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MRI-Based Indications for Neoadjuvant Radiochemotherapy in Rectal Carcinoma: Interim Results of a Prospective Multicenter Observational Study

  • Colorectal Cancer
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

This study evaluated use of circumferential resection margin status in preoperative MRI (mrCRM) as an indication for neoadjuvant radiochemotherapy (nRCT) in rectal carcinoma patients.

Materials and Methods

In a multicenter prospective study, nRCT was given to patients with carcinoma of the middle rectum with positive mrCRM (≤1 mm), with cT3 low rectal carcinoma, and all patients with cT4 tumors. The short-term endpoints were pathologic pCRM (≤1 mm) as a strong predictor of local recurrence rate and the quality of total mesorectal excision according to the plane of surgery. These endpoints were compared in patients with and without nRCT.

Results

Of 230 patients that met the inclusion criteria, 96 (41.7%) received a long course of nRCT and 134 (58.3%) were primarily operated on. The pCRM was positive in 13 of 230 (5.7%) (primarily operated on, 2 of 134 [1.5%]; after nRCT, 11 of 96 [11%]). In 1 of 134 (0.7%) case, the mrCRM was falsely negative. Patients at participating centers varied in terms of preoperative stage but not in pCRM positivity (0%–13%, P = .340). The plane of surgery was mesorectal (good) in 209 of 230 (90.9%), intramesorectal (moderate) in 16 of 230 (7%), and the muscularis propria plane (poor) in 2.2% (5 of 230).

Conclusions

Low pCRM positivity and the high quality of mesorectal excision support use of MRI-based nRCT in rectal carcinoma. nRCT was avoidable in 45% of patients with stage II and III disease without significant risk of undertreatment. Preoperative MRI thus allows identification of patients with high risk of local recurrence and use of selective nRCT.

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References

  1. Sauer R, Becker H, Hohenberger W, et al. Preoperative chemoradiotherapy as compared with postoperative chemoradiotherapy for locally advanced rectal cancer. N Engl J Med. 2004;351:11–20.

    Article  Google Scholar 

  2. Augestad K, Lindsetmo RO, Stulberg J, Reynolds H, Senagore A, Champagne B, et al. International preoperative rectal cancer management: staging, neoadjuvant treatment and impact of multidisciplinary teams. World J Surg. 2010;34;2689–700.

    Article  PubMed  Google Scholar 

  3. Swedish Rectal Cancer Trial. Improved survival with preoperative radiotherapy in resectable rectal cancer. New Engl J Med. 1997;336:980–7.

    Article  Google Scholar 

  4. Peeters KCMJ, Marijnen CAM, Nagtegaal ID, Kranenbarg EK, Putter H, Wiggers T, et al. The TME trial after a median follow-up of 6 years: increased local control but no survival benefit in irradiated patients with resectable rectal carcinoma. Ann Surg. 2007;246:693–701.

    Article  PubMed  Google Scholar 

  5. Sebag-Montefiore D, Stephens RJ, Steele R, Monson J, Grieve R, Khanna S, et al. Preoperative radiotherapy versus selective postoperative chemoradiotherapy in patients with rectal cancer (MRC CR07 and NCIC-CTG C016): a multicentre, randomised trial. Lancet. 2009;373:811–20.

    Article  PubMed  Google Scholar 

  6. Engstrom PF, Arnoletti JP, Benson AB III, Chen YJ, Choti MA, Cooper HS, et al. NCCN clinical practice guidelines in oncology: rectal cancer. J Natl Compr Canc Netw. 2009;7:838–81.

    PubMed  Google Scholar 

  7. Van Cutsem E, Dicato M, Haustermans K, Arber N, Bosset JF, Cunningham D, et al. The diagnosis and management of rectal cancer: expert discussion and recommendations derived from the 9th World Congress in Gastrointestinal Cancer, Barcelona, 2007. Ann Surg Oncol. 2008;19(Suppl 16):vi1–vi8.

