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Haddad P, Miraie M, Farhan F, Fazeli MS, Alikhassi A, Maddah-Safaei A, Aghili M, Kalaghchi B, Babaei M. Addition of oxaliplatin to neoadjuvant radiochemotherapy in MRI-defined T3, T4 or N+ rectal cancer: a randomized clinical trial. Asia Pac J Clin Oncol 2017; 13:416-422. [DOI: 10.1111/ajco.12675] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 01/15/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Peiman Haddad
- Radiation Oncology Research Centre; Cancer Institute; Tehran University of Medical Sciences; Tehran Iran
| | - Monir Miraie
- Cancer Research Centre & Radiation Oncology Department; Cancer Institute; Tehran University of Medical Sciences; Tehran Iran
| | - Farshid Farhan
- Cancer Research Centre & Radiation Oncology Department; Cancer Institute; Tehran University of Medical Sciences; Tehran Iran
| | - Mohammad-Sadegh Fazeli
- Colorectal Surgery Department; Imam-Khomeini Hospital; Tehran University of Medical Sciences; Tehran Iran
| | - Afsaneh Alikhassi
- Radiology Department; Cancer Institute; Tehran University of Medical Sciences; Tehran Iran
| | - Afsaneh Maddah-Safaei
- Radiation Oncology Department; Cancer Institute; Tehran University of Medical Sciences; Tehran Iran
| | - Mahdi Aghili
- Radiation Oncology Research Centre & Radiation Oncology Department; Cancer Institute; Tehran University of Medical Sciences; Tehran Iran
| | - Bita Kalaghchi
- Radiation Oncology Department; Cancer Institute; Tehran University of Medical Sciences; Tehran Iran
| | - Mohammad Babaei
- Radiation Oncology Department; Cancer Institute; Tehran University of Medical Sciences; Tehran Iran
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Jones RG, Tan D. How can we determine the best neoadjuvant chemoradiotherapy regimen for rectal cancer? COLORECTAL CANCER 2015. [DOI: 10.2217/crc.15.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
SUMMARY The current management of patients with clinically defined ‘locally advanced rectal cancer’ often involves fluoropyrimidine-based preoperative chemoradiotherapy (CRT) followed by total mesorectal excision. The focus remains primarily on reducing local recurrence, and improving survival, with organ preservation an increasing target. The best neoadjuvant CRT is the most effective regimen, balanced against the tolerability and late functional consequences, which should be selected for the individual according to their individual risk of local and distant recurrence. Hence, what makes the best neoadjuvant treatment depends on the activity and toxicity of the particular schedule, the aims of treatment, the individual disease characteristics and the individual patient pharmacogenomics. Current research efforts focus on enhancing the efficacy of CRT by integrating additional cytotoxics and biologically targeted agents.
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Affiliation(s)
- Rob Glynne Jones
- Consultant Radiation Oncologist, Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, Middlesex, HA6 2RN, UK
| | - David Tan
- Radiation Oncologist, FRCR, Consultant Radiation Oncologist, National Cancer Centre, Singapore
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Hill EJ, Nicolay NH, Middleton MR, Sharma RA. Oxaliplatin as a radiosensitiser for upper and lower gastrointestinal tract malignancies: what have we learned from a decade of translational research? Crit Rev Oncol Hematol 2012; 83:353-87. [PMID: 22309673 DOI: 10.1016/j.critrevonc.2011.12.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2011] [Revised: 12/14/2011] [Accepted: 12/28/2011] [Indexed: 01/08/2023] Open
Abstract
Some of the greatest advances in the treatment of solid malignancies have resulted from the combination of chemotherapy and radiotherapy treatments. This article comprehensively reviews the current clinical evidence for oxaliplatin-based chemo-radiotherapy that may improve local control and survival. In order to understand how clinical studies should be designed, the pre-clinical evidence for the use of oxaliplatin chemotherapy as a radiosensitising agent is appraised. Particular focus is placed on oxaliplatin's biological mechanisms of action, including cell cycle effects, the formation of DNA adducts and interstrand cross-links and the role of DNA repair proteins. At a clinical level, there is currently no evidence to suggest that oxaliplatin provides an additional benefit to concurrent chemo-radiation regimes that utilise fluoropyrimidines; we evaluate the reasons for this observation, the limitations of clinical trial design and the opportunities that currently exist to design clinical trials which are underpinned by an understanding of the basic biology.
