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Ofner D, Devries AF, Schaberl-Moser R, Greil R, Rabl H, Tschmelitsch J, Zitt M, Kapp KS, Fastner G, Keil F, Eisterer W, Jäger R, Offner F, Gnant M, Thaler J. Preoperative oxaliplatin, capecitabine, and external beam radiotherapy in patients with newly diagnosed, primary operable, cT₃NxM0, low rectal cancer: a phase II study. Strahlenther Onkol 2011; 187:100-7. [PMID: 21267531 DOI: 10.1007/s00066-010-2182-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2010] [Accepted: 11/11/2010] [Indexed: 01/08/2023]
Abstract
PURPOSE In patients with locally advanced rectal cancer (LARC), preoperative chemoradiation is known to improve local control, and down-staging of the tumor serves as a surrogate for survival. Intensification of the systemic therapy may lead to higher downstaging rates and, thus, enhance survival. This phase II study investigated the efficacy and safety of preoperative capecitabine and oxaliplatin in combination with radiotherapy. PATIENTS AND METHODS Patients with LARC of the mid and lower rectum, T₃NxM0 staged by MRI received radiotherapy (total dose 45 Gy) in combination with oral capecitabine (825 mg/m² twice a day on radiotherapy days; weeks 1-4) and oxaliplatin 50 mg/m² intravenously (days 1, 8, 15, and 22). Efficacy was evaluated as rate of tumor down-categorization at the T level. RESULTS A total of 59 patients were enrolled (19 women, 40 men; median age of 61 years) and all were evaluable for efficacy and toxicity. Down-categorization at the T level was observed in 53% with pathological complete response in 6 patients (10%). Actual total radiotherapy, oxaliplatin and capecitabine doses received were 97%, 90%, and 93% of the protocol-specified preplanned doses, respectively. Grade 3/4 toxicity was observed in 15 patients (25%). The most frequent was diarrhea (12%). CONCLUSIONS Preoperative chemoradiation with capecitabine and oxaliplatin is feasible in patients with MRI-proven cT₃ LARC. The only clinically relevant toxicity was diarrhea. Overall, efficacy of the multimodality treatment was good, but not markedly exceeding that of 5-FU- or capecitabine-based chemoradiation approaches.
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Affiliation(s)
- Dietmar Ofner
- Department of Surgery, Paracelsus Private Medical University, Salzburg, Austria.
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Maas M, Nelemans PJ, Valentini V, Das P, Rödel C, Kuo LJ, Calvo FA, García-Aguilar J, Glynne-Jones R, Haustermans K, Mohiuddin M, Pucciarelli S, Small W, Suárez J, Theodoropoulos G, Biondo S, Beets-Tan RGH, Beets GL. Long-term outcome in patients with a pathological complete response after chemoradiation for rectal cancer: a pooled analysis of individual patient data. Lancet Oncol 2010; 11:835-44. [PMID: 20692872 DOI: 10.1016/s1470-2045(10)70172-8] [Citation(s) in RCA: 1350] [Impact Index Per Article: 96.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Locally advanced rectal cancer is usually treated with preoperative chemoradiation. After chemoradiation and surgery, 15-27% of the patients have no residual viable tumour at pathological examination, a pathological complete response (pCR). This study established whether patients with pCR have better long-term outcome than do those without pCR. METHODS In PubMed, Medline, and Embase we identified 27 articles, based on 17 different datasets, for long-term outcome of patients with and without pCR. 14 investigators agreed to provide individual patient data. All patients underwent chemoradiation and total mesorectal excision. Primary outcome was 5-year disease-free survival. Kaplan-Meier survival functions were computed and hazard ratios (HRs) calculated, with the Cox proportional hazards model. Subgroup analyses were done to test for effect modification by other predicting factors. Interstudy heterogeneity was assessed for disease-free survival and overall survival with forest plots and the Q test. FINDINGS 484 of 3105 included patients had a pCR. Median follow-up for all patients was 48 months (range 0-277). 5-year crude disease-free survival was 83.3% (95% CI 78.8-87.0) for patients with pCR (61/419 patients had disease recurrence) and 65.6% (63.6-68.0) for those without pCR (747/2263; HR 0.44, 95% CI 0.34-0.57; p<0.0001). The Q test and forest plots did not suggest significant interstudy variation. The adjusted HR for pCR for failure was 0.54 (95% CI 0.40-0.73), indicating that patients with pCR had a significantly increased probability of disease-free survival. The adjusted HR for disease-free survival for administration of adjuvant chemotherapy was 0.91 (95% CI 0.73-1.12). The effect of pCR on disease-free survival was not modified by other prognostic factors. INTERPRETATION Patients with pCR after chemoradiation have better long-term outcome than do those without pCR. pCR might be indicative of a prognostically favourable biological tumour profile with less propensity for local or distant recurrence and improved survival. FUNDING None.
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Affiliation(s)
- Monique Maas
- Department of Surgery, Maastricht University Medical Centre, Maastricht, Netherlands
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Prasad DS, Scott N, Hyland R, Guthrie JA, Tolan DJM. Diffusion-weighted MR Imaging for Early Detection of Tumor Histopathologic Downstaging in Rectal Carcinoma after Chemotherapy and Radiation Therapy. Radiology 2010; 256:671-2; author reply 672. [DOI: 10.1148/radiol.100471] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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A phase I study of capecitabine, irinotecan, celecoxib, and radiation as neoadjuvant therapy of patients with locally advanced rectal cancer. Am J Clin Oncol 2010; 33:242-5. [PMID: 19806036 DOI: 10.1097/coc.0b013e3181a650fb] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES We conducted a prospective phase I trial to determine the maximum tolerated dose of capecitabine and irinotecan when used in combination with celecoxib and radiation as preoperative therapy for patients with locally advanced rectal cancer. METHODS Patients with histologic diagnosis of adenocarcinoma of distal rectum, evidence of T3/T4 tumor or nodal involvement by endorectal ultrasound/magnetic resonance imaging, any T status where tumor was close to but not involving the sphincter requiring abdominoperineal resection were evaluated by standard phase I methodology. Starting chemotherapy dosage (dose level: 0) was capecitabine 550 mg/m bid, day 1 to 5 every week through out x-ray therapy, irinotecan 30 mg/ m IV on days 1, 8, 22, 29 (no treatment on day 15 and day 36), and celecoxib 400 mg PO bid from day 1 till the last day of radiation. Radiation dosage of 50.4 Gy in 28 fractions was delivered in 5.6 weeks. If no dose limiting toxicity was observed, dose of capecitabine was escalated by 75 mg/m and irinotecan by 5 mg/m. Celecoxib dosage was fixed. RESULTS Fourteen patients were accrued. Dose limiting toxicity was observed at level 2 and was primarily hematological and gastrointestinal. Two patients at level 2 developed grade-3 diarrhea and thrombocytopenia and 1 patient at level 2 developed grade 3/4 vomiting, diarrhea and dehydration. CONCLUSIONS Recommended dosage for future trials is capecitabine 625 mg/m bid, irinotecan 35 mg/m, and celecoxib 400 mg orally bid in combination with pelvic radiation.
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Pomerri F, Pucciarelli S, Maretto I, Zandonà M, Del Bianco P, Amadio L, Rugge M, Nitti D, Muzzio PC. Prospective assessment of imaging after preoperative chemoradiotherapy for rectal cancer. Surgery 2010; 149:56-64. [PMID: 20452636 DOI: 10.1016/j.surg.2010.03.025] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2009] [Accepted: 03/25/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND The aim of the study was to assess the accuracy of imaging techniques in predicting pathologic tumor (ypT), node (ypN) stages and the circumferential resection margin (ypCRM) status of rectal cancers after preoperative chemoradiotherapy (CRT). METHODS Using pelvic computed tomography (CT), magnetic resonance imaging (MRI), and endorectal ultrasound (ERUS), 90 consecutive patients with locally advanced mid-to-low rectal cancer were prospectively assessed. Postirradiation T and N stages and infiltration of the CRM, as assessed by CT, MRI and ERUS, were compared with histopathologic findings. RESULTS The accuracy of ypT staging was low, whatever the imaging technique used (37% by CT, 34% by MRI, and 27% by ERUS), the most frequent inaccuracy being overstaging. Imaging showed a good specificity and good negative predictive values (NPV) when mural staging was grouped into ypT ≤ 3 and ypT4 categories; in particular, ERUS achieved a 92% specificity and 95% NPV. CRM involvement was correctly predicted in 71% of patients by CT (74% specificity; 93% NPV) and in 85% by MRI (88% specificity; 95% NPV). The accuracy for nodal staging was 62%, 68%, and 65% by CT, MRI and ERUS, respectively; the corresponding NPV were 88%, 78%, and 76%. CONCLUSION Current imaging techniques are inaccurate in restaging rectal cancer after CRT but are useful in predicting T ≤ 3 tumors, cases with negative nodes and tumor-free CRM. These findings may be of clinical relevance for planning less invasive surgery.
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Affiliation(s)
- Fabio Pomerri
- Department of Medical-Diagnostic Sciences and Special Therapies, University of Padua, Padua, Italy.
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Impact of tumor response on survival after radiochemotherapy in locally advanced rectal carcinoma. Am J Surg Pathol 2010; 34:562-8. [PMID: 20216380 DOI: 10.1097/pas.0b013e3181d438b0] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In locally advanced rectal adenocarcinoma, preoperative radiochemotherapy induces tumor response. The impact of pathologic tumor response on survival is still debated because of the numerous distinct tumor-response gradings available in the literature and the lack of standardized pathologic approach. The objective of this work was to study the impact of tumor response on survival, according to the 4 main tumor-response gradings available in the literature in locally advanced rectal adenocarcinoma after preoperative radiochemotherapy. From 1995 to 2004, 292 consecutive patients with cT3-T4 and/or N+ rectal adenocarcinoma were enrolled. Tumor response was evaluated according to ypTN-response gradings (downstaging: ypT0-2 N0 and complete pathologic response: ypT0 N0) and cellular-response gradings (ie, Mandard et al's and Rodel et al's gradings). The impact of tumor-response gradings and of different clinicopathologic variables on 5-year disease-free and overall survival were studied by univariate and multivariate analyses. We found that all tumor-response gradings were associated with survival. However, multivariate analysis showed that downstaging was the only tumor-response grading that influenced survival independently. In the subgroup of stage II patients (n=99), we also observed no difference on both 5-year disease-free and overall survival between low and high responders according to cellular response. In conclusion, in our experience, downstaging is the only tumor-response grading that influenced survival independently in locally advanced rectal adenocarcinomas. Cellular-response gradings had no impact on survival even in stage II patients.
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Maluta S, Romano M, Dall'oglio S, Genna M, Oliani C, Pioli F, Gabbani M, Marciai N, Palazzi M. Regional hyperthermia added to intensified preoperative chemo-radiation in locally advanced adenocarcinoma of middle and lower rectum. Int J Hyperthermia 2010; 26:108-17. [DOI: 10.3109/02656730903333958] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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Gunderson LL, Jessup JM, Sargent DJ, Greene FL, Stewart A. Revised tumor and node categorization for rectal cancer based on surveillance, epidemiology, and end results and rectal pooled analysis outcomes. J Clin Oncol 2010; 28:256-63. [PMID: 19949015 PMCID: PMC2815714 DOI: 10.1200/jco.2009.23.9194] [Citation(s) in RCA: 173] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2009] [Accepted: 09/04/2009] [Indexed: 12/22/2022] Open
Abstract
PURPOSE The sixth edition of the American Joint Committee on Cancer (AJCC) rectal cancer staging subdivided stage II into IIA (T3N0) and IIB (T4N0) and stage III into IIIA (T1-2N1M0), IIIB (T3-4N1M0), and IIIC (anyTN2M0). Subsequent analyses supported revised substaging of stage III as a result of improved survival with T1-2N2 versus T3-4N2 and survival of T4N1 more similar to T3-4N2 than T3N1. The AJCC Hindgut Taskforce sought population-based validation that depth of invasion interacts with nodal status to affect survival. METHODS Surveillance, Epidemiology, and End Results (SEER) population-based data from January 1992 to December 2004 for 35,829 patients with rectal cancer were compared with rectal pooled analysis data (3,791 patients). T4N0 cancers were stratified by tumors that perforate visceral peritoneum (T4a) versus tumors that invade or are adherent to adjacent organs or structures (T4b). N1 and N2 were stratified by number of positive nodes as follows: N1a/N1b (one v two to three nodes) and N2a/N2b (four to six v > or = seven nodes). Five-year observed and relative survival rates were obtained for each TN category. RESULTS SEER rectal cancer analyses confirm that T1-2N2 cancers have better prognosis than T3-4N2, T4bN1 have similar prognosis to T4N2, T1-2N1 have similar prognosis to T2N0/T3N0, and T1-2N2a have similar prognosis to T2N0/T3N0 (T1N2a) or T4aN0 (T2N2a). Prognosis for T4a lesions is better than T4b by N category. The number of positive nodes affects prognosis. CONCLUSION This SEER population-based rectal cancer analysis validates the rectal pooled analyses and supports the shift of T1-2N2 lesions from IIIC to IIIA or IIIB and T4bN1 from IIIB to IIIC. SEER outcomes support subdividing T4, N1, and N2 and revised substaging of stages II and III. Survival by TN category suggests a complex biologic interaction between depth of invasion and nodal status.
