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Adjuvant chemotherapy after neoadjuvant chemoradiation and proctectomy improves survival irrespective of pathologic response in rectal adenocarcinoma: a population-based cohort study. Int J Colorectal Dis 2022; 37:2137-2148. [PMID: 36048196 DOI: 10.1007/s00384-022-04245-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/24/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND This study sought to determine whether adjuvant chemotherapy (AC) compared to no AC (noAC) after neoadjuvant chemoradiation (CRT) and resection for rectal adenocarcinoma prolongs survival. Current guidelines from expert groups are conflicting, and data to support administering AC to patients who received neoadjuvant CRT are lacking. METHODS A total of 19,867 patients met inclusion/exclusion criteria. Mean age was 58.6 ± 12.0 years, and 12,396 (62.4%) were males. Complete response (CR) was documented in 3801 (19.1%) patients and 8167 (41.1%) received AC. The cohort was stratified into pathological complete (pCR, N = 3801) and incomplete (pIR, N = 16,066) subgroups, and pIR further subcategorized into ypN0 (N = 10,191) and ypN + (N = 5875) subgroups. After propensity score matching, AC was associated with improved OS in the pCR subgroups (mean 139.1 ± 1.9 vs. 134.0 ± 2.2 months; p < 0.001), in pIR ypN0 subgroup (141.6 ± 1.5 vs. 129.9 ± 1.2 months, p < 0.001), and in pIR ypN + subgroup (155.9 ± 5.4 vs. 126.5 ± 7.6 months; p < 0.001). RESULTS AC was associated with improved OS in patients who received neoadjuvant CRT followed by proctectomy for clinical stages II and III rectal adenocarcinoma. This effect persisted irrespective of pathological response status. CONCLUSIONS AC following neoadjuvant CRT and surgery is associated with improved OS in patients with rectal adenocarcinoma. These findings warrant adoption of AC after neoadjuvant CRT and surgery for clinical stage II and III rectal adenocarcinoma.
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Whealon MD, Paulson EC. Benefit or bias: Using retrospective databases to evaluate efficacy of cancer treatments. Colorectal Dis 2022; 24:899-903. [PMID: 36067051 DOI: 10.1111/codi.16302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 08/14/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Matthew D Whealon
- Department of Surgery, University of California Irvine, Orange, California, United States
| | - Emily Carter Paulson
- Department of Surgery, Corporal Michael J. Crescenz VA Medical Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Lupattelli M, Maranzano E, Bellavita R, Tarducci R, Latini R, Castagnoli P, Bufalari A, Corgna E, Pinaglia D, Rossetti R, Ribacchi R, Latini P. Adjuvant Radiochemotherapy in High-Risk Rectal Cancer Results of a Prospective Non-Randomized Study. TUMORI JOURNAL 2018; 87:239-47. [PMID: 11693802 DOI: 10.1177/030089160108700406] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims and Background In 1990 the National Institutes of Health Consensus Conference recommended adjuvant combined therapy for patients with radically resected rectal cancer at high risk for relapse (ie, stage II-III). The purpose of our prospective non-randomized study was to verify the feasibility and effectiveness of postoperative radiochemotherapy in terms of improvement in disease-free and overall survival in this patient subgroup. Study design From January 1990 to October 1998, 191 consecutive patients with radically resected stage II-III rectal cancer were treated. A total of 159 patients with a 24-month follow-up were assessable for toxicity and survival. Anterior resection was performed in 129 (81%) and abdomino-perineal resection in 30 (19%) patients. Fifty-four (34%) stage II and 105 (66%) stage III patients entered the study. Within 45-60 days of surgery, all patients received 5-fluorouracil chemotherapy at the dose of 500 mg/m2 as an iv bolus on days 1-5, every 4 weeks, for 6 cycles. Chemotherapy cycles III and IV were administered at the same daily dose on radiotherapy days 1-3 and 29-31. Radiotherapy consisted of 45 Gy/25 fractions plus a boost dose of 5.4 Gy. Results After a median follow-up of 57 months (range, 25-123), overall recurrent disease was reported in 58 (36%) patients: local, systemic, and both local and systemic relapses in 12 (8%), 37 (23%) and 9 (6%) cases, respectively. According to local extension, recurrence rates were 15% and 48% in stage II and III, respectively. Five-year overall and disease-free survival were 71% and 66%, respectively. Overall survival was 87% in stage II and 62% in stage III patients, and disease-free survival was 84% and 56% in stage II and III disease, respectively. According to univariate and multivariate analyses, significant prognostic factors for better tumor control were: stage (II vs III, P <0.001), the number of involved nodes (≤3 vs >3, P <0.0001), and no extracapsular node invasion (P <0.0001). The recommended dose of the combined radiochemotherapy regimen was generally well tolerated. The incidence of any ≥ grade 3 acute toxicity (according to the WHO scale) was 13% diarrhea, 11% proctitis, 5% perineal dermatitis and 4% myelosuppression. Four (3%) patients had radiotherapy-related severe late toxicity which required surgery. Conclusions The study provided recurrence rates and survival similar to other adjuvant radiochemotherapy regimens published in the literature. However, in view of the low 5-year survival rate recorded in stage III patients, a different approach should be investigated.
