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Annals of Surgical Oncology
Published in: Annals of Surgical Oncology 2/2020

01-02-2020 | Magnetic Resonance Imaging | Colorectal Cancer

MRI-Based Use of Neoadjuvant Chemoradiotherapy in Rectal Carcinoma: Surgical Quality and Histopathological Outcome of the OCUM Trial

Authors: Martin E. Kreis, MD, Reinhard Ruppert, MD, Rainer Kube, MD, Joachim Strassburg, MD, Andreas Lewin, MD, Joerg Baral, MD, Christoph A. Maurer, MD, Joerg Sauer, MD, Günther Winde, MD, Rena Thomasmeyer, MD, Sigmar Stelzner, MD, Cornelius Bambauer, MD, Soenke Scheunemann, MD, Axel Faedrich, MD, Theodor Junginger, MD, Paul Hermanek, MD, Susanne Merkel, MD, For the OCUM group

Published in: Annals of Surgical Oncology | Issue 2/2020

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Abstract

Background

Preoperative magnetic resonance imaging (MRI) allows highly reliable imaging of the mesorectal fascia (mrMRF) and its relationship to the tumor. The prospective multicenter observational study OCUM uses these findings to indicate neoadjuvant chemoradiotherapy (nCRT) in rectal carcinoma.

Methods

nCRT was indicated in patients with positive mrMRF (≤ 1 mm) in cT4 and cT3 carcinomas of the lower rectal third.

Results

A total of 527 patients (60.2%) underwent primary total mesorectal excision, and 348 patients (39.8%) underwent long-term nCRT followed by surgery. The mrMRF was involved in 4.6% of the primary surgery group and 80.7% of the nCRT group. Rates of resections within the mesorectal plane (90.8%), sparing of pelvic nerves on both sides (97.8%), and number of regional lymph nodes (95.3% with ≥ 12 lymph nodes examined) are indicative of high-quality surgery. Resection was classified as R0 in 98.3%, the pathological circumferential resection margin (pCRM) was negative in 95.1%. Patients in the nCRT group had more advanced carcinomas with a significantly higher rate of abdominoperineal excision. Independent risk factors for pCRM positivity were advanced stage (T4), metastatic lymph nodes, resection in the muscularis propria plane, and location in the lower third.

