Critical appraisal of the ‘wait and see’ approach in rectal cancer for clinical complete responders after chemoradiation

Glynne‐Jones, Robert; Hughes, Rob

doi:10.1002/bjs.8732

Cited by 230 publications

(130 citation statements)

References 79 publications

(190 reference statements)

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“…There is a clear doseresponse between the RT-dose and the tumour down staging when the same fractionations are compared (35,41). With tailored extended delays between CRT and surgery, an increase in the frequency of complete pathological response, (ypT0N0M0) is evident (11)(12)(13)(14)(15).…”

Section: The Biological Phasementioning

confidence: 99%

“…Extended times between chemoradiotherapy and surgery, novel chemotherapeutic agents and change in indications for neoadjuvant treatment has led to an increase in the frequency of complete response (11)(12)(13)(14)(15). Complete response can occur as a result of standard treatment following national guidelines for preoperative down staging.…”

Section: Introductionmentioning

confidence: 99%

“…It could also be viewed as a preferred outcome in a goal directed treatment aiming to avoid surgery. Hence the indications for neoadjuvant treatment can be extended to include less advanced tumours as well (11). The rate of complete response varies with the indication, as there is a better chance of complete response in the less advanced tumours (11,16).…”

Section: Introductionmentioning

confidence: 99%

“…Hence the indications for neoadjuvant treatment can be extended to include less advanced tumours as well (11). The rate of complete response varies with the indication, as there is a better chance of complete response in the less advanced tumours (11,16). Some single institution centers have presented high complete response rates in small tumours and in a highly selected patient population (12).…”

Section: Introductionmentioning

confidence: 99%

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Response to neoadjuvant treatment in rectal cancer surgery

Loftås

2016

Linköping University Medical Dissertations

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Rectal cancer is one of the three most common malignancies in Sweden with an annual incidence of about 2000 cases. Current treatment consists of surgical resection of the rectum including the loco-regional lymph nodes in the mesorectum. In advanced cases, neoadjuvant chemo-radiotherapy (CRT) prior to the operative treatment reduces local recurrences and enables surgery. The neoadjuvant treatment can also eradicate the tumour completely, i.e. complete response. This research project was designed to investigate the effects of preoperative radiotherapy/ CRT and analyze methods to predict response to CRT. Study I investigated the expression of the FXYD-3 protein with immunohistochemistry in rectal cancer, with or without preoperative radiotherapy. The results from the total cohort showed that, strong FXYD-3 expression was correlated to infiltrative tumour growth (p = 0.02). In the radiotherapy group, strong FXYD-3 expression was related to an unfavourable prognosis (p = 0.02). Tumours with strong FXYD-3 expression had less tumour necrosis (p = 0.02) after radiotherapy. FXYD-3 expression in the primary tumour was increased compared to normal mucosa (p=0.008). We concluded that FXYD-3 expression was a prognostic factor in patients receiving preoperative radiotherapy for rectal cancer. Study II investigated FXYD-3 expression in tumours that developed local recurrences following surgery and compared this with expression in tumours that did not develop local recurrences. There was no difference in the expression of FXYD-3 between the group that developed local recurrences and the group that did not develop local recurrences. There was no difference in survival between those with strong or weak FXYD-3 expression. We concluded that this study could not confirm the findings from study 1 i.e. that FXYD-3 expression has prognostic significance in rectal cancer. Study III was a register-based study on the incidence and effects of complete response to neoadjuvant treatment. Eight per cent of the patients with adequate CRT to achieve complete response also had a complete histological response of the luminal tumor in the resected bowel. Sixteen per cent of that group had remaining lymph node metastases in the operative specimen. Chemotherapy together with radiotherapy doubled the chance of complete response in the luminal tumour. Patients with remaining lymph node metastases had a lower survival rate compared to those without. We concluded that residual nodal involvement after neoadjuvant treatment was an important factor for reduced survival after complete response in the luminal tumour. Study IV followed up the results from the previous study by re-evaluating magnetic resonance imaging (MRI)- images in patients with complete tumour response. Two experienced MRI radiologists performed blinded re-staging of post CRT MR- images from patients with complete response in the luminal tumour. One group with lymph node metastases and another one without were studied and the results compared with the pathology reports. The sensitivity, spe...

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Section: The Biological Phasementioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Response to neoadjuvant treatment in rectal cancer surgery

Loftås

2016

Linköping University Medical Dissertations

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“…Based on this, they advocate a selective wait and watch approach for the patients with complete clinical response to neoadjuvant chemoradiotherapy [39]. Whilst Habr-Gama and colleagues have experienced very encouraging results, other series have not shown such high complete response rates and therefore until more evidence is available caution must be adopted in the widespread adoption of this technique [40][41][42].…”

Section: The Role Of Preoperative Neoadjuvant Therapymentioning

confidence: 99%

Paradigm Shift in the Management of Rectal Cancer

Rawat

Evans

2014

Indian J Surg

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Surgery for rectal cancer in the pre-Total Mesorectal Excision (TME) era was associated with high local recurrence rates. The widespread adoption of the TME technique together with the addition of neoadjuvant oncological therapies have reduced local failure rates and improved survival for patients with rectal cancer. Advances in our knowledge, better understanding of tumour biology and refinement in minimal access techniques and equipment have significantly changed the management of rectal cancer. This paper reviews these changes and proposes a paradigm shift in how rectal cancer management is conceptualised and treated, such that the treatment of rectal cancer is separated into early tumours (potentially suitable for local excison), TME tumours (optimally managed by TME) and beyond TME tumours (optimally managed by multivisceral resection outside the TME plane).

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