Analysis of long-term oncological results of clinical versus pathological responses after neoadjuvant treatment in locally advanced rectal cancer

Abstract Background Nonoperative management after neoadjuvant treatment in low rectal cancer enables organ preservation and avoids surgical morbidity. Our aim is to compare oncological outcomes in patients with clinical complete response in watch and wait strategy with those who received neoadjuvant therapy followed by surgery with a pathological complete response. Methods Patients with non-metastatic rectal cancer after neoadjuvant treatment with clinical complete response in watch and wait approach (group 1, n = 26) and complete pathological responders (ypT0N0) after chemoradiotherapy and surgery (group 2, n = 22), between January 2011 and October 2018, were included retrospectively, and all of them evaluated and followed in a multidisciplinary team. A comparative analysis of local and distant recurrence rates and disease-free and overall survival between both groups was carried out. Statistical analysis was performed using log-rank test, Cox proportional hazards regression model, and Kaplan-Meier curves. Results No differences were found between patient’s demographic characteristics in both groups. Group 1: distance from the anal verge mean 5 cm (r = 1–12), 10 (38%) stage III, and 7 (27%) circumferential resection margin involved. The median follow-up of 47 months (r = 6, a 108). Group 2: distance from the anal verge mean 7 cm (r = 2–12), 16 (72%) stage III, and 13 (59%) circumferential resection margin involved. The median follow-up 49.5 months (r = 3, a 112). Local recurrence: 2 patients in group 1 (8.3%) and 1 in group 2 (4.8%) (p = 0.6235). Distant recurrence: 1 patient in group 1 (3.8%) and 3 in group 2 (19.2%) (p = 0.2237). Disease-free survival: 87.9% in group 1, 80% in group 2 (p = 0.7546). Overall survival: 86% in group 1 and 85% in group 2 (p = 0.5367). Conclusion Oncological results in operated patients with pathological complete response were similar to those in patients under a watch and wait strategy mediating a systematic and personalized evaluation. Surgery can safely be deferred in clinical complete responders.

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Watch and Wait Approach for Rectal Cancer Following Neoadjuvant Treatment: The Experience of a High Volume Cancer Center

Diagnostics ◽

10.3390/diagnostics11081507 ◽

2021 ◽

Vol 11 (8) ◽

pp. 1507

Author(s):

Daniela Rega ◽

Vincenza Granata ◽

Carmela Romano ◽

Valentina D’Angelo ◽

Ugo Pace ◽

...

Keyword(s):

Rectal Cancer ◽

Locally Advanced ◽

Neoadjuvant Treatment ◽

High Volume ◽

Complete Response ◽

Response To Therapy ◽

Cancer Center ◽

Watch And Wait ◽

Clinical Complete Response

Multimodal treatments for rectal cancer, along with significant research on predictors to response to therapy, have led to more conservative surgical strategies. We describe our experience of the rectal sparing approach in rectal cancer patients with clinical complete response (cCR) after neoadjuvant treatment. We also specifically highlight our clinical and imaging criteria to select patients for the watch and wait strategy (w&w). Data came from 39 out of 670 patients treated for locally advanced rectal cancer between January 2016 until February 2020. The selection criteria were a clinical complete response after neoadjuvant chemotherapy managed with a watch and wait (w&w) strategy. A strict follow-up period was adopted in these selected patients and follow-ups were performed every three months during the first two years and every six months after that. The median follow-up time was 28 months. Six patients had a local recurrence (15.3%); all were salvageable by total mesorectal excision (TME). Five patients had a distant metastasis (12.8%). There was no local unsalvageable disease after w&w strategy. The rectal sparing approach in patients with clinical complete response after neoadjuvant treatment is the best possible treatment and is appropriate to analyze from this perspective. The watch and wait approach after neoadjuvant treatment for rectal cancer can be successfully explored after inflexible and strict patient selection.

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Does transition from standard to Retzius-sparing technique in robot-assisted radical prostatectomy affect the functional and oncological outcomes?

