Peritoneal Carcinomatosis in Colorectal Cancers - Management Perspective Needs a Change

BACKGROUND

Peritoneal carcinomatosis (PC) from colorectal cancers (CRC) either at initial presentation or at subsequent recurrence presents a significant treatment challenge. The aim of our study was to find its incidence and analyze outcomes of patients with PC from CRC origin managed by different treatment modalities.

PATIENTS AND METHODS

A retrospective analysis of patients, from August 2013 to July 2014, presenting with metastatic peritoneal disease from CRC with or without metastasis to other sites was performed. PC was classified as limited (peritoneal carcinomatosis index [PCI] < 10) and widespread (PCI > 10).

RESULTS

This study included 70 patients; 45 patients had peritoneum as the only site of metastasis and the remaining 25 visceral metastasis with peritoneum. Resections were performed in 23 patients (19 underwent R0 resection and 4 were R+). All patients received systemic chemotherapy (FOLFOX [Oxaliplatin with fluorouracil and folinic acid]/CAPOX [oxaliplatin and capecitabine]). At a median follow-up of 11 months, the median OS was 14 months. Patients with PCI < 10 had significantly better survival (median not reached) as compared with those with PCI > 10 (15 months). Patients undergoing R0 resection had better survival (24 months) versus those with R+ resection (16 months). The survival of patients receiving only systemic chemotherapy was 11 months.

CONCLUSION

The incidence of peritoneal metastasis in CRC is about 10%. A select group of patients who have low PCI who undergo R0 resection of only the diseased portion, without entire peritonectomy, still do well. Where facilities for hyperthermic intraperitoneal chemotherapy are not available, cytoreduction followed by systemic chemotherapy should be considered. The added role of hyperthermic intraperitoneal chemotherapy in this subgroup needs to be evaluated.

Olanzapine as Antiemetic Prophylaxis in Moderately Emetogenic Chemotherapy: A Phase 3 Randomized Clinical Trial

IMPORTANCE

The role of olanzapine has not been adequately evaluated in moderately emetogenic chemotherapy (MEC) regimens with or without neurokinin-1 receptor antagonists.

OBJECTIVE

To evaluate whether addition of olanzapine to an MEC regimen reduces nausea, vomiting, and use of nausea rescue medications among patients with solid malignant tumors.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter, open-label phase 3 randomized clinical trial included patients aged 18 years or older with solid malignant tumors who were receiving oxaliplatin-, carboplatin-, or irinotecan-based chemotherapy. The trial was conducted at 3 institutes in India from March 26, 2019, to August 26, 2023; the final cutoff date for analysis was September 10, 2023.

EXPOSURE

Patients were randomized 1:1 to dexamethasone, aprepitant, and palonosetron with olanzapine (experimental group) or without olanzapine (observation group). The experimental group received 10 mg of olanzapine orally once at night on days 1 through 3 of the chemotherapy regimen.

MAIN OUTCOMES AND MEASURES

The primary end point was complete response (CR), defined as the proportion of patients with no vomiting, no significant nausea (scored as <5 on a visual analog scale of 1 to 100), and no use of rescue medications for nausea. Secondary end points included the proportion of patients experiencing nausea and chemotherapy-induced nausea and vomiting (CINV), receiving rescue medications, and experiencing adverse events.

RESULTS

A total of 560 patients (259 [64%] male; median age, 51 years [range, 19-80 years]) were randomized. The analysis included 544 patients with evaluable data (274 assigned to olanzapine and 270 to observation). Baseline characteristics were evenly matched between the 2 groups. The proportion of patients with CR was significantly greater in the group with (248 [91%]) than without (222 [82%]) olanzapine in the overall 120-hour treatment period (P = .005). Likewise, there were significant differences between the olanzapine and observation groups for nausea control (264 [96%] vs 234 [87%]; P < .001) and CINV (262 [96%] vs 245 [91%]; P = .02) during the overall assessment period, and the proportion of patients receiving rescue medications significantly increased in the observation group (30 [11%]) compared with the olanzapine group (11 [4%]) (P = .001). Grade 1 somnolence was reported by 27 patients (10%) following administration of chemotherapy and olanzapine and by no patients in the observation group.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, the addition of olanzapine significantly improved CR rates as well as nausea and vomiting prevention rates in chemotherapy-naive patients who were receiving MEC regimens containing oxaliplatin, carboplatin, or irinotecan. These findings suggest that use of olanzapine should be considered as one of the standards of care in these chemotherapy regimens.

TRIAL REGISTRATION

Clinical Trials Registry-India (CTRI) Identifier: CTRI/2018/12/016643.

Carcinoembryonic antigen directed PET-CECT scanning for postoperative surveillance of colorectal cancer

AIM

During the follow-up of surgically resected colorectal cancer (CRC), positron emission tomography-contrast-enhanced computed tomography (PET-CECT) is indicated for asymptomatic elevation of carcinoembryonic antigen (CEA) > 5 ng/ml and no obvious site of recurrence on clinical examination and basic imaging. As an institutional policy, a PET-CECT scan was performed at our institute whenever (1) CEA levels rose above 5 ng/ml and (2) CEA values were doubled (even if the CEA level was < 5 ng/ml). Our aim was to correlate the range of CEA elevation with recurrence rates and to evaluate the diagnostic utility of PET-CECT scanning in this setting.

