Download Watchful waiting

”Watchfulwaiting”ved rektum cancer,
radiologiske aspekter
SørenR.Rafaelsen,MD,DMSc
VejleCancerHospital,SLB
DanishColorectalCancerGroupSouth,CCE
InstituteofRegionalHealthResearch
FacultyofHealthSciences
UniversityofSouthernDenmark
ypT0,N0,V0,M0pTRG 1
TumorRegressionGrade
Mandard
TRG1completeregression
TRG3moderateresponse
TRG2 fibrosis withscatteredtumor cells
TRG4minor response ornone
TRG Grading System
Mandard
Dworak
Junker/Muller
Japanese
Wheeler
Bujko/Glynne-Jones
Rodel based on Dworak
Rodel based on Wittekind (modified Dworak)
Cologne
mrTRG
MRIfindings
1
Radiologicalcompleteresponse :
noevidenceofevertreatedtumour
2
Good response: densefibrosis;noobvious residualtumour, signifying minimal
residualdiseaseornotumour
3
Moderateresponse: 50%fibrosisormucin, andvisibleintermediatesignal
4- 5
Slight- tonoresponse:littleareasoffibrosis ormucinbutmostlytumour
orsameappearancesasoriginal tumour (5)
High-dosechemoradiotherapy and
watchfulwaitingfordistalrectalcancer
• T2orT3,N0-N1adenocarcinomainthelower6cm
• Chemoradiotherapy
• Endoscopicbiopsiesofthetumour0,2,4,6weeks
watchful waiting
• completeclinicaltumour regression
• negativetumour sitebiopsies
• nonodalordistantmetastasesonCTandMRI
Oct2009- Dec2013
58%af51pt´erhavdekompletrespons
2åroverlevelse:100%
Re-growthintheobservation
group at1yearwas15·5%
(95%CI3·3-26·3).
Complications- Bleeding
Maastricht
Curative chemoradiation of low rectal cancer.
A prospective multicenter observational study
WW2
WW2,Objectives
• To investigate whether curative
chemoradiation of low rectal cancer is
feasible, safe and effective in a multicenter
study with results comparable to those of
single center studies.
Response and tumor control on MRI scans
compared to clinical observations,
including rectoscopic examination
Design
• Prospective multicenter, observational
study with 3 sites and 105 participants.
Vejle
Aalborg
København
The decision as to allocating the
patient to operation or observation:
• No obvious tumor by inspection and
palpation.
• No malignant cells in the biopsy from the
tumor bed.
• No obvious residual tumor or lymph node
metastases on MRI.
• No distant metastases on chest and
abdominal CT
?
• In case of doubt as to the clinical
evaluation of a residual lesion
(benign/malignant) in the rectal mucosa,
but with no malignant cells in the tumor
bed biopsy, the patient can be referred to
observation – and followed at shorter
intervals, if indicated.
WW2, Inclusion Criteria
• Histopathologically verified adenocarcinoma of the
rectum
• Planned APR or ultralow resection
• Primary, resectable T1-T3, N0 tumor. N1 nodal disease
is acceptable if the positive lymph nodes are localized
to the mesorectum at the level of the tumor.
• Distance from anal verge to lower edge of tumor ≤ 6
cm measured by rigid rectoscope
• Performance status 0-2
• Kidney function
- Serum creatinine < 1.5 x
or measured GFR > 30 ml/min
WW2,Exclusion Criteria
• Previous surgical treatment of the present
cancer, including transanal excision of tumor.
• Other malignant disease within the past five
years except basocellular skin cancer and
carcinoma in situ cervicis uteri
• Distant metastases verified by imaging or
biopsy
• Previous radiation treatment of the pelvis
Treatment
• Radiotherapy: 62 Gy/28 fractions with
concomitant boost to the tumor volume.
50.4 Gy/28 fractions to elective lymph
node regions.
• Chemotherapy: capecitabine
WW2, Imaging
• CT and MRI are performed six weeks and
potentially 12 weeks after end of treatment for
response evaluation, and additionally as a part of
each follow-up visit to the clinic.
• Standardized forms will be used for reporting
the imaging results, especially for the description
of tumor regression as assessed by MRI
including dwi.
• The total number of CT scans during the course
of treatment and follow-up (5 years) is 11.
WW2,MRI
• Before enrollment (staging)
• Before start of treatment (baseline and
dose planning)
• 2 weeks after start of radiation treatment
(assessment of early response)
• 6 (and potentially 12) weeks after end of
treatment (response evaluation)
• Before each follow-up visit
MRI
•
• T2 weighted
imaging
• Transversal, sagittal. •
• Transversal imaging •
with a section
(slice+gap) thickness
making fusion with CT•
as simple as possible
(2-3mm) and in-plane
resolution <=1mm.
Diffusion weighted imaging
(DWI)
Section thickness 4-5mm and
acquired voxel size 2-3mm
b-values: 0, 300, 500, 800,1000
3NSA – multiply factor:
1(b<500), 2(500<=b<1000), 3
(1000<=b)
Immediately before DWI a T2
sequence is performed with the
same resolution as the DWI
sequence.
Nodal staging in rectal cancer: why
is restaging after chemoradiation
more accurate than primary nodal
staging?
LucHetal.2016
Goodandcompleterespondinglocallyadvanced
rectaltumors afterchemoradiotherapy:wherearethe
residualpositivenodeslocatedonrestagingMRI?
95yT0-2patients
• NoN+werefoundbelowthetumor level
• 55%oftheN+nodeswerelocatedatthelevel
ofthetumor
• 45%proximaltothetumor
• 82%ofthenodeswerelocatedatthe
ipsilateralcircumferenceofthetumor
• Mediandistanceof0.9 cmfromthetumor
Heijnen LAetal.Abdom Radiol. 2016[Epub aheadofprint]
Lymphnodes
Laterallymphnodes
AnnSurg.2015Jun23.[Epubaheadofprint]
Diffusion-weightedMRIforEarlyPredictionofTreatmentResponseonPreoperative
ChemoradiotherapyforPatientsWithLocallyAdvancedRectalCancer:AFeasibilityStudy.
JacobsLetal.
TheΔADCduring CRTandfour weekspost-CRT
werethebestpredictiveparametersfor
pathological good response.
Watch-and-waitapproachversussurgicalresection
afterchemoradiotherapy forpatientswithrectalcancer
AndrewGetal.LancetOncol 2016
• 3-yearnon-regrowthdisease-freesurvival
• 74%[95%CI64–82]vs47%[37–57]
MRIfollow-up
•
•
•
•
•
Increasesizeoftumor
Growthoflymphnodes
Newlymphnodes
Increasedsignalonb800byfollow-up
LowsignalonADCmap
Continue
Follow-up
•
•
•
•
Sizereduction(cm)/disappearanceoftumour
Sizereduction(mm)/disappearanceoflymphnodes
Reducedsignalinthetumour onb800
IncreasedsignalonADCmap
GodSommer
Ewelina Kluza et al. Eur Radiol May 2016, Volume 26, Issue 5, pp 1311-19