    Google Scholar 

  8. Bakx R, Emous M, Legemate DA, Zoetmulder FAN, von Tienhoven G, Bemelman WA, et al. Harm und benefits of short-term pre-operative radiotherapy in patients with resectable rectal carcinomas. EJSO. 2006;32:520–6.

    PubMed  CAS  Google Scholar 

  9. Glynne-Jones R, Mawdsley S, Novell JR. The clinical significance oft the circumferential resection margin following preoperative pelvic chemo-radiotherapy in rectal cancer: why we need a common language. Colorect Dis. 2006;8:800–7.

    Article  PubMed  CAS  Google Scholar 

  10. Glynne-Jones R, Mawdsley S, Pearce T, Buyse M. Alternative clinical endpoints in rectal cancer—are we getting closer? Ann Oncol. 2006;17:1239–48.

    Article  PubMed  CAS  Google Scholar 

  11. Nagtegaal ID, Quirke P. What is the role for the circumferential margin in the modern treatment for rectal cancer? J Clin Oncol. 2008;26:303–12.

    Article  PubMed  Google Scholar 

  12. Strassburg J, Junginger T, Trinh T, Püttcher O, Oberholzer K, Heald RJ, et al. Magnetic resonance imaging (MRT-)based indication for neoadjuvant treatment of rectal carcinoma and the surrogate endpoint CRM status. Int J Colorect Dis. 2008;23:1099–107.

    Article  Google Scholar 

  13. MERCURY Study Group. Diagnostic accuracy of preoperative magnetic resonance imaging in predicting curative resection of rectal cancer: prospective observation study. Br Med J. 2006;333:779–82.

    Article  Google Scholar 

  14. Daniels IR, Fisher SE, Heald RJ, Moran BJ. Accurate staging, selective preoperative therapy and optimal surgery improves outcome in rectal cancer. A review of the recent evidence. Colorect Dis. 2007;9:290–301.

    Article  PubMed  CAS  Google Scholar 

  15. Smith N, Brown G. Preoperative staging of rectal cancer. Acta Oncol. 2008;47:20–31.

    Article  PubMed  Google Scholar 

  16. Shibab OC, Moran BJ, Heald RJ, Quirke P, Brown G. MRI staging of low rectal cancer. Eur Radiol. 2009:19:643–50.

    Article  Google Scholar 

  17. Hermanek P, Hohenberger W, Fietkau R, Rödel C. Individualized magnetic resonance imaging-based neoadjuvant chemoradiation for middle and lower rectal carcinoma. Colorect Dis. 2011;13:39–47.

    Article  PubMed  CAS  Google Scholar 

  18. UICC (2002) Sobin LH, Wittekind Ch, editors. TNM classification of malignant tumors. 6th ed. New York: Wiley-Liss; 2002.

    Google Scholar 

  19. Brown G, Daniels IR. Preoperative staging of rectal cancer: the MERCURY research project. Recent Results Cancer Res. 2005;165:58–74.

    Article  PubMed  CAS  Google Scholar 

  20. Brown G, Daniels IR, Richardson C, Revell F, Pepperson D, Bourne M. Techniques and trouble-shooting in high spatial resolution thin slice MRI for rectal cancer. Br J Radiol. 2005;78:245–51.

    Article  PubMed  CAS  Google Scholar 

  21. Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal surgery—the clue to pelvic recurrence? Br J Surg. 1982;69:613–6.

    Article  PubMed  CAS  Google Scholar 

  22. Nagtegaal ID, van de Velde CJH, Marijnen CAM, van Krieken JH, Quirke P. Low rectal cancer: a call for a change of approach in abdominoperineal resection. J Clin Oncol. 2005;23:9257–64.

