Preoperative Radio Research Articles

Prediction of survival after neoadjuvant therapy in locally advanced rectal cancer - a retrospective analysis.

The aim of this retrospective analysis was to determine if the response to preoperative radio(chemo)therapy is predictive for survival among patients with locally advanced rectal cancer and may act as a potential surrogate endpoint for disease free survival and overall survival. Eight hundred seventy-eight patients from five centers were analyzed. There were 304 women and 574 men; the median age was 64.7 years. 77.6% and 22.4% of patients received neoadjuvant radiochemotherapy or short-course radiotherapy, resulting in a pathological complete response in 7.3%. T-downstaging and N-downstaging occurred in 50.5% and 37% of patients after neoadjuvant therapy. In patients with T-downstaging, the 10-year DFS and 10-year OS were 64.8% and 66.8% compared to 37.1% and 45.9% in patients without T-downstaging. N-downstaging resulted in 10-year DFS and 10-year OS in 56.2% and 62.5% compared to 47.3% and 52.3% without N-downstaging. Based on routinely evaluated clinical parameters, an absolute risk prediction calculator was generated for 5-year disease-free survival, and 5-year overall survival. T-downstaging and N-downstaging after neoadjuvant radiochemotherapy or short-course radiotherapy resulted in better DFS and OS compared to patients without response. Based on clinical parameters, 5-year DFS, and 5-year OS can be predicted using a prediction calculator.

Rectal Sparing Approach after preoperative Radio- and/or Chemo-therapy (ReSARCh): a prospective, multicenter, observational study.

Rectal-sparing approaches for patients with rectal cancer who achieved a complete or major response following neoadjuvant therapy constitute a paradigm of a potential shift in the management of patients with rectal cancer; however, their role remains controversial. The aim of this study was to investigate the feasibility of rectal-sparing approaches to preserve the rectum without impairing the outcomes. This prospective, multicenter, observational study investigated the outcomes of patients with clinical stage II-III mid-low rectal adenocarcinoma treated with any neoadjuvant therapy, and either transanal local excision or watch-and-wait approach, based on tumor response (major or complete) and patient/surgeon choice. The primary endpoint of the study was rectum preservation at a minimum follow-up of 2 years. Secondary endpoints were overall, disease-free, local and distant recurrence-free, and stoma-free survival at 3 years. Of the 178 patients enrolled in 16 centers, 112 (62.9%) were managed with local excision and 66 (37.1%) with watch-and-wait. At a median (interquartile range) follow-up of 36.1 (30.6-45.6) months, the rectum was preserved in 144 (80.9%) patients. The 3-year rectum-sparing, overall survival, disease-free survival, local recurrence-free survival, and distant recurrence-free survival was 80.6% (95% CI 73.9-85.8), 97.6% (95% CI 93.6-99.1), 90.0% (95% CI 84.3-93.7), 94.7% (95% CI 90.1-97.2), and 94.6% (95% CI 89.9-97.2), respectively. The 3-year stoma-free survival was 95.0% (95% CI 89.5-97.6). The 3-year regrowth-free survival in the watch-and-wait group was 71.8% (95% CI 59.9-81.2). In rectal cancer patients with major or complete clinical response after neoadjuvant therapy, the rectum can be preserved in about 80% of cases, without compromising the outcomes.

Which tumour factors preclude organ preservation in patients with rectal cancer?

