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Ayala-de Miguel C, Jiménez-Castro J, Sánchez-Vegas A, Díaz-López S, Chaves-Conde M. Third-line treatment and beyond in metastatic colorectal cancer: What do we have and what can we expect? Crit Rev Oncol Hematol 2024; 202:104454. [PMID: 39043356 DOI: 10.1016/j.critrevonc.2024.104454] [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: 05/12/2024] [Revised: 07/11/2024] [Accepted: 07/13/2024] [Indexed: 07/25/2024] Open
Abstract
Colorectal cancer remains the third most common cancer worldwide and the second cause of cancer-related death. Treatment advances and precision oncological medicine for these tumours have been stalled in comparison to those for other common tumours such as lung and breast cancer. However, the recent publication of the SUNLIGHT trial results with the trifluridine/tipiracil (TAS-102)-bevacizumab combination and the irruption of new molecular targets with guided treatments have opened new possibilities in third-line metastatic colorectal cancer management. Anti-EGFR rechallenge, anti-HER2 targeted therapies or the promising results of Pressurised Intraperitoneal Aerosol Chemotherapy (PIPAC), are some of the available options that may modify what is presumably third-line colorectal treatment. Hereby, we present the evidence of the different treatment options in third-line colorectal cancer and beyond, as well as the possibilities of sequencing them.
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Affiliation(s)
- Carlos Ayala-de Miguel
- Servicio Oncología Médica, Hospital Universitario Virgen de Valme, Ctra, de Cádiz Km 548,9, Seville C.P. 41014, Spain.
| | - Jerónimo Jiménez-Castro
- Servicio Oncología Médica, Hospital Universitario Virgen de Valme, Ctra, de Cádiz Km 548,9, Seville C.P. 41014, Spain.
| | - Adrián Sánchez-Vegas
- Servicio Oncología Médica, Hospital Universitario Virgen de Valme, Ctra, de Cádiz Km 548,9, Seville C.P. 41014, Spain.
| | - Sebastián Díaz-López
- Servicio Oncología Médica, Hospital Universitario Virgen de Valme, Ctra, de Cádiz Km 548,9, Seville C.P. 41014, Spain.
| | - Manuel Chaves-Conde
- Servicio Oncología Médica, Hospital Universitario Virgen de Valme, Ctra, de Cádiz Km 548,9, Seville C.P. 41014, Spain.
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Bellio H, Bertaut A, Hervieu A, Zanetta S, Hennequin A, Vincent J, Palmier R, Bengrine-Lefevre L, Ghiringhelli F, Fumet JD. Phase I Dose-Escalation Trial of an Innovative Chemotherapy Regimen Combining a Fractionated Dose of Irinotecan Plus Bevacizumab, Oxaliplatin, 5-Fluorouracil, and Folinic Acid (bFOLFIRINOX-3) in Chemorefractory Metastatic Colorectal Cancer. Cancers (Basel) 2021; 13:cancers13215472. [PMID: 34771635 PMCID: PMC8582415 DOI: 10.3390/cancers13215472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 10/24/2021] [Accepted: 10/25/2021] [Indexed: 11/20/2022] Open
Abstract
Simple Summary Treatment of non-resectable metastatic colorectal cancer (mCRC) involves chemotherapy based on 5-fluorouracil, oxaliplatin and irinotecan and monoclonal antibodies targeting VEGF or EGFR. After an initial progression, it is usual to change the chemotherapy regimen and targeted therapy, with rather moderate results. Several studies have focused on the interest of using again already used molecules and rechallenge with oxaliplatin and irinotecan bi fractionation (FOLFIRI3) have previously shown efficacy in chemorefractory patients, but desynchronized triplet chemotherapy was never tested. The aim of this study was to evaluate the safety and efficacy of a new regimen so-called: FOLFIRINOX-3 bevacizumab in chemorefractory metastatic colorectal cancer. Abstract The care of metastatic colorectal cancers is based on combination chemotherapies including 5-fluorouracil, oxaliplatin, irinotecan, and monoclonal antibodies targeting the epidermal growth factor receptor or vascular endothelial growth factor. The regimen is determined based on the patient’s molecular biology and general condition. Irinotecan bifractionation showed efficacy in chemorefractory patients in a previous study, FOLFIRI-3, but a desynchronized triplet has never been tested. The aim of bFOLFIRINOX-3 is to determine the safety, tolerance, and efficacy of a new regimen (FOLFIRINOX-3 bevacizumab) in chemorefractory patients. The aim of this study was to evaluate the safety and efficacy of FOLFIRINOX-3 bevacizumab in chemorefractory metastatic colorectal cancer (mCRC). A standard phase I, “3 + 3” design study was performed. The standard protocol comprised simplified FOLFOX 4 (folinic acid 400 mg/m2), 5-fluorouracil (a 400 mg/m2 bolus followed by 2400 mg/m2 for 46 h), oxaliplatin (85 mg/m2) and irinotecan (administered before and after 5-fluorouracil infusion), plus bevacizumab (5 mg/kg). In a “3 + 3” design, three different doses of irinotecan were tested: 60, 70 and 90 mg/m2. The primary endpoint was the maximum tolerable dose (MTD) of irinotecan. The secondary endpoints included the objective response (at 8 and 16 weeks) according to the RECIST 1.1 criteria and progression free survival. Thirteen patients were enrolled, and twelve patients were finally evaluated for dose-limiting toxicity (DLT). The dose level defined was 70 mg/m2 irinotecan. A total of three DLTs were observed (grade 3 diarrhea): two DLTs at the 90 mg/m2 dose level and one at the 70 mg/m2 dose level. The most frequently described adverse events were asthenia (93%), diarrhea (77%), nausea (62%) and peripheral sensory neuropathy (46%). The most frequent biological event was thrombopenia (54%). Regarding efficacy, among the 11 evaluable patients, no progression was observed at 8 weeks, and the partial response rate was 18.2%. At 16 weeks, a partial response rate of 27.3% was observed, and five patients had a stable disease. The new regimen of bFOLFIRINOX-3 with irinotecan at 70 mg/m2 was well tolerated. In chemorefractory patients, this protocol shows a high response rate.