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Affiliation(s)
- M Lupattelli
- Radiation Oncology Center, Policlinico Hospital of Perugia, Italy
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Xu Z, Mohile SG, Tejani MA, Becerra AZ, Probst CP, Aquina CT, Hensley BJ, Arsalanizadeh R, Noyes K, Monson JR, Fleming FJ. Poor compliance with adjuvant chemotherapy use associated with poorer survival in patients with rectal cancer: An NCDB analysis. Cancer 2016; 123:52-61. [DOI: 10.1002/cncr.30261] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 06/14/2016] [Accepted: 07/06/2016] [Indexed: 12/22/2022]
Affiliation(s)
- Zhaomin Xu
- Department of Surgery; University of Rochester Medical Center; Rochester New York
| | - Supriya Gupta Mohile
- Division of Hematology/Oncology, Department of Medicine; University of Rochester Medical Center; Rochester New York
| | - Mohamedtaki Abdulaziz Tejani
- Division of Hematology/Oncology, Department of Medicine; University of Rochester Medical Center; Rochester New York
| | - Adan Z. Becerra
- Department of Surgery; University of Rochester Medical Center; Rochester New York
| | - Christian P. Probst
- Department of Surgery; University of Rochester Medical Center; Rochester New York
| | | | - Bradley J. Hensley
- Department of Surgery; University of Rochester Medical Center; Rochester New York
| | - Reza Arsalanizadeh
- Department of Surgery; University of Rochester Medical Center; Rochester New York
| | - Katia Noyes
- Department of Surgery; University of Rochester Medical Center; Rochester New York
| | - John R.T. Monson
- Center for Colon and Rectal Surgery, Florida Hospital Medical Group; University of Central Florida College of Medicine; Orlando Florida
| | - Fergal J. Fleming
- Department of Surgery; University of Rochester Medical Center; Rochester New York
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Genovesi D, Cèfaro GA, Vinciguerra A, Augurio A, D'alessandro M, Borzillo V, Marchese R, Di Nicola M. Retrospective Long-Term Results and Prognostic Factors of Postoperative Treatment for UICC Stages II and III Rectal Cancer. TUMORI JOURNAL 2009; 95:675-82. [DOI: 10.1177/030089160909500606] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aims To retrospectively evaluate 5-year local control, disease-free survival, cancer-specific survival and overall survival rates in patients with UICC stages II and III rectal cancer treated with adjuvant therapy and especially to analyze the impact of some prognostic factors on clinical outcome at univariate and multivariate analyses. Methods and Materials We retrospectively reviewed 306 patients treated with postoperative 5-fluorouracil-based chemoradiation (278 patients) or radiotherapy alone (28 patients) after curative surgery. The following prognostic factors were considered at univariate and multivariate analyses: age, sex, tumor location, surgery procedure, pathological stage, histology, tumor grade, surgical margins and radiotherapy technique. Results The 5-year actuarial rates for local control, disease-free survival, cancer-specific survival and overall survival were respectively 89.7%, 59.7%, 68.6% and 61.4% for the 278 patients (91%) treated with postoperative chemoradiation. Univariate analysis showed that abdominal-perineal resection impacted disease-free survival and that the T4 variable had an impact on cancer-specific survival and disease-free survival. Instead, age ≥70, N2, IIIB (p T3 p N1) and IIIC (pT3 p N2) stage impacted cancer-specific survival, disease-free survival and rate of distant metastases. Multivariate analysis showed as significant variables age ≥70 years, pN1 and pN2 and extraperitoneal tumor location. Conclusions Our retrospective study showed a good 5-year local control. Factors such as individual pT4, pN1, pN2, age ≥70 years, abdominal-perineal resection, stages IIIB-IIIC versus II-IIIA and extraperitoneal tumor location negatively influenced disease-free survival, distant metastases and cancer-specific survival. Differences exist between stages II and III rectal cancer and treatment modulation and intensification are required in order to offer the most appropriate and effective adjuvant treatment and to improve survival of rectal cancer patients.
