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Alvarez JA, Shi Q, Dasari A, Garcia-Aguilar J, Sanoff H, George TJ, Hong T, Yothers G, Philip P, Nelson G, Al Baghdadi T, Alese OB, Zambare W, Omer D, Verheij FS, Bercz A, Kim MJ, Buckley J, Williams H, George M, Garcia R, Gallagher P, O'Reilly EM, Meyerhardt JA, Crawley J, Shergill A, Horvat N, Romesser PB, Hall W, Smith JJ. Alliance A022104/NRG-GI010: The Janus Rectal Cancer Trial: a randomized phase II/III trial testing the efficacy of triplet versus doublet chemotherapy regarding clinical complete response and disease-free survival in patients with locally advanced rectal cancer. BMC Cancer 2024; 24:901. [PMID: 39060961 PMCID: PMC11282593 DOI: 10.1186/s12885-024-12529-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Accepted: 06/17/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND Recent data have demonstrated that in locally advanced rectal cancer (LARC), a total neoadjuvant therapy (TNT) approach improves compliance with chemotherapy and increases rates of tumor response compared to neoadjuvant chemoradiation (CRT) alone. They further indicate that the optimal sequencing of TNT involves consolidation (rather than induction) chemotherapy to optimize complete response rates. Data, largely from retrospective studies, have also shown that patients with clinical complete response (cCR) after TNT may be managed safely with the watch and wait approach (WW) instead of preemptive total mesorectal resection (TME). However, the optimal consolidation chemotherapy regimen to achieve cCR has not been established, and a randomized clinical trial has not robustly evaluated cCR as a primary endpoint. Collaborating with a multidisciplinary oncology team and patient groups, we designed this NCI-sponsored study of chemotherapy intensification to address these issues and to drive up cCR rates, to provide opportunity for organ preservation, improve quality of life for patients and improve survival outcomes. METHODS In this NCI-sponsored multi-group randomized, seamless phase II/III trial (1:1), up to 760 patients with LARC, T4N0, any T with node positive disease (any T, N +) or T3N0 requiring abdominoperineal resection or coloanal anastomosis and distal margin within 12 cm of anal verge will be enrolled. Stratification factors include tumor stage (T4 vs T1-3), nodal stage (N + vs N0) and distance from anal verge (0-4; 4-8; 8-12 cm). Patients will be randomized to receive neoadjuvant long-course chemoradiation (LCRT) followed by consolidation doublet (mFOLFOX6 or CAPOX) or triplet chemotherapy (mFOLFIRINOX) for 3-4 months. LCRT in both arms involves 4500 cGy in 25 fractions over 5 weeks + 900 cGy boost in 5 fractions with a fluoropyrimidine (capecitabine preferred). Patients will undergo assessment 8-12 (± 4) weeks post-TNT completion. The primary endpoint for the phase II portion will compare cCR between treatment arms. A total number of 312 evaluable patients (156 per arm) will provide statistical power of 90.5% to detect a 17% increase in cCR rate, at a one-sided alpha = 0.048. The primary endpoint for the phase III portion will compare disease-free survival (DFS) between treatment arms. A total of 285 DFS events will provide 85% power to detect an effect size of hazard ratio 0.70 at a one-sided alpha of 0.025, requiring enrollment of 760 patients (380 per arm). Secondary objectives include time-to event outcomes (overall survival, organ preservation time and time to distant metastasis) and adverse event rates. Biospecimens including archival tumor tissue, plasma and buffy coat, and serial rectal MRIs will be collected for exploratory correlative research. This study, activated in late 2022, is open across the NCTN and had accrued 330 patients as of May 2024. Study support: U10CA180821, U10CA180882, U24 CA196171; https://acknowledgments.alliancefound.org . DISCUSSION Building on data from modern day rectal cancer trials and patient input from national advocacy groups, we have designed The Janus Rectal Cancer Trial studying chemotherapy intensification via a consolidation chemotherapy approach with the intent to enhance cCR and DFS rates, increase organ preservation rates, and improve quality of life for patients with rectal cancer. TRIAL REGISTRATION Clinicaltrials.gov ID: NCT05610163; Support includes U10CA180868 (NRG) and U10CA180888 (SWOG).
