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Dong J, Wang B, Xiao Y, Liu J, Wang Q, Xiao H, Jin Y, Liu Z, Chen Z, Li Y, Fan S, Li Y, Cui M. Roseburia intestinalis sensitizes colorectal cancer to radiotherapy through the butyrate/OR51E1/RALB axis. Cell Rep 2024; 43:113846. [PMID: 38412097 DOI: 10.1016/j.celrep.2024.113846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 10/30/2023] [Accepted: 02/06/2024] [Indexed: 02/29/2024] Open
Abstract
The radioresistant signature of colorectal cancer (CRC) hampers the clinical utility of radiotherapy. Here, we find that fecal microbiota transplantation (FMT) potentiates the tumoricidal effects of radiation and degrades the intertwined adverse events in azoxymethane (AOM)/dextran sodium sulfate (DSS)-induced CRC mice. FMT cumulates Roseburia intestinalis (R. intestinalis) in the gastrointestinal tract. Oral gavage of R. intestinalis assembles at the CRC site and synthetizes butyrate, sensitizing CRC to radiation and alleviating intestinal toxicity in primary and CRC hepatic metastasis mouse models. R. intestinalis-derived butyrate activates OR51E1, a G-protein-coupled receptor overexpressing in patients with rectal cancer, facilitating radiogenic autophagy in CRC cells. OR51E1 shows a positive correlation with RALB in clinical rectal cancer tissues and CRC mouse model. Blockage of OR51E1/RALB signaling restrains butyrate-elicited autophagy in irradiated CRC cells. Our findings highlight that the gut commensal bacteria R. intestinalis motivates radiation-induced autophagy to accelerate CRC cell death through the butyrate/OR51E1/RALB axis and provide a promising radiosensitizer for CRC in a pre-clinical setting.
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Affiliation(s)
- Jiali Dong
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin 300192, China
| | - Bin Wang
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin 300192, China
| | - Yunong Xiao
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin 300192, China
| | - Jia Liu
- Department of Microbiology, College of Life Sciences, Nankai University, Tianjin 300071, China
| | - Qi Wang
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin 300192, China
| | - Huiwen Xiao
- Department of Microbiology, College of Life Sciences, Nankai University, Tianjin 300071, China
| | - Yuxiao Jin
- Department of Anesthesiology, Changshu No. 2 People's Hospital, Changshu, Jiangsu Province 215501, China
| | - Zhihong Liu
- Department of General Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province 215004, China
| | - Zhiyuan Chen
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin 300192, China
| | - Yiliang Li
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin 300192, China
| | - Saijun Fan
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin 300192, China
| | - Yuan Li
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin 300192, China.
| | - Ming Cui
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin 300192, China.
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Andel D, Viergever BJ, Peters NA, Elisabeth Raats DA, Schenning-van Schelven SJ, Willem Intven MP, Zandvliet M, Hagendoorn J, Max Borel Rinkes IH, Kranenburg O. Pre-existing subclones determine radioresistance in rectal cancer organoids. Cell Rep 2024; 43:113735. [PMID: 38310513 DOI: 10.1016/j.celrep.2024.113735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 12/05/2023] [Accepted: 01/17/2024] [Indexed: 02/06/2024] Open
Abstract
More than half of all patients with cancer receive radiation therapy, but resistance is commonly observed. Currently, it is unknown whether resistance to radiation therapy is acquired or inherently present. Here, we employed organoids derived from rectal cancer and single-cell whole-genome sequencing to investigate the long-term evolution of subclones in response to radiation. Comparing single-cell whole-genome karyotypes between in-vitro-unirradiated and -irradiated organoids revealed three patterns of subclonal evolution: (1) subclonal persistence, (2) subclonal extinction, and (3) subclonal expansion. Organoids in which subclonal shifts occurred (i.e., expansion or extinction) became more resistant to radiation. Although radioresistant subclones did not share recurrent copy-number alterations that could explain their radioresistance, resistance was associated with reduced chromosomal instability, an association that was also observed in 529 human cancer cell lines. These data suggest that resistance to radiation is inherently present and associated with reduced chromosomal instability.
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Affiliation(s)
- Daan Andel
- Department of Surgical Oncology, University Medical Center Utrecht, Cancer Center, Utrecht, the Netherlands; Laboratory for Translational Oncology, University Medical Center Utrecht, Cancer Center, Utrecht, the Netherlands
| | - Bas Jeroen Viergever
- Laboratory for Translational Oncology, University Medical Center Utrecht, Cancer Center, Utrecht, the Netherlands
| | - Niek Alexander Peters
- Department of Surgical Oncology, University Medical Center Utrecht, Cancer Center, Utrecht, the Netherlands; Laboratory for Translational Oncology, University Medical Center Utrecht, Cancer Center, Utrecht, the Netherlands
| | | | | | - Martijn Peter Willem Intven
- Department of Radiation Oncology, University Medical Center Utrecht, Cancer Center, Utrecht, the Netherlands
| | - Maurice Zandvliet
- Department of Clinical Sciences - Companion Animals, Faculty of Veterinary Medicine, Utrecht University, Utrecht, the Netherlands
| | - Jeroen Hagendoorn
- Department of Surgical Oncology, University Medical Center Utrecht, Cancer Center, Utrecht, the Netherlands; Laboratory for Translational Oncology, University Medical Center Utrecht, Cancer Center, Utrecht, the Netherlands
| | - Inne Hilbrand Max Borel Rinkes
- Department of Surgical Oncology, University Medical Center Utrecht, Cancer Center, Utrecht, the Netherlands; Laboratory for Translational Oncology, University Medical Center Utrecht, Cancer Center, Utrecht, the Netherlands.
| | - Onno Kranenburg
- Department of Surgical Oncology, University Medical Center Utrecht, Cancer Center, Utrecht, the Netherlands; Laboratory for Translational Oncology, University Medical Center Utrecht, Cancer Center, Utrecht, the Netherlands; Utrecht Platform for Organoid Technology, Utrecht University, Utrecht, the Netherlands.
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Zhou H, Wang L, Lin Z, Jiang C, Chen X, Wang K, Liu L, Shao L, Pan J, Li J, Zhang D, Wu J. Methylglyoxal from gut microbes boosts radiosensitivity and radioimmunotherapy in rectal cancer by triggering endoplasmic reticulum stress and cGAS-STING activation. J Immunother Cancer 2023; 11:e007840. [PMID: 38035726 PMCID: PMC10689421 DOI: 10.1136/jitc-2023-007840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Preoperative radiation therapy (preRT) is a fundamental aspect of neoadjuvant treatment for rectal cancer (RC), but the response to this treatment remains unsatisfactory. The combination of radiation therapy (RT) and immunotherapy (iRT) presents a promising approach to cancer treatment, though the underlying mechanisms are not yet fully understood. The gut microbiota may influence the response to RT and immunotherapy. Therefore, we aimed to identify the metabolism of gut microbiota to reverse radioresistance and enhance the efficacy of iRT. METHODS Fecal and serum samples were prospectively collected from patients with locally advanced rectal cancer (LARC) who had undergone pre-RT treatment. Candidate gut microbiome-derived metabolites linked with radiosensitization were screened using 16s rRNA gene sequencing and ultrahigh-performance liquid chromatography-mass coupled with mass spectrometry. In vitro and in vivo studies were conducted to assess the radiosensitizing effects of the metabolites including the syngeneic CT26 tumor model and HCT116 xenograft tumor model, transcriptomics and immunofluorescence. The CT26 abscopal effect modeling was employed to evaluate the combined effects of metabolites on iRT. RESULTS We initially discovered the gut microbiota-associated metabolite, methylglyoxal (MG), which accurately predicts the response to preRT (Area Under Curve (AUC) value of 0.856) among patients with LARC. Subsequently, we observed that MG amplifies the RT response in RC by stimulating intracellular reactive oxygen species (ROS) and reducing hypoxia in the tumor in vitro and in vivo. Additionally, our study demonstrated that MG amplifies the RT-induced activation of the cyclic guanosine monophosphate AMP synthase-stimulator of interferon genes pathway by elevating DNA double-strand breaks. Moreover, it facilitates immunogenic cell death generated by ROS-mediated endoplasmic reticulum stress, consequently leading to an increase in CD8+ T and natural killer cells infiltrated in the tumor immune microenvironment. Lastly, we discovered that the combination of anti-programmed cell death protein 1 (anti-PD1) therapy produced long-lasting complete responses in all irradiated tumor sites and half of the non-irradiated ones. CONCLUSIONS Our research indicates that MG shows promise as a radiosensitizer and immunomodulator for RC. Furthermore, we propose that combining MG with iRT has great potential for clinical practice.