METHOD

We retrospectively analysed all cases where a PET-CECT scan was performed for elevated CEA levels during surveillance visits after complete resection of the primary tumour followed by adjuvant therapy. This study was conducted from 1 January 2013 to 31 July 2015.

RESULTS

In all, 104 patients underwent a PET-CECT scan for rising CEA values, and 62 patients (59.6%) were found to have recurrent disease. At CEA levels < 5, 5.1-10, 10.1-15, 15.1-50 and > 50 ng/ml, disease recurred in 10%, 45%, 70%, 94% and 100% patients, respectively. Sensitivity, specificity, positive predictive value and negative predictive value of the PET-CECT scan were 92.7%, 95.2%, 96.2% and 90.9%, respectively. Elevation of CEA levels during follow-up was indicative of recurrence in 68% of the secretors and 45% of the non-secretors (based on baseline CEA status).

CONCLUSION

In the setting of rising CEA levels during follow-up of patients with CRC, a PET-CECT scan is a valuable tool to detect recurrence, irrespective of the baseline CEA secretor status. The likelihood of recurrence of disease was directly proportional to the value of the raised CEA level.

Outcomes of exenteration in cT4 and fixed cT3 stage primary rectal adenocarcinoma: a subgroup analysis of consolidation chemotherapy following neoadjuvant concurrent chemoradiotherapy

PURPOSE

The aim was to evaluate the oncological outcomes and the prognostic factors following pelvic exenteration (PE) in cT4 and fixed cT3 stage primary rectal adenocarcinoma and to study the impact of consolidation chemotherapy following neoadjuvant concurrent chemoradiotherapy (NACRT).

METHODS

A retrospective analysis of a prospectively maintained database of PE from 2013 to 2018.

RESULTS

Out of 2900 colorectal resections, there were 131 pelvic exenterations that were performed, and 100 of these patients had undergone exenteration for primary rectal adenocarcinoma. Of these 100 patients, there were 81 patients who had received NACRT followed by surgery, 50 of whom who had received consolidation chemotherapy and 31 who had undergone surgery without consolidation chemotherapy. R0 resection was achieved in 90% cases. At a median follow-up of 32 months, 2-year disease free survival was 61.8% and estimated 5-year overall survival was 62%. The incidence of distant metastases was 44% vs. 19% (p = 0.023), and the 2-year distant recurrence-free survival was 58% vs. 89% (p = 0.025), respectively, in the 'consolidation chemotherapy group' and the 'no chemotherapy group'. The poorly differentiated grade of tumours, presence of lympho-vascular-invasion, consolidation chemotherapy, and disease recurrence were all found to affect the survival.

CONCLUSION

PE with R0 resection achieves excellent survival rates in cT4 and fixed cT3 stage primary rectal adenocarcinoma. The distant recurrence rate may not be altered by consolidation chemotherapy in the subset of high-risk patients. However, further research on consolidation chemotherapy following NACRT in cT4 and fixed cT3 stage primary rectal adenocarcinoma will give a definite answer in the future.

Toxicity and early outcomes of regorafenib in multiply pre-treated metastatic colorectal adenocarcinoma-experience from a tertiary cancer centre in India

BACKGROUND

Regorafenib is a multikinase inhibitor (MKI) approved for use in multiply pre-treated metastatic colorectal cancers (mCRC). To the best of our knowledge, this is the first report of regorafenib from India.

MATERIALS AND METHODS

Records of 23 cases treated with regorafenib at our centre between June 2013 till September 2015 were reviewed. All had received at least two non cross resistant lines of therapy prior to regorafenib. Toxicity was recorded using CTCAE version 4.03. Responses were assessed using RECIST 1.1 criteria. Response evaluation was done every three months or earlier if clinically indicated. Five patients were still on therapy at the time of this report.

RESULTS

The median age was 50 years. Thirty-nine percent (9/23) had upfront metastatic disease. Twenty-six percent (6/23) and 39% (9/23) patients had received prior treatment with cetuximab and bevacizumab respectively. Mean duration of regorafenib treatment was 3.8 months. At least one grade III/IV toxicity was noted in 65% (15/23) cases. The most common were handfoot syndrome (HFS) and fatigue seen in 86.9% (20/23) patients. Grade II and III HFS was seen in 65% patients. One patient required stoppage of treatment due to grade III hepatotoxicity. Dose reduction was required for 86.9% (20/23) patients. Best response noted was stable disease in 34.8% (8/23), partial response in 8.7% (2/23) patients and progression in 56.5% (13/23). Median progression free survival was 3 months and median follow-up was 4.5 months.

CONCLUSIONS

Regorafenib, although an effective treatment strategy in multiply pre-treated mCRC, is associated with significant side effects.

Laparoscopic versus open resection in locally advanced rectal cancers: a propensity matched analysis of oncological and short-term outcomes

AIM

The aim was to compare oncological and short-term outcomes between open and laparoscopic surgery in locally advanced rectal cancers.