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Affiliation(s)
- Janet A Alvarez
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-201, New York, NY, 10065, USA
| | | | - Arvind Dasari
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Julio Garcia-Aguilar
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-201, New York, NY, 10065, USA
| | - Hanna Sanoff
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Thomas J George
- University of Florida Health Cancer Center, University of Florida, Gainesville, FL, USA
| | | | | | | | | | | | | | - Wini Zambare
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-201, New York, NY, 10065, USA
| | - Dana Omer
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-201, New York, NY, 10065, USA
| | - Floris S Verheij
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-201, New York, NY, 10065, USA
| | - Aron Bercz
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-201, New York, NY, 10065, USA
| | - Min Jung Kim
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-201, New York, NY, 10065, USA
| | - James Buckley
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-201, New York, NY, 10065, USA
| | - Hannah Williams
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-201, New York, NY, 10065, USA
| | - Manju George
- COLONTOWN/Paltown Development Foundation, Crownsville, MD, USA
| | | | | | - Eileen M O'Reilly
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-201, New York, NY, 10065, USA
| | | | | | | | - Natally Horvat
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-201, New York, NY, 10065, USA
| | - Paul B Romesser
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-201, New York, NY, 10065, USA
| | - William Hall
- Medical College of Wisconsin, Milwaukee, WI, USA
| | - J Joshua Smith
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-201, New York, NY, 10065, USA.
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Alvarez J, Shi Q, Dasari A, Garcia-Aguilar J, Sanoff H, George TJ, Hong TS, Yothers G, Philip PA, Nelson GD, Al Baghdadi T, Alese O, Zambare W, Omer DM, Verheij FS, Buckley J, Williams H, George M, Garcia R, O'Reilly EM, Meyerhardt JA, Shergill A, Horvat N, Romesser PB, Hall WA, Smith JJ. ALLIANCE A022104/NRG-GI010: The Janus Rectal Cancer Trial: a randomized phase II/III trial testing the efficacy of triplet versus doublet chemotherapy regarding clinical complete response and disease-free survival in patients with locally advanced rectal cancer. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.04.25.24306396. [PMID: 38712176 PMCID: PMC11071544 DOI: 10.1101/2024.04.25.24306396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
Background Recent data have demonstrated that in locally advanced rectal cancer (LARC), a total neoadjuvant therapy (TNT) approach improves compliance with chemotherapy and increases rates of tumor response compared to neoadjuvant chemoradiation (CRT) alone. They further indicate that the optimal sequencing of TNT involves consolidation (rather than induction) chemotherapy to optimize complete response rates. Data, largely from retrospective studies, have also shown that patients with clinical complete response (cCR) after neoadjuvant therapy may be managed safely with the watch and wait approach (WW) instead of preemptive total mesorectal resection (TME). However, the optimal consolidation chemotherapy regimen to achieve cCR has not been established, and a randomized clinical trial has not robustly evaluated cCR as a primary endpoint. Collaborating with a multidisciplinary oncology team and patient groups, we designed this NCI-sponsored study of chemotherapy intensification to address these issues and to drive up cCR rates, to provide opportunity for organ preservation, improve quality of life for patients and improve survival outcomes. Methods In this NCI-sponsored multi-group randomized, seamless phase II/III trial (1:1), up to 760 patients with LARC, T4N0, any T with node positive disease (any T, N+) or T3N0 requiring abdominoperineal resection or coloanal anastomosis and distal margin within 12 cm of anal verge will be enrolled. Stratification factors include tumor stage (T4 vs T1-3), nodal stage (N+ vs N0) and distance from anal verge (0-4; 4-8; 8-12 cm). Patients will be randomized to receive neoadjuvant long course chemoradiation (LCRT) followed by consolidation doublet (mFOLFOX6 or CAPOX) or triplet chemotherapy (mFOLFIRINOX) for 3-4 months. LCRT in both arms involves 4500 cGy in 25 fractions over 5 weeks + 900 cGy boost in 5 fractions with a fluoropyrimidine (capecitabine preferred). Patients will undergo assessment 8-12 (+/- 4) weeks post-TNT completion. The primary endpoint for the phase II portion will compare cCR between treatment arms. A total number of 296 evaluable patients (148 per arm) will provide statistical power of 90.5% to detect an 17% increase in cCR rate, at a one-sided alpha=0.048. The primary endpoint for the phase III portion will compare disease-free survival (DFS) between treatment arms. A total of 285 DFS events will provide 85% power to detect an effect size of hazard ratio 0.70 at a one-sided alpha of 0.025, requiring enrollment of 760 patients (380 per arm). Secondary objectives include time-to event outcomes (overall survival, organ preservation time and time to distant metastasis) and adverse effects. Biospecimens including archival tumor tissue, plasma and buffy coat in EDTA tubes, and serial rectal MRIs will be collected for exploratory correlative research. This study, activated in late 2022, is open across the NCTN and has a current accrual of 312. Support: U10CA180821, U10CA180882, U24 CA196171; https://acknowledgments.alliancefound.org . Discussion Building off of data from modern day rectal cancer trials and patient input from national advocacy groups, we have designed the current trial studying chemotherapy intensification via a consolidation chemotherapy approach with the intent to enhance cCR and DFS rates, increase organ preservation rates, and improve quality of life for patients with rectal cancer. Trial Registration Clinicaltrials.gov ID: NCT05610163 ; Support includes U10CA180868 (NRG) and U10CA180888 (SWOG).
