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Mahmood A, Bhuva N, Fokas E, Glynne-Jones R. Compliance to chemoradiation in squamous cell carcinoma of the anus. Cancer Treat Rev 2022; 106:102381. [DOI: 10.1016/j.ctrv.2022.102381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/09/2022] [Accepted: 03/11/2022] [Indexed: 11/02/2022]
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The role of haematological parameters in predicting the response to radical chemoradiotherapy in patients with anal squamous cell cancer. Radiol Oncol 2021; 55:449-458. [PMID: 34626531 PMCID: PMC8647797 DOI: 10.2478/raon-2021-0039] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 07/16/2021] [Indexed: 12/24/2022] Open
Abstract
Background Historically, the treatment of choice for anal cancer had been abdominoperineal resection (APR). Radical radiotherapy with concurrent 5-fluorouracil plus mitomycin C chemotherapy was later established as standard therapy, although with a failure rate of 20–30%. The aim of this study was to evaluate the outcomes after radical chemoradiotherapy (CRT), prognostic and predictive factors and patterns of failure. Patients and methods This study included 47 patients treated with radical CRT for patohistologicaly confirmed anal squamous cell carcinoma. Analysed haematological parameters included: neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and haemoglobin level. The final logistic regression model included treatment break period. Tumour response was assessed at 24 weeks from CRT completion. Follow-up was performed every 3 months during the first two years, and every 6 months thereafter. Results A complete clinical response (CR) was detected in 30 patients (63.8%). Patients who did not achieve a 6-months CR and those who had a CR after 6 months but then relapsed were referred to surgical treatment. With combined CRT and surgical salvage treatment the CR rate was 80.9%. Patients with CR after 6 months had significantly longer disease-free survival (DFS), progression-free survival (PFS), and overall survival (OS). A significant effect on the 6-month response was confirmed for PLR (p = 0.03). Conclusions Important prognostic factors associated with CR were baseline haemoglobin level and period of treatment interruptions. Potential haematological prognostic factors could be PLR and NLR, which can be routinely determined by low-cost and minimally invasive methods.
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Saif MW, Hamal R, Siddiqui N, Maloney A, Smith M. Alternative chemoradiotherapy in anal carcinoma patients with mutations in thymidylate synthase and dihydropyrimidine dehydrogenase genes. Therap Adv Gastroenterol 2021; 14:17562848211024464. [PMID: 34276810 PMCID: PMC8255561 DOI: 10.1177/17562848211024464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 05/18/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND 5-fluorouracil (5-FU) and mitomycin-C (MMC) with radiotherapy (RT) remain an established treatment for patients with anal cancer (AC). Genetic mutations in two major metabolizing enzymes for 5-FU; dihydropyrimidine dehydrogenase (DPYD and thymidylate synthetase (TYMS), have been associated with clinical response and toxicity. However, their place in the treatment of AC remains undetermined. METHODS We retrospectively reviewed 21 patients with AC, including T2-4, N0-1, M0 or T1-4, N2-3, and M0 treated between 2012 and 2018. All patients were treated with 5-FU 1,000 mg/m2/day via continuous intravenous (IV) infusion 1-4 and 29-32, MMC 10 mg/m2 IV bolus days 1 and 29 plus RT. Patients who developed ⩾3 grade toxicities were tested for the DPYD and TYMS genes. Treatment was either modified with reduced doses or changed to MMC 10 mg/m2 day 1 and 29 with cisplatin 25 mg/m2/week plus RT. Toxicities and responses were collected. RESULTS Six out of 21 patients who developed ⩾3 grade toxicities including pancytopenia, neutropenia, thrombocytopenia, mucositis, nausea, rash, and nephritis were found to have genetic mutations: TYMS 2RG/3RC (n = 2), 3RG/3RC (n = 1), 2R/2R (n = 2), TYMS 3'UTR del/Ins (n = 2), and DPYD c.2864A > T heterozygous (n = 1). Two patients received 5-FU at a 50% reduced dose on days 29-32; one patient refused to receive 5-FU (continued with MMC and RT); one patient received only radiation therapy due to persistent pancytopenia despite the use of growth factors; two patients received an alternative regimen consisting of MMC 10 mg/m2 on day 29 with cisplatin (CDDP) 25 mg/m2/week plus RT; and two patients received cisplatin/MMC with RT from the beginning as they were prospectively detected to have TYMS abnormalities prior to dosing the chemotherapy. These patients tolerated treatment very well with only grade 2 toxicities. All the patients (4/4) on cisplatin/MMC achieved clinical complete response (cCR), while four patients (4/15) on 5-FU/MMC reached cCR at the first assessment. Radiological response showed complete response at the end of 24 weeks assessment. CONCLUSIONS Molecular testing for DPYD and TYMS genes can allow us to identify patients who are most likely to respond or face severe toxicity to 5-FU in a potentially curable cancer. Combining radiation with CDDP with MMC in patients with AC is feasible. A prospective study based on pharmacogenetic testing comparing MMC/cisplatin with MMC/5-FU is indicated in patients with AC.
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Li J, Xu H, Zou J, Wang X, Li Z, Shen Y. Cisplatin/capecitabine with intensity-modulated radiation therapy in anal squamous cell carcinoma: a preliminary study. Scand J Gastroenterol 2021; 56:432-436. [PMID: 33556252 DOI: 10.1080/00365521.2021.1879250] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Mitomycin (MMC)/5-fluoroural (5-FU) with concurrent radiation is the standard treatment of anal squamous cell carcinoma (ASCC). The aim of this study is to evaluate the efficacy and safety of cisplatin/capecitabine (XP) as an alternative with intensity-modulated radiation therapy (IMRT) in ASCC setting. METHODS We retrospectively screened all patients with stage I-IV ASCC from January 2010 to June 2019. The records of patients who received definitive chemoradiation with cisplatin/capecitabine (XP) and IMRT were collected and analyzed. RESULTS The first patient was treated with XP in 2017, so totally 11 patients were included in our study from January 2017 to June 2019. All patients have experienced clinical complete response (cCR). After a median follow-up of 30 months (range, 18-39 months), no patient had local recurrence or distant metastasis. Two-year colostomy-free survival (CFS) and two-year disease-free survival (DFS) were both 100%. The median overall survival (OS) has not reached. Grade 3 acute toxicities included leukopenia (1, 9.1%), neutropenia (2, 18.2%) and thrombocytopenia (2, 18.2%). No grade 4 acute adverse events occurred. CONCLUSION In our study, cisplatin/capecitabine combined with IMRT was safe in ASCC patients, with favorable efficacy as an alternative, and is expected to be explored in study with larger sample.
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Affiliation(s)
- Jielang Li
- Department of Abdominal Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, PR China
| | - Huanji Xu
- Department of Abdominal Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, PR China
| | - Jiahuan Zou
- Department of Abdominal Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, PR China
| | - Xin Wang
- Department of Abdominal Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, PR China
| | - Zhiping Li
- Department of Radiation Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, PR China
| | - Yali Shen
- Department of Abdominal Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, PR China
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Werner RN, Gaskins M, Avila Valle G, Budach V, Koswig S, Mosthaf FA, Raab HR, Rödel C, Nast A, Siegel R, Aigner F. State of the art treatment for stage I to III anal squamous cell carcinoma: A systematic review and meta-analysis. Radiother Oncol 2021; 157:188-196. [DOI: 10.1016/j.radonc.2021.01.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 01/20/2021] [Accepted: 01/21/2021] [Indexed: 12/21/2022]
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7
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Bruyere D, Monnien F, Colpart P, Roncarati P, Vuitton L, Hendrick E, Lepinoy A, Luquain A, Pilard C, Lerho T, Molimard C, Maingon P, Arnould L, Bone-Lepinoy MC, Dusserre L, Martin L, Reynders C, Ancion M, Peiffert D, Leroux A, Hubert P, Delhorme JB, Ghnassia JP, Woronoff AS, Delvenne P, Prétet JL, Bosset JF, Peulen O, Mougin C, Valmary-Degano S, Herfs M. Treatment algorithm and prognostic factors for patients with stage I-III carcinoma of the anal canal: a 20-year multicenter study. Mod Pathol 2021; 34:116-130. [PMID: 32728225 DOI: 10.1038/s41379-020-0637-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/15/2020] [Accepted: 07/15/2020] [Indexed: 01/01/2023]
Abstract
Despite a growing incidence in developed countries and a recent improved understanding of its pathogenesis, anal cancer management has not evolved over the past decades and drug combination used as first-line regimen still largely depends on clinician preferences. Aiming at paving the way for precision medicine, a large cohort of 372 HIV-negative patients diagnosed over a 20-year time period with locally advanced anal carcinoma was collected and carefully characterized at the clinical, demographic, histopathologic, immunologic, and virologic levels. Both the prognostic relevance of each clinicopathological parameter and the efficacy of different concurrent chemoradiation strategies were determined. Overall, the incidence of anal cancer peaked during the sixth decade (mean: 63.4) and females outnumbered males (ratio: 2.51). After completion of treatment, 95 (25.5%) patients experienced progression of persistent disease or local/distant recurrence and 102 (27.4%) died during the follow-up period (median: 53.8 months). Importantly, uni-multivariate analyses indicated that both negative HPV/p16ink4a status and aberrant p53 expression were far better predictors for reduced progression-free survival than traditional risk factors such as tumor size and nodal status. As for overall survival, the significant influences of age at diagnosis, p16ink4a status, cTNM classification as well as both CD3+ and CD4+ T-cell infiltrations within tumor microenvironment were highlighted. Cisplatin-based chemoradiotherapy was superior to both radiotherapy alone and other concurrent chemoradiation therapies in the treatment of HPV-positive tumors. Regarding their HPV-uninfected counterparts, frequent relapses were observed, whatever the treatment regimen administered. Taken together, our findings reveal that current anal cancer management and treatment have reached their limits. A dualistic classification according to HPV/p53 status should be considered with implications for therapy personalization and optimization.