METHODS

It is a retrospective analysis conducted in a high volume tertiary centre. Matching was carried out for nine variables, including preoperative factors, neoadjuvant treatment and sphincter preservation.

RESULTS

Both the open and laparoscopic surgery arms had 239 patients each. The distributions of pretreatment MRI T3, T4, circumferential resection margin (CRM) positive tumours, neoadjuvant long-course chemoradiation and sphincter preservation were 80.3%, 13.6%, 50%, 89% and 56.4% respectively. The mean number of nodes harvested (12.9 vs. 12.7, P = 0.716), pathological CRM positivity (6.3% in open vs. 5.4% in laparoscopic, P = 0.697) and distal resection margins were similar. The mean blood loss was higher in open surgeries (910 ml vs. 349 ml, P < 0.001). Anastomotic leaks and Clavien-Dindo Grade 3-4 complications were higher in the open arm than in the laparoscopy arm (5.9% vs. 1.7%, P = 0.024, and 12.5% vs. 6.7%, P = 0.015 respectively). The median postoperative hospital stay was significantly shorter in the laparoscopy arm (7 vs. 6, P = 0.015). In CRM positive and threatened cases, the measured outcomes were similar between the two groups except for blood loss which was significantly higher in the open surgery (872 vs. 379, P = 0.000).

CONCLUSIONS

In high volume centres, in the hands of experienced colorectal surgeons, laparoscopic rectal surgery is oncologically safe in locally advanced rectal cancers and has lesser morbidity and shorter hospital stay than open surgery. In CRM positive and threatened cases the laparoscopic surgery showed less blood loss compared to open surgery, while other outcome measures were similar to open surgery.

EMERALD: Emergency visit audit of patients treated under medical oncology in a tertiary cancer center: Logical steps to decrease the burden

BACKGROUND

We are a tertiary care cancer center and have approximately 1000-1500 emergency visits by cancer patients undergoing treatment under the adult medical oncology unit each month. However, due to the lack of a systematic audit, we are unable to plan steps toward the improvement in quality of emergency services, and hence the audit was planned.

METHODS

All emergency visits under the adult medical oncology department in the month of July 2015 were audited. The cause of visit, the demographic details, cancer details, and chemotherapy status were obtained from the electronic medical records. The emergency visits were classified as avoidable or unavoidable. Descriptive statistics were performed. Reasons for avoidable emergency visits were sought.

RESULTS

Out of 1199 visits, 1168 visits were classifiable. Six hundred and ninety-six visits were classified as unavoidable (59.6%, 95% CI: 56.7-62.4), 386 visits were classified as probably avoidable visit (33.0%, 95% CI: 30.4-35.8) whereas the remaining 86 (7.4%, 95% CI: 6.0-9.01) were classified as absolutely avoidable. Two hundred and ninety-seven visits happened on weekends (25.6%) and 138 visits converted into an inpatient admission (11.9%). The factors associated with avoidable visits were curative intention of treatment (odds ratio - 2.49), discontinued chemotherapy status (risk ratio [RR] - 8.28), and private category file status (RR - 1.89).

CONCLUSION

A proportion of visits to emergency services can be curtailed. Approximately one-fourth of patients are seen on weekends, and only about one-tenth of patients get admitted.

Resection of Isolated Port Site Metastasis in Gall Bladder Cancers-Careful Selection and Perioperative Systemic Therapy May Improve Outcomes

Excision of port site (PSE) for patients having undergone laparoscopic cholecystectomy (LC) is not a standard recommendation. We retrospectively evaluated a cohort of patients with isolated PSM without any prior cancer-directed therapy who were assessed for resection between March 2012 and July 2016 at Tata Memorial Hospital, Mumbai. Eleven of a total 13 patients underwent wide excision for PSM in the given time period. Upfront resection was undertaken in six patients while seven patients received neoadjuvant chemotherapy (NACT) and two received neoadjuvant chemo radiotherapy (NACTRT) prior to attempted resection. With the median follow-up of 22 months, post PSM disease-free survival (DFS) was 20 months (95% CI 15-24 months) and overall survival (OS) was 37 months (95% CI 22-51 months). Careful selection along with an aggressive management strategy may be a step forward in the treatment of patients with isolated PSM.

Gemcitabine-cisplatin (GC) as adjuvant chemotherapy in resected stage II and stage III gallbladder cancers (GBC): a potential way forward

Data on adjuvant chemotherapy with gemcitabine-cisplatin (GC) in resected gallbladder cancers (GBC) are scarce. Patients who underwent upfront curative resection for GBC from 2010 to 2016 were analyzed. Patients with stage II-III GBC treated with adjuvant GC were analyzed. A total of 242 patients were evaluated, of whom 125 patients received GC regimen as adjuvant chemotherapy. The median age was 50 years (range 31-74), majority were female (77.6%), and 37 patients (29.6%) had raised CA 19.9 levels at baseline. One hundred and thirteen patients (90.4%) underwent radical cholecystectomy with R0 resections. Median number of GC administered was 6, with completion rates of 84%. Toxicity data were comprehensively available for 110 patients, with common grade 3 and grade 4 being neutropenia (9.9%), fatigue (7.3%) and febrile neutropenia (3.6%), respectively. With a median follow-up of 36.88 months, 3-year RFS was 60.3%. Patients with stage II (28%; n = 35), stage IIIA (28%; n = 35) and stage IIIB GBC (44%; n = 55) had a 3-year OS of 91.9, 67 and 58.1% (p = 0.001), respectively. Patients with stage II-III GBC undergoing R0 resections receiving adjuvant GC have good tolerance, high completion rates and encouraging outcomes in a non-trial high GBC prevalence scenario.

