OBJECTIVETo analyze the association between the response of primary tumor to neoadjuvant chemoradiotherapy (CRT) and lymph node status in mid and low rectal cancer.

METHODSSeventy-one patients with locally advanced mid and low rectal cancer underwent preoperative CRT followed by surgery. Surgical specimens were examined by surgeons and pathologists to obtain more lymph nodes and the histological sections were examined. Tumor responses to preoperative CRT were assessed in terms of tumor downstaging and tumor regression. Statistical analyses were performed to investigate the relationship between tumor regression and lymph node status.

RESULTSAll the patients completed the neoadjuvant CRT. Twelve patients achieved pathological complete response, of whom one was not operated and on surveillance. Pathological examination of the remaining 70 patients showed that the tumor was downstaged to T 0-2 group in 39 patients, among whom 5 patients (12.8%) had positive lymph nodes. Tumor was not downstaged in 31 patients, of whom 10 patients (32.3%) had positive nodes. The difference between the two groups was statistically significant (P=0.029).

CONCLUSIONTumor regression is consistent with the reduction of lymph node metastasis after preoperative CRT.

Chemoradiotherapy ; Humans ; Lymphatic Metastasis ; Neoadjuvant Therapy ; Rectal Neoplasms ; therapy

Neoadjuvant chemoradiation combined with radical surgery has been established as the standard care for locally advanced rectal cancer(T3-T4 and/or N1-N2). Approximately 20% patients who achieve complete pathological response have an improved prognosis. Appropriate patient selection may help avoid over-treatment. Evaluation of treatment response mostly with imaging study and pathology after neoadjuvant chemoradiation and following surgery is essential for the subsequent selection of treatment strategy.
Chemoradiotherapy ; Humans ; Neoadjuvant Therapy ; Patient Selection ; Prognosis ; Rectal Neoplasms ; therapy

The combination of preoperative chemoradi-otherapy and surgery has become the standard treatment for locally advanced rectal cancer. Up to 30% of patients received pathologic complete response(pCR) after neoadjuvant therapy, for whom low rates of local recurrence and improved outcome after surgery were achieved. Given that, some authors have recommended local resection for clinical extensive response or non operative "wait and see" policy for clinical complete response(cCR) respectively, in which radical surgery-associated complication and dysfunction can be avoided. Current imaging can provide excellent accuracy in primary staging of rectal cancer, however, when used for restaging, the ability is less satisfactory, especially for pCR prediction, as a result of modification on tumor and surrounding tissue induced by neoadjuvant therapy. The question on how to identify patients with pCR before surgery has received more attention recently. On the basis of pathological findings after surgery, in this article, we review the reliability and predictive ability of current imaging for restaging and pCR after preoperative chemoradiotherapy in rectal cancer.
Chemoradiotherapy ; Humans ; Neoadjuvant Therapy ; Rectal Neoplasms ; pathology ; therapy ; Treatment Outcome

Surgery is still considered to be the mainstay for the treatment of localized gastric cancer with negative margins (R0-resection) and an adequate lymph-node-dissection (D2-lymphadenectomy). Unfortunately, most cases of gastric cancer are only diagnosed at an advanced stage due to frequent recurrences after primary resection in curative intent. In order to improve prognosis after curative resection, in the recent past, patients with locally advanced tumors were subjected to a pre-, peri-, or postoperative treatment. Interestingly, postoperative chemotherapy has significantly improved survival after gastric resection in Asia, adjuvant radiochemotherapy is favored in North America and perioperative chemotherapy is considered as a treatment of choice in Europe indicating region specific approach towards the treatment. Recently there has also been growing evidence of positive outcomes of neoadjuvant radiochemotherapy on patient survival. In the present article, we discuss the concepts of neoadjuvant treatment approach and provide recommendations to surgeons based on current evidence.
Asia ; Chemoradiotherapy ; Chemoradiotherapy, Adjuvant ; Europe ; Humans ; Neoadjuvant Therapy ; North America ; Prognosis ; Recurrence ; Stomach Neoplasms

Close observation or local excision have developed to be acceptable choices of managing rectal cancer patients who had a complete or major response to neoadjuvant chemoradiation. Indications of these rectum-preserving strategies, however, remain debatable due to inaccurate tumor staging after chemoradiation, apparent discrepancy between pathological and clinical complete responses, and uncertain lymph node status. Both responses to chemoradiation and original tumor staging must be considered to decide the treatment plan. For patients with major response to chemoradiation and with an original staging of cTis-2, a local excision is now acceptable with close postoperative observation or additive radical surgery according to pathological results. Otherwise, a standard radical surgery is still the treatment of choice. Post-radiation tumor evaluation can be employed for decision on sphincter preservation. A longer waiting time of 6-12 weeks before surgery is suggested.
Chemoradiotherapy ; Humans ; Neoadjuvant Therapy ; Neoplasm Staging ; Rectal Neoplasms ; therapy ; Remission Induction

OBJECTIVETo investigate the consistence of human epidermal growth factor receptor 2 (HER-2) expression in resection samples and biopsy samples from rectal cancer and its clinical implication.