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Affiliation(s)
- Hélène Bellio
- Platform of Transfer in Biological Oncology, Georges François Leclerc Cancer Center—UNICANCER, 1 rue du Professeur Marion, 21000 Dijon, France; (A.B.); (A.H.); (S.Z.); (A.H.); (J.V.); (R.P.); (L.B.-L.); (F.G.)
- Department of Medical Oncology, Georges François Leclerc Cancer Center—UNICANCER, 1 rue du Professeur Marion, 21000 Dijon, France
- Maison de L’université Esplanade Erasme, University of Burgundy-Franche Comté, 21000 Dijon, France
- Correspondence: (H.B.); (J.-D.F.)
| | - Aurélie Bertaut
- Platform of Transfer in Biological Oncology, Georges François Leclerc Cancer Center—UNICANCER, 1 rue du Professeur Marion, 21000 Dijon, France; (A.B.); (A.H.); (S.Z.); (A.H.); (J.V.); (R.P.); (L.B.-L.); (F.G.)
- Department of Medical Oncology, Georges François Leclerc Cancer Center—UNICANCER, 1 rue du Professeur Marion, 21000 Dijon, France
- Maison de L’université Esplanade Erasme, University of Burgundy-Franche Comté, 21000 Dijon, France
| | - Alice Hervieu
- Platform of Transfer in Biological Oncology, Georges François Leclerc Cancer Center—UNICANCER, 1 rue du Professeur Marion, 21000 Dijon, France; (A.B.); (A.H.); (S.Z.); (A.H.); (J.V.); (R.P.); (L.B.-L.); (F.G.)
- Department of Medical Oncology, Georges François Leclerc Cancer Center—UNICANCER, 1 rue du Professeur Marion, 21000 Dijon, France
- Maison de L’université Esplanade Erasme, University of Burgundy-Franche Comté, 21000 Dijon, France
| | - Sylvie Zanetta
- Platform of Transfer in Biological Oncology, Georges François Leclerc Cancer Center—UNICANCER, 1 rue du Professeur Marion, 21000 Dijon, France; (A.B.); (A.H.); (S.Z.); (A.H.); (J.V.); (R.P.); (L.B.-L.); (F.G.)
- Department of Medical Oncology, Georges François Leclerc Cancer Center—UNICANCER, 1 rue du Professeur Marion, 21000 Dijon, France
- Maison de L’université Esplanade Erasme, University of Burgundy-Franche Comté, 21000 Dijon, France
| | - Audrey Hennequin
- Platform of Transfer in Biological Oncology, Georges François Leclerc Cancer Center—UNICANCER, 1 rue du Professeur Marion, 21000 Dijon, France; (A.B.); (A.H.); (S.Z.); (A.H.); (J.V.); (R.P.); (L.B.-L.); (F.G.)
- Department of Medical Oncology, Georges François Leclerc Cancer Center—UNICANCER, 1 rue du Professeur Marion, 21000 Dijon, France
- Maison de L’université Esplanade Erasme, University of Burgundy-Franche Comté, 21000 Dijon, France
| | - Julie Vincent
- Platform of Transfer in Biological Oncology, Georges François Leclerc Cancer Center—UNICANCER, 1 rue du Professeur Marion, 21000 Dijon, France; (A.B.); (A.H.); (S.Z.); (A.H.); (J.V.); (R.P.); (L.B.-L.); (F.G.)
- Department of Medical Oncology, Georges François Leclerc Cancer Center—UNICANCER, 1 rue du Professeur Marion, 21000 Dijon, France
- Maison de L’université Esplanade Erasme, University of Burgundy-Franche Comté, 21000 Dijon, France
| | - Rémi Palmier
- Platform of Transfer in Biological Oncology, Georges François Leclerc Cancer Center—UNICANCER, 1 rue du Professeur Marion, 21000 Dijon, France; (A.B.); (A.H.); (S.Z.); (A.H.); (J.V.); (R.P.); (L.B.-L.); (F.G.)
- Department of Medical Oncology, Georges François Leclerc Cancer Center—UNICANCER, 1 rue du Professeur Marion, 21000 Dijon, France
- Maison de L’université Esplanade Erasme, University of Burgundy-Franche Comté, 21000 Dijon, France
| | - Leila Bengrine-Lefevre
- Platform of Transfer in Biological Oncology, Georges François Leclerc Cancer Center—UNICANCER, 1 rue du Professeur Marion, 21000 Dijon, France; (A.B.); (A.H.); (S.Z.); (A.H.); (J.V.); (R.P.); (L.B.-L.); (F.G.)
