MRI-Based Use of Neoadjuvant Chemoradiotherapy in Rectal Carcinoma: Surgical Quality and Histopathological Outcome of the OCUM Trial
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Preoperative magnetic resonance imaging (MRI) allows highly reliable imaging of the mesorectal fascia (mrMRF) and its relationship to the tumor. The prospective multicenter observational study OCUM uses these findings to indicate neoadjuvant chemoradiotherapy (nCRT) in rectal carcinoma.
nCRT was indicated in patients with positive mrMRF (≤ 1 mm) in cT4 and cT3 carcinomas of the lower rectal third.
A total of 527 patients (60.2%) underwent primary total mesorectal excision, and 348 patients (39.8%) underwent long-term nCRT followed by surgery. The mrMRF was involved in 4.6% of the primary surgery group and 80.7% of the nCRT group. Rates of resections within the mesorectal plane (90.8%), sparing of pelvic nerves on both sides (97.8%), and number of regional lymph nodes (95.3% with ≥ 12 lymph nodes examined) are indicative of high-quality surgery. Resection was classified as R0 in 98.3%, the pathological circumferential resection margin (pCRM) was negative in 95.1%. Patients in the nCRT group had more advanced carcinomas with a significantly higher rate of abdominoperineal excision. Independent risk factors for pCRM positivity were advanced stage (T4), metastatic lymph nodes, resection in the muscularis propria plane, and location in the lower third.
The risk classification of rectal cancer patients by MRI seems to be highly reliable and allows the restriction of nCRT to approximately half of the patients with clinical stage II and III rectal carcinoma, provided there is a high-quality MRI diagnostic protocol, high-quality surgery, and standardized examination of the resected specimen.
None to declare.
Martin E. Kreis, Reinhard Ruppert, Rainer Kube, Joachim Strassburg, Andreas Lewin, Joerg Baral, Christoph A. Maurer, Joerg Sauer, Günther Winde, Rena Thomasmeyer, Sigmar Stelzner, Cornelius Bambauer, Soenke Scheunemann, Axel Faedrich, Theodor Junginger, Paul Hermanek, and Susanne Merkel have no conflicts of interest to declare.
- 2.Peeters KC, Marijnen CA, 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.Google Scholar
- 4.Peeters KC, van de Velde CJ, Leer JW, Martijn H, Junggeburt JM, Kranenbarg EK, et al. Late side effects of short-course preoperative radiotherapy combined with total mesorectal excision for rectal cancer: increased bowel dysfunction in irradiated patients: a Dutch Colorectal Cancer Group study. J Clin Oncol. 2005;23:6199–206.CrossRefGoogle Scholar
- 5.Marijnen CA, van de Velde CJ, Putter H, van den Brink M, Maas CP, Martijn H, et al. Impact of short-term preoperative radiotherapy on health-related quality of life and sexual functioning in primary rectal cancer: report of a multicentre randomized trial. J Clin Oncol. 2005;23:1847–58.CrossRefGoogle Scholar
- 6.Stephens RJ, Thompson LC, Quirke P, Steele R, Grieve R, Couture J, et al. Impact of short-course preoperative radiotherapy for rectal cancer on patients’ quality of life: data from the medical research council CR07/National Cancer Institute of Canada Clinical Trials Group C016 Randomized Clinical Trial. J Clin Oncol. 2010;28:4233–9.CrossRefGoogle Scholar
- 7.Edge DB, Byrd DR, Compton U, Grimelius FL, Trotti A (eds). American joint committee on cancer staging manual. 7th ed. Springer, New York; 2009.Google Scholar
- 17.Wittekind C, Greene R, Hutter RVP, Sobin LH, Henson DE (eds). TNM supplement: a commentary on uniform use. 3rd ed. Wiley, New York; 2003.Google Scholar
- 18.Greene FL, Page DL, Fleming ID, Fritz AG, Balch CM, Haller DG, et al. (eds). AJCC cancer staging manual, 6th ed. Springer, Berlin; 2002.Google Scholar
- 19.Ptok H, Ruppert R, Strassburg J, Maurer CA, Oberholzer K, Junginger T, et al. Pretherapeutic MRI for decision-making regarding selective neoadjuvant radiochemotherapy for rectal carcinoma: interim analysis of a multicentric prospective observational study. J Magn Reson Imaging 2013;37:1122–8.CrossRefGoogle Scholar
- 20.Kim YW, Cha SW, Pyo J, Kim NK, Min BS, Kim MJ, et al. Factors related to preoperative assessment of the circumferential resection margin and the extend of mesorectal invasion by magnetic resonance imaging in rectal cancer: a prospective comparison study. World J Surg. 2009;33:1952–60.CrossRefGoogle Scholar
- 23.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.CrossRefGoogle Scholar
- 24.Seegenschmiedt MH, Sauer R. The systematicy of acute and chronic radiation sequelae. Strahlenther Oncol. 1993;169:83–95 (in German).Google Scholar
- 27.Dindo C, Demartines N, Clavien PA. Classification of surgical complications. A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–13.Google Scholar
- 38.Beets-Tan RGH, Lambregts DMJ, Maas M, Bipat S, Barbaro B, Curvo-Semedo L et al. Magnetic resonance imaging for clinical management or rectal cancer: Updated recommendations from the 2016 European Society of Gastrointestinal and Abdominal Radiology (ESGAR) consensus meeting. Eur Radiol. 2018;28:1465–75CrossRefGoogle Scholar