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Affiliation(s)
- Esme J Hill
- Gray Institute of Radiation Oncology and Biology, Oncology Department, Old Road Campus Research Building, Oxford OX3 7DQ, UK
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Minsky BD. Progress in the Treatment of Locally Advanced Clinically Resectable Rectal Cancer. Clin Colorectal Cancer 2011; 10:227-37. [DOI: 10.1016/j.clcc.2011.06.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2011] [Accepted: 06/21/2011] [Indexed: 12/11/2022]
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Abstract
In the past two decades, substantial progress has been made in the adjuvant management of colorectal cancer. Chemotherapy has improved overall survival in patients with node-positive (N+) disease. In contrast with colon cancer, which has a low incidence of local recurrence, patients with rectal cancer have a higher incidence requiring the addition of pelvic radiation therapy (chemoradiation). Patients with rectal cancer have a number of unique management considerations: for example, the role of short-course radiation, whether postoperative adjuvant chemotherapy is necessary for all patients, and if the type of surgery following chemoradiation should be based on the response rate. More accurate imaging techniques and/or molecular markers may help identify patients with positive pelvic nodes to reduce the chance of overtreatment with preoperative therapy. Will more effective systemic agents both improve the results of radiation as well as modify the need for pelvic radiation? This review will address these and other controversies specific to patients with rectal cancer.
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Affiliation(s)
- Bruce D Minsky
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, IL 60637, USA.
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Preoperative intensified radiochemotherapy for rectal cancer: experience of a single institution. Int J Colorectal Dis 2011; 26:153-64. [PMID: 21107849 DOI: 10.1007/s00384-010-1064-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/04/2010] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim of our study was to evaluate the feasibility and the effectiveness of an intensified neoadjuvant protocol with the addition of weekly oxaliplatin in the preoperative strategy of rectal cancer treatment. PATIENTS AND METHODS Patients with locally advanced rectal cancer received continous infusion 5-Fluorouracil (5-FU) 200 mg/m(2)/day in combination with weekly oxaliplatin at a dose of 50 mg/m(2). Doses of radiotherapy were 45 Gy to the whole pelvis plus 5.4-9 Gy to the tumour mass. The primary end-points of the study were evaluation of toxicity, compliance with radiotherapy and chemotherapy, downstaging, pathological complete response (pCR) and the rate of sphincter preservation for distal cancers. Secondary end-points were relapse-free and overall survival. RESULTS From November 2006 to June 2009, 51 patients were enrolled into the study. Compliance with chemotherapy was 80%. The incidence of G3 diarrhoea and proctitis were 17.6% and 21.5%, respectively. Surgery was performed in 48 patients with 100% R0 resection. 76.4% of low-lying tumours underwent conservative treatment. Seventy-nine percent of patients were downstaged: T and N downstaging were observed in 71% and 75% of patients, respectively. A pCR was obtained in 11 (22.9%) patients. CONCLUSIONS Intensification of neoadjuvant treatment for rectal cancer with the addition of weekly oxaliplatin is feasible, with remarkable rates of downstaging and pathological complete response. Data on sphincter preservation for distal cancers were excellent. Phase III trials with a longer follow-up will establish whether this good outcome in terms of surrogate end-points will translate into better rates of disease-free and overall survival.
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Minsky BD. Chemoradiation for rectal cancer: rationale, approaches, and controversies. Surg Oncol Clin N Am 2011; 19:803-18. [PMID: 20883955 DOI: 10.1016/j.soc.2010.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The standard adjuvant treatment of cT3 and/or N+ rectal cancer is preoperative chemoradiation. However, there are many controversies regarding this approach. These controversies include the role of short course radiation, whether postoperative adjuvant chemotherapy is necessary for all patients, and if the type of surgery following chemoradiation should be based on the response rate. More accurate imaging techniques and/or molecular markers may help identify patients with positive pelvic nodes to reduce the chance of overtreatment with preoperative therapy. Will more effective systemic agents both improve the results of radiation, as well as modify the need for pelvic radiation? These questions and others remain active areas of clinical investigation.