- Department of Medical Oncology, Georges François Leclerc Cancer Center—UNICANCER, 1 rue du Professeur Marion, 21000 Dijon, France
- Maison de L’université Esplanade Erasme, University of Burgundy-Franche Comté, 21000 Dijon, France
| | - François Ghiringhelli
- Platform of Transfer in Biological Oncology, Georges François Leclerc Cancer Center—UNICANCER, 1 rue du Professeur Marion, 21000 Dijon, France; (A.B.); (A.H.); (S.Z.); (A.H.); (J.V.); (R.P.); (L.B.-L.); (F.G.)
- Department of Medical Oncology, Georges François Leclerc Cancer Center—UNICANCER, 1 rue du Professeur Marion, 21000 Dijon, France
- Maison de L’université Esplanade Erasme, University of Burgundy-Franche Comté, 21000 Dijon, France
- UMR INSERM 1231, 7 Boulevard Jeanne d’Arc, 21000 Dijon, France
| | - Jean-David Fumet
- Platform of Transfer in Biological Oncology, Georges François Leclerc Cancer Center—UNICANCER, 1 rue du Professeur Marion, 21000 Dijon, France; (A.B.); (A.H.); (S.Z.); (A.H.); (J.V.); (R.P.); (L.B.-L.); (F.G.)
- Department of Medical Oncology, Georges François Leclerc Cancer Center—UNICANCER, 1 rue du Professeur Marion, 21000 Dijon, France
- Maison de L’université Esplanade Erasme, University of Burgundy-Franche Comté, 21000 Dijon, France
- Correspondence: (H.B.); (J.-D.F.)
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Current Treatment Landscape for Third- or Later-Line Therapy in Metastatic Colorectal Cancer. CURRENT COLORECTAL CANCER REPORTS 2021. [DOI: 10.1007/s11888-021-00469-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Benson AB, Venook AP, Al-Hawary MM, Arain MA, Chen YJ, Ciombor KK, Cohen S, Cooper HS, Deming D, Farkas L, Garrido-Laguna I, Grem JL, Gunn A, Hecht JR, Hoffe S, Hubbard J, Hunt S, Johung KL, Kirilcuk N, Krishnamurthi S, Messersmith WA, Meyerhardt J, Miller ED, Mulcahy MF, Nurkin S, Overman MJ, Parikh A, Patel H, Pedersen K, Saltz L, Schneider C, Shibata D, Skibber JM, Sofocleous CT, Stoffel EM, Stotsky-Himelfarb E, Willett CG, Gregory KM, Gurski LA. Colon Cancer, Version 2.2021, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2021; 19:329-359. [PMID: 33724754 DOI: 10.6004/jnccn.2021.0012] [Citation(s) in RCA: 735] [Impact Index Per Article: 245.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
This selection from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Colon Cancer focuses on systemic therapy options for the treatment of metastatic colorectal cancer (mCRC), because important updates have recently been made to this section. These updates include recommendations for first-line use of checkpoint inhibitors for mCRC, that is deficient mismatch repair/microsatellite instability-high, recommendations related to the use of biosimilars, and expanded recommendations for biomarker testing. The systemic therapy recommendations now include targeted therapy options for patients with mCRC that is HER2-amplified, or BRAF V600E mutation-positive. Treatment and management of nonmetastatic or resectable/ablatable metastatic disease are discussed in the complete version of the NCCN Guidelines for Colon Cancer available at NCCN.org. Additional topics covered in the complete version include risk assessment, staging, pathology, posttreatment surveillance, and survivorship.
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Affiliation(s)
- Al B Benson
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | - Alan P Venook
- UCSF Helen Diller Family Comprehensive Cancer Center
| | | | | | | | | | - Stacey Cohen
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | | | | | - Linda Farkas
- UT Southwestern Simmons Comprehensive Cancer Center
| | | | | | | | | | | | | | - Steven Hunt
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | | | - Smitha Krishnamurthi
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | | | - Eric D Miller
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | - Mary F Mulcahy
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | | | | | | | - Katrina Pedersen
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
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Oxaliplatin retreatment in metastatic colorectal cancer: Systematic review and future research opportunities. Cancer Treat Rev 2020; 91:102112. [PMID: 33091698 DOI: 10.1016/j.ctrv.2020.102112] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 09/28/2020] [Accepted: 10/02/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Oxaliplatin represents a main component of cytotoxic treatment regimens in colorectal cancer (CRC). Given its efficacy, oxaliplatin is frequently re-administered in the context of the continuum of care in metastatic CRC (mCRC). However, efficacy and tolerability of this therapeutic strategy has not been comprehensively assessed. METHODS We performed a systematic review of the literature on September 19th 2020, according to PRISMA criteria 2009. The research was performed on PubMed, ASCO Meeting Library, ESMO library and ClinicalTrials.gov for citations or ongoing trials. RESULTS 64 records were retrieved and 13 included in the systematic review: 8 full-text articles, 4 abstracts and 1 ongoing clinical trial. According to readministration timing, studies were classified as rechallenge/reintroduction (n = 8) or stop & go/intermittent therapeutic strategies (n = 4). The studies presented wide heterogeneity in terms of efficacy (Response Rate 6-31%; Disease Control Rate 39-79%; median Progression-Free Survival 3.1-7 months). Those patients who received retreatment after prior adjuvant oxaliplatin or exploiting a stop-&-go strategy appeared to achieve better outcomes. However, no formal comparisons on treatment outcomes were feasible. The most frequent grade 3 or higher adverse events were hematologic toxicities (5-27%), peripheral neuropathy (5-14%) and hypersensitivity reactions (5-20%). CONCLUSIONS Retreatment with oxaliplatin for mCRC is practiced based on scarce and heterogeneous data indicating efficacy and manageable toxicity. The best strategy to exploit this approach remains to be defined, and the most promising research avenue to improve therapeutic index of oxaliplatin is represented by selection of responder patients whose tumors harbor molecular defects in the DNA damage repair pathway.