Archivio Italiano di Urologia e Andrologia ◽

10.4081/aiua.2021.4.399 ◽

2021 ◽

Vol 93 (4) ◽

pp. 399-403

Author(s):

Hakan Anıl ◽

Kaan Karamık ◽

Ali Yıldız ◽

Murat Savaş

Keyword(s):

Radical Prostatectomy ◽

Learning Curve ◽

Surgical Margin ◽

Nerve Sparing ◽

Robot Assisted ◽

Continence Status ◽

Oncological Results ◽

Group 2 ◽

Group 1

Objective: To appraise the outcomes on the Retzius-sparing robot-assisted radical prostatectomy (Rs-RARP) learning curve of a surgeon with previous experience of anterior (standard) RARP. Materials and methods: The first 50 cases during the Rs-RARP learning curve (group 1) and 50 cases after the second 100 cases with the standard approach (group 2) were comprised in the study. Patients who used zero or one safety pads were considered continent. Erectile function recuperation was characterized as the competence to achieve penetrative intercourse without receiving any medication. All patients were reevaluated at two weeks, first, third, sixth, and 12th months after surgery using IIEF-5, PSA level, and continence status. Results: Immediate continence rates following catheter removal were 32/50 (64%) in Rs-RARP group and 26/50 (52%) in S-RARP group (p = 0.224). The continence recovery rate was 48/50 (96%) in Rs-RARP group and 46/50 (92%) in the S-RARP group at 12 months follow-up (p = 0.400). Total nerve-sparing surgery was enforced in 36/50 (72%) patients for group 1 and 35/50 (70%) patients for group 2. Potency recovery was 27/43 (62.8%) in Rs-RARP and 30/44 (68.2%) for S-RARP at 12 months follow up (p = 0.597). Surgical margin positivity was detected in 6/50 (12%) cases in the Rs-RARP group and in 4/50 (8%) cases in the S-RARP (p = 0.444). Conclusions: Functional and oncological results are not negatively affected in the first 50 cases for a surgeon who is experienced in S-RARP before transition to the Rs-RARP method.

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Carboplatin, ifosfamide, and mesna (CIM) for the treatment of gynecological carcinosarcoma

Journal of Clinical Oncology ◽

10.1200/jco.2009.27.15_suppl.e16539 ◽

2009 ◽

Vol 27 (15_suppl) ◽

pp. e16539-e16539

Author(s):

N. Walji ◽

A. Zachariah ◽

C. Yap ◽

S. A. Hussain ◽

C. J. Poole ◽

...

Keyword(s):

Complete Response ◽

Kaplan Meier ◽

Metastatic Setting ◽

The Common ◽

Group 2 ◽

Grade 3 ◽

Abdominal Irradiation ◽

Toxicity Criteria ◽

Group 1

e16539 Background: A GOG trial comparing cisplatin/ifosfamide/mesna chemotherapy versus whole abdominal irradiation for FIGO stages I-IV carcinosarcoma (CS) showed an estimated median survival (MS) of 50 months for chemotherapy but high toxicity. This study investigates the efficacy and tolerability of a novel regimen using carboplatin AUC 5, ifosfamide 3 g/m2 and mesna 1 g/m2 (CIM) in both the adjuvant and metastatic setting. Methods: Retrospective analysis of women with CS treated from May 1997-May 2007 with CIM (group 1) versus other chemotherapy regimens (group 2). Toxicity was graded according to the Common Toxicity Criteria and MS estimated using the Kaplan-Meier method. Results: Of 51 eligible women (median age 71 years) 35 (69%) had stage 3 or 4 disease. 35/51 (69%) received chemotherapy; 2 with stage 1c disease received pelvic radiotherapy (pRT) alone whilst the remaining 14 were unfit for any treatment. Median follow-up for the treated patients is 45 months. 11/35 patients (31%) received CIM as first-line chemotherapy. Other regimens included: carboplatin (n = 14); carboplatin/paclitaxel (n = 3); carboplatin/epirubicin (n = 3); carboplatin/doxorubicin (n = 2); doxorubicin/ifosfamide (n = 1); cisplatin/ifosfamide (n = 1). 20/35 (57%) received adjuvant chemotherapy (AC) of which 8 received CIM; 11/20 patients also received adjuvant pRT. MS in the CIM AC group is 54.7 months compared to 37.4 months for other regimens. 3/8 patients (37.5%) in the CIM arm developed recurrent disease compared to 9/12 (75%) for other regimens. 4/16 patients received CIM as first- or second-line palliative chemotherapy. All patients responded of whom 2 achieved clinical and radiological complete response (CR). One woman subsequently relapsed and achieved a second CR with CIM. MS for all chemotherapy-treated patients is 54.7 months (group 1) versus 20.6 months (group 2) (p = 0.07). No patients in group 1 experienced any grade 3/4 toxicity and all patients completed the prescribed treatment. There were 2 unexpected treatment-related deaths in group 2, one of whom received carboplatin/paclitaxel and the other carboplatin/epirubicin. Conclusions: CIM appears to be efficacious and well tolerated in the treatment of CS and merits further investigation in clinical trials. No significant financial relationships to disclose.

