Annals of Coloproctology

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Colorectal cancer

Effects of clinical information on the treatment decisions for good responders to neoadjuvant chemoradiotherapy among rectal cancer patients: Eon Bin Kim, In Ja Park, Hwa Jung Kim, Jong Keon Jang, Seong Ho Park, Young Il Kim, Min Hyun Kim, Jong Lyul Lee, Chan Wook Kim, Yong Sik Yoon, Seok-Byung Lim, Chang Sik Yu; Ann Coloproctol. 2025;41(5):473-482. Published online July 10, 2025; DOI: https://doi.org/10.3393/ac.2024.00276.0039

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Purpose
The decision for treatment after neoadjuvant chemoradiotherapy (nCRT) in rectal cancer is intricately linked to tumor response and clinical parameters. This study was designed to elucidate determinants influencing treatment decisions for good responders to nCRT, while concurrently evaluating the ramifications of modifications in magnetic resonance imaging (MRI) tumor response evaluation protocols.
Methods
A survey was constructed with 5 cases of good responder after nCRT based on the magnetic resonance–based tumor regression grade (mrTRG) criteria. A total of 35 colorectal surgeons in Korea participated in the survey via email, and they were introduced to 2 discrete MRI-based tumor response evaluation methodologies: the conventional mrTRG and an emergent complete response (CR)/non-CR classification system. Surgeons were directed to select between total mesorectal excision, local excision, or a watch and wait strategy.
Results
Treatment decisions varied significantly (P<0.01), as gradually more clinical information was provided with mrTRG. The paradigm shift from mrTRG to CR/non-CR evaluation criterion instigated the highest alteration in decision (P<0.01). Even comparing with other sets of information, decision change with different tumor response assessment (i.e., mrTRG vs. CR/non-CR) was statistically significant (P<0.01). Three particular cases consistently displayed a declining predilection for total mesorectal excision, favoring a more pronounced inclination towards watch and wait strategy or local excision. Nonetheless, the magnitude of these decisional shifts oscillated depending on the specific endoscopic imagery present.
Conclusion
Our current findings underscore the significant role of tumor response assessment methods in shaping treatment decisions for rectal cancer patients who respond well to nCRT. This highlights the need for clear and accurate tools to interpret MRI results.

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Clinical implications of radiologic criteria and prognostic factors for lateral lymph node metastasis in low rectal cancer
Gyung Mo Son
Annals of Coloproctology.2025; 41(6): 489. CrossRef

Clinical Impact of Tumor Regression Grade after Preoperative Chemoradiation for Locally Advanced Rectal Cancer: Subset Analyses in Lymph Node Negative Patients: Byung Soh Min, Nam Kyu Kim, Ju Yeon Pyo, Hoguen Kim, Jinsil Seong, Ki Chang Keum, Seung Kook Sohn, Chang Hwan Cho; J Korean Soc Coloproctol. 2011;27(1):31-40. Published online February 28, 2011; DOI: https://doi.org/10.3393/jksc.2011.27.1.31

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Abstract PDF

Background

We investigated the prognostic significance of tumor regression grade (TRG) after preoperative chemoradiation therapy (preop-CRT) for locally advanced rectal cancer especially in the patients without lymph node metastasis.

Methods

One-hundred seventy-eight patients who had cT3/4 tumors were given 5,040 cGy preoperative radiation with 5-fluorouracil/leucovorin chemotherapy. A total mesorectal excision was performed 4-6 weeks after preop-CRT. TRG was defined as follows: grade 1 as no cancer cells remaining; grade 2 as cancer cells outgrown by fibrosis; grade 3 as a minimal presence or absence of regression. The prognostic significance of TRG in comparison with histopathologic staging was analyzed.

