Fluorouracil, mitomycin, and radiotherapy vs fluorouracil, cisplatin, and radiotherapy for carcinoma of the anal canal: a randomized controlled trial

Impact of overall treatment time on survival and local control in patients with anal cancer: a pooled data analysis of Radiation Therapy Oncology Group trials 87-04 and 98-11

PURPOSE

To determine whether increased duration of radiation therapy (RT) and overall treatment (RX) time has a detrimental effect in anal cancer.

PATIENTS AND METHODS

Data from Radiation Therapy Oncology Group (RTOG) 87-04 and RTOG 98-11 trials were combined to form three treatment groups: RT/fluorouracil (FU)/mitomycin (n = 472), RT/FU/cisplatin (n = 320), and RT/FU (n = 145). Cox proportional hazards models were used with the following variables: RT duration, RT intensity, RX duration, treatment group, age, sex, Karnofsky performance score (KPS), T stage, N stage, and RT dose.

RESULTS

In the univariate analysis, there was a significant association between RX duration and colostomy failure (CF; hazard ratio [HR] = 1.51; 95% CI, 1.07 to 2.14; P = .02), local failure (HR = 1.52; 95% CI, 1.14 to 2.03; P = .005), locoregional failure (HR = 1.51; 95% CI, 1.15 to 1.98; P = .003), and time to failure (HR = 1.40; 95% CI, 1.10 to 1.79; P = .007). The significance of RX duration was maintained after adjusting for treatment group. In multivariate modeling there was a trend toward an association between RX duration and CF (HR = 1.57; 95% CI, 0.98 to 2.50; P = .06) and a statistically significant association with local failure (HR = 1.96; 95% CI, 1.34 to 2.87; P = .0006). Age, sex, KPS, T stage, N stage, and RT dose, but not RT duration, RT intensity, or RX duration, were found to be statistically significant predictors of OS and colostomy-free survival.

CONCLUSION

Total treatment time, but not duration of radiation therapy, seems to have a detrimental effect on local failure and colostomy rate in anal cancer. Induction chemotherapy may contribute to local failure by increasing total treatment time.

"Mind the gap"--the impact of variations in the duration of the treatment gap and overall treatment time in the first UK Anal Cancer Trial (ACT I)

PURPOSE

The United Kingdom Coordinating Committee on Cancer Research anal cancer trial demonstrated the benefit of combined modality treatment (CMT) using radiotherapy (RT), infusional 5-fluorouracil, and mitomycin C over RT alone. The present study retrospectively examines the impact of the recommended 6-week treatment gap and local RT boost on long-term outcome.

METHODS AND MATERIALS

A total of 577 patients were randomly assigned RT alone or CMT. After a 6-week gap responders received a boost using either additional external beam radiotherapy (EBRT) (15 Gy) or iridium-192 implant (25 Gy). The effect of boost, the gap between initial treatment (RT alone or CMT) and boost (Tgap), and overall treatment time (OTT) were examined for their impact on outcome.

RESULTS

Among the 490 good responders, 436 (89%) patients received a boost after initial treatment. For boosted patients, the risk of anal cancer death decreased by 38% (hazard ratio [HR]: 0.62, 99% CI 0.35-1.12; p=0.04), but there was no evidence this was mediated via a reduction in locoregional failure (LRF) (HR: 0.90, 99% CI 0.48-1.68; p=0.66). The difference in Tgap was only 1.4 days longer for EBRT boost, compared with implant (p=0.51). OTT was longer by 6.1 days for EBRT (p=0.006). Tgap and OTT were not associated with LRF. Radionecrosis was reported in 8% of boosted, compared with 0% in unboosted patients (p=0.03).

CONCLUSIONS

These results question the benefit of a radiotherapy boost after a 6-week gap. The higher doses of a boost may contribute more to an increased risk of late morbidity, rather than local control.

HIV- positive anal cancer: an update for the clinician

Anal cancer used to be a rare cancer traditionally associated with elderly women. There are approximately 5260 cases per year in the U.S. (1). The onslaught of the Human Immunodeficiency Virus (HIV) virus has led to a change in anal cancer demographics. Anal cancer is on the rise in the U.S and the number of anal cases documented has quadrupled in the past 20 yrs correlating with the rise of the HIV epidemic. The incidence of anal cancer is 40 to 80 fold higher in the HIV positive (HIV+) population when compared to the general population (2). With the advent of highly active antiretroviral therapy (HAART), HIV+ patients are living longer as less are progressing to AIDS. As a consequence non AIDS defining cancers such as anal cancer are on the rise. Factors implicated in the etiology of anal cancer in HIV+ patients include (Human papillomavirus) HPV virus status, sexual habits, and a history of smoking. HPV 16 and receptive anal intercourse (RAI) increase the risk of anal cancer by 33% over the general population. In the general population, the rate of anal cancer is approximately 0.9 cases per 100,000. In patients with a history of RAI, the rate approaches 35 cases per 100,000 which is equivalent to the prevalence of cervical cancer (3). Smokers are eight times more likely to develop anal cancer. There has been much discussion about tailoring treatment decisions in HIV+ patients with anal cancer. This review focuses on squamous cell carcinomas of the anal canal which comprise 80 to 90% of all anal cancers diagnosed and highlight key issues in the management of HIV+ anal cancer patients including recent clinical trials.

Prognostic factors derived from a prospective database dictate clinical biology of anal cancer: the intergroup trial (RTOG 98-11)

BACKGROUND

Only 4 prospective randomized phase 3 trials have been reported for anal cancer. A prognostic factor analysis for anal cancer from a prospective database has been published from only 1 study (N = 110). To confirm and uncover new prognostic factors, we analyzed the prospective database of intergroup RTOG 98-11.