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Affiliation(s)
- Bruce D Minsky
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, 5841 South Maryland Avenue, Chicago, IL 60637, USA.
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Abstract
The standard adjuvant treatment for cT3 and/or N+ rectal cancer is preoperative chemoradiation. However, there are many controversies regarding this approach. These include the role of short course radiation, whether postoperative adjuvant chemotherapy necessary for all patients and whether the type of surgery after chemoradiation should be based on the response rate. More accurate imaging techniques and/or molecular markers may help identify patients with positive pelvic nodes to reduce the chance of overtreatment with preoperative therapy. Will more effective systemic agents both improve the results of radiation as well as modify the need for pelvic radiation? These questions and others remain active areas of clinical investigation.
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Fakih MG, Fetterly G, Egorin MJ, Muindi JR, Espinoza-Delgado I, Zwiebel JA, Litwin A, Holleran JL, Wang K, Diasio RB. A phase I, pharmacokinetic, and pharmacodynamic study of two schedules of vorinostat in combination with 5-fluorouracil and leucovorin in patients with refractory solid tumors. Clin Cancer Res 2010; 16:3786-94. [PMID: 20463088 DOI: 10.1158/1078-0432.ccr-10-0547] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE We conducted a phase I clinical trial to determine the maximum tolerated dose (MTD) of daily or twice daily vorinostat x 3 days when combined with fixed doses of 5-fluorouracil (FU) and leucovorin every 2 weeks. EXPERIMENTAL DESIGN Vorinostat doses were escalated in a standard 3 x 3 phase I design. FU/leucovorin was started on day 2 of vorinostat and consisted of leucovorin 400 mg/m(2) i.v. over 2 hours followed by FU 400 mg/m(2) i.v. bolus and 2,400 mg/m(2) over 46 hours (sLV5FU2). RESULTS Forty-three patients were enrolled. Grade 3 fatigue, and hand and foot syndrome were the dose-limiting toxicities (DLT) at the 2,000 mg vorinostat once-daily dose level. Grade 3 fatigue and mucositis were DLTs at the 800 mg vorinostat twice-daily dose level. None of six patients at the 1,700 mg once daily or six patients at the 600 mg twice daily dose levels had a DLT; those dose levels represent the MTD. Twenty-one of 38 patients with FU-refractory colorectal cancer had stable disease, and one had a partial response. Vorinostat maximum serum concentrations at the MTD exceeded concentrations associated with thymidylate synthase downregulation in vitro. No pharmacokinetic interactions were noted between vorinostat and FU. CONCLUSIONS The MTD of vorinostat in combination with sLV5FU2 is 1,700 mg orally once daily x 3 or 600 mg orally twice daily x 3 days every 2 weeks. Clinical activity in refractory colorectal cancer supports further clinical development of this combination.
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Affiliation(s)
- Marwan G Fakih
- Department of Medicine, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York 14263, USA.
