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Kagawa Y, Smith JJ, Fokas E, Watanabe J, Cercek A, Greten FR, Bando H, Shi Q, Garcia-Aguilar J, Romesser PB, Horvat N, Sanoff H, Hall W, Kato T, Rödel C, Dasari A, Yoshino T. Future direction of total neoadjuvant therapy for locally advanced rectal cancer. Nat Rev Gastroenterol Hepatol 2024; 21:444-455. [PMID: 38485756 DOI: 10.1038/s41575-024-00900-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/26/2024] [Indexed: 05/31/2024]
Abstract
Despite therapeutic advancements, disease-free survival and overall survival of patients with locally advanced rectal cancer have not improved in most trials as a result of distant metastases. For treatment decision-making, both long-term oncologic outcomes and impact on quality-of-life indices should be considered (for example, bowel function). Total neoadjuvant therapy (TNT), comprised of chemotherapy and radiotherapy or chemoradiotherapy, is now a standard treatment approach in patients with features of high-risk disease to prevent local recurrence and distant metastases. In selected patients who have a clinical complete response, subsequent surgery might be avoided through non-operative management, but patients who do not respond to TNT have a poor prognosis. Refined molecular characterization might help to predict which patients would benefit from TNT and non-operative management. Specifically, integrated analysis of spatiotemporal multi-omics using artificial intelligence and machine learning is promising. Three prospective trials of TNT and non-operative management in Japan, the USA and Germany are collaborating to better understand drivers of response to TNT. Here, we address the future direction for TNT.
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Affiliation(s)
- Yoshinori Kagawa
- Department of Gastroenterological Surgery, Osaka General Medical Center, Osaka, Japan
| | - J Joshua Smith
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Emmanouil Fokas
- Department of Radiotherapy and Oncology, University of Frankfurt, Frankfurt, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- Frankfurt Cancer Institute, Frankfurt, Germany
- Department of Radiation Oncology, CyberKnife and Radiation Therapy, Centre for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
- German Cancer Consortium (DKTK), Frankfurt, Germany
| | - Jun Watanabe
- Gastroenterological Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Andrea Cercek
- Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Florian R Greten
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- Frankfurt Cancer Institute, Frankfurt, Germany
- German Cancer Consortium (DKTK), Frankfurt, Germany
- Institute for Tumour Biology and Experimental Therapy, Georg-Speyer-Haus, Frankfurt, Germany
| | - Hideaki Bando
- Department of Gastroenterology and Gastrointestinal Oncology, National Cancer Center Hospital East, Chiba, Japan
| | - Qian Shi
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Julio Garcia-Aguilar
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Paul B Romesser
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Natally Horvat
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hanna Sanoff
- Department of Medicine, Division of Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - William Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Takeshi Kato
- Department of Surgery, NHO Osaka National Hospital, Osaka, Japan
| | - Claus Rödel
- Department of Radiotherapy and Oncology, University of Frankfurt, Frankfurt, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- Frankfurt Cancer Institute, Frankfurt, Germany
- German Cancer Consortium (DKTK), Frankfurt, Germany
| | - Arvind Dasari
- Department of GI Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Takayuki Yoshino
- Department of Gastroenterology and Gastrointestinal Oncology, National Cancer Center Hospital East, Chiba, Japan.
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Valentini V, Alfieri S, Coco C, D'Ugo D, Crucitti A, Pacelli F, Persiani R, Sofo L, Picciocchi A, Doglietto GB, Barbaro B, Vecchio FM, Ricci R, Damiani A, Savino MC, Boldrini L, Cellini F, Meldolesi E, Romano A, Chiloiro G, Gambacorta MA. Four steps in the evolution of rectal cancer managements through 40 years of clinical practice: Pioneering, standardization, challenges and personalization. Radiother Oncol 2024; 194:110190. [PMID: 38438019 DOI: 10.1016/j.radonc.2024.110190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 02/26/2024] [Indexed: 03/06/2024]
Affiliation(s)
- Vincenzo Valentini
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Sergio Alfieri
- Chirurgia Digestiva, Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Claudio Coco
- U.O.C. Chirurgia Generale 2, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Domenico D'Ugo
- Unità di chirurgia generale, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | | | - Fabio Pacelli
- Unità chirurgica del peritoneo e del retroperitoneo, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Roberto Persiani
- Unità di chirurgia generale, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Luigi Sofo
- Divisione di Chirurgia Addominale, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Aurelio Picciocchi
- Dipartimento di Chirurgia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giovanni Battista Doglietto
- Chirurgia Digestiva, Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Brunella Barbaro
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Fabio Maria Vecchio
- Dipartimento di Patologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Riccardo Ricci
- Dipartimento di Patologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Andrea Damiani
- Gemelli Generator Real World Data Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Maria Chiara Savino
- Gemelli Generator Real World Data Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Luca Boldrini
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Francesco Cellini
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Elisa Meldolesi
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Angela Romano
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giuditta Chiloiro
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.
| | - Maria Antonietta Gambacorta
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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3
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Cicalini I, Chiarelli AM, Chiacchiaretta P, Perpetuini D, Rosa C, Mastrodicasa D, d'Annibale M, Trebeschi S, Serafini FL, Cocco G, Narciso M, Corvino A, Cinalli S, Genovesi D, Lanuti P, Valentinuzzi S, Pieragostino D, Brocco D, Beets-Tan RGH, Tinari N, Sensi SL, Stuppia L, Del Boccio P, Caulo M, Delli Pizzi A. Multi-omics staging of locally advanced rectal cancer predicts treatment response: a pilot study. LA RADIOLOGIA MEDICA 2024; 129:712-726. [PMID: 38538828 PMCID: PMC11088547 DOI: 10.1007/s11547-024-01811-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 03/13/2024] [Indexed: 05/12/2024]
Abstract
Treatment response assessment of rectal cancer patients is a critical component of personalized cancer care and it allows to identify suitable candidates for organ-preserving strategies. This pilot study employed a novel multi-omics approach combining MRI-based radiomic features and untargeted metabolomics to infer treatment response at staging. The metabolic signature highlighted how tumor cell viability is predictively down-regulated, while the response to oxidative stress was up-regulated in responder patients, showing significantly reduced oxoproline values at baseline compared to non-responder patients (p-value < 10-4). Tumors with a high degree of texture homogeneity, as assessed by radiomics, were more likely to achieve a major pathological response (p-value < 10-3). A machine learning classifier was implemented to summarize the multi-omics information and discriminate responders and non-responders. Combining all available radiomic and metabolomic features, the classifier delivered an AUC of 0.864 (± 0.083, p-value < 10-3) with a best-point sensitivity of 90.9% and a specificity of 81.8%. Our results suggest that a multi-omics approach, integrating radiomics and metabolomic data, can enhance the predictive value of standard MRI and could help to avoid unnecessary surgical treatments and their associated long-term complications.
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Affiliation(s)
- Ilaria Cicalini
- Center for Advanced Studies and Technology (CAST), University "G. d'Annunzio" of Chieti-Pescara, Chieti, Italy
- Department of Innovative Technologies in Medicine and Odontoiatry, "G. d'Annunzio" University, Chieti, Italy
| | - Antonio Maria Chiarelli
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University, Chieti, Italy
| | - Piero Chiacchiaretta
- Department of Innovative Technologies in Medicine and Odontoiatry, "G. d'Annunzio" University, Chieti, Italy.
