Defining response to radiotherapy in rectal cancer using magnetic resonance imaging and histopathological scales

Aim: To define good and poor regression using pathology and MRI regression scales after neo-adjuvant chemotherapy for rectal cancer. Methods: A systematic review of all studies up to December 2015, without language restriction that were identified from MEDLINE, Cochrane Controlled Trials Register (1960–2015), and EMBASE (1991–2015). Searches were performed of article bibliographies and conference abstracts. MeSH and text words, included “tumour regression”, “mrTRG”, “poor response” and “colorectal cancers”. Clinical studies using either MRI or histopathological TRG scales to define good and poor responders were included in relation to outcomes (local (LR), distant recurrence (DR), disease free (DFS), overall survival (OS)). There was no age restriction to included patients nor stage of cancer.Data was extracted by two authors independently using pre-defined outcome measures. Results: Quantitative data (prevalence) were extracted and analysed according to meta-analytical techniques using comprehensive meta-analysis. Qualitative data (LR, DR, DFS &OS) were presented as ranges. The overall proportion of poor responders after neo-adjuvant CRT was 37.7% (CI: 30.1 to 45.8). There were 19 different reported histopathological scales and one MRI regression scale (mrTRG). Clinical studies used nine and six histopathological scales for poor and good responders respectively. All studies using MRI to define good and poor response used one scale. The most common histopathological definition for good response was the Mandard grades 1&2 or Dworak grades 3&4; Mandard 3,4&5 and Dworak 0,1&2 were used for poor response. For histopathological grades, the 5-year outcomes for poor responders were LR 3.4-4.3%, DR 14.3-20.3%, DFS 61.7-68.1% and OS 60.7-69.1. Good pathological response 5-year outcomes were LR, 0-1.8%; DR, 0-11.6%; DFS, 78.4-86.7%; and, OS, 77.4-88.2%. A poor response on MRI (mrTRG 4,5) resulted in 5-year LR 4-29%, DR 9%, DFS 31-59% and OS 27-68%. The 5-year outcomes with a good response on MRI (mrTRG 1,2 & 3) was LR 1-14%, DR 3%, DFS 64-83% and OS 72-90%. Conclusions: For histopathology regression assessment Mandard1,2/Dworak3,4 should be used for good and Mandard3,4,5/Dworak0,1,2 for poor response. MRI indicates good and poor response by mrTRG1-3 and mrTRG4-5 respectively

Interobserver agreement of radiologists assessing the response of rectal cancers to preoperative chemoradiation using the MRI tumour regression grading (mrTRG)

AIM: To investigate whether the magnetic resonance imaging (MRI) tumour regression grading (mrTRG) scale can be taught effectively resulting in a clinically reasonable interobserver agreement (>0.4; moderate to near perfect agreement). MATERIALS AND METHODS: This study examines the interobserver agreement of mrTRG, between 35 radiologists and a central reviewer. Two workshops were organised for radiologists to assess regression of rectal cancers on MRI staging scans. A range of mrTRGs on 12 patient scans were used for assessment. RESULTS: Kappa agreement ranged from 0.14–0.82 with a median value of 0.57 (95% CI: 0.37–0.77) indicating good overall agreement. Eight (26%) radiologists had very good/near perfect agreement (κ>0.8). Six (19%) radiologists had good agreement (0.8≥κ>0.6) and a further 12 (39%) had moderate agreement (0.6≥κ>0.4). Five (16%) radiologists had a fair agreement (0.4≥κ>0.2) and two had poor agreement (0.2>κ). There was a tendency towards good agreement (skewness: 0.92). In 65.9% and 90% of cases the radiologists were able to correctly highlight good and poor responders, respectively. CONCLUSIONS: The assessment of the response of rectal cancers to chemoradiation therapy may be performed effectively using mrTRG. Radiologists can be taught the mrTRG scale. Even with minimal training, good agreement with the central reviewer along with effective differentiation between good and intermediate/poor responders can be achieved. Focus should be on facilitating the identification of good responders. It is predicted that with more intensive interactive case-based learning a κ>0.8 is likely to be achieved. Testing and retesting is recommended

2017 Research & Innovation Day Program

A one day showcase of applied research, social innovation, scholarship projects and activities.https://first.fanshawec.ca/cri_cripublications/1004/thumbnail.jp

How Should Imaging Direct/Orient Management of Rectal Cancer?

Modern rectal cancer management is dependent on preoperative staging, and radiological assessment is a crucial part of this process. Imaging must provide sufficient information to guide preoperative decision-making that is reliable and reproducible. Different methods have been used for local staging; however, magnetic resonance imaging (MRI) has shown to be the most reliable tool for this purpose. MRI offers prognostic information about the patients and guides the decision between neoadjuvant treatment and total mesorectal excision alone. Also, not only the initial staging but also restaging by MRI can provide significant information regarding tumor response that is essential when considering alternative approaches

Session 4: What should we do for poor responders after chemoradiotherapy: bad biology or should the fight go on?

Just over 50% of patients with advanced rectal cancer have a poor response to chemoradiotherapy with resultant poor outcomes. Professor Glimelius reviews the evidence base for defining such patients and the potential role, if any, of further treatment

Temporal changes in circulating P-selectin, plasminogen activator inhibitor-1, magnesium, and creatine kinase after percutaneous coronary intervention*

Objective: This study aims to determine the mechanisms underlying restenosis and ischemia-reperfusion injury of the myocardium after percutaneous coronary intervention (PCI). Methods: The present study examined serial changes (5 min, 30 min, 2 h, 6 h, and 24 h after PCI) in circulating P-selectin, plasminogen activator inhibitor-1 (PAI-1), magnesium (Mg), and creatine kinase-myocardial band fraction (CK-MB) levels, which may be associated with restenosis and myocardial injury in patients undergoing PCI. The occurrence rates of major adverse cardiovascular events were collected over a six-month follow-up. Results: PCI induced an early elevation of P-selectin, which correlated positively with the inflation pressure used in the PCI procedure. PCI also caused a significant and sustained decrease in serum Mg in PCI patients, without an effect on PAI-1. An increase in CK-MB was observed in PCI patients, although values were within normal reference range. In addition, elevated P-selectin and decreased Mg measured shortly after the coronary angioplasty procedure were associated with recurrent treatment and heart failure, respectively. Conclusions: Our study demonstrates that PCI induces temporal changes of P-selectin, Mg, and CK-MB, which may be involved in restenosis and ischemia-reperfusion injury. These findings highlight the need for using antiplatelet therapy and Mg to reduce the risks associated with PCI