BackgroundcT3cdT4, cN2, mesorectal nodes > 8 mm, clinically positive lateral nodes, extramural vascular invasion (EMVI) and mesorectal fascia threatening (MRF+) have been utilized as exclusion criteria in several studies on the watch-and-wait (w&w) strategy. Here, our aim was to validate these criteria through a post hoc analysis of two pooled prospective studies on w&w following routine radio(chemo)therapy. MethodsA review of baseline magnetic resonance imaging was performed in a subgroup of 223 patients treated at a single institution. Of these, 17.9 % started w&w, 12.6 % achieved clinical complete response (cCR) and 9.0 % sustained cCR during median follow-up of 54 months. ResultsThe multivariable logistic analysis showed that the proportion of circumferential bowel involvement and EMVI significantly influenced the chance of sustained cCR; odds ratios were 0.063 (95 % confidence interval [CI] 0.008–0.489, p = 0.008), and 0.109 (95 % CI 0.014–0.850, p = 0.034), respectively. Sustained cCR was observed in none of the 57 patients with 90 %–100 % circumferential bowel involvement and in only one of the 89 patients with EMVI. In contrast, cT3cdT4, cN2, mesorectal nodes > 8 mm, clinically positive lateral nodes or MRF+ were not independently associated with sustained cCR. Among the subgroups of patients with these features but without (near-)circular tumour or EMVI+, sustained cCR was observed in 12 %–25 % of patients. ConclusionSustained cCR after routine preoperative radio(chemo)therapy is unlikely in patients with (near-)circular tumour or EMVI, whereas patients with cT3cdT4, cN2, mesorectal nodes > 8 mm, clinically positive lateral nodes and MRF+ should not be denied w&w.

PO-1398 Long term urinary function after preoperative radio(chemo)therapy in locally advanced rectal cancer

PO-1398 Long term urinary function after preoperative radio(chemo)therapy in locally advanced rectal cancer

Preoperative Radio(Chemo)Therapy in Breast Cancer: Time to Switch the Perspective?

Radiation therapy represents, together with surgery and systemic treatment, the triad on which the current management of patients with breast cancer is based, achieving high control and survival rates. In recent years we have witnessed a (r)evolution in the conception of breast cancer treatment. The classic scheme of surgery followed by systemic treatment and radiotherapy is being subverted and it is becoming more and more frequent to propose the primary administration of systemic treatment before surgery, seeking to maximize its effect and favoring not only the performance of more conservative surgeries but also, in selected cases, increasing the rates of disease-free survival and overall survival. Radiotherapy is also evolving toward a change in perspective: considering preoperative primary administration of radiotherapy may be useful in selected groups. Advances in radiobiological knowledge, together with technological improvements that are constantly being incorporated into clinical practice, support the administration of increasingly reliable, precise, and effective radiotherapy, as well as its safe combination with antitumor drugs or immunotherapy in the primary preoperative context. In this paper, we present a narrative review of the usefulness of preoperative radiotherapy for breast cancer patients and the possibilities for its combination with other therapies.

CAD of BCD from Thermal Mammogram Images Using Machine Learning

Lump in the breast, discharge of blood from the nipple, and deformation of the nipple/breast and its texture are the symptoms of breast cancer. Though breast cancer is very common in women, men can also get breast cancer. In the early stages, BCD makes use of Thermal Mammograms Breast Images (TMBI). The cost of treatment can be severely reduced in the early stages of detection. Based on the techniques of segmentation, the Breast Cancer Detection (BCD) works. Moreover, by providing a balanced, reliable and appropriate second opinion, a tremendous role has been played by ML in medical practices due to enhanced Information and Communication Technology (ICT). For the purpose of making the whole detection process of Malignant Tumor (MT)/Benign Tumor (BT) very resourceful and time-efficient, there is now a possibility to form an automated and precise Computer-Aided Diagnosis System (CADs). Several Image Pattern Recognition Techniques were used to classify breast cancer using Thermal Mammograms Image Processing Techniques (TMIPT) in the present investigation. Presenting a new model to classify the BCD with the help of TMIPT, thermal imaging, and smart devices is the aim of this research article. Using well-designed experiments like Intensive Preoperative Radio Therapy (IPRT) and BCD, the implementation and valuation of a concrete application are carried out. This proposed method is for the automatic classification of TMBI of a similar standard so that the thermal camera of FLIR One Gen 3 One 3rd Generation (FLIR One Gen 3) that can be attached to the smart devices are capable of capturing BCD using Machine Learning (ML) algorithms. To imitate the behaviour of human Artificial Intelligence (AI), designing drug formulations, helping in clinical diagnosis and robotic surgery systems, finding medical statistical datasets, and decoding human diseases’ wireless network model as well as cancer are the reasons for the ML to empower the computer and robots. The outperformance of the ML models against all other classifiers and scoring impressively across heterogeneous performance metrics like 98.44% of Precision, 98.83% of Accuracy, and 100% of Recall are observed from the comparative analysis.

