Skip to main content

Advertisement

SpringerLink
Log in

Organ Preservation in Rectal Cancer After Chemoradiation: Should We Extend the Observation Period in Patients with a Clinical Near-Complete Response?

  • Colorectal Cancer
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

To assess whether extending the observation period in patients with a near clinical complete response (near cCR) after chemoradiation (CRT) leads to an impaired oncological outcome.

Methods

Patients who had a clinical complete response (cCR) 8–10 weeks after CRT restaging with magnetic resonance imaging and endoscopy were offered a watch-and-wait strategy (W&W1), while patients with a near cCR were offered to undergo local excision or a second restaging 6–12 weeks later. Patients who achieved a cCR at the second restaging were also offered a watch-and-wait strategy (W&W2).

Results

Overall, 102 patients with a cCR at the first restaging immediately entered the W&W1, while the remaining 68 patients had a near cCR: 19 patients underwent transanal endoscopic microsurgery and 49 patients opted for a second restaging. Additionally, 44/49 (90%) patients showed a cCR at the second restaging and entered the W&W2. Patients in the W&W1 group had a 2-year local regrowth-free rate (LRFR) of 84% and 2-year overall survival (OS) of 99%, while patients in the W&W2 group had a 2-year LRFR of 73% and OS of 98% (p > 0.05). Multivariable Cox regression analyses showed that late inclusion was not a significant predictive factor for higher risk of LR or lower non-regrowth disease-free survival.

Conclusions

Overall, 90% of patients with a near cCR 8–10 weeks after CRT will proceed to a cCR 6–12 weeks later; therefore, it seems logical to extend the observation period rather than to proceed to surgery. Although there is a non-significant increase in local regrowth rate in these patients, it does not seem to impact the oncological outcome.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Maas M, Nelemans PJ, Valentini V, et al. Long-term outcome in patients with a pathological complete response after chemoradiation for rectal cancer: a pooled analysis of individual patient data. Lancet Oncol 2010; 11(9):835–44.

    Article  PubMed  Google Scholar 

  2. Habr-Gama A, Perez RO, Nadalin W, et al. Operative versus nonoperative treatment for stage 0 distal rectal cancer following chemoradiation therapy: long-term results. Ann Surg 2004; 240(4):711–7; discussion 717-8.

    PubMed  PubMed Central  Google Scholar 

  3. Maas M, Beets-Tan RG, Lambregts DM, et al. Wait-and-see policy for clinical complete responders after chemoradiation for rectal cancer. J Clin Oncol 2011; 29(35):4633–40.

    Article  PubMed  Google Scholar 

  4. Smith JD, Ruby JA, Goodman KA, et al. Nonoperative management of rectal cancer with complete clinical response after neoadjuvant therapy. Ann Surg 2012; 256(6):965–72.

    Article  PubMed  Google Scholar 

  5. Ayloor SR KS, Jayanand SB, et al. Complete clinical response to neoadjuvant chemoradiation in rectal cancers: can surgery be avoided? Hepatogastroenterology 2013;60(123):410–414.

    Google Scholar 

  6. Appelt AL, Ploen J, Harling H, et al. High-dose chemoradiotherapy and watchful waiting for distal rectal cancer: a prospective observational study. Lancet Oncol 2015;16(8):919–927.

    Article  PubMed  Google Scholar 

  7. Renehan AG, Malcomson L, Emsley R, et al. Watch-and-wait approach versus surgical resection after chemoradiotherapy for patients with rectal cancer (the OnCoRe project): a propensity-score matched cohort analysis. Lancet Oncol 2016;17(2):174–83.

    Article  PubMed  Google Scholar 

  8. Martens MH, Maas M, Heijnen LA, Lambregts DM, Leijtens JW, Stassen LP, et al. Long-term outcome of an organ preservation program after neoadjuvant treatment for rectal cancer. J Natl Cancer Inst. 2016. https://doi.org/10.1093/jnci/djw171.

    Google Scholar 

  9. Beets GL, Figueiredo NF, Beets-Tan RG. Management of Rectal Cancer Without Radical Resection. Annu Rev Med 2017;68:169–182.

    Article  CAS  PubMed  Google Scholar 

  10. Lezoche G, Baldarelli M, Guerrieri M, et al. A prospective randomized study with a 5-year minimum follow-up evaluation of transanal endoscopic microsurgery versus laparoscopic total mesorectal excision after neoadjuvant therapy. Surg Endosc 2008; 22(2):352–8.