Multivisceral resections for rectal cancers: short-term oncological and clinical outcomes from a tertiary-care center in India

BACKGROUND

Locally advanced rectal cancers (LARCs) involve one or more of the adjacent organs in upto 10-20% patients. The cause of the adhesions may be inflammatory or neoplastic, and the exact causes cannot be determined pre- or intra-operatively. To achieve complete resection, partial or total mesorectal excision (TME) en bloc with the involved organs is essential. The primary objective of this study is to determine short-term oncological and clinical outcomes in these patients undergoing multivisceral resections (MVRs).

METHODS

This is a retrospective review of a prospectively maintained database. Between 1 July 2013 and 31 May 2015, all patients undergoing MVRs for adenocarcinoma of the rectum were identified from this database. All patients who had en bloc resection of an adjacent organ or part of an adjacent organ were included. Those with unresectable metastatic disease after neoadjuvant therapy were excluded.

RESULTS

Fifty-four patients were included in the study. Median age of the patients was 43 years. Mucinous histology was detected in 29.6% patients, and signet ring cell adenocarcinoma was found in 24.1% patients. Neoadjuvant therapy was given in 83.4% patients. R0 resection was achieved in 87% patients. Five-year overall survival (OS) was 70% for the entire cohort of population.

CONCLUSIONS

In Indian subcontinent, MVRs in young patients with high proportion of signet ring cell adenocarcinomas based on magnetic resonance imaging (MRI) of response assessment (MRI 2) is associated with similar circumferential resection margin (CRM) involvement and similar adjacent organ involvement as the western patients who are older and surgery is being planned on MRI 1 (baseline pelvis). However, longer follow-up is needed to confirm noninferiority of oncological outcomes.

Long-term oncological outcomes of the sphincter preserving total mesorectal excision with varying distal resection margins

INTRODUCTION

A subcentimeter distal resection margin (DRM) appears to be acceptable for most patients, however, long-term follow up and specific subsets where DRM would influence recurrences have not been adequately investigated.

METHODS

A retrospective analysis of all sphincter-preserving resections for mid and low rectal cancers between July 2011 and May 2015 was performed. Extended total mesorectal excisions (TME) and patients with positive pathologic circumferential margins (CRM) were excluded.

RESULTS

Two hundred and thirty-six patients fit the inclusion criteria. DRM > 20 mm was obtained in 117 patients (49.6%), between 10 and 20 mm in 78 (33%) and <10 mm in 41 (17.4%) patients. Pathological DRM was positive in 4 patients (1.7%). Sixty-five recurrences occurred at a median follow up of 78.5 months. DRM did not influence any of the oncological outcomes. In a subset analysis of patients with poor pathological response to neoadjuvant radiation, that is, tumor regression grade > 3, DRM influenced disease-free survival (DFS) but not overall survival with a hazard ratio of 4.4 (p = 0.02). This was confirmed on multivariate regression analysis in this subgroup as well where pathological nodal status and DRM < 10 mm were independent predictors of DFS.

CONCLUSIONS

A subcentimeter DRM may be acceptable in most patients except those who have an inadequate response to neoadjuvant radiation.

Do Acellular Mucin Pools in Resection Margins for Rectal Cancer Influence Outcomes?

Positive resection margins predict poor prognosis in rectal cancer (RC). Literature on the impact of acellular mucin (ACM) in circumferential resection margin (CRM) or distal resection margin (DRM) of proctectomy specimens on RC recurrence and outcomes is lacking. The retrospective study was conducted to determine the oncological outcomes of the RC patients with ACM in or within 1 mm of margins of the rectal resection specimens. Histopathology reports of RC resection specimens dated from June 2013 till May 2016 were reviewed to identify cases with ACM in CRM (n = 10) and DRM (n = 2). Relevant details of these patients were gathered from the electronic medical record. Pattern of recurrence was studied. In cases with only ACM in CRM (n = 10), disease (primary tumor or nodes) was radiologically reaching the mesorectal fascia except two, who had extra mesorectal nodes. Median distance of tumor from anal verge was 2 cm. All patient received neoadjuvant therapy: four patients received chemoradiotherapy (NACTRT), one received short-course radiotherapy, and five received NACTRT followed by neoadjuvant chemotherapy. Abdominoperineal resection, intersphincteric resection and total pelvic exenteration were done for six, three, and one patient, respectively. In two additional cases of anterior resection with ACM in DRM, one underwent upfront resection while the other received NACTRT. Over a mean follow-up period of 43 months, four patients developed recurrences. Two of them had local recurrence and only one had isolated local recurrence. ACM in resection margins of RC resection specimens does not seem to increase likelihood of local recurrence.