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Affiliation(s)
- Leonard L Gunderson
- Mayo Clinic Cancer Center-Arizona, 13400 East Shea Blvd, Scottsdale, AZ 85259, USA.
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Brophy S, Sheehan KM, McNamara DA, Deasy J, Bouchier-Hayes DJ, Kay EW. GLUT-1 expression and response to chemoradiotherapy in rectal cancer. Int J Cancer 2009; 125:2778-82. [PMID: 19569052 DOI: 10.1002/ijc.24693] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Preoperative chemoradiotherapy is used in locally advanced rectal cancer to reduce local recurrence and improve operability, however a proportion of tumors do not undergo significant regression. Identification of predictive markers of response to chemoradiotherapy would improve patient selection and may allow response modification by targeting of specific pathways. The aim of this study was to determine whether expression of glucose transporter-1 (GLUT-1) and p53 in pretreatment rectal cancer biopsies was predictive of tumor response to chemoradiotherapy. Immunohistochemical staining for GLUT-1 and p53 was performed on 69 pretreatment biopsies and compared to tumor response in the resected specimen as determined by the tumor regression grade (TRG) scoring system. GLUT-1 expression was significantly associated with reduced response to chemoradiotherapy and increasing GLUT expression correlated with poorer response (p=0.02). GLUT-1 negative tumors had a 70% probability of good response (TRG3/4) compared to a 31% probability of good response in GLUT-1 positive tumors. GLUT-1 may be a useful predictive marker of response to chemoradiotherapy in rectal cancer.
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Affiliation(s)
- Sarah Brophy
- Department of Surgery, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin, Ireland.
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Neoadjuvant therapy for advanced rectal carcinoma in China: Whether radiochemotherapy is superior to radiotherapy? Chin J Cancer Res 2009. [DOI: 10.1007/s11670-009-0295-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Berardi R, Maccaroni E, Onofri A, Giampieri R, Pistelli M, Bittoni A, Scartozzi M, Pierantoni C, Mandolesi A, Bearzi I, Cascinu S. Locally advanced rectal cancer: from molecular profiling to clinical practice. A literature review: Part 2. Expert Opin Pharmacother 2009; 10:2467-78. [PMID: 19761354 DOI: 10.1517/14656560903143784] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Colorectal cancer is the third most common cause of cancer deaths worldwide. The management of rectal cancer has undergone, and continues to undergo, significant evolutions. In the last two decades, new multimodality strategies have been developed. The ability to predict tumor response before treatment could significantly impact the selection of patients for preoperative combined-modality therapy, as well as potentially modify postoperative treatment plans. The present review analyzes the new molecular targets that could be involved in predicting response and prognosis.
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Affiliation(s)
- Rossana Berardi
- Università Politecnica delle Marche, Azienda Ospedaliero-Universitaria Ospedali Riuniti Umberto I, GM Lancisi - G Salesi di Ancona, Medical Oncology Unit, 60020 Ancona, Italy.
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Kim TH, Chang HJ, Kim DY, Jung KH, Hong YS, Kim SY, Park JW, Oh JH, Lim SB, Choi HS, Jeong SY. Pathologic nodal classification is the most discriminating prognostic factor for disease-free survival in rectal cancer patients treated with preoperative chemoradiotherapy and curative resection. Int J Radiat Oncol Biol Phys 2009; 77:1158-65. [PMID: 19800178 DOI: 10.1016/j.ijrobp.2009.06.019] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2009] [Revised: 06/01/2009] [Accepted: 06/09/2009] [Indexed: 02/07/2023]
Abstract
PURPOSE We retrospectively evaluated the effects of clinical and pathologic factors on disease-free survival (DFS) with the aim of identifying the most discriminating factor predicting DFS in rectal cancer patients treated with preoperative chemoradiotherapy (CRT) and curative resection. METHODS AND MATERIALS The study involved 420 patients who underwent preoperative CRT and curative resection between August 2001 and October 2006. Gender, age, distance from the anal verge, histologic type, histologic grade, pretreatment carcinoembryonic antigen (CEA) level, cT, cN, cStage, circumferential resection margin, type of surgery, preoperative chemotherapy, adjuvant chemotherapy, ypT, ypN, ypStage, and tumor regression grade (TRG) were analyzed to identify prognostic factors associated with DFS. To compare the discriminatory prognostic ability of four tumor response-related pathologic factors (ypT, ypN, ypStage, and TRG), the Akaike information criteria were calculated. RESULTS The 5-year DFS rate was 75.4%. On univariate analysis, distance from the anal verge, histologic type, histologic grade, pretreatment CEA level, cT, circumferential resection margin, type of surgery, preoperative chemotherapeutic regimen, ypT, ypN, ypStage, and TRG were significantly associated with DFS. Multivariate analysis showed that the four parameters ypT, ypN, ypStage, and TRG were, consistently, significant prognostic factors for DFS. The ypN showed the lowest Akaike information criteria value for DFS, followed by ypStage, ypT, and TRG, in that order. CONCLUSION In our study, ypT, ypN, ypStage, and TRG were important prognostic factors for DFS, and ypN was the most discriminating factor.
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Affiliation(s)
- Tae Hyun Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
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Tumor volume changes assessed by three-dimensional magnetic resonance volumetry in rectal cancer patients after preoperative chemoradiation: the impact of the volume reduction ratio on the prediction of pathologic complete response. Int J Radiat Oncol Biol Phys 2009; 76:1018-25. [PMID: 19647949 DOI: 10.1016/j.ijrobp.2009.03.066] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2008] [Revised: 03/09/2009] [Accepted: 03/09/2009] [Indexed: 01/11/2023]
Abstract
PURPOSE The aim of this study was to determine the correlation between tumor volume changes assessed by three-dimensional (3D) magnetic resonance (MR) volumetry and the histopathologic tumor response in rectal cancer patients undergoing preoperative chemoradiation therapy (CRT). METHODS AND MATERIALS A total of 84 patients who underwent preoperative CRT followed by radical surgery were prospectively enrolled in the study. The post-treatment tumor volume and tumor volume reduction ratio (% decrease ratio), as shown by 3D MR volumetry, were compared with the histopathologic response, as shown by T and N downstaging and the tumor regression grade (TRG). RESULTS There were no significant differences in the post-treatment tumor volume and the volume reduction ratio shown by 3D MR volumetry with respect to T and N downstaging and the tumor regression grade. In a multivariate analysis, the tumor volume reduction ratio was not significantly associated with T and N downstaging. The volume reduction ratio (>75%, p = 0.01) and the pretreatment carcinoembryonic antigen level (< or =3 ng/ml, p = 0.01), but not the post-treatment volume shown by 3D MR (< or = 5 ml), were, however, significantly associated with an increased pathologic complete response rate. CONCLUSION More than 75% of the tumor volume reduction ratios were significantly associated with a high pathologic complete response rate. Therefore, limited treatment options such as local excision or simple observation might be considered after preoperative CRT in this patient population.
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Baatrup G, Endreseth BH, Isaksen V, Kjellmo Ä, Tveit KM, Nesbakken A. Preoperative staging and treatment options in T1 rectal adenocarcinoma. Acta Oncol 2009; 48:328-42. [PMID: 19180365 DOI: 10.1080/02841860802657243] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Major rectal resection for T1 rectal cancer offers more than 95% cancer specific five-year survival to patients surviving the first 30 days after surgery. A significant further improvement by development of the surgical technique may not be possible. Improvements in the total survival rate have to come from a more differentiated treatment modality, taking patient and procedure related risk factors into account. Subgroups of patients have operative mortality risks of 10% or more. Operative complications and long-term side effects after rectum resection are frequent and often severe. RESULTS Local treatment of T1 cancers combined with close follow-up, early salvage surgery or later radical resection of local recurrences or with chemo-radiation may lead to fewer severe complications and comparable, or even better, long-term survival. Accurate preoperative staging and careful selection of patients for local or non-operative treatment are mandatory. As preoperative staging, at present, is not sufficiently accurate, strategies for completion, salvage or rescue surgery is important, and must be accepted by the patient before local treatment for cure is initiated. RECOMMENDATIONS It is recommended that polyps with low-risk T1 cancers should be treated with endoscopic snare resection in case of Haggitt's stage 1 or 2. TEM is recommended if resection margins are uncertain after snare resection for Haggitt's stage 3 and 4, and for sessile and flat, low-risk T1 cancers. Average risk patients with high-risk T1 cancers should be offered rectum resection, but old and comorbid patients with high-risk T1 cancers should be treated individually according to objective criteria as age, physical performance as well as patient's preference. All patients treated for cure with local resection or non-surgical methods should be followed closely.
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Berho M, Oviedo M, Stone E, Chen C, Nogueras J, Weiss E, Sands D, Wexner S. The correlation between tumour regression grade and lymph node status after chemoradiation in rectal cancer. Colorectal Dis 2009; 11:254-8. [PMID: 18513188 DOI: 10.1111/j.1463-1318.2008.01597.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To determine the correlation between tumour response to preoperative RCTX and lymph node status, an established parameter of clinical outcome. METHOD After IRB approval, 86 consecutive rectal cancer patients who received preoperative RCTX were identified. Fifty seven were males. Mean age 62 years. Preoperative staging by ultrasound was available in 60 patients. Radiotherapy consisted of (40-60 g) and chemotherapy of 5-FU infusion (1500 mg/m(2) week), assessed using Dworak's system. RESULTS Tumour response according to Tumor regression grade (TRG) were: TRG 0: 8 (9.3%); TRG 1: 15 (17.4%); TRG 2: 14 (16.2%); TRG 3: 31 (36%); TRG 4: 18 (20%). Eighteen patients had tumour stage 0 (20.9%); while 8 (9.2%), 28 (32.1%), 30 (34.5%) and three had tumours stages 1, 2, 3 and 4 respectively. Evaluation of nodal status revealed no involvement in 65 patients (N0), and positive nodes in 21 (14 N1, 7 N2). Response to RCTX was significantly associated with node stage, hence individuals without node involvement (N0) had 66% of positive tumour response (TRG 4), while individuals with node metastasis had less response to RCTX (TRG 0, 1 and 2) 35% N1 and 14% for N2 (P = 0.007). Node status was independently associated to poor response to preoperative RCTX, even after adjusting for tumour stage, age and gender (OR 0.02, 95% CI 0.0009-0.67). CONCLUSION Tumour shrinkage by preoperative RCTX appears to correlate with lymph node metastasis suggesting that neoadjuvant RCTX may have a positive impact in overall patient survival.
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Affiliation(s)
- M Berho
- Department of Pathology, Cleveland Clinic Florida, Weston, Florida 33331, USA
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Liauw SL, Minsky BD. The use of capecitabine in the combined-modality therapy for rectal cancer. Clin Colorectal Cancer 2008; 7:99-104. [PMID: 18501068 DOI: 10.3816/ccc.2008.n.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Locally advanced rectal adenocarcinoma is treated by combined-modality therapy, which consists of surgery, chemotherapy, and radiation therapy. A series of randomized trials established a preferred treatment sequence of preoperative radiation therapy and 5-fluorouracil(5-FU)-based chemotherapy, total mesorectal excision, and adjuvant 5-FU-based chemotherapy for patients with stage II/III disease. Capecitabine is an oral prodrug of 5-FU that has potential advantages compared with intravenous 5-FU, including ease of administration and potentially increased therapeutic effect. Capecitabine is converted by a 3-step enzymatic process; the last step involves the enzyme thymidine phosphorylase, which is overexpressed in tumor tissues and is stimulated by concurrent radiation therapy. Over the past 5 years, several phase I/II trials of capecitabine-based therapy were reported. This review discusses the evolution of combined-modality therapy for rectal cancer with specific attention given to the use of capecitabine in conjunction with radiation therapy.