Rectal Sparing Approach After Neoadjuvant Therapy in Patients with Rectal Cancer: The Preliminary Results of the ReSARCh Trial.

Rectum-preservation for locally advanced rectal cancer has been proposed as an alternative to total mesorectal excision (TME) in patients with major (mCR) or complete clinical response (cCR) after neoadjuvant therapy. The purpose of this study was to report on the short-term outcomes of ReSARCh (Rectal Sparing Approach after preoperative Radio- and/or Chemotherapy) trial, which is a prospective, multicenter, observational trial that investigated the role of transanal local excision (LE) and watch-and-wait (WW) as integrated approaches after neoadjuvant therapy for rectal cancer. Patients with mid-low rectal cancer who achieved mCR or cCR after neoadjuvant therapy and were fit for major surgery were enrolled. Clinical response was evaluated at 8 and 12weeks after completion of chemoradiotherapy. Treatment approach, incidence, and reasons for subsequent TME were recorded. From 2016 to 2019, 160 patients were enrolled; mCR or cCR at 12weeks was achieved in 64 and 96 of patients, respectively. Overall, 98 patients were managed with LE and 62 with WW. In the LE group, Clavien-Dindo 3+ complications occurred in three patients. The rate of cCR increased from 8- to 12-week restaging. Thirty-three (94.3%) of 35 patients with cCR had ypT0-1 tumor. At a median 24months follow-up, a tumor regrowth was found in 15 (24.2%) patients undergoing WW. LE for patients achieving cCR or mCR is safe. A 12-week interval from chemoradiotherapy completion to LE is correlated with an increased cCR rate. The risk of ypT > is reduced when LE is performed after cCR.

A Molecular Biomarker Prediction Model for Preoperative Radio sensitivity in Rectal Cancer: An Analysis of 33 Patients’ Information

A Molecular Biomarker Prediction Model for Preoperative Radio sensitivity in Rectal Cancer: An Analysis of 33 Patients’ Information

Organ-preserving Management in Patients With Complete or Near-complete Tumour Response After Preoperative Radio(Chemo)Therapy for Rectal Cancer

Organ-preserving Management in Patients With Complete or Near-complete Tumour Response After Preoperative Radio(Chemo)Therapy for Rectal Cancer

Association between Preoperative Pelvic Irradiation and Toxicity of Subsequent Chemotherapy in Rectal Cancer

Background: Randomized trials have shown a lower efficacy of postoperative chemotherapy in rectal cancer patients having received preoperative radiotherapy than in nonirradiated colorectal cancer (CRC) patients. We hypothesized that preoperative radio(chemo)therapy impairs the relative dose intensity (RDI) of further chemotherapy because of long-term radiation damage. This retrospective study aimed to test this hypothesis. Methods: The analysis was conducted on 220 consecutive patients with CRC who received FOLFOX-4 postoperatively or because of cancer relapse. Of these, 41 patients with rectal cancer had preoperatively received radio(chemo)therapy (study group) and the remaining 179 with CRC had not (control group). The RDI of oxaliplatin at 8 and 16 weeks was calculated. Results: The median RDI of oxaliplatin at 8 weeks was 95.91% in the study group and 96.15% in the control group (p = 0.79). The corresponding percentages at 16 weeks were 87.6 and 86.5%, respectively (p = 0.55). It was found that within 0–8 weeks, 26.9% of the patients in the study group and 26.3% in the control group had grade 3+ toxicity, hypersensitivity reactions, or granulocyte colony-stimulating factor administration (p = 0.94). The corresponding percentages for 0–16 weeks were 44.8 and 43.9%, respectively (p = 0.92). Conclusions: We found no association between preoperative radio(chemo)therapy and the RDI of FOLFOX-4. We failed to explain the inferior efficacy of postoperative chemotherapy in patients with rectal cancer who had preoperatively received irradiation compared to those with CRC who had not.