METHODS

Univariate and multivariate analyses of the baseline characteristics for 5-year overall survival (OS) and disease-free survival (DFS) were carried out. Various combinations of tumor diameter and clinically positive nodes (N(+)) were analyzed to identify subgroups.

RESULTS

A total of 644 were assessable and analyzed. Tumor diameter >5 cm was associated with poorer 5-year DFS (P = .0003) and poorer 5-year OS (P = .0031), and N(+) was associated with poorer 5-year DFS (P 5-cm tumor and N(+) had the worst DFS (only 30% at 3 years compared with 74% for the best group; <5 cm primary and N0) and OS (only 48% at 4 years compared with 81% for the best group; <5 cm primary and N0). Men had worse DFS (P = .02) and OS (P = .016). These factors maintained their influence in each treatment arm.

CONCLUSIONS

This prospective prognostic factor analysis establishes tumor diameter as an independent prognosticator of poorer 5-year DFS and OS and confirms N(+) and male sex as poor prognostic factors. This analysis also uncovers novel subgroups (derived from combining prognostic factors) with incremental worsening of DFS and OS.

The role of radiotherapy in locally advanced pancreatic carcinoma

The prognosis for locally advanced pancreatic carcinoma remains dismal despite advances in chemotherapy and radiotherapy over the past few decades. The use of radiotherapy for pancreatic carcinoma is often disputed because of the hypothesis that patients with pancreatic cancer die from distant metastases. It is well accepted that the greatest chance for cure of pancreatic cancer involves surgical resection of the primary tumor. However, there is much controversy about the role of radiotherapy in local disease control. The aim of this Review is to discuss data from the available studies, both prospective and retrospective, that evaluate treatment options for locally advanced pancreatic cancer. We focus on the benefits associated with local therapies, including radiotherapy and surgical resection, as they relate to improved local disease control, prolonged overall survival and improved symptom control.

The prognostic value of hemoglobin in patients with anal cancer treated with chemoradiotherapy

PURPOSE

This study aimed to evaluate the impact of hemoglobin level on clinical outcome (local response, progression-free survival, and overall survival) in patients with carcinoma of the anal canal treated with definitive chemoradiotherapy.

METHODS

This is a retrospective study of patients with anal cancer treated between 1992 and 2005 with definitive chemoradiotherapy at Tom Baker Cancer Centre. Patient treatment, laboratory, and outcome data were extracted from the chart.

RESULTS

Seventy-two patients treated with definitive chemoradiotherapy were identified. The median age was 56 years, the male-to-female ratio was 1:2, and the median tumor size was 3.5 cm. At 6 weeks after the completion of chemoradiotherapy, 62% of patients (38/61) had complete clinical response, and 34% (21/61) had achieved a partial clinical response. At 3 months after treatment, complete clinical response was observed in 78% (49/63) and a partial response in 16% (10/63). The median pretreatment hemoglobin level was 138.5 g/L, and the median on-treatment hemoglobin level was 129 g/L. Distant relapse was associated with hemoglobin levels in the lowest quartiles, pretreatment and on-treatment (P = .007 and P = .008, respectively). Hemoglobin levels were not associated with response at 6 weeks or 3 months. A pretreatment hemoglobin level of <130 g/L was associated with worse progression-free and overall survival (P < .0001, both). A hemoglobin on-treatment level of <121 g/L was associated with progression-free and overall survival (P < .0001 and P = .019, respectively), when stratified by gender.

CONCLUSIONS

Hemoglobin status was correlated with progression-free and overall survival, and distant relapse, but not clinical response, in patients with carcinoma of the anal canal treated with chemoradiotherapy. The clinically relevant cut point, and the value of correcting hemoglobin levels before or during treatment, remains to be elucidated.

Clinical trials in the management of anal cancer

Our understandings of anal canal cancer pathogenesis and treatment have undergone significant changes due to continuing research into its pathogenesis and the results of major clinical trials conducted over the past 20 years. Anal canal cancer can be cured by combined modality chemoradiation therapy, a treatment that preserves continence and reserves abdominoperineal resection of the rectum and anal canal in patients with recurrent or residual disease after primary chemoradiotherapy. The research into more effective, less toxic therapies is continuing. Future challenges include an increasing incidence of human papillomavirus infection, the AIDS epidemic, diagnosis of early disease, and optimization of chemotherapy and radiation regimens. This article aims to provide a summary of recently completed and ongoing clinical trials in the management of anal canal cancer.

Epidermoid cancers of the anal canal: current treatment

Epidermoid carcinoma of the anal canal is an uncommon disease, but has increased in incidence with the HIV epidemic. Prior to the 1970s, treatment consisted of radical surgery with abdominoperineal resection. With the pioneering work of Dr. Norman Nigro, this has shifted to a nonsurgical approach, with primary treatment consisting of multimodality therapy with radiation and chemotherapy. This review provides an overview of the historical, current, and future treatments of epidermoid anal canal malignancies.

Chemo-radiation with or without mandatory split in anal carcinoma: experiences of two institutions and review of the literature

Background

The split-course schedule of chemo-radiation for anal cancer is controversial.

Methods

Eighty-four patients with invasive anal cancer treated with definitive external beam radiotherapy (RT) with a mandatory split of 12 days (52 patients, Montreal, Canada) or without an intended split (32 patients, Zurich, Switzerland) were reviewed. Total RT doses were 52 Gy (Montreal) or 59.4 Gy (Zurich) given concurrently with 5-FU/MMC.

Results

After a mean follow-up of 40 ± 27 months, overall survival and local tumor control at 5 years were 57% and 78% (Zurich) compared to 67% and 82% (Montreal), respectively. Split duration of patients with or without local relapse was 15 ± 7 d vs. 14 ± 7 d (Montreal, NS) and 11 ± 11 d vs. 5 ± 7 d (Zurich; P < 0.001). Patients from Zurich with prolonged treatment interruption (≥ 7 d) had impaired cancer-specific survival compared with patients with only minor interruption (<7 d) (P = 0.06). Bowel toxicity was associated with prolonged RT (P = 0.03) duration as well as increased relapse probability (P = 0.05). Skin toxicity correlated with institution and was found in 79% (Montreal) and 28% (Zurich) (P < 0.0001).