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Affiliation(s)
- Han Zhou
- Department of Radiation Oncology, College of Clinical Medicine for Oncology, Fujian Medical University & Fujian Cancer Hospital, Fuzhou, Fujian, China
- Department of Clinical Oncology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Lei Wang
- Department of Oncology, the Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Zhiwen Lin
- The United Innovation of Mengchao Hepatobiliary Technology Key Laboratory of Fujian Province, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, China
- Department of Hepatopancreatobiliary Surgery, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Chenwei Jiang
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Xingte Chen
- Department of Radiation Oncology, College of Clinical Medicine for Oncology, Fujian Medical University & Fujian Cancer Hospital, Fuzhou, Fujian, China
| | - Kai Wang
- Department of Radiation, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Libin Liu
- Department of Radiation Oncology, College of Clinical Medicine for Oncology, Fujian Medical University & Fujian Cancer Hospital, Fuzhou, Fujian, China
| | - Lingdong Shao
- Department of Radiation Oncology, College of Clinical Medicine for Oncology, Fujian Medical University & Fujian Cancer Hospital, Fuzhou, Fujian, China
| | - Jianji Pan
- Department of Radiation Oncology, College of Clinical Medicine for Oncology, Fujian Medical University & Fujian Cancer Hospital, Fuzhou, Fujian, China
| | - Jinluan Li
- Department of Radiation Oncology, College of Clinical Medicine for Oncology, Fujian Medical University & Fujian Cancer Hospital, Fuzhou, Fujian, China
| | - Da Zhang
- The United Innovation of Mengchao Hepatobiliary Technology Key Laboratory of Fujian Province, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, China
| | - Junxin Wu
- Department of Radiation Oncology, College of Clinical Medicine for Oncology, Fujian Medical University & Fujian Cancer Hospital, Fuzhou, Fujian, China
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Temmink SJD, Martling A, Angenete E, Nilsson PJ. Complete response rates in rectal cancer: Temporal changes over a decade in a population-based nationwide cohort. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:106991. [PMID: 37495447 DOI: 10.1016/j.ejso.2023.106991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 07/19/2023] [Indexed: 07/28/2023]
Abstract
INTRODUCTION In the past decade many changes in neoadjuvant treatment for patients with rectal cancer have taken place and are expected to impact complete response rates. The aim of this study was to investigate the impact on pathological, and overall, complete response rates in a nationwide population-based cohort, in relation to changes in neoadjuvant treatment and the start of a Watch & Wait (WoW) study. MATERIALS AND METHODS A nationwide register study using prospectively collected data from the Swedish Colorectal Cancer Register between 2009 and 2020. Patients with rectal cancer stage I-III with a ypT0N0 in the resected specimen after neoadjuvant treatment and clinical complete responders from the yearly inclusion data of the national WoW study were included. Temporal changes in pathological and overall complete response rates were analysed, and differences in neoadjuvant treatment regimens over time and per region were studied. RESULTS Between 2009 and 2020 the pathological complete response rate for rectal cancer remained similar (Mann-Kendall tau of 0.091, p = 0.68) while the overall complete response rate increased significantly from 3.0% to 9.6% (Mann-Kendall tau of 0.818, p < 0.001). The pathological complete response rate for patients receiving short course radiotherapy followed by chemotherapy was reduced by 50% after the introduction of the WoW study. CONCLUSIONS During the studied time period the overall complete response rate increased significantly presumably due to changes in national neoadjuvant treatment regimens. Since the start of the national WoW study clinical complete response seem to partly replace pathological complete response.
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Affiliation(s)
- Sofieke J D Temmink
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
| | - Anna Martling
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
| | - Eva Angenete
- Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Surgery, Gothenburg, Sweden.
| | - Per J Nilsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
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Liao H, Yang S, Liang Z, Xiao L, Xie S, Lin P, Xia F, Fang C, Chen Q, Ling D, Li F. A Cancer Cell Selective Replication Stress Nano Amplifier Promotes Replication Fork Catastrophe to Overcome Radioresistance. ACS NANO 2023; 17:18548-18561. [PMID: 37706454 DOI: 10.1021/acsnano.3c06774] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
Replication stress (RS) induced by DNA damage plays a significant role in conferring the anticancer effects of radiotherapy and is tightly associated with radioresistance of cancer cells. Amplification of RS represents an effective approach to improving the efficacy of radiotherapy, although the development of selective RS amplifiers remains an unexplored frontier. We herein present an RS nano amplifier (RSNA) consisting of a catalytic FePt nanoparticle loaded with the chemotherapeutic doxorubicin (DOX), which selectively exacerbates RS in cancer cells by promoting replication fork (RF) catastrophe. RSNA converts the excessive reactive oxygen species (ROS) in cancer cells into oxygen, enhancing the DNA-damaging effects of radiotherapy to create more template lesions that impede RF progression in coalition with DOX. After radiation, ROS scavenging by RSNA accelerates RF progression through damaged template strands, increasing the frequency of RF collapse into double-strand breaks. Moreover, pretreatment with RSNA accumulates cancer cells in the S phase, exposing more RFs to radiation-induced RS. These effects of RSNA convergently maximize RS in cancer cells, effectively overcoming the radioresistance of cancer cells without affecting normal cells. Our study demonstrates the feasibility of selectively amplifying RS to boost radiotherapy.
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Affiliation(s)
- Hongwei Liao
- Institute of Pharmaceutics, Hangzhou Institute of Innovative Medicine, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China
| | - Shengfei Yang
- Institute of Pharmaceutics, Hangzhou Institute of Innovative Medicine, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China
| | - Zeyu Liang
- Institute of Pharmaceutics, Hangzhou Institute of Innovative Medicine, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China
- Frontiers Science Center for Transformative Molecules, School of Chemistry and Chemical Engineering, National Center for Translational Medicine, Shanghai Jiao Tong University, Shanghai 200240, China
| | - Lin Xiao
- Institute of Pharmaceutics, Hangzhou Institute of Innovative Medicine, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China
| | - Shangzhi Xie
- Institute of Pharmaceutics, Hangzhou Institute of Innovative Medicine, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China
| | - Peihua Lin
- Institute of Pharmaceutics, Hangzhou Institute of Innovative Medicine, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China
| | - Fan Xia
- Institute of Pharmaceutics, Hangzhou Institute of Innovative Medicine, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China
| | - Chunyan Fang
- Frontiers Science Center for Transformative Molecules, School of Chemistry and Chemical Engineering, National Center for Translational Medicine, Shanghai Jiao Tong University, Shanghai 200240, China
| | - Qian Chen
- Institute of Pharmaceutics, Hangzhou Institute of Innovative Medicine, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China
| | - Daishun Ling
- Frontiers Science Center for Transformative Molecules, School of Chemistry and Chemical Engineering, National Center for Translational Medicine, Shanghai Jiao Tong University, Shanghai 200240, China
- WLA Laboratories, Shanghai 201203, China
| | - Fangyuan Li
- Institute of Pharmaceutics, Hangzhou Institute of Innovative Medicine, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China
- WLA Laboratories, Shanghai 201203, China
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6
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Verweij ME, Tanaka MD, Kensen CM, van der Heide UA, Marijnen CAM, Janssen T, Vijlbrief T, van Grevenstein WMU, Moons LMG, Koopman M, Lacle MM, Braat MNGJA, Chalabi M, Maas M, Huibregtse IL, Snaebjornsson P, Grotenhuis BA, Fijneman R, Consten E, Pronk A, Smits AB, Heikens JT, Eijkelenkamp H, Elias SG, Verkooijen HM, Schoenmakers MMC, Meijer GJ, Intven M, Peters FP. Towards Response ADAptive Radiotherapy for organ preservation for intermediate-risk rectal cancer (preRADAR): protocol of a phase I dose-escalation trial. BMJ Open 2023; 13:e065010. [PMID: 37321815 PMCID: PMC10277084 DOI: 10.1136/bmjopen-2022-065010] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 05/07/2023] [Indexed: 06/17/2023] Open
Abstract
INTRODUCTION Organ preservation is associated with superior functional outcome and quality of life (QoL) compared with total mesorectal excision (TME) for rectal cancer. Only 10% of patients are eligible for organ preservation following short-course radiotherapy (SCRT, 25 Gy in five fractions) and a prolonged interval (4-8 weeks) to response evaluation. The organ preservation rate could potentially be increased by dose-escalated radiotherapy. Online adaptive magnetic resonance-guided radiotherapy (MRgRT) is anticipated to reduce radiation-induced toxicity and enable radiotherapy dose escalation. This trial aims to establish the maximum tolerated dose (MTD) of dose-escalated SCRT using online adaptive MRgRT. METHODS AND ANALYSIS The preRADAR is a multicentre phase I trial with a 6+3 dose-escalation design. Patients with intermediate-risk rectal cancer (cT3c-d(MRF-)N1M0 or cT1-3(MRF-)N1M0) interested in organ preservation are eligible. Patients are treated with a radiotherapy boost of 2×5 Gy (level 0), 3×5 Gy (level 1), 4×5 Gy (level 2) or 5×5 Gy (level 3) on the gross tumour volume in the week following standard SCRT using online adaptive MRgRT. The trial starts on dose level 1. The primary endpoint is the MTD based on the incidence of dose-limiting toxicity (DLT) per dose level. DLT is a composite of maximum one in nine severe radiation-induced toxicities and maximum one in three severe postoperative complications, in patients treated with TME or local excision within 26 weeks following start of treatment. Secondary endpoints include the organ preservation rate, non-DLT, oncological outcomes, patient-reported QoL and functional outcomes up to 2 years following start of treatment. Imaging and laboratory biomarkers are explored for early response prediction. ETHICS AND DISSEMINATION The trial protocol has been approved by the Medical Ethics Committee of the University Medical Centre Utrecht. The primary and secondary trial results will be published in international peer-reviewed journals. TRIAL REGISTRATION NUMBER WHO International Clinical Trials Registry (NL8997; https://trialsearch.who.int).