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Affiliation(s)
- Stanley L Liauw
- Department of Radiation and Cellular Oncology, University of Chicago Hospitals, Chicago, IL 60637, USA.
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Brændengen M, Tveit KM, Berglund Å, Birkemeyer E, Frykholm G, Påhlman L, Wiig JN, Byström P, Bujko K, Glimelius B. Randomized Phase III Study Comparing Preoperative Radiotherapy With Chemoradiotherapy in Nonresectable Rectal Cancer. J Clin Oncol 2008; 26:3687-94. [DOI: 10.1200/jco.2007.15.3858] [Citation(s) in RCA: 342] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PurposePreoperative chemoradiotherapy is considered standard treatment for locally advanced rectal cancer, although the scientific evidence for the chemotherapy addition is limited. This trial investigated whether chemotherapy as part of a multidisciplinary treatment approach would improve downstaging, survival, and relapse rate.Patients and MethodsThe randomized study included 207 patients with locally nonresectable T4 primary rectal carcinoma or local recurrence from rectal carcinoma in the period 1996 to 2003. The patients received either chemotherapy (fluorouracil/leucovorin) administered concurrently with radiotherapy (50 Gy) and adjuvant for 16 weeks after surgery (CRT group, n = 98) or radiotherapy alone (50 Gy; RT group, n = 109).ResultsThe two groups were well balanced according to pretreatment characteristics. An R0 resection was performed in 82 patients (84%) in the CRT group and in 74 patients (68%) in the RT group (P = .009). Pathologic complete response was seen in 16% and 7%, respectively. After an R0 + R1 resection, local recurrence was found in 5% and 7%, and distant metastases in 26% and 39%, respectively. Local control (82% v 67% at 5 years; log-rank P = .03), time to treatment failure (63% v 44%; P = .003), cancer-specific survival (72% v 55%; P = .02), and overall survival (66% v 53%; P = .09) all favored the CRT group. Grade 3 or 4 toxicity, mainly GI, was seen in 28 (29%) of 98 and six (6%) of 109, respectively (P = .001). There was no difference in late toxicity.ConclusionCRT improved local control, time to treatment failure, and cancer-specific survival compared with RT alone in patients with nonresectable rectal cancer. The treatments were well tolerated.
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Affiliation(s)
- Morten Brændengen
- From the Departments of Medical Oncology and Surgery, Norwegian Radium Hospital; Ullevål University Hospital, Cancer Centre, Oslo, Norway; University of Oslo, Oslo; Division of Hematology and Oncology, Stavanger University Hospital, Stavanger; Department of Oncology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway; Department of Oncology and Pathology, Karolinska Institutet, Stockholm; Department of Oncology, Radiology, and Clinical Immunology, University of Uppsala; Department of
| | - Kjell M. Tveit
- From the Departments of Medical Oncology and Surgery, Norwegian Radium Hospital; Ullevål University Hospital, Cancer Centre, Oslo, Norway; University of Oslo, Oslo; Division of Hematology and Oncology, Stavanger University Hospital, Stavanger; Department of Oncology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway; Department of Oncology and Pathology, Karolinska Institutet, Stockholm; Department of Oncology, Radiology, and Clinical Immunology, University of Uppsala; Department of
| | - Åke Berglund
- From the Departments of Medical Oncology and Surgery, Norwegian Radium Hospital; Ullevål University Hospital, Cancer Centre, Oslo, Norway; University of Oslo, Oslo; Division of Hematology and Oncology, Stavanger University Hospital, Stavanger; Department of Oncology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway; Department of Oncology and Pathology, Karolinska Institutet, Stockholm; Department of Oncology, Radiology, and Clinical Immunology, University of Uppsala; Department of
| | - Elke Birkemeyer
- From the Departments of Medical Oncology and Surgery, Norwegian Radium Hospital; Ullevål University Hospital, Cancer Centre, Oslo, Norway; University of Oslo, Oslo; Division of Hematology and Oncology, Stavanger University Hospital, Stavanger; Department of Oncology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway; Department of Oncology and Pathology, Karolinska Institutet, Stockholm; Department of Oncology, Radiology, and Clinical Immunology, University of Uppsala; Department of
| | - Gunilla Frykholm
- From the Departments of Medical Oncology and Surgery, Norwegian Radium Hospital; Ullevål University Hospital, Cancer Centre, Oslo, Norway; University of Oslo, Oslo; Division of Hematology and Oncology, Stavanger University Hospital, Stavanger; Department of Oncology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway; Department of Oncology and Pathology, Karolinska Institutet, Stockholm; Department of Oncology, Radiology, and Clinical Immunology, University of Uppsala; Department of
| | - Lars Påhlman
- From the Departments of Medical Oncology and Surgery, Norwegian Radium Hospital; Ullevål University Hospital, Cancer Centre, Oslo, Norway; University of Oslo, Oslo; Division of Hematology and Oncology, Stavanger University Hospital, Stavanger; Department of Oncology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway; Department of Oncology and Pathology, Karolinska Institutet, Stockholm; Department of Oncology, Radiology, and Clinical Immunology, University of Uppsala; Department of
| | - Johan N. Wiig
- From the Departments of Medical Oncology and Surgery, Norwegian Radium Hospital; Ullevål University Hospital, Cancer Centre, Oslo, Norway; University of Oslo, Oslo; Division of Hematology and Oncology, Stavanger University Hospital, Stavanger; Department of Oncology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway; Department of Oncology and Pathology, Karolinska Institutet, Stockholm; Department of Oncology, Radiology, and Clinical Immunology, University of Uppsala; Department of
| | - Per Byström
- From the Departments of Medical Oncology and Surgery, Norwegian Radium Hospital; Ullevål University Hospital, Cancer Centre, Oslo, Norway; University of Oslo, Oslo; Division of Hematology and Oncology, Stavanger University Hospital, Stavanger; Department of Oncology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway; Department of Oncology and Pathology, Karolinska Institutet, Stockholm; Department of Oncology, Radiology, and Clinical Immunology, University of Uppsala; Department of
| | - Krzysztof Bujko
- From the Departments of Medical Oncology and Surgery, Norwegian Radium Hospital; Ullevål University Hospital, Cancer Centre, Oslo, Norway; University of Oslo, Oslo; Division of Hematology and Oncology, Stavanger University Hospital, Stavanger; Department of Oncology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway; Department of Oncology and Pathology, Karolinska Institutet, Stockholm; Department of Oncology, Radiology, and Clinical Immunology, University of Uppsala; Department of
| | - Bengt Glimelius
- From the Departments of Medical Oncology and Surgery, Norwegian Radium Hospital; Ullevål University Hospital, Cancer Centre, Oslo, Norway; University of Oslo, Oslo; Division of Hematology and Oncology, Stavanger University Hospital, Stavanger; Department of Oncology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway; Department of Oncology and Pathology, Karolinska Institutet, Stockholm; Department of Oncology, Radiology, and Clinical Immunology, University of Uppsala; Department of
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Quah HM, Chou JF, Gonen M, Shia J, Schrag D, Saltz LB, Goodman KA, Minsky BD, Wong WD, Weiser MR. Pathologic stage is most prognostic of disease-free survival in locally advanced rectal cancer patients after preoperative chemoradiation. Cancer 2008; 113:57-64. [PMID: 18442099 DOI: 10.1002/cncr.23516] [Citation(s) in RCA: 180] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Preoperative chemoradiation is the standard treatment for locally advanced rectal cancer. However, it is uncertain whether pretreatment clinical stage, degree of response to neoadjuvant treatment, or pathologic stage is the most reliable predictor of outcome. This study compared various staging elements and treatment-related variables to identify which factors or combination of factors reliably prognosticates disease-free survival in rectal cancer patients receiving neoadjuvant combined modality therapy. METHODS From a prospectively maintained single institution database, 342 consecutive patients with locally advanced rectal cancer staged by endorectal ultrasound were identified. Patients underwent rectal resection 4 to 8 weeks after a 5.5-week course of pelvic radiotherapy/concurrent chemotherapy. The degree of tumor regression was histologically graded on each resected specimen using a previously reported response scale of 0% to 100%. Predictive models of disease-free survival were created utilizing available pretherapy and postoperative staging elements in addition to the degree of tumor regression noted histologically. Model accuracy was measured and compared by concordance index, with 95% confidence interval (CI). RESULTS Stratifying patients by degree of tumor regression predicted outcome with a concordance index of 0.65 (95% CI, 0.59-0.71), which was significantly better than models using preoperative stage elements (concordance index of 0.54; 95% CI, 0.50-0.58). However, the model found to be most predictive of disease-free survival stratified patients by final pathologic T classification and N classification elements, with a concordance index of 0.75 (95% CI, 0.70-0.80). CONCLUSIONS Tumor response to preoperative therapy is a strong predictor of disease-free survival. However, outcome is most accurately estimated by final pathologic stage, which is influenced by both preoperative stage and response to therapy.
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Affiliation(s)
- Hak-Mien Quah
- Department of Colorectal Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
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69
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Nakagawa K, Yamashita H, Nakamura N, Igaki H, Tago M, Hosoi Y, Momose T, Ohtomo K, Muto T, Nagawa H. Preoperative radiation response evaluated by 18-fluorodeoxyglucose positron emission tomography predicts survival in locally advanced rectal cancer. Dis Colon Rectum 2008; 51:1055-60. [PMID: 18449608 DOI: 10.1007/s10350-008-9243-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2007] [Revised: 09/10/2007] [Accepted: 10/17/2007] [Indexed: 02/08/2023]
Abstract
PURPOSE This study focuses on the prognostic survival value of postirradiation metabolic activity in primary rectal cancer as measured with 18-fluorodeoxyglucose positron emission tomography. METHODS From July 1995 to March 2002, all 59 patients underwent two series of fluorodeoxyglucose positron emission tomography: one before preoperative radiation (standardized uptake values-1), and the other two to three weeks after radiation (standardized uptake values-2). Standardized uptake values-1 and standardized uptake values-2 correspond to before and after radiation, respectively. RESULTS In univariate analysis, the following emerged as significant prognostic variables: with or without residual tumor, pathologic differentiation, with or without recurrence, standardized uptake values-2, and with or without lymph node metastases. In multivariate analysis, residual tumor and standardized uptake values-2 were significant prognostic factors for survival. The median survival and the five-year overall survival rate comparing standardized uptake values-2 values <5 vs. >5 were 95 vs. 42 months and 70 vs. 44 percent, respectively (P = 0.042). CONCLUSION A significant survival benefit was observed in patients with low fluorodeoxyglucose uptake after preoperative radiotherapy in primary tumors of rectal cancer.
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Affiliation(s)
- Keiichi Nakagawa
- Department of Radiology, University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
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Capirci C, Valentini V, Cionini L, De Paoli A, Rodel C, Glynne-Jones R, Coco C, Romano M, Mantello G, Palazzi S, Mattia FO, Friso ML, Genovesi D, Vidali C, Gambacorta MA, Buffoli A, Lupattelli M, Favretto MS, La Torre G. Prognostic value of pathologic complete response after neoadjuvant therapy in locally advanced rectal cancer: long-term analysis of 566 ypCR patients. Int J Radiat Oncol Biol Phys 2008; 72:99-107. [PMID: 18407433 DOI: 10.1016/j.ijrobp.2007.12.019] [Citation(s) in RCA: 334] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2007] [Revised: 12/10/2007] [Accepted: 12/10/2007] [Indexed: 12/14/2022]
Abstract
PURPOSE In the literature, a favorable prognosis was observed for complete pathologic response after preoperative therapy (ypCR) in patients with locally advanced rectal cancer. The aim of this study is to verify whether ypCR predicts a favorable outcome in a large series of patients. METHODS AND MATERIALS The Gastro-Intestinal Working Group of the Italian Association of Radiation Oncology collected clinical data for 566 patients with ypCR (ypT0N0) after neoadjuvant therapy. Eligibility criteria included locally advanced rectal cancer with no evidence of metastases at the time of diagnosis, evidence of ypCR after preoperative radiotherapy +/- chemotherapy (CT). RESULTS Median radiation dose was 50 Gy. A total of 527 patients (93%) received one of 12 different neoadjuvant CT schedules. Sphincter preservation, anteroposterior resection, and endoscopic surgery were performed in 73%, 22%, and 5% of patients, respectively. Adjuvant CT was administered to 22% of patients. Median follow-up was 46.4 months. Locoregional recurrence occurred in 7 patients (1.6%). Distant metastases occurred in 49 patients (8.9%). Overall, 5-year rates of disease-free survival, overall survival, and cancer-specific survival were 85%, 90%, and 94%, respectively. In multivariate analysis, only age and clinical stage statistically correlated with survival outcome. Adjuvant CT was still of borderline significance (worse for adjuvant CT). No relation was found between survival and neoadjuvant CT schedules. CONCLUSION A ypCR after neoadjuvant therapy identified a favorable group of patients, even in this large series of 566 patients collected in 61 centers. Locoregional recurrence occurred only in 1.6% patients.
