Induction chemotherapy followed by neoadjuvant chemoradiotherapy and surgery for patients with locally advanced rectal cancer: a systematic review and meta-analysis

Neoadjuvant chemotherapy for treatment patients with rectal cancer with adverse prognostic factors: A review

Rectal cancer (RC) is one of the leading tumor location in the structure of the incidence of malignant neoplasms in the Russian Federation and the world. And the standard approach to the treatment of patients with locally advanced forms of RC is preoperative chemo-radiotherapy (CRT) with delayed surgery. The use of such sort of approach in the recent decades has led to the reduction of the frequency of local recurrence up to 10% and even less. However, approximately a third of patients die of distant metastases. In this regard, one of the main tasks in the treatment of patients with locally advanced forms of RC with adverse prognostic factors is the prevention of distant metastasis formation. Early initiation of the systemic therapy before surgery is aimed at solving this issue. Conducting neoadjuvant chemotherapy (NCT) instead of CRT in RC treatment allows to avoid radiation reactions and injuries, occurring in some patients. Two-component oxaliplatin-containing regimens are the most well studied types of NCT in the treatment of patients with non-metastatic RC. In this connection, despite the differences in the treatment regimens and the number of cycles, a good tolerability of the method as well as no effect on the frequency of postoperative complications and in general a satisfactory results comparable to the effects of CRT were observed. The use of NCT in combination with targeted treatment modalities as well as three-component chemotherapy regimens are promising and encouraging treatment options for patients with RC with adverse prognostic factors.

Efficacy Analysis of Combining Sintilimab with Neoadjuvant Chemotherapy in Treating Middle and Advanced Rectal Cancer Based on Big Data

Objective

To analyze the efficacy of combining sintilimab with neoadjuvant chemotherapy in treating middle and advanced rectal cancer based on big data.

Methods

According to the inclusion and exclusion criteria, 43 patients with middle and advanced rectal cancer, who were treated with sintilimab and neoadjuvant chemotherapy in General Surgery of the hospitals of Zhangjiakou city from January 2020 to January 2022, were selected for the retrospective study. The patients' short-term efficacy was scientifically evaluated, and the factors affecting efficacy and the correlation were analyzed.

Results

Among the 43 enrolled patients, 30 of them had regional lymphatic metastasis but none had distant metastasis; most patients were at Broders II and TNM III, and all of them had adenocarcinoma; the total response rate was 69.77% (30 cases), with no grade IV and V adverse reactions; the patients were divided into the effective group and the ineffective group after treatment based on the evaluation results of short-term efficacy, and analysis of the relevant factors exposed in both groups revealed significant differences in age, tumor size, CEA, NLR value, PLR value, TNM stage, and presence of combined lymphatic metastasis between the two groups (P < 0.05); univariate analysis showed that tumor size, CEA, TNM stage, and combined lymphatic metastasis were the independent risk factors affecting the efficacy in patients with middle to advanced rectal cancer (P < 0.05); and through the Spearman correlation analysis of the above independent risk factors, it was further confirmed that tumor size, CEA, TNM stage, and combined lymphatic metastasis were negatively correlative with the efficacy of combining sintilimab with neoadjuvant chemotherapy in treating middle to advanced rectal cancer (P < 0.05).

Conclusion

Combining sintilimab with neoadjuvant chemotherapy has good efficacy and safety profile, which is conducive to subsequent surgery; in contrast, larger tumor diameter, higher CEA level, higher TNM stage, and more serious lymphatic metastasis are all independent risk factors affecting treatment sensitivity and can lead to poor efficacy.

Current status of total neoadjuvant therapy for locally advanced rectal cancer

Neoadjuvant chemoradiotherapy (nCRT) plus total mesorectal excision (TME) has been the standard regimen for treatment of patients with locally advanced rectal cancer (LARC), because it significantly reduces the rate of local recurrence and enables sphincter preservation. However, distant metastasis remains the major reason for treatment failure, and the value of postoperative chemotherapy is still controversial. Recent studies have examined the use of total neoadjuvant therapy (TNT), defined as induction and/or consolidation chemotherapy (CONCT) with radiotherapy (RT) or nCRT prior to surgery. The results indicated that TNT may increase the rates of chemotherapy compliance and pathological complete response (pCR), and probably improve the success rate of sphincter preservation surgery. TNT may also improve disease-free survival and overall survival, and even reduce the rate of relapse. Here, we critically appraise the existing literature on three different TNT schemes used for LARC patients.

Intensified Total Neoadjuvant Therapy in Patients With Locally Advanced Rectal Cancer: A Phase II Trial

AIMS

We assessed the efficacy and safety of total neoadjuvant therapy, including targeted agent plus FOLFOXIRI (5-fluorouracil, leucovorin, oxaliplatin and irinotecan) induction chemotherapy followed by intensified chemoradiotherapy (CRT) and surgical resection, in patients with locally advanced rectal cancer.

MATERIALS AND METHODS

This was a single-arm, single-centre phase II trial. Eligible patients had non-metastatic locally advanced rectal adenocarcinoma. Based on Ras-BRAF status, patients were treated with bevacizumab (mutated Ras-BRAF) or panitumumab/cetuximab (wild-type Ras-BRAF) plus FOLFOXIRI regimen followed by oxaliplatin-5-fluorouracil-based CRT and surgery. The primary end point was pathological complete response rate. Secondary end points were toxicity, compliance, tumour downstaging, complete resection, surgical complications, local and distant failures and overall survival. The sample size was planned to expect an absolute 20% improvement in pathological complete response rate over historical literature data with an α error of 0.05 and a power of 80%.

RESULTS

Between October 2015 and September 2019, 28 patients (median age 66 years) were enrolled. All patients had regional lymph node involvement at diagnosis. FOLFOXIRI plus bevacizumab was administered in 11 mutated Ras-BRAF patients, whereas the 17 wild-type Ras-BRAF patients received FOLFOXIRI plus panitumumab/cetuximab. Overall, total neoadjuvant therapy was well tolerated and 26 patients (92.9%) completed the programmed strategy. A complete response was achieved in nine cases (32.1%) and a nearly pathological complete response (ypT1 ypN0) in two patients (7.2%). There was no evidence of febrile neutropenia and no grade 4 adverse events were recorded. Radical resection was achieved in all cases.

CONCLUSION

FOLFOXIRI plus targeted agent-based induction chemotherapy and intensified CRT before surgery showed promising clinical activity and was well tolerated in locally advanced rectal cancer patients. This phase II trial provides a strong rationale for phase III studies.

Super-Enhancers in the Regulation of Gene Transcription: General Aspects and Antitumor Targets

Super-enhancers (genome elements that activate gene transcription) are DNA regions with an elevated concentration of transcriptional complexes. These multiprotein structures contain, among other components, the cyclin-dependent kinases 8 and 19. These and other transcriptional protein kinases are regarded as novel targets for pharmacological inhibition by antitumor drug candidates.