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Promises and Challenges of Predictive Blood Biomarkers for Locally Advanced Rectal Cancer Treated with Neoadjuvant Chemoradiotherapy. Cells 2023; 12:cells12030413. [PMID: 36766755 PMCID: PMC9913546 DOI: 10.3390/cells12030413] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 01/24/2023] [Indexed: 01/27/2023] Open
Abstract
The treatment of locally advanced rectal cancer (LARC) requires a multimodal approach combining neoadjuvant radiotherapy or chemoradiotherapy (CRT) and surgery. Predicting tumor response to CRT can guide clinical decision making and improve patient care while avoiding unnecessary toxicity and morbidity. Circulating biomarkers offer both the advantage to be easily accessed and followed over time. In recent years, biomarkers such as proteins, blood cells, or nucleic acids have been investigated for their predictive value in oncology. We conducted a comprehensive literature review with the aim to summarize the status of circulating biomarkers predicting response to CRT in LARC. Forty-nine publications, of which forty-seven full-text articles, one review and one systematic review, were retrieved. These studies evaluated circulating markers (CEA and CA 19-9), inflammatory biomarkers (CRP, albumin, and lymphocytes), hematologic markers (hemoglobin and thrombocytes), lipids and circulating nucleic acids (cell-free DNA [cfDNA], circulating tumor DNA [ctDNA], and microRNA [miRNA]). Post-CRT CEA levels had the most consistent association with tumor response, while cfDNA integrity index, MGMT promoter methylation, ERCC-1, miRNAs, and miRNA-related SNPs were identified as potential predictive markers. Although circulating biomarkers hold great promise, inconsistent results, low statistical power, and low specificity and sensibility prevent them from reliably predicting tumor response following CRT. Validation and standardization of methods and technologies are further required to confirm results.
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Lordick F, Gockel I. Chances, risks and limitations of neoadjuvant therapy in surgical oncology. Innov Surg Sci 2016; 1:3-11. [PMID: 31579713 PMCID: PMC6753981 DOI: 10.1515/iss-2016-0004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 07/04/2016] [Indexed: 01/19/2023] Open
Abstract
Over the last decades, neoadjuvant treatment has been established as a standard of care for a variety of tumor types in visceral oncology. Neoadjuvant treatment is recommended in locally advanced esophageal and gastric cancer as well as in rectal cancer. In borderline resectable pancreatic cancer, neoadjuvant therapy is an emerging treatment concept, whereas in resectable colorectal liver metastases, neoadjuvant treatment is often used, although the evidence for improvement of survival outcomes is rather weak. What makes neoadjuvant treatment attractive from a surgical oncology viewpoint is its ability to shrink tumors to a smaller size and to increase the chances for complete resection with clear surgical margins, which is a prerequisite for cure. Studies suggest that local tumor control is increased in some visceral tumor types, especially with neoadjuvant chemoradiotherapy. In some other studies, a better control of systemic disease has contributed to significantly improved survival rates. Additionally, delaying surgery offers the chance to bring the patient into a better general condition for major surgery, but it also confers the risk of progression. Although it is a relatively rare event, cancers may progress locally during neoadjuvant treatment or distant metastases may occur, jeopardizing a curative surgical treatment approach. Although this is seen as risk of neoadjuvant treatment, it can also be seen as a chance to select only those patients for surgery who have a better control of systemic disease. Some studies showed increased perioperative morbidity in patients who underwent neoadjuvant treatment, which is another potential disadvantage. Optimal multidisciplinary teamwork is key to controlling that risk. Meanwhile, the neoadjuvant treatment period is also used as a "window of opportunity" for studying the activity of novel drugs and for investigating predictive and prognostic biomarkers of chemoradiotherapy and radiochemotherapy. Although the benefits of neoadjuvant treatment have been clearly established, the risk of overtreatment of cancers with an unfavorable prognosis remains an issue. All indications for neoadjuvant treatment are based on clinical staging. Even if staging is done meticulously, making use of all recommended diagnostic modalities, the risk of overstaging and understaging remains considerable and may lead to false indications for neoadjuvant treatment. Finally, despite all developments and emerging concepts in medical oncology, many cancers remain resistant to the currently available drugs and radiation. This may in part be due to specific molecular resistance mechanisms that are marginally understood thus far. Neoadjuvant treatment has been one of the major advances in multidisciplinary oncology in the last decades, requiring a dedicated treatment team and an optimal infrastructure for complex oncology care. This article discusses the goals and novel directions as well as limitations in neoadjuvant treatment of visceral cancers.