| | - David Perpetuini
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University, Chieti, Italy
| | - Consuelo Rosa
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University, Chieti, Italy
| | | | - Martina d'Annibale
- Department of Radiology, SS. Annunziata Hospital, "G. d'Annunzio" University, Via dei Vestini, 66100, ChietiChieti, Italy
| | - Stefano Trebeschi
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Giulio Cocco
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University, Chieti, Italy
- Unit of Ultrasound in Internal Medicine, Department of Medicine and Science of Aging, "G. D'Annunzio" University, Chieti, Italy
| | - Marco Narciso
- Department of Radiology, SS. Annunziata Hospital, "G. d'Annunzio" University, Via dei Vestini, 66100, ChietiChieti, Italy
| | - Antonio Corvino
- Medical, Movement and Wellbeing Sciences Department, Via Medina 40, 80133, Naples, Italy
| | - Sebastiano Cinalli
- Division of Pathology, ASST of Valtellina and Alto Lario, Sondrio, Italy
| | - Domenico Genovesi
- Department of Medical, Oral and Biotechnological Sciences and CeSI-MeT, "G. D'Annunzio" University of Chieti, Via dei Vestini, 66100, Chieti, Italy
| | - Paola Lanuti
- Center for Advanced Studies and Technology (CAST), University "G. d'Annunzio" of Chieti-Pescara, Chieti, Italy
- Department of Medicine and Aging Science, "G. D'Annunzio" University of Chieti, Via dei Vestini, 66100, Chieti, Italy
| | - Silvia Valentinuzzi
- Center for Advanced Studies and Technology (CAST), University "G. d'Annunzio" of Chieti-Pescara, Chieti, Italy
- Department of Pharmacy, "G. D'Annunzio" University of Chieti, Via dei Vestini, 66100, Chieti, Italy
| | - Damiana Pieragostino
- Center for Advanced Studies and Technology (CAST), University "G. d'Annunzio" of Chieti-Pescara, Chieti, Italy
- Department of Innovative Technologies in Medicine and Odontoiatry, "G. d'Annunzio" University, Chieti, Italy
| | - Davide Brocco
- Clinical Oncology Unit, SS. Annunziata Hospital, Via dei Vestini, 66100, Chieti, Italy
| | - Regina G H Beets-Tan
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Nicola Tinari
- Department of Medicine and Aging Science, "G. D'Annunzio" University of Chieti, Via dei Vestini, 66100, Chieti, Italy
| | - Stefano L Sensi
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University, Chieti, Italy
| | - Liborio Stuppia
- Center for Advanced Studies and Technology (CAST), University "G. d'Annunzio" of Chieti-Pescara, Chieti, Italy
- Department of Psychological, Health and Territory Sciences, "G. d'Annunzio" University of Chieti-Pescara, 66100, Chieti, Italy
| | - Piero Del Boccio
- Center for Advanced Studies and Technology (CAST), University "G. d'Annunzio" of Chieti-Pescara, Chieti, Italy
- Department of Pharmacy, "G. D'Annunzio" University of Chieti, Via dei Vestini, 66100, Chieti, Italy
| | - Massimo Caulo
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University, Chieti, Italy
- Department of Radiology, SS. Annunziata Hospital, "G. d'Annunzio" University, Via dei Vestini, 66100, ChietiChieti, Italy
| | - Andrea Delli Pizzi
- Department of Innovative Technologies in Medicine and Odontoiatry, "G. d'Annunzio" University, Chieti, Italy
- Department of Radiology, SS. Annunziata Hospital, "G. d'Annunzio" University, Via dei Vestini, 66100, ChietiChieti, Italy
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Nazari R, Piozzi GN, Ghalehtaki R, Ahmadi-Tafti SM, Behboudi B, Mousavi Darzikolaee N, Aghili M, Gambacorta MA. Role of Oxaliplatin in the Neoadjuvant Concurrent Chemoradiotherapy in Locally Advanced Rectal Cancer: a Review of Evidence. Clin Med Insights Oncol 2024; 18:11795549241236409. [PMID: 38510317 PMCID: PMC10952988 DOI: 10.1177/11795549241236409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 02/12/2024] [Indexed: 03/22/2024] Open
Abstract
The treatment of locally advanced rectal cancer (LARC) is a challenging situation for radiation oncologists and colorectal surgeons. Most current approaches recommend neoadjuvant fluorouracil or capecitabine-based chemoradiotherapy followed by surgery as a standard of care. Intensification of concurrent chemotherapy by adding oxaliplatin to fluorouracil or capecitabine backbone to get better outcomes is the matter that has remained unresolved. In this review, we searched Medline and Google Scholar databases and selected 28 prospective phase II and III clinical trials that addressed this question. We discussed the potential advantages and drawbacks of incorporating oxaliplatin into concurrent chemoradiation therapy. We tried to define whether adding oxaliplatin to concurrent chemoradiation with excellent performance and high-risk features benefits some subpopulations. The available literature suggests that by adding oxaliplatin there are some benefits in enhancing response to neoadjuvant chemoradiotherapy, however, without any translated improvements in long-term outcomes including overall and disease-free survival.
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Affiliation(s)
- Reza Nazari
- Department of Radiation Oncology, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Guglielmo Niccolò Piozzi
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Reza Ghalehtaki
- Department of Radiation Oncology, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
- Radiation Oncology Research Center, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Mohsen Ahmadi-Tafti
- Division of Colorectal Surgery, Department of Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran
| | - Behnam Behboudi
- Division of Colorectal Surgery, Department of Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran
| | - Nima Mousavi Darzikolaee
- Department of Radiation Oncology, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahdi Aghili
- Radiation Oncology Research Center, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Maria Antonietta Gambacorta
- UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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Hearn N, Leppien A, O’Connor P, Cahill K, Atwell D, Vignarajah D, Min M. Radiotherapy dose escalation using pre-treatment diffusion-weighted imaging in locally advanced rectal cancer: a planning study. BJR Open 2024; 6:tzad001. [PMID: 38352181 PMCID: PMC10860507 DOI: 10.1093/bjro/tzad001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/14/2023] [Accepted: 10/09/2023] [Indexed: 02/16/2024] Open
Abstract
Objectives Diffusion-weighted MRI (DWI) may provide biologically relevant target volumes for dose-escalated radiotherapy in locally advanced rectal cancer (LARC). This planning study assessed the dosimetric feasibility of delivering hypofractionated boost treatment to intra-tumoural regions of restricted diffusion prior to conventional long-course radiotherapy. Methods Ten patients previously treated with curative-intent standard long-course radiotherapy (50 Gy/25#) were re-planned. Boost target volumes (BTVs) were delineated semi-automatically using 40th centile intra-tumoural apparent diffusion coefficient value with expansions (anteroposterior 11 mm, transverse 7 mm, craniocaudal 13 mm). Biased-dosed combined plans consisted of a single-fraction volumetric modulated arc therapy flattening-filter-free (VMAT-FFF) boost (phase 1) of 5, 7, or 10 Gy before long-course VMAT (phase 2). Phase 1 plans were assessed with reference to stereotactic conformality and deliverability measures. Combined plans were evaluated with reference to standard long-course therapy dose constraints. Results Phase 1 BTV dose targets at 5/7/10 Gy were met in all instances. Conformality constraints were met with only 1 minor violation at 5 and 7 Gy. All phase 1 and combined phase 1 + 2 plans passed patient-specific quality assurance. Combined phase 1 + 2 plans generally met organ-at-risk dose constraints. Exceptions included high-dose spillage to bladder and large bowel, predominantly in cases where previously administered, clinically acceptable non-boosted plans also could not meet constraints. Conclusions Targeted upfront LARC radiotherapy dose escalation to DWI-defined is feasible with appropriate patient selection and preparation. Advances in knowledge This is the first study to evaluate the feasibility of DWI-targeted upfront radiotherapy boost in LARC. This work will inform an upcoming clinical feasibility study.
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Affiliation(s)
- Nathan Hearn
- Department of Medical Imaging, Sunshine Coast University Hospital, Birtinya, QLD 4575, Australia
- Thompson Institute, University of the Sunshine Coast, Birtinya, QLD 4575, Australia
| | - Alexandria Leppien
- Department of Radiation Oncology, Sunshine Coast University Hospital, Birtinya, QLD 4575, Australia
| | - Patrick O’Connor
- Department of Radiation Oncology, Sunshine Coast University Hospital, Birtinya, QLD 4575, Australia
- School of Information Technology and Electrical Engineering, University of Queensland, St Lucia, QLD 4072, Australia
| | - Katelyn Cahill
- Thompson Institute, University of the Sunshine Coast, Birtinya, QLD 4575, Australia
- Department of Radiation Oncology, Sunshine Coast University Hospital, Birtinya, QLD 4575, Australia
| | - Daisy Atwell
- Thompson Institute, University of the Sunshine Coast, Birtinya, QLD 4575, Australia
- Department of Radiation Oncology, Sunshine Coast University Hospital, Birtinya, QLD 4575, Australia
| | - Dinesh Vignarajah
- Department of Radiation Oncology, Sunshine Coast University Hospital, Birtinya, QLD 4575, Australia
- School of Medicine and Dentistry, Griffith University, Sunshine Coast Health Institute, Birtinya, QLD 4575, Australia
| | - Myo Min
- Thompson Institute, University of the Sunshine Coast, Birtinya, QLD 4575, Australia
- Department of Radiation Oncology, Sunshine Coast University Hospital, Birtinya, QLD 4575, Australia
- School of Medicine and Dentistry, Griffith University, Sunshine Coast Health Institute, Birtinya, QLD 4575, Australia
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Yu Z, Hao Y, Huang Y, Ling L, Hu X, Qiao S. Radiotherapy in the preoperative neoadjuvant treatment of locally advanced rectal cancer. Front Oncol 2023; 13:1300535. [PMID: 38074690 PMCID: PMC10704030 DOI: 10.3389/fonc.2023.1300535] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 10/30/2023] [Indexed: 04/04/2024] Open
Abstract
Radiotherapy and chemotherapy are effective treatments for patients with locally advanced rectal cancer (LARC) and can significantly improve the likelihood of R0 resection. Radiotherapy can be used as a local treatment to reduce the size of the tumor, improve the success rate of surgery and reduce the residual cancer cells after surgery. Early chemotherapy can also downgrade the tumor and eliminate micrometastases throughout the body, reducing the risk of recurrence and metastasis. The advent of neoadjuvant concurrent radiotherapy (nCRT) and total neoadjuvant treatment (TNT) has brought substantial clinical benefits to patients with LARC. Even so, given increasing demand for organ preservation and quality of life and the disease becoming increasingly younger in its incidence profile, there is a need to further explore new neoadjuvant treatment options to further improve tumor remission rates and provide other opportunities for patients to choose watch-and-wait (W&W) strategies that avoid surgery. Targeted drugs and immunologic agents (ICIs) have shown good efficacy in patients with advanced rectal cancer but have not been commonly used in neoadjuvant therapy for patients with LARC. In this paper, we review several aspects of neoadjuvant therapy, including radiation therapy and chemotherapy drugs, immune drugs and targeted drugs used in combination with neoadjuvant therapy, with the aim of providing direction and thoughtful perspectives for LARC clinical treatment and research trials.