Conclusions

The study design did not allow demonstrating a clear difference in efficacy between the treatment regimens with or without short mandatory split. Cause-specific outcome appears to be impaired by unplanned prolonged interruption.

[Anal intraepithelial neoplasia and anal carcinoma: an increasing problem in HIV patients]

Anal dysplasia is common in HIV patients, especially in HIV-positive men having sex with men (MSM). High-grade anal dysplasia can progress to invasive anal cancer. As in cervical carcinoma, there is a cause and effect relationship between anal cancer and human papillomavirus (HPV) infection, especially with high-risk types such as HPV16. Several experts have recommended screening programs for anal cancer, including anal cytology along the lines of the Pap smear in women. Such screenings should only be performed if pathological findings result in further diagnostic steps and, if necessary, appropriate treatment. Clinical inspection, lesion biopsy, and treatment of anal dysplasia are performed under high-resolution anoscopy. Anal cancer is divided into cancer of the anal margin and cancer of the anal canal. This classification is important because of the difference in treatment regimens. Early cancer of the anal margin is excised akin to squamous cell cancer of the exposed skin, whereas cancer of the anal canal is treated by radiochemotherapy. HIV-positive and HIV-negative patients have similar response rates to combined radiochemotherapy. However, side effects, especially acute post-irradiation skin toxicity, early local recurrences, and abdominoperineal rectal excision are more common in HIV-positive patients. Physicians working in the field of HIV/AIDS should regularly screen their patients for the presence of anal dysplasia and anal cancer. Basic diagnostic workup includes clinical inspection of the perianal area, digital rectal examination, and anal cytology.

Molecular biomarkers correlate with disease-free survival in patients with anal canal carcinoma treated with chemoradiation

Large primary tumor and clinical nodal involvement in patients with anal carcinoma treated with chemoradiation are associated with poor disease-free survival (DFS). However, the outcome in individual patient is unpredictable. We hypothesized that biomarkers related to chemotherapy and/or radiation resistance would be associated with DFS. We analyzed clinical and biomarker data in 30 patients with anal carcinoma who had chemoradiation. Patient selection was based on the availability of untreated cancer for biomarkers, completion of prescribed chemoradiation, and patient outcomes (~50% disease-free) nonrepresentative of published cohorts but conducive to biomarker discovery. Ten biomarkers, Ki67, human telomerase (hTERT), epidermal growth factor receptor (EGFR), p53, p16, Bcl-2, vascular endothelial growth factor (VEGF), nuclear factor kappa-B (NF-kappaB), SHH, and Gli-1, were studied. Raw data as continuous variable (only EGFR was trichotomized) were analyzed. Univariate and multivariate Cox models were utilized to assess relationship between DFS and biomarkers. Twenty-three of 30 patients were women, tumor diameter was >5 cm in 30, and 37% had clinically positive nodes. Fourteen (30%) patients had a DFS event after chemoradiation. In univariate analysis, NF-kappaB (P = 0.01), SHH (P = 0.02), Gli-1 (P = 0.02), and tumor diameter (P = 0.03) were significantly associated with DFS, and Ki67 (P = 0.07) was marginally significant. In multivariate analysis, tumor diameter (P = 0.003), Ki67 (P = 0.005), NF-kappaB (P = 0.002), SHH (P = 0.02), and Gli-1 (P = 0.02) were significantly associated with DFS. Our data, albeit preliminary, suggest that several biomarkers (Ki67, NF-kappaB, SHH, and Gli-1) are associated with DFS. Upon further expansion and validation, these results may provide a biomarker-based understanding of heterogeneous clinical biology of patients with anal carcinoma.

Octreotide acetate in prevention of chemoradiation-induced diarrhea in anorectal cancer: randomized RTOG trial 0315

BACKGROUND

In anorectal cancer patients, an acute side effect of chemoradiotherapy is gastrointestinal toxicity, which often impedes treatment delivery. Based on previous trials, octreotide acetate is widely recommended for the control of chemotherapy-induced diarrhea. However, the effectiveness of octreotide in preventing or controlling radiation- and chemoradiation-induced diarrhea is not known.

METHODS

A randomized, double-blinded, placebo-controlled trial was designed to determine the efficacy of long-acting octreotide acetate (LAO) in preventing the onset of acute diarrhea in patients undergoing chemoradiation therapy for rectal or anal cancer. Between 4 and 7 days before the start of radiation therapy, patients received a 30-mg dose of LAO (109 patients) or placebo (106 patients) via intramuscular injection. A second dose was given on day 22 (+/-3 days) of radiation treatment. A total of 215 patients were included in the final analysis. The primary endpoint was the incidence of grade 2-4 acute diarrhea; secondary endpoints included treatment compliance, medical resource utilization, patient-reported bowel function, and quality of life (QoL). Statistical tests were one- or two-sided, as specified.

RESULTS

After a median follow-up time of 9.64 months, incidence rates of grades 2-4 acute diarrhea were similar in both groups (49% placebo vs 44% LAO; P = .21). No statistically significant treatment differences in chemotherapy or radiation delivery, medical resource utilization, patient-reported bowel function, or QoL were observed.

CONCLUSION

In this study, the prophylactic use of LAO did not prevent the incidence or reduce the severity of diarrhea and had no notable impact on patient-reported bowel function or QoL.