Downstaging in Advanced Rectal Cancers: A Propensity-Matched Comparison Between Short-Course Radiotherapy Followed by Chemotherapy and Long-Course Chemoradiotherapy

BACKGROUND

Short-course radiotherapy followed by chemotherapy has not been widely evaluated as an alternative to traditional long-course chemoradiotherapy in locally advanced rectal cancer.

OBJECTIVE

This study compared the oncological and short-term outcomes between short-course radiotherapy + chemotherapy and long-course chemoradiotherapy in locally advanced rectal cancer.

DESIGN

This is a retrospective propensity-matched study.

SETTINGS

The study was conducted in a colorectal department at a tertiary care oncology center in India.

PATIENTS

There were 173 patients. Group A had 47 patients and group B had 126 patients. A 1:2.7 matching was done for age, sex, distance of tumor from the anal verge, sphincter preservation surgeries, MRI-based pretreatment T stage, and circumferential resection margin.

INTERVENTIONS

The interventions performed were short-course radiotherapy + chemotherapy (group A) and long-course chemoradiotherapy (group B) in locally advanced rectal cancer.

MAIN OUTCOME MEASURES

The primary measures were pathological circumferential resection margin positivity, downstaging, tumor regression grade, and postoperative complications.

RESULTS

Of the patients, 52% had a positive circumferential resection margin on MRI, 57% had low rectal tumors, and 20% had T4 tumors. Distribution of rectal surgeries was similar between the 2 groups. pT downstaging and tumor regression scores were significantly better in group B ( p = 0.028 and 0.026). Pathological circumferential resection margin, distal resection margin, and nodal yield were similar. On multivariate analysis, pretreatment N status was the only independent predictive factor for pathological circumferential resection margin status. Grade 3 to 4 Clavien-Dindo complications, anastomotic leak rates, and hospital stay were similar between the 2 groups.

LIMITATIONS

This was a retrospective study. Although propensity matching was performed, selection bias cannot be eliminated completely, as seen in the difference in the surgical approaches between the 2 groups.

CONCLUSIONS

In a cohort containing a significant portion of MRI circumferential resection margin-positive low rectal cancers, short-course radiotherapy + chemotherapy followed by delayed surgery resulted in lower T downstaging and lower tumor regression scores compared with long-course chemoradiotherapy, but pathological circumferential margin status, distal resection margin, nodal yield, and perioperative morbidity were similar between the 2 groups. This suggests that short-course radiotherapy + chemotherapy could be a viable alternative to long-course chemoradiotherapy in locally advanced rectal cancers. See Video Abstract at http://links.lww.com/DCR/B855 .

REDUCCIN DEL ESTADIO EN LOS CNCERES RECTALES AVANZADOS UNA COMPARACIN DE PROPENSIN EQUIPARADA ENTRE LA RADIACIN DE CICLO CORTO SEGUIDA DE QUIMIOTERAPIA Y LA QUIMIO RADIACIN DE CICLO LARGO

ANTECEDENTES:La radioterapia de ciclo corto seguida de quimioterapia no ha sido evaluada ampliamente como una alternativa a la tradicional quimio radioterapia de ciclo largo en el cáncer de recto localmente avanzado.OBJETIVO:Estudio que compara los resultados oncológicos y a corto plazo entre la radioterapia de ciclo corto + quimioterapia y la quimio radioterapia de ciclo largo en el cáncer de recto localmente avanzado.DISEÑO:Estudio comparado de propensión de manera retrospectiva.AJUSTE:Departamento colorrectal en un centro de atención oncológica de tipo terciario en la India.PACIENTES:Hubo 173 pacientes. El grupo A tenía 47 y el grupo B tenía 126 pacientes. Se realizó una comparación de 1: 2,7 para edad, sexo, distancia del tumor desde el margen anal, cirugías de preservación del esfínter, estadio T previo al tratamiento basada en resonancia magnética y margen de resección circunferencial (CRM).INTERVENCIONES:Radioterapia de ciclo corto + quimioterapia (grupo A) y quimio radioterapia de ciclo largo (grupo B) en cáncer de recto localmente avanzado (LARC).PRINCIPALES MEDIDAS DE RESULTADO:Positividad histopatológica de CRM, reducción del estadio tumoral, grado de regresión tumoral, complicaciones posoperatorias.RESULTADOS:El 52% de los pacientes han tenido un margen de resección circunferencial positivo en la resonancia magnética, 57% de tumores rectales bajos, 20% de tumores T4. La distribución de cirugías rectales fue similar entre los 2 grupos. Las puntuaciones de regresión tumoral y de reducción del estadio de pT fueron significativamente mejores en el grupo B ( p = 0.028 y 0.026 respectivamente). El margen de resección circunferencial patológico, el margen de resección distal y los ganglios arrojados fueron similares. En el análisis multivariado, el estadio N previo al tratamiento fue el único factor predictivo independiente para el estadio de pCRM. Las complicaciones Clavien-Dindo de grado 3-4, las tasas de fuga anastomótica y la estancia hospitalaria fueron similares entre los dos grupos.LIMITACIONES:Retrospectiva; aunque la propensión coincide, existe potencial sesgo de selección.CONCLUSIONES:En una cohorte que contenía una porción significativa de cánceres rectales bajos con margen de resección circunferencial positivo por resonancia magnética, la radioterapia de ciclo corto + quimioterapia seguida de cirugía tardía dio como resultado una mayor reducción del estadio T y de regresión tumoral en comparación con la quimio radioterapia de ciclo largo. Pero el estatus histopatológico del margen circunferencial, el margen de resección distal, el rendimiento ganglionar y la morbilidad perioperatoria fueron similares entre los dos grupos. Esto sugiere que la radioterapia de ciclo corto + quimioterapia podría ser una alternativa viable a la quimio radioterapia de ciclo largo en cánceres rectales localmente avanzados. Consulte Video Resumen en http://links.lww.com/DCR/B855 . (Traducción-Dr. Osvaldo Gauto ).