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Affiliation(s)
- Florian Lordick
- University Cancer Center Leipzig (UCCL), University Hospital Leipzig, Liebigstr. 20, Leipzig 04103, Germany
| | - Ines Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Medicine Leipzig, Leipzig, Germany
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Li Q, Shi R, Wang Y, Niu X. TAGLN suppresses proliferation and invasion, and induces apoptosis of colorectal carcinoma cells. Tumour Biol 2012; 34:505-13. [PMID: 23138394 DOI: 10.1007/s13277-012-0575-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Accepted: 10/24/2012] [Indexed: 12/14/2022] Open
Abstract
In order to find the correlation between transgelin gene (TAGLN) and colorectal carcinoma occurrence, we investigated the expression of TAGLN in colorectal carcinoma tissue samples and colorectal carcinoma LoVo cells. Meanwhile, the effects of TAGLN on the characteristics of LoVo cells were also examined. The expressions of TAGLN in colorectal carcinoma tissues, adjacent normal tissues, and LoVo cells were detected by the Western blot method. The recombinant plasmid pcDNA3.1-TAGLN was established and transfected into LoVo cells with the help of Lipofectamine™ 2000. At the same time, the TAGLN siRNA was transfected into LoVo cells in another group. Forty-eight hours later, the expressions of TAGLN in all groups were assayed by Western blot, and the cell viability was analyzed by MTT (3-(4, 5-dimethylthiazol-2-yl)-2, 5-diphenyltetrazolium bromide) assay. The cell cycle and cell apoptosis were examined by flow cytometry, and the cell invasive ability was analyzed by Transwell invasion experiment. The effect of TALGN on the expression of matrix metalloproteinase 9 (MMP9) was detected by Western blot. Western blot analysis showed that the expressions of TALGN in colorectal carcinoma tissues and LoVo cells were significantly decreased compared with colorectal carcinoma adjacent normal tissues (p < 0.01). In the overexpression or RNAi experiments, the plasmid pcDNA3.1-TAGLN significantly enhanced TALGN expression (p < 0.01), and TAGLN siRNA significantly decreased TAGLN expression (p < 0.01) in LoVo cells 48 h after transfection. In addition, MTT assay indicated that the cell viability of LoVo cells in the pcDNA3.1-TAGLN transfection group was significantly lower than that in the untransfected control group (p < 0.05). Furthermore, the overexpression of TAGLN significantly lowered the cell proliferation index (p < 0.05) and improved cell apoptosis (p < 0.01) in LoVo cells. In Transwell invasive experiments, the cell number, which had migrated through the chamber membrane, significantly decreased in the pcDNA3.1-TAGLN transfection group (p < 0.05) and significantly increased in the TAGLN knockdown group (p < 0.05) compared to the untransfected control group. At the same time, the expression of MMP9 was notably inhibited in the pcDNA3.1-TAGLN transfection group (p < 0.01). The expressions of TAGLN were inhibited in colorectal carcinoma tissues and colorectal carcinoma LoVo cells. The study also demonstrated that TAGLN could attenuate the proliferation and invasive ability of LoVo cells and enhance LoVo cell apoptosis. Furthermore, the expression of MMP9 was also inhibited by TAGLN. All these results could bring us a new perspective for biological therapy in colorectal carcinoma.
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Affiliation(s)
- Qinmin Li
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, 210029, People's Republic of China
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