The Prognostic Effect of Downstaging in Patients with Metastatic Rectal Cancer Operated for Cure
*Anne M Dinaux, *Lieve GJ Leijssen, Hiroko Kunitake, Liliana G Bordeianou, David L Berger
Massachusetts General Hospital, Boston, MA
Objective: To determine whether downstaging of T- and/or N-stage has beneficial effects on outcomes of patients with rectal cancer with liver metastases. Current guidelines do not recommend neoadjuvant radiotherapy when a patients has Stage IV disease, while downstaging by neoadjuvant therapy in non-metastatic rectal cancer has shown to result in better outcomes.
Design:
Retrospective analyses of a IRB approved dataset
Setting:
Tertiary care center
Patients:
Patients with rectal cancer metastatic to the liver, who received neoadjuvant radiotherapy and were operated on with curative intent between 2004-2015. All patients received a liver resection for metastases prior to/during/after the rectal resection.
Main Outcome Measures:
Disease specific and overall mortality and survival duration.
Results:
A total of 37 patients were included, in whom 11 downstaging of T- and/or N-stage was achieved due to the administration of neoadjuvant radiotherapy. Downstaged patients had non-significantly higher rates of disease specific mortality (45.5% vs. 23.1%;P=0.244) and overall mortality (45.5% vs. 34.6%;P=0.713). Median disease specific (DSS) and overall survival (OS) were comparable for both groups (P=0.931 and P=0.987, respectively), while Kaplan Meier analyses showed worse outcomes for downstaged patients (DSS: P=0.119 and OS: P=0.356). However, multivariable cox-analyses demonstrated point estimates favorable for downstaged patients: DSS: HR:4.12, adjusted for ypT-stage and ypN-stage (95%CI:0.86-19.75); P=0.071 and OS: HR:3.42, adjusted for BMI, ypT-stage, and ypN-stage (95%CI:0.86-13.61); P=0.081.
Conclusions:
Downstaging of metastatic rectal tumors due to administration of neoadjuvant radiotherapy demonstrated trends towards better survival outcomes when correcting for disease stage on surgical pathology. Although more evidence is needed, outcomes suggest that patients with rectal cancer metastastic to the liver, who are candidate for curative surgery, should receive neoadjuvant radiotherapy to increase chances of down staging.
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