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Affiliation(s)
- Carlo Capirci
- Department of Radiotherapy, State Hospital, Rovigo, Italy.
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71
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Coco C, Manno A, Mattana C, Verbo A, Rizzo G, Valentini V, Gambacorta MA, Vecchio FM, D'Ugo D. The role of local excision in rectal cancer after complete response to neoadjuvant treatment. Surg Oncol 2007; 16 Suppl 1:S101-4. [PMID: 18023178 DOI: 10.1016/j.suronc.2007.10.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Correlation between pathological response of primary tumour and mesorectal lymph node involvement was prospectively evaluated to assess the role of local excision (LE) in rectal cancer after complete response to neoadjuvant treatment. A series of 272 consecutive rectal cancer, submitted to neoadjuvant radiochemotherapy (RCT) and surgery with total mesorectal excision (TME) were analysed. Tumour downstaging (pT) and tumour regression grade (TRG) together with sex, age, location of the tumour, pre-treatment clinical stage, type of chemoradiation and operation performed entered in an univariate and multivariate analysis. Pathological complete response on primary tumour was found in 56 patients (20.6%). Lymph node metastases were found in 72 patients (26.5%). The rate of positive nodes was 1.8% for pT0 and TRG1 cases, respectively, to go up to 6.3% for pT1 and 24.1% for TRG 2 cases, respectively. At the univariate analysis, factors with a statistically significant correlation with the risk of lymph node metastasis were: clinical pre-treatment N stage (p<0.05), pT stage (p<0.001) and TRG (p<0.001). At the multivariate analysis, the best predictors of pathologic lymph node involvement were pT stage (p=0.0013 ) and TRG (p=0.0011). Because LE is an adequate technique to assess the tumour pathological response and nodal involvement in pT0 or TRG1 cases seems extremely infrequent, radical resection is probably not justified after pathological complete response. Prospective randomized trials are necessary to establish if, in these cases, LE can guarantee the same oncologic results offered by the currently adopted protocols of RCT followed by radical resections.
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Affiliation(s)
- C Coco
- Department of Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
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72
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Deutsch E, Ezra P, Mangoni M, Ducreux M. Radiotherapy for localized rectal cancer. Ann Oncol 2007; 18 Suppl 9:ix105-13. [PMID: 17631562 DOI: 10.1093/annonc/mdm304] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- E Deutsch
- Department of Radiation Therapy Institut Gustave Roussy, Villejuif, France
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Aschele C, Lonardi S. Multidisciplinary treatment of rectal cancer: medical oncology. Ann Oncol 2007; 18 Suppl 9:ix114-21. [PMID: 17631563 DOI: 10.1093/annonc/mdm305] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Affiliation(s)
- C Aschele
- Department of Medical Oncology, E. O. Ospedali Galliera, Genova
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Aschele C, Lonardi S. Corrections to “Multidisciplinary treatment of rectal cancer: medical oncology”. Ann Oncol 2007; 18:1908-15. [DOI: 10.1093/annonc/mdm478] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Grillo-Ruggieri F, Mantello G, Berardi R, Cardinali M, Fenu F, Iovini G, Montisci M, Fabbietti L, Marmorale C, Guerrieri M, Saba V, Bearzi I, Mattioli R, Bonsignori M, Cascinu S. Mucinous rectal adenocarcinoma can be associated to tumor downstaging after preoperative chemoradiotherapy. Dis Colon Rectum 2007; 50:1594-603. [PMID: 17846841 DOI: 10.1007/s10350-007-9026-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE The aim of this study was to evaluate downstaging as primary end point, and progression-free survival and overall survival as secondary end points, in rectal adenocarcinoma patients treated with preoperative chemoradiation. METHODS One hundred and thirty-six extraperitoneal adenocarcinoma patients (33 low rectum T2, 74 T3, 29 T4 [without sacral invasion], 25 with mucinous subtype) were treated with posterior pelvis preoperative radiotherapy (5040 cGy total dose, 180 cGy/fr, 5 fr/w, 10-15 MV linac X-rays) and concomitant 5-fluorouracil-based chemotherapy. After 6 to 8 weeks patients underwent surgery and prechemoradiation clinical stage was compared with pathologic stage to evaluate downstaging in each patient. Seventy-four patients received adjuvant chemotherapy. Median follow-up was 39 months (4-84). RESULTS Forty-four patients had macroscopic complete response, 52 patients had partial response, 37 patients showed no change and 3 patients had progression. At multivariate analysis only histotype showed correlation with downstaging (hazard ratio = 0.350 and 0.138 - 0.885 95 percent confidence interval) because of the evidence for poor downstaging in mucinous subtype. There were no significant differences in overall survival and progression-free survival between adenocarcinoma and mucinous subtype. CONCLUSIONS The main finding is that mucinous histology is associated with poor downstaging after preoperative chemoradiation but this poor response was not associated with worse outcome in this small study. The good outcome for mucinous histology is at odds with other reports in the literature and requires further study.
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Affiliation(s)
- Filippo Grillo-Ruggieri
- Dipartimento di Oncologia e Radioterapia Generale, Azienda Ospedaliero Universitaria Ospedali Riuniti, Ancona, Italy.
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Vuong T, Devic S, Podgorsak E. High dose rate endorectal brachytherapy as a neoadjuvant treatment for patients with resectable rectal cancer. Clin Oncol (R Coll Radiol) 2007; 19:701-5. [PMID: 17714925 DOI: 10.1016/j.clon.2007.07.006] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2006] [Accepted: 07/15/2007] [Indexed: 12/25/2022]
Abstract
In the era of total mesorectal surgery, the issue of radiation toxicity is raised. A novel endocavitary brachytherapy technique was tested as a neoadjuvant treatment for patients with resectable rectal cancer. The objectives of the study were to evaluate the treatment-related toxicity and effects on local recurrence. A dose of 26 Gy was prescribed to the gross tumour volume and intramesorectal deposits seen on magnetic resonance imaging and given over four daily treatments, using the high dose rate delivery system followed by surgery 6-8 weeks later. The study included 93 T3, four T4 and three T2 tumours. Acute proctitis of grade 2 was observed in all patients, but one required transfusion. At a median follow-up time of 60 months, the 5-year actual local recurrence rate was 5%, disease-free survival was 65%, and overall survival was 70%. High dose rate endorectal brachytherapy seems to prevent local recurrence and has a favourable toxicity pattern compared with external beam radiotherapy.
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Affiliation(s)
- T Vuong
- Department of Radiation Oncology, McGill University Health Centre, Montreal, Quebec, Canada.
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Nabhan C, Ragam A, Samuels B, Milton DT, Prasad L, Hooberman A, Hartsell W, Anthony A, Weisman R, Bitran JD. Mitomycin-C/5-fluorouracil/leucovorin and hyperfractionated radiation therapy for rectal carcinoma: a phase II study with long-term follow-up. Clin Colorectal Cancer 2007; 6:436-41. [PMID: 17531107 DOI: 10.3816/ccc.2007.n.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE Preoperative chemotherapy followed by surgery and adjuvant chemotherapy is a standard treatment for most patients with rectal cancer. We aimed to determine efficacy and tolerability of preoperative mitomycin, fluorouracil (5-FU), and leucovorin (LV) concurrent with hyperfractionated radiation therapy (RT) followed by surgery and adjuvant chemotherapy. PATIENTS AND METHODS Patients with clinical stage II/III disease were treated with mitomycin 10 mg/m(2) on day 1, continuous venous infusion 5-FU 600 mg/m(2) per day for 96 hours, and oral LV 25 mg every 6 hours on days 1-5. All patients received concurrent RT in fractions of 150 cGy twice daily beginning on day 1. Unfixed tumors received 3000 cGy, whereas fixed tumors received a dose of 4500 cGy. Patients then underwent resection and postoperative adjuvant chemotherapy with oral LV and continuous venous infusion 5-FU 600 mg/m(2) per day on days 1-5 on a 28-day cycle for 6 cycles. Primary endpoints were to determine the rate of pathologic response and downstaging, long-term locoregional control, progression-free survival, and overall survival. RESULTS Between the years 1993 and 2000, 83 patients were enrolled. Eighteen patients (31%) were downstaged. Six patients (7%) had pathologic complete response. Median follow-up was 62 months with a 5-year overall survival of 71%. Local control rate was 96%. Treatment was well tolerated with stomatitis, diarrhea, and radiation proctitis being the most common toxicities. CONCLUSION This regimen is effective in the treatment of rectal carcinoma. The favorable toxicity profile of mitomycin and hyperfractionated RT allows these strategies to be utilized with the newer chemotherapies for this disease.
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Affiliation(s)
- Chadi Nabhan
- Department of Medicine, Division of Hematology/Oncology, Advocate Lutheran General Hospital and Cancer Care Center, Park Ridge, IL 60078, USA.
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Glynne-Jones R, Meadows H, Wood W. Chemotherapy or No Chemotherapy in Clear Margins after Neoadjuvant Chemoradiation in Locally Advanced Rectal Cancer: CHRONICLE. A Randomised Phase III Trial of Control vs. Capecitabine plus Oxaliplatin. Clin Oncol (R Coll Radiol) 2007; 19:327-9. [PMID: 17434299 DOI: 10.1016/j.clon.2007.03.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2007] [Accepted: 02/19/2007] [Indexed: 11/28/2022]
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Capirci C, Rampin L, Erba PA, Galeotti F, Crepaldi G, Banti E, Gava M, Fanti S, Mariani G, Muzzio PC, Rubello D. Sequential FDG-PET/CT reliably predicts response of locally advanced rectal cancer to neo-adjuvant chemo-radiation therapy. Eur J Nucl Med Mol Imaging 2007; 34:1583-93. [PMID: 17503039 DOI: 10.1007/s00259-007-0426-1] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2006] [Accepted: 02/12/2007] [Indexed: 12/27/2022]
Abstract
PURPOSE Prediction of rectal cancer response to preoperative, neo-adjuvant chemo-radiation therapy (CRT) provides the opportunity to identify patients in whom a major response is expected and who may therefore benefit from alternative surgical approaches. Traditional morphological imaging techniques are effective in defining tumour extension in the initial diagnostic and staging work-up, but perform poorly in distinguishing residual neoplastic tissue from scarring post CRT, when restaging the patient before surgery. Fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) is a promising tool for monitoring the effect of anti-tumour therapy. The aim of this study was to prospectively assess the value of sequential FDG-PET scans in predicting the response of locally advanced rectal cancer to neo-adjuvant CRT. METHODS Forty-four consecutive patients with locally advanced (cT3-4) primary rectal cancer and four patients with pelvic recurrence of rectal cancer were enrolled in this prospective study. Treatment consisted of external beam intensified radiotherapy (50 Gy to the posterior pelvis, 56 Gy to the tumour), chemotherapy (in most cases PVI 5-FU at 300 mg/m(2) per day) and, 8-10 weeks later, surgery with curative intent. All patients underwent FDG-PET/CT both before CRT and 5-6 weeks after completing CRT. One patient died before surgery because of acute myocardial infarction, and was therefore excluded from further analysis. Semi-quantitative measurements of FDG uptake (SUV(max)), absolute difference (DeltaSUV(max)) and percent SUV(max) difference (Response Index, RI) between pre- and post-CRT PET scans were considered. Results were correlated with pathological response, assessed both by histopathological staging of the surgical specimens (pTNM) and by the tumour regression grade (TRG) according to Mandard's criteria (patients with TRG1-2 being defined as responders and patients with TRG3-5 as non-responders). RESULTS Following neo-adjuvant CRT, of the 45 patients submitted to surgery, 23 (51.1%) were classified as responders according to Mandard's criteria (8 TRG1 and 15 TRG2), while the remaining 22 (48.9%) were non-responders (9 TRG3 and 13 TRG4-5). Considering all patients, the mean pre-CRT SUV(max) was 15.6, significantly higher than the mean value of 5.4 post CRT (p < 0.001). Nevertheless, when stratifying patients according to response to CRT (using Mandard's criteria), the mean RI was significantly higher in responders than in non-responders (75.9% versus 46.9%,p = 0.0015). Using a 66.2% SUV(max) decrease as the cut-off value (identified by ROC analysis) for defining response to therapy, the following parameters were obtained: 79.2% specificity, 81.2% sensitivity, 77% positive predictive value, 89% negative predictive value and 80% overall accuracy. CONCLUSION The results suggest the potential utility of FDG-PET as a complementary diagnostic and prognostic procedure in the assessment of neo-adjuvant CRT response of locally advanced rectal cancer. DeltaSUV(max) and RI seem the best predictors of CRT response.