Results

Seventeen patients (9.6%) showed TRG1. TRG was found to be significantly associated with cancer-specific survival (CSS; P = 0.001) and local recurrence (P = 0.039) in the univariate study, but not in the multivariate analysis. The ypN stage was the strongest prognostic factor in the multivariate analysis. Subgroup analysis revealed TRG to be an independent prognostic factor for the CSS of ypN0 patients (P = 0.031). TRG had a stronger impact on the CSS of ypN (-) patients (P = 0.002) than on that of ypN (+) patients (P = 0.521). In ypT2N0 and ypT3N0, CSS was better for TRG2 than for TRG3 (P = 0.041, P = 0.048), and in ypN (-) and TRG2 tumors, CSS was better for ypT1-2 than for ypT3-4 (P = 0.034).

Conclusion

TRG was found to be the strongest prognostic factor in patients without lymph node metastasis (ypN0), and different survival was observed according to TRG among patients with a specific histopathologic stage. Thus, TRG may provide an accurate prediction of prognosis and may be used for f tailoring treatment for patients without lymph node metastasis.

Citations

Citations to this article as recorded by

Tumor Regression Grade as a Prognostic Factor in Metastatic Colon Cancer Following Preoperative Chemotherapy
Yufei Yang, Dakui Luo, Ruoxin Zhang, Sanjun Cai, Qingguo Li, Xinxiang Li
Clinical Colorectal Cancer.2022; 21(2): 96. CrossRef
Prediction of tumor response of rectal cancer cells via 3D cell culture and in�vitro cytotoxicity assay before initiating preoperative chemoradiotherapy
Jeonghyun Kang, Min Park, Jina Kim, Hyuk Hur, Byung Min, Seung Baik, Kang Lee, Nam Kim
Oncology Letters.2019;[Epub] CrossRef
Prognostic significance of tumour regression grade after neoadjuvant chemoradiotherapy for a cohort of patients with locally advanced rectal cancer: an 8‐year retrospective single‐institutional study
L. Xu, S. Cai, T. Xiao, Y. Chen, H. Qiu, B. Wu, G. Lin, X. Sun, J. Lu, W. Zhou, Y. Xiao
Colorectal Disease.2017;[Epub] CrossRef
Neoadjuvant chemoradiotherapy for rectal cancer: how important is tumour regression?
Melanie J. McCoy, Chris Hemmings, Simon Hillery, Cheryl Penter, Max K. Bulsara, Nik Zeps, Cameron F. Platell
ANZ Journal of Surgery.2017;[Epub] CrossRef
Defining response to radiotherapy in rectal cancer using magnetic resonance imaging and histopathological scales
Muhammed R S Siddiqui, Jemma Bhoday, Nicholas J Battersby, Manish Chand, Nicholas P West, Al-Mutaz Abulafi, Paris P Tekkis, Gina Brown
World Journal of Gastroenterology.2016; 22(37): 8414. CrossRef
Interobserver agreement of radiologists assessing the response of rectal cancers to preoperative chemoradiation using the MRI tumour regression grading (mrTRG)
M.R.S. Siddiqui, K.L. Gormly, J. Bhoday, S. Balyansikova, N.J. Battersby, M. Chand, S. Rao, P. Tekkis, A.M. Abulafi, G. Brown
Clinical Radiology.2016; 71(9): 854. CrossRef
Controversies in the pathological assessment of colorectal cancer
Aoife Maguire
World Journal of Gastroenterology.2014; 20(29): 9850. CrossRef
The prognostic value of tumour regression grade following neoadjuvant chemoradiation therapy for rectal cancer
K. I. Abdul‐Jalil, K. M. Sheehan, J. Kehoe, R. Cummins, A. O'Grady, D. A. McNamara, J. Deasy, O. Breathnach, L. Grogan, B. D. P. O'Neill, C. Faul, I. Parker, E. W. Kay, B. T. Hennessy, P. Gillen
Colorectal Disease.2014;[Epub] CrossRef
Pathological grading of regression: an International Study Group perspective
Runjan Chetty, P Gill, Adrian C Bateman, David K Driman, Dhirendra Govender, Andrew R Bateman, Y J Chua, Godman Greywoode, Christine Hemmings, I Imat, Eleanor Jaynes, Cheok Soon Lee, Michael Locketz, Corwyn Rowsell, Anne Rullier, Stefano Serra, Eva Szentg
Journal of Clinical Pathology.2012; 65(10): 865. CrossRef
Pathological grading of regression following neoadjuvant chemoradiation therapy: the clinical need is now: Table 1
Tom P MacGregor, Tim S Maughan, Ricky A Sharma
Journal of Clinical Pathology.2012; 65(10): 867. CrossRef