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Affiliation(s)
- Domenico Genovesi
- Radiation Oncology Department, “G. d'Annunzio University”, Chieti, Italy
| | | | | | - Antonietta Augurio
- Radiation Oncology Department, “G. d'Annunzio University”, Chieti, Italy
| | - Marco D'alessandro
- Radiation Oncology Department, “G. d'Annunzio University”, Chieti, Italy
| | - Valentina Borzillo
- Radiation Oncology Department, “G. d'Annunzio University”, Chieti, Italy
| | - Rita Marchese
- Radiation Oncology Department, “G. d'Annunzio University”, Chieti, Italy
| | - Marta Di Nicola
- Laboratory of Biostatistics, Department of Biomedical Science, “G. d'Annunzio University”, Chieti, Italy
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Valentini V, Morganti AG, Macchia G, Mantini G, Mattiucci GC, Brizi MG, Alfieri S, Bossola M, Pacelli F, Sofo L, Doglietto G, Cellini N. Intraoperative radiation therapy in resected pancreatic carcinoma: long-term analysis. Int J Radiat Oncol Biol Phys 2008; 70:1094-9. [PMID: 18313525 DOI: 10.1016/j.ijrobp.2007.07.2346] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2007] [Revised: 07/16/2007] [Accepted: 07/16/2007] [Indexed: 12/30/2022]
Abstract
PURPOSE The combination of external radiotherapy (RT) plus intraoperative radiotherapy (IORT) in patients with pancreatic cancer is still debated. This study presents long-term results (minimum follow-up, 102 months) for 26 patients undergoing integrated adjuvant RT (external RT+IORT). METHODS AND MATERIALS From 1990 to 1995, a total of 17 patients with pancreatic cancer underwent IORT (10 Gy) and postoperative external RT (50.4 Gy). Preoperative "flash" RT was included for the last 9 patients. The liver and pancreatic head received 5 Gy (two 2.5-Gy fractions) the day before surgery. In the subsequent period (1996-1998), 9 patients underwent preoperative concomitant chemoradiation (39.6 Gy) with 5-fluorouracil, IORT (10 Gy), and adjuvant chemotherapy. RESULTS Preoperative chemoradiation was completed in all patients, whereas postoperative therapy was completed in 13 of 17 patients. All 26 patients underwent pancreatectomy (25 R0 and one R1 resections). One patient died of postoperative complications (3.8%) not related to IORT. The 9 patients undergoing concomitant chemoradiation were candidates for adjuvant chemotherapy; however, only 4 of 9 underwent adjuvant chemotherapy. At last follow-up, 4 patients (15.4%) were alive and disease free. Disease recurrence was documented in 20 patients (76.9%). Sixteen patients (61.5%) showed distant metastasis, and 5 patients (19.2%) showed local recurrence. The incidence of local recurrence in R0 patients was 4 of 25 (16.0%). The overall 5-year survival rate was 15.4%. There was significant correlation with overall survival of tumor diameter (p=0.019). CONCLUSIONS The incidence of local recurrence in this long follow-up series (19.2%) was definitely less than that reported in other studies of adjuvant RT (approximately 50%), suggesting a positive impact on local control of integrated adjuvant RT (IORT+external RT).