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Lam M, Lum C, Latham S, Tipping Smith S, Prenen H, Segelov E. Refractory Metastatic Colorectal Cancer: Current Challenges and Future Prospects. Cancer Manag Res 2020; 12:5819-5830. [PMID: 32765085 PMCID: PMC7369412 DOI: 10.2147/cmar.s213236] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 06/26/2020] [Indexed: 01/19/2023] Open
Abstract
Despite advances, patients with metastatic colorectal cancer (mCRC) still have poor long-term survival. Identification of molecular subtypes is important to guide therapy through standard treatment pathways and holds promise for the development of new treatments. Following standard first- and second-line chemotherapy plus targeted agents, many patients retain a reasonable performance status, and thus are seeking further effective treatment to extend life and maintain symptom control. The challenge lies in selecting the most appropriate therapy in the third- and fourth-line settings, from a range of options including the relatively new oral agents TAS-102 and regorafenib, or rechallenge with previous chemotherapy or anti-epidermal growth factor receptor (anti-EGFR) monoclonal antibodies (mAB). Beyond this, therapy consists of trials involving novel agents and new combinations of treatments with theoretical synergy and/or non-overlapping toxicity. There is a great focus on enhancing immunogenicity in mCRC, to reflect the impressive results of immunotherapy drugs in the small cohort with mismatch repair deficient (dMMR) mCRC. Rare molecular subtypes of mCRC are increasingly being identified, including Her2-positive disease, NTRK fusions and others. Clinical trials exploring the efficacy of immunomodulatory and precision agents are plentiful and will hopefully yield clinically meaningful results that can be rapidly translated into routine care.
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Affiliation(s)
- Marissa Lam
- Department of Medical Oncology, Monash Medical Center, Clayton, Australia
| | - Caroline Lum
- Department of Medical Oncology, Monash Medical Center, Clayton, Australia
| | - Sarah Latham
- Department of Medical Oncology, Monash Medical Center, Clayton, Australia
| | - Sam Tipping Smith
- Department of Medical Oncology, Monash Medical Center, Clayton, Australia
| | - Hans Prenen
- Department of Oncology, University Hospital Antwerp, Edegem, Belgium
| | - Eva Segelov
- Department of Medical Oncology, Monash Medical Center, Clayton, Australia
- Faculty of Medicine, Monash University, Clayton, Australia
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Karani A, Felismino TC, Diniz L, Macedo MP, Silva VSE, Mello CA. Is there a role for rechallenge and reintroduction of anti-EGFR plus chemotherapy in later lines of therapy for metastatic colorectal carcinoma? A retrospective analysis. Ecancermedicalscience 2020; 14:1069. [PMID: 32728385 PMCID: PMC7373642 DOI: 10.3332/ecancer.2020.1069] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Indexed: 12/22/2022] Open
Abstract
Background Mechanisms of resistance have been described during disease progression (PD) for patients under treatment with anti-EGFR plus chemotherapy (CT). The aim of our study was to evaluate efficacy of anti-EGFR rechallenge (ReCH) and reintroduction (ReIn) in metastatic colorectal cancer (mCRC). Materials and methods This is a retrospective analysis of patients with mCRC that previously received anti-EGFR + CT and interrupted therapy due to PD in the ReCH group and other reasons in the ReIn group. We aimed to describe progression-free survival (PFS), overall survival (OS) and response rate (RR) after re-exposure and to evaluate prognostic factors associated with PFS. Results Sixty-eight patients met the inclusion criteria. The median follow-up after re-exposure was 39.3 months. ReCH was adopted in 25% and ReIn in 75%. The median anti-EGFR free interval was at 10.5 months. At re-exposure, the main CT regimen was FOLFIRI in 58.8%. Cetuximab and Panitumumab were used in 59 and 9 patients, respectively. mPFS for ReCH and ReIn was 3.3 × 8.4 months, respectively (p 0.001). The objective response rate for ReCH and ReIn was 18% and 52%, respectively. In univariate analysis, adverse prognostic factors related to PFS were: stable disease or PD at first anti-EGFR exposure (HR: 2.12, CI:1.20-3.74; p = 0.009); ReCH (HR: 3.44, CI:1.88-6.29, p < 0.0001); rechallenge at fourth or later lines (HR: 2.51, CI:1.49-4.23, p = 0.001); panitumumab use (HR: 2.26 CI:1.18-5.54, p = 0.017). In the multivariate model, only ReCH remained statistically significant (HR = 2.63, CI: 1.14-6.03, p = 0.022). Conclusion In our analysis, ReCH resulted in short PFS and low RR. However, reintroduction of anti-EGFR plus CT before complete resistance arose resulted in prolonged PFS. These data could be clinically useful to guide a treatment break due to side effects or patient decisions. Our data should be confirmed by larger and prospective trials.