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Affiliation(s)
- Diane Bruyere
- Laboratory of Experimental Pathology, GIGA-Cancer, University of Liege, 4000, Liege, Belgium
| | - Franck Monnien
- Department of Pathology, University Hospital of Besançon, 25000, Besançon, France
| | - Prudence Colpart
- Department of Pathology, University Hospital of Besançon, 25000, Besançon, France
| | - Patrick Roncarati
- Laboratory of Experimental Pathology, GIGA-Cancer, University of Liege, 4000, Liege, Belgium
| | - Lucine Vuitton
- Department of Gastroenterology, University Hospital of Besançon, 25000, Besançon, France.,EA3181, University Bourgogne Franche-Comté, LabEx LipSTIC ANR-11-LABX-0021, 25000, Besançon, France
| | - Elodie Hendrick
- Laboratory of Experimental Pathology, GIGA-Cancer, University of Liege, 4000, Liege, Belgium
| | | | - Alexandra Luquain
- Department of Pathology, University Hospital of Besançon, 25000, Besançon, France
| | - Charlotte Pilard
- Laboratory of Experimental Pathology, GIGA-Cancer, University of Liege, 4000, Liege, Belgium
| | - Thomas Lerho
- Laboratory of Experimental Pathology, GIGA-Cancer, University of Liege, 4000, Liege, Belgium
| | - Chloé Molimard
- Department of Pathology, University Hospital of Besançon, 25000, Besançon, France
| | - Philippe Maingon
- Department of Radiation Oncology, Georges-François Leclerc Center, 21000, Dijon, France.,Department of Radiation Oncology, La Pitié Salpêtrière University Hospital, Sorbonne University, 75013, Paris, France
| | - Laurent Arnould
- Department of Biology and Pathology of Tumors, Georges-François Leclerc Center, 21000, Dijon, France
| | | | | | - Laurent Martin
- Department of Pathology, University Hospital of Dijon, 21000, Dijon, France
| | - Celia Reynders
- Laboratory of Experimental Pathology, GIGA-Cancer, University of Liege, 4000, Liege, Belgium
| | - Marie Ancion
- Laboratory of Experimental Pathology, GIGA-Cancer, University of Liege, 4000, Liege, Belgium
| | - Didier Peiffert
- Department of Radiation Oncology, Lorraine Institute of Oncology, 54519, Vandœuvre-lès-Nancy, France
| | - Agnès Leroux
- Department of Pathology, Lorraine Institute of Oncology, 54519, Vandœuvre-lès-Nancy, France
| | - Pascale Hubert
- Laboratory of Experimental Pathology, GIGA-Cancer, University of Liege, 4000, Liege, Belgium
| | - Jean-Baptiste Delhorme
- Department of Digestive Surgery, University Hospital of Strasbourg, 67200, Strasbourg, France
| | | | - Anne-Sophie Woronoff
- Doubs and Belfort Territory Cancer Registry, University Hospital of Besançon, 25000, Besançon, France
| | - Philippe Delvenne
- Laboratory of Experimental Pathology, GIGA-Cancer, University of Liege, 4000, Liege, Belgium.,Department of Pathology, University Hospital of Liege, 4000, Liege, Belgium
| | - Jean-Luc Prétet
- EA3181, University Bourgogne Franche-Comté, LabEx LipSTIC ANR-11-LABX-0021, 25000, Besançon, France.,CNR Papillomavirus, University Hospital of Besançon, 25000, Besançon, France
| | - Jean-François Bosset
- Department of Radiation Oncology, University Hospital of Besançon, 25000, Besançon, France
| | - Olivier Peulen
- Metastasis Research Laboratory, GIGA-Cancer, University of Liege, 4000, Liege, Belgium
| | - Christiane Mougin
- EA3181, University Bourgogne Franche-Comté, LabEx LipSTIC ANR-11-LABX-0021, 25000, Besançon, France.,CNR Papillomavirus, University Hospital of Besançon, 25000, Besançon, France
| | - Séverine Valmary-Degano
- Department of Pathology, University Hospital of Besançon, 25000, Besançon, France.,EA3181, University Bourgogne Franche-Comté, LabEx LipSTIC ANR-11-LABX-0021, 25000, Besançon, France.,Department of Pathology, University Hospital of Grenoble-Alps, 38043, Grenoble cedex 9, France
| | - Michael Herfs
- Laboratory of Experimental Pathology, GIGA-Cancer, University of Liege, 4000, Liege, Belgium.
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Gouvas N, Gourtsoyianni S, Kalogeridi MA, Sougklakos J, Vini L, Xynos E. Hellenic society of medical oncology (HESMO) guidelines for the management of anal cancer. Updates Surg 2020; 73:7-21. [PMID: 33231836 DOI: 10.1007/s13304-020-00923-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 10/29/2020] [Indexed: 01/01/2023]
Abstract
Despite considerable improvement in the management of anal cancer, there is a great deal of variation in the outcomes among European countries, and in particular among different hospital centres in Greece and Cyprus. The aim was to elaborate a consensus on the multidisciplinary management of anal cancer, based on European guidelines (European Society of Medical Oncologists-ESMO), considering local special characteristics of our healthcare system. Following discussion and online communication among members of an executive team, a consensus was developed. Guidelines are proposed along with algorithms of diagnosis and treatment. The importance of centralisation, care by a multidisciplinary team (MDT) and adherence to guidelines are emphasised.
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Affiliation(s)
- Nikolaos Gouvas
- Colorectal Surgeon, Nicosia General Hospital, Medical School, Shacolas Educational Centre for Clinical Medicine, University of Cyprus, Palaios Dromos Lefkosias Lemesou No.215/6Aglantzia, 2029, Nicosia, Cyprus.
| | - Sophia Gourtsoyianni
- Abdominal Radiologist, "Aretaieion" Hospital, Faculty of Medicine, University of Athens, Athens, Greece
| | | | - John Sougklakos
- Medical Oncologist, University Hospital of Heraklion, Faculty of Medicine, University of Crete, Heraklion, Greece
| | - Louisa Vini
- Clinical Oncologist/Radiotherapist, "Iatriko" Hopsital of Athens, Athens, Greece
| | - Evangelos Xynos
- Colorectal Surgeon, Creta Inter-Clinic Hopsital, Heraklion, Greece
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Russo S, Anker CJ, Abdel-Wahab M, Azad N, Bianchi N, Das P, Dragovic J, Goodman KA, Jones W, Kennedy T, Kumar R, Lee P, Sharma N, Small W, Suh WW, Jabbour SK. Executive Summary of the American Radium Society Appropriate Use Criteria for Treatment of Anal Cancer. Int J Radiat Oncol Biol Phys 2019; 105:591-605. [PMID: 31288054 PMCID: PMC11101015 DOI: 10.1016/j.ijrobp.2019.06.2544] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 06/10/2019] [Accepted: 06/11/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Suzanne Russo
- Case Western Reserve University School of Medicine and University Hospitals, Cleveland Ohio
| | | | - May Abdel-Wahab
- International Atomic Energy Agency, Division of Human Health, New York City, New York
| | - Nilofer Azad
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nancy Bianchi
- University of Vermont Cancer Center, Burlington, Vermont
| | - Prajnan Das
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | | | - William Jones
- UT Health Cancer Center, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | | | - Rachit Kumar
- Banner MD Anderson Cancer Center, Gilbert, Arizona
| | - Percy Lee
- University of California, Los Angeles, Jonsson Comprehensive Cancer Center, Los Angeles, California
| | - Navesh Sharma
- Milton S. Hershey Cancer Institute, Hershey, Pennsylvania
| | | | - W Warren Suh
- Ridley-Tree Cancer Center, Sansum Clinic, Santa Barbara, California
| | - Salma K Jabbour
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey.
