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      Quimioradioterapia en cáncer de recto y tasa de respuesta patológica Translated title: Chemoradiotherapy in rectal cancer and pathological response

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          Abstract

          Resumen Introducción. El tratamiento neoadyuvante con radioterapia y quimioterapia radiosensibilizante en el cáncer de recto localmente avanzado (CRLA) disminuye significativamente las tasas de recurrencia local. Por tanto el objetivo de este estudio es analizar la respuesta patológica completa (RPC) y parcial (RPP) tras el tratamiento neoadyuvante con quimioradioterapia en pacientes con CRLA. Material y método. Se realizó un estudio descriptivo, retrospectivo en pacientes con diagnóstico de CRLA desde enero 2016 a diciembre 2018 en el Servicio de Oncología-Radioterápica del Hospital Universitario La Paz. Se incluyeron 140 pacientes. Un grupo de pacientes (92,9%) se trató con radioterapia 3D conformada con una dosis de 45Gy sobre pelvis y una sobreimpresión de 5,4Gy sobre tumor primario y otro grupo (7,1%) se trató con radioterapia con técnica volumétrica y en arcoterapia (VMAT) guiado por imagen (IGRT) con una dosis de 53,7Gy en pelvis con sobreimpresión concurrente al tumor. La dosis de capecitabina oral fue de 850mg/m2 dos veces al día durante el tratamiento. Todos los pacientes fueron reevaluados con resonancia magnética (RM) post-neoadyuvancia. Los pacientes se operaron entre 6-8 semanas tras quimioradioterapia. Resultados. Se obtuvo una RPC de 17,1% y RPP de 80,1% con una tasa global de downstaging de 31,8%. Conclusión. Se concluye que la quimioradioterapia neoadyuvante es un tratamiento seguro con aceptables tasas de control local en los pacientes con CRLA.

          Translated abstract

          Abstract Introduction. Neoadjuvant treatment with radiotherapy and radiosensitizing chemotherapy in locally advanced rectal cancer (LARC) significantly decreases local recurrence rates. Therefore the objective of this study is to analyze the pathological complete response (PCR) and partial response (PPR) of neoadjuvant treatment with exclusive chemoradiotherapy in patients with locally advanced rectal cancer. Matherial and Method. It has been made a study descriptive, retrospective in a cohort of patients with LARC in the January 2016 to December 2018 period in the Radiation-Oncology Department of Hospital Universitario La Paz. 140 patients were included. A group of patients (92,9%) received treatment with radiotherapy 3D conformed technique with a dose administered the 45 Gy on pelvis and a boost of 5,4 Gy on tumor and other group (7,1%) received treatment with volumetric archotherapy radiotherapy (VMAT) guided by image (IGRT) with a dose administered of 53,7% on pelvis with concurrent boost and. The dose of capecitabine was 850 mg/m2, twice a day during the treatment. The patients were re-evaluated with post-neoadjuvant MRI. Patients were operated 6 to 8 weeks post chemoradiotherapy. Results. CPR was obtained of 17,1% and pPR of 80,1% with a global rate downstaging of 31,8%. Conclusion. It concludes that chemoradiotherapy neoadjuvant is a safe treatment with acceptable rates of local control in patients with LARC.

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          Systematic review and meta-analysis of outcomes following pathological complete response to neoadjuvant chemoradiotherapy for rectal cancer.

          Following neoadjuvant chemoradiotherapy (CRT) and interval proctectomy, 15-20 per cent of patients are found to have a pathological complete response (pCR) to combined multimodal therapy, but controversy persists about whether this yields a survival benefit. This systematic review evaluated current evidence regarding long-term oncological outcomes in patients found to have a pCR to neoadjuvant CRT. Three major databases (PubMed, MEDLINE and the Cochrane Library) were searched. The systematic review included all original articles reporting long-term outcomes in patients with rectal cancer who had a pCR to neoadjuvant CRT, published in English, from January 1950 to March 2011. A total of 724 studies were identified for screening. After applying inclusion and exclusion criteria, 16 studies involving 3363 patients (1263 with pCR and 2100 without) were included (mean age 60 years, 65·0 per cent men). Some 73·4 per cent had a sphincter-saving procedure. Mean follow-up was 55·5 (range 40-87) months. For patients with a pCR, the weighted mean local recurrence rate was 0·7 (range 0-2·6) per cent. Distant failure was observed in 8·7 per cent. Five-year overall and disease-free survival rates were 90·2 and 87·0 per cent respectively. Compared with non-responders, a pCR was associated with fewer local recurrences (odds ratio (OR) 0·25; P = 0·002) and less frequent distant failure (OR 0·23; P < 0·001), with a greater likelihood of being alive (OR 3·28; P = 0·001) and disease-free (OR 4·33, P < 0·001) at 5 years. A pCR following neoadjuvant CRT is associated with excellent long-term survival, with low rates of local recurrence and distant failure. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
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            Assessment of a Watch-and-Wait Strategy for Rectal Cancer in Patients With a Complete Response After Neoadjuvant Therapy