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Affiliation(s)
- Amanda Karani
- Department of Medical Oncology, AC Camargo Cancer Center, Sao Paulo 01509-000, Brazil
| | | | - Lara Diniz
- Department of Medical Oncology, AC Camargo Cancer Center, Sao Paulo 01509-000, Brazil
| | | | | | - Celso Abdon Mello
- Department of Medical Oncology, AC Camargo Cancer Center, Sao Paulo 01509-000, Brazil.,https://orcid.org/0000-0002-8315-1562
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Current Options for Third-line and Beyond Treatment of Metastatic Colorectal Cancer. Spanish TTD Group Expert Opinion. Clin Colorectal Cancer 2020; 19:165-177. [PMID: 32507561 DOI: 10.1016/j.clcc.2020.04.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 04/08/2020] [Accepted: 04/13/2020] [Indexed: 12/13/2022]
Abstract
Colorectal cancer (CRC) is a public health problem: it is the third most common cancer in men (746,000 new cases/year) and the second in women (614,000 new cases/year), representing the second leading cause of death by cancer worldwide. The survival of patients with metastatic CRC (mCRC) has increased prominently in recent years, reaching a median of 25 to 30 months. A growing number of patients with mCRC are candidates to receive a treatment in third line or beyond, although the optimal drug regimen and sequence are still unknown. In this situation of refractoriness, there are several alternatives: (1) To administer sequentially the 2 oral drugs approved in this indication: trifluridine/tipiracil and regorafenib, which have shown a statistically significant benefit in progression-free survival and overall survival with a different toxicity profile. (2) To administer cetuximab or panitumumab in treatment-naive patients with RAS wild type, which is increasingly rare because these drugs are usually indicated in first- or second-line. (3) To reuse drugs already administered that were discontinued owing to toxicity or progression (oxaliplatin, irinotecan, fluoropyrimidine, antiangiogenics, anti-epidermal growth factor receptor [if RAS wild-type]). High-quality evidence is limited, but this strategy is often used in routine clinical practice in the absence of alternative therapies especially in patients with good performance status. (4) To use specific treatments for very selected populations, such as trastuzumab/lapatinib in mCRC human epidermal growth factor receptor 2-positive, immunotherapy in microsatellite instability, intrahepatic therapies in limited disease or primarily located in the liver, although the main recommendation is to include patients in clinical trials.
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Current Evidence on miRNAs as Potential Theranostic Markers for Detecting Chemoresistance in Colorectal Cancer: A Systematic Review and Meta-Analysis of Preclinical and Clinical Studies. Mol Diagn Ther 2019; 23:65-82. [PMID: 30726546 DOI: 10.1007/s40291-019-00381-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Findings from observational clinical studies examining the relationship between biomarker expression and theranosis in colorectal cancer (CRC) have been conflicting. OBJECTIVE We conducted this systematic review and meta-analysis to summarise the existing evidence to demonstrate the involvement of microRNAs (miRNAs) in chemoresistance and sensitivity in CRC through drug genetic pathways. METHODS Using PRISMA guidelines, we systematically searched PubMed and Science Direct for relevant studies that took place between 2012 and 2017. A random-effects model of meta-analysis was applied to evaluate the pooled effect size of hazard ratios (HRs) across the included studies. Cochran's Q test and the I2 statistic were used to detect heterogeneity. A funnel plot was used to assess potential publication bias. RESULTS Of the 4700 studies found, 39 studies comprising 2822 patients with CRC met the inclusion criteria. The included studies used one or a combination of 14 chemotherapy drugs, including 5-fluorouracil and oxaliplatin. Of the 60 miRNAs, 28 were associated with chemosensitivity, 20 with chemoresistance, and one with differential expression and radiosensitivity; ten miRNAs were not associated with any impact on chemotherapy. The results outline the importance of 34 drug-regulatory pathways of chemoresistance and sensitivity in CRC. The mean effect size was 0.689 (95% confidence interval 0.428-1.110), indicating that the expression of miRNAs decreased the likelihood of death by about 32%. CONCLUSION Studies have consistently shown that multiple miRNAs could act as clinical predictors of chemoresistance and sensitivity. An inclusion of supplementary miRNA estimation in CRC routine practice needs to be considered to evaluate the efficacy of chemotherapy after confirming our findings with large-scale prospective cohort studies. PROSPERO REGISTRATION NUMBER CRD42017082196.