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Rivin Del Campo E, Matzinger O, Haustermans K, Peiffert D, Glynne-Jones R, Winter KA, Konski AA, Ajani JA, Bosset JF, Hannoun-Levi JM, Puyraveau M, Chakravarthy AB, Meadows H, Northover J, Collette L, Christiaens M, Maingon P. Pooled Analysis of external-beam RADiotherapy parameters in phase II and phase III trials in radiochemotherapy in Anal Cancer (PARADAC). Eur J Cancer 2019; 121:130-143. [PMID: 31574418 PMCID: PMC6924923 DOI: 10.1016/j.ejca.2019.08.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 08/16/2019] [Accepted: 08/24/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Concomitant external-beam radiochemotherapy (5-fluorouracil-mitomycin C) has become the standard of care in anal cancer since the '90s. A pooled analysis of individual patient data from 7 major trials was performed quantifying the effect of radiation therapy (RT)-related parameters on the outcome of patients with anal cancer. MATERIALS AND METHODS Pooling databases from combined modality trials, the impact of RT parameters (total dose, gap duration, OTT: overall treatment time) on outcome including locoregional failure (LRF), 5-year progression free survival (PFS) and toxicities were investigated. Individual patient data were received for 10/13 identified published studies conducted from 1987 to 2008 (n = 3031). A Cox regression model was used (landmark = 3 months after RT for first follow-up). RESULTS After data inspection indicating severe heterogeneity between trials, only 1343 patients from 7/10 studies received were analysed (the most recent ones, since 1994; median follow-up = 4.1 years). A higher overall 5-year LRF rate [22.8% (95% confidence interval [CI] 22.3-27.3%)] significantly correlated with longer OTT (p = 0.03), larger tumour size (p < 0.001) and male gender (p = 0.045). Although significant differences were not observed, subset analyses for LRF (dose range: 50.4-59 Gy) seemed to favour lower doses (p = 0.412), and when comparing a 2-week gap versus 3 (dose: 59.4 Gy), results suggested 3 weeks might be detrimental (p = 0.245). For a 2-week gap versus none (dose range: 55-59.4 Gy), no difference was observed (p = 0.89). Five-year PFS was 65.7% (95% CI: 62.8-68.5%). Higher PFS rates were observed in women (p < 0.001), smaller tumour sizes (p < 0.001) and shorter OTT (p = 0.025). Five-year overall survival [76.7% (95% CI: 73.9%-79.3%)] correlated positively with female gender (p < 0.001), small tumour size (p = 0.027) and short OTT (p = 0.026). Descriptive toxicity data are presented. CONCLUSION For patients receiving concurrent external-beam doublet chemoradiation, a longer OTT seems detrimental to outcome. Further trials involving modern techniques may better define optimal OTT and total dose.
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Affiliation(s)
- Eleonor Rivin Del Campo
- Department of Radiation Oncology, Tenon University Hospital, Sorbonne University, Paris, France.
| | - Oscar Matzinger
- Department of Radiation Oncology, Genolier Clinic, Genolier, Switzerland
| | - Karin Haustermans
- Department of Radiation Oncology, UZ Leuven University Hospital, Leuven, Belgium
| | - Didier Peiffert
- Department of Radiation Oncology, Institut de Cancérologie de Lorraine, Nancy, France
| | - Robert Glynne-Jones
- Department of Radiation Oncology, Mount Vernon Cancer Centre, Northwood, United Kingdom
| | - Kathryn A Winter
- NRG Oncology Statistics and Data Management Center, American College of Radiology, Philadelphia, PA, USA
| | - Andre A Konski
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Leonard Davis Institute of Health Economics, West Chester, PA, USA; Department of Radiation Oncology, The Chester County Hospital, West Chester, PA, USA
| | - Jaffer A Ajani
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Jean-François Bosset
- Department of Radiation Oncology, Jean Minjoz University Hospital, Besançon, France
| | | | - Marc Puyraveau
- Department of Statistics, Jean Minjoz University Hospital, Besançon, France
| | - A Bapsi Chakravarthy
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Helen Meadows
- Cancer Research UK & UCL Cancer Trials Centre, London, United Kingdom
| | - John Northover
- Department of Surgery, The London Clinic and St Marks Hospital, London, United Kingdom
| | | | - Melissa Christiaens
- Department of Radiation Oncology, UZ Leuven University Hospital, Leuven, Belgium
| | - Philippe Maingon
- Department of Radiation Oncology, La Pitié Salpêtrière - Charles Foix University Hospital, Sorbonne University, Paris, France
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Pumpalova Y, Kozak MM, von Eyben R, Kunz P, Fisher G, Chang DT, Haraldsdottir S. Comparison of definitive chemoradiation with 5-fluorouracil versus capecitabine in anal cancer. J Gastrointest Oncol 2019; 10:605-615. [PMID: 31392040 DOI: 10.21037/jgo.2019.02.17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Capecitabine (Cap) is an established treatment alternative to 5-fluorouracil (5-FU) for chemoradiation in rectal cancer. Few studies have compared the two agents in anal cancer. We compared outcomes and toxicities using Cap versus 5-FU in non-metastatic anal cancer patients at Stanford. METHODS All non-metastatic anal cancer patients treated with definitive chemoradiation at Stanford from 1997-2016 were included. Fisher's exact and Mann-Whitney U tests were used to compare nominal and continuous variables. Gray's test was used to compare incidence of recurrence and colostomy, and Log-rank test was used to compare survival. RESULTS Sixty-eight patients were included. Thirty-six patients received Cap and 32 received 5-FU (12 received standard 5-FU and 20 received low-dose continuous 5-FU). Patient characteristics were similar between the two groups. There was no difference in the 3-year overall and disease-specific survival between Cap and 5-FU (94% vs. 80%, P=0.197; 100% vs. 86%, P=0.051). Overall incidence of recurrence was equivalent between Cap and 5-FU (11% vs. 13%, P=0.703), but incidence of locoregional recurrence was higher in the 5-FU group (0% vs. 13%, P=0.042); patients treated with Cap had longer recurrence-free intervals (18 vs. 6 months, P=0.400), and all recurrences were distant. More colostomies were needed with 5-FU (3% vs. 13%, P=0.133). Toxicities were similar between the two groups. The most common grade ≥2 toxicities were dermatitis (77%), anal pain (78%), and diarrhea (56%). CONCLUSIONS Overall survival (OS), cancer-specific survival and incidence of recurrence were equivalent between Cap and 5-FU in anal cancer. Patients treated with Cap had statistically significant lower incidence of loco-regional relapses.