    Article  CAS  PubMed  Google Scholar 

  11. Perez RO, Habr-Gama A, Sao Juliao GP, et al. Transanal endoscopic microsurgery (TEM) following neoadjuvant chemoradiation for rectal cancer: outcomes of salvage resection for local recurrence. Ann Surg Oncol 2016;23(4):1143–8.

    Article  PubMed  Google Scholar 

  12. Perez RO, Habr-Gama A, Sao Juliao GP, et al. Transanal endoscopic microsurgery for residual rectal cancer after neoadjuvant chemoradiation therapy is associated with significant immediate pain and hospital readmission rates. Dis Colon Rectum 2011; 54(5):545–51.

    Article  PubMed  Google Scholar 

  13. Coco C, Rizzo G, Mattana C, et al. Transanal endoscopic microsurgery after neoadjuvant radiochemotherapy for locally advanced extraperitoneal rectal cancer: short-term morbidity and functional outcome. Surg Endosc 2013; 27(8):2860–7.

    Article  CAS  PubMed  Google Scholar 

  14. Garcia-Aguilar J, Renfro LA, Chow OS, et al. Organ preservation for clinical T2N0 distal rectal cancer using neoadjuvant chemoradiotherapy and local excision (ACOSOG Z6041): results of an open-label, single-arm, multi-institutional, phase 2 trial. Lancet Oncol 2015; 16(15):1537–46.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Sloothaak DA, Geijsen DE, van Leersum NJ, et al. Optimal time interval between neoadjuvant chemoradiotherapy and surgery for rectal cancer. Br J Surg 2013; 100(7):933–9.

    Article  CAS  PubMed  Google Scholar 

  16. Maas M, Lambregts DM, Nelemans PJ, et al. Assessment of clinical complete response after chemoradiation for rectal cancer with digital rectal examination, endoscopy, and MRI: selection for organ-saving treatment. Ann Surg Oncol 2015; 22(12):3873–80.

    Article  PubMed  PubMed Central  Google Scholar 

  17. West MA, Dimitrov BD, Moyses HE, et al. Timing of surgery following neoadjuvant chemoradiotherapy in locally advanced rectal cancer—a comparison of magnetic resonance imaging at two time points and histopathological responses. Eur J Surg Oncol 2016; 42(9):1350–8.

    Article  CAS  PubMed  Google Scholar 

  18. Nahas SC, Rizkallah Nahas CS, Sparapan Marques CF, et al. Pathologic complete response in rectal cancer: can we detect it? Lessons learned from a proposed randomized trial of watch-and-wait treatment of rectal cancer. Dis Colon Rectum 2016;59(4):255–63.

    Article  PubMed  Google Scholar 

  19. Hughes R, Harrison M, Glynne-Jones R. Could a wait and see policy be justified in T3/4 rectal cancers after chemo-radiotherapy? Acta Oncol 2010; 49(3):378–81.

    Article  PubMed  Google Scholar 

  20. Nakagawa WT, Rossi BM, de OFF, et al. Chemoradiation instead of surgery to treat mid and low rectal tumors: is it safe? Ann Surg Oncol 2002;9(6):568–73.

    Article  PubMed  Google Scholar 

  21. Lim L, Chao M, Shapiro J, et al. Long-term outcomes of patients with localized rectal cancer treated with chemoradiation or radiotherapy alone because of medical inoperability or patient refusal. Dis Colon Rectum 2007; 50(12):2032-9.

    Article  CAS  PubMed  Google Scholar 

  22. Habr-Gama A, Lynn PB, Jorge JM, et al. Impact of organ-preserving strategies on anorectal function in patients with distal rectal cancer following neoadjuvant chemoradiation. Dis Colon Rectum 2016; 59(4):264–9.

    Article  PubMed  Google Scholar 

  23. Habr-Gama A, de Souza PM, Ribeiro U, Jr., et al. Low rectal cancer: impact of radiation and chemotherapy on surgical treatment. Dis Colon Rectum 1998;41(9):1087–96.