            What are the rates of local regrowth, pelvic control, and survival when using a watch-and-wait approach for patients with rectal cancer after a clinical complete response to neoadjuvant therapy? A watchful waiting strategy for 113 patients with rectal cancer achieving a clinical complete response after neoadjuvant therapy resulted in excellent rectal preservation (82%) and pelvic tumor control (91%) in this case series study. However, worse survival was observed compared with 136 patients undergoing total mesorectal excision who had a pathologic complete response; a higher incidence of distant progression was also noted among patients managed by the watch-and-wait strategy who developed local regrowth vs those who did not develop local regrowth. A watch-and-wait strategy may be safe for most patients, but better risk stratification is needed for more precise patient selection to identify those at high risk of local regrowth who are not optimal candidates. This case series of patients with rectal cancer compares outcomes between those who had a clinical complete response to neoadjuvant therapy and agreed to a watch-and-wait strategy and those who underwent total mesorectal excision and had a pathologic complete response at resection. The watch-and-wait (WW) strategy aims to spare patients with rectal cancer unnecessary resection. To analyze the outcomes of WW among patients with rectal cancer who had a clinical complete response to neoadjuvant therapy. This retrospective case series analysis conducted at a comprehensive cancer center in New York included patients who received a diagnosis of rectal adenocarcinoma between January 1, 2006, and January 31, 2015. The median follow-up was 43 months. Data analyses were conducted from June 1, 2016, to October 1, 2018. Patients had a clinical complete response after completing neoadjuvant therapy and agreed to a WW strategy of active surveillance and possible salvage surgery (n = 113), or patients underwent total mesorectal excision and were found to have a pathologic complete response (pCR) at resection (n = 136). Kaplan-Meier estimates were used for analyses of local regrowth and 5-year rates of overall survival, disease-free survival, and disease-specific survival. Compared with the 136 patients in the pCR group, the 113 patients in the WW group were older (median [range], 67.2 [32.1-90.9] vs 57.3 [25.0-87.9] years, P  < .001) with cancers closer to the anal verge (median [range] height from anal verge, 5.5 [0.0-15.0] vs 7.0 [0.0-13.0] cm). All 22 local regrowths in the WW group were detected on routine surveillance and treated by salvage surgery (20 total mesorectal excisions plus 2 transanal excisions). Pelvic control after salvage surgery was maintained in 20 of 22 patients (91%). No pelvic recurrences occurred in the pCR group. Rectal preservation was achieved in 93 of 113 patients (82%) in the WW group (91 patients with no local regrowths plus 2 patients with local regrowths salvaged with transanal excision). At 5 years, overall survival was 73% (95% CI, 60%-89%) in the WW group and 94% (95% CI, 90%-99%) in the pCR group; disease-free survival was 75% (95% CI, 62%-90%) in the WW group and 92% (95% CI, 87%-98%) in the pCR group; and disease-specific survival was 90% (95% CI, 81%-99%) in the WW group and 98% (95% CI, 95%-100%) in the pCR group. A higher rate of distant metastasis was observed among patients in the WW group who had local regrowth vs those who did not have local regrowth (36% vs 1%, P  < .001). A WW strategy for select rectal cancer patients who had a clinical complete response after neoadjuvant therapy resulted in excellent rectal preservation and pelvic tumor control; however, in the WW group, worse survival was noted along with a higher incidence of distant progression in patients with local regrowth vs those without local regrowth.
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              MRI of Rectal Cancer: Tumor Staging, Imaging Techniques, and Management

              Rectal cancer is prone to local recurrence and systemic metastasis. However, owing to improvements in TNM staging and treatment, including a more widespread use of rectal MRI and increased radiologist awareness of the key rectal cancer TNM staging features, the mortality rate of rectal cancer has been declining over the past few decades in adults over 50 years of age. Currently, rectal MRI plays a key role in the pre- and posttreatment evaluation of rectal cancer, assisting the multidisciplinary team in tailoring the most appropriate treatment option. The benefits achieved with rectal MRI are strictly dependent on obtaining good-quality images, which is important for the characterization of the main anatomic structures and their relationship with the tumor. In primary staging, rectal MRI helps the radiologist (a) describe the tumor location and morphology, (b) provide its T and N categories, (c) detect the presence of extramural vascular invasion, and (d) identify its relationship with surrounding structures, including the sphincter complex and involvement of the mesorectal fascia. These features help diagnose locally advanced rectal tumors (categories T3c-d, T4, N1, and N2), for which neoadjuvant chemoradiotherapy (CRT) is indicated. In restaging after neoadjuvant CRT, in addition to reassessing the features noted during primary staging, rectal MRI can help in the assessment of treatment response, especially with the emergence of nonsurgical approaches such as “watch and wait.” © RSNA, 2019
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                Author and article information

                Journal
                jonnpr
                Journal of Negative and No Positive Results
                JONNPR
                Research and Science S.L. (Madrid, Madrid, Spain )
                2529-850X
                2020
                : 5
                : 11
                : 1378-1389
                Affiliations
                [1] Madrid orgnameHospital Universitario La Paz orgdiv1Servicio de Oncología-Radioterápica España
                Article
                S2529-850X2020001100010 S2529-850X(20)00501100010
                10.19230/jonnpr.3812
                c12aafca-e13f-4a6e-acb8-97111a469aa0

                This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

                History
                : 19 August 2020
                : 12 May 2020
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 28, Pages: 12
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                SciELO Spain

                Categories
                Original

                cáncer de recto,quimioradioterapia,radioterapia,cáncer,chemoradiotherapy,cancer of rectum,radiotherapy,cancer

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