Recent advances in gastrointestinal oncology--updates and insights from the 2009 annual meeting of the American society of clinical oncology

We have reviewed the pivotal presentations related to gastrointestinal malignancies from 2009 annual meeting of the American Society of Clinical Oncology with the theme of "personalizing cancer care". We have discussed the scientific findings and the impact on practice guidelines and ongoing clinical trials. Adding trastuzumab to chemotherapy improved the survival of patients with advanced gastric cancer overexpressing human epidermal growth factor receptor 2. Gemcitabine plus cisplatin has become a new standard for first-line treatment of advanced biliary cancer. Octreotide LAR significantly lengthened median time to tumor progression compared with placebo in patients with metastatic neuroendocrine tumors of the midgut. Addition of oxaliplatin to fluoropyrimidines for preoperative chemoradiotherapy in patients with stage II or III rectal cancer did not improve local tumor response but increased toxicities. Bevacizumab did not provide additional benefit to chemotherapy in adjuvant chemotherapy for stage II or III colon cancer. In patients with resected stage II colon cancer, recurrence score estimated by multigene RT-PCR assay has been shown to provide additional risk stratification. In stage IV colorectal cancer, data have supported the routine use of prophylactic skin treatment in patients receiving antibody against epidermal growth factor receptor, and the use of upfront chemotherapy as initial management in patients with synchronous metastasis without obstruction or bleeding from the primary site.

Intensity-modulated radiation therapy for anal malignancies: a preliminary toxicity and disease outcomes analysis

PURPOSE

Intensity-modulated radiation therapy (IMRT) has the potential to reduce toxicities associated with chemoradiotherapy in the treatment of anal cancer. This study reports the results of using IMRT in the treatment of anal cancer.

METHODS AND MATERIALS

Records of patients with anal malignancies treated with IMRT at Duke University were reviewed. Acute toxicity was graded using the NCI CTCAEv3.0 scale. Overall survival (OS), metastasis-free survival (MFS), local-regional control (LRC) and colostomy-free survival (CFS) were calculated using the Kaplan-Meier method.

RESULTS

Forty-seven patients with anal malignancy (89% canal, 11% perianal skin) were treated with IMRT between August 2006 and September 2008. Median follow-up was 14 months (19 months for SCC patients). Median radiation dose was 54 Gy. Eight patients (18%) required treatment breaks lasting a median of 5 days (range, 2-7 days). Toxicity rates were as follows: Grade 4: leukopenia (7%), thrombocytopenia (2%); Grade 3: leukopenia (18%), diarrhea (9%), and anemia (4%); Grade 2: skin (93%), diarrhea (24%), and leukopenia (24%). The 2-year actuarial overall OS, MFS, LRC, and CFS rates were 85%, 78%, 90% and 82%, respectively. For SCC patients, the 2-year OS, MFS, LRC, and CFS rates were 100%, 100%, 95%, and 91%, respectively.

CONCLUSIONS

IMRT-based chemoradiotherapy for anal cancer results in significant reductions in normal tissue dose and acute toxicities versus historic controls treated without IMRT, leading to reduced rates of toxicity-related treatment interruption. Early disease-related outcomes seem encouraging. IMRT is emerging as a standard therapy for anal cancer.

Chemoradiation for the treatment of epidermoid anal cancer: 13-year follow-up of the first randomised UKCCCR Anal Cancer Trial (ACT I)

Background:

The first UKCCCR Anal Cancer Trial (1996) demonstrated the benefit of chemoradiation over radiotherapy (RT) alone for treating epidermoid anal cancer, and it became the standard treatment. Patients in this trial have now been followed up for a median of 13 years.

Methods:

A total of 577 patients were randomised to receive RT alone or combined modality therapy using 5-fluorouracil and mitomycin C. All patients were scheduled to receive 45 Gy by external beam irradiation. Patients who responded to treatment were recommended to have boost RT, with either an iridium implant or external beam irradiation. Data on relapse and deaths were obtained until October 2007.

Results:

Twelve years after treatment, for every 100 patients treated with chemoradiation, there are an expected 25.3 fewer patients with locoregional relapse (95% confidence interval (CI): 17.5–32.0 fewer) and 12.5 fewer anal cancer deaths (95% CI: 4.3–19.7 fewer), compared with 100 patients given RT alone. There was a 9.1% increase in non-anal cancer deaths in the first 5 years of chemoradiation (95% CI +3.6 to +14.6), which disappeared by 10 years.

Conclusions:

The clear benefit of chemoradiation outweighs an early excess risk of non-anal cancer deaths, and can still be seen 12 years after treatment. Only 11 patients suffered a locoregional relapse as a first event after 5 years, which may influence the choice of end points in future studies.

Anal neoplasms

A variety of lesions comprise tumors of the anal canal, with carcinoma in situ and epidermoid cancers being the most common. Less common anal neoplasms include adenocarcinoma, melanoma, gastrointestinal stromal cell tumors, neuroendocrine tumors, and Buschke-Lowenstein tumors. Treatment strategies are based on anatomic location and histopathology. In this article different tumors and management of each, including a brief review of local excision for rectal cancer, are discussed in turn.

Long-term quality of life after radiotherapy for the treatment of anal cancer

BACKGROUND

Radiotherapy is the current standard of care for patients with localized squamous cell cancer of the anal canal. The goal of the current study was to evaluate long-term quality of life (QoL) in patients after this treatment.

METHODS

Questionnaires were mailed to 80 patients treated with definitive radiotherapy, with or without concurrent chemotherapy, for anal cancer, with a minimum 2-year interval after the completion of radiotherapy. The questionnaire included the Functional Assessment of Cancer Therapy-Colorectal (FACT-C), the Medical Outcomes Study (MOS) Sexual Problems Scale, and questions regarding demographic characteristics and comorbidities.