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Fakih MG, Pendyala L, Fetterly G, Toth K, Zwiebel JA, Espinoza-Delgado I, Litwin A, Rustum YM, Ross ME, Holleran JL, Egorin MJ. A phase I, pharmacokinetic and pharmacodynamic study on vorinostat in combination with 5-fluorouracil, leucovorin, and oxaliplatin in patients with refractory colorectal cancer. Clin Cancer Res 2009; 15:3189-95. [PMID: 19383814 DOI: 10.1158/1078-0432.ccr-08-2999] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE We conducted a phase I study to determine the maximum tolerated dose of vorinostat in combination with fixed doses of 5-fluorouracil (FU), leucovorin, and oxaliplatin (FOLFOX). EXPERIMENTAL DESIGN Vorinostat was given orally twice daily for 1 week every 2 weeks. FOLFOX was given on days 4 and 5 of vorinostat. The vorinostat starting dose was 100 mg twice daily. Escalation occurred in cohorts of three to six patients. Pharmacokinetics of vorinostat, FU, and oxaliplatin were studied. RESULTS Twenty-one patients were enrolled. Thrombocytopenia, neutropenia, gastrointestinal toxicities, and fatigue increased in frequency and severity at higher dose levels of vorinostat. Two of 4 evaluable patients at dose level 4 (vorinostat 400 mg orally twice daily) developed dose-limiting fatigue. One of 10 evaluable patients at dose level 3 (vorinostat 300 mg orally twice daily) had dose-limiting fatigue, anorexia, and dehydration. There were significant relationships between vorinostat dose and the area under the curve on days 1 and 5 (Pearson, < 0.001). The vorinostat area under the curve increased (P = 0.005) and clearance decreased (P = 0.003) on day 5 compared with day 1. The median C(max) of FU at each dose level increased significantly with increasing doses of vorinostat, suggesting a pharmacokinetic interaction between FU and vorinostat. Vorinostat-induced thymidylate synthase (TS) modulation was not consistent; only two of six patients had a decrease in intratumoral TS expression by reverse transcription-PCR. CONCLUSIONS The maximum tolerated dose of vorinostat in combination with FOLFOX is 300 mg orally twice daily x 1 week every 2 weeks. Alternative vorinostat dosing schedules may be needed for optimal down-regulation of TS expression.
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Affiliation(s)
- Marwan G Fakih
- Department of Medicine, Pharmacology, and Radiology, Roswell Park Cancer Institute, Buffalo, NY, USA.
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Liauw SL, Minsky BD. The use of capecitabine in the combined-modality therapy for rectal cancer. Clin Colorectal Cancer 2008; 7:99-104. [PMID: 18501068 DOI: 10.3816/ccc.2008.n.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Locally advanced rectal adenocarcinoma is treated by combined-modality therapy, which consists of surgery, chemotherapy, and radiation therapy. A series of randomized trials established a preferred treatment sequence of preoperative radiation therapy and 5-fluorouracil(5-FU)-based chemotherapy, total mesorectal excision, and adjuvant 5-FU-based chemotherapy for patients with stage II/III disease. Capecitabine is an oral prodrug of 5-FU that has potential advantages compared with intravenous 5-FU, including ease of administration and potentially increased therapeutic effect. Capecitabine is converted by a 3-step enzymatic process; the last step involves the enzyme thymidine phosphorylase, which is overexpressed in tumor tissues and is stimulated by concurrent radiation therapy. Over the past 5 years, several phase I/II trials of capecitabine-based therapy were reported. This review discusses the evolution of combined-modality therapy for rectal cancer with specific attention given to the use of capecitabine in conjunction with radiation therapy.
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Affiliation(s)
- Stanley L Liauw
- Department of Radiation and Cellular Oncology, University of Chicago Hospitals, Chicago, IL 60637, USA.
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Hector S, Tummala R, Kisiel ND, Diegelman P, Vujcic S, Clark K, Fakih M, Kramer DL, Porter CW, Pendyala L. Polyamine catabolism in colorectal cancer cells following treatment with oxaliplatin, 5-fluorouracil and N1, N11 diethylnorspermine. Cancer Chemother Pharmacol 2008; 62:517-27. [PMID: 17987291 DOI: 10.1007/s00280-007-0633-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2007] [Accepted: 10/21/2007] [Indexed: 10/22/2022]
Abstract
PURPOSE Our previous studies showed that combined treatment of oxaliplatin and N(1), N(11) diethyl-norspermine (DENSPM) results in massive induction of spermidine/spermine N(1)-acetyltransferase (SSAT) mRNA and activity. Since oxaliplatin and 5-fluorouracil (5FU) are used clinically in treatment of colorectal cancers, this study examines the effect of adding DENSPM to oxaliplatin/5FU combination on SSAT and spermine oxidase (SMO) in HCT-116 cells. METHODS HCT-116 cells were treated with clinically relevant concentrations of drugs for 20 h followed by 24 h in drug free medium. SSAT and SMO mRNA and protein were assayed by QRT-PCR and Westerns respectively; polyamine pools were measured by HPLC. SSAT and SMO mRNA in tumor biopsies from patients with rectal cancer receiving oxaliplatin, capecitabine and radiation were measured by QRT-PCR. RESULTS Oxaliplatin + 5FU + DENSPM produced significantly higher levels of SSAT and SMO mRNA, protein and activity than those seen with oxaliplatin+5FU with a significant depletion of cellular spermine and spermidine pools. Oxaliplatin/DENSPM was superior to 5FU/DENSPM in SSAT induction but similar for SMO. Oxaliplatin + DENSPM revealed synergistic growth inhibition at >IC(50) concentrations and antagonism at CONCLUSIONS These studies demonstrated that combining DENSPM with oxaliplatin + 5FU provides an added benefit by aiming at the clinically relevant therapeutic target, the polyamine catabolism. Further, we show for the first time, that SMO and SSAT induction could be measured in tumor biopsies in patients receiving chemo-radiation. Optimization of treatment conditions in vivo should facilitate a clinical evaluation of the three drug combination.
