Oncological outcomes of local excision compared with radical surgery after neoadjuvant chemoradiotherapy for rectal cancer: a systematic review and meta-analysis
Tóm tắt
Low rectal cancer is conventionally managed with neoadjuvant chemoradiotherapy (CRT) followed by radical surgery (RS). In patients who refuse a stoma or are unfit for RS, an alternative approach may be the use of pre-op CRT and local excision (LE) where tumours are responsive. The aim of this systematic review is to determine whether differences exist in local recurrence (LR), overall survival (OS) and disease-free (DFS) survival between patients treated with CRT + LE and CRT + RS. A literature search was performed using MEDLINE/PubMed/Ovid databases and Google Scholar between 1946 and 2013. Studies comparing outcome following LE and RS post-CRT were included. A pooled analysis was carried out using the Mantel-Haenszel statistical (random effects) model to identify differences in LR, OS and DFS between CRT + LE and CRT + RS. Eight studies were suitable for pooled analyses of LR whereas five and four studies were analysed for OS and DFS, respectively. When RS was used as the reference group, LR rate was higher in the LE group. However, this was non-significant (odds ratio (OR) 1.29, confidence interval (CI) 0.72–2.31, p = 0.40). Similarly, no difference was observed in 10-year OS (OR 0.96, CI 0.38–2.43, p = 0.93) or 5-year DFS (OR 1.04, CI 0.61–1.76, p = 0.89). There was evidence of publication bias in studies used for DFS. Subgroup analysis of above outcomes in T3/any N stage cancers showed no difference in LE versus RS. In the current evidence synthesis, there was no statistical difference in the LR, OS and DFS rates observed between patients treated with LE and RS for rectal cancer post-CRT. LE post-CRT may represent a viable alternative to RS for some patients wishing to avoid RS. However, further randomised studies are required to confirm these results.
Tài liệu tham khảo
Kapiteijn E, Marijnen CA, Nagtegaal ID et al (2001) Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med 345:638–646
Swedish Rectal Cancer Trial (1997) Improved survival with preoperative radiotherapy in resectable rectal cancer. Swedish Rectal Cancer Trial. N Eng J Med 336(14):980–987
Habr-Gama A, Perez RO, São Julião GP, Proscurshim I, Gama-Rodrigues J (2011) Nonoperative approaches to rectal cancer: a critical evaluation. Semin Radiat Oncol 21:234–239
Kim TH, Jeong S-Y, Choi DH et al (2008) Lateral lymph node metastasis is a major cause of locoregional recurrence in rectal cancer treated with preoperative chemoradiotherapy and curative resection. Ann Surg Oncol 15:729–737
Sauer R, Becker H, Hohenberger W et al (2004) Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 351:1731–1740
Morino M, Allaix ME (2013) Transanal endoscopic microsurgery: what indications in 2013? Gastroenterology report 1:75–84
Mengual-Ballester M, García-Marín JA, Pellicer-Franco E et al (2012) Protective ileostomy: complications and mortality associated with its closure. Rev Esp de Enferm Dig 104:350–354
Habr-Gama A, Perez RO, Proscurshim I et al (2006) Patterns of failure and survival for nonoperative treatment of stage c0 distal rectal cancer following neoadjuvant chemoradiation therapy. J Gastrointest Surg 10:1319–1328, discussion 1328–9
Dedemadi G, Wexner SD (2012) Complete response after neoadjuvant therapy in rectal cancer: to operate or not to operate? Dig Dis 30(Suppl 2):109–117. doi:10.1159/000342039
Habr-Gama A, Gama-Rodrigues J, São Julião GP et al (2014) Local recurrence after complete clinical response and watch and wait in rectal cancer after neoadjuvant chemoradiation: impact of salvage therapy on local disease control. Int J Radiat Oncol Biol Phys 88:822–828