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Pasch CA, Favreau PF, Yueh AE, Babiarz CP, Gillette AA, Sharick JT, Karim MR, Nickel KP, DeZeeuw AK, Sprackling CM, Emmerich PB, DeStefanis RA, Pitera RT, Payne SN, Korkos DP, Clipson L, Walsh CM, Miller D, Carchman EH, Burkard ME, Lemmon KK, Matkowskyj KA, Newton MA, Ong IM, Bassetti MF, Kimple RJ, Skala MC, Deming DA. Patient-Derived Cancer Organoid Cultures to Predict Sensitivity to Chemotherapy and Radiation. Clin Cancer Res 2019; 25:5376-5387. [PMID: 31175091 DOI: 10.1158/1078-0432.ccr-18-3590] [Citation(s) in RCA: 132] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 03/08/2019] [Accepted: 06/03/2019] [Indexed: 11/16/2022]
Abstract
PURPOSE Cancer treatment is limited by inaccurate predictors of patient-specific therapeutic response. Therefore, some patients are exposed to unnecessary side effects and delays in starting effective therapy. A clinical tool that predicts treatment sensitivity for individual patients is needed. EXPERIMENTAL DESIGN Patient-derived cancer organoids were derived across multiple histologies. The histologic characteristics, mutation profile, clonal structure, and response to chemotherapy and radiation were assessed using bright-field and optical metabolic imaging on spheroid and single-cell levels, respectively. RESULTS We demonstrate that patient-derived cancer organoids represent the cancers from which they were derived, including key histologic and molecular features. These cultures were generated from numerous cancers, various biopsy sample types, and in different clinical settings. Next-generation sequencing reveals the presence of subclonal populations within the organoid cultures. These cultures allow for the detection of clonal heterogeneity with a greater sensitivity than bulk tumor sequencing. Optical metabolic imaging of these organoids provides cell-level quantification of treatment response and tumor heterogeneity allowing for resolution of therapeutic differences between patient samples. Using this technology, we prospectively predict treatment response for a patient with metastatic colorectal cancer. CONCLUSIONS These studies add to the literature demonstrating feasibility to grow clinical patient-derived organotypic cultures for treatment effectiveness testing. Together, these culture methods and response assessment techniques hold great promise to predict treatment sensitivity for patients with cancer undergoing chemotherapy and/or radiation.
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Affiliation(s)
- Cheri A Pasch
- University of Wisconsin Carbone Cancer Center, Madison, Wisconsin
| | | | - Alexander E Yueh
- Division of Hematology and Oncology, Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Christopher P Babiarz
- Division of Hematology and Oncology, Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Amani A Gillette
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | - Joe T Sharick
- Morgridge Institute for Research, Madison, Wisconsin
| | | | - Kwangok P Nickel
- University of Wisconsin Carbone Cancer Center, Madison, Wisconsin.,Department of Human Oncology, University of Wisconsin-Madison, Madison, Wisconsin
| | - Alyssa K DeZeeuw
- Division of Hematology and Oncology, Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | | | - Philip B Emmerich
- Division of Hematology and Oncology, Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Rebecca A DeStefanis
- Division of Hematology and Oncology, Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Rosabella T Pitera
- Division of Hematology and Oncology, Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Susan N Payne
- University of Wisconsin Carbone Cancer Center, Madison, Wisconsin
| | - Demetra P Korkos
- Division of Hematology and Oncology, Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Linda Clipson
- McArdle Laboratory for Cancer Research, Department of Oncology, University of Wisconsin-Madison, Madison, Wisconsin
| | | | - Devon Miller
- Division of Hematology and Oncology, Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Evie H Carchman
- University of Wisconsin Carbone Cancer Center, Madison, Wisconsin.,Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin
| | - Mark E Burkard
- University of Wisconsin Carbone Cancer Center, Madison, Wisconsin.,Division of Hematology and Oncology, Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Kayla K Lemmon
- University of Wisconsin Carbone Cancer Center, Madison, Wisconsin
| | - Kristina A Matkowskyj
- University of Wisconsin Carbone Cancer Center, Madison, Wisconsin.,Department of Pathology and Laboratory Medicine, University of Wisconsin-Madison, Madison, Wisconsin.,William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin
| | - Michael A Newton
- Departments of Statistics and of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, Wisconsin
| | - Irene M Ong
- University of Wisconsin Carbone Cancer Center, Madison, Wisconsin.,Departments of Statistics and of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, Wisconsin
| | - Michael F Bassetti
- University of Wisconsin Carbone Cancer Center, Madison, Wisconsin.,Department of Human Oncology, University of Wisconsin-Madison, Madison, Wisconsin
| | - Randall J Kimple
- University of Wisconsin Carbone Cancer Center, Madison, Wisconsin.,Department of Human Oncology, University of Wisconsin-Madison, Madison, Wisconsin
| | - Melissa C Skala
- University of Wisconsin Carbone Cancer Center, Madison, Wisconsin.,Morgridge Institute for Research, Madison, Wisconsin.,Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | - Dustin A Deming
- University of Wisconsin Carbone Cancer Center, Madison, Wisconsin. .,Division of Hematology and Oncology, Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin.,McArdle Laboratory for Cancer Research, Department of Oncology, University of Wisconsin-Madison, Madison, Wisconsin
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11
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Chambers AE, Frick J, Tanner N, Gerkin R, Kundranda M, Dragovich T. Chemotherapy re-challenge response rate in metastatic colorectal cancer. J Gastrointest Oncol 2018; 9:679-686. [PMID: 30151264 DOI: 10.21037/jgo.2018.04.08] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background There are few treatment options in metastatic colorectal cancer (mCRC) after progression on standard chemotherapy. Third and fourth line therapies typically consist of regorafenib or trifluridine-tipiracil, however, clinical benefit of these medications is limited, as progression free survival is approximately 1.9 months for regorafenib (Grothey et al. 2013) and 2.0 months for trifluridine-tipiracil (Mayer et al. 2015). Another choice in this setting may include the re-initiation of previously used chemotherapy, therefore in this study we assessed the efficacy and tolerability of chemotherapy re-challenge. Methods This was a retrospective, cohort study assessing patients with mCRC who were 18-89 years of age and treated with re-challenge chemotherapy. Re-challenge chemotherapy was defined as re-initiation of oxaliplatin or irinotecan-based regimens at least nine months from the end of initial exposure. A minimum of four chemotherapy cycles was required to qualify as initial exposure. The key endpoints of this study were clinical benefit rate (CBR), defined as the proportion of patients with partial response or stable disease, and time to progression (TTP). Results A total of 67 chemotherapy re-challenges were accounted for in 51 patients. The overall CBR was 70.7%. Partial responses occurred in 50.7% cases. The TTP was 6.0 months. For the 51 cases of first re-challenge, the CBR was 75.5% and TTP was 6.5 months. Fourteen patients had a second re-challenge, and in these patients, the CBR was 61.5% and TTP was 4.1 months. Conclusions Oxaliplatin or irinotecan-based re-challenge should be considered as a third or fourth line treatment option in select patients with mCRC. CBR and especially TTP compare favorably to approved third line therapies such as regorafenib or trifluridine-tipiracil.