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Affiliation(s)
- Suzanne Hector
- Department of Medicine, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263, USA
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Phase II study of weekly intravenous oxaliplatin combined with oral daily capecitabine and radiotherapy with biologic correlates in neoadjuvant treatment of rectal adenocarcinoma. Int J Radiat Oncol Biol Phys 2008; 72:650-7. [PMID: 18565686 DOI: 10.1016/j.ijrobp.2008.01.020] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2007] [Revised: 01/05/2008] [Accepted: 01/09/2008] [Indexed: 02/04/2023]
Abstract
PURPOSE To evaluate the efficacy of a combination of capecitabine, oxaliplatin, and radiotherapy (RT) in the neoadjuvant treatment of Stage II and III rectal cancers. METHODS Capecitabine was given at 725 mg/m(2) orally twice daily Monday through Friday concurrently with RT. Oxaliplatin was given intravenously at 50 mg/m(2) once weekly five times starting the first day of RT. The radiation dose was 50.4 Gy in 28 fractions (1.8 Gy/fraction), five fractions weekly. Endorectal tumor biopsies were obtained before treatment and on the third day of treatment to explore the effects of treatment on thymidine phosphorylase, thymidylate synthase, excision repair cross-complementing rodent repair deficiency complementation group 1 (ERCC1), and apoptosis. RESULTS A total of 25 patients were enrolled in this study; 6 patients (24%) had a complete pathologic response. T-downstaging occurred in 52% of patients, and N-downstaging occurred in 53%. Grade 3 diarrhea was the most common Grade 3-4 toxicity, occurring in 20% of patients. Only 2 patients experienced disease recurrence, with a median of 20 months of follow-up. Thymidylate synthase, thymidine phosphorylase, ERCC1, and apoptosis did not vary significantly between the pretreatment and Day 3 tumor biopsies, nor did they predict for T-downstaging or a complete pathologic response. CONCLUSION Capecitabine at 725 mg/m(2) orally twice daily, oxaliplatin 50 mg/m(2)/wk, and RT at 50.4 Gy is an effective neoadjuvant combination for Stage II and III rectal cancer and results in a greater rate of complete pathologic responses than historically shown in fluoropyrimidine plus RT controls.
