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Prognostic risk factors and survival models for T3 locally advanced rectal cancer: what can we learn from the baseline MRI?

  • Gastrointestinal
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Abstract

Objectives

To evaluate the baseline MRI characteristics for predicting survival outcomes and construct survival models for risk stratification to facilitate personalized treatment and follow-up strategies in patients with MRI-defined T3 (mrT3) locally advanced rectal cancer (LARC).

Methods

We retrospectively reviewed 256 mrT3 LARC patients evaluated between 2008 and 2012 in our institution, with an average follow-up period of 6.8 ± 1.2 years. The baseline MRI characteristics, clinical data, and follow-up information were evaluated. The patients were randomized into a training cohort (TC, 186 patients) and validation cohort (VC, 70 patients). The TC dataset was used to develop multivariate nomograms for disease-free survival (DFS) and overall survival (OS), while the VC dataset was used for independent validation of the models. Harrell concordance (C) indices and Hosmer-Lemeshow calibration were used to evaluate the performances of the models.

Results

Baseline mrT3 substage, extramural venous invasion (EMVI) grading, mucinous adenocarcinoma, mesorectal fascia involvement, elevated pretreatment carcinoembryonic antigen level, and neoadjuvant chemoradiotherapy (NCRT) were independent predictors of DFS. T3 substage, EMVI grading, and NCRT were also independent predictors of OS. The nomograms constructed permitted the individualized prediction of 3-year and 5-year DFS and 5-year OS with high discrimination (C-index range, 0.833–0.892) and good calibration in the TC and VC.

Conclusions

We have identified baseline MRI characteristics that help independently predict survival outcomes in patients with mrT3 LARC. The survival models based on these characteristics allow for the individualized pretreatment risk stratification in patients with mrT3 LARC.

Key Points

• Baseline MRI characteristics can independently stratify risk and predict survival outcomes in patients with mrT3 LARC.

• The nomograms built using selected baseline MRI characteristics facilitate the individualized pretreatment risk stratification and help with clinical decision-making in patients with mrT3 LARC.

• MR-defined risk factors should, therefore, be carefully reported in the baseline MRI evaluation.

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Abbreviations

CEA:

Carcinoembryonic antigen

DFS:

Disease-free survival

EMD:

Extramural depth

EMVI:

Extramural venous invasion

LARC:

Locally advanced rectal cancer

LNM:

Lymph node metastasis

MAC:

Mucinous adenocarcinoma

MRF:

Mesorectal fascia

MRI:

Magnetic resonance imaging

OS:

Overall survival

References

  1. Siegel RL, Miller KD, Jemal A (2018) Cancer statistics, 2018. CA Cancer J Clin 68:7–30

    Article  Google Scholar 

  2. Benson AB 3rd, Venook AP, Al-Hawary MM et al (2018) Rectal cancer, Version 2.2018, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 16:874–901

    Article  Google Scholar 

  3. Kolarich A, George TJ Jr, Hughes SJ et al (2018) Rectal cancer patients younger than 50 years lack a survival benefit from NCCN guideline-directed treatment for stage II and III disease. Cancer 124:3510–3519

    Article  Google Scholar 

  4. Sineshaw HM, Jemal A, Thomas CR Jr, Mitin T (2016) Changes in treatment patterns for patients with locally advanced rectal cancer in the United States over the past decade: an analysis from the National Cancer Data Base. Cancer 122:1996–2003

    Article  Google Scholar 

  5. Zinicola R, Pedrazzi G, Haboubi N, Nicholls RJ (2017) The degree of extramural spread of T3 rectal cancer: an appeal to the American Joint Committee on Cancer. Colorectal Dis 19:8–15

    Article  CAS  Google Scholar 

  6. Ma B, Gao P, Wang H et al (2017) What has preoperative radio(chemo)therapy brought to localized rectal cancer patients in terms of perioperative and long-term outcomes over the past decades? A systematic review and meta-analysis based on 41,121 patients. Int J Cancer 141:1052–1065

    Article  CAS  Google Scholar 

  7. Cho SH, Kim SH, Bae JH et al (2014) Prognostic stratification by extramural depth of tumor invasion of primary rectal cancer based on the Radiological Society of North America proposal. AJR Am J Roentgenol 202:1238–1244

    Article  Google Scholar 

  8. Chand M, Bhangu A, Wotherspoon A et al (2014) EMVI-positive stage II rectal cancer has similar clinical outcomes as stage III disease following preoperative chemoradiotherapy. Ann Oncol 25:858–863

    Article  CAS  Google Scholar 

  9. Son IT, Kim YH, Lee KH et al (2017) Oncologic relevance of magnetic resonance imaging-detected threatened mesorectal fascia for patients with mid or low rectal cancer: a longitudinal analysis before and after long-course, concurrent chemoradiotherapy. Surgery 162:152–163

