Adjuvant therapy for adenocarcinoma of the rectum

[Clinical research of intraperitoneal chemotherapy plus Shenmai Injection in treating advanced colorectal cancer]

OBJECTIVE

To study the effects of intraperitoneal chemotherapy (IPC) plus Shenmai Injection (SMI) in treating advanced colorectal cancer following radical resections.

METHODS

Fifty-eight cases of colorectal cancer in stage B2 and C following radical resections were divided into two groups: SMI+IPC group (36 cases) and IPC group (22 cases). In the SMI+IPC group, IPC (5-fluorouracil combined with cisplatin) plus SMI was administered, while in the IPC group, only IPC was administered. Clinical symptoms, quality of life (Karnofsky score), white blood cell counts, natural killer cells and CD4/CD8 were observed, and disease-free survival (DFS) rate was also evaluated.

RESULTS

The total short-term response rate was 83.33% in the SMI+IPC group, significantly higher than 63.64% in the IPC group (P<0.05). The data of clinical symptoms, quality of life, white blood cell counts, natural killer cells and CD4/CD8 in the SMI+IPC group were also significantly improved as compared with those in the IPC group (P<0.05 or P<0.01). In the SMI+IPC group, 1-, 3- and 5-year DFS rates were 91.7% (33/36), 77.8% (28/36) and 72.2% (26/36) respectively, and those in the IPC group were 90.9% (20/22), 72.7% (16/22) and 45.5% (10/22) respectively. The 5-year DFS rate was significantly improved in the SMI+IPC group as compared with that in the IPC group (P<0.05), while the 1-year and 3-year DFS rates had no significant difference between these two groups.

CONCLUSION

IPC plus SMI is effective in treating post-operative patients with advanced colorectal cancer.

Prospective randomized study of post-operative chemotherapy with levamisole and UFT for head and neck carcinoma

AIMS

A prospective randomized study was conducted to evaluate the benefit of adjuvant levamisole/UFT (futraful and uracil) chemotherapy in head and neck squamous cell carcinoma.

METHODS

Sixty-five patients with stage III and IV squamous cell carcinomas of oral cavity, oropharynx, hypopharynx and larynx with no distant metastasis were randomized for the chemotherapy study. Thirty-one patients were randomized for chemotherapy and two of them were subsequently excluded. In this study, a total of 29 patients on levamisole/UFT therapy and 34 patients on the control group were analysed. The main outcome was measured by the 5-year disease-free actuarial survival rate.

RESULTS

The rates of distant metastasis were 10% for chemotherapy group and 32% for control group (P=0.06). The 5-year disease-free actuarial survival rates for patients with and without adjuvant chemotherapy were 57% and 39% respectively (P=0.207).

CONCLUSIONS

A trend of better distant control in head and neck cancer patients with post-operative adjuvant oral chemotherapy was observed. The side effects were minimal. However, there was no statistically significant improvement in the overall long-term survival. It may be of value to conduct a large-scale multi-centre prospective randomized study to verify the efficacy of levamisole and UFT as post-operative adjuvant chemotherapy for the control of distant metastasis in high-risk population.

Morbidities of adjuvant chemotherapy and radiotherapy for resectable rectal cancer: an overview

PURPOSE

Although adjuvant chemoradiotherapy may improve outcomes after surgery for high-risk rectal cancer, its toxicities are not well documented. This is a review of complications associated with adjuvant therapy in randomized, controlled trials.

METHODS

A MEDLINE and literature search was performed for randomized, controlled trials of adjuvant therapy for rectal cancer. Modalities of adjuvant therapy evaluated included preoperative radiotherapy, preoperative chemoradiotherapy, postoperative radiotherapy, and postoperative chemoradiotherapy. All documented complications were analyzed, including any effect on pelvic floor function and quality of life.