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Affiliation(s)
| | - Jacob Frick
- Department of Pharmacy, Banner MD Anderson Cancer Center, Gilbert, AZ, USA
| | - Natalee Tanner
- Department of Pharmacy, Banner MD Anderson Cancer Center, Gilbert, AZ, USA
| | - Richard Gerkin
- Graduate Medical Research, Banner-University Medical Center, Phoenix, AZ, USA
| | - Madappa Kundranda
- Gastrointestinal Medical Oncology, Department of Medicine, Banner MD Anderson Cancer Center, Gilbert, AZ, USA
| | - Tomislav Dragovich
- Medical Oncology, Department of Medicine, Banner MD Anderson Cancer Center, Gilbert, AZ, USA
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12
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Rechallenge with oxaliplatin and peripheral neuropathy in colorectal cancer patients. J Cancer Res Clin Oncol 2018; 144:1793-1801. [PMID: 29955956 DOI: 10.1007/s00432-018-2691-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 06/18/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Oxaliplatin (OXA) is a cornerstone in the treatment of colorectal cancer (CRC). Retreatment with OXA is frequently considered as salvage treatment. OXA-induced neuropathy (OIN) is the most frequent and feared long-term side effect. PATIENTS AND METHODS CRC patients receiving at least twice OXA-based chemotherapy lines at our institution between June 2000 and July 2016 were reviewed. The aim of this study was to investigate whether retreatment with OXA increases the risk of developing new or worsening previous neuropathy. OIN was assessed by National Cancer Institute-Common Toxicity Criteria for Adverse Events (NCI), Total Neuropathy Score© (TNS) and nerve-conduction studies. RESULTS 106 patients were included in the analysis. Median age at OXA-based retreatment was 61.5 (20-83) years. After the first OXA-based chemotherapy treatment, 63.4% of patients developed OIN, 30.7 and 8.9% grades 2 and 3, respectively, after a median of 11 (1-17) cycles. After 30 (11-90) months of median to retreatment with a median of 8 (1-14) OXA cycles, 39.6, 22.6, and 0% of patients developed grade 1, 2, and 3 OIN, respectively. Worsening of the previous OIN was observed in one-third (31.1%) of all patients. OXA-cumulative dose was independently associated with greater risk of worsening OIN (p < 0.001). Non-significant trend towards higher TNSc© scores after retreatment was observed [5 (0-11) vs 6 (3-13), p = 0.083]. CONCLUSION Retreatment with OXA in CRC patients is a feasible option even in patients who previously developed moderate or severe OIN. One-third of patients' OIN was worsened by retreatment. Neurological monitoring should be considered.
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13
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Cicero G, De Luca R, Dieli F. Progression-free survival as a surrogate endpoint of overall survival in patients with metastatic colorectal cancer. Onco Targets Ther 2018; 11:3059-3063. [PMID: 29872317 PMCID: PMC5975605 DOI: 10.2147/ott.s151276] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background In many clinical trials designed to assess the efficacy of anticancer treatments, overall survival (OS) is often used as a primary endpoint despite its several points of weakness. Methods This study evaluated the role of progression-free survival (PFS) in the first three lines of treatment as a potential surrogate endpoint of OS in patients with metastatic colorectal cancer (MCRC). One hundred and twenty patients with MCRC were enrolled in this study. The median PFS of the first-, second-, and third-lines of treatment and the OS were evaluated. The correlation between the time to progression and the OS was analyzed. The median PFS of the three lines of treatment were 8.5, 5, and 3 months, respectively. Results The median OS was 32.4 months. A modest correlation was found between the PFS to the first-line treatment with Folfox–avastin and OS. Similar data were obtained with the second-line treatment. However, no correlation was found between the PFS and OS during the third-line treatment. The regression analysis revealed that PFS is predictive of OS. Conclusion In brief, the PFS of the first- and second-lines of treatment could be a good candidate as a surrogate endpoint of OS in patients with MCRC.