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Affiliation(s)
- Carlo Capirci
- Division of Radiotherapy, S. Maria della Misericordia Hospital, Rovigo, Italy
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Bertolini F, Bengala C, Losi L, Pagano M, Iachetta F, Dealis C, Jovic G, Depenni R, Zironi S, Falchi AM, Luppi G, Conte PF. Prognostic and predictive value of baseline and posttreatment molecular marker expression in locally advanced rectal cancer treated with neoadjuvant chemoradiotherapy. Int J Radiat Oncol Biol Phys 2007; 68:1455-61. [PMID: 17445998 DOI: 10.1016/j.ijrobp.2007.02.018] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2006] [Revised: 02/12/2007] [Accepted: 02/13/2007] [Indexed: 12/20/2022]
Abstract
PURPOSE To evaluate expression of a panel of molecular markers, including p53, p21, MLH1, MSH2, MIB-1, thymidylate synthase, epidermal growth factor receptor (EGFR), and tissue vascular endothelial growth factor (VEGF), before and after treatment in patients treated with neoadjuvant chemoradiotherapy for locally advanced rectal cancer, to correlate the constitutive profile and dynamics of expression with pathologic response and outcome. METHODS AND MATERIALS Expression of biomarkers was evaluated by immunohistochemistry in tumor samples from 91 patients with clinical Stage II and III rectal cancer treated with preoperative pelvic radiotherapy (50 Gy) plus concurrent 5-fluorouracil by continuous intravenous infusion. RESULTS A pathologic complete remission was observed in 14 patients (15.4%). Patients with MLH1-positive tumors had a higher pathologic complete response rate (24.3% vs. 9.4%; p = 0.055). Low expression of constitutive p21, absence of EGFR expression after chemoradiotherapy, and high Dworak's tumor regression grade (TRG) were significantly associated with improved disease-free survival and overall survival. A high MIB-1 value after chemoradiotherapy was significantly associated with worse overall survival. Multivariate analysis confirmed the prognostic value of constitutive p21 expression as well as EGFR expression and MIB-1 value after chemoradiotherapy among patients not achieving TRG 3-4. CONCLUSIONS In our study, we observed the independent prognostic value of EGFR expression after chemoradiotherapy on disease-free survival. Moreover, our study suggests that a constitutive high p21 expression and a high MIB-1 value after neoadjuvant chemoradiotherapy treatment could predict worse outcome in locally advanced rectal cancer.
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Affiliation(s)
- Federica Bertolini
- Division of Medical Oncology, Department of Oncology and Hematology, University of Modena and Reggio Emilia, Modena, Italy.
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81
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Ghouti L, Portier G, Kirzin S, Guimbaud R, Lazorthes F. [Surgical treatment of recurrent locoregional rectal cancer]. ACTA ACUST UNITED AC 2007; 31:55-67. [PMID: 17273131 DOI: 10.1016/s0399-8320(07)89326-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Local recurrence (LR) after curative surgery for rectal cancer occurs in 4 to 33% of cases especially if surgery is sub-optimal (without total excision of the mesorectum). In many cases, diagnosis of LR is made at a late stage because of the high rate of asymptomatic patients, 56% in the experience of the Mayo Clinic. MRI and PETscan are most effective for assessing local and general extension, with a high diagnostic accuracy. Surgical treatment alone or with radiation (preoperative and/or intraoperative) is the only curative treatment of LR with R0 resectability rates of 30% to 45%. Morbidity and mortality rates are high, especially for total exenteration and abdomino-sacral resection. After curative surgery, 5-year global survival is between 30% and 40%. Palliative resection of macroscopic residues is not recommended. Careful patient selection for curative surgery is the best way to optimize treatment in these cases.
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Affiliation(s)
- Laurent Ghouti
- Service de Chirurgie Digestive et Oncologique, Hôpital Purpan, Toulouse.
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82
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Glynne-Jones R, Mawdsley S, Pearce T, Buyse M. Alternative clinical end points in rectal cancer--are we getting closer? Ann Oncol 2007; 17:1239-48. [PMID: 16873440 DOI: 10.1093/annonc/mdl173] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND In rectal cancer a high risk of local recurrence has been reported for patients treated by surgery alone. It is also recognised that 20%-40% of rectal cancer patients continue to develop distant metastases and die, even when a very low risk of local recurrence has been achieved with the use of preoperative radiotherapy and total mesorectal excision (TME). Hence, the current design of randomised trials in rectal cancer continues to use the standard end points of local control and survival. This strategy is time-consuming. The recently published EORTC 22921 trial, which compared radiotherapy with chemoradiotherapy and tested the role of postoperative adjuvant chemotherapy, has taken 14 years from planning to results. The aim of this review was to use the evidence from both phase II and phase III trials to provide a comprehensive survey of alternative clinical trial end points in rectal cancer, where preoperative chemoradiation has now become the standard treatment. We describe their strengths and weaknesses. Some are clearly defined, easy to assess and can be obtained early, because surgical resection usually takes place within 6-8 weeks of the completion of treatment. Some pathological response end points reflect biological activity, although their effect on survival has yet to be validated in randomised controlled trials. We will propose measurement and analytical techniques for minimising bias and intra- and inter-observer variability of the non-validated end points in the hope of basing these judgements on as firm a ground as possible. METHODS A literature search identified both randomised and non-randomised trials of preoperative radiation therapy (RT) and chemoradiation therapy (CRT) in rectal cancer from 1993 to 2005. The aim was to find those studies that documented potential alternative end points. RESULTS Pathological parameters have been used as early end points to compare studies of preoperative radiotherapy or chemoradiation. In the light of the German CAO/ARO/AIO-94 study, which demonstrated an improved therapeutic ratio for preoperative treatment, enthusiasm for preoperative chemoradiation in the management of rectal cancer is increasing. Current evidence cannot indicate whether the degree of response to chemoradiation (e.g. complete pathological response; downsizing the primary tumour; sterilizing the regional nodes; tumour regression grades or residual cell density) or the achievement of a curative resection (CRM/R0 resection) is the best early clinical end point. Problems with these end points include lack of structured measurement and analysis techniques to control for intra- and inter-observer variation and lack of validation as surrogates for long-term clinical end points such as local control and survival. However, retrospective studies in rectal cancer have confirmed a strong association between the presence of microscopic tumour cells within 1 mm of the CRM and increased risks of both local recurrence and distant metastases. Further end points of current clinical relevance for which adequate methodologies for assessment are lacking include sphincter sparing end points, and assessment of long-term toxicities, ano-rectal function and their specific impact on quality of life. Recommendations are made as to the most appropriate information, which should be documented in future trials. CONCLUSIONS Pathological complete response following preoperative chemoradiation does not reliably predict late outcome. There are other events not mediated through this end point and there are also unintended effects (often an excess of non-cancer related deaths). Disease-free survival currently remains the best (because it is relatively quick) primary end point in designing randomised phase III studies of preoperative chemoradiation in rectal cancer, although it is necessary to control for postoperative adjuvant chemotherapy. However, the CRM status can substantially account for effects on disease-free and overall survival after chemoradiation, radiation or surgery alone. Hopefully, randomised controlled trials, which utilise these alternative clinical end points, will in future determine the precise percentages of the effect of different chemoradiation schedules on disease-free and overall survival.
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Affiliation(s)
- R Glynne-Jones
- Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, Middlesex, UK.
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83
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Yasui M, Ikeda M, Sekimoto M, Yamamoto H, Takemasa I, Ueda T, Shimizu J, Fukunaga M, Suzuki O, Inoue T, Monden M. Preliminary results of phase I trial of oral uracil/tegafur (UFT), leucovorin plus irinotecan and radiation therapy for patients with locally recurrent rectal cancer. World J Surg Oncol 2006; 4:83. [PMID: 17118210 PMCID: PMC1664567 DOI: 10.1186/1477-7819-4-83] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2006] [Accepted: 11/22/2006] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Surgical attempts for locally recurrent rectal cancer often fail due to local re-recurrence and distant metastasis. Preoperative chemoradiation may enhance better local control and survival. The aim of this study was to assess the safety of oral uracil and tegafur (UFT) plus leucovorin (LV), and irinotecan combined with radiation and determine the maximum-tolerated dose (MTD) and dose limiting toxicity (DLT) of the triple drug regimen. PATIENTS AND METHODS Patients with locally recurrent rectal cancer received escalating doses of irinotecan on days 1, 8, 15, and 22 (starting at 30 mg/m2, with 10 mg increments between consecutive cohorts) and fixed doses of UFT (300 mg/m2) plus LV (75 mg/day) on days 3 to 7, 10 to 14, 17 to 21, and 24 to 28. Radiation was given 5 days per week totaling 40 to 50 Gy (2Gy/day). RESULTS Six patients were treated at the starting dose, and 2 received the full scheduled chemoradiotherapy. The other 4 patients had grade 3 diarrhea and diarrhea was the DLT. One patient had partial response and he had subsequently radical surgical resection. Median progression free survival for local recurrence was 320 days. CONCLUSION Irinotecan plus UFT/LV with concomitant radiotherapy in patients with locally recurrent rectal cancer was not feasible due to diarrhea in this setting. Modification of the treatment is needed.
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Affiliation(s)
- Masayoshi Yasui
- Department of Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Masataka Ikeda
- Department of Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Mitsugu Sekimoto
- Department of Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Hirofumi Yamamoto
- Department of Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Ichiro Takemasa
- Department of Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Takafumi Ueda
- Department of Orthopeadics, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Junzo Shimizu
- Department of Surgery, Sakai Municipal Hospital, Osaka, Japan
| | | | - Osamu Suzuki
- Department of Radiation Oncology, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Takehiro Inoue
- Department of Radiation Oncology, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Morito Monden
- Department of Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
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84
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Bujko K, Michalski W, Kepka L, Nowacki MP, Nasierowska-Guttmejer A, Tokar P, Dymecki D, Pawlak M, Lesniak T, Richter P, Wojnar A, Chmielik E. Association between pathologic response in metastatic lymph nodes after preoperative chemoradiotherapy and risk of distant metastases in rectal cancer: An analysis of outcomes in a randomized trial. Int J Radiat Oncol Biol Phys 2006; 67:369-77. [PMID: 17118570 DOI: 10.1016/j.ijrobp.2006.08.065] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2006] [Revised: 07/27/2006] [Accepted: 08/26/2006] [Indexed: 12/14/2022]
Abstract
PURPOSE To compare 5 x 5 Gy preoperative radiotherapy with immediate surgery vs. preoperative chemoradiotherapy (50.4 Gy, 5-fluorouracil, leucovorin) with delayed surgery in a randomized trial for cT3-T4 low-lying rectal cancer. Despite the downstaging effect of chemoradiotherapy, similar long-term outcomes were observed in both groups. METHODS The Cox model was used to evaluate the prognostic value of ypTN ("yp" denotes that pathologic classification was performed after initial multimodality therapy) categories and the surgical margin status in 291 patients. RESULTS Disease-free survival (DFS) (hazard ratio [HR] 1.05, 95% confidence interval [CI], 0.73-1.51), distant metastases (HR, 1.17; 95% CI, 0.77-1.78), and local control (HR, 1.45; 95% CI, 0.74-2.84) were similar in both arms. The ypN status was the only independent prognostic factor for DFS (p < 0.001). An interaction (p = 0.016) between N stage and the assigned treatment was demonstrated. For ypN-negative patients, DFS was similar in both arms (HR, 0.83, 95% CI, 0.47-1.48); however, for ypN-positive patients, DFS was worse in the chemoradiotherapy arm (HR, 1.73; 95% CI, 1.07-2.77). The 4-year (median follow-up) DFS rate in N-positive patients was 51% in the 5 x 5-Gy arm vs. 25% in the chemoradiotherapy arm. The corresponding 4-year rates for the incidence of local recurrence and distant metastases were 14% vs. 27% (HR, 1.95; 95% CI, 0.78-4.86) and 38% vs. 68% (HR, 2.05; 95% CI, 1.21-3.48). CONCLUSION N-positive disease after chemoradiotherapy indicates radiochemoresistance. N-positive disease after 5 x 5 Gy RT includes both radiosensitive and radioresistant tumors, because the interval between radiotherapy and surgery was too short for radiosensitive cancer to undergo necrosis. Thus, the greater risk of distant metastases recorded in the chemoradiotherapy arm suggests that radiochemoresistance of nodal metastases from rectal cancer is associated with a high potential for developing distant metastases.
