1
|
Roth RH, Malfitano MJ, Reilley M, Martin LW. Delayed esophageal anastomotic complication and ramucirumab therapy: A case report. Thorac Cancer 2023; 14:2976-2980. [PMID: 37667428 PMCID: PMC10569901 DOI: 10.1111/1759-7714.15084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 08/01/2023] [Accepted: 08/03/2023] [Indexed: 09/06/2023] Open
Abstract
Current NCCN guidelines for second-line therapy in recurrent or metastatic esophago-gastric cancers recommend the use of VEGF inhibitors such as ramucirumab. VEGF inhibitors have been shown to be associated with gastrointestinal perforation in clinical trials and late colorectal anastomotic leaks in a few case reports. Here, we present a case of late esophageal anastomotic leak in a patient receiving ramucirumab. Case information was obtained from our institution's electronic medical records. The patient was found to have T4N1M0, poorly differentiated invasive adenocarcinoma and subsequently received neoadjuvant chemoradiation followed by hybrid Ivor-Lewis esophagectomy 6 weeks later. He recovered well with no leak or perioperative complications. The patient had disease progression 9 months postoperatively on CT and PET imaging. Sixteen months after surgery he began paclitaxel and ramucirumab and 16 weeks after ramucirumab initiation, he was found to have an esophago-pulmonary fistula in the region of the anastomosis. Biopsies were negative for recurrence at the anastomosis. He died one week later from progressive pneumonia despite stenting. In conclusion, this is the only known report of delayed esophageal anastomotic complication associated with ramucirumab. VEGF inhibitor therapies such as bevacizumab have been associated with late (greater than 3 months postoperative) colorectal anastomotic complications including fistulas and leaks. Risk factors that have been associated are perioperative radiotherapy and history of early postoperative leak. These findings raise concern whether VEGF inhibitor therapy should be used in post-esophagectomy patients with recurrence if these rare but catastrophic events are likely to be terminal.
Collapse
Affiliation(s)
- Robert H. Roth
- Department of AnesthesiologyDartmouth‐Hitch Medical CenterLebanonNew HampshireUSA
| | - Madison J. Malfitano
- Department of General SurgeryMedstar Georgetown University HospitalWashingtonDCUSA
| | - Matthew Reilley
- UVA Health, Division of Medical OncologyCharlottesvilleVirginiaUSA
| | - Linda W. Martin
- UVA Health, Division of Thoracic and Cardiovascular SurgeryCharlottesvilleVirginiaUSA
| |
Collapse
|
2
|
Wu F, Zhou C, Wu B, Zhang X, Wang K, Wang J, Xiao L, Wang G. Adding Adjuvants to Fluoropyrimidine-based Neoadjuvant Chemoradiotherapy for Locally Advanced Rectal Cancer: An Option Worthy of Serious Consideration. J Cancer 2021; 12:417-427. [PMID: 33391438 PMCID: PMC7739002 DOI: 10.7150/jca.48337] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 10/29/2020] [Indexed: 12/28/2022] Open
Abstract
The application of fluoropyrimidine-based neoadjuvant chemoradiotherapy (Fu-nCRT) of locally advanced rectal cancer (LARC) has become a common therapeutic regimen. In order to improve the efficacy and enable more patients to benefit from this treatment, an accumulation of studies have been carried out on the auxiliary use of other drugs with Fu-nCRT. However, due to specific challenges and the potential opportunities that coexist in this field, a more reasonable approach to the mode of treatment remains to be explored. In this review, we have summarized the results of the studies on the combination of Fu-nCRT with cytotoxic drugs, anti-tumor angiogenesis, and anti-EGFR agents, as well as the status of the application of immune checkpoint inhibitors in the neoadjuvant therapy of LARC patients.