Clinical practice and outcomes in advanced gastrointestinal stromal tumor: Experience from an Indian tertiary care center

BACKGROUND

Management of advanced Gastrointestinal stromal tumors (GIST) has been revolutionized with the use of Imatinib guided by mutation analysis. Data from India remains scarce.

MATERIALS AND METHODS

Patients with metastatic GIST who were treated at Department of Gastro-intestinal & Hepaticopancreaticobiliary Oncology Unit at Tata Memorial Hospital, Mumbai between December, 2004 and December 2015 were included in the analysis. Clinical and radiological data was retrieved from stored medical records and charts.

RESULTS

A total of 83 patients with metastatic GIST were available for analysis. Median age was 54 years with a 3:1 male predominance. Stomach was the most common site of primary with liver being the most common site of metastasis. c-Kit mutation analysis results were available for 44 patients with exon 11 mutant being the most common mutation. With a median follow up of 33 months, the 10 years estimated progression free and overall survival (OS) was 18% and 51% respectively. Overall response rate to first line imatinib was 37.6% and estimated 3 years OS to first line therapy was significantly better for Exon 11 mutated patients (p=0.016). 34 patients received second line therapy in the form of either sunitinib, pazopanib or increased dose imatinib with a clinical benefit rate of 73.5%. C-Kit mutated patients had a better median OS compared to non mutated patients.

CONCLUSIONS

GIST diagnosed and treated in the Indian subcontinent appears to show improved outcomes. The importance of c-Kit mutation analysis in determining the prognosis and outcomes of patients with advanced GIST is emphasized.

Survival of Trial-Like and Non-Trial-Like Patients With Immunotherapy in Advanced Hepatocellular Carcinoma in Real World: A Collaborative Multicenter Indian Study (IMHEP)

PURPOSE

Immune checkpoint inhibitors (ICIs) is the initial line of management in advanced hepatocellular carcinoma (HCC), but survivals in the real world are not known.

MATERIALS AND METHODS

A retrospective study of patients with advanced HCC receiving ICIs (as first-line therapy or as later lines of therapy) across 11 Indian institutions was conducted. Patients were divided into either cohort 1 (trial-like receiving ICI as first-line therapy), with a Child Pugh score (CTP) of ≤6, an Eastern Cooperative Oncology Group performance status (ECOG PS) of 0/1, and no VP4 (main portal vein thrombosis [MPVT]) or cohort 2 (trial unlike) who did not satisfy at least one of the above criteria. The primary end point was 12-month overall survival (OS).

RESULTS

Between January 2017 and January 2022, 133 patient data were analyzed. The presence of MPVT was seen in 33 patients (25%). The ICIs used were atezolizumab-bevacizumab, nivolumab, and pembrolizumab in 89 (66%), 44 (33%), and one (1%) patients, respectively. With a median follow-up of 13.8 months, the 12-month OS for the entire cohort was 33.4% (95% CI, 23.6 to 43.2). Patients in cohort 1 (n = 31) had a significantly improved OS compared with patients in cohort 2 (n = 102; 12-month OS, 57.9% [95% CI, 38.5 to 77.3] v 24% [95% CI, 13.4 to 34.6]; P = .005). Patients with CTP A as compared with CTP B (9.7 v 4.3 months; P < .001) and an ECOG PS of 0/1 as compared with a PS of ≥2 (8.7 v 7.2 months; P = .04) and without MPVT (9.4 v 4.0; P < .001) had superior survivals.

CONCLUSION

Patients with advanced HCC in the real world, trial-like have survivals in consonance with trial data, whereas patients with features excluding them from trials, such as main portal vein thrombosis, poor ECOG PS, and child Pugh B status, have markedly inferior survivals, despite good tolerance to immunotherapy.

Pathological N3 Stage (pN3/ypN3) Gastric Cancer: Outcomes, Prognostic Factors and Pattern of Recurrences After Curative Treatment

BACKGROUND

pN3 or ypN3 stage gastric cancers (GCs) are known to have aggressive clinical behaviour. This study aimed to investigate factors affecting survival and pattern of recurrences of N3 stage GCs, treated with curative intent.

METHODS

A total of 196 GC patients, operated on at the Tata Memorial Centre from 2003 to 2017 and reported as pN3 or ypN3 status on histopathology after D2 gastrectomy were included in this retrospective analysis.