RESULTS

Short-term (acute) complications of preoperative radiotherapy include lethargy, nausea, diarrhea, and skin erythema or desquamation. These acute effects develop to some degree in most patients during treatment but are usually self-limiting. With preoperative radiotherapy the incidence of perineal wound infection increases from 10 to 20 percent. The acute toxicities after postoperative radiotherapy for rectal cancer occur in 4 to 48 percent of cases, and serious toxicities, requiring hospitalization or surgical intervention, occur in 3 to 10 percent of cases. Postoperative radiotherapy is associated with more complications than preoperative radiotherapy. The main problems with postoperative radiotherapy are small-bowel obstruction (5-10 percent), delay in starting radiotherapy caused by delayed wound healing (6 percent) and postoperative fatigue (14 percent), and toxicities precluding completion of adjuvant therapy (49-97 percent). The morbidity and mortality of both preoperative and postoperative radiotherapy are higher in elderly patients and when two-portal rather than three-portal or four-portal radiation technique is used. Meticulous radiation technique is important, and multiple fields of irradiation are mandatory. After combined adjuvant chemotherapy and radiotherapy acute hematologic and gastrointestinal toxic effects are frequent (5-50 percent). Delayed radiation toxicities include radiation enteritis (4 percent), small-bowel obstruction (5 percent), and rectal stricture (5 percent). Pelvic floor function and quality of life have not been well evaluated in randomized, controlled trials.

CONCLUSION

Adjuvant therapy for rectal cancer has considerable adverse effects. Adverse effects on bowel and sphincter function and quality of life have not been defined.

Preoperative staging of rectal carcinoma by magnetic resonance imaging with a pelvic phased-array coil

BACKGROUND

The use of surface coils for magnetic resonance imaging (MRI) allows enhanced image definition and so potentially more accurate staging of colorectal cancer. Endorectal coil imaging is invasive, operator dependent and impossible in a high proportion of patients due to rectal stricture. The phased-array pelvic coil, however, is non-invasive and applicable to all rectal tumours.

METHODS

A pelvic phased-array coil was used for preoperative MRI staging of 38 primary rectal carcinomas. Results were expressed according to the Dukes and tumour nodes metastasis (TNM) classifications. After resection of the tumour, the stage predicted on MRI was compared with the pathological classification.

RESULTS

The overall accuracy of preoperative staging with the pelvic phased-array coil was 55 per cent for both Dukes class and T stage. Assessment of nodal involvement gave an overall accuracy for MRI of 76 per cent with a sensitivity of 57 per cent and specificity of 88 per cent.

CONCLUSION

Use of a pelvic phased-array coil did not improve the staging accuracy of MRI to a clinically useful level.

Transforming growth factor beta 1 expression in human colorectal tumours: an independent prognostic marker in a subgroup of poor prognosis patients

Members of the transforming growth factor beta (TGF-beta family, in particular TGF-beta 1, are some of the most potent inhibitory growth factors in a variety of cell types. Resistance to TGF-beta 1-induced growth inhibition is frequently observed in colorectal carcinomas and is associated with tumour progression. Perturbations of TGF-beta 1 expression and function, therefore, may contribute to the loss of some constraints on tumour cell growth. In this study we have examined the expression of TGF-beta 1 and its precursor latency-associated peptide (LAP)-TGF-beta in human colorectal tumours using immunohistochemical techniques. In 86% of the tumours the LAP-TGF-beta complex was present in both the stromal and epithelial cells, whereas the mature TGF-beta 1 peptide was expressed in the glandular epithelium of 58.3% of these tumours. Intense staining for TGF-beta 1 was positively associated with advanced Dukes' stage. Furthermore, there was a significant correlation between the presence of TGF-beta 1 in the tumours and a shorter post-operative survival. This was most significant in a subgroup of patients who had received only a palliative operation. These results suggest that TGF-beta 1 expression may be useful as an independent prognostic indicator for a subgroup of patients who have a particularly poor prognosis.