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Factors of local immunity in patients with rectal cancer after prolonged radiotherapy.

Journal of Clinical Oncology ◽

10.1200/jco.2019.37.15_suppl.e15164 ◽

2019 ◽

Vol 37 (15_suppl) ◽

pp. e15164-e15164

Author(s):

Oleg Ivanovich Kit ◽

Aleksandr V. Snezhko ◽

Elena Yu. Zlatnik ◽

Inna A. Novikova ◽

Nabil Al-haj ◽

...

Keyword(s):

Rectal Cancer ◽

Neoadjuvant Treatment ◽

Proliferation Index ◽

Tumor Proliferation ◽

Immunological Study ◽

Dna Cytometry ◽

Local Immunity ◽

Cd8 Cells ◽

Group 2 ◽

Group 1

e15164 Background: Immunological study of the blood and tumor tissues was performed in patients with rectal cancer receiving neoadjuvant chemoradiotherapy. Methods: 30 patients with rectal cancer (13 women and 17 men aged 37-68 years with stage II-III adenocarcinomas G1-G3) were divided into groups according to results of DNA cytometry and their response to neoadjuvant treatment. When tumor proliferative activity was stable for 4 weeks of treatment, patients received surgery on time (group 1), while patients with verified inhibition of tumor proliferation (the index decrease by 1.5 times and more) continued treatment for 6-8 weeks and then were operated on (group 2). The immune status of patients (T, B, NK, DN, Tregs) was assessed during treatment. Homogenates of tumor tissue samples obtained during surgery were studied for the levels of lymphocytes (flow cytometry) and cytokines TNF-α, IL-1ß, IL-1RA, IL-6, IL-8, IFN-α, IFN-γ (ELISA); tumor proliferation index was assessed by DNA cytometry. Results were analyzed by Statistica 10.0 program. Results: The dynamics of parameters of the cellular immunity was different in patients of two groups. In group 1, percentage of T lymphocytes in blood decreased (from 66.7±3.3 to 50.4±1.6%), as well as their main subsets (CD4+ and CD8+ cells: from 33.6±2.7 to 27.0±1.7% and from 26.7±2.4 to 20.7±1.7% respectively). Patients of group 2 developed an increase in levels of NK cells from 10.1±1.2 to 15.3±2.2%, and levels of CD3+, CD4+ and CD8+ cells were significantly higher than in group 1: 35.0±1.8% for CD4+ and 28.3±2.9% for CD8+ (p < 0.05). The groups also differed in indices of local immunity: DN cells levels in group 2 were lower than in group 1 (5.8±1.0 vs. 18.4±5.4%) and CD4+ were higher (36.6±3.3 vs. 26.2±3.1%; p < 0.05). Patients of group 2 showed lower levels of IL-1ß, IL-6, IL-10, while IFNγ was elevated by 5.4 times, indicating a more favorable local cytokine status of the patients, compared to group 1. Conclusions: In rectal cancer patients with effect confirmed by DNA cytometry, prolongation of chemoradiotherapy to 6-8 weeks provides the formation of a more favorable immunological microenvironment of the tumor, and in such cases it is considered appropriate.

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Effect of downstaging without complete pathologic response after neoadjuvant treatment on cancer outcomes for cIII and cII rectal cancers

Journal of Clinical Oncology ◽

10.1200/jco.2009.27.15_suppl.4108 ◽

2009 ◽

Vol 27 (15_suppl) ◽

pp. 4108-4108

Author(s):

L. F. Lobato ◽

L. Stocchi ◽

A. da Luz Moreira ◽

M. Kalady ◽

D. Dietz ◽

...