Conclusions

The risk classification of rectal cancer patients by MRI seems to be highly reliable and allows the restriction of nCRT to approximately half of the patients with clinical stage II and III rectal carcinoma, provided there is a high-quality MRI diagnostic protocol, high-quality surgery, and standardized examination of the resected specimen.
Literature
1.
Wibe A, Moller B, Norstein J, Carlsen E, Wiig JN, Heald RJ, et al. A national strategic change in treatment policy for rectal cancer—implementation of total mesorectal excision as routine treatment in Norway. A national audit. Dis Colon Rectum 2002;45:857–66.CrossRef
2.
Peeters KC, Marijnen CA, Nagtegaal ID, Kranenbarg EK, Putter H, Wiggers T, et al. The TME trial after a median follow-up of 6 years. Increased local control but no survival benefit in irradiated patients with resectable rectal carcinoma. Ann Surg. 2007;246:693–701.CrossRef
3.
Sebag-Montefiore D, Stephens RJ, Steele R, Monson J, Grieve R, Khanna S, et al. Preoperative radiotherapy versus selective postoperative chemoradiotherapy in patients with rectal cancer (MRC CR 07 and NCIC CTG C016): a multicentre, randomised trial. Lancet 2009;373:811–20.CrossRef
4.
Peeters KC, van de Velde CJ, Leer JW, Martijn H, Junggeburt JM, Kranenbarg EK, et al. Late side effects of short-course preoperative radiotherapy combined with total mesorectal excision for rectal cancer: increased bowel dysfunction in irradiated patients: a Dutch Colorectal Cancer Group study. J Clin Oncol. 2005;23:6199–206.CrossRef
5.
Marijnen CA, van de Velde CJ, Putter H, van den Brink M, Maas CP, Martijn H, et al. Impact of short-term preoperative radiotherapy on health-related quality of life and sexual functioning in primary rectal cancer: report of a multicentre randomized trial. J Clin Oncol. 2005;23:1847–58.CrossRef
6.
Stephens RJ, Thompson LC, Quirke P, Steele R, Grieve R, Couture J, et al. Impact of short-course preoperative radiotherapy for rectal cancer on patients’ quality of life: data from the medical research council CR07/National Cancer Institute of Canada Clinical Trials Group C016 Randomized Clinical Trial. J Clin Oncol. 2010;28:4233–9.CrossRef
7.
Edge DB, Byrd DR, Compton U, Grimelius FL, Trotti A (eds). American joint committee on cancer staging manual. 7th ed. Springer, New York; 2009.
8.
Brouwer NPM, Stijns RCH, Lemmens VEPP, Nagtegaal ID, Beets-Tan RGH, Fütterer JJ, et al. Clinical lymph node staging in colorectal cancer; a flip of a coin? Eur J Surg Oncol. 2018;44:1241–6.CrossRef
9.
Sauer R, Becker H, Hohenberger W, Rödel C, Wittekind C, Fietkau R, et al. Preoperative chemoradiotherapy as compared with postoperative chemoradiotherapy for locally advanced rectal cancer. N Engl J Med. 2004;351:11–20.CrossRef
10.
Nagtegaal ID, Quirke P. What is the role for the circumferential margin in the modern treatment of rectal cancer? J Clin Oncol. 2008;26:303–12.CrossRef
11.
Beets-Tan RG, Beets GL, Vliegen RF, Kessels AG, Van Boven H, De Bruine A, et al. Accuracy of magnetic resonance imaging in prediction of tumour-free resection margin in rectal cancer surgery. Lancet 2001;357:497–504.CrossRef
12.
Brown G, Radcliffe AG, Newcombe RG, Dallimore NS, Bourne MW, Williams GT. Preoperative assessment of prognostic factors in rectal cancer using high-resolution magnetic resonance imaging. Br J Surg. 2003;90:355–64.CrossRef
13.
Strassburg J, Ruppert R, Ptok H, Maurer C, Junginger T, Merkel S, et al. MRI-based indications for neoadjuvant radiochemotherapy in rectal carcinoma: interim results of a prospective multicenter observational study. Ann Surg Oncol. 2011;18:2790–9.CrossRef
14.
Quirke P, Dixon MF. The prediction of local recurrence in rectal adenocarcinoma by histopathological examination. Int J Colorectal Dis. 1988;3:127–31.CrossRef
15.
Kreis ME, Ruppert R, Ptok H, Strassburg J, Brosi P, Lewin A, et al. Use of preoperative magnetic resonance imaging to select patients with rectal cancer for neoadjuvant chemoradiation: interim analysis of the German OCUM trial (NCT01325649). J Gastrointest Surg. 2016;20:25–32.CrossRef
16.
Ruppert R, Junginger T, Ptok H, Strassburg J, Maurer CA, Brosi P, et al. Oncological outcome after MRI-based selection for neoadjuvant chemoradiotherapy in the OCUM rectal cancer trial. Br J Surg. 2018;105:1519–29.CrossRef
17.
Wittekind C, Greene R, Hutter RVP, Sobin LH, Henson DE (eds). TNM supplement: a commentary on uniform use. 3rd ed. Wiley, New York; 2003.
18.
Greene FL, Page DL, Fleming ID, Fritz AG, Balch CM, Haller DG, et al. (eds). AJCC cancer staging manual, 6th ed. Springer, Berlin; 2002.
19.
Ptok H, Ruppert R, Strassburg J, Maurer CA, Oberholzer K, Junginger T, et al. Pretherapeutic MRI for decision-making regarding selective neoadjuvant radiochemotherapy for rectal carcinoma: interim analysis of a multicentric prospective observational study. J Magn Reson Imaging 2013;37:1122–8.CrossRef