Clinical Significance of Tumor Regression Grade in Rectal Cancer with Preoperative Chemoradiotherapy: Young Joo Park, Byung Ryul Oh, Sang Woo Lim, Jung Wook Huh, Jae Kyun Joo, Young Jin Kim, Hyeong Rok Kim; J Korean Soc Coloproctol. 2010;26(4):279-286. Published online August 31, 2010; DOI: https://doi.org/10.3393/jksc.2010.26.4.279

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Abstract PDF

Purpose

Neoadjuvant chemoradiotherapy applied to the locally advanced rectal cancer reduces local recurrence and improves survival. We assessed tumor regression grade (TRG) and its influence on survival in rectal cancer patients treated with chemoradiotherapy followed by surgical resection.

Methods

We studied 108 patients that were seen at our hospital between August 2004 and December 2008. Patients received preoperative chemoradiotherapy consisting of 5-fluorouracil and leucovorin by continous infusion during the first and fifth week, delivered with concurrent pelvic radiation of 50.4 Gy, followed by radical surgery at 6-8 weeks. The TRG was determined by the amount of fibrosis in the tumor embedding area and was divided into 5 grades based on the relative amount of fibrosis. We analyzed all preoperative clinicopathologic factors, postoperative pathologic stages, TRG and prognosis, retrospectively.

Results

Downstaging of rectal cancer through neoadjuvant chemoradiotherapy occurred in 64 (59%) patients. The numbers of total regressions (TRG4), good regressions (TRG3), moderate regressions (TRG2), minor regressions (TRG1), and no regression (TRG0) were 19 (18%), 65 (60%), 17 (16%), 6 (5%), and 1 (1%) respectively. The TRG was inversely correlated with perineural invasion and lymphovascular invasion (P = 0.008, P = 0.032). The local recurrence rate declined as the tumor regression grade increased (P = 0.032). The 19 patients with TRG4 had a better three-year disease free survival than the 89 patients with TRG0-3 (P = 0.034). The 16 patients with pathologic complete remission (pCR) had a better three-year disease free survival than the 92 patients with non-pCR (P = 0.025).

Conclusion

Higher TRG after preoperative chemoradiotherapy for rectal cancer closely correlates with better survival and low local recurrence. The TRG is considered to be a significant prognostic factor.