Ileostomy dysfunction with adjuvant chemoradiation for rectal carcinoma requiring in-hospital management: a cause for concern

The morbidity and mortality of 20 patients undergoing adjuvant chemoradiation for rectal carcinoma was documented. Of nine patients with defunctioning loop ileostomies, two suffered from dehydration and electrolyte disturbance during the treatment phase and required admission to hospital. These two cases suggest that dehydration and electrolyte disturbance from high stomal output could be a serious problem following chemoradiation therapy in patients with an ileostomy.

Early experience with postoperative adjuvant chemoradiation for rectal carcinoma: focus on morbidity

The morbidity of postoperative adjuvant chemoradiation for primary extraperitoneal rectal carcinoma is documented in this ongoing study. Patients who presented electively for resection with ACPS Dukes' B and C extraperitoneal rectal carcinoma during the period January 1990 to June 1993 were studied. Twenty patients received postoperative adjuvant chemoradiation. At a mean follow up of 32.6 months (s.d. 7.1), three of the 20 patients who received combined adjuvant chemoradiation reported no side effects. In 10 patients (50%) complications were classified as minor. In the remaining seven patients (35%) major complications of therapy occurred. There were no deaths. These early results highlight the morbidity of postoperative adjuvant chemoradiation that has been presumed but not documented.

[Developments up to now and current status of adjuvant chemo- and radiotherapy in colonic and rectal carcinoma]

A review is given of the historical and current concepts of adjuvant chemo- and radiotherapy of colorectal cancer. Early studies analyzing the use of single drug regimens were followed by a second study generation investigating adjuvant chemotherapeutic combinations. 5-FU proved to be the most efficient single drug investigated and 5-FU/MeCCNU/vincristin the most efficient chemotherapeutic combination, but no significant improvement in 5-year survival rates was achieved. Clear progress was noted with the introduction of levamisol (LEV) for modulation of 5-FU. A 33% improval in the 5-year survival rate in patients with stage III colon carcinoma was documented. It was therefore recommended (NIH consensus conference 1990) that all patients with stage III colon carcinoma be treated with this regimen unless admitted to other trials of adjuvant therapy. Preoperative radiotherapy with a dosage of 35-45 Gy can lead to downstaging of rectal cancer. Nevertheless, significant improvement in patient survival has not been proved convincingly using either isolated pre- or postoperative adjuvant radiotherapy. However, combined radiochemotherapy has been shown to improve both patient survival and local tumor control compared to surgical resection alone. It is therefore recommended that all stage II and III rectal cancer patients be treated with adjuvant combined radiochemotherapy. 5-FU/MeCCNU is currently expected to be the most efficient chemotherapy in combination with radiotherapy. Early data point out that MeCCNU could possibly be omitted. Intraoperative radiotherapy (IORT) allows further dosage escalation in order to improve local tumor control without affecting radiosensitive structures. Available data are still sparse and mostly based on the treatment of advanced carcinoma. A general validation of IORT is not yet possible, but current data are promising.

Surgical adjuvant therapy for rectal cancer: present options

Recent advances have been made with the publication of the results of GITSG and NCCTG trials, which demonstrated the significant improvement of survival by combined postoperative radiochemotherapy protocols for Stage II and III rectal cancer. These data show that systemic chemotherapy has a decisive role to play in this policy. Some of the advantages of preoperative irradiation compared with postoperative radiation therapy consist of the improvement of resectability of T4 tumors and the anal preservation for low-lying cancers. These data suggest that preoperative chemoradiotherapy should be applied not only to T4 tumors but also to all T3 tumors even when the transrectal extension is limited. The most usual protocol combines 5-fluorouracil (300-350 mg/m2/day) and leucovorin (20 mg/m2/day) for 5 days, followed by radiation therapy (30-35 Gy in 10 fractions within 12-15 days), with surgery taking place 4 to 8 weeks later, after the tumor has been restaged. Systemic therapy is continued for four more months. T2 cancers should not be excluded from the benefit of preoperative irradiation.