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Affiliation(s)
- Vincenzo Valentini
- Department of Radiotherapy, Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy
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Uzcudun AE, Batlle JF, Velasco JC, Sánchez Santos ME, Carpeño JDC, Grande AG, Juberías AM, Piñeiro EH, Olivar LM, García AG. Efficacy of preoperative radiation therapy for resectable rectal adenocarcinoma when combined with oral tegafur-uracil modulated with leucovorin: results from a phase II study. Dis Colon Rectum 2002; 45:1349-58. [PMID: 12394434 DOI: 10.1007/s10350-004-6424-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.7] [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 the efficacy of preoperative radiation therapy for resectable rectal adenocarcinoma (T3-T4) when delivered in combination with chemotherapy (oral tegafur-uracil modulated with leucovorin). METHODS Thirty-eight patients (23 males; mean age, 62 years.) with histologically proven rectal adenocarcinoma with primary tumor clinical classification T3-T4 (resectable) and N0 or N1-N2, according to TNM staging system, took part in the present clinical trial. After tumor and metastasis resectability confirmation, radiation therapy was administered by delivering a dose of 45 Gy in 25 fractions for 5 weeks. Chemotherapy treatment was initiated on the same day as radiotherapy and consisted of intravenous infusion of 6S-steroisomer of leucovorin 250 mg/m /day in 2 hours on Day 1, followed by oral 350 or 300 mg/m /day of tegafur (a 5-fluorouracil prodrug) plus uracil on Days 1 to 14 divided into 2 daily doses, and oral 6S-steroisomer of leucovorin 7.5 mg/12 hours on Days 2 to 14, with a total of 102 courses of neoadjuvant chemotherapy (, mean of 2.7 courses per patient). Six additional courses of tegafur-uracil were given postoperatively to all 38 patients but 1 who refused. RESULTS As a result of preoperative chemoradiation treatment, 4 (10.5 percent) complete responses, 20 (52.6 percent) partial responses, and 14 (36.8 percent) patients with disease stabilization were observed. No patients had preoperative disease progression. Histologically proven downstaging was observed in 23 (60 percent) patients. On initial evaluation, only 39 percent of patients were considered as being good candidates for sphincter-preserving surgery; however, on preoperative chemoradiation completion this figure increased up to 60 percent. For the 23 patients eventually undergoing sphincter-preserving surgery, postoperative sphincter function assessment showed excellent function in 15 (65 percent) patients, good in 5 (22 percent), fair in 2 (9 percent), and poor in 1(4 percent). With a median follow-up of 37 (range, 10-62) months, local failure was found in 3 (8 percent) patients and distant failure in 2 (5 percent). Three-year actuarial disease-free survival and 3-year overall survival rates were 83 and 90 percent, respectively. Local control rate was 92 percent. Toxicity and postoperative complication rates were reasonable. CONCLUSIONS Our neoadjuvant radiation therapy protocol is efficient for the preoperative treatment of resectable rectal adenocarcinoma when combined with chemotherapy (oral tegafur-uracil modulated with leucovorin). this protocol needs to be tested in a phase-III clinical trial with a larger sample size.
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Abstract
Colorectal cancer is still a majorhealth and social problem. However, many important advances in treatment have been made in the last 4 to 5 years, and more optimism is now justified both among clinicians and patients. In surgically resectable disease, adjuvant chemotherapy has been clearly demonstrated as able to increase overall survival in patients with colon cancer Dukes' stage C, whereas the role of medical treatment in patients with Dukes' stage B colon cancer is still controversial. At present, the standard regimen is bolus fluorouracil (5-FU) modulated by folinic acid (leucovorin) for 6 months. For rectal cancer, the best adjuvant treatment seems to be represented by radiotherapy (better if administered preoperatively) combined with chemotherapy (usually based on modulated or continuously infused 5-FU). In advanced disease, many new drugs have recently emerged: the most active regimens are those combining an optimal modality of 5-FU administration (i.e. continuous infusion) and one of the most active innovative compounds (irinotecan or oxaliplatin). The role of the oral drugs (e.g. tegafur/uracil, capecitabine) is still under investigation as is the combination of agents excluding 5-FU. It is now recognised that first-line treatment must be offered to all suitable pa- tients, even though asymptomatic, and that a second-line therapy (chiefly with irinotecan) is of value in many patients with cancer that progresses during treatment with 5-FU. From a strategic point of view, the best sequence of drugs/regimens has not yet been defined, while the duration and timing of chemotherapy is still a matter for clinical research. Finally, there is an increasing interest in the role of biological prognostic factors as an aid to a patient-tailored therapy, both in the adjuvant setting and in advanced disease. To achieve further progress in knowledge in this field, we strongly recommended that more and more patients are included in clinical trials.
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Affiliation(s)
- R F Labianca
- Medical Oncology Unit, Ospedali Riuniti, Bergamo, Italy.