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Affiliation(s)
- Yoanna Pumpalova
- Department of Internal Medicine, Department of Internal Medicine, Stanford University, Stanford, CA, USA
| | - Margaret M Kozak
- Department of Radiation Oncology, Department of Internal Medicine, Stanford University, Stanford, CA, USA
| | - Rie von Eyben
- Department of Radiation Oncology, Department of Internal Medicine, Stanford University, Stanford, CA, USA
| | - Pamela Kunz
- Division of Medical Oncology, Department of Internal Medicine, Stanford University, Stanford, CA, USA
| | - George Fisher
- Division of Medical Oncology, Department of Internal Medicine, Stanford University, Stanford, CA, USA
| | - Daniel T Chang
- Department of Radiation Oncology, Department of Internal Medicine, Stanford University, Stanford, CA, USA
| | - Sigurdis Haraldsdottir
- Division of Medical Oncology, Department of Internal Medicine, Stanford University, Stanford, CA, USA
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12
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Eng C, Jácome AA, Das P, Chang GJ, Rodriguez-Bigas M, Skibber JM, Wolff RA, Qiao W, Xing Y, Sethi S, Ohinata A, Crane CH. A Phase II Study of Capecitabine/Oxaliplatin With Concurrent Radiotherapy in Locally Advanced Squamous Cell Carcinoma of the Anal Canal. Clin Colorectal Cancer 2019; 18:301-306. [PMID: 31350201 DOI: 10.1016/j.clcc.2019.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 06/21/2019] [Accepted: 06/25/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Squamous cell carcinoma of the anal canal (SCCA) presents a rising incidence in the United States. Standard of care for locally advanced disease is comprised of infusional 5-fluorouracil with mitomycin C or cisplatin concurrent with radiation therapy (RT). We designed this trial to evaluate the efficacy and safety of a more convenient regimen composed of capecitabine and oxaliplatin. PATIENTS AND METHODS This was a single-arm, phase II trial, with treatment-naive stage II to IIIB (TX,1-4NxM0) SCCA patients. The regimen was composed of capecitabine (825 mg/m2 twice per day for 5 days) and oxaliplatin (50 mg/m2 weekly) during weeks 1 through 6, concurrent with RT (XELOX-XRT; group 1). After the first 11 patients, the study was amended to omit chemotherapy during the third and sixth weeks (group 2). The primary objective was 3-year time to treatment failure (TTF) and safety. Secondary objectives were complete response (CR) rate, locoregional control, colostomy-free survival (CFS), and overall survival (OS). RESULTS Twenty patients were enrolled. Seven patients of group 1 (63%) developed Grade 3 toxicity, which reduced to 22% in Group 2. No Grade 4 toxicities were noted. The median RT dose was 55 Gy. CR occurred in 100% of the 19 patients evaluable for response at 12 to 14 weeks. After a median follow-up of 47.6 months, 2 patients had local recurrence and 1 had distant recurrence. Three-year TTF was 90.0%, with similar rates between groups 1 and 2 (respectively, 90.9% vs. 88.8%, P = .984). Three-year CFS was 90.0%. The median OS has not been reached. CONCLUSION The XELOX-XRT regimen is safe, with promising efficacy, and should be explored in larger trials for the treatment of locally advanced SCCA.
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Affiliation(s)
- Cathy Eng
- Department of Gastrointestinal Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX.
| | - Alexandre A Jácome
- Department of Gastrointestinal Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - George J Chang
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Miguel Rodriguez-Bigas
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - John M Skibber
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Robert A Wolff
- Department of Gastrointestinal Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Wei Qiao
- Department of Biostatistics, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Yan Xing
- Department of Biostatistics, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Salil Sethi
- Department of Gastrointestinal Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Aki Ohinata
- Department of Gastrointestinal Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Christopher H Crane
- Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX
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Eng C, Messick C, Glynne-Jones R. The Management and Prevention of Anal Squamous Cell Carcinoma. Am Soc Clin Oncol Educ Book 2019; 39:216-225. [PMID: 31099616 DOI: 10.1200/edbk_237433] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Our aim is to discuss the current established management of care and associated prevention strategies of anal squamous cell carcinoma (SCCA). In general, the development of SCCA is commonly linked to a prior history of HPV. Unfortunately, HPV vaccination continues to be underutilized in the United States versus other countries. Increased acknowledgment of the importance of HPV vaccination as an anticancer vaccine should be encouraged. The present standard of care is primary chemoradiotherapy (CRT), which results in a high level of disease control for small, early-stage SCCA. More advanced cancers still fare poorly with this treatment, and the disease relapses locoregionally in the majority of cases (30%-50% of patients), resulting in an abdominoperineal resection. Current treatment recommendations are associated with substantial morbidity; alternative radiation doses and/or novel combinations of agents with CRT are needed to improve quality of life and oncologic outcomes. Cytotoxic chemotherapy remains the standard of care for treatment-naïve patients with metastatic disease, with a possible new treatment paradigm of carboplatin/weekly paclitaxel. In addition, immune checkpoint inhibition appears to have a promising role in the setting of patients with refractory disease. Several clinical trials with immunotherapeutic and vaccine approaches for locally advanced and metastatic anal cancer are ongoing, as are HPV-agnostic umbrella trials. Whenever possible, clinical trial enrollment is always encouraged for further therapeutic development in the setting of a rare cancer, given the potentially substantial global impact for other HPV-associated malignancies.
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Affiliation(s)
- Cathy Eng
- 1 Gastrointestinal Medical Oncology Department, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Craig Messick
- 2 Surgical Oncology Department, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Rob Glynne-Jones
- 3 East and North Hertfordshire NHS Trust, Lister Hospital, Stevenage, United Kingdom
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The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for Anal Squamous Cell Cancers (Revised 2018). Dis Colon Rectum 2018; 61:755-774. [PMID: 29878949 DOI: 10.1097/dcr.0000000000001114] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Fish R, Sanders C, Ryan N, der Veer SV, Renehan AG, Williamson PR. Systematic review of outcome measures following chemoradiotherapy for the treatment of anal cancer (CORMAC). Colorectal Dis 2018; 20:371-382. [PMID: 29566456 PMCID: PMC5969105 DOI: 10.1111/codi.14103] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Accepted: 01/26/2018] [Indexed: 12/18/2022]
Abstract
AIM Six Phase III randomized trials have determined the effectiveness of chemoradiotherapy as primary treatment for anal squamous cell carcinoma (ASCC), but outcomes reported in these trials varied widely, hindering evidence synthesis. To improve reporting in all future trials, we aim to develop a core outcomes set (COS). As the first stage of COS development, we undertook a systematic review to summarize the outcomes reported in studies evaluating chemoradiotherapy for ASCC. METHOD Systematic literature searches identified studies evaluating radiotherapy or chemoradiotherapy for ASCC. Outcomes and accompanying definitions were extracted verbatim and categorized into domains. RESULTS From 5170 abstracts, we identified 95 eligible studies, reporting 1192 outcomes and 533 unique terms. We collapsed these terms into 86 standardized outcomes and five domains: survival; disease activity; life impact [including quality of life (QoL)]; delivery of care; and toxicity. The most commonly reported domains were survival and disease activity, reported in 74 (86%) and 54 (62%) studies, respectively. No outcome was reported in every publication. Over half (43/86) of the standardized outcome terms were reported in fewer than five studies, and 21 (25%) were reported in a single study only. There was wide variation in definitions of disease-free survival, colostomy-free survival and progression-free survival (PFS). Anal continence was reported in only 35 (41%) studies. CONCLUSION Outcomes reported in studies evaluating chemoradiotherapy for ASCC were heterogenous and definitions varied widely. Outcomes likely to be important to patients, such as ano-rectal function, toxicity and QoL, have been neglected. A COS for future trials will address these issues.
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Affiliation(s)
- R. Fish
- Division of Cancer SciencesSchool of Medical SciencesFaculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
- Peritoneal and Colorectal Oncology CentreChristie NHS Foundation TrustManchesterUK
| | - C. Sanders
- Centre for Primary CareUniversity of ManchesterManchesterUK
| | - N. Ryan
- Division of Cancer SciencesSchool of Medical SciencesFaculty of Biology, Medicine and Health Fifth Floor ‐ ResearchSt Mary's HospitalUniversity of ManchesterManchesterUK
| | - S. Van der Veer
- Centre for Health InformaticsInformatics, Imaging and Data ScienceSchool of Health SciencesFaculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
- Farr Institute of Health Informatics ResearchHealth eResearch CentreUniversity of ManchesterManchesterUK
| | - A. G. Renehan
- Division of Cancer SciencesSchool of Medical SciencesFaculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
- Peritoneal and Colorectal Oncology CentreChristie NHS Foundation TrustManchesterUK
| | - P. R. Williamson
- MRC North West Hub for Trials Methodology ResearchDepartment of BiostatisticsUniversity of LiverpoolLiverpoolUK
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Ludmir EB, Kachnic LA, Czito BG. Evolution and Management of Treatment-Related Toxicity in Anal Cancer. Surg Oncol Clin N Am 2018; 26:91-113. [PMID: 27889040 DOI: 10.1016/j.soc.2016.07.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Over the past several decades, clinical trials have demonstrated improved disease-related outcomes in the definitive treatment of anal cancer. Although treatment with radiation and concurrent chemotherapy results in high rates of cure, significant acute and late toxicities are seen. This review focuses on the evolution of treatment-related toxicity for anal cancer. Management of these adverse effects is reviewed, as are future directions in anal cancer treatment and their impact on toxicity.
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Affiliation(s)
- Ethan B Ludmir
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1422, Houston, TX 77030, USA
| | - Lisa A Kachnic
- Department of Radiation Oncology, Vanderbilt University Medical Center, 2220 Pierce Avenue, Suite B1034, Nashville, TN 37232, USA
| | - Brian G Czito
- Department of Radiation Oncology, Duke University Medical Center, Box 3085, Durham, NC 27710, USA.