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Affiliation(s)
| | | | | | | | - Xigang Hu
- Department of Radiation Oncology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
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7
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Chiloiro G, Romano A, Cusumano D, Boldrini L, Panza G, Placidi L, Meldolesi E, Nardini M, Meffe G, Nicolini G, Votta C, Indovina L, Gambacorta MA. THeragnostic utilities for neoplastic DisEases of the rectum by MRI guided radiotherapy (THUNDER 2) phase II trial: interim safety analysis. Radiat Oncol 2023; 18:163. [PMID: 37803322 PMCID: PMC10557246 DOI: 10.1186/s13014-023-02353-x] [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] [Received: 07/17/2023] [Accepted: 09/19/2023] [Indexed: 10/08/2023] Open
Abstract
BACKGROUND The THUNDER-2 phase II single institutional trial investigates the benefits of MRI-guided radiotherapy (MRIgRT) in treating locally advanced rectal cancer (LARC). This study focuses on evaluating the impact of escalating radiation therapy dose in non-responder patients using the Early Tumour Regression Index (ERI) for predicting complete response (CR). The trial's primary endpoint is to increase the CR rate in non-responders by 10% and assess the feasibility of the delta radiomics-based MRIgRT predictive model. This interim analysis assesses the feasibility and safety of the proposed MRIgRT dose escalation strategy in terms of acute toxicity (gastrointestinal, genitourinary and haematological) and treatment adherence. METHODS Stage cT2-3, N0-2, or cT4 patients with anal sphincter involvement, N0-2a, M0, but without high-risk features were enrolled. MRIgRT treatment consisted of a standard dose of 55 Gy to the Gross Tumor Volume (GTV) and mesorectum, and 45 Gy to the mesorectum and drainage nodes in 25 fractions with concomitant chemotherapy. 0.35 T MRI was used for simulation imaging and daily alignment. ERI was calculated at the 10th fraction. Non-responders with an ERI above 13.1 received intensified dose escalation from the 11th fraction, resulting in a total dose of 60.1 Gy. Acute toxicity was assessed using the CTCAE v.5 scale. RESULTS From March 2021 to November 2022, 33 out of the total number of 63 patients to be enrolled (52.4%) were included, with one withdrawal unrelated to treatment. Sixteen patients (50%) underwent dose escalation. Treatment was well tolerated, with only one patient (3.1%) in the standard treatment group experiencing acute Grade 3 diarrhea, proctitis, and cystitis. No significant differences in toxicity were observed between the two groups (p = 0.5463). CONCLUSIONS MRIgRT treatment with dose escalation up to 60.1 Gy is well tolerated in LARC patients predicted as non-responders by ERI, confirming the feasibility and safety of this approach. The THUNDER-2 trial's primary and secondary endpoints will be fully analyzed when all planned patients will be enrolled.
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Affiliation(s)
- Giuditta Chiloiro
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Angela Romano
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy.
| | - Davide Cusumano
- Mater Olbia Hospital, Strada Statale Orientale Sarda 125, Olbia, 07026, Italy
| | - Luca Boldrini
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Giulia Panza
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Lorenzo Placidi
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Elisa Meldolesi
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Matteo Nardini
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Guenda Meffe
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Gianluca Nicolini
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Claudio Votta
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Luca Indovina
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
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8
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Engels B, De Paoli A, Delmastro E, Munoz F, Vagge S, Norkus D, Everaert H, Tabaro G, Gariboldi E, Ricardi U, Borsatti E, Gabriele P, Innocente R, Palazzari E, Dubaere E, Mahé MA, Van Laere S, Gevaert T, De Ridder M. Preoperative Radiotherapy with a Simultaneous Integrated Boost Compared to Chemoradiotherapy for cT3-4 Rectal Cancer: Long-Term Results of a Multicenter Randomized Study. Cancers (Basel) 2023; 15:3869. [PMID: 37568685 PMCID: PMC10416952 DOI: 10.3390/cancers15153869] [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: 05/24/2023] [Revised: 07/14/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Preoperative chemoradiotherapy (CRT) is the standard treatment for T3-4 rectal cancer. Here, we compared image-guided and intensity-modulated RT (IG-IMRT) with a simultaneous integrated boost (SIB) (instead of concomitant chemotherapy) versus CRT in a multi-centric randomized trial. METHODS cT3-4 rectal cancer patients were randomly assigned to receive preoperative IG-IMRT 46 Gy/23 fractions plus capecitabine 825 mg/m² twice daily (CRT arm) or IG-IMRT 46 Gy/23 fractions with an SIB to the rectal tumor up to a total dose of 55.2 Gy (RTSIB arm). RESULTS A total of 174 patients were randomly assigned between April 2010 and May 2014. Grade 3 acute toxicities were 6% and 4% in the CRT and RTSIB arms, respectively. The mean fractional change in SUVmax at 5 weeks after completion of preoperative RT were -55.8% (±24.0%) and -52.9% (±21.6%) for patients in the CRT arm and RTSIB arm, respectively (p = 0.43). The pathologic complete response rate was 24% with CRT compared to 14% with RTSIB. There were no differences in 5-year overall survival (OS), progression-free survival (PFS) or local control (LC). CONCLUSIONS The preoperative RTSIB approach was not inferior to CRT in terms of metabolic response, toxicity, OS, PFS and LC, and could be considered an available option for patients unfit for fluorouracil-based CRT.
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Affiliation(s)
- Benedikt Engels
- Department of Radiotherapy, UZ Brussel, Vrije Universiteit Brussel, 1090 Brussels, Belgium
| | - Antonino De Paoli
- Department of Radiation Oncology, Centro di Riferimento Oncologico (CRO)-IRCCS, 33081 Aviano, Italy
| | - Elena Delmastro
- Department of Radiation Oncology, IRCC Candiolo, 10060 Candiolo, Italy
| | - Fernando Munoz
- Department of Oncology, University of Torino, 10126 Torino, Italy
| | - Stefano Vagge
- Department of Radiation Oncology, IRCCS San Martino-IST Genoa, 16132 Genoa, Italy
| | - Darius Norkus
- Department of Radiotherapy, National Cancer Institute, 08406 Vilnius, Lithuania
| | - Hendrik Everaert
- Department of Nuclear Medicine, UZ Brussel, Vrije Universiteit Brussel, 1090 Brussels, Belgium
| | - Gianna Tabaro
- Department of Radiation Oncology, Centro di Riferimento Oncologico (CRO)-IRCCS, 33081 Aviano, Italy
| | | | - Umberto Ricardi
- Department of Oncology, University of Torino, 10126 Torino, Italy
| | - Eugenio Borsatti
- Department of Radiation Oncology, Centro di Riferimento Oncologico (CRO)-IRCCS, 33081 Aviano, Italy
| | - Pietro Gabriele
- Department of Radiation Oncology, IRCC Candiolo, 10060 Candiolo, Italy
| | - Roberto Innocente
- Department of Radiation Oncology, Centro di Riferimento Oncologico (CRO)-IRCCS, 33081 Aviano, Italy
| | - Elisa Palazzari
- Department of Radiation Oncology, Centro di Riferimento Oncologico (CRO)-IRCCS, 33081 Aviano, Italy
| | - Emilie Dubaere
- Department of Radiotherapy, UZ Brussel, Vrije Universiteit Brussel, 1090 Brussels, Belgium
| | - Marc-André Mahé
- Department of Radiotherapy, Institut de Cancérologie de l’Ouest, Nantes, 44800 Saint-Herblain, France
| | - Sven Van Laere
- Department of Radiotherapy, UZ Brussel, Vrije Universiteit Brussel, 1090 Brussels, Belgium
| | - Thierry Gevaert
- Department of Radiotherapy, UZ Brussel, Vrije Universiteit Brussel, 1090 Brussels, Belgium
| | - Mark De Ridder
- Department of Radiotherapy, UZ Brussel, Vrije Universiteit Brussel, 1090 Brussels, Belgium
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9
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Gambacorta MA, Chiloiro G, Masciocchi C, Mariani S, Romano A, Gonnelli A, Gerard JP, Ngan S, Rödel C, Bujko K, Glynne-Jones R, van Soest J, Dekker A, Damiani A, Valentini V. pCR and 2-Year Disease-Free Survival: A Combination of the Two Endpoints as a New Classification for Locally Advanced Rectal Cancer Patients-An Updated Pooled Analysis of Eleven International Randomized Trials. Cancers (Basel) 2023; 15:3209. [PMID: 37370819 DOI: 10.3390/cancers15123209] [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: 04/29/2023] [Revised: 06/13/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023] Open
Abstract
LARC is managed by multimodal treatments whose intensity can be highly modulated. In this context, we need surrogate endpoints to help predict long-term outcomes and better personalize treatments. A previous study identified 2yDFS as a stronger predictor of OS than pCR in LARC patients undergoing neoadjuvant RT. The aim of this pooled analysis was to assess the role of pCR and 2yDFS as surrogate endpoints for OS in a larger cohort. The pooled and subgroup analyses were performed on large rectal cancer randomized trial cohorts who received long-course RT. Our analysis focused on the evaluation of OS in relation to the pCR and 2-year disease status. A total of 4600 patients were analyzed. Four groups were identified according to intermediate outcomes: 12% had both pCR and 2yDFS (the better); 67% achieved 2yDFS but not pCR (the good); 1% had pCR but not 2yDFS; and 20% had neither pCR nor 2yDFS (the bad). The pCR and 2yDFS were favorably associated with OS in the univariate analysis, and 2yDFS maintained a statistically significant association in the multivariate analysis independently of the pCR status. The combination of the pCR and 2yDFS results in a strong predictor of OS, whereas failure to achieve 2yDFS carries a poor prognosis regardless of the pCR status. This new stratification of LARC patients could help design predictive models where the combination of 2yDFS and pCR should be employed as the primary outcome.