RESULTS

On multivariate analysis, use of NACT (neoadjuvant chemotherapy) and LN ratio (≤ 0.5/> 0.5) emerged as significant predictors for long-term survival. Patients who received NACT but were still harbouring N3 nodes (ypN3; n = 102) had a worse prognosis than those operated on upfront (pN3; n = 94), with a median survival of 19 months versus 24 months respectively (p = 0.003). The 5-year overall survival of the entire cohort was 16.3% (95% CI 12.8-19.8%), while 5-year disease-free survival (DFS) was 14.6% (95% CI 12.6-20%). Adjuvant chemoradiotherapy, though offered in a small number of patients (n = 38) resulted in improvement in DFS. Median DFS of adjuvant CT versus adjuvant CRT was 13 months versus 23 months (p = 0.020). The commonest site of relapse was the peritoneum (49.18%) and incidence of isolated loco-regional failure was 10.7%.

CONCLUSION

In GCs with N3 stage determined after radical D2 gastrectomy, LN ratio of > 0.5 and ypN3 status are predictors of poor prognosis. Considering the high incidence of peritoneal and loco-regional relapse in these patients, the role of more radical surgery, adjuvant chemoradiotherapy after upfront resection and intraperitoneal chemotherapy should be evaluated in prospective randomized clinical trials.

Laparoscopic Versus Open Approach for Intersphincteric Resection-Results from a Tertiary Cancer Center in India

The study aims to compare open intersphincteric resection (OISR) with laparoscopic intersphincteric resection (LISR) in terms of short-term oncological and clinical outcomes. This is a retrospective review of a prospectively maintained database including all the patients of rectal cancer who underwent intersphincteric resection (ISR) at Tata Memorial Centre between 1st July 2013 and 30th November 2015. Short-term oncological parameters evaluated included circumferential resection margin involvement (CRM), distal resection margin involvement, and number of nodes harvested. Perioperative outcomes included blood loss, length of hospital stay and 30-day postoperative morbidity and mortality. Chi-square test was used to compare the results between the two groups. Thirty nine cases of OISR and 34 cases of LISR were included in the study. Median BMI was higher in LISR group; otherwise, the two groups were comparable in all aspects. There were no conversions in LISR group. CRM involvement was seen in four patients (10%) in the conventional group compared to none in the LISR group. Median hospital stay was comparable between the two groups. Laparoscopic ISR is safe and can be performed with low conversion rate in selected group of patients.

Neoadjuvant Imatinib in Locally Advanced Gastrointestinal stromal Tumours, Will Kit Mutation Analysis Be a Pathfinder?

INTRODUCTION

Longer duration of neoadjuvant (NA) imatinib (IM) used for locally advanced (LA) gastrointestinal stromal tumours (GIST) is not based on biology of the tumour reflected by kit mutation analysis.

MATERIAL AND METHODS

LA or locally recurrent (LR) GIST treated with NA IM from May 2008 to March 2015 from a prospective database were included in the analysis. Archived formalin-fixed paraffin-embedded tissues (FFPE) were used for testing KIT exons 9, 11, 13 and 17 by PCR.

RESULTS

One hundred twenty-five patients with LA or LR GIST were treated with NA IM. Forty-five patients (36 %) had undergone c-kit mutation testing. Exon 11 was seen in 25 patients (55.5 %), 3 with exon 9 (6.7 %) and 2 with exon 13 (4.4 %). Twelve were wild type (26.6 %) and  3 (6.7 %) were declared uninterpretable. Response rate (RR) for the exon 11 mutants was higher than the non-exon 11 mutant group (84 vs. 40 %, p = 0.01). Disease stabilization rate (DSR) rates were also higher in the exon 11 subgroup than non-exon 11 group (92 vs. 75 %). Eighty-four per cent exon 11 and 75 % non-exon 11 mutants were surgical candidates. Patients undergoing surgery had significantly improved event free survival (EFS) (p < 0.001) compared to patients not undergoing surgery, with the same trend seen in OS (p = 0.021). Patients with a SD on response to NA IM had a lower EFS (p = 0.076) and OS compared to patients achieving CR/PR. There were no differences between the various exon variants in terms of outcomes and responses CONCLUSION: Upfront evaluation of kit mutation status may help us in delineating separate treatment strategies for potentially biologically different tumours and assessing the correct timing of surgery for this subset of GIST.

An Analysis of Tolerance and Early Survival Outcomes with Perioperative Modified FLOT in Gastric Cancers

Anant RamaswamyPurpose  Perioperative chemotherapy with fluorouracil plus leucovorin, oxaliplatin, and docetaxel (FLOT) is a current standard of care for locoregionally advanced gastric adenocarcinomas. There is limited real world data with regard to the tolerance and efficacy of this regimen. Materials and Methods  This is a retrospective analysis of gastric cancer patients who were offered neoadjuvant perioperative modified FLOT regimen between December 2016 and October 2018, at the Tata Memorial Hospital, Mumbai. Chemotherapy-related side-effects are reported along with overall survival (OS), as calculated by Kaplan-Meier method. Results  Three hundred and forty-three consecutive patients were started on neoadjuvant chemotherapy (NACT) with mFLOT of which 298 patients (87%) completed the planned treatment. A total of 294 patients (86%) underwent curative resection of gastric cancer. Common grade 3 and grade 4 toxicities during NACT were diarrhea in 42 patients (12%) and febrile neutropenia in 27 patients (8%). Toxic death was seen in nine (2.6%) patients. A total of 264 patients (77%) completed planned adjuvant chemotherapy. Common grade 3 and grade 4 toxicities during adjuvant therapy were diarrhea in 42 patients (12%) and febrile neutropenia in 16 patients (6%). With a median follow-up of 19 months, the estimated 2-year median OS was 69.4%. Conclusion  Administration of modified FLOT regimen in locoregionally advanced gastric cancers is feasible in clinical practice with high completion rates, though requiring dose modifications due to the incidence of clinically relevant grade 3 to 5 toxicities. Early outcomes with the regimen are on par with survivals from the FLOT-AIO study.