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Schernberg A, Servagi-Vernat S, Loganadane G, Touboul E, Bosset JF, Huguet F. [Rectal squamous cell carcinoma treatment: Retrospective experience in two French university hospitals, review and proposals]. Cancer Radiother 2016; 20:824-829. [PMID: 27789176 DOI: 10.1016/j.canrad.2016.08.128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 07/29/2016] [Accepted: 08/03/2016] [Indexed: 11/16/2022]
Abstract
After publishing a retrospective series of 23 patients treated for a rectal squamous cell carcinoma with exclusive curative and conservative intent chemoradiation, we aim to propose a review of the literature about this rare tumour. We identified 11 retrospective studies, on 106 patients, treated between 2007 and 2016. Treatment of rectal squamous cell carcinoma should be similar to anal carcinoma, based on exclusive chemoradiation, displaying a 5-year overall survival rate over 80%, while it was 32% in surgical series. Baseline explorations should be similar as for anal carcinoma, with an interest in PET-CT at diagnosis and monitoring, after a delay over 6 weeks after chemoradiation. Intensity-modulated radiotherapy is legitimate, to a prophylactic dose between 36 and 45Gy, and over 54Gy to the tumour. Concomitant chemotherapy should combine an antimetabolite (5-fluorouracil or capecitabine) and mitomycin C, or cisplatin. This treatment seems well tolerated, associated with grade 2 or above toxicity below 30%. Follow-up should be established on anal squamous cell carcinoma schedule, with endoscopic ultrasonography and PET-CT. Rectal squamous cell carcinoma is a rare tumour; it management should be based on anal curative and conservative intent chemoradiation.
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Affiliation(s)
- A Schernberg
- Service de radiothérapie, hôpital Tenon, hôpitaux universitaires Est Parisien, 4, rue de la Chine, 75020 Paris, France; Université Paris VI Pierre-et-Marie-Curie, 4, rue de la Chine, 75020 Paris, France.
| | - S Servagi-Vernat
- Centre hospitalier régional et universitaire de Besançon, 2, place Saint-Jacques, 25000 Besançon, France
| | - G Loganadane
- Service de radiothérapie, hôpital Tenon, hôpitaux universitaires Est Parisien, 4, rue de la Chine, 75020 Paris, France; Université Paris VI Pierre-et-Marie-Curie, 4, rue de la Chine, 75020 Paris, France
| | - E Touboul
- Service de radiothérapie, hôpital Tenon, hôpitaux universitaires Est Parisien, 4, rue de la Chine, 75020 Paris, France; Université Paris VI Pierre-et-Marie-Curie, 4, rue de la Chine, 75020 Paris, France
| | - J-F Bosset
- Centre hospitalier régional et universitaire de Besançon, 2, place Saint-Jacques, 25000 Besançon, France
| | - F Huguet
- Service de radiothérapie, hôpital Tenon, hôpitaux universitaires Est Parisien, 4, rue de la Chine, 75020 Paris, France; Université Paris VI Pierre-et-Marie-Curie, 4, rue de la Chine, 75020 Paris, France
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Glynne-Jones R, Saleem W, Harrison M, Mawdsley S, Hall M. Background and Current Treatment of Squamous Cell Carcinoma of the Anus. Oncol Ther 2016; 4:135-172. [PMID: 28261646 PMCID: PMC5315080 DOI: 10.1007/s40487-016-0024-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Indexed: 12/19/2022] Open
Abstract
In this review, a summary of our current understanding of squamous cell carcinoma of the anus (SCCA) and the advances in our knowledge of SCCA regarding screening, prevention, the role of the immune system, current treatment and the potential for novel targets are discussed. The present standard of care in terms of treatment is 5-fluorouracil (5-FU) and mitomycin C (MMC) concurrently with radiation, which results in a high level of disease control for small early cancers. Preservation of the anal sphincter is achieved in the majority, although anorectal function is often impaired. Although evidence from prospective studies to support a change in the treatment strategy is lacking, patients with HPV-negative SCCA appear to be less responsive to chemoradiation (CRT) and relapse more frequently. In contrast, HPV-positive tumours usually fare better, but oncological outcomes are modified by smoking and immune incompetence. There is current interest in escalating the radiotherapy dose for larger, more advanced tumours, and de-escalating treatment for HPV-positive tumours. The use of novel immunological treatments to target the underlying different molecular pathways of HPV-positive cancers is exciting.
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Affiliation(s)
- Rob Glynne-Jones
- Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, Middlesex UK
| | - Waqar Saleem
- Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, Middlesex UK
| | - Mark Harrison
- Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, Middlesex UK
| | - Suzy Mawdsley
- Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, Middlesex UK
| | - Marcia Hall
- Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, Middlesex UK
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Vinayan A, Glynne-Jones R. Anal cancer - What is the optimum chemoradiotherapy? Best Pract Res Clin Gastroenterol 2016; 30:641-53. [PMID: 27644911 DOI: 10.1016/j.bpg.2016.06.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 06/16/2016] [Accepted: 06/23/2016] [Indexed: 01/31/2023]
Abstract
Radical concurrent chemoradiotherapy with 5FU and Mitomycin C is the standard-of-care for squamous-cell carcinoma of the anus (SCCA). Phase III trials combined radiation doses of 50-60 Gy with concurrent Fluoropyrimidines, Mitomycin C and Cisplatin in various doses and schedules. CRT is highly successful for early T1/T2 cancers, but results in appreciable late morbidities and still fails to control larger and node-positive tumours. Compliance to chemotherapy is important for local control. Modern radiotherapy techniques such as intensity-modulated radiotherapy (IMRT), rotational IMRT, image-guided radiotherapy (IGRT) have enabled smaller margins and highly conformal plans, resulting in decreased radiation doses to the organs at risk and ensuring a shorter overall treatment time. These advances offer the potential for integrating higher doses of radiation, escalation of the currently used drugs and the safe use of other more novel agents with acceptable toxicity. In this chapter potential novel approaches are discussed in the context of SCCA.
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Affiliation(s)
- A Vinayan
- Mount Vernon Centre for Cancer Treatment, Northwood, Middlesex HA6 2RN, UK.
| | - R Glynne-Jones
- Mount Vernon Centre for Cancer Treatment, Northwood, Middlesex HA6 2RN, UK.
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Loganadane G, Servagi-Vernat S, Schernberg A, Schlienger M, Touboul E, Bosset JF, Huguet F. Chemoradiation in rectal squamous cell carcinoma: Bi-institutional case series. Eur J Cancer 2016; 58:83-9. [PMID: 26974707 DOI: 10.1016/j.ejca.2016.02.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Revised: 01/18/2016] [Accepted: 02/04/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE Primary rectal squamous cell carcinoma (SCC) is an uncommon disease. Early reports stated that surgery is the most effective treatment. However, recent publications suggest conservative strategy with chemoradiation provides satisfactory results. PATIENTS AND METHODS We have retrospectively studied the medical charts of 23 patients treated for a rectal SCC in two teaching hospitals in France between 1992 and 2013. Twenty-one patients received an exclusive chemoradiotherapy (CRT) and two a pre-operative CRT followed by a planned surgery. Patients received pelvic irradiation with a dose ranging from 36-45 Gy followed by a boost of 15-23 Gy. Twenty-two patients received a concurrent chemotherapy. RESULTS After CRT, the rate of clinical complete response was 83%. With a median follow-up of 85 months, 5-year overall survival rate was 86%. Five patients presented with a relapse. The 5-year disease-free survival rate was 81%. The 5-year colostomy-free survival rate was 65%. Three patients (13%) presented with grade III-IV late rectal toxicity. CONCLUSIONS Although retrospective, this is the largest cohort of patients treated with CRT for a rectal SCC. Exclusive CRT could result in high local control rate and prolonged survival in rectal SCC patients with a high rate of organ preservation.
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Affiliation(s)
- Gokoulakrichenane Loganadane
- Department of Radiation Oncology, Tenon Hospital, Hôpitaux Universitaires Est Parisien, Pierre and Marie Curie Paris 6 University, Paris, France
| | | | - Antoine Schernberg
- Department of Radiation Oncology, Tenon Hospital, Hôpitaux Universitaires Est Parisien, Pierre and Marie Curie Paris 6 University, Paris, France
| | - Michel Schlienger
- Department of Radiation Oncology, Tenon Hospital, Hôpitaux Universitaires Est Parisien, Pierre and Marie Curie Paris 6 University, Paris, France
| | - Emmanuel Touboul
- Department of Radiation Oncology, Tenon Hospital, Hôpitaux Universitaires Est Parisien, Pierre and Marie Curie Paris 6 University, Paris, France
| | - Jean-François Bosset
- Department of Radiation Oncology, Besançon University Hospital, Besançon, France
| | - Florence Huguet
- Department of Radiation Oncology, Tenon Hospital, Hôpitaux Universitaires Est Parisien, Pierre and Marie Curie Paris 6 University, Paris, France.