Impact of pelvic bone marrow irradiation on the hematological toxicity of subsequent chemotherapy in rectal cancer

Preoperative radio(chemo)therapy in rectal cancer may irreversibly damage pelvic bone marrow (PBM) and impair the tolerance of subsequent chemotherapy. The aim of the study was to assess the relationship between the irradiated volume of PBM and the toxicity of subsequent 5-fluorouracil, oxaliplatin, leucovorin (FOLFOX-4) in rectal cancer. We included consecutive rectal cancer patients who received FOLFOX-4 postoperatively or due to cancer relapse. The PBM was divided into iliac (IM), lumbosacral (LSM), and lower pelvic (LPM) marrow. We assessed mean dose, and percentage of volume receiving 10%-90% (V10%-V90%) of the prescribed dose for PBM, IM, LSM, and LPM. Generalized linear model for repeated measures (GLM) was used to test an influence of dose-volumes distribution on toxicities grade 2 or higher (TOX2) and grade 3 or higher (TOX3). The two-sided t-test was used to evaluate the difference in mean dose, mean V20%, and mean V40% between patients who experienced TOX2 or TOX3 and those who did not. 39 patients met eligibility criteria. Because of the low occurrence of TOX3 (n=3), related analyses were abandoned. We found no influence of dose-volume distribution on TOX2 in GLM and no significant differences in mean dose, mean V20%, and mean V40% for PBM, IBM, LSM, and LPM between patients who experienced TOX2 and those who did not. To conclude, no relationship between doses received by PBM in preoperative radio(chemo)therapy in rectal cancer and hematological tolerance of subsequent FOLFOX-4 chemotherapy was found.

Validation of Portuguese version of the low anterior resection syndrome score

ObjectiveThe authors aim to perform a thorough translation with cultural adaptation of the patient reported outcome tool, Low Anterior Resection Syndrome (LARS) Score, to the Portuguese language (LARS-PT) in the Portuguese population with rectal cancer, after proctectomy with anastomosis. MethodsAccording to the current international recommendations, we designed this study encompassing three main phases: (i) cultural and linguistic validation to European Portuguese; (ii) feasibility and reliability tests of the version obtained in the previous phase; and (iii) validity tests to produce a final version. The questionnaire was completed by 154 patients from six Portuguese Colorectal Cancer Units, and 58 completed it twice. ResultsPortuguese version of LARS score showed high construct validity. Regarding the test-retest, the global Intraclass Correlation showed very strong test-retest reliability. Looking at all five items, only items 3 and 5 present a moderate correlation. LARS score was able to discriminate symptoms showing worse quality of life, in patients submitted to preoperative radio and chemotherapy. ConclusionsLARS questionnaire has been properly translated into European Portuguese, demonstrating high construct validity and reliability. This is a precise, reproducible, simple, clear and user-friendly tool for evaluating bowel function in rectal cancer patients after sphincter saving operation.

P-317 - A single centre experience of in-field recurrence following pre-operative radio(chemo)therapy in patients with rectal cancer

P-317 - A single centre experience of in-field recurrence following pre-operative radio(chemo)therapy in patients with rectal cancer

Impact of pelvis irradiation on toxicity of further oxaliplatin-based chemotherapy in rectal cancer.

777 Background: Radiotherapy is used in the neoadjuvant setting in majority of rectal cancer patients, while its effect on overall survival is limited mostly to patients with threatened resection margin. Preoperative pelvic irradiation might damage bone marrow. In consequence, relative dose intensity (RDI) and efficacy of further adjuvant or palliative CT might be reduced. The aim of the study was to assess whether radiation damage to the pelvic bone marrow influences the tolerance of further oxaliplatin-based CT. Methods: We have performed the cohort analysis of patients with adenocarcinoma of rectum or colon receiving FOLFOX-4 chemotherapy in adjuvant or palliative setting between 2011-2016. Oxaliplatin relative-dose intensity (RDI) within 8 weeks from the beginning of CT was calculated for each patient. The major factors, which can reduce oxaliplatin RDI, were analyzed independently (hemathological toxicity, neurological toxicity, occurrence of hypersensitivity reactions to oxaliplatin). The data regarding the first disruption of oxaliplatin dose within all planned courses of FOLFOX-4 was also collected. Results: 220 patients met eligibility criteria. 41 of them received neoadjuvant radio(chemo)therapy (study group), the remaining 179 patients were assigned to control group (n = 179). RDI did not differ significantly between irradiated and non-irradiated patients (p = 0.794). There were no statistically significant differences in observed oxaliplatin-related toxicities. The median time between the start of chemotherapy and the first disruption of oxaliplatin administration was also not statistically different between the two groups (p = 0.156). Conclusions: An impact of preoperative radio(chemo)therapy on RDI or tolerance of FOLFOX was not found in rectal cancer.