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Affiliation(s)
- Maaike E Verweij
- Department of Radiation-Oncology, University Medical Centre Utrecht, Utrecht, The Netherlands
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Max D Tanaka
- Department of Radiation-Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Chavelli M Kensen
- Department of Radiation-Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Uulke A van der Heide
- Department of Radiation-Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Corrie A M Marijnen
- Department of Radiation-Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Tomas Janssen
- Department of Radiation-Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Tineke Vijlbrief
- Department of Radiation-Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Leon M G Moons
- Department of Gastroenterology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Miriam Koopman
- Department of Medical Oncology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Miangela M Lacle
- Department of Pathology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Manon N G J A Braat
- Department of Radiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Myriam Chalabi
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Monique Maas
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Inge L Huibregtse
- Department of Gastroenterology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Petur Snaebjornsson
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Remond Fijneman
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Esther Consten
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - Apollo Pronk
- Department of Surgery, Diakonessenhuis Utrecht Zeist Doorn, Utrecht, The Netherlands
| | - Anke B Smits
- Department of Surgery, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Joost T Heikens
- Department of Surgery, Hospital Rivierenland, Tiel, The Netherlands
| | - Hidde Eijkelenkamp
- Department of Radiation-Oncology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Sjoerd G Elias
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Helena M Verkooijen
- Department of Radiation-Oncology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | | | - Gert J Meijer
- Department of Radiation-Oncology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Martijn Intven
- Department of Radiation-Oncology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Femke P Peters
- Department of Radiation-Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
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Couwenberg AM, Varvoglis DN, Grieb BC, Marijnen CA, Ciombor KK, Guillem JG. New Opportunities for Minimizing Toxicity in Rectal Cancer Management. Am Soc Clin Oncol Educ Book 2023; 43:e389558. [PMID: 37307515 PMCID: PMC10450577 DOI: 10.1200/edbk_389558] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Advances in multimodal management of locally advanced rectal cancer (LARC), consisting of preoperative chemotherapy and/or radiotherapy followed by surgery with or without adjuvant chemotherapy, have improved local disease control and patient survival but are associated with significant risk for acute and long-term morbidity. Recently published trials, evaluating treatment dose intensification via the addition of preoperative induction or consolidation chemotherapy (total neoadjuvant therapy [TNT]), have demonstrated improved tumor response rates while maintaining acceptable toxicity. In addition, TNT has led to an increased number of patients achieving a clinical complete response and thus eligible to pursue a nonoperative, organ-preserving, watch and wait approach, thereby avoiding toxicities associated with surgery, such as bowel dysfunction and stoma-related complications. Ongoing trials using immune checkpoint inhibitors in patients with mismatch repair-deficient tumors suggest that this subgroup of patients with LARC could potentially be treated with immunotherapy alone, sparing them the toxicity associated with preoperative treatment and surgery. However, the majority of rectal cancers are mismatch repair-proficient and less responsive to immune checkpoint inhibitors and require multimodal management. The synergy noted in preclinical studies between immunotherapy and radiotherapy on immunogenic tumor cell death has led to the design of ongoing clinical trials that explore the benefit of combining radiotherapy, chemotherapy, and immunotherapy (mainly of immune checkpoint inhibitors) and aim to increase the number of patients eligible for organ preservation.
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Affiliation(s)
- Alice M. Couwenberg
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Brian C. Grieb
- Vanderbilt University Medical Center/Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Corrie A.M. Marijnen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Kristen K. Ciombor
- Vanderbilt University Medical Center/Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Jose G. Guillem
- Department of Surgery, Lineberger Comprehensive Cancer Center, University of North Carolina-Chapel Hill, Chapel Hill, NC
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8
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Benlice C, Koc MA, Gulcu B, Bilgin IA, Akyol C, Baca B, Ozturk E, Guney Y, Utkan G, Er O, Agaoglu F, Yildirim I, Avci N, Elhan AH, Kuzu MA. Short-Course Radiotherapy Followed by Consolidation Chemotherapy Is Safe and Effective in Locally Advanced Rectal Cancer: Comparative Short-term Results of Multicenter Propensity Score Case-Matched Study. Dis Colon Rectum 2023; 66:681-690. [PMID: 36856669 DOI: 10.1097/dcr.0000000000002646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Consolidation chemotherapy strategies have demonstrated improved pathological complete response and tumor downstaging rates for patients diagnosed with rectal cancer. OBJECTIVE This study aimed to compare perioperative outcomes and pathological complete response rates among different neoadjuvant treatment strategies in patients undergoing total mesorectal excision for locally advanced rectal cancer. DESIGN Propensity score case-matched study. SETTING High-volume tertiary care centers. PATIENTS Consecutive patients undergoing curative total mesorectal excision between January 2014 and June 2021 were queried. INTERVENTIONS Patients were divided into 3 groups: long-course chemoradiation therapy with (N = 128) or without (N = 164) consolidation chemotherapy or short-course radiotherapy (N = 53) followed by consolidation chemotherapy. MAIN OUTCOME MEASURES Demographics, preoperative tumor characteristics, histopathologic outcomes, and postoperative complication rates were reviewed and compared. Propensity score match analysis was conducted. RESULTS A total of 345 patients (mean age: 58 ± 12 years; female: 36%) met the study inclusion criteria. Time interval from neoadjuvant treatment until surgery was longer for patients receiving consolidation chemotherapy ( p < 0.001). Pathological complete response rates were comparable among patients receiving long-course chemoradiation therapy (20.3%) and short-course radiotherapy with consolidation chemotherapy (20.8%) compared to long-course chemoradiation therapy alone (14.6%) ( p = 0.36). After the propensity score case-matched analysis, 48 patients in the long-course chemoradiation therapy with consolidation chemotherapy group were matched to 48 patients in the short-course radiotherapy with consolidation chemotherapy group. Groups were comparable with respect to age, sex, clinical stage, tumor location, type of surgical approach, and technique. Pathological complete response rate was comparable between the groups (20.8% and 18.8%, p = 0.99). LIMITATIONS Study was limited by its retrospective nature. CONCLUSIONS Among recent neoadjuvant treatment modalities, pathological complete response rates, and short-term clinical outcomes were comparable. Short-course radiotherapy with consolidation chemotherapy is safe and effective as long-course chemoradiation therapy as in a short-term period. See Video Abstract at http://links.lww.com/DCR/C174 . LA RADIOTERAPIA DE CORTA DURACIN SEGUIDA DE QUIMIOTERAPIA DE CONSOLIDACIN ES SEGURA Y EFICAZ EN EL CNCER DE RECTO LOCALMENTE AVANZADO RESULTADOS COMPARATIVOS A CORTO PLAZO DEL ESTUDIO MULTICNTRICO DE CASOS EMPAREJADOS POR PUNTAJE DE PROPENSION ANTECEDENTES: Las estrategias de quimioterapia de consolidación han demostrado una mejor respuesta patológica completa y tasas de reducción del estadio del tumor para pacientes diagnosticados con cáncer de recto.OBJETIVO: Comparar los resultados perioperatorios y las tasas de respuesta patológica completa entre diferentes estrategias de tratamiento neoadyuvante en pacientes sometidos a escisión mesorrectal total por cáncer de recto localmente avanzado.DISEÑO: Estudio de casos emparejados por puntaje de propensión.ENTORNO CLINICO: Centros de atención terciaria de alto volumen.PACIENTES: Pacientes consecutivos sometidos a escisión mesorrectal total curativa por cáncer de recto localmente avanzado entre enero de 2014 y junio de 2021.INTERVENCIONES: Los pacientes se dividieron en tres grupos según la modalidad de tratamiento neoadyuvante: quimiorradioterapia de ciclo largo con (N = 128) o sin (N = 164) quimioterapia de consolidación o radioterapia de ciclo corto (N = 53) seguida de quimioterapia de consolidación.PRINCIPALES MEDIDAS DE RESULTADO: El punto final primario fue la respuesta patológica completa. Se revisaron y compararon los datos demográficos, las características preoperatorias del tumor, los resultados histopatológicos y las tasas de complicaciones posoperatorias entre los grupos de estudio. Se realizó un análisis de casos emparejados por puntaje de propensión.RESULTADOS: Un total de 345 pacientes (edad media de 58 ± 12 años y mujeres: 36%) cumplieron los criterios de inclusión del estudio. El intervalo de tiempo desde el tratamiento neoadyuvante hasta la cirugía fue mayor para los pacientes que recibieron quimioterapia de consolidación ( p < 0,001). Las tasas de respuesta patológica completa fueron comparables entre los pacientes que recibieron quimiorradioterapia de larga duración con quimioterapia de consolidación (20,3 %) y radioterapia de corta duración con quimioterapia de consolidación (20,8%) en comparación con la quimiorradiación de larga duración sola (14,6%) ( p = 0,36). Después del análisis de casos emparejados por puntaje de propensión, 48 pacientes en el grupo de quimiorradioterapia de ciclo largo con quimioterapia de consolidación se emparejaron con 48 pacientes en el grupo de radioterapia de ciclo corto con quimioterapia de consolidación. Los grupos fueron comparables con respecto a la edad, sexo, estadio clínico, ubicación del tumor, tipo de abordaje quirúrgico y la técnica. La tasa de respuesta patológica completa fue comparable entre los grupos (20,8% y 18,8%, p = 0,99). La morbilidad postoperatoria a los 30 días y las tasas de fuga anastomótica fueron similares.LIMITACIONES: El estudio estuvo limitado por su naturaleza retrospectiva.CONCLUSIONES: Entre las modalidades de tratamiento neoadyuvante recientes, las tasas de respuesta patológica completa y los resultados clínicos a corto plazo fueron comparables. La radioterapia de corta duración con quimioterapia de consolidación es segura y eficaz como terapia de quimiorradioterapia de larga duración en un período corto. Consulte Video Resumen en http://links.lww.com/DCR/C174 . (Traducción-Dr. Fidel Ruiz Healy ).
