Douglas R. Johnston, B.A.
David W. Dietz, M.D.
Robert J. Myerson, M.D., Ph.D.
James W. Fleshman, M.D.
Elisa H. Birnbaum, M.D.
Matthew G. Mutch, M.D.
Ira J. Kodner, M.D.
Publication date: 01-06-2004
Publisher: Springer-Verlag
Published in: Diseases of the Colon & Rectum / Issue 6/2004
Print ISSN: 0012-3706
Electronic ISSN: 1530-0358
DOI: https://doi.org/10.1007/s10350-004-0535-x

2024 ASCO Annual Meeting

Springer Medicine

Neoadjuvant Therapy for Rectal Cancer: Histologic Response of the Primary Tumor Predicts Nodal Status

PURPOSE:

METHODS:

RESULTS:

CONCLUSIONS:

2024 ASCO Annual Meeting

Springer Medicine

PURPOSE:

METHODS:

RESULTS:

CONCLUSIONS:

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