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Affiliation(s)
| | - Giuditta Chiloiro
- Radiation Oncology Department, Fondazione Policlinico Universitario A. Gemelli-IRCCS, 00168 Rome, Italy
| | - Carlotta Masciocchi
- Radiation Oncology Department, Fondazione Policlinico Universitario A. Gemelli-IRCCS, 00168 Rome, Italy
| | - Silvia Mariani
- Radiation Oncology Department, Fondazione Policlinico Universitario A. Gemelli-IRCCS, 00168 Rome, Italy
| | - Angela Romano
- Radiation Oncology Department, Fondazione Policlinico Universitario A. Gemelli-IRCCS, 00168 Rome, Italy
| | - Alessandra Gonnelli
- Radiation Oncology Unit, Azienda Ospedaliero Universitaria Pisana, 56124 Pisa, Italy
| | | | - Samuel Ngan
- Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC 3000, Australia
| | - Claus Rödel
- Department of Radiotherapy of Oncology, University of Frankfurt, 60590 Frankfurt, Germany
- German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- German Cancer Consortium (DKTK), Partner Site, 60528 Frankfurt, Germany
- Frankfurt Cancer Institute (FCI), 60596 Frankfurt, Germany
| | - Krzysztof Bujko
- Department of Radiotherapy I, Maria Skłodowska-Curie National Research Institute of Oncology, 02-781 Warsaw, Poland
| | - Robert Glynne-Jones
- Department of Radiotherapy, Mount Vernon Centre for Cancer Treatment, Northwood, London HA6 2RN, UK
| | - Johan van Soest
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, 6229 ET Maastricht, The Netherlands
| | - Andre Dekker
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, 6229 ET Maastricht, The Netherlands
| | - Andrea Damiani
- Radiation Oncology Department, Fondazione Policlinico Universitario A. Gemelli-IRCCS, 00168 Rome, Italy
| | - Vincenzo Valentini
- Radiation Oncology Department, Fondazione Policlinico Universitario A. Gemelli-IRCCS, 00168 Rome, Italy
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10
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Chiloiro G, Cusumano D, Romano A, Boldrini L, Nicolì G, Votta C, Tran HE, Barbaro B, Carano D, Valentini V, Gambacorta MA. Delta Radiomic Analysis of Mesorectum to Predict Treatment Response and Prognosis in Locally Advanced Rectal Cancer. Cancers (Basel) 2023; 15:3082. [PMID: 37370692 DOI: 10.3390/cancers15123082] [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: 04/28/2023] [Revised: 05/23/2023] [Accepted: 05/31/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND The aim of this study is to evaluate the delta radiomics approach based on mesorectal radiomic features to develop a model for predicting pathological complete response (pCR) and 2-year disease-free survival (2yDFS) in locally advanced rectal cancer (LARC) patients undergoing neoadjuvant chemoradiotherapy (nCRT). METHODS Pre- and post-nCRT MRIs of LARC patients treated at a single institution from May 2008 to November 2016 were retrospectively collected. Radiomic features were extracted from the GTV and mesorectum. The Wilcoxon-Mann-Whitney test and area under the receiver operating characteristic curve (AUC) were used to evaluate the performance of the features in predicting pCR and 2yDFS. RESULTS Out of 203 LARC patients, a total of 565 variables were evaluated. The best performing pCR prediction model was based on two GTV features with an AUC of 0.80 in the training set and 0.69 in the validation set. The best performing 2yDFS prediction model was based on one GTV and two mesorectal features with an AUC of 0.79 in the training set and 0.70 in the validation set. CONCLUSIONS The results of this study suggest a possible role for delta radiomics based on mesorectal features in the prediction of 2yDFS in patients with LARC.
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Affiliation(s)
- Giuditta Chiloiro
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Davide Cusumano
- Mater Olbia Hospital, Strada Statale Orientale Sarda 125, 07026 Olbia, Italy
| | - Angela Romano
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Luca Boldrini
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Giuseppe Nicolì
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Claudio Votta
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Huong Elena Tran
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Brunella Barbaro
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Davide Carano
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Vincenzo Valentini
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
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11
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Savino M, Chiloiro G, Masciocchi C, Capocchiano ND, Lenkowicz J, Gottardelli B, Gambacorta MA, Valentini V, Damiani A. A process mining approach for clinical guidelines compliance: real-world application in rectal cancer. Front Oncol 2023; 13:1090076. [PMID: 37265796 PMCID: PMC10231435 DOI: 10.3389/fonc.2023.1090076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 05/04/2023] [Indexed: 06/03/2023] Open
Abstract
In the era of evidence-based medicine, several clinical guidelines were developed, supporting cancer management from diagnosis to treatment and aiming to optimize patient care and hospital resources. Nevertheless, individual patient characteristics and organizational factors may lead to deviations from these standard recommendations during clinical practice. In this context, process mining in healthcare constitutes a valid tool to evaluate conformance of real treatment pathways, extracted from hospital data warehouses as event log, to standard clinical guidelines, translated into computer-interpretable formats. In this study we translate the European Society of Medical Oncology guidelines for rectal cancer treatment into a computer-interpretable format using Pseudo-Workflow formalism (PWF), a language already employed in pMineR software library for Process Mining in Healthcare. We investigate the adherence of a real-world cohort of rectal cancer patients treated at Fondazione Policlinico Universitario A. Gemelli IRCCS, data associated with cancer diagnosis and treatment are extracted from hospital databases in 453 patients diagnosed with rectal cancer. PWF enables the easy implementation of guidelines in a computer-interpretable format and visualizations that can improve understandability and interpretability of physicians. Results of the conformance checking analysis on our cohort identify a subgroup of patients receiving a long course treatment that deviates from guidelines due to a moderate increase in radiotherapy dose and an addition of oxaliplatin during chemotherapy treatment. This study demonstrates the importance of PWF to evaluate clinical guidelines adherence and to identify reasons of deviations during a treatment process in a real-world and multidisciplinary setting.
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Affiliation(s)
- Mariachiara Savino
- Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giuditta Chiloiro
- Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Carlotta Masciocchi
- Real World Data Facility, Gemelli Generator, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Nikola Dino Capocchiano
- Real World Data Facility, Gemelli Generator, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Jacopo Lenkowicz
- Real World Data Facility, Gemelli Generator, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Benedetta Gottardelli
- Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Maria Antonietta Gambacorta
- Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Vincenzo Valentini
- Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Andrea Damiani
- Real World Data Facility, Gemelli Generator, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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12
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Ingle M, White I, Chick J, Stankiewicz H, Mitchell A, Barnes H, Herbert T, Nill S, Oelfke U, Huddart R, Ng-Cheng-Hin B, Hafeez S, Lalondrelle S, Dunlop A, Bhide S. Understanding the Benefit of Magnetic Resonance-guided Adaptive Radiotherapy in Rectal Cancer Patients: a Single-centre Study. Clin Oncol (R Coll Radiol) 2023; 35:e135-e142. [PMID: 36336579 DOI: 10.1016/j.clon.2022.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 09/01/2022] [Accepted: 10/12/2022] [Indexed: 11/06/2022]
Abstract
AIMS Neoadjuvant chemoradiotherapy followed by surgery is the mainstay of treatment for patients with rectal cancer. Standard clinical target volume (CTV) to planning target volume (PTV) margins of 10 mm are used to accommodate inter- and intrafraction motion of target. Treating on magnetic resonance-integrated linear accelerators (MR-linacs) allows for online manual recontouring and adaptation (MRgART) enabling the reduction of PTV margins. The aim of this study was to investigate motion of the primary CTV (CTVA; gross tumour volume and macroscopic nodes with 10 mm expansion to cover microscopic disease) in order to develop a simultaneous integrated boost protocol for use on MR-linacs. MATERIALS AND METHODS Patients suitable for neoadjuvant chemoradiotherapy were recruited for treatment on MR-linac using a two-phase technique; only the five phase 1 fractions on MR-linac were used for analysis. Intrafraction motion of CTVA was measured between pre-treatment and post-treatment MRI scans. In MRgART, isotropically expanded pre-treatment PTV margins from 1 to 10 mm were rigidly propagated to post-treatment MRI to determine overlap with 95% of CTVA. The PTV margin was considered acceptable if overlap was >95% in 90% of fractions. To understand the benefit of MRgART, the same methodology was repeated using a reference computed tomography planning scan for pre-treatment imaging. RESULTS In total, nine patients were recruited between January 2018 and December 2020 with T3a-T4, N0-N2, M0 disease. Forty-five fractions were analysed in total. The median motion across all planes was 0 mm, demonstrating minimal intrafraction motion. A PTV margin of 3 and 5mm was found to be acceptable in 96 and 98% of fractions, respectively. When comparing to the computed tomography reference scan, the analysis found that PTV margins to 5 and 10 mm only acceptably covered 51 and 76% of fractions, respectively. CONCLUSION PTV margins can be reduced to 3-5 mm in MRgART for rectal cancer treatment on MR-linac within an simultaneous integrated boost protocol.