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Abstract
Chemoradiotherapy is the standard-of-care treatment of squamous-cell carcinoma of the anus (SCCA), and this has not changed in decades. Radiation doses of 50-60 Gy, as used in many phase III trials, result in substantial late morbidities and fail to control larger and node-positive tumours. Technological advances in radiation therapy are improving patient outcomes and quality of life, and should be applied to patients with SCCA. Modern techniques such as intensity-modulated radiotherapy (IMRT), rotational IMRT, image-guided radiotherapy using cone-beam CT, and stereotactic techniques have enabled smaller margins and highly conformal plans, resulting in decreased radiation doses to the organs at risk and ensuring a shorter overall treatment time. In this Perspectives article, the use of novel approaches to target delineation, optimized radiotherapy techniques, adaptive radiotherapy, dose-escalation with external-beam radiotherapy (EBRT) or brachytherapy, and the potential for modified fractionation are discussed in the context of SCCA.
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Lépinoy A, Lescut N, Puyraveau M, Caubet M, Boustani J, Lakkis Z, Fantoli M, Buffet-Miny J, Kim S, Bednarek C, Maingon P, Créhange G, Bosset JF. Evaluation of a 36 Gy elective node irradiation dose in anal cancer. Radiother Oncol 2015; 116:197-201. [DOI: 10.1016/j.radonc.2015.07.050] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 07/26/2015] [Accepted: 07/27/2015] [Indexed: 01/21/2023]
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Helical Tomotherapy for the Treatment of Anal Canal Cancer: A Dosimetric Comparison with 3D Conformal Radiotherapy. TUMORI JOURNAL 2015; 101:268-72. [DOI: 10.5301/tj.5000269] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2015] [Indexed: 12/25/2022]
Abstract
Aims and Background The standard treatment of anal canal cancer (ACC) is combined chemotherapy and radiation therapy (RT), which is complex because of the shape of the target volumes and the need to minimize the irradiation of normal pelvic structures. In this study we compared the dosimetric results of helical tomotherapy (HT) plans with traditional 3D conformal RT (3DRT) plans for the treatment of ACC. Methods and Study Design Twelve patients (median age 57 years, range 38–83; F/M 8/4) treated with HT and concurrent chemotherapy for locally advanced ACC were selected. All had histologically confirmed squamous-cell carcinoma. A clinical target volume including the tumor and pelvic and inguinal lymph nodes was treated with HT to a total dose of 36 Gy in 1.8-Gy daily fractions. Then a sequential boost of 23.4 Gy in 1.8-Gy daily fractions (total dose 59.4 Gy) was delivered to the tumor and involved nodes. For all 12 patients, 3DRT plans were generated for comparison. Treatment plans were evaluated by means of standard dose-volume histograms. Dose coverage of the planning target volumes (PTVs), homogeneity index (HI), and mean doses to organs at risk (OARs) were compared. Results The coverage of PTV was comparable between the two treatment plans. HI was better in the HT vs. 3DRT plans (1.25 and 3.57, respectively; p<0.0001). HT plans resulted in better sparing of OARs (p<0.0001). Conclusions HT showed superior target dose conformality and significant sparing of pelvic structures compared with 3DRT. Further investigation should determine if these dosimetric improvements will improve clinical outcomes regarding locoregional control, survival, and treatment-related acute and late morbidity.
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Shridhar R, Shibata D, Chan E, Thomas CR. Anal cancer: current standards in care and recent changes in practice. CA Cancer J Clin 2015; 65:139-62. [PMID: 25582527 DOI: 10.3322/caac.21259] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Answer questions and earn CME/CNE The management of squamous cell carcinomas of the anal canal has evolved from surgery as first-line treatment to curative chemoradiation, with surgery reserved for salvage. Significant progress has been made in understanding how to most effectively deliver chemotherapy and reduce toxicity through advancements in radiation delivery. The purpose of this article is to review the multimodality approach to the diagnosis and management of anal cancer based on a review of the published data and in light of available guidelines.
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Affiliation(s)
- Ravi Shridhar
- Associate Professor, Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL
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Ghosn M, Kourie HR, Abdayem P, Antoun J, Nasr D. Anal cancer treatment: Current status and future perspectives. World J Gastroenterol 2015; 21:2294-2302. [PMID: 25741135 PMCID: PMC4342904 DOI: 10.3748/wjg.v21.i8.2294] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2014] [Revised: 10/24/2014] [Accepted: 12/22/2014] [Indexed: 02/07/2023] Open
Abstract
Anal cancers (AC) are relatively rare tumors. Their incidence is increasing, particularly among men who have sex with other men due to widespread infection by human papilloma virus. The majority of anal cancers are squamous cell carcinomas, and they are treated according to stage. In local and locally advanced AC, concomitant chemoradiation therapy based on mitomycin C and 5-Fluorouracil (5-FU) is the current best treatment, while metastatic AC, chemotherapy with 5-FU and cisplatin remains the gold standard. There are no indications for induction or maintenance therapies in locally advanced tumors. Many novel strategies, such as targeted therapies, vaccination, immunotherapy and photodynamic therapy are in clinical trials for the treatment of AC, with promising results in some indications.
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Foo M, Link E, Leong T, Chu J, Lee MT, Chander S, Tran PK, Tomaszewski JM, Michael M, Heriot A, Ngan SY. Impact of advancing age on treatment and outcomes in anal cancer. Acta Oncol 2014; 53:909-16. [PMID: 24456502 DOI: 10.3109/0284186x.2013.876513] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Chemoradiotherapy (CRT) for squamous cell carcinoma of the anus (SCCA) may cause significant toxicity, and concerns exist about its tolerability in the elderly. The authors compared tolerability and outcomes across the age groups following CRT for SCCA. METHODS Single-institution retrospective analysis of patients with localized SCCA treated with CRT. CRT was standardized at 50.4-54 Gy, with concurrent infusional 5-fluorouracil and mitomycin C. Patients were arbitrarily categorized into three groups: Group 1 - age < 50 years; Group 2 - age ≥ 50 and < 70 years; and Group 3 - age ≥ 70 years. RESULTS Of 284 patients identified, 278 were evaluable. The number of patients in each age group was: Group 1 - 51; Group 2 - 140; and Group 3 - 93. Baseline and treatment characteristics, tumor stage, rates of overall acute toxicity, need for unplanned treatment breaks and chemotherapy delivery were largely similar across the age groups. However, nine patients in Group 3 did not complete CRT, compared with five and none in Groups 1 and 2, respectively (p = 0.006). In addition, five patients in Group 3 had diarrhea requiring treatment break, compared with none in the other two groups (p = 0.004). At a median follow-up 5.3 years, there was no significant difference in overall survival (p = 0.11), disease-free survival (p = 0.22) or local-recurrence free survival (p = 0.34), across the three age groups. CONCLUSIONS CRT is safe and tolerable in the elderly age group, and provides equivalent disease control rates compared with the younger age group. Age alone should therefore not preclude aggressive curative treatment.
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Affiliation(s)
- Marcus Foo
- Division of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre , Melbourne, Victoria , Australia
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White BN, Waddell JA, Solimando DA. Mitomycin and Fluorouracil With Concurrent Radiation (FUMIR) Regimen for Anal Cancer. Hosp Pharm 2013; 48:464-9. [PMID: 24421505 PMCID: PMC3839500 DOI: 10.1310/hpj4806-464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2023]
Abstract
The complexity of cancer chemotherapy requires pharmacists be familiar with the complicated regimens and highly toxic agents used. This column reviews various issues related to preparation, dispensing, and administration of antineoplastic therapy, and the agents, both commercially available and investigational, used to treat malignant diseases. Questions or suggestions for topics should be addressed to Dominic A. Solimando, Jr, President, Oncology Pharmacy Services, Inc, 4201 Wilson Blvd #110-545, Arlington, VA 22203, e-mail: OncRxSvc@aol.com; or J. Aubrey Waddell, Professor, University of Tennessee College of Pharmacy; Oncology Pharmacist, Pharmacy Department, Blount Memorial Hospital, 907 E. Lamar Alexander Parkway, Maryville, TN 37804, e-mail: waddfour@charter.net.