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Affiliation(s)
- Giuseppe Cicero
- Department of Surgical, Oncological and Oral Sciences, Section of Medical Oncology, University of Palermo, Palermo, Italy
| | - Rossella De Luca
- Department of Surgical, Oncological and Oral Sciences, Section of Medical Oncology, University of Palermo, Palermo, Italy
| | - Francesco Dieli
- Central Laboratory of Advanced Diagnosis and Biomedical Research (CLADIBIOR), University of Palermo, Palermo, Italy
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14
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Yang Q, Huang Y, Jiang Z, Wang H, Li W, Zhang B, Xie D. Rechallenge of oxaliplatin-containing regimens in the third- or later-line therapy for patients with heavily treated metastatic colorectal cancer. Onco Targets Ther 2018; 11:2467-2473. [PMID: 29760556 PMCID: PMC5937494 DOI: 10.2147/ott.s154220] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Purpose The third- or later-line therapy available often yield poor survival benefit in patients metastatic colorectal cancer (mCRC). The retrospective study aimed to evaluate efficacy of rechallenge of oxaliplatin-containing regimens. Patients and methods Patients with mCRC who progressed from fluoropyrimidine, oxaliplatin, and irinotecan in the first- and second-line chemotherapy, were treated by reexposure to oxaliplatin-containing regimen. Patients treated by anti-epidermal growth factor receptor (EGFR) antibodies with irinotecan were included in the control arm. Results Ninety-five and 29 patients were treated with either oxaliplatin reexposure or anti-EGFR antibodies with irinotecan, respectively, as the third- or later-line therapy. The median time to treatment failure (TTF) and overall survival (OS) was 3.77 and 12.17 months in the oxaliplatin arm, with 4.77 months of TTF and 11.37 months of OS in the control arm; there was no significance between the 2 arms (p>0.05). Oxaliplatin reexposure resulted in 6.3% objective response rate with no complete response, 6 partial response, 39 stable disease, and 37 progressive disease. The disease control rate was 47.4% (45/95). The multivariate analysis found that patients who achieved disease control by oxaliplatin reexposure had a superior TTF (6.13 vs 1.7 months, p<0.001) and OS (15.73 vs 6.27 months, p<0.001) compared with those presenting with progressive disease. Conclusion This study showed that rechallenge of oxaliplatin-containing chemotherapy in the third- or later-line therapy may lead to tumor control and improved survival in mCRC patients, which was equivalent to that of anti-EGFR antibodies with irinotecan. Clinical significance Rechallenge of oxaliplatin-containing regimens in the third- or later-line of therapy is a common practice, despite few evidence available. The present study found that rechallenge of oxaliplatin-containing regimens produced equivalent tumor control and survival benefit to that of anti-EGFR antibodies with irinotecan in mCRC.
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Affiliation(s)
- Qiong Yang
- Department of Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.,Medical Research Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yuanyuan Huang
- VIP Region, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Zhimin Jiang
- Department of Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.,Medical Research Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Huizhong Wang
- Department of Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.,Medical Research Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Weiyu Li
- Department of Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.,Medical Research Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Bei Zhang
- VIP Region, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Derong Xie
- Department of Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.,Medical Research Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
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15
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Kim JJ, Kang J, Hong YS, Kim KP, Kim SY, Kim TW, Kim JE. Oxaliplatin rechallenge in metastatic colorectal cancer patients after prior oxaliplatin treatment. Med Oncol 2018; 35:65. [PMID: 29623500 DOI: 10.1007/s12032-018-1124-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 04/02/2018] [Indexed: 12/16/2022]
Abstract
Because the number of cytotoxic agents available for the treatment of metastatic colorectal cancer (mCRC) is limited, rechallenge with the same chemotherapy agents can provide a continuum of treatment. This study investigated the efficacy and feasibility of oxaliplatin rechallenge in mCRC patients who had been previously exposed to oxaliplatin-based chemotherapy. Patients were included if they had mCRC and evaluable disease, had remained disease-free or progression-free for at least 6 months after the last dose of prior oxaliplatin-based therapy, and were retreated with oxaliplatin therapy. Between January 2009 and May 2014, 110 patients were retreated with oxaliplatin-based regimens; of these, 42 (38.2%) had received prior oxaliplatin as adjuvant chemotherapy and 68 (61.8%) as palliative chemotherapy. The overall response rate to oxaliplatin rechallenge was 30.9% (34/110), and the disease control rate was 68.2% (75/110), with one patient achieving complete response, 33 achieving partial response, and 41 having stable disease. Median progression-free survival and overall survival following oxaliplatin rechallenge were 5.9 months (95% confidence interval [CI], 4.4-7.4 months) and 18.5 months (95% CI, 14.0-23.0 months), respectively. Sixteen patients experienced grade 2 or 3 neuropathy. Ten patients experienced any grade hypersensitivity reaction within four cycles of treatment, including six who stopped treatment due to grade 3 or 4 hypersensitivity reactions. Rechallenge with oxaliplatin-based therapy may be an option for patients who achieve at least 6 months of disease-free or progression-free survival with prior oxaliplatin-based chemotherapy. However, neurotoxicity and hypersensitivity reactions should be carefully monitored in this setting.
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Affiliation(s)
- Jae-Joon Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Jihoon Kang
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Yong Sang Hong
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Kyu-Pyo Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Sun Young Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Tae Won Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Jeong Eun Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
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