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Affiliation(s)
- Krzysztof Bujko
- Department of Radiotherapy, Maria Sklodowska-Curie Memorial Cancer Center, Warsaw, Poland.
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85
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Losi L, Luppi G, Gavioli M, Iachetta F, Bertolini F, D'Amico R, Jovic G, Bertoni F, Falchi AM, Conte PF. Prognostic value of Dworak grade of regression (GR) in patients with rectal carcinoma treated with preoperative radiochemotherapy. Int J Colorectal Dis 2006; 21:645-51. [PMID: 16317549 DOI: 10.1007/s00384-005-0061-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/17/2005] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIM Preoperative radiochemotherapy improves local control in locally advanced rectal cancer; however, its role in prolonging survival is still controversial. In order to better define the subset in patients who might benefit from this multimodal treatment, we have evaluated the correlation between grade of regression (GR) to preoperative treatment and disease-free survival (DFS). METHODS We reviewed retrospectively the surgical specimens of 106 patients with locally advanced T3/T4 N0/ M0 rectal cancer. All patients were treated preoperatively with radiotherapy and 5-fluorouracil-based regimen chemotherapy. We evaluated ypTNM stage, and tumor regression was graded using the Dworak system that varies from GR 0 (absence of regression) to GR 4 (complete regression). RESULTS GR was as follows: GR 4, 16 patients (15%); GR 3, 25 patients (23.6%), GR 2, 30 patients (28.4%), GR 1, 32 patients (30.2%) and GR 0, 3 patients (2.8%). A significant correlation was found between GR and DFS. Three-year DFS was 100, 85, 82, 66 and 33% in GR 4, 3, 2, 1 and 0, respectively (p=0.01). DFS was significantly lower in patients with advanced stages at diagnosis and in patients without down-staging. Moreover, in postoperative stage II and III cases, GR 3 correlated with a better DFS than GR 2-0 (p=0.2 and p=0.4, respectively). CONCLUSIONS The GR was a significant prognostic factor in locally advanced rectal carcinoma treated with preoperative chemoradiotherapy. The pathological stage and down-staging also have prognostic value. The use of a standardized system to evaluate GR in rectal cancer can allow for comparisons between different institutions and can identify patients at worse prognosis to be treated with adjuvant therapy.
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Affiliation(s)
- Lorena Losi
- Department of Pathology, University of Modena and Reggio Emilia, Modena, Italy.
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86
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Fietkau R, Barten M, Klautke G, Klar E, Ludwig K, Thomas H, Brinckmann W, Friedrich A, Prall F, Hartung G, Küchenmeister U, Kundt G. Postoperative chemotherapy may not be necessary for patients with ypN0-category after neoadjuvant chemoradiotherapy of rectal cancer. Dis Colon Rectum 2006; 49:1284-92. [PMID: 16758130 DOI: 10.1007/s10350-006-0570-x] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE After neoadjuvant radiochemotherapy and surgery, there is no general agreement about whether postoperative chemotherapy is necessary. With the help of clinical and pathohistologic data, prognostic factors were determined as a basis for the decision to spare a patient additional chemotherapy or to urgently recommend it. RESULTS Ninety-five patients treated with neoadjuvant 5-fluorouracil-based radiochemotherapy (November 4, 1997 and June 15, 2004) without distant metastases and an R0 (microscopically complete) resection were evaluated. Adjuvant chemotherapy (5-fluorouracil or 5-fluorouracil/folinic acid) was given to 65 of 95 patients (68.4 percent). The disease-free survival rate after 36 months was chosen as the target parameter (median follow-up, 36 months). METHODS The five-year survival rate for all patients was 80.3 +/- 5.6 percent; the five-year disease-free survival was 78.1 +/- 5.1 percent; the five-year local control rate was 94.2 +/- 5.1 percent. In the univariate and multivariate analysis of the disease-free survival, the pathohistologic lymph node status after radiochemotherapy (ypN) was the only significant prognostic parameter. Disease-free survival (36 months) for patients without lymph node metastases (ypN0) was excellent, independent of whether they had received postoperative chemotherapy (n = 43; 87.5 +/- 6.0 percent) or not (n = 29; 87.7 +/- 6.7 percent). Patients with ypN2 status have, despite chemotherapy, a poor disease-free survival at 30 +/- 17.6 percent after 36 months. CONCLUSIONS These retrospective data suggest that, for some patients, postoperative chemotherapy can be spared. For patients with ypN2 status, an intensification of the postoperative chemotherapy should be considered. Further evaluation in prospective studies is urgently recommended.
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Affiliation(s)
- Rainer Fietkau
- Department of Radiotherapy, University Hospital, Südring 75, 18059 Rostock, Germany.
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87
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Kim JS, Kim JM, Li S, Yoon WH, Song KS, Kim KH, Yeo SG, Nam JS, Cho MJ. Epidermal growth factor receptor as a predictor of tumor downstaging in locally advanced rectal cancer patients treated with preoperative chemoradiotherapy. Int J Radiat Oncol Biol Phys 2006; 66:195-200. [PMID: 16839708 DOI: 10.1016/j.ijrobp.2006.04.026] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2006] [Revised: 04/07/2006] [Accepted: 04/09/2006] [Indexed: 01/11/2023]
Abstract
PURPOSE To examine retrospectively whether levels of epidermal growth factor receptor (EGFR) expression can predict tumor downstaging after preoperative chemoradiotherapy in patients with locally advanced rectal cancer. METHODS AND MATERIALS A total of 183 patients with rectal cancer (cT3-T4 or N+) were enrolled in this study. Preoperative chemoradiotherapy consisted of 50.4 Gy of pelvic radiation with concurrent 5-fluorouracil and leucovorin bolus intravenous chemotherapy in 94 patients or oral capecitabine and leucovorin in 89 patients. EGFR expression in pretreatment paraffin-embedded tumor biopsy specimens was assessed by immunohistochemistry. EGFR expression was determined from the intensity and extent of staining. Tumor downstaging was defined as a reduction of at least one T-stage level. RESULTS Tumor downstaging occurred in 97 patients (53%), and the tumors showed a pathologic complete response in 27 patients (15%). Positive EGFR expression was observed in 140 (76%) of 183 patients. EGFR expression levels were low in 113 patients (62%) and high in 70 patients (38%). On logistic regression analysis, the significant predictive factor for increased tumor downstaging was a low level of EGFR expression and preoperative chemotherapy using oral capecitabine (odds ratio, 0.437; p = 0.012 vs. odds ratio, 3.235; p < 0.001, respectively). CONCLUSION A high level of EGFR expression may be a significant predictive molecular marker for decreased tumor downstaging after preoperative chemoradiotherapy in locally advanced rectal cancer.
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Affiliation(s)
- Jun-Sang Kim
- Department of Radiation Oncology, Chungnam National University College of Medicine, Daejeon, Republic of Korea.
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88
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Urso E, Serpentini S, Pucciarelli S, De Salvo GL, Friso ML, Fabris G, Lonardi S, Ferraro B, Bruttocao A, Aschele C, Nitti D. Complications, functional outcome and quality of life after intensive preoperative chemoradiotherapy for rectal cancer. Eur J Surg Oncol 2006; 32:1201-8. [PMID: 16872799 DOI: 10.1016/j.ejso.2006.07.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2006] [Accepted: 07/04/2006] [Indexed: 01/31/2023] Open
Abstract
AIMS To investigate early and late complications in 44 patients with locally advanced mid-low rectal cancer enrolled in a phase I-II study, who had received an aggressive chemoradiation treatment (50.4Gy/28F; 5-FU continuous infusion and weekly Oxaliplatin) followed by total mesorectal excision and 5-FU based postoperative chemotherapy. The aim of the present study is also to evaluate functional outcome and quality of life (QoL) in a sub-group of 22 patients. METHODS Standardized forms for early and late surgical complications were completed for all patients. Anorectal function and QoL were also investigated in 22 patients who underwent surgery in the same surgical unit, using the fecal incontinence scoring system (FIS) and EORTC-QLQ-CR38 questionnaires, compiled before and after radiotherapy and at least 8 months after surgery. The differences over time in scores were analyzed using repeated measure ANOVA. RESULTS The median age of patients (25 males and 19 females) was 58 (range: 34-73) years. A low anterior resection was performed in 39 cases, radical resection in 41, and 12 patients had a pathological complete response. There were no operative deaths; 4 and 9 patients required re-operation for early and late complications, respectively. FIS score did not present a significant worsening over time. According to data in the EORTC-QLQ-CR38 questionnaire, a significant improvement over time was found only for "future perspective". CONCLUSION Our findings seem to indicate that this aggressive 5-FU-Oxalipaltin-based treatment implies no impairment of QoL and anorectal function, even if a high rate of late major complications was observed. Studies on larger series are required to confirm these results.
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Affiliation(s)
- E Urso
- Clinica Chirurgica II, Dipartimento di Scienze Oncologiche e Chirurgiche, Policlinico Università di Padova, Policlinico, VI piano, Via Giustiniani 2, 35128 Padova, Italy
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89
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Navarro M, Dotor E, Rivera F, Sánchez-Rovira P, Vega-Villegas ME, Cervantes A, García JL, Gallén M, Aranda E. A Phase II study of preoperative radiotherapy and concomitant weekly irinotecan in combination with protracted venous infusion 5-fluorouracil, for resectable locally advanced rectal cancer. Int J Radiat Oncol Biol Phys 2006; 66:201-5. [PMID: 16814947 DOI: 10.1016/j.ijrobp.2006.04.007] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2006] [Revised: 04/06/2006] [Accepted: 04/06/2006] [Indexed: 01/24/2023]
Abstract
PURPOSE The aim of this study was to evaluate the efficacy and tolerance of preoperative chemoradiotherapy (CRT) with irinotecan (CPT-11) and 5-fluorouracil (5-FU) in patients with resectable rectal cancer. METHODS AND MATERIALS Patients with resectable T3-T4 rectal cancer and Eastern Cooperative Oncology Group performance status <2 were included. CPT-11 (50 mg/m(2) weekly) and 5-FU (225 mg/m(2)/day continuous infusion, 5 days/week) were concurrently administered with radiation therapy (RT) (45 Gy, 1.8 Gy/day, 5 days/week), during 5 weeks. RESULTS A total of 74 patients were enrolled: mean age, 59 years (20-74 years; SD, 11.7). Planned treatment was delivered to most patients (median relative dose intensity for both drugs was 100%). Grade 3/4 lymphocytopenia occurred in 35 patients (47%), neutropenia in 5 (7%), and anemia in 2 (3%). Main Grade 3 nonhematologic toxicities were diarrhea (14%), asthenia (9%), rectal mucositis (8%), and abdominal pain (8%). Of the 73 resected specimens, 13.7% (95% confidence interval [CI], 6.8-23.7) had a pathologic complete response and 49.3% (95% CI, 37.4-61.3) were downstaged. Additionally, 66.7% (95% CI, 51.1-80.0) of patients with ultrasound staged N1/N2 disease had no pathologic evidence of nodal involvement after CRT. CONCLUSIONS This preoperative CRT schedule has been shown to be effective and feasible in a large population of patients with resectable rectal cancer.