Current issues of preoperative radio(chemo)therapy and its future evolution in locally advanced rectal cancer.

Neoadjuvant therapies are effective for local control and tumor downstaging. Up to date, preoperative long-course chemoradiotherapy and short-course radiotherapy are the two primary guideline-recommended neoadjuvant therapies for locally advanced rectal cancer patients. However, clinicians throughout the world are trying their best to further optimize the regimens and concepts of neoadjuvants. Hence, there is an urgent need to summarize evidence regarding indications of neaoadjuvant therapies and relative merits of current standard regimens. In addition, we also reviewed the optimized regimens mainly based on short-course radiotherapy with delayed surgery, consolidation chemotherapy, induction chemotherapy, chemotherapy alone without radiation and concepts in terms of organ preservation and personalized treatments to further explore the future evolution of neoadjuvant therapies in rectal cancer.

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.

We asked what preoperative radiotherapy/chemoradiotherapy (PRT/PCRT) has brought to patients in terms of perioperative and long-term outcomes over the past decades. A systematic review and meta-analysis was conducted using PubMed, Embase and Web of Science databases. All original comparative studies published in English that were related to PRT/PCRT and surgical resection and which analyzed survival, postoperative and quality of life outcomes were included. Data synthesis and statistical analysis were carried out using Stata software. Data from 106 comparative studies based on 80 different trials enrolling 41,121 patients were included in our study. Based on our overall analyses, PRT/PCRT significantly improved patients' local recurrence-free survival (LRFS), but neither overall survival (OS) nor metastasis-free survival (MFS) showed improvement. In addition, PRT significantly increased the postoperative morbidity and mortality but PCRT did not have a significant effect. Furthermore, PRT/PCRT significantly increased the risk of postoperative wound complications but not anastomotic leakage and bowel obstruction. Our comprehensive subgroup analyses further supported the aforementioned results. Meanwhile, long-term anorectal symptoms (impaired squeeze pressures, use of pads, incontinence and urgency) and erectile dysfunction were also significantly increased in patients after PRT/PCRT. The benefits of PRT/PCRT as applied over the last several decades have not been sufficient to improve OS. Metastases of primary tumor and postoperative adverse effects were the two primary obstacles for an improved OS. In fact, the greatest advantage of PRT/PCRT is still local tumor control and a significantly improved LRFS.

Does Preoperative Radio(chemo)therapy Increase Anastomotic Leakage in Rectal Cancer Surgery? A Meta-Analysis of Randomized Controlled Trials.

Objective. Preoperative radio(chemo)therapy (pR(C)T) appears to increase postoperative complications of rectal cancer resection, but clinical trials have reported conflicting results. The objective of this meta-analysis was performed to assess the effects of pR(C)T on anastomotic leak after rectal cancer resection. Methods. PubMed, Embase, and the Cochrane Library were searched from January 1980 to January 2014. Randomized controlled trials included all original articles reporting anastomotic leak in patients with rectal cancer, among whom some received preoperative radiotherapy or chemoradiotherapy while others did not. The analysed end-points were the anastomotic leak. Result. Seven randomized controlled trials with 3375 patients were included in the meta-analysis. 1660 forming the group undergoing preoperative radiotherapy or chemoradiotherapy versus 1715 patients undergoing without preoperative radiotherapy or chemoradiotherapy. The meta-analyses found that pR(C)T was not an independent risk factor for anastomotic leakage (OR 1.02, 95% CI 0.80–1.30; P = 0.88). Subgroups analysis was performed and the result was not altered. Conclusions. Current evidence demonstrates that pR(C)T did not increase the risk of postoperative anastomotic leak after rectal cancer resection in patients.

