The Multimodality Treatment of Locally Advanced and Locally Recurrent Rectal Cancer

This thesis focused on several aspects to further improve locally advanced and recurrent rectal cancer management. During last decade, rectal cancer treatment has shifted increasingly towards a personalized treatment depending on the local tumor and the presence of distant metastases. A multimodality treatment can result in relatively good long-term outcomes for both Locally advanced rectal cancer (LARC)and locally recurrent rectal cancer (LRRC). This thesis aimed to further improve the multimodality treatment in order to offer patients the best oncological care. Briefly, the _first part_ of this thesis, focusing on staging, showed a beneficial effect of restaging by thoraco-abdominal CT-scan after (chemo-)radiotherapy. It resulted in newly discovered distant metastases altering treatment in a substantial number of patients. Unfortunately, the beneficial effect of adding DCE sequences to local restaging by MR imaging after (chemo-)radiotherapy was limited. The _second part,_ which focused on LARC, suggested that applying IOR

Muscle wasting and survival following pre-operative chemoradiotherapy for locally advanced rectal carcinoma

Background & aims: Neoadjuvant chemoradiotherapy (NACRT) has increased local control in locally advanced rectal cancer. Reduced skeletal muscle mass (sarcopenia), or ongoing muscle wasting, is associated with decreased survival in cancer. This study aims to assess the change in body composition during NACRT and its impact on outcome using computed tomography (CT) imaging in locally advancedrectal cancer (LARC) patients. Methods: LARC patients treated with NACRT were selected from a prospectively maintained database and retrospectively analyzed. One-hundred twenty-two patients who received treatment between 2004 and 2012 with available diagnostic CT imaging obtained before and after NACRT were identified. Cross-sectional areas for skeletal muscle was determined, and subsequently normalized for patient height. Differences between skeletal muscle areas before and after NACRT were computed, and their influenceon overall and disease-free survival was assessed. Results: A wide distribution in change of body composition was observed. Loss of skeletal muscle mass during chemoradiotherapy was independently associated with disease-free survival (HR0.971; 95% CI:0.946e0.996; p¼0.025) and distant metastasis-free survival (HR0.942; 95% CI: 0.898e0.988; p¼0.013).No relation was observed with overall survival in the current cohort. Conclusions:Loss of skeletal muscle mass during NACRT in rectal cancer patients is an independent prognostic factor for disease-free survival and distant metastasis-free survival following curative intentresection

Surgery of the primary tumour in stage iv colorectal cancer with unresectable metastases

Surgery plays an important role in the treatment of patients with limited metastatic disease of colorectal cancer (CRC). Long term survival and cure is reported in 20−50% of highly selected patients with oligometastatic disease who underwent surgery. This paper describes the role of surgery of the primary tumour in patients with unresectable stage IV colorectal cancer. Owing to the increased efficacy of chemotherapeutic regimens in stage IV colorectal cancer, complications from unresected primary tumours are relatively infrequent. The risk of emergency surgical intervention is less than 15% in patients with synchronous metastatic disease who are treated with chemotherapy. Therefore, there is a tendency among surgeons not to resect the primary tumour in case of unresectable metastases. However, it is suggested that resection of the primary tumour in case of unresectable metastatic disease might influence overall survival. All studies described in the literature (n = 24) are non-randomised and the majority is single-centre and retrospective of nature. Most studies are in favour of resection of the primary tumour in patients with symptomatic lesions. In asymptomatic patients the results are less clear, although median overall survival seems to be improved in resected patients in the majority of studies. The major drawback of all these studies is that primarily patients with a better performance status and better prognosis (less metastatic sites involved) are being operated on. Another limitation of these studies is that few if any data on the use of systemic therapy are presented, which makes it difficult to assess the relative contribution of resection on outcome. Prospective studies on this topic are warranted, and ar

Is restaging with chest and abdominal CT scan after neoadjuvant chemoradiotherapy for locally advanced rectal cancer necessary?

Background: There is no evidence regarding restaging of patients with locally advanced rectal cancer after a long course of neoadjuvant radiotherapy with or without chemotherapy. This study evaluated the value of restaging with chest and abdominal computed tomographic (CT) scan after radiotherapy. Methods: Between January 2000 and December 2010, all newly diagnosed patients in our tertiary referral hospital, who underwent a long course of radiotherapy for locally advanced rectal cancer, were analyzed. Patients were only included if they had chest and abdominal imaging before and after radiotherapy treatment. Results: A total of 153 patients who met the inclusion criteria and were treated with curative intent were included. A change in treatment strategy due to new findings on the CT scan after radiotherapy was observed in 18 (12 %) of 153 patients. Twelve patients (8 %) were spared rectal surgery due to progressive metastatic disease. Conclusions: Restaging with a chest and abdominal CT scan after radiotherapy for locally advanced rectal cancer is advisable because additional findings may alter the treatment strategy