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Affiliation(s)
- M Ingle
- The Royal Marsden Hospital NHS Trust, London, UK; The Institute of Cancer Research, London, UK.
| | - I White
- Guys and St Thomas NHS Trust, London, UK
| | - J Chick
- The Royal Marsden Hospital NHS Trust, London, UK
| | | | - A Mitchell
- The Royal Marsden Hospital NHS Trust, London, UK
| | - H Barnes
- The Royal Marsden Hospital NHS Trust, London, UK
| | - T Herbert
- The Royal Marsden Hospital NHS Trust, London, UK
| | - S Nill
- The Institute of Cancer Research, London, UK
| | - U Oelfke
- The Institute of Cancer Research, London, UK
| | - R Huddart
- The Royal Marsden Hospital NHS Trust, London, UK; The Institute of Cancer Research, London, UK
| | | | - S Hafeez
- The Royal Marsden Hospital NHS Trust, London, UK; The Institute of Cancer Research, London, UK
| | - S Lalondrelle
- The Royal Marsden Hospital NHS Trust, London, UK; The Institute of Cancer Research, London, UK
| | - A Dunlop
- The Royal Marsden Hospital NHS Trust, London, UK
| | - S Bhide
- The Royal Marsden Hospital NHS Trust, London, UK; The Institute of Cancer Research, London, UK
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13
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Guido A, Cuicchi D, Castellucci P, Cellini F, Di Fabio F, Llimpe FLR, Strigari L, Buwenge M, Cilla S, Deodato F, Macchia G, Galietta E, Golfieri R, Ardizzoni A, Zagari RM, Fanti S, Poggioli G, Fuccio L, Morganti AG. Adaptive Individualized high-dose preoperAtive (AIDA) chemoradiation in high-risk rectal cancer: a phase II trial. Eur J Nucl Med Mol Imaging 2023; 50:572-580. [PMID: 36127416 PMCID: PMC9816267 DOI: 10.1007/s00259-022-05944-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 08/12/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE To evaluate the pathological complete response (pCR) rate of locally advanced rectal cancer (LARC) after adaptive high-dose neoadjuvant chemoradiation (CRT) based on 18 F-fluorodeoxyglucose positron emission tomography/computed tomography (18 F-FDG-PET/CT). METHODS The primary endpoint was the pCR rate. Secondary endpoints were the predictive value of 18 F-FDG-PET/CT on pathological response and acute and late toxicity. All patients performed 18 F-FDG-PET/CT at baseline (PET0) and after 2 weeks during CRT (PET1). The metabolic PET parameters were calculated both at the PET0 and PET1. The total CRT dose was 45 Gy to the pelvic lymph nodes and 50 Gy to the primary tumor, corresponding mesorectum, and to metastatic lymph nodes. Furthermore, a sequential boost was delivered to a biological target volume defined by PET1 with an additional dose of 5 Gy in 2 fractions. Capecitabine (825 mg/m2 twice daily orally) was prescribed for the entire treatment duration. RESULTS Eighteen patients (13 males, 5 females; median age 55 years [range, 41-77 years]) were enrolled in the trial. Patients underwent surgical resection at 8-9 weeks after the end of neoadjuvant CRT. No patient showed grade > 1 acute radiation-induced toxicity. Seven patients (38.8%) had TRG = 0 (complete regression), 5 (27.0%) showed TRG = 2, and 6 (33.0%) had TRG = 3. Based on the TRG results, patients were classified in two groups: TRG = 0 (pCR) and TRG = 1, 2, 3 (non pCR). Accepting p < 0.05 as the level of significance, at the Kruskal-Wallis test, the medians of baseline-MTV, interim-SUVmax, interim-SUVmean, interim-MTV, interim-TLG, and the MTV reduction were significantly different between the two groups. 18 F-FDG-PET/CT was able to predict the pCR in 77.8% of cases through compared evaluation of both baseline PET/CT and interim PET/CT. CONCLUSIONS Our results showed that a dose escalation on a reduced target in the final phase of CRT is well tolerated and able to provide a high pCR rate.
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Affiliation(s)
- Alessandra Guido
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Dajana Cuicchi
- Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Paolo Castellucci
- Nuclear Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesco Cellini
- Dipartimento di Diagnostica per Immagini Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, UOC di Radioterapia Oncologica, Roma, Italy.
- Università Cattolica del Sacro Cuore, Dipartimento Universitario Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Largo Agostino Gemelli 8, 00168, Roma, Italy.
| | - Francesca Di Fabio
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Lidia Strigari
- Department of Medical Physics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Milly Buwenge
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Savino Cilla
- Medical Physics, Gemelli Molise Hospital-Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Francesco Deodato
- Università Cattolica del Sacro Cuore, Dipartimento Universitario Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Largo Agostino Gemelli 8, 00168, Roma, Italy
- Radiation Oncology, Gemelli Molise Hospital-Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Gabriella Macchia
- Radiation Oncology, Gemelli Molise Hospital-Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Erika Galietta
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Rita Golfieri
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andrea Ardizzoni
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Rocco Maurizio Zagari
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Gastroenterology Unit, Department of Medical and Surgical Sciences, Gastroenterology Unit, University of Bologna, Bologna, Italy
| | - Stefano Fanti
- Nuclear Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Gilberto Poggioli
- Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Digestive Medicine and Surgery, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Lorenzo Fuccio
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Gastroenterology Unit, Department of Medical and Surgical Sciences, Gastroenterology Unit, University of Bologna, Bologna, Italy
| | - Alessio G Morganti
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, Alma Mater Studiorum University of Bologna, Bologna, Italy
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14
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Van Limbergen EJ, Hazelaar C, Vaassen F, Bellezzo M, Verrijssen AS, Willems Y, Stewart AJ, Vanneste B, Buijsen J, Paiva Fonseca G, Leijtens J, Appelt AL, Verhaegen F, Berbee M. Endorectal contact radiation boosting: Making the case for dose AND volume reporting. Brachytherapy 2022; 21:887-895. [PMID: 36130857 DOI: 10.1016/j.brachy.2022.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 07/01/2022] [Accepted: 08/01/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The various rectal endoluminal radiation techniques all have steep, but different, dose gradients. In rectal contact brachytherapy (CXB) doses are typically prescribed and reported to the applicator surface and not to the gross tumor volume (GTV), clinical target volume (CTV) or organs at risk (OAR), which is crucial to understand tumor response and toxicity rates. To quantify the above-described problem, we performed a dose modeling study using a fixed prescription dose at the surface of the applicator and varied tumor response scenarios. METHODS Endorectal ultrasound-based 3D-volume-models of rectal tumors and the rectal wall were used to simulate the delivered dose to GTV, CTV and the rectal wall layers, assuming treatment with Maastro HDR contact applicator for rectal cancer with a fixed prescription dose to the applicator surface (equivalent to 3 × 30 Gy CXB) and various response scenarios. RESULTS An identical prescribed dose to the surface of the applicator resulted in a broad range of doses delivered to the GTV, CTV and the uninvolved intestinal wall. For example, the equieffective dose in 2 Gy per fraction (EQD2) D90% of the GTV varied between 63 and 231 Gy, whereas the EQD2 D2cc of the rectal wall varied between 97 and 165 Gy. CONCLUSION Doses prescribed at the surface are not representative of the dose received by the tumor and the bowel wall. This stresses the relevance of dose reporting and prescription to GTV and CTV volumes and OAR in order to gain insight between delivered dose, local control and toxicity and to optimize treatment protocols.
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Affiliation(s)
- Evert J Van Limbergen
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Colien Hazelaar
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Femke Vaassen
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Murillo Bellezzo
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - An-Sofie Verrijssen
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands; Department of Radiation Oncology, Catharina Ziekenhuis, Eindhoven, The Netherlands
| | - Yves Willems
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Alexandra J Stewart
- St Luke's Cancer Centre, Royal Surrey County Hospital, Guildford, England; University of Surrey, Guildford, England
| | - Ben Vanneste
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Jeroen Buijsen
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Gabriel Paiva Fonseca
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Jeroen Leijtens
- Department of Surgery, Laurentiusziekenhuis Roermond, The Netherlands
| | - Ane L Appelt
- Leeds Institute of Medical Research at St James's, University of Leeds, UK
| | - Frank Verhaegen
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Maaike Berbee
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands.