Prognostic value of imaging-based parameters in patients with intermediate-stage hepatocellular carcinoma undergoing transarterial radioembolization

OBJECTIVE

Patients with inoperable multilobar hepatocellular carcinoma (HCC) Barcelona Clinic Liver Cancer (BCLC) stage B, who have failed other liver-directed treatment options, are ideal candidates for transarterial radioembolization (TARE) with Yttrium-90 (Y-90)-labeled glass spheres. There is limited data regarding variables that impact the prognosis and outcome in these patients. 99mTc-MAA scan for lung shunt fraction (LSF) and 18F-FDG PET/CT are performed during initial workup. We, therefore, decided to assess the prognostic impact of LSF and metabolic parameters, such as maximum SUVmax, MTV and TLG in patients undergoing TARE for HCC.

METHODS

We retrospectively analyzed 64 patients of HCC, between January 2010 and December 2016, deemed suitable for TARE. Pre-TARE LSF was computed on 99mTc MAA scan, and SUVmax, MTV and TLG on fluoro-deoxyglucose positron emission tomography/computed tomography were measured using automated software by 3D region of interest. LSF and PET parameters were stratified using optimal cut-offs derived from receiver operating curve analysis. Survival curves for the groups were estimated using the Kaplan-Meier method and were compared using log-rank test.

RESULTS

Overall survival (OS) was 15 months. In univariate analysis, high LSF (greater than 7.19), MTV and TLG were statistically significant and were associated with poor OS. In multivariate analysis, TLG (P value 0.044), MTV (P value 0.290) and LSF (P value 0.010) were independent predictors of outcome, after adjustment for significant univariate variables. However, SUVmax was not statistically significant for OS.

CONCLUSIONS

LSF, MTV and TLG are significant independent prognostic indicators of outcome in patients undergoing TARE for HCC.

Role of adjuvant chemotherapy in T2N0M0 periampullary cancers

AIMS

Surgery is the only modality that offers cure for periampullary adenocarcinoma. However, surgery alone results in failure in 60% of patients. Studies have shown some benefits of chemotherapy in node positive and higher tumor stage patients. We sought to determine the role of adjuvant chemotherapy in early tumors with uninvolved nodes.

METHODS

A retrospective analysis of a prospectively maintained database of patients resected of periampullary tumors from 2007 to 2014 was performed. Patients were studied for adverse risk factors, adjuvant therapy received and the survival.

RESULTS

Of 105 patients, 14 patients received adjuvant chemotherapy and 85 were observed. After a median follow-up of over 36 months, the overall 3-year survival was 94.2% in the observed group and 100% in the group that received chemotherapy (P = 0.33), with the 3-year disease-free survival being 81.9% and 90.9%, respectively, (P = 0.477). Serum CA 19-9 levels above 100 U/mL were a poor prognostic factor.

CONCLUSION

This study did not find a benefit with the use of adjuvant chemotherapy, but chemotherapy might improve survival. The benefit for adjuvant chemotherapy needs further confirmation in prospective trials.

Peptide Receptor Radionuclide Therapy in the Management of Neuroendocrine Tumors (Neoplasms): Fundamentals and Salient Clinical Practice Points for Medical Oncologists

This editorial commentary is an expert summary of “Peptide Receptor Radionuclide Therapy (PRRT),” encompassing the essential fundamentals and salient clinical practice points, deliberated and designed in a point-wise manner with theme-based subheadings. Emphasis has been laid on the topics of practical relevance to the referring oncologists with relevant finer points where necessary. A part of the presented overview has been generated from the authors' own practical experience of more than 3500 successful therapies delivered over the last 9 years at a large tertiary care PRRT setting by the joint efforts of Radiation Medicine Centre (RMC), Bhabha Atomic Research Centre (BARC), and Gastrointestinal services of Tata Memorial Hospital (TMH) at the TMH-RMC premises. While the technical indigenization is beyond the scope of this treatise, we must mention here that India had been one of the frontrunners in this treatment modality, and the PRRT services in this country were developed purely as an indigenous effort right from the production of the radionuclide (177-Lutetium) at the reactor and radiolabeling and production of the radiopharmaceutical (177Lu-DOTATATE) by the radiopharmaceutical scientists at the BARC and RMC; such an endeavor allowed this very specialized therapy to be delivered at a very affordable cost in our setting which could be viewed as a major societal contribution of the atomic energy research in this country.