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Jin J, Li YX, Wang JW, Wang WH, Liu YP, Wang K, Fang H, Zhou ZX, Zhou AP, Yu ZH. Phase I study of oxaliplatin in combination with capecitabine and radiotherapy as postoperative treatment for stage II and III rectal cancer. Int J Radiat Oncol Biol Phys 2008; 72:671-7. [PMID: 18455328 DOI: 10.1016/j.ijrobp.2008.01.057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2007] [Revised: 01/09/2008] [Accepted: 01/30/2008] [Indexed: 11/24/2022]
Abstract
PURPOSE A Phase I study was conducted to determine the maximal tolerated dose and the dose-limiting toxicity (DLT) of oxaliplatin (OXA) combined with capecitabine and radiotherapy as adjuvant treatment in patients with operable rectal cancer. PATIENTS AND METHODS A total of 21 patients with Stage II or III rectal adenocarcinoma after curative surgery were treated with radiotherapy to a total dose of 50 Gy in 5 weeks. OXA was administered at a dosage of 40 (n = 6), 50 (n = 3),60 (n = 3), 70 (n = 3), or 80 mg/m(2) (n = 6) once a week for 2 weeks (first cycle) followed by a second cycle after a 7-day break. Capecitabine at a fixed dose of 1,300 mg/m(2)/d was administered orally at the same schedule as for OXA. DLT was defined as Grade 3 or 4 hematologic and nonhematologic toxicity. RESULTS Grade 1-3 leukopenia, diarrhea, and nausea/vomiting were the most common toxic side effects, and most were Grade 1-2. A DLT was first observed in 1 of 3 patients at 40 mg/m(2) (Grade 3 diarrhea) but was not observed in the next 3 patients at the same level or in patients who received a dose level of 50-70 mg/m(2). At 80 mg/m(2), DLT occurred in 3 of 6 patients (1 Grade 4 leukopenia and 2 Grade 3 diarrhea). CONCLUSIONS OXA combined with a fixed dose of capecitabine at 625 mg/m(2) twice daily by mouth plus radiotherapy in the adjuvant setting was tolerable and clinically feasible. The maximal tolerated dose of OXA in this setting was 80 mg/m(2), comparable to the maximal tolerated dose of OXA in the neoadjuvant setting.
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Affiliation(s)
- Jing Jin
- Department of Radiation Oncology, Cancer Hospital/Institute, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, People's Republic of China
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Folkvord S, Flatmark K, Seierstad T, Røe K, Rasmussen H, Ree AH. Inhibitory effects of oxaliplatin in experimental radiation treatment of colorectal carcinoma: does oxaliplatin improve 5-fluorouracil-dependent radiosensitivity? Radiother Oncol 2008; 86:428-34. [DOI: 10.1016/j.radonc.2007.10.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2007] [Accepted: 10/11/2007] [Indexed: 11/29/2022]
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Aristu JJ, Arbea L, Rodriguez J, Hernández-Lizoain JL, Sola JJ, Moreno M, Azcona JD, Díaz-González JA, García-Foncillas JM, Martínez-Monge R. Phase I-II trial of concurrent capecitabine and oxaliplatin with preoperative intensity-modulated radiotherapy in patients with locally advanced rectal cancer. Int J Radiat Oncol Biol Phys 2007; 71:748-55. [PMID: 18164861 DOI: 10.1016/j.ijrobp.2007.10.023] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2007] [Revised: 10/15/2007] [Accepted: 10/18/2007] [Indexed: 02/06/2023]
Abstract
PURPOSE To identify the maximal tolerated dose level of preoperative intensity-modulated radiotherapy combined with capecitabine and oxaliplatin and to evaluate the efficacy. PATIENTS AND METHODS Patients with rectal T3-T4 and/or N0-N+ rectal cancer received capecitabine 825 mg/m(2) twice daily Monday through Friday and oxaliplatin 60 mg/m(2) intravenously on Days 1, 8, and 15, concurrently with intensity-modulated radiotherapy. The radiation dose was increased in 5.0-Gy steps in cohorts of 3 patients starting from 37.5 Gy in 15 fractions (dose level [DL] 1). DL2 and DL3 were designed to reach 42.5 Gy in 17 fractions and 47.5 Gy in 19 fractions, respectively. RESULTS No dose-limiting toxicity was observed at DL1 or DL2. Of the 3 patients treated at DL3, 1 presented with Grade 3 diarrhea, which was considered a dose-limiting toxicity, and 3 additional patients were added. Of the 6 patients treated at DL3, no new dose-limiting toxicities were observed, and DL3 was identified as the recommended dose in this study. Eight additional patients were treated at 47.5 Gy. Grade 2 proctitis was the most frequent adverse event (40%); Grade 3 diarrhea occurred in 2 patients (10%). All patients underwent surgery, and 17 patients (85%) underwent R0 resection. Four patients (20%) presented with a histologic response of Grade 4, 11 (55%) with Grade 3+, 2 (15%) with Grade 3, and 2 patients (10%) with Grade 2. CONCLUSION The maximal tolerated dose in this study was 47.5 Gy. The high rates of pathologic response of Grade 3+ and 4 must be confirmed through the accrual of new patients in the Phase II study.