Lezoche E, Baldarelli M, Lezoche G, Paganini AM, Gesuita R, Guerrieri M (2012) Randomized clinical trial of endoluminal locoregional resection versus laparoscopic total mesorectal excision for T2 rectal cancer after neoadjuvant therapy. Br J Surg 99:1211–1218
Albert MR, Atallah SB, DeBeche-Adams TC, Izfar S, Larach SW (2013) Transanal minimally invasive surgery (TAMIS) for local excision of benign neoplasms and early-stage rectal cancer: efficacy and outcomes in the first 50 patients. Dis Colon Rectum 56:301–307
Bujko K, Richter P, Smith FM et al (2013) Preoperative radiotherapy and local excision of rectal cancer with immediate radical re-operation for poor responders: a prospective multicentre study. Radiother Oncol 106:198–205
Bannon JP, Marks GJ, Mohiuddin M, Rakinic J, Jian NZ, Nagle D (1995) Radical and local excisional methods of sphincter-sparing surgery after high-dose radiation for cancer of the distal 3 cm of the rectum. Ann Surg Oncol 2:221–227
Bonnen M, Crane C, Vauthey J-N et al (2004) Long-term results using local excision after preoperative chemoradiation among selected T3 rectal cancer patients. Int J Radiat Oncol Biol Phys 60:1098–1105
Callender GG, Das P, Rodriguez-Bigas M (2010) Local excision after preoperative chemoradiation results in an equivalent outcome to total mesorectal excision in selected patients with T3 rectal cancer. Ann Surg Oncol 17:441–447
Caricato M, Borzomati D, Ausania F et al (2006) Complementary use of local excision and transanal endoscopic microsurgery for rectal cancer after neoadjuvant chemoradiation. Surg Endosc 20:1203–1207
Habr-Gama A, de Souza PM, Ribeiro U et al (1998) Low rectal cancer: impact of radiation and chemotherapy on surgical treatment. Dis Colon Rectum 41:1087–1096
Huh JW, Jung EJ, Park YA, Lee KY, Sohn S, Ph D (2008) Preoperative chemoradiation followed by transanal excision for rectal cancer. J Surg Res 148(2):244–250
Kundel Y, Brenner R, Purim MDO, et al. (2010) Is local excision after complete pathological response to neoadjuvant chemoradiation for rectal cancer an acceptable treatment option? Dis Colon Rectum 53(12):1624–1631.
Mohiuddin M, Marks G (1993) Patterns of recurrence following high-dose preoperative radiation and sphincter-preserving surgery for cancer of the rectum. Dis Colon Rectum 36:117–126
Numata M, Shiozawa M, Watanabe T et al (2012) The clinicopathological features of colorectal mucinous adenocarcinoma and a therapeutic strategy for the disease. World J Surg Oncol 10:109
Guerrieri M, Baldarelli M, Organetti L et al (2008) Transanal endoscopic microsurgery for the treatment of selected patients with distal rectal cancer: 15 years experience. Surg Endosc 22:2030–2035
Park C, Lee W, Han S, Yun S, Chun H-K (2007) Transanal local excision for preoperative concurrent chemoradiation therapy for distal rectal cancer in selected patients. Surg Today 37:1068–1072
Smith FM, Waldron D, Winter DC (2010) Rectum-conserving surgery in the era of chemoradiotherapy. Br J Surg 97:1752–1764
Chang AJ, Nahas CS, Araujo SE et al (2008) Early rectal cancer: local excision or radical surgery? J Surg Educ 65(1):67–72
Middleton PF, Sutherland LM, Maddern GJ (2005) Transanal endoscopic microsurgery: a systematic review. Dis Colon Rectum 48:270–284
Schell SR, Zlotecki RA, Mendenhall WM (2002) Transanal excision of locally advanced rectal cancers downstaged using neoadjuvant chemoradiotherapy. J Am College Surg 194:584–590, discussion 590–1