Collapse
Affiliation(s)
- Fengpeng Wu
- Department of Radiation Oncology, Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Chaoxi Zhou
- Department of Colorectal Surgery, Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Bingyuan Wu
- Department of Medical Imaging, Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Xiaoxiao Zhang
- Department of Radiation Oncology, Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Kanghua Wang
- Department of Radiation Oncology, Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Jun Wang
- Department of Radiation Oncology, Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Linlin Xiao
- Department of Radiation Oncology, Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Guiying Wang
- Department of Colorectal Surgery, Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| |
Collapse
|
3
|
Baxter NN, Sutradhar R, Dossa F, Fu L, Rochon P, Wei AC, Kennedy ED, Earle CC. Does the presence of an intact primary increase the risk of nonelective colorectal surgery in patients treated with bevacizumab? Colorectal Dis 2020; 22:1974-1983. [PMID: 32767608 DOI: 10.1111/codi.15294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 07/25/2020] [Indexed: 02/08/2023]
Abstract
AIM In patients with incurable metastatic colorectal cancer (mCRC), resection of the primary tumour is debated; however, patients with intact primaries may be at a higher risk of complications requiring surgery when receiving treatment with bevacizumab. Our aim was to estimate the risk of nonelective colorectal surgery in patients undergoing bevacizumab therapy for mCRC and evaluate the association between intact primary tumours and risk of nonelective surgery. METHOD We designed a population-based, retrospective cohort study using administrative and cancer registry data in Ontario, Canada. We included patients with mCRC who received bevacizumab from 1 January 2008 to 31 December 2014. The primary outcome was nonelective colorectal surgery after initiation of bevacizumab. We determined the cumulative incidence of nonelective colorectal surgery among patients with previously resected and unresected primaries, accounting for the competing risk of death. We explored the relationship between previous resection of the primary and need for nonelective surgery using a cause-specific hazards model, controlling for patient, tumour and treatment factors. RESULTS We identified 1840 (32.7%) patients with intact primaries and 3784 (67.3%) patients with prior resection. The cumulative incidence of nonelective surgery 1 year after initiating bevacizumab for all patients was 3.9% (95% CI 3.4-4.5%). One-year cumulative incidence was higher in those with intact primaries than in those with resected primaries (6.1% vs 2.9%, P < 0.0001). After adjustment, an intact primary remained strongly associated with nonelective colorectal surgery (hazard ratio = 2.89, 95% CI 2.32-3.61; P < 0.0001). CONCLUSION Bevacizumab is associated with a low but meaningful risk for serious gastrointestinal complications, necessitating vigilance, particularly among patients with an intact primary tumour.
Collapse
Affiliation(s)
- N N Baxter
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - R Sutradhar
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - F Dossa
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - L Fu
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - P Rochon
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - A C Wei
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - E D Kennedy
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Sinai Health System, Toronto, Ontario, Canada
| | - C C Earle
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
4
|
Influence of concurrent capecitabine based chemoradiotherapy with bevacizumab on the survival rate, late toxicity and health-related quality of life in locally advanced rectal cancer: a prospective phase II CRAB trial. Radiol Oncol 2020; 54:461-469. [PMID: 32738130 PMCID: PMC7585344 DOI: 10.2478/raon-2020-0043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 06/13/2020] [Indexed: 01/02/2023] Open
Abstract
Background Few studies reported early results on efficacy, toxicity of combined modality treatment for locally advanced rectal cancer (LARC) by adding bevacizumab to preoperative chemoradiotherapy, but long-term data on survival, and late complications are lacking. Further, none of the studies reported on the assessment of quality of life (QOL). Patients and methods After more than 5 years of follow-up, we updated the results of our previous phase II trial in 61 patients with LARC treated with neoadjuvant capecitabine, radiotherapy and bevacizumab (CRAB study) before surgery and adjuvant chemotherapy. Secondary endpoints of updated analysis were local control (LC), disease free (DFS) and overall survival (OS), late toxicity and longitudinal health related QOL (before starting the treatment and one year after the treatment) with questionnaire EORTC QLQ-C30 and EORTC QLQ-CR38. Results Median follow-up was 67 months. During the follow-up period, 16 patients (26.7%) died. The 5-year OS, DFS and LC rate were 72.2%, 70% and 92.4%. Patients with pathological positive nodes or pathological T3–4 tumors had significantly worse survival than patients with pathological negative nodes or T0–2 tumors. Nine patients (14.8%) developed grade 33 late complications of combined modality treatment, first event 12 months and last 87 months after operation (median time 48 months). Based on EORTC QLQ-C30 scores one year after treatment there were no significant changes in global QOL and three symptoms (pain, insomnia and diarrhea), but physical and social functioning significantly decreased. Based on QLQ-CR38 scores body image scores significantly increase, problems with weight loss significantly decrease, but sexual dysfunction in men and chemotherapy side effects significantly increase. Conclusions Patients with LARC and high risk factors, such as positive pathological lymph nodes and high pathological T stage, deserve more aggressive treatment in the light of improving long-term survival results. Patients after multimodality treatment should be given greater attention to the regulation of individual aspects of quality of life and the occurrence of late side effects.