    Article  CAS  PubMed  Google Scholar 

  24. Lefevre JH, Mineur L, Kotti S, et al. Effect of interval (7 or 11 weeks) between neoadjuvant radiochemotherapy and surgery on complete pathologic response in rectal cancer: a multicenter, randomized, controlled trial (GRECCAR-6). J Clin Oncol 2016;34:3773–3780.

    Article  PubMed  Google Scholar 

  25. Petrelli F, Sgroi G, Sarti E, et al. Increasing the interval between neoadjuvant chemoradiotherapy and surgery in rectal cancer: a meta-analysis of published studies. Ann Surg 2016; 263(3):458–64.

    Article  PubMed  Google Scholar 

  26. Creavin B, Ryan E, Martin ST, et al. Organ preservation with local excision or active surveillance following chemoradiotherapy for rectal cancer. Br J Cancer 2017;116(2):169–174.

    Article  CAS  PubMed  Google Scholar 

  27. Huang CM, Huang MY, Tsai HL, et al. An observational study of extending FOLFOX chemotherapy, lengthening the interval between radiotherapy and surgery, and enhancing pathological complete response rates in rectal cancer patients following preoperative chemoradiotherapy. Therap Adv Gastroenterol 2016; 9(5):702-12.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Garcia-Aguilar J, Chow OS, Smith DD, et al. Effect of adding mFOLFOX6 after neoadjuvant chemoradiation in locally advanced rectal cancer: a multicentre, phase 2 trial. Lancet Oncol 2015; 16(8):957–66.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

Download references

Disclosures

Britt J. P. Hupkens, Monique Maas, Milou H. Martens, Marit E. van der Sande, Doenja M. J. Lambregts, Stéphanie O. Breukink, Jarno Melenhorst, Janneke B. Houwers, Christiaan Hoff, Meindert N. Sosef, Jeroen W. A. Leijtens, Maaike Berbee, Regina G. H. Beets-Tan, and Geerard L. Beets have no conflicts of interest to declare.

Funding

No funding or grants were used to assist in the preparation of this study.

Author information

Authors and Affiliations

  1. Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands

    Britt J. P. Hupkens MD, Stéphanie O. Breukink MD, PhD & Jarno Melenhorst MD, PhD

  2. GROW School for Oncology and Developmental Biology, Maastricht, The Netherlands

    Britt J. P. Hupkens MD, Regina G. H. Beets-Tan MD, PhD & Geerard L. Beets MD, PhD

  3. Department of Radiology, Maastricht University Medical Centre, Maastricht, The Netherlands

    Britt J. P. Hupkens MD & Janneke B. Houwers MD

  4. Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands

    Britt J. P. Hupkens MD, Monique Maas MD, PhD, Doenja M. J. Lambregts MD, PhD & Regina G. H. Beets-Tan MD, PhD

  5. Department of Surgery, Zuyderland Medical Centre, Heerlen/Sittard, The Netherlands

    Milou H. Martens MD, PhD & Meindert N. Sosef MD, PhD

  6. Department of Surgery, Netherlands Cancer Institute, Amsterdam, The Netherlands

    Marit E. van der Sande MD & Geerard L. Beets MD, PhD

  7. Department of Surgery, Medical Centre Leeuwarden, Leeuwarden, The Netherlands

    Christiaan Hoff MD, PhD

  8. Department of Surgery, Laurentius Hospital, Roermond, The Netherlands

    Jeroen W. A. Leijtens MD

  9. Department of Radiotherapy, Maastro Clinic, Maastricht, The Netherlands

    Maaike Berbee MD

Authors
  1. Britt J. P. Hupkens MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Monique Maas MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Milou H. Martens MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Marit E. van der Sande MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Doenja M. J. Lambregts MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Stéphanie O. Breukink MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Jarno Melenhorst MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Janneke B. Houwers MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Christiaan Hoff MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Meindert N. Sosef MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Jeroen W. A. Leijtens MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Maaike Berbee MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Regina G. H. Beets-Tan MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  14. Geerard L. Beets MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Monique Maas MD, PhD.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Hupkens, B.J.P., Maas, M., Martens, M.H. et al. Organ Preservation in Rectal Cancer After Chemoradiation: Should We Extend the Observation Period in Patients with a Clinical Near-Complete Response?. Ann Surg Oncol 25, 197–203 (2018). https://doi.org/10.1245/s10434-017-6213-8

Download citation

  • Received:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1245/s10434-017-6213-8

Keywords

Search

Navigation