Low rectal cancer: Sphincter preserving techniques-selection of patients, techniques and outcomes

Background: Organ preservation in the treatment of rectal cancer has seen an increase in interest. Clinical complete response (cCR) after high-dose chemoradiotherapy (CRT) allows for non-surgical management (NSM), but the selection of patients is challenging and standard clinical staging insufficient. MicroRNA-21-5p (miR-21) is ubiquitously upregulated in cancer and has been associated with treatment response in rectal cancer treated with standard preoperative CRT. The aim of the present study was to investigate this association in low rectal cancer treated in the NSM setting. Methods: Forty-eight patients from our single-arm phase II trial (NCT00952926) were eligible for analysis. All patients had resectable T2 or T3, N0–N1 low adenocarcinoma and received intensity-modulated radiotherapy plus brachytherapy boost and oral tegafur–uracil. Patients with cCR six weeks after end of treatment assessed by clinical examination, magnetic resonance imaging, and biopsy, were referred to observation and close follow-up. The miR expression in the diagnostic biopsies was measured by qPCR. The relationship between miR-21 expression and cCR was assessed using the Wilcoxon rank-sum test. Results: Thirty-eight patients had cCR after treatment and were allocated to observation while 10 patients had incomplete response and underwent surgery. MicroRNA-21 was successfully analyzed in all samples. The median tumor expression of miR-21 was significantly higher in patients with incomplete response than in those with cCR, 24.3 (95% confidence interval (CI) 17.1–36.8) and 16.6 (95% CI 13.9–21.1), respectively, p = 0.03. Conclusions: The present study adds to the evidence of the clinical impact of miR-21 in rectal cancer treated with CRT. The findings are comparable with results seen in patients treated in the standard preoperative setting and may assist in the selection of patients for an organ preserving approach.

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Optimizing the selection of patients with low rectal cancer for intersphincteric resection by evaluating vertical invasion to the levator and external sphincter

Colorectal Disease ◽

10.1111/codi.12769 ◽

2015 ◽

Vol 17 (2) ◽

pp. 133-140

Author(s):

K. Narui ◽

Y. Ichikawa ◽

H. Ike ◽

M. Ota ◽

S. Saito ◽

...

Keyword(s):

Rectal Cancer ◽

External Sphincter ◽

Intersphincteric Resection ◽

Low Rectal Cancer ◽

Selection Of Patients ◽

Selection Of

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Preoperative staging of rectal cancer allows selection of patients for preoperative radiotherapy

British Journal of Surgery ◽

10.1046/j.1365-2168.2000.01689-4.x ◽

2000 ◽

Vol 87 (12) ◽

pp. 1733-1733

Author(s):

I. M. Loftus

Keyword(s):

Rectal Cancer ◽

Preoperative Radiotherapy ◽

Preoperative Staging ◽

Selection Of Patients ◽

Selection Of

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Progress in Rectal Cancer Treatment

ISRN Gastroenterology ◽

10.5402/2012/648183 ◽

2012 ◽

Vol 2012 ◽

pp. 1-15 ◽

Cited By ~ 5

Author(s):

Wim P. Ceelen

Keyword(s):

Rectal Cancer ◽

Neoadjuvant Therapy ◽

Imaging Techniques ◽

Dramatic Improvement ◽

Term Outcome ◽

Long Term Outcome ◽

Number Of Patients ◽

Systemic Relapse ◽

Selection Of Patients ◽

Selection Of

The dramatic improvement in local control of rectal cancer observed during the last decades is to be attributed to attention to surgical technique and to the introduction of neoadjuvant therapy regimens. Nevertheless, systemic relapse remains frequent and is currently insufficiently addressed. Intensification of neoadjuvant therapy by incorporating chemotherapy with or without targeted agents before the start of (chemo)radiation or during the waiting period to surgery may present an opportunity to improve overall survival. An increasing number of patients can nowadays undergo sphincter preserving surgery. In selected patients, local excision or even a “wait and see” approach may be feasible following active neoadjuvant therapy. Molecular and genetic biomarkers as well as innovative imaging techniques may in the future allow better selection of patients for this treatment option. Controversy persists concerning the selection of patients for adjuvant chemotherapy and/or targeted therapy after neoadjuvant regimens. The currently available evidence suggests that in complete pathological responders long-term outcome is excellent and adjuvant therapy may be omitted. The results of ongoing trials will help to establish the ideal tailored approach in resectable rectal cancer.

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Selection of Patients With Rectal Cancer for Preoperative Chemoradiotherapy

Diseases of the Colon & Rectum ◽

10.1097/dcr.0000000000001229 ◽

2019 ◽

Vol 62 (4) ◽

pp. 447-453 ◽

Cited By ~ 2

Author(s):

Amandeep Pooni ◽

Eisar Al-Sukhni ◽

Laurent Milot ◽

Mark Fruitman ◽

J. Charles Victor ◽

...

Keyword(s):

Rectal Cancer ◽

Preoperative Chemoradiotherapy ◽

Selection Of Patients ◽

Selection Of

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MRI-based selection of patients with metastatic extramesorectal rectal cancer nodes for preoperative chemoradation.

Journal of Clinical Oncology ◽

10.1200/jco.2012.30.4_suppl.570 ◽

2012 ◽

Vol 30 (4_suppl) ◽

pp. 570-570

Author(s):

Monique Maas ◽

Doenja MJ Lambregts ◽

Freek Gillissen ◽

Sanne ME Engelen ◽

Max J Lahaye ◽

...

Keyword(s):

Rectal Cancer ◽

Cancer Patients ◽

Poor Prognosis ◽

Extensive Resection ◽

Kaplan Meier ◽

Expert Radiologist ◽

Contrast Enhanced ◽

Selection Of Patients ◽

Selection Of

570 Background: 20% of rectal cancer patients have metastatic lymph nodes outside the mesorectum (EMRs). These EMR node positives are associated with poor prognosis. Accurate selection would help to tailor treatment and improve prognosis for these patients. Methods: Rectal cancer patients were included in a study in which treatment was based on (contrast-enhanced) MRI. EMR-status was predicted by an expert radiologist. Based on this prediction patients underwent chemoradiation (CRT) of the EMRs. 6-8 weeks after CRT EMRs were restaged. If still involved, the EMRs were resected. When the EMRs were sterilised by the CRT, they were not resected. Patients were followed 3 to 6-monthly after surgery by a combination of modalities. 3-year outcome was estimated with Kaplan-Meier curves. Results: 50 patients with suspected EMRs were included. Median follow-up was 26(0-50) months. In 13 patients EMRs were resected after CRT and in only 2/13 positive nodes were found. Of the remaining 37 patients 5 had a local recurrence (LR). In total 32+11=43 patients (86%) had no involved EMRs after CRT. Five patients had metastasis of whom 2 also had a LR. 3-year LR was 2.3%, 3-year DFS was 86% and 3-year OS was 90%. Conclusions: MRI-based selection of patients with EMRs for CRT provides adequate local control. Distant metastasis is the main cause of poor prognosis in these patients. When MRI is used for EMR identification and thus for identification of patients who need CRT also on the obturator regions, patients can be spared an extensive resection with associated morbidity.

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