Collapse
|
5
|
Machida E, Miyakura Y, Takahashi J, Tamaki S, Ishikawa H, Hasegawa F, Kikugawa R, Tsujinaka S, Lefor AK, Rikiyama T. Bevacizumab is associated with delayed anastomotic leak after low anterior resection with preoperative radiotherapy for rectal cancer: a case report. Surg Case Rep 2019; 5:14. [PMID: 30706233 PMCID: PMC6357210 DOI: 10.1186/s40792-019-0573-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 01/21/2019] [Indexed: 12/14/2022] Open
Abstract
Background Bevacizumab is an anti-angiogenesis agent used to treat patients with metastatic colorectal cancer and is associated with a variety of complications. We present a patient with rectal cancer who developed a delayed anastomotic leak more than 5 years after undergoing low anterior resection. Case report A 78-year-old man with hematochezia was diagnosed with two synchronous rectal cancers 7 years prior to presentation. Preoperative chemo-radiotherapy was given followed by a very low anterior resection. During follow-up, multiple lymph node metastases developed, which were treated with chemotherapy. First-line chemotherapy, capecitabine, oxizaliplatin, and bevacizumab, was given over 3 years, and second-line chemotherapy, capecitabine, irinotecan, and bevacizumab, was administered over a 3-month period. After the last treatment, the patient presented with pneumaturia and fecaluria. Computed tomography scan revealed extraluminal air between the prostate and rectum, adjacent to the anastomotic site. Ulceration and fistula formation were observed on colonoscopy, and contrast radiography demonstrated a fistula at the anastomotic site. An anastomotic-urethral fistula was diagnosed and transverse colostomy was performed. Conclusions This patient highlights a rare late adverse event at the anastomotic site associated with bevacizumab treatment and preoperative chemo-radiotherapy. Signs and symptoms suggesting anastomotic complications should be thoroughly evaluated during bevacizumab treatment, even long after surgical resection.
Collapse
Affiliation(s)
- Erika Machida
- Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitamashi, Saitamaken, 330-8503, Japan
| | - Yasuyuki Miyakura
- Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitamashi, Saitamaken, 330-8503, Japan.
| | - Jun Takahashi
- Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitamashi, Saitamaken, 330-8503, Japan
| | - Sawako Tamaki
- Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitamashi, Saitamaken, 330-8503, Japan
| | - Hideki Ishikawa
- Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitamashi, Saitamaken, 330-8503, Japan
| | - Fumi Hasegawa
- Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitamashi, Saitamaken, 330-8503, Japan
| | - Rina Kikugawa
- Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitamashi, Saitamaken, 330-8503, Japan
| | - Shingo Tsujinaka
- Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitamashi, Saitamaken, 330-8503, Japan
| | | | - Toshiki Rikiyama
- Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitamashi, Saitamaken, 330-8503, Japan
| |
Collapse
|