20.
Kim YW, Cha SW, Pyo J, Kim NK, Min BS, Kim MJ, et al. Factors related to preoperative assessment of the circumferential resection margin and the extend of mesorectal invasion by magnetic resonance imaging in rectal cancer: a prospective comparison study. World J Surg. 2009;33:1952–60.CrossRef
21.
Wibe A, Syse A, Andersen E, Tretli S, Myrvold HE, Søreide O, et al. Oncological outcomes after total mesorectal excision for cure for cancer of the lower rectum: anterior vs. abdominoperineal resection. Dis Colon Rectum 2004;47:48–58.CrossRef
22.
Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal surgery-the clue to pelvic recurrence? Br J Surg. 1982;69:613–6.CrossRef
23.
Quirke P, Steele R, Monson J, Grieve R, Khanna S, Couture J, et al. Effect of the plane of surgery achieved on local recurrence in patients with operable rectal cancer: a prospective study using data from the MRC CR07 and NCIC-CTG C016 randomised clinical trial. Lancet 2009;373:821–8.CrossRef
24.
Seegenschmiedt MH, Sauer R. The systematicy of acute and chronic radiation sequelae. Strahlenther Oncol. 1993;169:83–95 (in German).
25.
Cox JD, Stetz J, Pajak TF. Toxicity criteria of the Radiation Therapy Oncology Group (RTOG) and the European Organization for Research and Treatment of Cancer (EORTC). Int J Radiat Oncol Biol Phys. 1995;31:1341–6.CrossRef
26.
Dworak O, Keilholz I, Hoffmann A. Pathological features of rectal cancer after preoperative radiochemotherapy. Int J Colorectal Dis. 1997;12:19–23.CrossRef
27.
Dindo C, Demartines N, Clavien PA. Classification of surgical complications. A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–13.CrossRef
28.
Wittekind C, Compton C, Quirke P, Nagtegaal I, Merkel S, Hermanek P, et al. A uniform residual tumor (R) classification: integration of the R classification and the circumferential margin status. Cancer 2009;115:3483–8.CrossRef
29.
Eveno C, Lamblin A, Mariette C, Pocard M. Sexual and urinary dysfunction after proctectomy for rectal cancer. J Visc Surg. 2010; 147:e21–30.CrossRef
30.
Creavin B, Kelly ME, Ryan E, Winter DC. Meta-analysis of the impact of surgical approach on the grade of mesorectal excision in rectal cancer. Br J Surg. 2017;104:1609–19.CrossRef
31.
Arezzo A, Passera R, Salvai A, Arolfo S, Allaix ME, Schwarzer G, et al. Laparoscopy for rectal cancer is oncologically adequate: a systematic review and meta-analysis of the literature. Surg Endosc. 2015;29:334–48.CrossRef
32.
Guillou PJ, Quirke P, Thorpe H, Walker J, Jayne DG, Smith AM, et al. Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASSICC trial): multicentre, randomised controlled trial. Lancet 2005;365:1718–26.CrossRef
33.
Bustamante-Lopez L, Nahas CS, Nahas SC, Ribeiro U Jr, Marques CF, Cotti G, et al. Understanding the factors associated with reduction in the number of lymph nodes in rectal cancer patients treated by neoadjuvant treatment. Int J Colorectal Dis. 2017;32:925–7.CrossRef
34.
Hermanek P, Junginger T. The circumferential resection margin in rectal carcinoma surgery. Tech Coloproctol. 2005;9:193–200.CrossRef
35.
Torok J, Palta M, Willett CG, Czito BG. Nonoperative management of rectal cancer. Cancer 2016;122:34–41.CrossRef
36.
Garland ML, Vather R, Bunkley N, Pearse M, Bissett IP. Clinical tumour size and nodal status predict pathologic complete response following neoadjuvant chemoradiotherapy for rectal cancer. Int J Colorectal Dis. 2014;29:301–7.CrossRef
37.
Van der Sluis FJ, van Westreenen HL, van Etten B, van Leeuwen BL, de Bock GH. Pretreatment identification of patients likely to have pathologic complete response after neoadjuvant chemoradiotherapy for rectal cancer. Int J Colorectal Dis. 2018;33:149–57.CrossRef
38.
Beets-Tan RGH, Lambregts DMJ, Maas M, Bipat S, Barbaro B, Curvo-Semedo L et al. Magnetic resonance imaging for clinical management or rectal cancer: Updated recommendations from the 2016 European Society of Gastrointestinal and Abdominal Radiology (ESGAR) consensus meeting. Eur Radiol. 2018;28:1465–75CrossRef
Metadata
Title
MRI-Based Use of Neoadjuvant Chemoradiotherapy in Rectal Carcinoma: Surgical Quality and Histopathological Outcome of the OCUM Trial
Authors
Martin E. Kreis, MD
Reinhard Ruppert, MD
Rainer Kube, MD
Joachim Strassburg, MD
Andreas Lewin, MD
Joerg Baral, MD
Christoph A. Maurer, MD
Joerg Sauer, MD
Günther Winde, MD
Rena Thomasmeyer, MD
Sigmar Stelzner, MD
Cornelius Bambauer, MD
Soenke Scheunemann, MD
Axel Faedrich, MD
Theodor Junginger, MD
Paul Hermanek, MD
Susanne Merkel, MD
For the OCUM group
Publication date
01-02-2020
Publisher
Springer International Publishing
Published in
Annals of Surgical Oncology / Issue 2/2020
Print ISSN: 1068-9265
Electronic ISSN: 1534-4681
DOI
https://doi.org/10.1245/s10434-019-07696-y

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