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Affiliation(s)
- Brittany N White
- Dr. White is a pharmacy practice (PGY1) resident at Blount Memorial Hospital, Maryville, Tennesse
| | - J Aubrey Waddell
- Dr. White is a pharmacy practice (PGY1) resident at Blount Memorial Hospital, Maryville, Tennesse
| | - Dominic A Solimando
- Dr. White is a pharmacy practice (PGY1) resident at Blount Memorial Hospital, Maryville, Tennesse
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Abstract
Historically, squamous cell carcinoma of the anal canal was treated with abdominoperineal resection. Nigro discovered that radiation therapy combined with 5-fluorouracil and mitomycin resulted in high rates of local control and colostomy-free and overall survival without surgical intervention. Recent advances include the integration of PET into staging, radiation treatment planning, disease monitoring, and the use of intensity-modulated radiation therapy. For rectal cancer, clinical trials have established the role for neoadjuvant therapy for T3-4 and/or node-positive tumor presentations. Chemotherapy and targeted agents are under study in both anal and rectal cancers to improve on the standard combinations of chemotherapy and radiation.
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Affiliation(s)
- Brian G Czito
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA.
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Dewas CV, Maingon P, Dalban C, Petitfils A, Peignaux K, Truc G, Martin E, Khoury C, Dewas S, Créhange G. Does gap-free intensity modulated chemoradiation therapy provide a greater clinical benefit than 3D conformal chemoradiation in patients with anal cancer? Radiat Oncol 2012. [PMID: 23190693 PMCID: PMC3576273 DOI: 10.1186/1748-717x-7-201] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chemoradiation is the standard treatment for anal cancer. 3D conformal radiotherapy (3D-CRT) is usually split in 2 sequences with a therapeutic break (gap) in between. Intensity-modulated radiation therapy (IMRT) makes it possible to reduce treatment time by abandoning this gap. The purpose of this study was to compare outcomes and toxicities in patients treated with either IMRT or 3D-CRT. METHODS Between 2004 and 2011, the data of 51 patients treated with exclusive radiotherapy with or without concomitant chemotherapy for non-metastatic anal carcinoma were retrospectively analyzed. Twenty-seven patients were treated with 3D-CRT and 24 patients with IMRT, with a median dose delivered to the tumor of 59.4Gy [30.6-66.6], whatever the radiotherapy technique (p= 0.99). The median follow-up was 40 months [26.4-51.6]. RESULTS There was no difference between the two groups for response to treatment (p= 0.46). Two-year overall survival, locoregional relapse-free survival and colostomy-free survival rates were 88.5%, 63% and 60.3%, respectively for the IMRT group and 81%, 76.5% and 81.1% for the 3D-CRT group (all NS). Ten patients (37%) in 3D-CRT and 11 patients (45.8%) in IMRT (p= 0.524) had grade 3 acute toxicity. No grade 4 toxicity occurred. CONCLUSIONS Our study suggests that further investigations concerning the use of IMRT to treat cancer of the anus are warranted. IMRT makes it possible to remove the gap, but with no impact on the prognosis. Nonetheless, a longer follow-up is essential to determine whether or not IMRT has an impact on late toxicity, local control and survival compared with conventional 3D-CRT.
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Affiliation(s)
- Claire Vautravers Dewas
- Department of Radiation Oncology, Anticancer center Georges François Leclerc, 1 rue du Professeur Marion, Dijon 21000, France
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Akhlaghpoor S, Aziz-Ahari A, Amoui M, Tolooee S, Poorbeigi H, Sheybani S. Short-term effectiveness of radiochemoembolization for selected hepatic metastases with a combination protocol. World J Gastroenterol 2012; 18:5249-59. [PMID: 23066320 PMCID: PMC3468858 DOI: 10.3748/wjg.v18.i37.5249] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Revised: 05/30/2012] [Accepted: 07/18/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To introduce the combination method of radiochemoembolization for the treatment of selected hepatic metastases.
METHODS: Twenty patients with biopsy proven hepatic metastases were selected from those who underwent transarterial radiochemoembolization, a novel combination protocol, between January 2009 and July 2010. Patients had different sources of liver metastasis. The treatment included transarterial administration of three chemotherapeutic drugs (mitomycin, doxorubicin and cisplatin), followed by embolization with large (50-150 μm) radioisotope particles of chromic 32P. Multiphasic computer tomography or computer tomography studies, with and without contrast medium injections, were performed for all patients for a short-term period before and after the treatment sessions. The short-term effectiveness of this procedure was evaluated by modified response evaluation criteria in solid tumors (mRECIST), which also takes necrosis into account. The subjective percentage of necrosis was also assessed. The response evaluation methods were based on the changes in size, number, and the enhancement patterns of the lesions between the pre- and post-treatment imaging studies.
RESULTS: Patients had liver metastasis from colorectal carcinomas, breast cancer, lung cancer and carcinoid tumors. The response rate based on the mRECIST criteria was 5% for complete response, 60% for partial response, 10% for stable disease, and 25% for progressive disease. Regarding the subjective necrosis percentage, 5% of patients had complete response, 50% had partial response, 25% had stable disease, and 20% had progressive disease. Based on traditional RECIST criteria, 3 patients (15%) had partial response, 13 patients (65%) had stable disease, and 4 patients (20%) had disease progression. In most patients, colorectal carcinoma was the source of metastasis (13 patients). Based on the mRECIST criteria, 8 out of these 13 patients had partial responses, while one remained stable, and 5 showed progressive disease. We also had 5 cases of breast cancer metastasis which mostly remained stable (4 cases), with only one partial response after the procedure. Six patients had bilobar involvement; three of them received two courses of radiochemoembolization. The follow up imaging study of these patients was performed after the second session. In the studied patients there was no evidence of extrahepatic occurrence, including pulmonary radioactive deposition, which was proven by Bremsstrahlung scintigraphy performed after the treatment sessions. For the short-term follow-ups for the 2 mo after the therapy, no treatment related death was reported. The mostly common side effect was post-embolization syndrome, presented as vomiting, abdominal pain, and fever. Nineteen (95%) patients experienced this syndrome in different severities. Two patient had ascites (with pleural effusion in one patient) not related to hepatic failure. Moreover, no cases of acute liver failure, hepatic infarction, hepatic abscess, biliary necrosis, tumor rupture, surgical cholecystitis, or non-targeted gut embolization were reported. Systemic toxicities such as alopecia, marrow suppression, renal toxicity, or cardiac failure did not occur in our study group.
CONCLUSION: Radiochemoembolization is safe and effective for selected hepatic metastases in a short-term follow-up. Further studies are required to show the long-term effects and possible complications of this approach.
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Cacheux W, Lievre A, De La Rochefordiere A, Dieumegard B, Cvitkovic F, Labib A, Mitry E, Buecher B. Chemotherapy in the treatment of anal canal carcinoma. Dig Liver Dis 2012; 44:803-11. [PMID: 22658644 DOI: 10.1016/j.dld.2012.04.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Accepted: 04/18/2012] [Indexed: 12/11/2022]
Abstract
Squamous cell carcinomas of the anal canal are generally diagnosed at a localized or locally advanced stage and only 5% are metastatic at the time of diagnosis. Advanced forms are therefore much rarer than localized forms and usually correspond to metachronous metastases of initially localized disease. Systemic chemotherapy is indicated for the treatment of both localized disease, in combination with radiotherapy, and metastatic disease. The purpose of this article is to define the current indications and modalities of chemotherapy in the treatment of these cancers based on a review of the published data and in the light of available guidelines.