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15
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Bao QR, Crimì F, Valotto G, Chiminazzo V, Bergamo F, Prete AA, Galuppo S, El Khouzai B, Quaia E, Pucciarelli S, Urso EDL. Obesity may not be related to pathologic response in locally advanced rectal cancer following neoadjuvant chemoradiotherapy. Front Oncol 2022; 12:994444. [PMID: 36249024 PMCID: PMC9556820 DOI: 10.3389/fonc.2022.994444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 09/13/2022] [Indexed: 11/13/2022] Open
Abstract
Background The aim of this study is to evaluate the correlation between body mass index (BMI) and body fat composition (measured with radiological fat parameters (RFP)) and pathological response after neoadjuvant chemoradiotherapy for locally advanced rectal cancer patients. The secondary aim of the study was to assess the role of BMI and RFP on major surgical complications, overall survival (OS), and disease-free survival (DFS). Methods All patients who underwent surgical resection following nCRT between 2005 and 2017 for mid-low rectal cancer were retrospectively collected. Visceral fat area (VFA), superficial fat area (SFA), visceral/superficial fat area ratio (V/S), perinephric fat thickness (PNF), and waist circumference (WC) were estimated by baseline CT scan. Predictors of pathologic response and postoperative complications were investigated using logistic regression analysis. The correlations between BMI and radiologic fat parameters and survival were investigated using the Kaplan-Meier method and log-rank test. Results Out of 144 patients included, a complete (TRG1) and major (TRG1+2) pathologic response was reported in 32 (22%) and 60 (45.5%) cases, respectively. A statistically significant correlation between BMI and all the RFP was found. At a median follow-up of 60 (35-103) months, no differences in terms of OS and DFS were found considering BMI and radiologic fat parameters. At univariable analysis, neither BMI nor radiologic fat parameters were predictors of complete or major pathologic response; nevertheless, VFA, V/S>1, and BMI were predictors of postoperative major complications. Conclusions We found no associations between BMI and body fat composition and pathological response to nCRT, although VFA, V/S, and BMI were predictors of major complications. BMI and RFP are not related to worse long-term OS and DFS.
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Affiliation(s)
- Quoc Riccardo Bao
- General Surgery 3, Department of Surgical- Oncological and Gastroenterological Sciences DiSCOG, University of Padova, Padova, Italy,*Correspondence: Quoc Riccardo Bao,
| | - Filippo Crimì
- Institute of Radiology - Department of Medicine, University of Padova, Padova, Italy
| | - Giovanni Valotto
- General Surgery 3, Department of Surgical- Oncological and Gastroenterological Sciences DiSCOG, University of Padova, Padova, Italy
| | - Valentina Chiminazzo
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Francesca Bergamo
- Unit of Medical Oncology 1, Veneto Institute of Oncology IOV - IRCCS, Padova, Italy
| | | | - Sara Galuppo
- Radiotherapy Unit, Veneto Institute of Oncology IOV - IRCCS, Padova, Italy
| | - Badr El Khouzai
- Radiotherapy Unit, Veneto Institute of Oncology IOV - IRCCS, Padova, Italy
| | - Emilio Quaia
- Institute of Radiology - Department of Medicine, University of Padova, Padova, Italy
| | - Salvatore Pucciarelli
- General Surgery 3, Department of Surgical- Oncological and Gastroenterological Sciences DiSCOG, University of Padova, Padova, Italy
| | - Emanuele Damiano Luca Urso
- General Surgery 3, Department of Surgical- Oncological and Gastroenterological Sciences DiSCOG, University of Padova, Padova, Italy
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16
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Which radiotherapy technique is better for neoadjuvant treatment of rectal cancer: A dosimetric comparison. MARMARA MEDICAL JOURNAL 2022. [DOI: 10.5472/marumj.1120583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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17
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Hudson EM, Noutch S, Brown S, Adapala R, Bach SP, Burnett C, Burrage A, Gilbert A, Hawkins M, Howard D, Jefford M, Kochhar R, Saunders M, Seligmann J, Smith A, Teo M, Webb EJ, Webster A, West N, Sebag-Montefiore D, Gollins S, Appelt AL. A Phase II trial of Higher RadiOtherapy Dose In The Eradication of early rectal cancer (APHRODITE): protocol for a multicentre, open-label randomised controlled trial. BMJ Open 2022; 12:e049119. [PMID: 35487526 PMCID: PMC9052059 DOI: 10.1136/bmjopen-2021-049119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 02/18/2022] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The standard of care for patients with localised rectal cancer is radical surgery, often combined with preoperative neoadjuvant (chemo)radiotherapy. While oncologically effective, this treatment strategy is associated with operative mortality risks, significant morbidity and stoma formation. An alternative approach is chemoradiotherapy to try to achieve a sustained clinical complete response (cCR). This non-surgical management can be attractive, particularly for patients at high risk of surgical complications. Modern radiotherapy techniques allow increased treatment conformality, enabling increased radiation dose to the tumour while reducing dose to normal tissue. The objective of this trial is to assess if radiotherapy dose escalation increases the cCR rate, with acceptable toxicity, for treatment of patients with early rectal cancer unsuitable for radical surgery. METHODS AND ANALYSIS APHRODITE (A Phase II trial of Higher RadiOtherapy Dose In The Eradication of early rectal cancer) is a multicentre, open-label randomised controlled phase II trial aiming to recruit 104 participants from 10 to 12 UK sites. Participants will be allocated with a 2:1 ratio of intervention:control. The intervention is escalated dose radiotherapy (62 Gy to primary tumour, 50.4 Gy to surrounding mesorectum in 28 fractions) using simultaneous integrated boost. The control arm will receive 50.4 Gy to the primary tumour and surrounding mesorectum. Both arms will use intensity-modulated radiotherapy and daily image guidance, combined with concurrent chemotherapy (capecitabine, 5-fluorouracil/leucovorin or omitted). The primary endpoint is the proportion of participants with cCR at 6 months after start of treatment. Secondary outcomes include early and late toxicities, time to stoma formation, overall survival and patient-reported outcomes (European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaires QLQ-C30 and QLQ-CR29, low anterior resection syndrome (LARS) questionnaire). ETHICS AND DISSEMINATION The trial obtained ethical approval from North West Greater Manchester East Research Ethics Committee (reference number 19/NW/0565) and is funded by Yorkshire Cancer Research. The final trial results will be published in peer-reviewed journals and adhere to International Committee of Medical Journal Editors guidelines. TRIAL REGISTRATION NUMBER ISRCTN16158514.
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Affiliation(s)
- Eleanor M Hudson
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Samantha Noutch
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Sarah Brown
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Ravi Adapala
- Department of Radiology, Wrexham Maelor Hospital, Wrexham, UK
| | - Simon P Bach
- Academic Department of Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Carole Burnett
- Leeds Cancer Centre, St James's University Hospital, Leeds, UK
| | | | - Alexandra Gilbert
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - Maria Hawkins
- Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Debra Howard
- National Radiotherapy Trials QA (RTTQA) Group, Mount Vernon Cancer Centre, Northwood, UK
| | | | - Rohit Kochhar
- Department of Radiology, The Christie NHS Foundation Trust, Manchester, UK
| | - Mark Saunders
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Jenny Seligmann
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - Alexandra Smith
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Mark Teo
- Leeds Cancer Centre, St James's University Hospital, Leeds, UK
| | - Edward Jd Webb
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Amanda Webster
- National Radiotherapy Trials QA (RTTQA) Group, Mount Vernon Cancer Centre, Northwood, UK
| | - Nicholas West
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | | | - Simon Gollins
- North Wales Cancer Treatment Centre, Glan Clwyd Hospital, Bodelwyddan, UK
| | - Ane L Appelt
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
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18
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Chiloiro G, Boldrini L, Preziosi F, Cusumano D, Yadav P, Romano A, Placidi L, Lenkowicz J, Dinapoli N, Bassetti MF, Gambacorta MA, Valentini V. A Predictive Model of 2yDFS During MR-Guided RT Neoadjuvant Chemoradiotherapy in Locally Advanced Rectal Cancer Patients. Front Oncol 2022; 12:831712. [PMID: 35280799 PMCID: PMC8907443 DOI: 10.3389/fonc.2022.831712] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 01/31/2022] [Indexed: 01/04/2023] Open
Abstract
Purpose Distant metastasis is the main cause of treatment failure in locally advanced rectal cancer (LARC) patients, despite the recent improvement in treatment strategies. This study aims to evaluate the “delta radiomics” approach in patients undergoing neoadjuvant chemoradiotherapy (nCRT) treated with 0.35-T magnetic resonance-guided radiotherapy (MRgRT), developing a logistic regression model able to predict 2-year disease-free-survival (2yDFS). Methods Patients affected by LARC were enrolled in this multi-institutional study. A predictive model of 2yDFS was developed taking into account both clinical and radiomics variables. Gross tumour volume (GTV) was delineated on the magnetic resonance (MR) images acquired during MRgRT, and 1,067 radiomic features (RF) were extracted using the MODDICOM platform. The performance of RF in predicting 2yDFS was investigated in terms of the Wilcoxon–Mann–Whitney test and area under receiver operating characteristic (ROC) curve (AUC). Results 48 patients have been retrospectively enrolled, with 8 patients (16.7%) developing distant metastases at the 2-year follow-up. A total of 1,099 variables (1,067 RF and 32 clinical variables) were evaluated in two different models: radiomics and radiomics/clinical. The best-performing 2yDFS predictive model was a delta radiomics one, based on the variation in terms of area/surface ratio between biologically effective doses (BED) at 54 Gy and simulation (AUC of 0.92). Conclusions The results of this study suggest a promising role of delta radiomics analysis on 0.35-T MR images in predicting 2yDFS for LARC patients. Further analyses including larger cohorts of patients and an external validation are needed to confirm these preliminary results.