Keyword(s):

Rectal Cancer ◽

Local Recurrence ◽

Anal Verge ◽

Locally Advanced ◽

Pathologic Complete Response ◽

Neoadjuvant Treatment ◽

Significant Prognostic Factor ◽

Cancer Outcomes ◽

The Impact

4108 Background: Neoadjuvant chemoradiation followed by surgery is standard of care for locally advanced rectal cancer. The impact of downstaging on prognosis when pathologic complete response (pCR) cannot be achieved remains unclear. The aim of this study was to evaluate whether downstaging impacts prognosis in patients with cII vs. cIII rectal cancer. Methods: We identified from our colorectal cancer database 233 patients with primary cII and cIII rectal cancer staged by CT and ERUS/MRI who received 5FU-based chemoradiation followed by R0 surgery after a median interval of 7 weeks during 1997–2007. Median radiotherapy dose was 5040 cGy. We excluded 58 patients with pCR and. Compared among the remaining 175 patients pathologic downstaging (cII to ypI, cIII to ypII or ypI) vs. No pathologic downstaging (c stage ≤ yp stage). Outcomes evaluated were 5-year overall survival, 3-year recurrence-free survival, overall recurrence, local recurrence and distant recurrence. Results: Median age was 58 years and median follow-up was 48 months. Patients with cII vs. cIII stage were statistically comparable regarding demographics, chemoradiation regimen, interval to surgery after neoadjuvant treatment, tumor distance from anal verge, operations performed and follow-up. The incidence of downstaging was increased in stage cIII vs. cII patients (68% vs. 21%, p <0.001). With the exception of local recurrence rates, downstaging resulted in significantly improved cancer outcomes for cIII but not cII ( Table ). Conclusions: Downstaging without pCR is a significant prognostic factor for patients with stage cIII rectal cancer. A larger sample size is required to confirm lack of downstaging benefits in stage cII. [Table: see text] No significant financial relationships to disclose.

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The evaluation of follow‐up strategies of watch‐and‐wait patients with a complete response after neoadjuvant therapy in rectal cancer

Colorectal Disease ◽

10.1111/codi.15636 ◽

2021 ◽

Author(s):

Hester E. Haak ◽

Jan Zmuc ◽

Doenja M.J. Lambregts ◽

Regina G.H. Beets‐Tan ◽

Jarno Melenhorst ◽

...

Keyword(s):

Rectal Cancer ◽

Neoadjuvant Therapy ◽

Complete Response ◽

Watch And Wait

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Total neoadjuvant treatment of locally advanced rectal cancer with high risk factors in Slovenia

Radiology and Oncology ◽

10.2478/raon-2019-0046 ◽

2019 ◽

Vol 53 (4) ◽

pp. 465-472

Author(s):

Mojca Tuta ◽

Nina Boc ◽

Erik Brecelj ◽

Mirko Omejc ◽

Franc Anderluh ◽

...

Keyword(s):

Risk Factors ◽

Rectal Cancer ◽

High Risk ◽

Locally Advanced ◽

Pathologic Complete Response ◽

Neoadjuvant Treatment ◽

Complete Response ◽

Distant Recurrence ◽

High Risk Factors ◽

Grade 3

Abstract Background In the light of a high rate of distant recurrence and poor compliance of adjuvant chemotherapy in high risk rectal cancer patients the total neoadjuvant treatment was logical approach to gaining acceptance. We aimed to evaluate toxicity and efficiency of this treatment in patients with rectal cancer and high risk factors for local or distant recurrence. Patients and methods Patients with rectal cancer stage II and III and with at least one high risk factor: T4, presence of extramural vein invasion (EMVI), positive extramesorectal lymph nodes or mesorectal fascia (MRF) involvement were treated with four cycles of induction CAPOX/FOLFOX, followed by capecitabine-based radiochemotherapy (CRT) and two consolidation cycles of CAPOX/FOLFOX before the operation. Surgery was scheduled 8–10 weeks after completition of CRT. Results From November 2016 to July 2018 66 patients were evaluable. All patients had stage III disease, 24 (36.4%) had T4 tumors, in 46 (69.7%) EMVI was present and in 47 (71.2%) MRF was involved. After induction chemotherapy, which was completed by 61 (92.4%) of patients, radiologic downstaging of T, N, stage, absence of EMVI or MRF involvement was observed in 42.4%, 62.1%, 36.4%, 69.7% and 68.2%, respectively. All patients completed radiation and 54 (81.8%) patients received both cycles of consolidation chemotherapy. Grade 3 adverse events of neoadjuvant treatment was observed in 4 (6%) patients. Five patients rejected surgery, 3 of them with radiologic complete clinical remissions. One patient did not have definitive surgery of primary tumor due to unexpected cardiac arrest few days after sigmoid colostomy formation. Among 60 operated patients pathological complete response rate was 23.3%, the rate of near complete response was 20% and in 96.7% radical resection was achieved. Pathological T, N and stage downstaging was 65%, 96.7% and 83.4%, respectively. Grade ≥ 3 perioperative complications were anastomotic leakage in 3, pelvic abscess in 1 and paralytic ileus in 2 patients. The rate of pathologic complete response (pCR) in patients irradiated with 3D conformal technique was 12.1% while with IMRT and VMAT it was 37% (p < 0.05). Hypofractionation with larger dose per fraction and simultaneous integrated boost used in the latest two was the only factor associated with pCR. ConclusionsTotal neoadjuvant treatment of high risk rectal cancer is well tolerated and highly effective with excellent tumor and node regression rate and with low toxicity rate. Longer follow up will show if this strategy will improve distant disease control and survival.