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Affiliation(s)
- Cigdem Benlice
- Department of General Surgery, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Mehmet Ali Koc
- Department of General Surgery, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Baris Gulcu
- Department of General Surgery, Bursa Medicana Hospital, Bursa, Turkey
| | - Ismail Ahmet Bilgin
- Department of General Surgery, Faculty of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Cihangir Akyol
- Department of General Surgery, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Bilgi Baca
- Department of General Surgery, Faculty of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Ersin Ozturk
- Department of General Surgery, Bursa Medicana Hospital, Bursa, Turkey
| | - Yildiz Guney
- Department of Radiation Oncology, Yuksek Ihtisas University, Memorial Ankara Hospital, Ankara, Turkey
| | - Gungor Utkan
- Department of Medical Oncology, Ankara University, Ankara, Turkey
| | - Ozlem Er
- Department of Medical Oncology, Faculty of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Fulya Agaoglu
- Department of Radiation Oncology, Faculty of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Ibrahim Yildirim
- Department of Radiation Oncology, Bursa Medicana Hospital, Bursa, Turkey
| | - Nilufer Avci
- Department of Medical Oncology, Bursa Medicana Hospital, Bursa, Turkey
| | - Atilla Halil Elhan
- Department of Biostatistics; Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Mehmet Ayhan Kuzu
- Department of General Surgery, Faculty of Medicine, Ankara University, Ankara, Turkey
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Kensen CM, Betgen A, Wiersema L, Peters FP, Kayembe MT, Marijnen CAM, van der Heide UA, Janssen TM. Online Adaptive MRI-Guided Radiotherapy for Primary Tumor and Lymph Node Boosting in Rectal Cancer. Cancers (Basel) 2023; 15:cancers15041009. [PMID: 36831354 PMCID: PMC9953931 DOI: 10.3390/cancers15041009] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 02/01/2023] [Accepted: 02/02/2023] [Indexed: 02/09/2023] Open
Abstract
The purpose of this study was to characterize the motion and define the required treatment margins of the pathological mesorectal lymph nodes (GTVln) for two online adaptive MRI-guided strategies for sequential boosting. Secondly, we determine the margins required for the primary gross tumor volume (GTVprim). Twenty-eight patients treated on a 1.5T MR-Linac were included in the study. On T2-weighted images for adaptation (MRIadapt) before and verification after irradiation (MRIpost) of five treatment fractions per patient, the GTVln and GTVprim were delineated. With online adaptive MRI-guided radiotherapy, daily plan adaptation can be performed through the use of two different strategies. In an adapt-to-shape (ATS) workflow the interfraction motion is effectively corrected by redelineation and the only relevant motion is intrafraction motion, while in an adapt-to-position (ATP) workflow the margin (for GTVln) is dominated by interfraction motion. The margin required for GTVprim will be identical to the ATS workflow, assuming each fraction would be perfectly matched on GTVprim. The intrafraction motion was calculated between MRIadapt and MRIpost for the GTVln and GTVprim separately. The interfraction motion of the GTVln was calculated with respect to the position of GTVprim, assuming each fraction would be perfectly matched on GTVprim. PTV margins were calculated for each strategy using the Van Herk recipe. For GTVln we randomly sampled the original dataset 20 times, with each subset containing a single randomly selected lymph node for each patient. The resulting margins for ATS ranged between 3 and 4 mm (LR), 3 and 5 mm (CC) and 5 and 6 mm (AP) based on the 20 randomly sampled datasets for GTVln. For ATP, the margins for GTVln were 10-12 mm in LR and AP and 16-19 mm in CC. The margins for ATS for GTVprim were 1.7 mm (LR), 4.7 mm (CC) and 3.2 mm anterior and 5.6 mm posterior. Daily delineation using ATS of both target volumes results in the smallest margins and is therefore recommended for safe dose escalation to the primary tumor and lymph nodes.
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Affiliation(s)
- Chavelli M. Kensen
- Department of Radiation Oncology, The Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands
| | - Anja Betgen
- Department of Radiation Oncology, The Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands
| | - Lisa Wiersema
- Department of Radiation Oncology, The Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands
| | - Femke P. Peters
- Department of Radiation Oncology, The Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands
| | - Mutamba T. Kayembe
- Department of Scientific Administration, The Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands
| | - Corrie A. M. Marijnen
- Department of Radiation Oncology, The Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands
| | - Uulke A. van der Heide
- Department of Radiation Oncology, The Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands
| | - Tomas M. Janssen
- Department of Radiation Oncology, The Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands
- Correspondence: ; Tel.: +31-(0)-20-5122164
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10
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Organ Preservation in Rectal Cancer: An Overview of the Dutch Perspective and Recent Developments. Clin Oncol (R Coll Radiol) 2023; 35:107-116. [PMID: 36253320 DOI: 10.1016/j.clon.2022.09.055] [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: 05/09/2022] [Revised: 08/17/2022] [Accepted: 09/22/2022] [Indexed: 01/20/2023]
Abstract
Although current guidelines on rectal cancer treatment often recommend rectal resection with or without neoadjuvant (chemo)radiotherapy, there is growing interest in organ-preserving treatment approaches among patients and clinicians in the Netherlands. Currently, multiple ongoing studies are investigating the value of different non-operative treatment modalities to improve tumour response rates and increase the chance of successful organ preservation. Papillon contact X-ray brachytherapy is a promising treatment modality to improve the chance of organ preservation, which seems especially relevant for elderly and frail patients unable or refusing to undergo total mesorectal excision surgery. The elderly and frail patient with rectal cancer poses a significant challenge and warrants a thorough multidisciplinary approach to provide the most optimal organ-preserving treatment. In this overview, an insight into the Dutch perspectives and developments within the field of organ preservation and the set-up of a Papillon facility to complete the spectrum of organ-preserving treatment options in a tertiary referral centre for rectal cancer treatment has been provided.
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11
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Promises and Challenges of Predictive Blood Biomarkers for Locally Advanced Rectal Cancer Treated with Neoadjuvant Chemoradiotherapy. Cells 2023; 12:cells12030413. [PMID: 36766755 PMCID: PMC9913546 DOI: 10.3390/cells12030413] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 01/24/2023] [Indexed: 01/27/2023] Open
Abstract
The treatment of locally advanced rectal cancer (LARC) requires a multimodal approach combining neoadjuvant radiotherapy or chemoradiotherapy (CRT) and surgery. Predicting tumor response to CRT can guide clinical decision making and improve patient care while avoiding unnecessary toxicity and morbidity. Circulating biomarkers offer both the advantage to be easily accessed and followed over time. In recent years, biomarkers such as proteins, blood cells, or nucleic acids have been investigated for their predictive value in oncology. We conducted a comprehensive literature review with the aim to summarize the status of circulating biomarkers predicting response to CRT in LARC. Forty-nine publications, of which forty-seven full-text articles, one review and one systematic review, were retrieved. These studies evaluated circulating markers (CEA and CA 19-9), inflammatory biomarkers (CRP, albumin, and lymphocytes), hematologic markers (hemoglobin and thrombocytes), lipids and circulating nucleic acids (cell-free DNA [cfDNA], circulating tumor DNA [ctDNA], and microRNA [miRNA]). Post-CRT CEA levels had the most consistent association with tumor response, while cfDNA integrity index, MGMT promoter methylation, ERCC-1, miRNAs, and miRNA-related SNPs were identified as potential predictive markers. Although circulating biomarkers hold great promise, inconsistent results, low statistical power, and low specificity and sensibility prevent them from reliably predicting tumor response following CRT. Validation and standardization of methods and technologies are further required to confirm results.
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12
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Muacevic A, Adler JR. Predictors of Definitive Treatment Interruptions of Long-Course Neoadjuvant Chemoradiotherapy in Locally Advanced Rectal Cancer. Cureus 2022; 14:e30159. [PMID: 36397912 PMCID: PMC9647122 DOI: 10.7759/cureus.30159] [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] [Accepted: 10/10/2022] [Indexed: 12/04/2022] Open
Abstract
Introduction To identify predictors of definitive treatment interruptions (DTI) of the neoadjuvant long-course radiotherapy (LCRT) in locally advanced rectal cancer (LARC), and to determine their impact on clinical outcomes. Methods Patients with stage II-III LARC treated between 2009-2018 were retrospectively analyzed (n=101, median FU 49.5 months). Logistic regression models evaluated the impact of relevant clinical variables on grade 3 or greater (G3+) acute toxicity, definitive treatment interruption (DTI), pCR, and definitive ostomy (dOST) rates. The secondary outcomes were LRC, MFS, PFS, CSS, and OS. Results The incidences of grade 3 and 4 toxicities were 25.3%, and 1.1%, respectively. The most common G3+ toxicities were peri-anal dermatitis (14.7%) and diarrhea (7.4%), which were more frequent in females (p=0.040) and tumors close to the anal verge (p=0.019). In this study, 11 patients (10.9%) developed DTI, which was associated with these G3+ events (p<0.001). Resection occurred after 7.1 weeks (median, IQR:6.1-8.9). Downstaging occurred in 57.4% (17.8% pCR), 88% achieved negative margins and the dOST rate was 56.4%. The five-year LRC, MFS, PFS, CSS and OS were: 94.4%, 78.9%, 74.7%, 85.2% and 81.6%, respectively. DTI events did not impact any outcome. The factors associated with loco-regional failure were close/positive margins (p<0.001) and stage ypIII (p=0.002). Conclusions: Tumors close to the anal verge and female sex were associated with increased G3+ toxicity, which was predictive of DTI. The resultant partial/complete omission of the planned boost, however, dose did not increase the chance of LR. Further studies to clarify the benefit and optimal timing to deliver the boost are warranted, especially for positive margins.