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Affiliation(s)
- Giuditta Chiloiro
- Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia Fondazione Policlinico Universitario Agostino Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Luca Boldrini
- Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia Fondazione Policlinico Universitario Agostino Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Francesco Preziosi
- Dipartimento Universitario di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Davide Cusumano
- Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia Fondazione Policlinico Universitario Agostino Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Poonam Yadav
- Department of Human Oncology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
| | - Angela Romano
- Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia Fondazione Policlinico Universitario Agostino Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Lorenzo Placidi
- Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia Fondazione Policlinico Universitario Agostino Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Jacopo Lenkowicz
- Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia Fondazione Policlinico Universitario Agostino Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Nicola Dinapoli
- Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia Fondazione Policlinico Universitario Agostino Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Michael F Bassetti
- Department of Human Oncology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
| | - Maria Antonietta Gambacorta
- Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia Fondazione Policlinico Universitario Agostino Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Vincenzo Valentini
- Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia Fondazione Policlinico Universitario Agostino Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
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19
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Chiloiro G, Meldolesi E, Corvari B, Romano A, Barbaro B, Coco C, Crucitti A, Genovesi D, Lupattelli M, Mantello G, Menghi R, Falchetto Osti M, Persiani R, Petruzziello L, Ricci R, Sofo L, Valentini C, De Paoli A, Valentini V, Antonietta Gambacorta M. BRIDGE -1 TRIAL: BReak Interval Delayed surgery for Gastrointestinal Extraperitoneal rectal cancer, a multicentric phase III randomized trial. Clin Transl Radiat Oncol 2022; 34:30-36. [PMID: 35340685 PMCID: PMC8943334 DOI: 10.1016/j.ctro.2022.03.002] [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: 12/29/2021] [Revised: 03/04/2022] [Accepted: 03/05/2022] [Indexed: 12/01/2022] Open
Abstract
The lengthening of the surgical interval has a positive impact on pathological complete response (pCR) rate. Lengthening the surgical interval from the end of preoperative chemoradiation is not detrimental to survival outcomes in locally advanced rectal cancer. Prospective validation of the impact of surgical interval lengthening on complete response and survival outcomes in a randomized trial.
Design Methods Conclusions
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Affiliation(s)
- Giuditta Chiloiro
- Department of Diagnostic Imaging, Radiation Oncology and Haematology, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Elisa Meldolesi
- Department of Diagnostic Imaging, Radiation Oncology and Haematology, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Barbara Corvari
- Department of Diagnostic Imaging, Radiation Oncology and Haematology, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Angela Romano
- Department of Diagnostic Imaging, Radiation Oncology and Haematology, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
- Corresponding author at: Department of Diagnostic Imaging, Radiation Oncology and Haematology Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy.
| | - Brunella Barbaro
- Department of Diagnostic Imaging, Radiation Oncology and Haematology, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Claudio Coco
- Department of Surgical Sciences, Catholic University of Rome, Rome, Italy
| | - Antonio Crucitti
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Domenico Genovesi
- Department of Radiotherapy, “SS Annunziata” Hospital “G. D’Annunzio” University, Chieti, Italy
| | | | - Giovanna Mantello
- Department of Oncology and Radiotherapy, Azienda Ospedaliero Universitaria Ospedali Riuniti, Ancona, Italy
| | - Roberta Menghi
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center) Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Mattia Falchetto Osti
- Department of Radiation Oncology, “Sapienza” University, Sant'Andrea Hospital, Rome, Italy
| | - Roberto Persiani
- Department of General Surgery, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome - Università Cattolica del Sacro Cuore, Rome, Italy
| | - Lucio Petruzziello
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Riccardo Ricci
- Department of Pathology, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Luigi Sofo
- Department of Gastroenterological, Endocrino-Metabolic and Nephro-Urological Sciences, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome - Università Cattolica del Sacro Cuore, Rome, Italy
| | - Chiara Valentini
- Klinik für Radioonkologie-OncoRay Universitätsklinikum C.G. Carus an der TU, Dresden, Germany
| | - Antonino De Paoli
- Department of Radiation Oncology, Centro di Riferimento Oncologico, Aviano, Italy
| | - Vincenzo Valentini
- Department of Diagnostic Imaging, Radiation Oncology and Haematology, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Maria Antonietta Gambacorta
- Department of Diagnostic Imaging, Radiation Oncology and Haematology, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
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De Mattia E, Canzonieri V, Polesel J, Mezzalira S, Dalle Fratte C, Dreussi E, Roncato R, Bignucolo A, Innocente R, Belluco C, Pucciarelli S, De Paoli A, Palazzari E, Toffoli G, Cecchin E. SMAD3 Host and Tumor Profiling to Identify Locally Advanced Rectal Cancer Patients at High Risk of Poor Response to Neoadjuvant Chemoradiotherapy. Front Pharmacol 2022; 12:778781. [PMID: 35002714 PMCID: PMC8740633 DOI: 10.3389/fphar.2021.778781] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 11/15/2021] [Indexed: 12/20/2022] Open
Abstract
Identifying patients at risk of poor response to neoadjuvant chemoradiotherapy (nCRT) is an emerging clinical need in locally advanced rectal cancer (LARC). SMAD3 is a key player in the chemoradio-resistance phenotype and its expression is both constitutive and locally induced. The aim was to investigate both host (genetic polymorphisms) and tumor SMAD3 profiling to predict response to nCRT. In a group of 76 LARC patients, SMAD3 and phosphorylated-SMAD3 expression was assessed by immunohistochemistry in preoperative tumor tissue. In an expanded study group (n = 378), a set of SMAD3 polymorphisms (rs35874463, rs1065080, rs1061427, rs17228212, rs744910, and rs745103) was analyzed. Association with tumor regression grade (TRG) and patient prognosis (progression-free survival [PFS] and overall survival [OS]) was assessed. Patients with high tumor expression of SMAD3 had a significantly increased risk of poor response (TRG≥2) [cellularity >55% (OR:10.36, p = 0.0004), or moderate/high intensity (OR:5.20, p = 0.0038), or an H-score≥1 (OR:9.84, p = 0.0004)]. Patients carrying the variant SMAD3 rs745103-G allele had a poorer response (OR:0.48, p = 0.0093), a longer OS (HR:0.65, p = 0.0307), and a trend for longer PFS (HR:0.75, p = 0.0944). Patients who carried both high SMAD3 tumor expression and the wild-type rs745103-A allele had an extremely high risk of not achieving a complete response (OR:13.45, p = 0.0005). Host and tumor SMAD3 status might be considered to improve risk stratification of LARC patients to facilitate selection for alternative personalized neoadjuvant strategies including intensified regimens.
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Affiliation(s)
- Elena De Mattia
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Vincenzo Canzonieri
- Pathology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy.,Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Jerry Polesel
- Unit of Cancer Epidemiology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Silvia Mezzalira
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Chiara Dalle Fratte
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Eva Dreussi
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Rossana Roncato
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Alessia Bignucolo
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Roberto Innocente
- Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Claudio Belluco
- Surgical Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | | | - Antonino De Paoli
- Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Elisa Palazzari
- Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Giuseppe Toffoli
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Erika Cecchin
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
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Kraszkiewicz M, Napieralska A, Wydmański J, Suwiński R, Majewski W. Evaluation of Efficacy and Tolerance of Radical Radiotherapy and Radiochemotherapy in Treatment of Locally Advanced, Unresectable Rectal Cancer. Technol Cancer Res Treat 2022; 21:15330338221086085. [PMID: 35296187 PMCID: PMC9123928 DOI: 10.1177/15330338221086085] [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] [Indexed: 12/24/2022] Open
Abstract
Background: A retrospective evaluation of tolerance and efficacy of
two schemes of neoadjuvant treatment in patients (pts) with unresectable rectal
cancer: radiochemotherapy (CRT) and radiotherapy (RT), including conventional
and accelerated hyperfractionation. Material and Method: A total of
145 consecutive pts with unresectable, locally advanced rectal cancer. The
schemes used are RT in 73 (50%) or CRT in 72 (50%). In CRT, 54 Gy in 1.8 Gy
fractions was given with chemotherapy, In the RT group, conventional
fractionation (CFRT) and hyperfractionated accelerated radiotherapy (HART). HART
was introduced at first as an alternative to CFRT, after radiobiological studies
suggesting a therapeutic gain of hyperfractionation in other cancers, and second
to administer relatively high dose needed in unresectable cancer, which is not
feasible in hypofractionation because of critical organs sensitivity to high
fraction doses (fd). HART was an alternative option in pts with medical
contraindications to chemotherapy and to shorten overall treatment time with
greater radiobiological effectiveness than CFRT. Results: Objective
response (OR) in the RT and CRT group was 60% versus 75%. Resection rate (RR) in
RT and CRT: 37% versus 65%. Tumor mobility and laparotomy-based unresectability
were significant factors for OR. Performance status (PS), tumor mobility, and
neoadjuvant treatment method were significant for RR.