Fatores preditores de fístula salivar pós-laringectomia total

To evaluate the incidence of pharyngocutaneous fistula after total laryngectomy and try to identify its predictors. From May 2005 to April 2010, 93 patients underwent total laryngectomy. We evaluated complications during and after surgery and compared them with the following variables: gender, nutritional status, previous tracheotomy, tumor location, type of surgery, TNM staging, prior treatment with chemotherapy and/or radiotherapy, use of flaps for reconstruction and surgical margin. All patients presented with advanced neoplastic disease according to TNM. 14 (15.1%) patients developed postoperative salivary fistula. The mean time to onset of salivary fistula was 3.5 days, with a standard deviation of 13.7 days. Comparing salivary fistula with TNM variables, type of operation and neck dissection, prior tracheotomy, use of flap, preoperative radio and chemotherapy and surgical margin, there was no statistically significant difference (p> 0,05). The incidence of salivary fistula was 15.1% and no predictive factor for its formation was found.

Preoperative radiotherapy does not alter pre- and early postoperative serum CRP and albumin concentrations in colorectal cancer patients

Aim of the studyWe aimed to assess the alterations of serum C-reactive protein (CRP) and albumin levels in colorectal cancer patients who underwent preoperative radio(chemo)therapy and those who did not.Material and methodsThe determinations of albumin and CRP were performed before and at 2, 3, 5 and 7 days after surgery in 60 colorectal cancer patients. 25 healthy subjects served as a reference group. For each patient the modified Glasgow Prognostic Score (mGPS) was calculated.ResultsOn the operation day CRP and albumin concentrations were not different in preoperatively treated or radiotherapy naïve patients. On postoperative day 2, 3, 5 and 7 no significant differences were observed between the two groups, with the only exception for albumin concentration, which was significantly higher on postoperative days 2 and 7 in the radiation naïve group. In all patients perioperative alterations of serum CRP level were significant at all time points (preoperatively vs. day 2, day 2 vs. day 3, day 3 vs. day 5, day 5 vs. day 7). The albumin decrease from the preoperative day to postoperative day 2 was significant, as was its increase from postoperative day 3 to 5.ConclusionsWe have seen no differences in the CRP and albumin concentrations in preoperatively irradiated versus non-irradiated colorectal cancer patients on the day of surgery and on postoperative days 2, 3, 5 and 7. There were, however, significant concentration changes in the value of these two serum markers from preoperatively to postoperative day 2 and over the following postoperative week, but presumably related to the surgical trauma, not the neoadjuvant treatment.

Effect of Preoperative Radio(chemo)therapy on Long-term Functional Outcome in Rectal Cancer Patients: A Systematic Review and Meta-analysis

Preoperative radio(chemo)therapy (pR(C)T) significantly reduces the local recurrence risk and is therefore recommended in stage II/III rectal cancer. However, this multimodal treatment approach may be associated with late adverse effects. To determine the impact of pR(C)T on long-term anorectal, sexual, and urinary function, we performed a systematic review and meta-analysis. PubMed, Embase, and the Cochrane Library were systematically searched for studies reporting on long-term functional outcome after rectal cancer resection with pR(C)T. Only studies that reported anorectal, sexual, and/or urinary function after rectal cancer resection in TME-technique with pR(C)T were eligible for inclusion. Twenty-five studies, including 6,548 patients, were identified. Methodological quality of the eligible studies was low. The majority of studies reported higher rates of anorectal (14/18 studies) and male sexual dysfunction (9/10 studies) after pR(C)T. Few studies examined female sexual dysfunction (n=4). Meta-analysis revealed that stool incontinence occurred more often in irradiated patients (risk ratio (RR)=1.67; 95% confidence interval (CI), 1.36, 2.05; p<0.0001) and manometric results were significantly worse after pR(C)T (mean resting pressures (weighted mean difference (WMD)=15.04; 95% CI, 0.77, 29.31; p=0.04) and maximum squeeze pressures (WMD = 30.39; 95% CI, 21.48, 39.3; p<0.0001)). Meta-analysis of erectile dysfunction revealed no statistical significance (RR=1.41; 95% CI, 0.74, 2.72; p=0.3). Six of eight studies and meta-analysis demonstrated no negative effect of pR(C)T on urinary function (RR=1.05; 95% CI, 0.67, 1.65; p=0.82). Although quality of studies on long-term functional outcome is limited, current evidence demonstrates that pR(C)T negatively affects anorectal function after TME.