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13
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Liao CK, Kuo YT, Lin YC, Chern YJ, Hsu YJ, Yu YL, Chiang JM, Hsieh PS, Yeh CY, You JF. Neoadjuvant Short-Course Radiotherapy Followed by Consolidation Chemotherapy before Surgery for Treating Locally Advanced Rectal Cancer: A Systematic Review and Meta-Analysis. Curr Oncol 2022; 29:3708-3727. [PMID: 35621687 PMCID: PMC9139840 DOI: 10.3390/curroncol29050297] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/14/2022] [Accepted: 05/18/2022] [Indexed: 11/17/2022] Open
Abstract
Neoadjuvant short course radiotherapy (SCRT) followed by consolidation chemotherapy (CCT) is an alternative treatment for locally advanced rectal cancer (LARC). We performed this systematic review and meta-analysis to explore the tumor response and oncological outcomes of this new approach compared to conventional chemoradiotherapy (CRT). An online search of the PubMed, Embase, and Cochrane Library databases was performed. This review included 7507 patients from 14 different cohorts. The pCR rate was higher with SCRT + CCT than that with CRT (RR: 1.60; 95% CI: 1.35−1.91; p < 0.01). SCRT + CCT provided a higher ypN0 response (RR: 1.06; 95% CI: 1.01−1.12; p = 0.02). There were no differences in R0 resection and positive CRM rates; however, more sphincter-preservation surgeries were performed in the SCRT + CCT arm (RR: 1.06; 95% CI: 1.01−1.11; p = 0.02). There was no difference in the OS and DFS between the SCRT + CCT and the CRT arms (OS: HR: 0.85, p = 0.07; DFS: HR: 0.88, p = 0.08). The compliance and toxicity were comparable between the SCRT and CRT groups. In the subgroup analysis, patients who underwent four or more cycles of CCT had better pCR and DFS events. Therefore, SCRT followed by consolidation chemotherapy might be an effective alternative treatment for LARC.
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Affiliation(s)
- Chun-Kai Liao
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou, No. 5, Fuxing St., Guishan Dist., Taoyuan 333423, Taiwan; (C.-K.L.); (Y.-T.K.); (Y.-C.L.); (Y.-J.C.); (Y.-J.H.); (J.-M.C.); (P.-S.H.); (C.-Y.Y.)
| | - Ya-Ting Kuo
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou, No. 5, Fuxing St., Guishan Dist., Taoyuan 333423, Taiwan; (C.-K.L.); (Y.-T.K.); (Y.-C.L.); (Y.-J.C.); (Y.-J.H.); (J.-M.C.); (P.-S.H.); (C.-Y.Y.)
| | - Yueh-Chen Lin
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou, No. 5, Fuxing St., Guishan Dist., Taoyuan 333423, Taiwan; (C.-K.L.); (Y.-T.K.); (Y.-C.L.); (Y.-J.C.); (Y.-J.H.); (J.-M.C.); (P.-S.H.); (C.-Y.Y.)
| | - Yih-Jong Chern
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou, No. 5, Fuxing St., Guishan Dist., Taoyuan 333423, Taiwan; (C.-K.L.); (Y.-T.K.); (Y.-C.L.); (Y.-J.C.); (Y.-J.H.); (J.-M.C.); (P.-S.H.); (C.-Y.Y.)
| | - Yu-Jen Hsu
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou, No. 5, Fuxing St., Guishan Dist., Taoyuan 333423, Taiwan; (C.-K.L.); (Y.-T.K.); (Y.-C.L.); (Y.-J.C.); (Y.-J.H.); (J.-M.C.); (P.-S.H.); (C.-Y.Y.)
| | - Yen-Lin Yu
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Keelung Branch, No. 222, Maijin Rd., Anle Dist., Keelung City 204201, Taiwan;
| | - Jy-Ming Chiang
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou, No. 5, Fuxing St., Guishan Dist., Taoyuan 333423, Taiwan; (C.-K.L.); (Y.-T.K.); (Y.-C.L.); (Y.-J.C.); (Y.-J.H.); (J.-M.C.); (P.-S.H.); (C.-Y.Y.)
- School of Medicine, Chang Gung University, No. 259, Wenhua 1st Road, Guishan Dist., Taoyuan 333323, Taiwan
| | - Pao-Shiu Hsieh
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou, No. 5, Fuxing St., Guishan Dist., Taoyuan 333423, Taiwan; (C.-K.L.); (Y.-T.K.); (Y.-C.L.); (Y.-J.C.); (Y.-J.H.); (J.-M.C.); (P.-S.H.); (C.-Y.Y.)
- School of Medicine, Chang Gung University, No. 259, Wenhua 1st Road, Guishan Dist., Taoyuan 333323, Taiwan
| | - Chien-Yuh Yeh
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou, No. 5, Fuxing St., Guishan Dist., Taoyuan 333423, Taiwan; (C.-K.L.); (Y.-T.K.); (Y.-C.L.); (Y.-J.C.); (Y.-J.H.); (J.-M.C.); (P.-S.H.); (C.-Y.Y.)
- School of Medicine, Chang Gung University, No. 259, Wenhua 1st Road, Guishan Dist., Taoyuan 333323, Taiwan
| | - Jeng-Fu You
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou, No. 5, Fuxing St., Guishan Dist., Taoyuan 333423, Taiwan; (C.-K.L.); (Y.-T.K.); (Y.-C.L.); (Y.-J.C.); (Y.-J.H.); (J.-M.C.); (P.-S.H.); (C.-Y.Y.)
- School of Medicine, Chang Gung University, No. 259, Wenhua 1st Road, Guishan Dist., Taoyuan 333323, Taiwan
- Correspondence: ; Tel.: +886-975-365-617
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Ketelaers SHJ, Jacobs A, Verrijssen ASE, Cnossen JS, van Hellemond IEG, Creemers GJM, Schreuder RM, Scholten HJ, Tolenaar JL, Bloemen JG, Rutten HJT, Burger JWA. A Multidisciplinary Approach for the Personalised Non-Operative Management of Elderly and Frail Rectal Cancer Patients Unable to Undergo TME Surgery. Cancers (Basel) 2022; 14:2368. [PMID: 35625976 PMCID: PMC9139821 DOI: 10.3390/cancers14102368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/05/2022] [Accepted: 05/09/2022] [Indexed: 02/07/2023] Open
Abstract
Despite it being the optimal curative approach, elderly and frail rectal cancer patients may not be able to undergo a total mesorectal excision. Frequently, no treatment is offered at all and the natural course of the disease is allowed to unfold. These patients are at risk for developing debilitating symptoms that impair quality of life and require palliative treatment. Recent advancements in non-operative treatment modalities have enhanced the toolbox of alternative treatment strategies in patients unable to undergo surgery. Therefore, a proposed strategy is to aim for the maximal non-operative treatment, in an effort to avoid the onset of debilitating symptoms, improve quality of life, and prolong survival. The complexity of treating elderly and frail patients requires a patient-centred approach to personalise treatment. The main challenge is to optimise the balance between local control of disease, patient preferences, and the burden of treatment. A comprehensive geriatric assessment is a crucial element within the multidisciplinary dialogue. Since limited knowledge is available on the optimal non-operative treatment strategy, these patients should be treated by dedicated multidisciplinary rectal cancer experts with special interest in the elderly and frail. The aim of this narrative review was to discuss a multidisciplinary patient-centred treatment approach and provide a practical suggestion of a successfully implemented clinical care pathway.
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Affiliation(s)
- Stijn H. J. Ketelaers
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (J.L.T.); (J.G.B.); (H.J.T.R.); (J.W.A.B.)
| | - Anne Jacobs
- Department of Gerontology and Geriatrics, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands;
| | - An-Sofie E. Verrijssen
- Department of Radiation Oncology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (A.-S.E.V.); (J.S.C.)
| | - Jeltsje S. Cnossen
- Department of Radiation Oncology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (A.-S.E.V.); (J.S.C.)
| | - Irene E. G. van Hellemond
- Department of Medical Oncology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (I.E.G.v.H.); (G.-J.M.C.)
| | - Geert-Jan M. Creemers
- Department of Medical Oncology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (I.E.G.v.H.); (G.-J.M.C.)
| | - Ramon-Michel Schreuder
- Department of Gastroenterology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands;
| | - Harm J. Scholten
- Department of Anaesthesiology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands;
| | - Jip L. Tolenaar
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (J.L.T.); (J.G.B.); (H.J.T.R.); (J.W.A.B.)
| | - Johanne G. Bloemen
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (J.L.T.); (J.G.B.); (H.J.T.R.); (J.W.A.B.)
| | - Harm J. T. Rutten
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (J.L.T.); (J.G.B.); (H.J.T.R.); (J.W.A.B.)
- GROW, School for Oncology and Reproduction, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Jacobus W. A. Burger
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (J.L.T.); (J.G.B.); (H.J.T.R.); (J.W.A.B.)