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Affiliation(s)
- Wulfran Cacheux
- Department of Medical Oncology, Groupe Hospitalier, Institut Curie, 26 rue d'Ulm, 75248 Paris Cédex 5, France
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Three cytotoxic drugs combined with pelvic radiation and as maintenance chemotherapy for patients with squamous cell carcinoma of the anus (SCCA): Long-term follow-up of a phase II pilot study using 5-fluorouracil, mitomycin C and cisplatin. Radiother Oncol 2012; 104:155-60. [DOI: 10.1016/j.radonc.2012.06.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Revised: 05/26/2012] [Accepted: 06/10/2012] [Indexed: 11/20/2022]
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Peiffert D, Tournier-Rangeard L, Gérard JP, Lemanski C, François E, Giovannini M, Cvitkovic F, Mirabel X, Bouché O, Luporsi E, Conroy T, Montoto-Grillot C, Mornex F, Lusinchi A, Hannoun-Lévi JM, Seitz JF, Adenis A, Hennequin C, Denis B, Ducreux M. Induction chemotherapy and dose intensification of the radiation boost in locally advanced anal canal carcinoma: final analysis of the randomized UNICANCER ACCORD 03 trial. J Clin Oncol 2012; 30:1941-8. [PMID: 22529257 DOI: 10.1200/jco.2011.35.4837] [Citation(s) in RCA: 242] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Concomitant radiochemotherapy (RCT) is the standard for locally advanced anal canal carcinoma (LAACC). Questions regarding the role of induction chemotherapy (ICT) and a higher radiation dose in LAACC are pending. Our trial was designed to determine whether dose escalation of the radiation boost or two cycles of ICT before concomitant RCT lead to an improvement in colostomy-free survival (CFS). PATIENTS AND METHODS Patients with tumors ≥ 40 mm, or < 40 mm and N1-3M0 were randomly assigned to one of four treatment arms: (A) two ICT cycles (fluorouracil 800 mg/m(2)/d intravenous [IV] infusion, days 1 through 4 and 29 to 32; and cisplatin 80 mg/m(2) IV, on days 1 and 29), RCT (45 Gy in 25 fractions over 5 weeks, fluorouracil and cisplatin during weeks 1 and 5), and standard-dose boost (SD; 15 Gy); (B) two ICT cycles, RCT, and high-dose boost (HD; 20-25 Gy); (C): RCT and SD boost (reference arm); and (D) RCT and HD boost. RESULTS Two hundred eighty-three of 307 patients achieved full treatment. With a median follow-up period of 50 months, the 5-year CFS rates were 69.6%, 82.4%, 77.1%, and 72.7% in arms A, B, C, and D, respectively. Considering the 2 × 2 factorial analysis, the 5-year CFS was 76.5% versus 75.0% (P = .37) in groups A and B versus C and D, respectively (ICT effect), and 73.7% versus 77.8% in groups A and C versus B and D, respectively (RT-dose effect; P = .067). CONCLUSION Using CFS as our main end point, we did not find an advantage for either ICT or HD radiation boost in LAACC. Nevertheless, the results of the most treatment-intense arm B should prompt the design of further intensification studies.
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Affiliation(s)
- Didier Peiffert
- EA 4360Centre, Alexis Vautrin and Nancy University,Vandoeuvre-lès-Nancy, France.
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Grégoire V, Bartelink H, Bernier J, Bolla M, Bosset JF, Collette L, Haustermans K, Horiot JC, Hurkmans CW, Mirimanoff R, Poortmans P, Weber DC, Maingon P. EORTC Radiation Oncology Group: 50 years of continuous accomplishments. EJC Suppl 2012. [DOI: 10.1016/s1359-6349(12)70024-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Ozsahin M, Santa Cruz O, Bouchaab H, Matzinger O, Tsoutsou PG. Definitive organ-sparing treatment of anal canal cancer: can we afford to question it? J Clin Oncol 2012; 30:673-4; author reply 674-5. [PMID: 22278906 DOI: 10.1200/jco.2011.39.6838] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Glynne-Jones R, Lim F. Anal Cancer: An Examination of Radiotherapy Strategies. Int J Radiat Oncol Biol Phys 2011; 79:1290-301. [DOI: 10.1016/j.ijrobp.2010.10.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2010] [Revised: 10/12/2010] [Accepted: 10/14/2010] [Indexed: 01/29/2023]
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Zampino MG, Magni E, Leonardi MC, Santoro L, Petazzi E, Fodor C, Petralia G, Trovato C, Nolè F, Orecchia R. Concurrent cisplatin, continuous infusion fluorouracil and radiotherapy followed by tailored consolidation treatment in non metastatic anal squamous cell carcinoma. BMC Cancer 2011; 11:55. [PMID: 21291546 PMCID: PMC3055231 DOI: 10.1186/1471-2407-11-55] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2010] [Accepted: 02/03/2011] [Indexed: 12/15/2022] Open
Abstract
Background To evaluate efficacy and feasibility of chemo-radiotherapy in patients with non-metastatic anal squamous-cell-cancer. Methods TNM staged anal squamous-cell cancer patients were treated with pelvic radiotherapy concomitant to continuous infusion fluorouracil plus cisplatin for at least 2 cycles. In T3-T4 or any T - N+ tumours or in "slow-responder" cases, 1-2 chemotherapy courses were subsequently administered. Tumour assessment was performed at baseline and 6-8 weeks after radiotherapy to evaluate response. Results 29 patients were enrolled: 4 males, 25 females; median age 57 years; baseline T1/T2/T3/T4 2/12/7/8; N involvement 17. Median dose pelvic radiotherapy was 59.4 Gy (range: 54-74). In 5 patients 2 chemotherapy courses, in 12 patients three and in 12 patients four courses were performed. At first evaluation, 27 CR (93.1%; 95% CI: 78% - 98%) and 2 SD were observed. Main grade (G) 3 toxic events were neutropenia (8%), diarrhoea (8%) and dermatitis (62%). Most frequent late events G3-G4 occurred in 14 patients: proctitis (5), dermatitis (4), bladder dysfunctions (2), sexual dysfunctions (9), lower extremity venous thromboses (2), dysuria (1), stenosis (1) and tenesmus (1). Five patients reported G1 leucopoenia. The rate of colostomy was 14%. After a median follow up of 42 months (range: 4-81), 20 patients are still alive without relapse and 3 died due to PD. The estimated 7-year DFS was 83.4% (C.I.: 68.3%-98.5%) and the estimated 7-year OS was 85.7% (C.I.: 70% - 100%). The 1-year and the estimated 7-year colostomy-free survivals were 85.9% (C.I.: 73.1% - 98.7%). Conclusions Concurrent cisplatin plus fluorouracil and radiotherapy is associated with favourable local control rates and acute toxicity. Future investigations will be directed towards research into molecular biomarkers related to disease progression and resistance to chemo-radiotherapy and to the evaluation of new cytotoxic agents or targeted drugs, such as anti-epidermal growth factor receptor, concomitant to RT and to determining the role of intensity-modulated radiotherapy.
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Affiliation(s)
- Maria G Zampino
- Medical Care Unit, Department of Medicine, European Institute of Oncology, via Ripamonti 435, Milan 20141, Italy.
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Affiliation(s)
- M Kronfli
- Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, Middlesex, UK
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Glynne-Jones R, Sebag-Montefiore D, Adams R, McDonald A, Gollins S, James R, Northover JMA, Meadows HM, Jitlal M. "Mind the gap"--the impact of variations in the duration of the treatment gap and overall treatment time in the first UK Anal Cancer Trial (ACT I). Int J Radiat Oncol Biol Phys 2010; 81:1488-94. [PMID: 20934265 DOI: 10.1016/j.ijrobp.2010.07.1995] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2010] [Revised: 07/01/2010] [Accepted: 07/19/2010] [Indexed: 12/13/2022]
Abstract
PURPOSE The United Kingdom Coordinating Committee on Cancer Research anal cancer trial demonstrated the benefit of combined modality treatment (CMT) using radiotherapy (RT), infusional 5-fluorouracil, and mitomycin C over RT alone. The present study retrospectively examines the impact of the recommended 6-week treatment gap and local RT boost on long-term outcome. METHODS AND MATERIALS A total of 577 patients were randomly assigned RT alone or CMT. After a 6-week gap responders received a boost using either additional external beam radiotherapy (EBRT) (15 Gy) or iridium-192 implant (25 Gy). The effect of boost, the gap between initial treatment (RT alone or CMT) and boost (Tgap), and overall treatment time (OTT) were examined for their impact on outcome. RESULTS Among the 490 good responders, 436 (89%) patients received a boost after initial treatment. For boosted patients, the risk of anal cancer death decreased by 38% (hazard ratio [HR]: 0.62, 99% CI 0.35-1.12; p=0.04), but there was no evidence this was mediated via a reduction in locoregional failure (LRF) (HR: 0.90, 99% CI 0.48-1.68; p=0.66). The difference in Tgap was only 1.4 days longer for EBRT boost, compared with implant (p=0.51). OTT was longer by 6.1 days for EBRT (p=0.006). Tgap and OTT were not associated with LRF. Radionecrosis was reported in 8% of boosted, compared with 0% in unboosted patients (p=0.03). CONCLUSIONS These results question the benefit of a radiotherapy boost after a 6-week gap. The higher doses of a boost may contribute more to an increased risk of late morbidity, rather than local control.
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Combined-Modality Treatment for Anal Cancer. Strahlenther Onkol 2010; 186:361-6. [DOI: 10.1007/s00066-010-2162-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2010] [Accepted: 04/27/2010] [Indexed: 11/25/2022]
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