Marks G, Mohiuddin MM, Masoni L, Pecchioli L (1990) High-dose preoperative radiation and full-thickness local excision. A new option for patients with select cancers of the rectum. Dis Colon Rectum 33:735–739
Canda AE, Terzi C, Gorken IB, Oztop I, Sokmen S, Fuzun M (2010) Effects of preoperative chemoradiotherapy on anal sphincter functions and quality of life in rectal cancer patients. Int J Colorectal Dis 25:197–204
Do L, Syed N, Puthawala A, Azawi S, Shbeeb I, Gong I-Y (2011) Low-lying rectal cancer with anal canal involvement: abdominoperineal or low anterior resection after neoadjuvant chemoradiotherapy. Gastrointest Cancer Res 4(3):90–95
Koebrugge B, Bosscha K, Ernst MF (2009) Transanal endoscopic microsurgery for local excision of rectal lesions: is there a learning curve? Dig Surg 26:372–377
Bignell MB, Ramwell A, Evans JR, Dastur N, Simson JNL (2010) Complications of transanal endoscopic microsurgery (TEMS): a prospective audit. Colorectal Dis 12(7 Online):e99-103
Gracia Solanas JA, Ramírez Rodríguez JM, Aguilella Diago V, Elía Guedea M, Martínez DM (2006) A prospective study about functional and anatomic consequences of transanal endoscopic microsurgery. Rev Esp Enferm Dig 98:234–240
Jin Z, Yin L, Xue L, Lin M, Zheng Q (2010) Anorectal functional results after transanal endoscopic microsurgery in benign and early malignant tumors. World J Surg 34:1128–1132
Morino M, Allaix ME, Famiglietti F, Caldart M, Arezzo A (2013) Does peritoneal perforation affect short- and long-term outcomes after transanal endoscopic microsurgery? Surg Endosc 27:181–188
Hughes R, Glynne-Jones R, Grainger J et al (2006) Can pathological complete response in the primary tumour following pre-operative pelvic chemoradiotherapy for T3-T4 rectal cancer predict for sterilisation of pelvic lymph nodes, a low risk of local recurrence and the appropriateness of local excision? Int J Colorectal Dis 21:11–17
Pucciarelli S, De Paoli A, Guerrieri M et al (2013) Local excision after preoperative chemoradiotherapy for rectal cancer: results of a multicenter phase II clinical trial. Dis Colon Rectum 56:1349–1356
Bruheim K, Guren MG, Skovlund E et al (2010) Late side effects and quality of life after radiotherapy for rectal cancer. Int J Radiat Oncol Biol Phys 76:1005–1011
Brændengen M, Tveit KM, Bruheim K, Cvancarova M, Berglund Å, Glimelius B (2011) Late patient-reported toxicity after preoperative radiotherapy or chemoradiotherapy in nonresectable rectal cancer: results from a randomized phase III study. Int J Rad Oncol Biol Phys 81:1017–1024
Park IJ, You YN, Skibber JM et al (2013) Comparative analysis of lymph node metastases in patients with ypT0-2 rectal cancers after neoadjuvant chemoradiotherapy. Dis Colon Rectum 56:135–141
Richman P, Makris A, Harrison M et al (2006) Can pathological complete response in the primary tumour following pre-operative pelvic chemoradiotherapy for T3–T4 rectal cancer predict for sterilisation of pelvic lymph nodes, a low risk of local recurrence and the appropriateness of local excision. Int J Colorectal Dis 21(1):11–17
Kim D-W, Kim DY, Kim TH et al (2006) Is T classification still correlated with lymph node status after preoperative chemoradiotherapy for rectal cancer? Cancer 106:1694–1700
Read TE, Andujar JE, Caushaj PF et al (2004) Neoadjuvant therapy for rectal cancer: histologic response of the primary tumor predicts nodal status. Dis Colon Rectum 47:825–831
Heald RJ, Beets G, Carvalho C (2014) Report from a consensus meeting: response to chemoradiotherapy in rectal cancer—predictor of cure and a crucial new choice for the patient: on behalf of the Champalimaud 2014 Faculty for “Rectal cancer: when NOT to operate”. Colorectal Dis 16:334–337