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Affiliation(s)
- José Javier Aristu
- Service of Radiation Oncology, Department of Oncology, Clínica Universitaria, University of Navarre, Pamplona, Spain.
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Lindegaard J, Gerard JP, Sun Myint A, Myerson R, Thomsen H, Laurberg S. Whither Papillon? — Future Directions for Contact Radiotherapy in Rectal Cancer. Clin Oncol (R Coll Radiol) 2007; 19:738-41. [PMID: 17870428 DOI: 10.1016/j.clon.2007.07.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2007] [Accepted: 07/25/2007] [Indexed: 11/24/2022]
Abstract
Although contact radiotherapy was developed 70 years ago, and is highly effective with cure rates of over 90% for early rectal cancer, there are few centres that offer this treatment today. One reason is the lack of replacement of ageing contact X-ray machines, many of which are now over 30 years old. To address this problem, the International Contact Radiotherapy Evaluation (ICONE) group was formed at a meeting in Liverpool in 2005 with the aim of developing a new contact X-ray unit and to establish clinical protocols that would enable the new machine to safely engage in the treatment of rectal cancer. As a result of these efforts, a European company is starting production of the new Papillon RT-50 machine, which will be available shortly. In addition, the ICONE group is planning an observational study on contact X-ray and transanal endoscopic microsurgery (CONTEM) for curative treatment of rectal cancer. This protocol will ensure standardised diagnostic procedures, patient selection and treatment in centres across the world and the data will be collected prospectively for analysis and audit. It is hoped that the CONTEM trial will provide the scientific evidence that is needed to obtain a broader acceptance of local contact radiotherapy as a treatment option for selected cases with early stage rectal cancer.
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Affiliation(s)
- J Lindegaard
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
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De Ridder M, Tournel K, Van Nieuwenhove Y, Engels B, Hoorens A, Everaert H, Op de Beeck B, Vinh-Hung V, De Grève J, Delvaux G, Verellen D, Storme GA. Phase II study of preoperative helical tomotherapy for rectal cancer. Int J Radiat Oncol Biol Phys 2007; 70:728-34. [PMID: 17904302 DOI: 10.1016/j.ijrobp.2007.07.2332] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2007] [Revised: 07/02/2007] [Accepted: 07/04/2007] [Indexed: 12/17/2022]
Abstract
PURPOSE To explore the efficacy and toxicity profile of helical tomotherapy in the preoperative treatment of patients with rectal cancer. PATIENTS AND METHODS Twenty-four patients with T3/T4 rectal cancer were included in this nonrandomized noncontrolled study. A dose of 46 Gy in daily fractions of 2 Gy was delivered to the presacral space and perineum if an abdominoperineal resection was deemed necessary. This dose was increased by a simultaneous integrated boost to 55.2 Gy when the circumferential resection margin was less than 2 mm on magnetic resonance imaging. Acute toxicity was evaluated weekly. Metabolic response was determined in the fifth week after the end of radiotherapy by means of fluorodeoxyglucose-positron emission tomography scan. A metabolic response was defined as a decrease in maximal standardized uptake value of more than 36%. RESULTS The mean volume of small bowel receiving more than 15 Gy and mean bladder dose were 227 ml and 20.8 Gy in the no-boost group and 141 ml and 21.5 Gy in the boost group. Only 1 patient developed Grade 3 enteritis. No other Grade 3 or 4 toxicities were observed. Two patients developed an anastomotic leak within 30 days after surgery. The metabolic response rate was 45% in the no-boost group compared with 77% in the boost group. All except 1 patient underwent an R0 resection. CONCLUSIONS Helical tomotherapy may decrease gastrointestinal toxicity in the preoperative radiotherapy of patients with rectal cancer. A simultaneous integrated radiation boost seems to result in a high metabolic response rate without excessive toxicity.
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Affiliation(s)
- Mark De Ridder
- Department of Radiation Oncology, Oncologisch Centrum UZ Brussel, Brussels, Belgium.