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Abstract
The currently available evidence from randomized clinical trials clearly supports the use of adjuvant therapy in general and preoperative combined modality therapy in particular as effective means of decreasing the rates of local recurrence, improving sphincter preservation rates, and probably im-proving overall survival when managing patients with locally advanced adenocarcinomas of the lower two thirds of the rectum. A radical surgical approach with adequately performed, sharp TME remains the standard of care for those patients. There is clearly a need to develop and validate surrogate biomarkers for the identification of patients who respond favorably to preoperative treatment. There is still a significant fraction of rectal cancer patients who ultimately die from their disease. The armamentarium of avail-able therapies is evolving rapidly, and hopefully local control rates and overall survival of rectal cancer patients will continue to improve in the near future.
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Affiliation(s)
- J Pablo Arnoletti
- Section of Surgical Oncology, Department of Surgery, University of Alabama at Birmingham, 1922 7th Avenue South, KB321, Birmingham, AL 35294, USA
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91
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Ceelen W, Pattyn P, Boterberg T, Peeters M. Pre-operative combined modality therapy in the management of locally advanced rectal cancer. Eur J Surg Oncol 2006; 32:259-68. [PMID: 16443345 DOI: 10.1016/j.ejso.2005.12.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2005] [Accepted: 12/07/2005] [Indexed: 12/19/2022] Open
Abstract
AIMS To review the use of pre-operative combined modality therapy (CMT, chemotherapy with radiotherapy) in the management of resectable rectal cancer. METHODS A systematic search was performed on pre-operative CMT and rectal cancer. Additional information was retrieved from hand searching the literature and from relevant congress proceedings. We addressed the following issues: Phase II studies of pre-operative CMT, pre-operative radiotherapy (RT) alone vs pre-operative CMT, pre-operative vs post-operative CMT, functional outcome and pathologic downstaging after CMT, prediction and importance of complete response to CMT. RESULTS Pre-operative CMT results in an average pathological complete response (pCR) rate of 18.5% in Phase II studies. Compared with pre-operative RT alone, the addition of CT significantly improves tumour response but not overall survival while acute toxicity increases and the effect on sphincter preservation is at present unclear. Pre-operative CMT has been proven to be superior to post-operative CMT in a German multicenter randomized trial. The scarce available data suggest that the addition of CT might worsen anorectal function compared to pre-operative RT alone. Although a significant pathological response is prognostically favourable, the clinical and imaging tools available at present do not allow to accurately predict pCR in clinical complete responders confirming the indication for surgery in this subgroup. CONCLUSIONS Pre-operative CMT enhances tumour response and could therefore, have a role in patients with possibly invaded resection margins or low lying cancers, although both acute toxicity and anorectal function are worse compared to RT alone. The final results of ongoing randomized trials will more accurately establish the role of pre-operative CMT in resectable rectal cancer patients.
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Affiliation(s)
- W Ceelen
- Department of Surgery, University Hospital, 2K12 IC, De Pintelaan 185, B-9000 Ghent, Belgium.
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Ferrigno R, Novaes PERDS, Silva MLG, Nishimoto IN, Nakagawa WT, Rossi BM, Ferreira FDO, Lopes A. Neoadjuvant radiochemotherapy in the treatment of fixed and semi-fixed rectal tumors. Analysis of results and prognostic factors. Radiat Oncol 2006; 1:5. [PMID: 16722598 PMCID: PMC1459184 DOI: 10.1186/1748-717x-1-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2005] [Accepted: 03/28/2006] [Indexed: 12/21/2022] Open
Abstract
PURPOSE To report the retrospective analysis of patients with locally advanced rectal cancer treated with neodjuvant radiochemotherapy. METHODS AND MATERIALS From January 1994 to December 2003, 101 patients with fixed (25%) or semi-fixed (75%) rectal adenocarcinoma were treated by preoperative radiotherapy with a dose of 45 Gy at the whole pelvis and 50.4 Gy at primary tumor, concomitant to four weekly chemotherapies with 5-Fluorouracil (425 mg/m2) and Leucovorin (20 mg/m2). In 71 patients (70.3%) the primary tumor was located up to 6 cm from the anal verge and in 30 (29.7%) from 6.5 cm to 10 cm. Age, gender, tumor fixation, tumor distance from the anal verge, clinical response, surgical technique, and postoperative TNM stage were the prognostic factors analyzed for overall survival (OS), disease-free survival (DFS), and local control (LC) at five years. RESULTS Median follow-up time was 38 months (range, 2-141). Complete response was observed in eight patients (7.9%), partial in 54 (53.4%) and absence in 39 (38.7%). OS, DFS and LC were 52.6%, 53.8%, and 75.9%, respectively. Distant metastasis occurred in 40 (39.6%) patients, local recurrence in 20 (19.8%) and both in 16 (15.8%). Patients with fixed tumors had lower OS (17% Vs 65.6%; p < 0.001), DFS (31.2% Vs 60.9%; p = 0.005), and LC (58% Vs 82%; p = 0.004). Patients with tumors more than 6 cm above the anal verge had better LC (93% Vs 69%; p = 0.04). The postoperative TNM stage was a significant factor for DFS (I:64.1%, II:69.6%, III:35.2%, IV:11.1%; p < 0.001) and for LC (I:75.7%, II: 92.9%, III:54.1%, IV:100%; p = 0.005). Patients with positive lymph nodes had worse OS (37.9% Vs 70.4%, p = 0.006), DFS (32% Vs 72.7%, p < 0.001) and LC (56.2% Vs 93.4%; p < 0.001). CONCLUSION This study suggests that the neoadjuvant treatment employed was effective for local control. Fixation of the lesion and lymph nodes metastasis were the main adverse prognostic factors. Distant failures were frequent, supporting the need of new drugs for adjuvant chemotherapy.
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Affiliation(s)
- Robson Ferrigno
- Department of Radiation Oncology, Hospital do Câncer A. C. Camargo, Rua Prof. Antonio Prudente, 211, São Paulo, SP 01509-900, Brazil
| | | | - Maria Letícia Gobo Silva
- Department of Radiation Oncology, Hospital do Câncer A. C. Camargo, Rua Prof. Antonio Prudente, 211, São Paulo, SP 01509-900, Brazil
| | - Ines Nobuko Nishimoto
- Department of Biostatistics, Fundação Antonio Prudente, Rua Prof. Antonio Prudente, 211, São Paulo, SP 01509-900, Brazil
| | - Wilson Toshihiko Nakagawa
- Department of Pelvic Surgery, Hospital do Câncer A. C. Camargo, Rua Prof. Antonio Prudente, 211, São Paulo, SP 01509-900, Brazil
| | - Benedito Mauro Rossi
- Department of Pelvic Surgery, Hospital do Câncer A. C. Camargo, Rua Prof. Antonio Prudente, 211, São Paulo, SP 01509-900, Brazil
| | - Fábio de Oliveira Ferreira
- Department of Pelvic Surgery, Hospital do Câncer A. C. Camargo, Rua Prof. Antonio Prudente, 211, São Paulo, SP 01509-900, Brazil
| | - Ademar Lopes
- Department of Pelvic Surgery, Hospital do Câncer A. C. Camargo, Rua Prof. Antonio Prudente, 211, São Paulo, SP 01509-900, Brazil
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93
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Park YA, Sohn SK, Seong J, Baik SH, Lee KY, Kim NK, Cho CW. Serum CEA as a predictor for the response to preoperative chemoradiation in rectal cancer. J Surg Oncol 2006; 93:145-50. [PMID: 16425302 DOI: 10.1002/jso.20320] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES Recent data suggest that good responders to preoperative chemoradiation (CRT) have a favorable prognosis in rectal cancer patients. The aim of this study was to investigate the predictive value of serum carcinoembryonic antigen (CEA) levels for the tumor response to preoperative CRT in rectal cancer patients. METHODS The study comprised 141 rectal adenocarcinoma patients who underwent preoperative radiotherapy with 5-fluorouracil (FU) based chemotherapy, followed by radical surgery. The staging workup was consisted of endorectal ultrasound, abdominopelvic computed tomography scan, or magnetic resonance imaging. The outcome parameters were cancer-specific survival and disease-free survival. Pre-CRT clinicopathologic features, including age, gender, location of the tumor, clinical tumor (cT) classification, clinical nodal (cN) classification, and serum CEA levels were investigated as possible predictors for the response to preoperative CRT. RESULTS Pathologic complete or near complete responses (good responders, GR) occurred in 26 (19%) patients, while partial or no response (poor responders, PR) occurred in the remaining 115 (81%) patients. GR showed better cancer-specific survival (P = 0.028) and disease-free survival rates (P = 0.011) than PR. Univariate analysis revealed that positive cN and elevated (>5 ng/ml) pre-CRT serum CEA levels are associated with poor tumor response to preoperative CRT. Using logistic regression analysis, elevated pre-CRT serum CEA levels were the only significant predictor for the poor response to CRT (Odd ratio = 2.876, 95% confidence interval = 1.04-7.46, P = 0.041). CONCLUSIONS Our data suggest that elevated pre-CRT serum CEA levels are associated with poor tumor response to CRT. Therefore, pre-CRT serum CEA levels provide useful information about tumor response to preoperative CRT in rectal cancer patients.
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Affiliation(s)
- Yoon-Ah Park
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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94
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Mohiuddin M, Winter K, Mitchell E, Hanna N, Yuen A, Nichols C, Shane R, Hayostek C, Willett C. Randomized phase II study of neoadjuvant combined-modality chemoradiation for distal rectal cancer: Radiation Therapy Oncology Group Trial 0012. J Clin Oncol 2006; 24:650-5. [PMID: 16446336 DOI: 10.1200/jco.2005.03.6095] [Citation(s) in RCA: 190] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
PURPOSE To evaluate the rate of pathologic complete response and toxicity of neoadjuvant chemoradiation for advanced T3/T4 distal rectal cancers in a randomized phase II study PATIENTS AND METHODS Patients with clinical T3/T4 distal rectal cancers were randomly assigned in a phase II study to receive combined neoadjuvant chemoradiotherapy followed by surgical resection. Patients were randomly assigned to receive continuous venous infusion (CVI) fluorouracil (FU) 225 mg/m2 per day, 7 days per week, plus pelvic hyperfractionated radiation 55.2 to 60 Gy at 1.2 Gy bid (arm 1) or CVI FU 225 mg/m2 per day Monday to Friday, 120 hours per week plus irinotecan 50 mg/m2 once weekly for 4 weeks plus pelvic radiation therapy 50.4 to 54 Gy at 1.8 Gy per day (arm 2). Surgery was performed 4 to 10 weeks after completion of neoadjuvant therapy. The primary end point of this study was pathologic complete response (pCR). Secondary end points included acute and late normal tissue morbidity. RESULTS A total of 106 patients were entered onto the study, with 103 assessable for response. The overall resectability rate was 93%. The median time to surgery was 7 weeks. Tumor downstaging was observed in 78% of patients in both arms. The pCR rate for all assessable patients was 26% in each arm. For patients who had surgery, the pCR rate was also the same (28%) in both arms. Acute and late toxicity was also similar. Grade 3 and 4 acute hematologic and nonhematologic toxicity occurred in 13% and 38% in arm 1 and 12% and 45% in arm 2, respectively. CONCLUSION Although the overall complete response rate and toxicity seems similar in both arms, this is the first multi-institutional study to establish a relatively high (28%) pCR rate after neoadjuvant therapy.