Citations

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An investigation into tumor regression grade as a parameter for locally advanced rectal cancer and 5-year overall survival rate
Supparerk Laohawiriyakamol, Wongsakorn Chaochankit, Worawit Wanichsuwan, Kanet Kanjanapradit, Teeranan Laohawiriyakamol
Annals of Coloproctology.2023; 39(1): 59. CrossRef
Rezultate preliminare ale markerilor ca predictori ai răspunsului tisular la radiochimioterapie în cancerul rectal
Sânziana Ionescu, Petre Radu, Octavia Luciana Madge, Victor Strâmbu
Oncolog-Hematolog.ro.2022; 1(58): 8. CrossRef
Clinical Implication of Perineural and Lymphovascular Invasion in Rectal Cancer Patients Who Underwent Surgery After Preoperative Chemoradiotherapy
Young Il Kim, Chan Wook Kim, Jong Hoon Kim, Jihun Kim, Jun-Soo Ro, Jong Lyul Lee, Yong Sik Yoon, In Ja Park, Seok-Byung Lim, Chang Sik Yu, Jin Cheon Kim
Diseases of the Colon & Rectum.2022; 65(11): 1325. CrossRef
Downstaging in Advanced Rectal Cancers: A Propensity-Matched Comparison Between Short-Course Radiotherapy Followed by Chemotherapy and Long-Course Chemoradiotherapy
Praveen S. Kammar, Niharika R. Garach, Sivasanker Masillamany, Ashwin de’Souza, Vikas Ostwal, Avanish P. Saklani
Diseases of the Colon & Rectum.2022; 65(10): 1215. CrossRef
Overexpression of MLPH in Rectal Cancer Patients Correlates with a Poorer Response to Preoperative Chemoradiotherapy and Reduced Patient Survival
Wan-Shan Li, Chih-I Chen, Hsin-Pao Chen, Kuang-Wen Liu, Chia-Jen Tsai, Ching-Chieh Yang
Diagnostics.2021; 11(11): 2132. CrossRef
How to measure tumour response in rectal cancer? An explanation of discrepancies and suggestions for improvement
Iris D. Nagtegaal, Rob Glynne-Jones
Cancer Treatment Reviews.2020; 84: 101964. CrossRef
Neoadjuvant chemoradiotherapy might provide survival benefit in patients with stage IIIb/IIIc locally advanced rectal cancer: A retrospective single‐institution study with propensity score‐matched comparative analysis
Xi‐yu Sun, Song‐hua Cai, Lai Xu, Dan Luo, Hui‐zhong Qiu, Bin Wu, Guo‐le Lin, Jun‐yang Lu, Guan‐nan Zhang, Yi Xiao
Asia-Pacific Journal of Clinical Oncology.2020; 16(3): 142. CrossRef
Prognostic value of tumour regression grade in locally advanced rectal cancer: a systematic review and meta‐analysis
J. C. Kong, G. R. Guerra, S. K. Warrier, A. Craig Lynch, M. Michael, S. Y. Ngan, W. Phillips, G. Ramsay, A. G. Heriot
Colorectal Disease.2018; 20(7): 574. CrossRef
UEG Week 2018 Poster Presentations

United European Gastroenterology Journal.2018;[Epub] CrossRef
Prognostic significance of tumour regression grade after neoadjuvant chemoradiotherapy for a cohort of patients with locally advanced rectal cancer: an 8‐year retrospective single‐institutional study
L. Xu, S. Cai, T. Xiao, Y. Chen, H. Qiu, B. Wu, G. Lin, X. Sun, J. Lu, W. Zhou, Y. Xiao
Colorectal Disease.2017;[Epub] CrossRef
Magnetic resonance tumor regression grade (MR-TRG) to assess pathological complete response following neoadjuvant radiochemotherapy in locally advanced rectal cancer
Marco Rengo, Simona Picchia, Simona Marzi, Davide Bellini, Damiano Caruso, Mauro Caterino, Maria Ciolina, Domenico De Santis, Daniela Musio, Vincenzo Tombolini, Andrea Laghi
Oncotarget.2017; 8(70): 114746. CrossRef
Oncologic impact of pathologic response on clinical outcome after preoperative chemoradiotherapy in locally advanced rectal cancer
Wook Hyeon Yoon, Hun Jin Kim, Chang Hyun Kim, Jae Kyoon Joo, Young Jin Kim, Hyeong Rok Kim
Annals of Surgical Treatment and Research.2015; 88(1): 15. CrossRef
Low Lymph Node Retrieval After Preoperative Chemoradiation for Rectal Cancer is Associated with Improved Prognosis in Patients with a Good Tumor Response
Hun Jin Kim, Jeong Seon Jo, Soo Young Lee, Chang Hyun Kim, Young Jin Kim, Hyeong Rok Kim
Annals of Surgical Oncology.2015; 22(6): 2075. CrossRef
Clinical Prediction of Pathological Complete Response After Preoperative Chemoradiotherapy for Rectal Cancer
Jung Wook Huh, Hyeong Rok Kim, Young Jin Kim
Diseases of the Colon & Rectum.2013; 56(6): 698. CrossRef
Prognostic Significance of Partial Tumor Regression After Preoperative Chemoradiotherapy for Rectal Cancer
Yen-Chien Lee, Chung-Cheng Hsieh, Jen-Pin Chuang
Diseases of the Colon & Rectum.2013; 56(9): 1093. CrossRef
Prognostic Role of p53 Messenger Ribonucleic Acid Expression in Patients after Curative Resection for Stage I to III Colorectal Cancer: Association with Colon Cancer Stem Cell Markers
Jung Wook Huh, Hyeong Rok Kim, Young Jin Kim
Journal of the American College of Surgeons.2013; 216(6): 1063. CrossRef
A phase II study of neoadjuvant chemoradiotherapy with oxaliplatin and capecitabine for rectal cancer
Lin Zhao, Chunmei Bai, Yajuan Shao, Mei Guan, Ning Jia, Yi Xiao, Huizhong Qiu, Fuquan Zhang, Ti Yang, Guangxi Zhong, Shuchang Chen
Cancer Letters.2011; 310(2): 134. CrossRef
Oncologic outcomes of pathologic stage I lower rectal cancer with or without preoperative chemoradiotherapy: Are they comparable?
Jung Wook Huh, Chang Hyun Kim, Hyeong Rok Kim, Young Jin Kim
Surgery.2011; 150(5): 980. CrossRef