METHODSClinical data and tissue samples of 544 rectal cancer patients who received surgical resection at Peking University Cancer Hospital from September 2009 to March 2012 were collected and analyzed retrospectively. Immunohistochemical method was used to test HER-2 expression in both surgical resection samples and preoperative biopsy samples. Suspect positive samples with HER-2 (++) were further examined by FISH. Consistence of HER-2 expression between resection samples and biopsy samples, and between resection samples from those patients undergoing neoadjuvant radiotherapy or radiochemotherapy and biopsy samples was analyzed. Association between HER-2 expression and clinicopathological characteristics was examined as well.

RESULTSAmong 544 surgical resection samples, positive HER-2 samples of 20 cases (3.7%) were identified either by immunohistochemistry (HER-2, +++) or by FISH amplification. Among 235 paired biopsy samples, positive HER-2 samples of 5 cases (2.1%) were identified. Consistence of HER-2 expression between these two samples was 99.6% (234/235). The kappa value of consistence test was 0.907 (P<0.01). Consistence between resection samples from patients receiving neoadjuvant therapy and biopsy samples was 98.6% (73/74). There was no association of HER-2 over-expression or amplification with gender, age, tumor differentiation grade, lymph-node metastasis, distant metastasis, TNM stage and overall survival.

CONCLUSIONSPositive rate of HER-2 expression is quite low in rectal cancer and has no relation to clinicopathological characteristics and prognosis. HER-2 status in biopsy samples of rectal cancer is highly consistent with paired surgical resection samples, which is not affected by neoadjuvant radiochemotherapy.

Chemoradiotherapy ; Humans ; Immunohistochemistry ; Lymphatic Metastasis ; Neoadjuvant Therapy ; Prognosis ; Receptor, ErbB-2 ; Rectal Neoplasms ; Retrospective Studies

Recently, treatment strategy optimization for neoadjuvant therapy of rectal cancer includes two aspects: (1) Increasing treatment intensity may improve pathological complete response rate, including increasing radiation dose or concurrent chemotherapy intensity, or shifting adjuvant chemotherapy; (2) Short-course radiotherapy or neoadjuvant chemotherapy which can promise treatment efficacy will decrease toxicity and lead to better tolerance. Long-course chemoradiotherapy is the recent treatment standard for locally advanced rectal cancer. NCCN guidelines do not recommend combined chemotherapy in the radiotherapy period. However, it is important for individualized treatment of rectal cancer if appropriate patients who may benefit from the combined concurrent chemotherapy can be selected. Short-course radiotherapy is defined as 5 Gy × 5. It is recommended for T3 or N+ rectal cancer in NCCN guidelines, but not for T4 patients. In ESMO guidelines, stratified patients of intermediate risk by MRI can be treated with either short-course or long-course radiotherapy, but short-course radiotherapy is not recommended for T4 or positive mesorectum fascia (MRF+) patients with high risk. Neoadjuvant chemotherapy incorporated in the neoadjuvant part has been a therapeutic choice in NCCN guidelines. However, It is still unclear whether chemotherapy upfront as a component of neoadjuvant treatment or even completion of chemotherapy before surgery can improve treatment outcome or not. There are phase II( studies focused on this issue and final results are pending.
Chemoradiotherapy ; Chemotherapy, Adjuvant ; Humans ; Neoadjuvant Therapy ; Rectal Neoplasms ; radiotherapy ; Treatment Outcome