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95
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Kim JS, Kim JS, Cho MJ, Yoon WH, Song KS. Comparison of the efficacy of oral capecitabine versus bolus 5-FU in preoperative radiotherapy of locally advanced rectal cancer. J Korean Med Sci 2006; 21:52-7. [PMID: 16479065 PMCID: PMC2733979 DOI: 10.3346/jkms.2006.21.1.52] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
The effects of treatment with oral capecitabine vs. bolus 5-FU, administered concurrently with preoperative radiotherapy, were compared in the treatment of locally advanced rectal cancer (LARC). One hundred and twenty-seven patients with LARC received concurrent preoperative chemoradiation using two cycles bolus 5-FU (500 mg/m2/day) plus leucovorin (LV, 20 mg/m2/day) (Group I). Another LARC group received concurrent chemoradiation using two cycles 1,650 mg/m2/day of oral capecitabine and 20 mg/m2/day of LV (Group II, 97 patients). Radiation was delivered to the primary tumor at 50.4 Gy in both groups. Definitive surgery was performed 6 weeks after the completion of chemoradiation. A pathologic complete remission was achieved in 11.4% of patients in Group I and in 22.2% of patients in Group II (p= 0.042). The down-staging rates of the primary tumor and lymph nodes were 39.0/ 68.7% in Group I and 61.1/87.5% in Group II (p=0.002/0.005). Sphincter-preserving surgery was possible in 42.1% of patients in Group I and 66.7% of those in Group II (p=0.021). Grade 3 or 4 leucopenia, diarrhea, and radiation dermatitis were statistically more prevalent in Group I than in Group II, while the opposite was true for grade 3 hand-foot syndrome. Preoperative chemoradiation using oral capecitabine was better tolerated than bolus 5-FU and was more effective in the promotion of both down-staging and sphincter preservation in patients with LARC.
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Affiliation(s)
- Jae-Sung Kim
- Department of Radiation Oncology, College of Medicine, Seoul National University, Seoul, Korea
| | - Jun-Sang Kim
- Department of Radiation Oncology, College of Medicine, Chungnam National University, Daejeon, Korea
- Cancer Research Institute, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Moon-June Cho
- Department of Radiation Oncology, College of Medicine, Chungnam National University, Daejeon, Korea
- Cancer Research Institute, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Wan-Hee Yoon
- Department of General Surgery, College of Medicine, Chungnam National University, Daejeon, Korea
- Cancer Research Institute, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Kye-Sang Song
- Department of Pathology, College of Medicine, Chungnam National University, Daejeon, Korea
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96
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Hughes R, Glynne-Jones R, Grainger J, Richman P, Makris A, Harrison M, Ashford R, Harrison RA, Livingstone JI, McDonald PJ, Meyrick Thomas J, Mitchell IC, Northover JMA, Phillips R, Wallace M, Windsor A, Novell JR. Can pathological complete response in the primary tumour following pre-operative pelvic chemoradiotherapy for T3-T4 rectal cancer predict for sterilisation of pelvic lymph nodes, a low risk of local recurrence and the appropriateness of local excision? Int J Colorectal Dis 2006; 21:11-7. [PMID: 15864605 DOI: 10.1007/s00384-005-0749-y] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/25/2005] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Local excision is considered inappropriate treatment for T3-T4 rectal adenocarcinomas, as it cannot provide prognostic information regarding lymph node involvement and has a high risk of pelvic recurrence. Preoperative chemoradiation (CRT) studies in rectal cancer suggest that a pathological complete response (pCR) in the primary tumour provides an excellent long-term outcome. If downstaging to stage pT0 predicts a tumour response within the perirectal and pelvic lymph nodes, this may allow local excision to be performed without increased risk of pelvic recurrence. This retrospective study aimed to determine the incidence of involved lymph nodes following pCR (ypT0) after preoperative CRT and total mesorectal excision. METHOD The outcome and treatment details of 211 patients undergoing preoperative CRT for clinically staged T3-T4 unresectable rectal adenocarcinomas between 1993 and 2003 at Mount Vernon Hospital were reviewed. RESULTS Data were recorded from the 143 patients who completed treatment with a median follow-up of 25 months. Twenty-three patients (18%) were found to have had a pCR. Four out of 23 patients (17%) had involved lymph nodes. No pelvic recurrences developed after a ypCR. Overall survival was similar for patients with ypT0 or residual tumour. CONCLUSION Pathological complete response in the primary tumour failed to predict a response in the perirectal lymph nodes (p=0.08). The degree of response predicted a lymph node response (p=0.02). The detection of ypCR identified patients with a low rate of pelvic recurrence. This may in the future allow selection of patients for whom local excision can be performed without a higher risk of local relapse.
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Affiliation(s)
- R Hughes
- Mount Vernon Cancer Centre, Northwood, Middlesex, UK, HA6 2RN
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97
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Mawdsley S, Glynne-Jones R, Grainger J, Richman P, Makris A, Harrison M, Ashford R, Harrison RA, Osborne M, Livingstone JI, MacDonald P, Mitchell IC, Meyrick-Thomas J, Northover JMA, Windsor A, Novell R, Wallace M. Can histopathologic assessment of circumferential margin after preoperative pelvic chemoradiotherapy for T3-T4 rectal cancer predict for 3-year disease-free survival? Int J Radiat Oncol Biol Phys 2005; 63:745-52. [PMID: 16199310 DOI: 10.1016/j.ijrobp.2005.03.003] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2005] [Revised: 03/04/2005] [Accepted: 03/07/2005] [Indexed: 01/06/2023]
Abstract
PURPOSE This study set out to determine the impact of a positive circumferential resection margin (CRM) (R1-R2) and pathologic downstaging on local recurrence and survival in patients with borderline resectable or unresectable rectal adenocarcinoma treated with neoadjuvant chemoradiotherapy (CRT). METHODS AND MATERIALS A total of 150 patients with locally advanced rectal cancer were treated with long-course neoadjuvant CRT using low-dose folinic acid and 5-fluorouracil. CRT was followed 6-12 weeks later by surgical excision. The CRM rate and incidence, site, and pattern of local and systemic recurrences were recorded. The median follow-up was 25 months. RESULTS The overall median survival was 37 months, with a 5-year overall survival rate of 34%. Of the 150 patients, 122 underwent curative resection; 12% had a complete pathologic response, and downstaging to pT1-T2 occurred in an additional 16%. A negative CRM (R0) was achieved in 65% overall (98 of 150). Local recurrence occurred in 10% of those with R0 resection and 62% of those with R1-R2 resections. Distant metastases occurred in 29% of those with R0 resections and 75% of those with R1-R2 resections. The 3-year disease-free and 3-year overall survival rate was 9% and 25% and 52% and 64%, respectively, for patients with and without a histologically positive CRM. CONCLUSION After 5-fluorouracil-based CRT, a positive CRM predicted for a high risk of subsequent local recurrence and a 3-year disease-free survival rate of only 9%. For this reason, the CRM should be considered a major prognostic factor and should be validated in future trials as an early alternative clinical endpoint.
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98
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Goethals L, Haustermans K, Perneel C, Bussels B, D'Hoore A, Geboes K, Ectors N, Van Cutsem E, Van den Bogaert W, Penninckx F. Chemo-radiotherapy versus radiotherapy alone in the pre-operative treatment of resectable rectal cancer. Eur J Surg Oncol 2005; 31:969-76. [PMID: 15936170 DOI: 10.1016/j.ejso.2005.03.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2004] [Revised: 03/07/2005] [Accepted: 03/16/2005] [Indexed: 11/20/2022] Open
Abstract
AIM To determine the differences in downstaging, local control (LC), disease free survival (DFS) and overall survival (OS) between combined pre-operative chemoradiation and pre-operative radiotherapy alone in the treatment of resectable rectal cancer. METHODS One hundred and ten patients who underwent pre-operative radiotherapy or chemo-radiotherapy were reviewed. Fifty-seven patients were treated with radiotherapy (30 Gy/3 Gy) alone and 53 patients with chemo-radiotherapy (bolus 5FU+45 Gy/1.8 Gy). The median interval between the end of neo-adjuvant treatment and surgery was 28 and 46 days for the patients treated with radiotherapy alone and chemo-radiotherapy. RESULTS The groups were homogeneously distributed for all characteristics except for cN-stage with more clinically node positive patients in the combined modality treatment group (47 vs 73%). A significant downstaging for tumour and/or lymph node status was observed in both groups. More ypT0-x-is were observed after chemoradiation than after radiotherapy alone (26 vs 7%; p=0.02). The local control rate at 3 years was 94% for both groups. DFS after radiation and chemoradiation was comparable with a 3-year DFS of 83 and 88%, respectively. CONCLUSION Both pre-operative schemes have similar outcomes concerning DFS, OS and LC. Tumour downstaging is associated with improved survival.
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Affiliation(s)
- L Goethals
- Department of Radiation Oncology, University Hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium.
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99
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Wiig JN, Larsen SG, Dueland S, Giercksky KE. Clinical outcome in patients with complete pathologic response (pT0) to preoperative irradiation/chemo-irradiation operated for locally advanced or locally recurrent rectal cancer. J Surg Oncol 2005; 92:70-5. [PMID: 16180215 DOI: 10.1002/jso.20340] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The importance of pT0 stage after preoperative radiation/chemoradiation is unclear. METHODS Four hundred and nineteen patients had preoperative irradiation (46-50 Gy/2 Gy fractions) for primary locally advanced (PLA) or locally recurrent (LR) rectal cancer. 141 PLA and 65 LR cases with R0 resections/M0 stage are studied. Two of the pT0 PLA patients had also been given sensitizing chemotherapy and two pT0 in the LR group had received pelvic hyperthermia as well. RESULTS pT0 was achieved in 7% of 229 PLA and 8% of 190 LR patients. For the PLA group, actuarial 5-year survival of pT0 was 90% versus 53% for the pT > 0 group. The difference was statistically significant. At five years local recurrence was zero in pT0 patients versus 23% in pT > 0 (not significant). For the LR groups 5-year-survival was 62% for pT0 versus 45% for the other pT-stages, local recurrence was 17 and 35% respectively (not significant). The seemingly better results for pT0 cases of PLA cancers versus the LR ones did not reach statistical significance. CONCLUSION pT0 after preoperative irradiation is associated with improved survival for pT0 cases of PLA. Our studies on pT0 LR was suggestive of an improvement in this group as well.
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Affiliation(s)
- Johan N Wiig
- Department of Surgical Oncology, The Norwegian Radium Hospital, Oslo, Norway.
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100
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Chao M, Gibbs P, Tjandra J, Cullinan M, McLaughlin S, Faragher I, Skinner I, Jones I. Preoperative chemotherapy and radiotherapy for locally advanced rectal cancer. ANZ J Surg 2005; 75:286-91. [PMID: 15932438 DOI: 10.1111/j.1445-2197.2005.03348.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The adjuvant treatment of rectal cancer is a rapidly evolving field. The standard approach is a combination of chemotherapy and radiotherapy, with the optimal treatment combination and sequencing yet to be determined. Here, we report our early experience of preoperative chemotherapy and radiotherapy (CRT) in locally advanced rectal cancer at Radiation Oncology Victoria to determine its efficacy and the rate of sphincter preservation. METHODS Sixty-nine patients (46 men and 23 women) with locally advanced rectal cancer (T3-4 or N1) were treated with preoperative CRT followed by surgical resection of disease. Chemotherapy consisted of either bolus or continuous venous infusion of 5-fluorouracil (5-FU). Radiotherapy to a dose of 45 Gy was delivered to the pelvis followed by a boost of 5.4-14.4 Gy in the majority of patients. Surgical resection was carried out 4-8 weeks following completion of preoperative CRT. Univariate and multivariate analyses were performed to examine variables that may influence local recurrence and overall survival rates. RESULTS All patients underwent a complete macroscopic resection, including the three patients that had unrecognized distant metastases discovered at the time of operation. Only two patients had microscopic residual disease. Sphincter preservation was achieved in 16 of 25 patients who were thought to require an abdominoperineal resection. Tumour and/or nodal downstaging were achieved in 47 patients (68%), with a pathological complete response in 12 (17%). At a median follow up of 29 months post-surgery, five patients (7.2%) have developed a local recurrence. Overall 21 patients (30%) have progressed and 12 (18%) have died. Treatment-related toxicity was acceptable and there was no treatment-related mortality. There was no significant relationship found between the pathological response to treatment and any clinical endpoint. CONCLUSIONS Our results confirm the high response rates and acceptable toxicity of preoperative treatment. Further studies are required to better define the impact of preoperative chemotherapy and radiotherapy on long-term outcomes.
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Affiliation(s)
- Michael Chao
- Radiation Oncology Victoria, Royal Milbourne Hospital, Melbourne, Victoria, Australia.
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