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20
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Abstract
Patients with stage II and III rectal cancer benefit from a multidisciplinary approach to treatment. Studies of postoperative adjuvant therapy consistently demonstrate decreases in locoregional recurrence with the use of radiation therapy. The use of postoperative chemotherapy results in improved disease-free survival and overall survival in certain studies. Preoperative radiation therapy decreases locoregional recurrence and in one study demonstrated an improvement in survival. The addition of chemotherapy to preoperative radiation results in improved locoregional control, but not survival. Preoperative chemoradiation is the standard of care for patients with clinical stage II and III rectal cancer in the United States due to improved local recurrence, acute and late toxicity, and sphincter preservation compared with postoperative chemoradiation. Promising approaches include the incorporation of new chemotherapeutic and biologic agents into chemoradiation and adjuvant chemotherapy regimens; new radiation techniques, such as the use of intraoperative radiation therapy and an accelerated concomitant radiation boost; and gene and protein expression profiling, to better predict response to treatment and prognosis.
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Affiliation(s)
- Smitha S. Krishnamurthi
- Department of Medicine, University Hospitals Case Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
- Case Comprehensive Cancer Center, University Hospitals Case Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Yuji Seo
- Department of Radiation Oncology, University Hospitals Case Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Timothy J. Kinsella
- Case Comprehensive Cancer Center, University Hospitals Case Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Radiation Oncology, University Hospitals Case Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
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Seierstad T, Folkvord S, Røe K, Flatmark K, Skretting A, Olsen DR. Early changes in apparent diffusion coefficient predict the quantitative antitumoral activity of capecitabine, oxaliplatin, and irradiation in HT29 xenografts in athymic nude mice. Neoplasia 2007; 9:392-400. [PMID: 17534444 PMCID: PMC1877980 DOI: 10.1593/neo.07154] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2007] [Revised: 03/29/2007] [Accepted: 04/02/2007] [Indexed: 01/22/2023] Open
Abstract
PURPOSE The purpose of this study was to evaluate the possible use of changes in apparent diffusion coefficient (ADC) measured by magnetic resonance imaging for pretreatment prediction and early detection of tumor response in a mouse model during fractionated chemoradiotherapy. MATERIALS AND METHODS Athymic mice with bilateral HT29 xenografts on rear flanks were allocated into three groups: control, capecitabine, and capecitabine and oxaliplatin. The left flanks of the mice received daily irradiation. T2 and diffusion images were acquired before therapy and weekly for the following 9 weeks. Pretreatment and changes in ADC were calculated and compared with tumor doubling growth delay. RESULTS No correlations between pretreatment ADC and changes in tumor volumes after therapy were seen. All treated tumors, except those receiving capecitabine (P = .06), showed increased mean tumor ADC values 11 days after initialization of therapy (P < .05) before returning to pretreatment values within 5 days posttherapy (day 18 after onset of therapy). This increase in mean tumor ADC showed a strong positive correlation (r = 0.92, P < .01) with mean tumor doubling growth delay. CONCLUSIONS Pretreatment ADC values did not predict the effectiveness of therapy, whereas early changes in mean ADC quantitatively correlated with treatment outcome.
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Affiliation(s)
- Therese Seierstad
- Department of Medical Physics, Rikshospitalet-Radiumhospitalet Medical Center, Oslo, Norway
- Department of Radiation Biology, Rikshospitalet-Radiumhospitalet Medical Center, Oslo, Norway
- Buskerud University College, Faculty of Health, Drammen, Norway
| | - Sigurd Folkvord
- Department of Tumor Biology, Rikshospitalet-Radiumhospitalet Medical Center, Oslo, Norway
| | - Kathrine Røe
- Department of Radiation Biology, Rikshospitalet-Radiumhospitalet Medical Center, Oslo, Norway
| | - Kjersti Flatmark
- Department of Tumor Biology, Rikshospitalet-Radiumhospitalet Medical Center, Oslo, Norway
| | - Arne Skretting
- Department of Medical Physics, Rikshospitalet-Radiumhospitalet Medical Center, Oslo, Norway
| | - Dag Rune Olsen
- Department of Radiation Biology, Rikshospitalet-Radiumhospitalet Medical Center, Oslo, Norway
- University of Oslo, Oslo, Norway
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