RESULTS

A total of 32 (40%) patients completed the questionnaire. There were no significant differences noted with regard to clinical and demographic characteristics between the survey responders and nonresponders. Among the 32 responders, the median dose of radiotherapy was 55 Grays (Gy), and 97% had received concurrent chemotherapy. The median interval between radiotherapy and survey participation was 5 years (range, 3-13 years). The median total FACT-C score was 108 (range, 47-128), of a maximum (best possible) score of 136. Patients who reported depression or anxiety and younger patients were found to have significantly lower total FACT-C scores. The median scores on the Physical, Social/Family, Emotional, Functional, and Colorectal subscales of the FACT-C were 20, 23, 21, 22, and 21, respectively, of maximum (best possible) scores of 28, 28, 24, 28, and 28, respectively. The median score on the MOS Sexual Problems Scale was 67 (range, 0-100), of a maximum (worst possible) score of 100.

CONCLUSIONS

Patients treated with radiotherapy for anal cancer reported acceptable overall QoL scores, but poor sexual function scores. Investigations are warranted into more modern radiation techniques that could potentially reduce late toxicity from radiotherapy.

Randomized clinical trials in rectal and anal cancers

This article reviews randomized clinical trials (RCTs) published between April 2001 and November 2008 on the management of patients with rectal cancer. In total, the authors reviewed 78 RCTs on therapy for rectal cancer. Of these, five met the authors' criteria for level 1a evidence. The article discusses the major RCTs and relevant findings that have impacted clinical management most and includes most but not all RCTs on therapy for rectal cancer published during this period.

Radiotherapy for patients with the human immunodeficiency virus: are special precautions necessary?

Shortly after the onset of the acquired immunodeficiency syndrome (AIDS) epidemic in the 1980s, reports of radiation-associated toxicity in patients with the human immunodeficiency virus (HIV) and AIDS began to appear in the medical literature. Although the majority of reports have focused on AIDS-defining malignancies such as Kaposi sarcoma, greater-than-expected toxicity after a course of radiotherapy or chemoradiotherapy has also been documented in cancers not generally classified as being related to HIV. With improved antiretroviral therapies, HIV patients are living longer and have the potential to develop a variety of HIV-associated and nonassociated malignancies that require treatment, including radiotherapy. This review reports the published data regarding the interactions of HIV, AIDS, and antiretroviral therapy with radiotherapy and implications for the management of malignancies in patients with HIV.

Capped-dose mitomycin C: a pooled safety analysis from three prospective clinical trials

BACKGROUND

Mitomycin C (MMC) up-regulates topoisomerase-I and thymidine phosphorylase making it ideal to combine with irinotecan or capecitabine. One of the most devastating toxicities MMC has been associated with is thrombotic thrombocytopenic purpura/hemolytic uremic syndrome (TTP/HUS) in 4-15% of patients, especially when receiving cumulative doses higher than 60 mg/m(2).

METHODS

We conducted a pooled safety analysis of 140 patients enrolled in three prospective clinical trials at our institution from 2001 to 2008. MMC on all our studies was capped to a cumulative dose of 36 mg/m(2) to limit toxicity while retaining efficacy. We reviewed our electronic medical records and clinical trial database for individual patient data on these studies with a specific intent to identify patients meeting criteria for TTP/HUS.

RESULTS

In combination with irinotecan or capecitabine, MMC was associated with manageable toxicities. We found no cases of MMC-associated TTP/HUS. There were no reported cardiac or pulmonary toxicities in our analysis. Most common grade 3/4 toxicities were diarrhea (19%), neutropenia (17%) and dehydration (12%) predominantly when MMC was combined with irinotecan.

CONCLUSIONS

In this large pooled analysis, we found MMC, when capped at a cumulative dose of 36 mg/m(2), to be safe and tolerable in combination with capecitabine or irinotecan with no reportable cases of TTP/HUS.

Treatment of anal carcinoma in immune-compromised patients

BACKGROUND

Immune-compromised populations show an increased incidence of anogenital tract neoplasms. This study was undertaken to evaluate local control (LC), overall survival (OS) and toxicity in immune-compromised patients with anal carcinoma treated with radiotherapy with or without chemotherapy.

METHODS

We identified 25 patients with anal carcinoma and human immunodeficiency virus (HIV) infection or history of solid-organ transplant on chronic medical immune-suppression. Median age and follow-up were 44 years and 26 months respectively. AJCC T-stages were Tis (4%), T1 (8%), T2 (58%) and T3 (29%). N-stages were N0 (79%), N1 (4%), N2 (13%) and N3 (4%). One patient had metastatic disease at diagnosis. Seventy-five percent received concurrent chemoradiotherapy. Median radiation dose to the primary tumour was 50 Gy.

RESULTS

One-, 3- and 5-year LC without salvage therapy was 87%, 87% and 70% respectively. One-, 3- and 5-year actuarial OS was 96%, 73% and 61% respectively. One-, 3- and 5-year OS was 100% for treatment time (TT) <50 days and 57%, 38% and 0% for TT > or =50 days (p=0.0009). All patients had acute grade 2-3 skin toxicity. Acute grade 3-4 gastrointestinal (GI), genitourinary (GU) and haematological toxicity occurred in 8%, 0% and 38%. Late grade 3-4 skin, GI and GU toxicity occurred in 8%, 4% and 0%.

CONCLUSIONS

Most HIV-positive and organ transplant patients receiving radiotherapy with or without chemotherapy experience acute toxicity but few have chronic complications. T-stage and CD4 level in HIV-positive patients predict for LC. T-stage and TT predict for OS.

Anal cancer treated with radio-chemotherapy: correlation between length of treatment interruption and outcome

AIM

The purpose of this study was the evaluation of the feasibility and outcome of definitive radio-chemotherapy without split-course technique but with individualised short treatment interruption in anal cancer patients.

