Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Is there a role for post-neoadjuvant MRI scans for rectal cancers?
- durgesh s raje (24 September 2006)
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Rectal Cancer Multidisciplinary Team Management – The New Dilemma
- RJ Heald, Brian DP O’Neill, Gina Brown, Brendan Moran, Ara W Darzi, Andrew C Wotherspoon, David Cunningham, and Diana M Tait. (26 September 2006)
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Serial MRI after chemoradiotherapy for rectal cancer can help to define a "window of opportunity" for laparoscopic surgery
- Bruce F. Sizer, Tan Arulampalam, Ralph Austin, Nicola Lacey, Don Menzies, Roger Motson (1 October 2006)
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3D Endorectal ultrasound complements MRI staging
- shyam menon (15 October 2006)
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Colorectal Carcinoma
- Sameer Chadha, Shikha Mehta, Medical Student, MAULANA AZAD MEDICAL COLLEGE (17 October 2006)
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durgesh s raje, research fellow whittington hospital, london N19 5NF
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I read this article with interest as I have recently completed collecting data for a study assessing the outcomes of neo-adjuvant therapy for rectal cancers. What is interesting is the 27 patients from the mercury study in whom MRI incorrectly predicted tumour in the margin. 21 of these had neo-adjuvant therapy in the form of chemoradiation. This is quite important as more recently a large proportion of rectal cancers undergo neo-adjuvant therapy. The preliminary results from our data also show that the Post neo-adjuvant staging scans do not accurately match in a significant proportion of patients with the final histological stage. This requires further comparison with results from other studies and centres. This discrepancy is thought to be related to the post radiotherapy scarring associated with the downsizing of the tumour which may cause difficulty in interpretation of the scans. As neo-adjuvant therapy is used quite frequently to treat rectal cancers,it might be something one needs to study to ascertain the significance of conducting post-treatment scans. These may have little if any role to play as majority of patients would undergo surgery irrespective of the scan results except those who show a complete response to treatment which is quite rare. Competing interests: None declared |
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RJ Heald, Surgical Director Pelican Cancer Foundation, RG24 9NA, Brian DP O’Neill, Gina Brown, Brendan Moran, Ara W Darzi, Andrew C Wotherspoon, David Cunningham, and Diana M Tait.
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Tumour shrinkage by preoperative chemoradiotherapy (CRT) is now an everyday reality and pathological complete responses are not uncommon[1]. A “new dilemma” is posed by the apparent complete disappearance of cancer on Magnetic Resonance Imaging (MRI), and often clinically, after CRT. A 6- 10 weeks delay is usual before operating – a time perceived as a “window of opportunity”, as re- growth within the irradiated area is believed inevitable. This concept has been challenged by Habr-Gama’s series [2]. Three hundred and sixty patients with T3 and T4 rectal cancer (or T2 when considered for abdomino-perineal resection) were treated with preoperative CRT [3]. Ninety nine patients (27.5%) classified as clinical complete responders at 8 weeks following completion of CRT were managed by surveillance alone. Only 2% in this observation group have died of cancer in a follow-up extending for up to ten years, while local recurrence occurred in just 5 patients, all amenable to successful salvage surgery. We propose to open accrual into a pilot study of observation for complete responders, as assessed on MRI at 4 weeks following completion of CRT. This will be administered at the Pelican Centre and largely delivered at the Royal Marsden Hospital. MRI, whose excellence in accurately predicting surgical mesorectal margins has been demonstrated by the MERCURY group [4,5], will be central to this study’s intensive follow-up, in addition to regular clinical and sigmoidoscopic assessment. Specialised primary surgery, backed by MRI-based selection for preoperative CRT, will continue to be the cornerstone of management. Nevertheless, our fundamental understanding of modern cancer treatment for all solid tumours demands that this group of complete responders be properly investigated. Furthermore, if Habr-Gama’s experience is confirmed, several hundred rectal cancer patients in the UK each year may one day be spared the necessity for major surgery. Correspondence / requests for re-prints – Complete response@pelicancancer.org REFERENCES 1. Chau I, Brown G, Cunningham D, Tait D, Wotherspoon A, Norman AR, et al. Neoadjuvant capecitabine and oxaliplatin followed by synchronous chemoradiation and total mesorectal excision in magnetic resonance imaging -defined poor-risk rectal cancer. J Clin Oncol 2006;24(4):668-74. 2. Habr-Gama A, Perez RO, Nadalin W, Sabbaga J, Ribeiro U, Jr., Silva e Sousa AH, Jr., et al. Operative versus nonoperative treatment for stage 0 distal rectal cancer following chemoradiation therapy: long-term results. Ann Surg 2004;240(4):711-7; discussion 717-8. 3. Habr-Gama A. Assessment and management of the complete clinical response of rectal cancer to chemoradiotherapy. Colorectal Dis 2006;8 Suppl 3:21-4. 4. The MERCURY Study Group. Diagnostic accuracy of magnetic resonance imaging in predicting surgical resection margin status: prospective observational study. BMJ 2006,in press; e-pub September 2006. 5. Brown G, Daniels IR. Preoperative staging of rectal cancer: the MERCURY research project. Recent Results Cancer Res 2005;165:58-74. Competing interests: None declared |
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Bruce F. Sizer, Consultant in Clinical Oncology Essex County Hospital, Colchester, Tan Arulampalam, Ralph Austin, Nicola Lacey, Don Menzies, Roger Motson