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15
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Eijkelenkamp H, Boekhoff MR, Verweij ME, Peters FP, Meijer GJ, Intven MPW. Planning target volume margin assessment for online adaptive MR-guided dose-escalation in rectal cancer on a 1.5 T MR-Linac. Radiother Oncol 2021; 162:150-155. [PMID: 34280404 DOI: 10.1016/j.radonc.2021.07.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 07/07/2021] [Accepted: 07/08/2021] [Indexed: 02/08/2023]
Abstract
PURPOSE This study assessed the margins needed to cover tumor intrafraction motion during an MR-guided radiotherapy (MRgRT) dose-escalation strategy in intermediate risk rectal cancer. METHODS Fifteen patients with rectal cancer were treated with neoadjuvant short-course radiotherapy, 5x5 Gy, according to an online adaptive workflow on a 1.5 T MR-linac. Per patient, 26 3D T2 weighted MRIs were made; one reference scan preceding treatment and five scans per treatment fraction. The primary tumor was delineated on each scan as gross tumor volume (GTV). Target coverage margins were assessed by isotropically expanding the reference GTV until more than 95% of the voxels of the sequential GTVs were covered. A margin with a coverage probability threshold of 90% was defined as adequate. Intra- and interfraction margins to cope with the movement of the GTV in the period between scans were calculated to indicate the target volume margins. Furthermore, the margin needed to cover GTV movement was calculated for different time intervals. RESULTS The required margins to cover inter- and intrafraction GTV motion were 17 mm and 6 mm, respectively. Analysis based on time intervals between scans showed smaller margins were needed for adequate GTV coverage as time intervals became shorter, with a 4 mm margin required for a procedure of 15 min or less. CONCLUSION The shorter the treatment time, the smaller the margins needed to cover for the GTV movement during an online adaptive MRgRT dose-escalation strategy for intermediate risk rectal cancer. When time intervals between replanning and the end of dose delivery could be reduced to 15 min, a 4 mm margin would allow adequate target coverage.
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Affiliation(s)
- Hidde Eijkelenkamp
- Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands.
| | - Mick R Boekhoff
- Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands
| | - Maaike E Verweij
- Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands
| | - Femke P Peters
- Department of Radiation Oncology, Leiden University Medical Center, The Netherlands; Department of Radiation Oncology, Netherlands Cancer Institute/Antoni van Leeuwenhoek, The Netherlands
| | - Gert J Meijer
- Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands
| | - Martijn P W Intven
- Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands
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16
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Imam I, Hammarström K, Sjöblom T, Glimelius B. Neoadjuvant rectal (NAR) score: Value evaluating the efficacy of neoadjuvant therapy and prognostic significance after surgery? Radiother Oncol 2021; 157:70-77. [PMID: 33453311 DOI: 10.1016/j.radonc.2021.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/24/2020] [Accepted: 01/03/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION The Neoadjuvant rectal (NAR) score is a new surrogate endpoint to be used in clinical trials for early determination of treatment response to different preoperative therapies. The aim is to further validate the NAR-score, primarily developed using chemoradiotherapy (CRT) with a delay to surgery 6-8 weeks, and explore its value using other schedules. MATERIALS AND METHODS The study included all 9978 patients diagnosed with non-metastasized RC in 2007-2015 that had undergone surgery and was registered in the Swedish Colorectal Cancer Registry. The patients of interest had either short-course radiotherapy (scRT)/CRT + delayed surgery, long-course radiotherapy (RT) + delayed surgery, (C)RT + additional chemotherapy, primary surgery, or scRT + immediate surgery. The scRT/CRT + delayed surgery groups were further divided based on time to surgery. RESULTS Mean NAR-score differed significantly (p < 0.0001) between different treatments. (C)RT + additional chemotherapy had the lowest mean score of 16.3 and CRT + delayed surgery had 17.7. There was a significant difference (p < 0.05) in overall survival (OS) and time to recurrence (TTR) of patients with a Low NAR-score (<8) compared to those with a High score (>16) for both CRT- and scRT, with a stronger correlation for CRT-patients. C-index for the NAR-score model (0.623) was not superior to when only pathological T- and N-stage was used (0.646). CONCLUSIONS The NAR-score is prognostic, but it is not better than pT- and pN-stage. However, the NAR-score can still discriminate between two treatments that have different cell killing effect and may still be of value in clinical trials as an easier method than pT- and N-stage.
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Affiliation(s)
- Israa Imam
- Department of Immunology, Genetics and Pathology, Uppsala University, Sweden.
| | - Klara Hammarström
- Department of Immunology, Genetics and Pathology, Uppsala University, Sweden
| | - Tobias Sjöblom
- Department of Immunology, Genetics and Pathology, Uppsala University, Sweden
| | - Bengt Glimelius
- Department of Immunology, Genetics and Pathology, Uppsala University, Sweden
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A Comprehensive Evaluation of Associations Between Routinely Collected Staging Information and The Response to (Chemo)Radiotherapy in Rectal Cancer. Cancers (Basel) 2020; 13:cancers13010016. [PMID: 33375133 PMCID: PMC7792936 DOI: 10.3390/cancers13010016] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/10/2020] [Accepted: 12/17/2020] [Indexed: 12/22/2022] Open
Abstract
Simple Summary Rectal cancer patients are often treated with radiotherapy, either alone or combined with chemotherapy, prior to surgery to enable radical surgery on a non-resectable tumor or to lower the recurrence risk. For some patients, the tumor disappears completely after preoperative treatment, while others experience little or no benefit. Accurate prediction of therapy response before treatment is of great importance for a personalized treatment approach and intentional organ preservation. We performed a comprehensive evaluation of the predictive capacity of all routinely collected staging information at diagnosis in a population-based, completely staged patient material of 383 patients representing a real-life clinical situation. Size or stage of the rectal tumor were independent predictors of excellent response irrespective of preoperative treatment, with small/early-stage tumors being significantly more likely to reach a complete response. Levels of the tumor marker carcinoembryonic antigen (CEA) above upper normal limit halved the chance of response. Abstract Radiotherapy (RT) or chemoradiotherapy (CRT) are frequently used in rectal cancer, sometimes resulting in complete tumor remission (CR). The predictive capacity of all clinical factors, laboratory values and magnetic resonance imaging parameters performed in routine staging was evaluated to understand what determines an excellent response to RT/CRT. A population-based cohort of 383 patients treated with short-course RT (5 × 5 Gy in one week, scRT), CRT, or scRT with chemotherapy (scRT+CT) and having either had a delay to surgery or been entered into a watch-and-wait program were included. Complete staging according to guidelines was performed and associations between investigated variables and CR rates were analyzed in univariate and multivariate analyses. In total, 17% achieved pathological or clinical CR, more often after scRT+CT and CRT than after scRT (27%, 18% and 8%, respectively, p < 0.001). Factors independently associated with CR included clinical tumor stage, small tumor size (<3 cm), tumor level, and low CEA-value (<3.8 μg/L). Size or stage of the rectal tumor were associated with excellent response in all therapy groups, with small or early stage tumors being significantly more likely to reach CR (p = 0.01 (scRT), p = 0.01 (CRT) and p = 0.02 (scRT+CT). Elevated level of carcinoembryonic antigen (CEA) halved the chance of response. Extramural vascular invasion (EMVI) and mucinous character may indicate less response to RT alone.
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18
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Nocera F, von Flüe M, Steinemann DC. Rectal prolapse following short-course radiotherapy for rectal cancer: report of a case. J Surg Case Rep 2020; 2020:rjaa529. [PMID: 33391654 PMCID: PMC7769532 DOI: 10.1093/jscr/rjaa529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 11/18/2020] [Accepted: 11/23/2020] [Indexed: 11/29/2022] Open
Abstract
Palliative short-course radiotherapy may be considered as an alternative to abdominoperineal resection in elderly patients with advanced rectal cancer. A 92-year-old woman was diagnosed with a rectal prolapse after short-course radiotherapy; 2 months before she was diagnosed with advanced lower rectal cancer. A curative approach was declined. Therefore, a palliative short-course radiotherapy followed. Two weeks after termination of radiotherapy, a symptomatic rectal prolapse has been observed. Endoscopy confirmed a tumor completely included in the prolapsing rectum. A rectal prolapse resection by Altemeier’s technique was performed. Histological examination downgraded the tumor staging to ypT1 M0. This case discusses whether the prolapse was preexisting and led to overstaging the tumor or whether the prolapse is a new-onset complication of the radiotherapy. It seems of paramount importance to detect preexisting rectal prolapse to avoid overstaging. If presumed rectal prolapse was not present before therapy, rectal prolapse may represent a new-onset adverse event of short-course radiotherapy.
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Affiliation(s)
- Fabio Nocera
- Clarunis, Pelvic Floor Unit, University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Basel, Switzerland
| | - Markus von Flüe
- Clarunis, Pelvic Floor Unit, University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Basel, Switzerland
| | - Daniel C Steinemann
- Clarunis, Pelvic Floor Unit, University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Basel, Switzerland
- Department of Surgery, University Hospital Basel, Basel, Switzerland
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19
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Wanigasooriya K, Tyler R, Barros-Silva JD, Sinha Y, Ismail T, Beggs AD. Radiosensitising Cancer Using Phosphatidylinositol-3-Kinase (PI3K), Protein Kinase B (AKT) or Mammalian Target of Rapamycin (mTOR) Inhibitors. Cancers (Basel) 2020; 12:E1278. [PMID: 32443649 PMCID: PMC7281073 DOI: 10.3390/cancers12051278] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/08/2020] [Accepted: 05/12/2020] [Indexed: 02/07/2023] Open
Abstract
Radiotherapy is routinely used as a neoadjuvant, adjuvant or palliative treatment in various cancers. There is significant variation in clinical response to radiotherapy with or without traditional chemotherapy. Patients with a good response to radiotherapy demonstrate better clinical outcomes universally across different cancers. The PI3K/AKT/mTOR pathway upregulation has been linked to radiotherapy resistance. We reviewed the current literature exploring the role of inhibiting targets along this pathway, in enhancing radiotherapy response. We identified several studies using in vitro cancer cell lines, in vivo tumour xenografts and a few Phase I/II clinical trials. Most of the current evidence in this area comes from glioblastoma multiforme, non-small cell lung cancer, head and neck cancer, colorectal cancer, and prostate cancer. The biological basis for radiosensitivity following pathway inhibition was through inhibited DNA double strand break repair, inhibited cell proliferation, enhanced apoptosis and autophagy as well as tumour microenvironment changes. Dual PI3K/mTOR inhibition consistently demonstrated radiosensitisation of all types of cancer cells. Single pathway component inhibitors and other inhibitor combinations yielded variable outcomes especially within early clinical trials. There is ample evidence from preclinical studies to suggest that direct pharmacological inhibition of the PI3K/AKT/mTOR pathway components can radiosensitise different types of cancer cells. We recommend that future in vitro and in vivo research in this field should focus on dual PI3K/mTOR inhibitors. Early clinical trials are needed to assess the feasibility and efficacy of these dual inhibitors in combination with radiotherapy in brain, lung, head and neck, breast, prostate and rectal cancer patients.