METHOD

Between 1993 and 2008, 101 patients with anal cancer were treated in our institution with definitive radio-chemotherapy with individualised short treatment interruptions. Treatment was halted independent of dose in case of acute grade 3 toxicities and started again until improvement. Short interruption was defined as completing treatment without exceeding six cumulative treatment days beyond a scheduled plan; otherwise, it was defined as prolonged interruption.

RESULTS

Median overall treatment time was 47 days corresponding to an interruption of six cumulative treatment days. Fifty-one patients (50%) had treatment interruption of <or=6 days. No acute grade 4 toxicities were observed. One fatality occurred during treatment due to ileus-like symptoms according to acute grade 5 toxicity. After a median follow-up of 56 months, the 5-year actuarial rates for local control comparing patients with short vs. prolonged treatment interruption were 78% vs. 81% (p = 0.904) and, for colostomy-free survival, 83% vs. 85% (p = 0.784), respectively.

CONCLUSIONS

Definitive radio-chemotherapy with short individualised treatment interruption shows high local control and colostomy-free survival rates.

Intensity-modulated radiation therapy for the treatment of squamous cell anal cancer with para-aortic nodal involvement

PURPOSE

To determine the rates of toxicity, locoregional control, distant control, and survival in anal cancer patients with para-aortic nodal involvement, treated with intensity-modulated radiotherapy (IMRT) and concurrent chemotherapy at a single institution.

METHODS AND MATERIALS

Between 2001 and 2007, 6 patients with squamous cell anal cancer and para-aortic nodal involvement were treated with IMRT and concurrent infusional 5-fluorouracil and cisplatin. The primary tumor was treated with a median dose of 57.5 Gy (range, 54-60 Gy), involved para-aortic, pelvic, and inguinal lymph nodes were treated with a median dose of 55 Gy (range, 50.5-55 Gy), and noninvolved nodal regions were treated with a median dose of 45 Gy (range, 43.5-45 Gy).

RESULTS

After a median follow-up of 25 months, none of the patients had a recurrence at the primary tumor, pelvic/inguinal nodes, or para-aortic nodes, whereas 2 patients developed distant metastases to the liver. Four of the 6 patients are alive. The 3-year actuarial locoregional control, distant control, and overall survival rates were 100%, 56%, and 63%, respectively. Four of the 6 patients developed Grade 3 acute gastrointestinal toxicity during chemoradiation.

CONCLUSIONS

Intensity-modulated radiotherapy and concurrent chemotherapy could potentially serve as definitive therapy in anal cancer patients with para-aortic nodal involvement. Adjuvant chemotherapy may be indicated in these patients, as demonstrated by the distant failure rates. These patients need to be followed carefully because of the potential for treatment-related toxicities.

Review of 120 anal cancer patients

OBJECTIVE

Chemoradiotherapy is the mainstay of treatment for the majority of patients with anal cancer, with abdominoperineal resection reserved for salvage. The purpose of this study was to evaluate our results after radiotherapy with or without chemotherapy, and/or surgery in terms of overall survival and colostomy free survival in patients with anal cancer.

METHOD

A review of patients diagnosed with anal cancer between 1991 and 2004 was performed. The principle end-points of the study were overall and colostomy-free survival.

RESULTS

One hundred and twenty patients were identified. The T stage distribution was T1 32, T2 44, T3 19, T4 17 and TX 8. Eighteen patients had clinically involved regional nodes. Eighty patients received radiotherapy as a component of their treatment. Twenty-four of the 80 patients had a colostomy. The most common late toxicity was faecal incontinence. The overall survival and colostomy-free survival rates for all 120 patients were 58% and 79% at 5 years, respectively. For the 80 patients who received radiotherapy, the corresponding figures were 66% and 82% at 5 years, respectively.

CONCLUSION

Chemoradiation is effective organ preserving treatment for anal cancer. Grade 1 and 2 faecal incontinence is a relatively common late toxicity experienced by patients.

Current therapeutic strategies for anal squamous cell carcinoma in Japan

BACKGROUND

In Western countries, chemoradiotherapy (CRT) is well established as the standard therapy for stages II/III anal squamous cell carcinoma (ASCC). In Japan, the therapeutic modalities for and outcomes of this disease have not been clarified because ASCC is quite rare. The Colorectal Cancer Study Group of the Japan Clinical Oncology Group (JCOG-CCSG) conducted a survey to determine the current therapeutic strategies for ASCC in Japan.

METHODS

In July 2006, a questionnaire was sent to 49 institutions affiliated with the JCOG-CCSG to gather information on numbers of cases, therapeutic modalities, and outcomes. The target subjects were patients with stages II/III ASCC, diagnosed from January 2000 to December 2004, who were 20-80 years of age with normal major organ function and no severe complications.

RESULTS

Replies were received from 40 institutions. A total of 59 patients satisfied the subject criteria. Detailed information was obtained for 55 subjects; 25 (45%) had stage II ASCC and 30 (55%) had stage III ASCC. CRT was performed in 25 patients (45%); surgery in 17 (31%); surgery combined with radiotherapy (RT), chemotherapy, or CRT in 8 (15%); and RT in 5 (9%). Complete response rate in CRT was 80% (20/25). The 3-year progression-free survival rates for all subjects and for CRT-only subjects were 67% and 77%, respectively.

CONCLUSION

From 2000 to 2004, only 59 patients with ASCC were identified in the JCOG-CCSG survey and about half of them underwent CRT.