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The excellent paper by the MERCURY Study Group provides clear evidence that preoperative Magnetic Resonance Imaging (MRI) can accurately predict surgical resection margins (1), and their work, in particular, has already led to a paradigm shift in the preoperative investigation and treatment of rectal cancer, at least in the UK. This is at least implicitly acknowledged in that both Rapid Responses so far focus on MRI in the increasingly frequent scenario of assessment after neoadjuvant chemoradiotherapy (CRT); indeed, Heald et al propose a pilot study of observation rather than “major surgery” for “complete responders as assessed on MRI at 4 weeks” post CRT(3). Over the last 3 years, our experience has been that, in addition to clinical and sigmoidoscopic examination, serial MRI can be of value post CRT in documenting an ongoing response beyond the conventional 4 to 6 weeks interval before surgery (4). In 30 consecutive patients with locally advanced rectal cancer, we repeated MRI scans at 4 weekly intervals to optimise the timing of surgery at maximal response, the median time for which was 12 weeks (range 8 to 15 weeks). In Heald’s proposed pilot study, no information would be available on the time-frame during which response might still be seen, as those patients who did not achieve complete response (CR) at 4 weeks would presumably proceed immediately to definitive surgical resection. Whilst it is open to conjecture whether this lengthened gap may increase the number of patients obtaining radiological and / or pathological CR, it has allowed us to perform laparoscopic TME for the majority of patients, the feasibility and short term safety of which we recently reported (5). We strongly agree with Heald et al’s concept of a “window of opportunity” after CRT, but the window is bigger than commonly believed, and the opportunity it affords may be to offer more patients the choice of minimally invasive surgery. References 1. The MERCURY Study Group. Diagnostic accuracy of magnetic resonance imaging in predicting surgical resection margin status: prospective observational study. BMJ 2006, in press; e-pub September 2006. 2. Durgesh S Raje Is there a role for post-neoadjuvant MRI scans for rectal cancers? Bmj.com Rapid Responses (24 September 2006) 3. Rectal Cancer Multidisciplinary Team Management – The New Dilemma RJ Heald, Brian DP O’Neill, Gina Brown, Brendan Moran, Ara W Darzi, Andrew C Wotherspoon, David Cunningham, and Diana M Tait. Bmj.com Rapid Responses (26 September 2006) 4. Sizer B, Motson R, Arulampalam T, Lacey N, Basu D, Austin R, Menzies D Evaluation of UFT and Radiotherapy with serial Imaging to oPtimise the Interval before Definitive Excisional Surgery: the EURIPIDES protocol in locally advanced rectal cancer Accepted abstract, NCRI Cancer Conference, Birmingham October 2006 5. Arulampalam T, Sizer B, Lacey N, Austin R, Motson R Laparoscopic Total Mesorectal Excision following Long Course Neoadjuvant Chemoradiotherapy 14th International Congress of the European Association for Endoscopic Surgery, Berlin September 2006 Competing interests: None declared |
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shyam menon, specialist registrar in gastroenterology university hospital of north staffordshire
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Imaging modalities for rectal cancer staging are evolving continuously and although high resolution MRI allows improved loco regional staging, 3-dimensional endorectal ultrasound (3D ERUS) is a technique which could be complementary to the staging process. 3- dimensional image reconstruction allows better definition of regional structures compared to conventional 2-dimensional ultrasound. Definition of the mesorectal fascia and nodal involvement were impressive with this technique in a recent small series.1 Incorporating this technique in a staging pathway could refine overall initial T and N staging and could deliver information comparable to high resolution MRI in patients in whom MRI is contraindicated. Whether the lack of sensitivity to post chemo radiotherapy T staging with conventional 2-D ultrasound will improve with improved software remains to be seen.2 1. Giovannini M, Bories E, Pesenti C, Moutardier V et al. Three- dimensional endorectal ultrasound using a new freehand software program: results in 35 patients with rectal cancer. Endoscopy 2006 Apr;38(4):339-43. 2. Maor Y, Nadler M, Barshack I, Zmora O et al. Endoscopic ultrasound staging of rectal cancer: diagnostic value before and following chemo radiation. J Gastroenterol Hepatol 2006 Feb;21(2):454-8. Competing interests: None declared |
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Sameer Chadha, Medical Student MAULANA AZAD MEDICAL COLLEGE, Shikha Mehta, Medical Student, MAULANA AZAD MEDICAL COLLEGE
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INVESTIGATIONS FOR EXTENT OF SPREAD- MRI along with the Endoluminal Ultrasound are used to assess the local spread of the tumour while the assessment of the spread includes CT of liver and chest radiograph/ CT scan of chest. RADIOTHERAPY- Adequate Adjuvant Radiotherapy can reduce the incidence of local recurrence but the long term survival is not affected. Another benefit of the pre-operative radiotherapy is that it reduces the size of the large tumour and makes its subsequent removal easier. Combined Radiotherapy and Chemotherapy can also shrink the tumour size prior to the surgical excision. Palliative irradition can also be given, even directlty, to the tumour from the rectal lumen in a case of inoperable primary tumour or a painful local recurrence. CHEMOTHERAPY AND IMMUNOTHERAPY- The combination of systemic 5- Fluorouracil(5-FU) and Folinic Acid has a significant effect on survival when combined with surgery in node positive disease. 5-FU can also be infused in portal vein intra and post operatively to prevent the metastases. New drugs include Irinotecan and Oxaliplatin. Immunotherapy can also have a role in the treatment of disseminated colorectal cancer. Monoclonal Antibodies to CEA , conjugated to the cancericidal cells can destroy the cancerous cells, but these antibodies are not sufficiently specific. Competing interests: None declared |
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