    Article  Google Scholar 

  10. Nougaret S, Rouanet P, Molinari N et al (2012) MR volumetric measurement of low rectal cancer helps predict tumor response and outcome after combined chemotherapy and radiation therapy. Radiology 263:409–418

    Article  Google Scholar 

  11. Chi YK, Zhang XP, Li J, Sun YS (2011) To be or not to be: significance of lymph nodes on pretreatment CT in predicting survival of rectal cancer patients. Eur J Radiol 77:473–477

    Article  Google Scholar 

  12. Lee ES, Kim MJ, Park SC et al (2018) Magnetic resonance imaging-detected extramural venous invasion in rectal cancer before and after preoperative chemoradiotherapy: diagnostic performance and prognostic significance. Eur Radiol 28:496–505

    Article  Google Scholar 

  13. Patel UB, Brown G, Machado I et al (2017) MRI assessment and outcomes in patients receiving neoadjuvant chemotherapy only for primary rectal cancer: long-term results from the GEMCAD 0801 trial. Ann Oncol 28:344–353

    Article  CAS  Google Scholar 

  14. Sun Y, Lin H, Lu X et al (2017) A nomogram to predict distant metastasis after neoadjuvant chemoradiotherapy and radical surgery in patients with locally advanced rectal cancer. J Surg Oncol 115:462–469

    Article  CAS  Google Scholar 

  15. Valentini V, van Stiphout RG, Lammering G et al (2011) Nomograms for predicting local recurrence, distant metastases, and overall survival for patients with locally advanced rectal cancer on the basis of European randomized clinical trials. J Clin Oncol 29:3163–3172

    Article  Google Scholar 

  16. Li ZH, Xie PY, Zhang DF et al (2019) Nomogram for predicting disease-free survival among a multicenter cohort of Chinese patients with locally advanced rectal cancer. Cancer Manag Res 11:2471–2483

    Article  Google Scholar 

  17. Ye F, Zhang H, Liang X, Ouyang H, Zhao X, Zhou C (2016) JOURNAL CLUB: preoperative MRI evaluation of primary rectal cancer: intrasubject comparison with and without rectal distention. AJR Am J Roentgenol 207:32–39

    Article  Google Scholar 

  18. Nougaret S, Reinhold C, Mikhael HW, Rouanet P, Bibeau F, Brown G (2013) The use of MR imaging in treatment planning for patients with rectal carcinoma: have you checked the “DISTANCE”? Radiology 268:330–344

    Article  Google Scholar 

  19. Smith NJ, Barbachano Y, Norman AR, Swift RI, Abulafi AM, Brown G (2008) Prognostic significance of magnetic resonance imaging-detected extramural vascular invasion in rectal cancer. Br J Surg 95:229–236

    Article  CAS  Google Scholar 

  20. Taylor FG, Quirke P, Heald RJ et al (2014) Preoperative magnetic resonance imaging assessment of circumferential resection margin predicts disease-free survival and local recurrence: 5-year follow-up results of the MERCURY study. J Clin Oncol 32:34–43

    Article  Google Scholar 

  21. Park SH, Lim JS, Lee J, et al (2017) Rectal mucinous adenocarcinoma: MR imaging assessment of response to concurrent chemotherapy and radiation therapy-a hypothesis-generating study. Radiology 162657

  22. Akiyoshi T, Matsueda K, Hiratsuka M et al (2015) Indications for lateral pelvic lymph node dissection based on magnetic resonance imaging before and after preoperative chemoradiotherapy in patients with advanced low-rectal cancer. Ann Surg Oncol 22(Suppl 3):S614–S620

    Article  Google Scholar 

  23. Brown G, Richards CJ, Bourne MW et al (2003) Morphologic predictors of lymph node status in rectal cancer with use of high-spatial-resolution MR imaging with histopathologic comparison. Radiology 227:371–377

    Article  Google Scholar 

  24. Amin MB, Greene FL, Edge SB et al (2017) AJCC Cancer Staging Manual, 8th edn. Springer, Chicago

    Book  Google Scholar 

  25. Meng WJ, Sun XF, Tian C et al (2007) Microsatellite instability did not predict individual survival in sporadic stage II and III rectal cancer patients. Oncology 72:82–88

    Article  CAS  Google Scholar 

  26. Russell MC, You YN, Hu CY et al (2013) A novel risk-adjusted nomogram for rectal cancer surgery outcomes. JAMA Surg 148:769–777

    Article  Google Scholar 

  27. van Gijn W, van Stiphout RG, van de Velde CJ et al (2015) Nomograms to predict survival and the risk for developing local or distant recurrence in patients with rectal cancer treated with optional short-term radiotherapy. Ann Oncol 26:928–935