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Total neoadjuvant treatment versus standard chemoradiation to increase the sphincter preservation rate for distal locally advanced rectal cancer (TESS).

Journal of Clinical Oncology ◽

10.1200/jco.2021.39.15_suppl.tps3615 ◽

2021 ◽

Vol 39 (15_suppl) ◽

pp. TPS3615-TPS3615

Author(s):

Weiwei Xiao ◽

Xiaojun Wu ◽

Peiqiang Cai ◽

YeZhong Zhuang ◽

Xiaozhong Wang ◽

...

Keyword(s):

Rectal Cancer ◽

Adjuvant Chemotherapy ◽

Standard Treatment ◽

Pathological Complete Response ◽

Neoadjuvant Treatment ◽

Complete Response ◽

Treatment Decisions ◽

Sphincter Preservation ◽

Watch And Wait ◽

Preservation Rate

TPS3615 Background: Standard treatment of rectal cancer is neoadjuvant capecitabine chemotherapy with radiotherapy, followed by total mesorectal excision (TME). Total neoadjuvant treatment (TNT), a new concept, suggests organ preservation as an alternative to rectal excision in good responders after neoadjuvant chemoradiotherapy to decrease surgical morbidity and increase quality of life. RAPIDO and PRODIGE-23 trials showed that TNT strategy could improve the pathological complete response (pCR) rateand reduce the risk of distant metastasis. The objective of this trial is to increase the proportion of sphincter preservation rate for distal rectal cancer patients by optimizing tumor response, by using TNT regimen as compared to conventional chemoradiotherapy. TESS (clinicalTrials.gov, NCT03840239), a prospective, open label, multicenter, randomized phase 2 study, is underway. Methods: Main inclusion criteria include: cT3-4aNany or cTanyN+ rectal adenocarcinoma aged 18-70y; ECOG performance 0-1; distance≤5cm from anal verge. 168 patients will be randomized 1:1. Patients in the TNT group will receive 2 cycles of neoadjuvant chemotherapy Capeox (capecitabine + oxaliplation) before, during and after radiotherapy 50Gy/25 fractions, before TME (or other treatment decisions, such as watch and wait) and adjuvant chemotherapy capecitabine 2 cycles. Patients in the standard treatment group will receive neoadjuvant radiotherapy 50Gy/25 fractions combined with capecitabine 5 weeks before TME (or other treatment decisions, such as watch and wait), and adjuvant chemotherapy Capeox 6 cycles. Primary endpoint is the rate of sphincter preservation rate (absence of stoma). Secondary endpoints include: Ratio of sphincter preservation strategy; pathological complete response rate and tumor regression grade distribution; acute toxicity; surgical complications; long-term anal function; late toxicity; ECOG standard score; disease-free survival; overall survival. First site opened in January 24, 2019. Clinical trial information: NCT03840239.

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The International Watch & Wait database (IWWD) for rectal cancer: An update.