Current management of anal canal cancer

Squamous cell carcinoma of the anal canal historically has been treated with abdominoperineal resection, resulting in high rates of morbidity and local recurrence. Pioneering work led to the finding that radiation therapy (RT) combined with 5-fluorouracil (5-FU) and mitomycin results in high rates of local control and disease-free and colostomy-free survival without surgery. Prospective randomized trials from Europe and the United States have shown the superiority of RT, 5-FU, and mitomycin over 1) RT alone, 2) RT with 5-FU, and 3) neoadjuvant cisplatin/5-FU with concurrent radiation, cisplatin, and 5-FU. At present, RT with 5-FU and mitomycin is the standard of care for anal cancer patients. Recent advances include the integration of positron emission tomography into staging, radiation treatment planning and monitoring, and the use of intensity modulated RT. European randomized trials are further evaluating the role of cisplatin in the neoadjuvant, concurrent, and adjuvant settings, as well as radiation dose escalation. Other studies are evaluating the use of capecitabine, oxaliplatin, and the anti-epidermal growth factor receptor agent cetuximab with RT in this malignancy.

Squamous cell cancer of the rectum

Squamous cell carcinoma of the rectum is a rare malignancy. It appears to be associated with chronic inflammatory conditions and infections. The clear association seen between Human Papilloma Virus and various squamous cancers has not been firmly established for the squamous cell cancer of the rectum. The presentation is nonspecific and patients tend to present with advanced stage disease. Diagnosis relies on endoscopic examination with biopsy of the lesion. Distinction from squamous cell cancer of the anus can be difficult, but can be facilitated by immunohistochemical staining for cytokeratins. Staging of the cancer with endoscopic ultrasound and computed tomography provides essential information on prognosis and can guide therapy. At present, surgery remains the main therapeutic option; however recent advances have made chemoradiation a valuable therapeutic addition. Squamous cell carcinoma of the rectum is a distinct entity and it is of crucial importance for the practicing Gastroenterologist to be thoroughly familiar with this disease. Compared to adenocarcinoma of the rectum and squamous cell cancer of the anal canal, squamous cell carcinoma of the rectum has different epidemiology, etiology, pathogenesis, and prognosis but, most importantly, requires a different therapeutic approach. This review will examine and summarize the available information regarding this disease from the perspective of the practicing gastroenterologist.

Concurrent chemoradiotherapy with 5-fluorouracil and mitomycin C for invasive anal carcinoma in human immunodeficiency virus-positive patients receiving highly active antiretroviral therapy

PURPOSE

To report the clinical outcomes of chemoradiotherapy (CRT) for anal carcinoma in human immunodeficiency virus (HIV)-infected patients receiving highly active antiretroviral therapy.

PATIENTS AND METHODS

Between 1997 and 2008, 21 HIV-positive patients who were receiving highly active antiretroviral therapy were treated with CRT (50.4 Gy at 1.8 Gy/fraction plus a 5.4-10.8-Gy external boost; 5-fluorouracil, 1,000 mg/m(2), Days 1-4 and 29-32; and mitomycin C, 10 mg/m(2), Days 1 and 29). A retrospective analysis was performed with respect to the tumor response, local control, cancer-specific and overall survival, and toxicity. The immunologic parameters, including pre- and post-treatment CD4 count, viral load, and acquired immunodeficiency syndrome-specific morbidity was recorded during follow-up (median, 53 months; range, 10-99).

RESULTS

CRT could be completed in all 21 patients with a reduction in the chemotherapy dose and/or interruption of radiotherapy in 5 and 5 cases, respectively. Acute Grade 3 toxicity occurred in 8 (38%) of the 21 patients. A complete response was achieved in 17 patients (81%), and tumor persistence or early progression was noted in 4 (19%). Six patients (29%) died, 5 of cancer progression and 1 of treatment-related toxicity. The 5-year local control, cancer-specific, and overall survival rate was 59%, 75%, and 67%, respectively. The median CD4 count significantly decreased from 347.5 cells/microL before CRT to 125 cells/microL 3-7 weeks after CRT completion (p <.001). In 6 (32%) of 19 patients, an increase of the HIV viral load was noted. Both parameters returned to the pretreatment values with additional follow-up.

CONCLUSION

Our data have confirmed that in the highly active antiretroviral therapy era, HIV-related anal cancer can be treated with standard CRT without dose reductions. Close surveillance of the immunologic parameters is necessary.

A multi-institutional acute gastrointestinal toxicity analysis of anal cancer patients treated with concurrent intensity-modulated radiation therapy (IMRT) and chemotherapy

Using previous dosimetric analysis methods, we identified the volume of bowel receiving 30 Gy (V(30)) correlated with acute gastrointestinal (GI) toxicity in anal cancer patients treated with intensity-modulated radiation therapy and concurrent chemotherapy. For V(30)>450 cc and < or =450 cc, acute GI toxicity was 33% and 8%, respectively (p=0.003).

Epidermoid anal cancer prognosis comparison among HIV+ and HIV- patients

BACKGROUND

Previous studies suggest a poor prognosis of epidermoid anal cancer in HIV+ patients.

AIM

To investigate the long-term outcome of epidermoid anal cancer in HIV+ and HIV- patients in the highly active antiretroviral treatment (HAART) era.

METHODS

We included all patients with epidermoid anal cancer referred to six hospitals from 1998 to 2004.

RESULTS

In all, 151 patients (44 HIV+, 107 HIV-) were reviewed retrospectively for 27 (median of 16-44) months. HIV+ patients were male (100% vs. 27%, P < 0.001) and younger (45 vs. 62 years old, P < 0.001) than HIV- patients. No significant differences were observed in the tumour stage, pelvic radiotherapy dose or concomitant chemotherapy, according to the HIV status. After chemoradiotherapy, similar numbers of HIV+ and HIV- patients had grade III-IV toxicity. A complete response was obtained in 82% and 75% (N.S.) of cases, respectively. The disease-free survival rates were 77% and 67% (N.S.) and the overall survival rates were 85% and 84% (N.S.), respectively, after 3 years of follow-up. Duration of HIV infection, viral load and CD4 count had no effect on the survival rate of HIV+ patients with EAC.