    Article  Google Scholar 

  28. Yu J, Huang DY, Xu HX, Li Y, Xu Q (2016) Correlation between magnetic resonance imaging-based evaluation of extramural vascular invasion and prognostic parameters of T3 stage rectal cancer. J Comput Assist Tomogr 40:537–542

    Article  Google Scholar 

  29. Zhang XY, Wang S, Li XT et al (2018) MRI of extramural venous invasion in locally advanced rectal cancer: relationship to tumor recurrence and overall survival. Radiology 289:677–685

    Article  Google Scholar 

  30. Taylor FG, Quirke P, Heald RJ et al (2011) Preoperative high-resolution magnetic resonance imaging can identify good prognosis stage I, II, and III rectal cancer best managed by surgery alone: a prospective, multicenter, European study. Ann Surg 253:711–719

    Article  Google Scholar 

  31. Yu SK, Chand M, Tait DM, Brown G (2014) Magnetic resonance imaging defined mucinous rectal carcinoma is an independent imaging biomarker for poor prognosis and poor response to preoperative chemoradiotherapy. Eur J Cancer 50:920–927

    Article  Google Scholar 

  32. Prampolini F, Taschini S, Pecchi A, et al (2020) Magnetic resonance imaging performed before and after preoperative chemoradiotherapy in rectal cancer: predictive factors of recurrence and prognostic significance of MR-detected extramural venous invasion. Abdom Radiol (NY) 45:2941–2949

  33. McCawley N, Clancy C, O'Neill BD, Deasy J, McNamara DA, Burke JP (2016) Mucinous rectal adenocarcinoma is associated with a poor response to neoadjuvant chemoradiotherapy: a systematic review and meta-analysis. Dis Colon Rectum 59:1200–1208

    Article  Google Scholar 

  34. Tarantino I, Warschkow R, Worni M et al (2012) Elevated preoperative CEA is associated with worse survival in stage I-III rectal cancer patients. Br J Cancer 107:266–274

    Article  CAS  Google Scholar 

  35. Beets-Tan RGH, Lambregts DMJ, Maas M et al (2018) Magnetic resonance imaging for clinical management of rectal cancer: updated recommendations from the 2016 European Society of Gastrointestinal and Abdominal Radiology (ESGAR) consensus meeting. Eur Radiol 28:1465–1475

    Article  Google Scholar 

  36. Kim S, Han K, Seo N et al (2018) T2-weighted signal intensity-selected volumetry for prediction of pathological complete response after preoperative chemoradiotherapy in locally advanced rectal cancer. Eur Radiol 28:5231–5240

    Article  Google Scholar 

  37. Zhang H, Zhang C, Zheng Z et al (2017) Chemical shift effect predicting lymph node status in rectal cancer using high-resolution MR imaging with node-for-node matched histopathological validation. Eur Radiol 27:3845–3855

    Article  Google Scholar 

  38. Shin R, Jeong SY, Yoo HY et al (2012) Depth of mesorectal extension has prognostic significance in patients with T3 rectal cancer. Dis Colon Rectum 55:1220–1228

    Article  Google Scholar 

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Acknowledgements

We appreciate Shangying Hu for her statistical advice for this manuscript.

Funding

This study has received funding from the National Nature Science Foundation of China (Grant 81971589); the Peking Union Medical College Youth Fund, the Fundamental Research Funds for the Central Universities (No. 3332018078); and the Beijing Hope Run Special Fund of the Cancer Foundation of China (No. LC2017B18).

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Authors and Affiliations

  1. Department of Diagnostic Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China

    Qing Zhao, Lijuan Wan, Chongda Zhang, Tuya E, Yang Yang, Feng Ye, Xinming Zhao, Han Ouyang & Hongmei Zhang

  2. Department of Diagnostic Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China

    Shuangmei Zou

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  1. Qing Zhao
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Corresponding author

Correspondence to Hongmei Zhang.

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The scientific guarantor of this publication is Hongmei Zhang.

Conflict of interest

The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

Shangying Hu kindly provided statistical advice for this manuscript.

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Only if the study is on human subjects: Written informed consent was waived by the Institutional Review Board.

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Institutional Review Board approval was obtained.

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• retrospective

• diagnostic or prognostic study/observational

• performed at one institution

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Zhao, Q., Wan, L., Zou, S. et al. Prognostic risk factors and survival models for T3 locally advanced rectal cancer: what can we learn from the baseline MRI?. Eur Radiol 31, 4739–4750 (2021). https://doi.org/10.1007/s00330-021-08045-y

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  • DOI: https://doi.org/10.1007/s00330-021-08045-y

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