Oncologic Result as According to Tumor Regression Grade after Neoadjuvant Chemoradiation Therapy in Locally Advanced Rectal Cancer.: Park, Jong Hyun , Song, Min Sang , Min, Hyo Suk , Kim, Ji Yeon; J Korean Soc Coloproctol. 2008;24(6):422-432.; DOI: https://doi.org/10.3393/jksc.2008.24.6.422

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Abstract PDF

PURPOSE
The effects of neoadjuvant chemoradiation therapy (NCRT) in cases of locally advanced rectal cancer include tumor downstaging with respect to a curative resection and a decreasing incidence of local recurrence. The aim of this study is to evaluate the oncologic results according to the tumor regression grade (TRG) after NCRT and radical surgical resection in cases of locally advanced rectal cancer.
METHODS
From 1999 to 2003, 140 consecutive patients, who suffered from locally advanced rectal cancer (T3 or T4, or lymph node positive) were enrolled in this study. They all received neoadjuvant chemoradiation therapy and a radical resection. Chemotherapy was based on 5-fluorouracil (5-FU), and the total radiation dose was 5,040 cGy over 6 weeks. A radical surgical resection, including a total mesorectal excision, was done 6 to 8 weeks after the completion of NCRT. We classified patients into subgroups by using the TRG; then, we investigated the overall and the disease-free survival rates and the local recurrence and the distant metastasis rates.
RESULTS
One hundred twenty-six (126, 90%) patients responded to radiation therapy. According to the TRG, the numbers of non- responders (Grade I, NR), partial responders (Grade II, PR), and patients who went into complete remission (Grade III, CR) were 14 (10%), 98 (70%), and 28 (20%), respectively. The overall survival (OS) and the disease-free survival (DFS) rates for 3 years (n=140) were 91.43% and 74.29%, and the rates for 5 years (n=117) were 81.20% and 67.52%, respectively. While there was no significant difference in the 3-year OS or DFS between the three groups stratified by TRG (P=0.1136, P=0.1215), the 5-year OS and DFS showed a statistical difference (P=0.0485, P=0.0458). Furthermore, the 3-year OS and DFS rates (P=0.0451, P=0.0458), as well as the 5-year OS and DFS rates (P=0.0139, P=0.0131) were significantly better for patients in the CR group than for the other patients. Still, no statistical significance differences existed between the CR group and the non-CR groups or between the TRG groups in terms of the local recurrence and the distant metastasis rates (P=0.447, P=0.271).
CONCLUSIONS
Any tumor response group that shows complete Rremission after NCRT and radical surgical resection has an oncologic benefit in overall survival and disease- free survival in our study.

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Citations to this article as recorded by

A Phase II Study of Additional Four-Week Chemotherapy With Capecitabine During the Resting Periods After Six-Week Neoadjuvant Chemoradiotherapy in Patients With Locally Advanced Rectal Cancer
Kyung Ha Lee, Min Sang Song, Jun Boem Park, Jin Soo Kim, Dae Young Kang, Ji Yeon Kim
Annals of Coloproctology.2013; 29(5): 192. CrossRef

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