Multi-disciplinary treatment (MDT) is an effective pattern to implement the standardized and individualized treatment for cancer. Under the pattern of MDT which integrates the surgery, chemotherapy, radiotherapy, interventional therapy, targeted therapy and immune therapy, there has been a landmark progress in the diagnosis and treatment of colorectal cancer. Curative resection followed by adjuvant chemotherapy has been established as a standard treatment for stage III( colon cancer, but it is still controversial about whether patients with stage II( colon cancer should receive adjuvant chemotherapy and which regimen is preferred. Decision making regarding the use of adjuvant therapy for stage II( patients should not only depend upon the clinicopathological features but also individualized discussion between patients and physicians about the biological behavior of the disease, evidence supporting the efficacy, and possible toxicity. Radical operation following neoadjuvant chemoradiotherapy is currently the standard modality for locally advanced rectal cancer, but the strategy of 'Wait and See' is proposed by some researchers for those achieving complete response after chemoradiotherapy, although there is no sufficient supportive data yet. Patients with metastatic colorectal cancer should undergo an upfront evaluation and discussion by a multidisciplinary team before the initial treatment. Achieving a negative surgical margin with adequate remanent liver reserve is the criteria for determining the resectability of liver metastasis. Both adjuvant and neoadjuvant chemotherapy are two alternatives for initially resectable liver metastasis. Concomitant with the progress of medicine, the MDT is moving toward a precise treatment system oriented by genes and being able to predict the prognosis, efficacy and side effects exactly.
Chemoradiotherapy ; Chemotherapy, Adjuvant ; Colorectal Neoplasms ; pathology ; therapy ; Humans ; Liver Neoplasms ; secondary ; Neoadjuvant Therapy ; Prognosis

BACKGROUNDThe effectiveness of neoadjuvant chemoradiotherapy (NCRT) treatment for patients with esophageal carcinoma (EC) remains controversial. The aim of this study was to compare the effect of NCRT followed by surgery (NCRTS) with surgery alone (SA) for EC.

METHODSThe PubMed, EMBASE, and the Cochrane Library databases were electronically searched up to August 2015 for all the published studies that investigated EC patients receiving either NCRTS or SA, and the reference lists were also manually examined for the eligible studies. The risk ratio (RR) with 95% confidence intervals (CI s) as effective size was determined to assess the 1-, 3-, 5-year survival rates (SRs), postoperative morbidity, and postoperative mortality. Heterogeneity was determined using the Q-test. The Begg's test and Egger's test were used for assessing any potential publication bias.

RESULTSOf 1120 identified studies, 16 eligible studies were included in this analysis (involving 2549 patients). Overall, the pooled results suggested that NCRTS was associated with significantly improved 1-year (RR: 1.07, 95% CI: 1.02-1.13), 3-year (RR: 1.26, 95% CI: 1.14-1.39), and 5-year (RR: 1.36, 95% CI: 1.18-1.56) SRs. However, the results also indicated that NCRTS had no or little effect on postoperative morbidity (RR: 0.93, 95% CI: 0.82-1.05) and postoperative mortality (RR: 1.17, 95% CI: 0.56-2.44).

CONCLUSIONSCompared with SA, NCRTS can increase 1-, 3-, and 5-year SRs in patients with EC.

Chemoradiotherapy ; methods ; Esophageal Neoplasms ; drug therapy ; mortality ; Humans ; Neoadjuvant Therapy ; methods ; Survival Rate

OBJECTIVESTo investigate the regression pattern of mid and low rectal cancer treated with neoadjuvant chemoradiotherapy and then to provide the pathological proofs for reasonable resectional margin in rectal cancer surgery.

METHODSForty cases of mid and low rectal cancer patients received concurrent chemoradiotherapy and then underwent radical operation. The whole-mount serial sections of resected rectal cancer specimen were stained with cytokeratin antibody using immunohistochemical techniques to show the residual cancer cells under the mucosa. The microscopic measurement was performed to determine the reverse infiltration of cancer cells in the rectal wall and to describe the cancer cells scatter ways in the cancer mass. The Ki-67 immunohistochemical stain was also performed to show the proliferation activity of residual cancer cells after neoadjuvant chemoradiotherapy.

RESULTSThe length of specimen was shrinking continuously during the pathologic section production and the shrink rate was 18%. There were remanent cancer cells which showed positive Ki-67 expression and the chemoradiotherapy decreased the Ki-67 expression significantly. The lower edge of remaining ulcers or scars could be used as the reference point from which the cancer infiltration could be measured. According to our measurement, the average reverse infiltration of cancer cells in the whole-mount section was (6.1±4.7) mm, the deepest one was 11.0 mm in the section which could be converted into fresh bowel length of 12.98 mm. The pathology showed that the residual cancer cells scattered in the fibrous tissue of ulcers, scars and manifested a regression of spatial distribution.

CONCLUSIONSThe rectal cancers show regression in different degrees after neoadjuvant chemoradiotherapy. The residual cancer cells in the fiber tissues manifest proliferation activity. The distal end of resection should be at least 2 cm away from the lower edge of ulcers or scars of primary tumor in the rectal wall in patients after neoadjuvant chemoradiotherapy. The circumferential resection margin should include all the fibrous scar of the tumor area to ensure the remove of tumor cells completely.

Aged ; Chemoradiotherapy ; Female ; Humans ; Male ; Middle Aged ; Neoadjuvant Therapy ; Rectal Neoplasms ; pathology ; surgery ; therapy