CONCLUSIONS

The clinical outcome of HIV+ patients with epidermoid anal cancer is similar to that of HIV- patients. Therefore, the same therapeutic guidelines should be applied to both populations.

Mitomycin C with continuous fluorouracil or with cisplatin in combination with radiotherapy for locally advanced anal cancer (European Organisation for Research and Treatment of Cancer phase II study 22011-40014)

PURPOSE

To assess the feasibility and activity of radio-chemotherapy with mitomycin C (MMC) and cisplatin (CDDP) in locally advanced squamous cell anal carcinoma with reference to radiotherapy (RT) combined with MMC and fluorouracil (5-FU).

PATIENTS AND METHODS

Patients with measurable disease >4 cmN0 or N+ received RT (36Gy+2 week gap+23.4Gy) with either MMC/CDDP or MMC/5-FU (MMC 10mg/m(2) d1 of each sequence; 5-FU 200mg/m(2)/day c.i.v. daily; CDDP 25mg/m(2) weekly). Forty patients/arm were needed to exclude a RECIST objective response rate (ORR), 8 weeks after treatment, of <75% (Fleming 1, alpha=10%, beta=10%).

RESULTS

The ORR was 79.5% (31/39) (lower bound confidence interval [CI]: 68.8%) with MMC/5-FU versus 91.9% (34/ 37) (lower bound CI: 82.8%) with MMC/CDDP. In the MMC/5-FU group, two patients (5.1%) discontinued treatment due to toxicity versus 11 (29.7%) in the MMC/CDDP group. Nine grade 3 haematological events occurred with MMC/CDDP versus none with 5-FU/MMC. The rate of other toxicities did not differ. There was no toxic death. Thirty-one patients in the MMC/5-FU arm (79.5%) and 18 in the MMC/CDDP arm (48.6%) were fully compliant with the protocol treatment (p=0.005).

CONCLUSIONS

Radio-chemotherapy with MMC/CDDP seems promising as only MMC/CDDP demonstrated enough activity (RECIST ORR >75%) to be tested further in phase III trials; MMC/5-FU did not. MMC/CDDP also had an overall acceptable toxicity profile.

Node-positive adenocarcinoma of the endometrium: outcome and patterns of recurrence with and without external beam irradiation

OBJECTIVE

To evaluate treatment outcomes and patterns of recurrence in patients with node-positive (International Federation of Obstetrics and Gynecology stage IIIC) adenocarcinoma of the uterus without serous or clear cell differentiation.

METHODS

The records of 71 women who were treated for stage IIIC endometrial adenocarcinoma at our institution between 1984 and 2005 were reviewed. All patients underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, and lymphadenectomy. Fifty patients received definitive pelvic or extended-field radiotherapy with or without systemic therapy (regional RT group). Eighteen received adjuvant systemic platinum-based chemotherapy or hormonal therapy without external beam RT. The median follow-up for patients not dying of disease was 67 months. Survival rates were calculated using the Kaplan-Meier method; differences were assessed using log-rank tests.

RESULTS

Thirty-nine percent (28/71) of patients had involved paraaortic lymph nodes while 61% (43/71) had only pelvic lymph nodes. Five- and 10-year disease-specific survival (DSS) rates were 63% and 54%, respectively; corresponding overall survival rates were 60% and 47%. Grade was strongly associated with DSS (76% vs 46% at 5 years for low-grade vs high-grade tumors, P=0.004). Cervical or adnexal involvement was associated with decreased DSS, but lymph-vascular space invasion, age, race, body mass index, and number and location of positive nodes were not. Five-year pelvic-relapse-free survival (98% vs 61%, P=0.001), DSS (78% vs 39%, P=0.01), and overall survival (73% vs 40%, P=0.03) were significantly better for the regional RT group than the systemic therapy group. In patients treated without regional RT, the most common site of relapse was the pelvis. DSS was not significantly correlated with number of nodes removed in the regional RT group but was in patients treated without regional RT (P=0.001).

CONCLUSIONS

Patients treated without regional RT had a high rate of locoregional recurrence. Patients with stage IIIC endometrial adenocarcinoma who underwent surgical staging followed by external beam irradiation had a high rate of cure. Relapses in patients treated with EBRT primarily occurred in patients with grade 3 cancer who may be most likely to benefit from combined-chemoradiation treatment.

HPV-induced oropharyngeal cancer, immune response and response to therapy

Approximately 25% of head and neck squamous cell carcinoma (HNSCC) worldwide are associated with high-risk human papillomaviruses (HPV). HPV-positive HNSCCs have a more favorable outcome and greater response to therapy. While chronic HPV infection allows for the evolution of immune evasion mechanisms, viral antigens can still elicit an immune response. Moreover, a robust lymphocytic response is associated with better prognosis in a variety of tumor types including head and neck cancer. This article outlines several mechanisms whereby the observed improved response of HPV-positive tumors to radiotherapy may be related to enhancement of the immune response following radiotherapy.

Future directions in neoadjuvant therapy of rectal cancer: maximizing pathological complete response rates

Neoadjuvant therapy is widely accepted as the current standard of care for localized rectal cancer. Downstaging of disease has been significantly improved and pathological complete response rates (pCR) which were historically below 10% with preoperative radiation alone, now range from 15% to 30% with preoperative chemo-radiation. While the availability of new chemotherapeutic drugs (Irinotecan, Oxaliplatin, etc.) and molecular targeted agents (Bevacizamab, Cetuximab, etc.) hold a great deal of promise, results of recent studies indicate that the pCR rate with neoadjuvant therapy appears to have plateaued at 20-30%. The use of more intensive multidrug combinations has, however, significantly increased the toxicity of treatment. New paradigms in neoadjuvant therapy are therefore needed to further improve results of treatment. This review presents strategies for neoadjuvant therapy, with the potential to improve pCR rates and also survival of patients.