    Article  PubMed  Google Scholar 

  23. Quirke P, Morris E. Reporting colorectal cancer. Histopathology. 2007;50:103–12.

    Article  PubMed  CAS  Google Scholar 

  24. Maughan NJ, Quirke P. Modern management of colorectal cancer—a pathologist’s view. Scand J Surg. 2003;92:11–9.

    PubMed  CAS  Google Scholar 

  25. Merkel S, Hohenberger W, Hermanek P. Intra-operative local tumor cell dissemination in rectal carcinoma surgery: effect of operation principles and neoadjuvant therapy. Chirurg. 2010;81:719–27.

    Article  PubMed  CAS  Google Scholar 

  26. Quirke P, Dixon MF. The prediction of local recurrence in rectal adenocarcinoma by histopathological examination. Int J Colorect Dis. 1988;3:127–31.

    Article  CAS  Google Scholar 

  27. Chambers W, Collins G, Warren B, Cunningham C, Mortensen N, Lindsey I. Benchmarking circumferential resection margin (R1) resection rate for rectal cancer in the neoadjuvant era. Colorectal Dis. 2010;12:909–13.

    Article  PubMed  CAS  Google Scholar 

  28. Burton S, Brown G, Daniels IR, Norman AR, Mason B, Cunningham. MRI directed multidisciplinary team preoperative treatment strategy: the way to eliminate positive circumferential margins? Brit J Cancer. 2006;94:351–7.

    Article  PubMed  CAS  Google Scholar 

  29. Quirke P, Steele R, Monson J, Grieve R, Khanna S, Couture J, et al. Effect of the plane of surgery achieved on local recurrence in patients with operable rectal cancer: a prospective study using data from the MRC CR07 and NCIC-CTG C016 randomised clinical trial. Lancet. 2009;373;821–8.

    Article  PubMed  Google Scholar 

  30. Nagtegaal ID, van de Velde CJH, van der Worp E, Kapiteijn E, Quirke P, van Krieken JHJM. Macroscopic evaluation of rectal cancer resection specimen: clinical significance of the pathologist in quality control. J Clin Oncol. 2002;20:1729–34.

    Article  PubMed  Google Scholar 

  31. Birbeck KF, Macklin CP, Tiffin NJ, Parsons W, Dixon MF, Mapstone NP, et al. Rates of circumferential resection margin involvement vary between surgeons and predict outcomes in rectal cancer surgery. Ann Surg. 2002;235:449–57.

    Article  PubMed  Google Scholar 

  32. Hermanek P, Merkel S, Fietkau R, Rödel C, Hohenberger W. Regional lymph node metastasis and locoregional recurrence of rectal carcinoma in the era of TME surgery. Implications for treatment decisions. Int J Colorect Dis. 2010;25:359–68.

    Article  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. General and Visceral Surgery, Vivantes Klinikum im Friedrichshain, Berlin, Germany

    Joachim Strassburg

  2. General and Visceral Surgery, Endocrine Surgery, and Coloproctology, The Municipal Hospital of Munich-Neuperlach, Munich, Germany

    Reinhard Ruppert

  3. Department of Surgery, Carl-Thiem-Klinik, Cottbus, Germany

    Henry Ptok

  4. Department of General, Visceral, and Transplantation Surgery, Kantonsspital, Liestal, Switzerland

    Christoph Maurer

  5. General and Abdominal Surgery, University Hospital, Mainz, Germany

    Theodor Junginger

  6. Surgery, University Hospital, Erlangen, Germany

    Susanne Merkel & Paul Hermanek

Authors
  1. Joachim Strassburg
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  2. Reinhard Ruppert
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  3. Henry Ptok
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  4. Christoph Maurer
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  5. Theodor Junginger
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  6. Susanne Merkel
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  7. Paul Hermanek
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Correspondence to Theodor Junginger.

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Strassburg, J., Ruppert, R., Ptok, H. et al. MRI-Based Indications for Neoadjuvant Radiochemotherapy in Rectal Carcinoma: Interim Results of a Prospective Multicenter Observational Study. Ann Surg Oncol 18, 2790–2799 (2011). https://doi.org/10.1245/s10434-011-1704-5

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  • DOI: https://doi.org/10.1245/s10434-011-1704-5

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