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Timing of Surgery after Neoadjuvant Long-course Chemoradiotherapy in the Management of Locally Advanced Rectal Cancer
Clinical Oncology 24 (2012) e195 Contents lists available at SciVerse ScienceDirect
Clinical Oncology journal homepage: www.clinicaloncologyonline.net
Letter
Timing of Surgery after Neoadjuvant Long-course Chemoradiotherapy in the Management of Locally Advanced Rectal Cancer Sir d Although preoperative chemoradiotherapy (CRT) is standard practice in the UK for the management of locally advanced rectal cancer, the optimal timing of surgery after CRT remains unclear [1,2]. Higher rates of histopathological complete response with a time interval to surgery of greater than 7 weeks have previously been reported [1,3]. We reviewed 33 patients with rectal cancer who had undergone long-course CRT before surgery over a 2 year period. An R0 resection was achieved in 30 patients; the remaining three had an R1 resection. After definitive surgery after CRT, nine patients showed a complete histopathological response (complete response) and 12 patients had documented evidence of tumour regression. There was a significantly longer delay to surgery after the completion of CRT in the nine patients with a complete response as compared with the rest of the group (incomplete response) (complete response mean 81 days versus incomplete response mean 67.5 days, P ¼ 0.0246 ManneWhitney U test). Eighteen of 33 patients (54.5%) were down-staged from radiologically assessed node positive to histologically proven node negative disease. However, there was no statistically significant difference in the interval to surgery between the postoperative histologically node negative group and the group that remained histologically node positive (node negative: mean 75 days versus node positive mean 66.2 days, P ¼ 0.0563), but a trend was apparent. There was no 30 day mortality in the cohort of patients studied. Our results suggest a correlation between a longer delay to surgery after the completion of CRT and achieving a pathological complete response. No significant difference
was detected in down-staging node positive to node negative disease with the timing to surgery. Further evidence, such as the results of the Deferral of Surgery Trial, is needed to determine the optimal interval between CRT and surgery. I.G. Panagiotopoulou*, D. Parasharyz, R. Mezher-Sikafi*x, J. Parmar*, A.D. Wells*, M. Menon*, C.R. Jephcottxjj *Department of General Surgery, Peterborough City Hospital, Edith Cavell Campus, Peterborough, UK yCambridge Cancer Trials Centre, Department of Oncology, University of Cambridge, Addenbrooke’s Hospital, Box 279, Cambridge, UK zMRC Biostatistics Unit Hub in Trials Methodology Research, University Forvie Site, Cambridge, UK xDepartment of Oncology, Peterborough City Hospital, Edith Cavell Campus, Peterborough, UK jjOncology Department, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
References [1] Wong RKS, Berry S, Spithoff K, et al, on behalf of the Gastrointestinal Cancer Disease Site Group. Preoperative or postoperative therapy for stage II or III rectal cancer: an updated practice guideline. Clin Oncol 2010;22:265e271. [2] Dewdney A, Cunningham D. Toward the non-surgical management of locally advanced rectal cancer. Curr Oncol Rep 2012;14:267e276. [3] Tulchinsky H, Shmueli E, Figer A, Klausner JM, Rabau M. An interval of >7 weeks between neoadjuvant therapy and surgery improves pathologic complete response and diseasefree survival in patients with locally advanced rectal cancer. Ann Surg Oncol 2008;15:2661e2667.
0936-6555/$36.00 Ó 2012 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.clon.2012.09.002
Clinical Oncology journal homepage: www.clinicaloncologyonline.net
Letter
Timing of Surgery after Neoadjuvant Long-course Chemoradiotherapy in the Management of Locally Advanced Rectal Cancer Sir d Although preoperative chemoradiotherapy (CRT) is standard practice in the UK for the management of locally advanced rectal cancer, the optimal timing of surgery after CRT remains unclear [1,2]. Higher rates of histopathological complete response with a time interval to surgery of greater than 7 weeks have previously been reported [1,3]. We reviewed 33 patients with rectal cancer who had undergone long-course CRT before surgery over a 2 year period. An R0 resection was achieved in 30 patients; the remaining three had an R1 resection. After definitive surgery after CRT, nine patients showed a complete histopathological response (complete response) and 12 patients had documented evidence of tumour regression. There was a significantly longer delay to surgery after the completion of CRT in the nine patients with a complete response as compared with the rest of the group (incomplete response) (complete response mean 81 days versus incomplete response mean 67.5 days, P ¼ 0.0246 ManneWhitney U test). Eighteen of 33 patients (54.5%) were down-staged from radiologically assessed node positive to histologically proven node negative disease. However, there was no statistically significant difference in the interval to surgery between the postoperative histologically node negative group and the group that remained histologically node positive (node negative: mean 75 days versus node positive mean 66.2 days, P ¼ 0.0563), but a trend was apparent. There was no 30 day mortality in the cohort of patients studied. Our results suggest a correlation between a longer delay to surgery after the completion of CRT and achieving a pathological complete response. No significant difference
was detected in down-staging node positive to node negative disease with the timing to surgery. Further evidence, such as the results of the Deferral of Surgery Trial, is needed to determine the optimal interval between CRT and surgery. I.G. Panagiotopoulou*, D. Parasharyz, R. Mezher-Sikafi*x, J. Parmar*, A.D. Wells*, M. Menon*, C.R. Jephcottxjj *Department of General Surgery, Peterborough City Hospital, Edith Cavell Campus, Peterborough, UK yCambridge Cancer Trials Centre, Department of Oncology, University of Cambridge, Addenbrooke’s Hospital, Box 279, Cambridge, UK zMRC Biostatistics Unit Hub in Trials Methodology Research, University Forvie Site, Cambridge, UK xDepartment of Oncology, Peterborough City Hospital, Edith Cavell Campus, Peterborough, UK jjOncology Department, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
References [1] Wong RKS, Berry S, Spithoff K, et al, on behalf of the Gastrointestinal Cancer Disease Site Group. Preoperative or postoperative therapy for stage II or III rectal cancer: an updated practice guideline. Clin Oncol 2010;22:265e271. [2] Dewdney A, Cunningham D. Toward the non-surgical management of locally advanced rectal cancer. Curr Oncol Rep 2012;14:267e276. [3] Tulchinsky H, Shmueli E, Figer A, Klausner JM, Rabau M. An interval of >7 weeks between neoadjuvant therapy and surgery improves pathologic complete response and diseasefree survival in patients with locally advanced rectal cancer. Ann Surg Oncol 2008;15:2661e2667.
0936-6555/$36.00 Ó 2012 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.clon.2012.09.002