Journal of Clinical Oncology ◽

10.1200/jco.2017.35.4_suppl.521 ◽

2017 ◽

Vol 35 (4_suppl) ◽

pp. 521-521 ◽

Cited By ~ 3

Author(s):

Maxime van der Valk ◽

Keyword(s):

Rectal Cancer ◽

Induction Therapy ◽

Complete Response ◽

Outcome Data ◽

Induction Treatment ◽

Watch And Wait ◽

International Consensus ◽

Regional Lymph Nodes ◽

Oncological Safety

521 Background: In 2014 the IWWD was established by EURECCA and the Champalimaud Foundation. The main goal of this database is to collect all available data to expand knowledge on the benefits, risks and oncological safety of organ preserving strategies in rectal cancer. In April 2015 the database was opened for data registration. Methods: An international multicentre observational study. Data was collected by participating centres and stored in a highly secured NEN7510 certified and encrypted research data server. Each centre always retains full ownership of their data. Results: In August 2016 the database included 775 patients from 11 countries and 35 participating institutes. 90% of all patients were included because of a clinical complete response (n = 679). All other reasons for a watch-and-wait regimen were excluded for the present analyses. As shown in table 1, imaging modalities used to assess response after induction therapy were variable. Induction treatment consisted of chemo-radiotherapy in 90% of cases. Median follow-up time is 2.6 years (range 0-24 years). Local regrowth occurred in 25% (n = 167) of all patients, of which 84% in the first 2 years of follow-up. A local regrowth was located endoluminal in 96% (n = 161) and in the loco-regional lymph nodes in 4% (n = 7). Distant metastasis occurred in 7% (n = 49). The overall 3 year-survival of all patients was 91% and for patients with a local regrowth this was 87%. Conclusions: This is the largest series of patients with rectal cancer in which surgery was omitted after induction therapy. These data illustrate differences in induction therapy as well as imaging strategies and provide some crude outcome data. Further data collection on the Watch-and-Wait strategy for rectal cancer is needed to increase knowledge on oncological safety of omitting surgery. This may contribute to international consensus on staging, treatment and surveillance guidelines in rectal cancer care. [Table: see text]

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Predictors of pathologic complete response after neoadjuvant treatment for rectal cancer: A multicenter study.

Journal of Clinical Oncology ◽

10.1200/jco.2014.32.3_suppl.397 ◽

2014 ◽

Vol 32 (3_suppl) ◽

pp. 397-397 ◽

Cited By ~ 2

Author(s):

Dawn Elizabeth Armstrong ◽

Soundouss Raissouni ◽

Julie A. Price Hiller ◽

Jamison Mercer ◽

Erin Diana Powell ◽

...

Keyword(s):

Rectal Cancer ◽

Anal Verge ◽

Univariate Analysis ◽

Pathologic Complete Response ◽

Neoadjuvant Treatment ◽

Multivariable Analysis ◽

Complete Response ◽

Cancer Center ◽

Cancer Centre ◽

Statin Use

397 Background: Pathologic complete response (pCR) to neoadjuvant chemoradiation (CRT) for rectal cancer is associated with better long-term outcomes, and is used as an early indicator of response to novel agents. To assess the rate and predictors of pCR, we performed a retrospective population based study in four Canadian provinces. Methods: Cancer Registries identified consecutive patients with clinical stage I-III rectal cancer from the Tom Baker Cancer Center, Cross Cancer Institute, BC Cancer Agency, Ottawa Hospital Cancer Centre and the Dr. H. Bliss Murphy Cancer Centre who received fluoropyrimidine-based CRT and had curative intent surgery (Sx) from 2005 to 2012. Patient, tumor, and therapy characteristics were correlated with response. Results: Of the 891 patients included, 885 patients had pCR data available. 161 (18.2%) had a pCR to CRT, while 724 (81.8%) did not. Patients with a pCR had a lower pre-treatment (tx) CEA, and higher hemoglobin on univariate analysis (see table). On multivariable analysis, statin use at baseline (OR 1.7, 95% CI 1.04-2.89, p=0.044), lower pre-tx CEA (OR 1.03, 95% CI 1.003-1.05 p=0.028) and distance closer to anal verge (OR 1.07, 95% CI 1.004-1.15, p=0.039) were significant predictors of pCR. The 3yr DFS was 86% in those with pCR vs 62.5% in those without a pCR (P<0.0001). Conclusions: Lower pre-tx CEA, distance closer to anal verge and statin use are predictors of pCR. Clinical trials investigating statins combined with neoadjuvant CRT may be warranted. [Table: see text]

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