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Affiliation(s)
- Kasun Wanigasooriya
- College of Medical and Dental Sciences, Institute of Cancer and Genomic Science, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK; (J.D.B.-S.); (Y.S.); (A.D.B.)
- The New Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham B15 2TH, UK; (R.T.); (T.I.)
| | - Robert Tyler
- The New Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham B15 2TH, UK; (R.T.); (T.I.)
| | - Joao D. Barros-Silva
- College of Medical and Dental Sciences, Institute of Cancer and Genomic Science, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK; (J.D.B.-S.); (Y.S.); (A.D.B.)
| | - Yashashwi Sinha
- College of Medical and Dental Sciences, Institute of Cancer and Genomic Science, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK; (J.D.B.-S.); (Y.S.); (A.D.B.)
- The New Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham B15 2TH, UK; (R.T.); (T.I.)
| | - Tariq Ismail
- The New Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham B15 2TH, UK; (R.T.); (T.I.)
| | - Andrew D. Beggs
- College of Medical and Dental Sciences, Institute of Cancer and Genomic Science, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK; (J.D.B.-S.); (Y.S.); (A.D.B.)
- The New Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham B15 2TH, UK; (R.T.); (T.I.)
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Buckley AM, Lynam-Lennon N, O'Neill H, O'Sullivan J. Targeting hallmarks of cancer to enhance radiosensitivity in gastrointestinal cancers. Nat Rev Gastroenterol Hepatol 2020; 17:298-313. [PMID: 32005946 DOI: 10.1038/s41575-019-0247-2] [Citation(s) in RCA: 148] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/26/2019] [Indexed: 12/19/2022]
Abstract
Radiotherapy is used in the treatment of approximately 50% of all malignancies including gastrointestinal cancers. Radiation can be given prior to surgery (neoadjuvant radiotherapy) to shrink the tumour or after surgery to kill any remaining cancer cells. Radiotherapy aims to maximize damage to cancer cells, while minimizing damage to healthy cells. However, only 10-30% of patients with rectal cancer or oesophageal cancer have a pathological complete response to neoadjuvant chemoradiation therapy, with the rest suffering the negative consequences of toxicities and delays to surgery with no clinical benefit. Furthermore, in pancreatic cancer, neoadjuvant chemoradiation therapy results in a pathological complete response in only 4% of patients and a partial pathological response in only 31%. Resistance to radiation therapy is polymodal and associated with a number of biological alterations both within the tumour itself and in the surrounding microenvironment including the following: altered cell cycle; repopulation by cancer stem cells; hypoxia; altered management of oxidative stress; evasion of apoptosis; altered DNA damage response and enhanced DNA repair; inflammation; and altered mitochondrial function and cellular energetics. Radiosensitizers are needed to improve treatment response to radiation, which will directly influence patient outcomes in gastrointestinal cancers. This article reviews the literature to identify strategies - including DNA-targeting agents, antimetabolic agents, antiangiogenics and novel immunotherapies - being used to enhance radiosensitivity in gastrointestinal cancers according to the hallmarks of cancer. Evidence from radiosensitizers from in vitro and in vivo models is documented and the action of radiosensitizers through clinical trial data is assessed.
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Affiliation(s)
- Amy M Buckley
- Department of Surgery, Trinity Translational Medicine Institute, St. James's Hospital, Trinity College Dublin, Dublin, Ireland
| | - Niamh Lynam-Lennon
- Department of Surgery, Trinity Translational Medicine Institute, St. James's Hospital, Trinity College Dublin, Dublin, Ireland
| | - Hazel O'Neill
- Department of Surgery, Trinity Translational Medicine Institute, St. James's Hospital, Trinity College Dublin, Dublin, Ireland
| | - Jacintha O'Sullivan
- Department of Surgery, Trinity Translational Medicine Institute, St. James's Hospital, Trinity College Dublin, Dublin, Ireland.
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21
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Yoon SM, Lee P, Raldow A. The Evolving Landscape of Neoadjuvant Radiation Therapy for Locally Advanced Rectal Cancer. CURRENT COLORECTAL CANCER REPORTS 2020. [DOI: 10.1007/s11888-020-00451-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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22
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Hoendervangers S, Sparreboom CL, Intven MPW, Lange JF, Verkooijen HM, Doornebosch PG, van Grevenstein WMU. The effect of neoadjuvant short-course radiotherapy and delayed surgery versus chemoradiation on postoperative outcomes in locally advanced rectal cancer patients - A propensity score matched nationwide audit-based study. Eur J Surg Oncol 2020; 46:1605-1612. [PMID: 32192792 DOI: 10.1016/j.ejso.2020.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 01/27/2020] [Accepted: 03/03/2020] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To investigate differences in postoperative outcomes between short-course radiotherapy and delayed surgery (SCRT-delay) and chemoradiation (CRT) in patients with locally advanced rectal cancer (LARC). BACKGROUND Previous trials suggest that SCRT-delay could serve as an adequate neoadjuvant treatment for LARC. Therefore, in frail LARC patients SCRT-delay is recommended as an alternative to CRT. However, data on postoperative outcomes after SCRT-delay in comparison to CRT is scarce. METHODS This was an observational study with data from the Dutch ColoRectal Audit (DCRA). LARC patients who underwent surgery (2014-2017) after an interval of ≥6 weeks were included. Missing values were replaced by multiple imputation. Propensity score matching (PSM), using age, Charlson Comorbidity Index, cT-stage and surgical procedure, was applied to create comparable groups. Differences in postoperative outcomes were analyzed using Chi-square test for categorical variables, independent sample t-test for continuous variables and Mann-Whitney U test for non-parametric data. RESULTS 2926 patients were included. In total, 288 patients received SCRT-delay and 2638 patients underwent CRT. Patients in the SCRT-delay group were older and had more comorbidities. Also, ICU-admissions and permanent colostomies were more common, as well as pulmonic, cardiologic, infectious and neurologic complications. After PSM, both groups comprised 246 patients with equivalent age, comorbidities and tumor stage. There were no differences in postoperative complications. CONCLUSION Postoperative complications were not increased in LARC patients undergoing SCRT-delay as neoadjuvant treatment. Regarding treatment-related complications, SCRT-delay is a safe alternative neoadjuvant treatment option for frail LARC patients.
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Affiliation(s)
- S Hoendervangers
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - C L Sparreboom
- Department of Surgery, Erasmus MC, Rotterdam, the Netherlands
| | - M P W Intven
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - J F Lange
- Department of Surgery, Erasmus MC, Rotterdam, the Netherlands; Department of Surgery, IJsselland Ziekenhuis, Capelle a/d Ijssel, the Netherlands
| | - H M Verkooijen
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - P G Doornebosch
- Department of Surgery, IJsselland Ziekenhuis, Capelle a/d Ijssel, the Netherlands
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23
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Qiaoli W, Yongping H, Wei X, Guoqiang X, Yunhe J, Qiuyan L, Cheng L, Mengling G, Jiayi L, Wei X, Yi Y. Preoperative short-course radiotherapy (5 × 5 Gy) with delayed surgery versus preoperative long-course radiotherapy for locally resectable rectal cancer: a meta-analysis. Int J Colorectal Dis 2019; 34:2171-2183. [PMID: 31745621 DOI: 10.1007/s00384-019-03433-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/17/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE Preoperative short-course radiotherapy (PSRT) and preoperative long-course radiotherapy (PLRT) are standard treatment regimens for locally advanced rectal cancer. However, whether the efficacy and safety of PSRT with delayed surgery (more than 4 weeks) are superior to those of PLRT remains unresolved and was explored in this meta-analysis. METHODS Studies published in PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov databases were systematically searched. RevMan 5.3 was used to calculate pooled hazard ratios (HR) and relative risk (RR). RESULTS Seven studies including 4973 patients were identified in the meta-analysis. Pooled statistics showed that there was no statistically significant difference in overall survival (HR = 1.30, 95% CI 0.58-2.89, P = 0.52) or disease-free survival (HR = 1.10, 95% CI 0.73-1.66, P = 0.64) between the preoperative short-course and long-course radiotherapy groups. Moreover, pathological complete remission, early postoperative complications, treatment-related grade 3/4 toxicity, local recurrence, and distant metastasis were similar between the two groups. Interestingly, a subgroup analysis revealed that preoperative short-course radiotherapy without adjuvant chemotherapy not only resulted in lower treatment-related grade 3/4 toxicity than the long-course radiotherapy group (RR = 0.19, 95% CI 0.08-0.48, P < 0.01) but also resulted in significantly lower overall survival and pathological complete remission (P = 0.02, P < 0.01, respectively). Disappointingly, pooled statistics observed few advantages over long-course radiotherapy in short-course radiotherapy with the adjuvant chemotherapy subgroup. CONCLUSIONS PSRT with delayed surgery was as effective as PLRT for the management of locally resectable rectal cancer. However, not adding additional chemotherapy to PSRT not only significantly decreased grade 3/4 toxicity but also decreased pathological complete remission and overall survival. TRIAL REGISTRATION The protocol for this meta-analysis was prospectively registered with PROSPERO (CRD42019133641).