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Abstract
Rectal cancer accounts for about 10% of new cancer cases each year. It strikes men and women at nearly the same rate, generally in the range of 50-80 years of age, with rising incidence with age. Despite simple screening procedures rectal cancer is often advanced when discovered. Current trends in the management of cancer have focused on organ preservation and improved quality of life without compromising the overall survival. During the last decade substantial progress has been made in treatment modalities: new and improved radiation techniques (conformal radiotherapy, altered fractionation, brachytherapy), chemotherapy (protracted infusion, use of radiosensitizers) and development of surgical procedures-enabling safer postoperative irradiation. In patients with advanced/unresectable disease aggressive combined chemoradiation can be added prior to surgery to downstage the tumour and increase the proportion treated with anal-rectal-sparing procedures. Preoperative chemoradiation therapy regimens are as safe and tolerable as the standard postoperative treatment. In this presentation indications for preoperative radiochemotherapy will be discussed in detail, together with treatment-related side effects, prognostic parameters, tumour response and outcome. Different irradiation settings and chemotherapy schedules are described. In patients with primary resectable disease (mainly Dukes C) several prospective randomised trials have shown less local recurrence with postoperative combined modality therapy.
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Affiliation(s)
- H Sobat
- University Hospital for Tumors, Zagreb, Croatia
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Svoboda V, Beck-Bornholdt HP, Herrmann T, Alberti W, Jung H. Late complications after a combined pre and postoperative (sandwich) radiotherapy for rectal cancer. Radiother Oncol 1999; 53:177-87. [PMID: 10660196 DOI: 10.1016/s0167-8140(99)00138-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND PURPOSE The purpose of this study was to analyse the treatment related side effects, the outcome and the prognostic significance of clinical parameters in two groups of patients with rectal cancer receiving either preoperative or pre and postoperative radiotherapy after radical resection. The authors of this study were not involved in the radiation treatments. PATIENTS AND METHODS From 1986 to 1990, 63 patients received a combined pre and postoperative (sandwich) radiotherapy. Preoperative irradiation was given in four fractions of 5 Gy each applied within 2 or 3 days. Postoperative irradiation consisted mostly of 15 x 2 Gy (31 patients) but the range was 20-40 Gy. The results were compared with those on 73 patients who only received preoperative radiotherapy in the same time period. The distribution of prognostic factors was not very different between treatment groups. Out of 63 patients in the sandwich group, 22 received concurrent chemotherapy and 18 also received radiotherapy to the liver. Radical surgery usually followed on the day after the last preoperative radiotherapy session. Median follow-up of survivors was 6 years. RESULTS Local tumour control was 88% after 5 years and 84% after 8 years in the sandwich group, and 90 and 85%, respectively, in the preoperative radiotherapy group. Thus, tumour control was similar for the two radiotherapy regimens applied. However, the percentage of patients suffering from one or more complications after 5 years was 84% in the sandwich and 17% in the preoperative radiotherapy group. The incidence of severe late complications (grade > or = 3) was recorded as a function of time after start of treatment. In the sandwich group the actuarial rates of late complications at 5 years (and the median time to diagnosis) were 53% (27 months) for anorectum, 43% (37 months) for bladder, 28% (51 months) for bone, 19% (36 months) for dermis, 47% (48 months) for ileum, 41% (32 months) for lymphatic and soft tissue, and 44% (53 months) for ureters. CONCLUSIONS Severe late reactions did not occur within a certain period of time, but continued to appear for at least 10 years after radiotherapy. Sandwich therapy, as given in this series, did not appear to give a greater tumour control than preoperative radiotherapy alone, whereas the rate of complications was drastically enhanced. Thus, the rationale of a sandwich therapy with a long time interval between surgery and postoperative irradiation appears questionable.
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Affiliation(s)
- V Svoboda
- Institute of Biophysics and Radiobiology, University of Hamburg, Germany
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Chapuis P, Bokey L. Where are we now with adjuvant therapy for rectal cancer? THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1997; 67:588-90. [PMID: 9322691 DOI: 10.1111/j.1445-2197.1997.tb04602.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- P Chapuis
- University of Sydney, Department of Colon and Rectal Surgery, Concord Hospital, New South Wales, Australia
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Chapuis P, Killingback M, Yuile P. BEST PRACTICE PARAMETERS FOR MANAGEMENT OF RECTAL CANCER: RECOMMENDATIONS OF THE COLORECTAL SURGICAL SOCIETY OF AUSTRALIA: REPLY. ANZ J Surg 1997. [DOI: 10.1111/j.1445-2197.1997.tb01945.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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