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Affiliation(s)
- Wang Qiaoli
- Department of Radiotherapy, Yunnan Cancer Hospital, the Third Affiliated Hospital of Kunming Medical University, 519 Kunzhou Road, Xishan District, Kunming City, 650118, Yunnan Province, China
| | - Huang Yongping
- Department of Thoracic Surgery, Yunnan Cancer Hospital, the Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Xiong Wei
- Department of Cancer Colorectal Surgery, Yunnan Cancer Hospital, the Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Xu Guoqiang
- Department of Radiotherapy, Yunnan Cancer Hospital, the Third Affiliated Hospital of Kunming Medical University, 519 Kunzhou Road, Xishan District, Kunming City, 650118, Yunnan Province, China
| | - Ju Yunhe
- Department of Radiotherapy, Yunnan Cancer Hospital, the Third Affiliated Hospital of Kunming Medical University, 519 Kunzhou Road, Xishan District, Kunming City, 650118, Yunnan Province, China
| | - Liu Qiuyan
- Department of Radiotherapy, Yunnan Cancer Hospital, the Third Affiliated Hospital of Kunming Medical University, 519 Kunzhou Road, Xishan District, Kunming City, 650118, Yunnan Province, China
| | - Li Cheng
- Department of Radiotherapy, Yunnan Cancer Hospital, the Third Affiliated Hospital of Kunming Medical University, 519 Kunzhou Road, Xishan District, Kunming City, 650118, Yunnan Province, China
| | - Guo Mengling
- Yunnan Cancer Institute, Yunnan Cancer Hospital, the Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Li Jiayi
- Department of Cancer Colorectal Surgery, Yunnan Cancer Hospital, the Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Xiong Wei
- Department of Radiotherapy, Yunnan Cancer Hospital, the Third Affiliated Hospital of Kunming Medical University, 519 Kunzhou Road, Xishan District, Kunming City, 650118, Yunnan Province, China.
| | - Yang Yi
- Department of Radiotherapy, Yunnan Cancer Hospital, the Third Affiliated Hospital of Kunming Medical University, 519 Kunzhou Road, Xishan District, Kunming City, 650118, Yunnan Province, China.
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Erlandsson J, Lörinc E, Ahlberg M, Pettersson D, Holm T, Glimelius B, Martling A. Tumour regression after radiotherapy for rectal cancer – Results from the randomised Stockholm III trial. Radiother Oncol 2019; 135:178-186. [DOI: 10.1016/j.radonc.2019.03.016] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 03/13/2019] [Accepted: 03/17/2019] [Indexed: 02/08/2023]
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Couwenberg AM, Intven MPW, Hoendervangers S, van der Sluis FJ, van Westreenen HL, Marijnen CAM, van Grevenstein WMU, Verkooijen HM. The effect of time interval from chemoradiation to surgery on postoperative complications in patients with rectal cancer. Eur J Surg Oncol 2019; 45:1584-1591. [PMID: 31053479 DOI: 10.1016/j.ejso.2019.04.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 03/19/2019] [Accepted: 04/24/2019] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND A prolonged time interval between chemoradiation and total mesorectal excision (TME) may render more rectal cancer patients eligible for organ-sparing approaches but may also cause more pelvic fibrosis and surgical morbidity. We estimated the effect of time interval on postoperative complications and other surgical outcomes in rectal cancer patients. METHODS This is a population-based cohort study using data of the Dutch Colorectal Audit. Rectal cancer patients treated with chemoradiation followed by TME after an interval of 3-20 weeks were selected (n = 6,268). Time interval from completion of chemoradiation to TME was categorized into 3-6, 7-8, 9-10, 11-12 and 13-20 weeks. Outcomes included postoperative complication (any, and stratified by medical and surgical complications), reintervention, intraoperative complication, incomplete resection, positive circumferential margin (CRM) and pathological complete response (pCR). The interval of 7-8 weeks was the reference group. RESULTS Prolonged time intervals were not associated with a higher risk of a postoperative complication (any, surgical or medical), reintervention, and incomplete resection. Intraoperative complications were however more common after 11-12 weeks than after 7-8 weeks (odds ratio (OR) = 1.79, 95% confidence interval (CI) = 1.20-2.69). The interval of 9-10 weeks was associated with less CRM positive resections, and 9-10 and 13-20 weeks with more pCR (relative to 7-8 weeks, OR = 0.74, 95%CI = 0.56-0.98; OR = 1.28, 95%CI = 1.04-1.58; and OR = 1.33, 95%CI = 1.04-1.71, respectively). CONCLUSIONS Compared with 7-8 weeks, longer time intervals up to 13-20 weeks between chemoradiation and TME are not associated with more postoperative complications or more positive resection margins. Accordingly, prolonging the interval aiming for organ-sparing treatment is safe.
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Affiliation(s)
- Alice M Couwenberg
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX Utrecht, the Netherlands.
| | - Martijn P W Intven
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX Utrecht, the Netherlands
| | - Sieske Hoendervangers
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX Utrecht, the Netherlands
| | | | | | - Corrie A M Marijnen
- Department of Radiation Oncology, Leiden University Medical Center, Albinusdreef 2, 2333, ZA Leiden, the Netherlands
| | | | - Helena M Verkooijen
- Imaging Division, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX Utrecht, the Netherlands; University of Utrecht, Utrecht, the Netherlands
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Couwenberg AM, Burbach JPM, Intven MPW, Consten ECJ, Schiphorst AHW, Smits AB, Wijffels NAT, Heikens JT, Koopman M, van Grevenstein WMU, Verkooijen HM. Health-related quality of life in rectal cancer patients undergoing neoadjuvant chemoradiation with delayed surgery versus short-course radiotherapy with immediate surgery: a propensity score-matched cohort study. Acta Oncol 2019; 58:407-416. [PMID: 30656996 DOI: 10.1080/0284186x.2018.1551622] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Neoadjuvant chemoradiation with delayed surgery (CRT-DS) and short-course radiotherapy with immediate surgery (SCRT-IS) are two commonly used treatment strategies for rectal cancer. However, the optimal treatment strategy for patients with intermediate-risk rectal cancer remains a discussion. This study compares quality of life (QOL) between SCRT-IS and CRT-DS from diagnosis until 24 months after treatment. METHODS In a prospective colorectal cancer cohort, rectal cancer patients with clinical stage T2-3N0-2M0 undergoing SCRT-IS or CRT-DS between 2013 and 2017 were identified. QOL was assessed using EORTC-C30 and EORTC-CR29 questionnaires before the start of neoadjuvant treatment (baseline) and at 3, 6, 12, 18 and 24 months after. Patients were 1:1 matched using propensity sore matching. Between- and within-group differences in QOL domains were analyzed with linear mixed-effects models. Symptoms and sexual interest at 12 and 24 months were compared using logistic regression models. RESULTS 156 of 225 patients (69%) remained after matching. The CRT-DS group reported poorer emotional functioning at 3, 6, 12, 18 and 24 months (mean difference with SCRT-IS: -9.4, -12.1, -7.3, -8.0 and -7.9 respectively), and poorer global health, physical-, role-, social- and cognitive functioning at 6 months (mean difference with SCRT-IS: -9.1, -9.8, -14.0, -9.2 and -12.6, respectively). Besides emotional functioning, all QOL domains were comparable at 12, 18 and 24 months. Within-group changes showed a significant improvement of emotional functioning after baseline in the SCRT-IS group, whereas only a minor improvement was observed in the CRT-DS group. Symptoms and sexual interest in male patients at 12 and 24 months were comparable between the groups. CONCLUSIONS In rectal cancer patients, CRT-DS may induce a stronger decline in short-term QOL than SCRT-IS. From 12 months onwards, QOL domains, symptoms and sexual interest in male patients were comparable between the groups. However, emotional functioning remained higher after SCRT-IS than after CRT-DS.
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Affiliation(s)
- Alice M. Couwenberg
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Martijn P. W. Intven
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | | | - Anke B. Smits
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Joost T. Heikens
- Department of Surgery, Rivierenland Hospital, Tiel, The Netherlands
| | - Miriam Koopman
- Department of Medical Oncology, University Medical Center, Utrecht, The Netherlands
| | | | - Helena M. Verkooijen
- Imaging Division, University Medical Center, Utrecht, The Netherlands
- Utrecht University, Utrecht, The Netherlands
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Abstract
PURPOSE OF REVIEW Rectal cancer is predominantly a disease of older adults but current guidelines do not incorporate the associated specific challenges leading to wide variation in the delivery of cancer care to this subset of population. Here, we will review the current data available regarding the management of rectal cancer in older adults. RECENT FINDINGS The greatest challenge arises in the management of stage II/III disease as it involves tri-modality treatment that can be harder to tolerate by frail older patients. Response to neoadjuvant treatment is being used as a new marker to tailor further therapy and possibly avoid surgery. Oxaliplatin can be omitted from the adjuvant treatment without compromising outcomes. Physicians should perform geriatric assessment utilizing many validated tools available to help predict treatment tolerability and outcomes in older adults that can help personalize subsequent management. Most older adults can undergo standard therapy for stages I, II, or III rectal cancer with curative intent. Increasing evidence suggests that patients with a clinical complete response to neoadjuvant treatment may be observed closely with the possibility of avoiding surgery. Studies are evaluating alternate systemic treatments for advanced metastatic disease with the hope of maintaining quality of life without compromising cancer outcomes.
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