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Affiliation(s)
- M Kraszkiewicz
- Maria Sklodowska-CUrie National Research Institute of Oncology Gliwice Branch, Radiotherapy Department, Gliwice, Poland
| | - A Napieralska
- Maria Sklodowska-CUrie National Research Institute of Oncology Gliwice Branch, Radiotherapy Department, Gliwice, Poland
| | - J Wydmański
- Maria Sklodowska-CUrie National Research Institute of Oncology Gliwice Branch, Radiotherapy Department, Gliwice, Poland
| | - R Suwiński
- Maria Sklodowska-CUrie National Research Institute of Oncology Gliwice Branch, II Radiotherapy and Chemotherapy Teaching Hospital, Gliwice, Poland
| | - W Majewski
- Maria Sklodowska-CUrie National Research Institute of Oncology Gliwice Branch, Radiotherapy Department, Gliwice, Poland
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22
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Chen W, Wang W. Serum hsa-miR-30e As a Potential Biomarker to Predict the Effect of Neoadjuvant Chemoradiation Therapy in Locally Advanced Rectal Cancer. Genet Test Mol Biomarkers 2021; 25:696-706. [PMID: 34788143 DOI: 10.1089/gtmb.2020.0300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objective: To identify serum microRNAs (miRNAs) correlated with response to neoadjuvant chemoradiation therapy (NCRT) in locally advanced rectal cancer (LARC) patients using in silico analysis and laboratory validation studies. Methods: GSE68204 and GSE68204 data sets were analyzed to identify differentially expressed (DE) miRNAs in NCRT responders using the GEO2R Limma package within the R software suite. Then we used quantitative real-time polymerase chain reaction to detect the upregulated target miRNAs in the serum of 20 LARC patients. Logistic regression was used to evaluate the effect of serum miRNA level on response. Gene Ontology and pathway enrichment analyses were performed to predict the corresponding functions of the DE miRNAs. Correlation between the expression of the hub target genes and the abundance of tumor-infiltrating lymphocytes was further investigated. Results: hsa-miR-30e and hsa-miR-210 were verified to be upregulated in tumor tissues of NCRT responders. Subsequent liquid-biopsy studies revealed that the serum level of miR-30e was associated with a 2.47-fold increased incidence of NCRT-responsive patients in comparison with nonresponders (p-value = 0.038, Mann-Whitney test). Nine hub target genes of hsa-miR-30e were enriched in pathways including immune regulation. The expression of these hub target genes was correlated with abundance of tumor-infiltrating lymphocytes. Conclusion: In summary, hsa-miR-30e was determined to be upregulated in rectal cancer tissues of NCRT-responders. Further investigations showed that increased serum levels of hsa-miR-30e were associated with an effective NCRT response in LARC patients.
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Affiliation(s)
- Weiwei Chen
- Department of Clinical Medicine, Guizhou Medical University, Guiyang, China.,Department of Oncology, Affiliated Hospital of Guizhou Medical University, Guiyang, China.,Department of Abdominal Oncology, Guizhou Cancer Hospital, Guiyang, China
| | - Wenling Wang
- Department of Oncology, Affiliated Hospital of Guizhou Medical University, Guiyang, China.,Department of Abdominal Oncology, Guizhou Cancer Hospital, Guiyang, China
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23
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Delishaj D, Fumagalli IC, Ursino S, Cristaudo A, Colangelo F, Stefanelli A, Alghisi A, De Nobili G, D’Amico R, Cocchi A, Ardizzoia A, Soatti CP. Neoadjuvant radiotherapy dose escalation for locally advanced rectal cancers in the new era of radiotherapy: A review of literature. World J Clin Cases 2021; 9:9077-9089. [PMID: 34786390 PMCID: PMC8567526 DOI: 10.12998/wjcc.v9.i30.9077] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/27/2021] [Accepted: 09/16/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The standard treatment of locally advanced rectal cancers (LARC) consists on neoadjuvant chemoradiotherapy followed by total mesorectal excision. Different data in literature showed a benefit on tumor downstaging and pathological complete response (pCR) rate using radiotherapy dose escalation, however there is shortage of studies regarding dose escalation using the innovative techniques for LARC (T3-4 or N1-2).
AIM To analyze the role of neoadjuvant radiotherapy dose escalation for LARC using innovative radiotherapy techniques.
METHODS In December 2020, we conducted a comprehensive literature search of the following electronic databases: PubMed, Web of Science, Scopus and Cochrane library. The limit period of research included articles published from January 2009 to December 2020. Screening by title and abstract was carried out to identify only studies using radiation doses equivalent dose 2 Gy fraction (EQD2) ≥ 54 Gy and Volumetric Modulated Arc Therapy (VMAT), intensity-modulated radiotherapy or image-guided radiotherapy (IGRT) techniques. The authors’ searches generated a total of 2287 results and, according to PRISMA Group (2009) screening process, 21 publications fulfil selection criteria and were included for the review.
RESULTS The main radiotherapy technique used consisted in VMAT and IGRT modality. The mainly dose prescription was 55 Gy to high risk volume and 45 Gy as prophylactic volume in 25 fractions given with simultaneous integrated boosts technique (42.85%). The mean pCR was 28.2% with no correlation between dose prescribed and response rates (P value ≥ 0.5). The R0 margins and sphincter preservation rates were 98.88% and 76.03%, respectively. After a mean follow-up of 35 months local control was 92.29%. G3 or higher toxicity was 11.06% with no correlation between dose prescription and toxicities. Patients receiving EQD2 dose > 58.9 Gy and BED > 70.7 Gy had higher surgical complications rates compared to other group (P value = 0.047).
CONCLUSION Dose escalation neoadjuvant radiotherapy using innovative techniques is safe for LARC achieving higher rates of pCR. EQD2 doses > 58.9 Gy is associated with higher rate of surgical complications.
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Affiliation(s)
- Durim Delishaj
- Department of Radiation Oncology, Alessandro Manzoni Hospital, Lecco 23900, Italy
| | | | - Stefano Ursino
- Department of Radiation Oncology, Santa Chiara University Hospital, Pisa 56126, Italy
| | - Agostino Cristaudo
- Royal Preston Hospital, Lancashire Teaching Hospital- NHS Tust, Preston PR2 9HT, United Kingdom
| | - Francesco Colangelo
- Department of Radiation Oncology, Alessandro Manzoni Hospital, Lecco 23900, Italy
| | - Antonio Stefanelli
- Department of Radiation Oncology, Azienda Ospedaliero-Universitaria di Ferrara, Ferrara 44124, Italy
| | - Alessandro Alghisi
- Department of Radiation Oncology, Alessandro Manzoni Hospital, Lecco 23900, Italy
| | - Giuseppe De Nobili
- Department of Radiation Oncology, Alessandro Manzoni Hospital, Lecco 23900, Italy
| | - Romerai D’Amico
- Department of Radiation Oncology, Alessandro Manzoni Hospital, Lecco 23900, Italy
| | - Alessandra Cocchi
- Department of Radiation Oncology, Alessandro Manzoni Hospital, Lecco 23900, Italy
| | - Antonio Ardizzoia
- Department of Clinical Oncology, Alessandro Manzoni Hospital, Lecco 23900, Italy
| | - Carlo Pietro Soatti
- Department of Radiation Oncology, Alessandro Manzoni Hospital, Lecco 23900, Italy
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24
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Piva C, Panier Suffat L, Petrucci ETF, Manuguerra G, Vittone F, Cante D, Ferrario S, Paolini M, Radici L, Vellani G, La Porta MR. Effect of delaying surgery by more than 10 weeks after neoadjuvant therapy in rectal cancer: a single institution experience. Updates Surg 2021; 74:145-151. [PMID: 34661871 DOI: 10.1007/s13304-021-01189-y] [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: 05/13/2021] [Accepted: 10/01/2021] [Indexed: 10/20/2022]
Abstract
The optimal timing of surgery after neoadjuvant chemoradiotherapy (CRT) in locally advanced rectal cancer is still controversial. Aim of this study was to evaluate the effect of increasing time interval between the end of CRT and surgery on pathological outcomes. This is a retrospective analysis on 114 patients treated with long-course neoadjuvant RT with or without chemotherapy between January 2005 and September 2020. 43 patients underwent surgery within 10 weeks from the end of CRT (1st group), whereas 71 patients underwent total mesorectal excision with a time interval equal or greater than 10 weeks (2nd group). Primary endpoint was pCR (pathological complete response). Secondary endpoints were near pCR (ypT0-1 N0), tumor downstaging (ypT less than cT), nodal downstaging (ypN less than cN), and overall response comparing clinical with pathological TN stage. Overall, the pCR rate was 8.8%, whereas we observed no significantly difference in primary endpoint between the two groups. Considering near pCR, a trend toward significant difference in favor of 2nd group was seen (p = 0.072). Tumor and nodal downstaging rates were 39.5%, 41.9%, 59.2%, and 56.3% in the 1st and 2nd group, respectively, with a statistically significant difference for T category (p = 0.042). Overall response rates (TN stage) showed a trend toward significant difference in favor of patients of the ≥ 10 week group (p = 0.059). Our study suggests that a prolonged time interval between the end of CRT and surgery (≥ 10 weeks) increases pathological response rates.
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Affiliation(s)
- Cristina Piva
- Department of Radiation Oncology, ASL TO4, Ivrea Community Hospital, Ivrea, Italy
| | - Luca Panier Suffat
- Department of Surgery, ASL TO4, Ivrea Community Hospital, Piazza Credenza 2, 10015, Ivrea, Italy.
| | | | | | - Federico Vittone
- Department of Pathology, ASL TO4, Ivrea Community Hospital, Ivrea, Italy
| | - Domenico Cante
- Department of Radiation Oncology, ASL TO4, Ivrea Community Hospital, Ivrea, Italy
| | - Silvia Ferrario
- Department of Radiation Oncology, ASL TO4, Ivrea Community Hospital, Ivrea, Italy
| | - Marina Paolini
- Department of Radiation Oncology, ASL TO4, Ivrea Community Hospital, Ivrea, Italy
| | - Lorenzo Radici
- Department of Medical Physics, ASL TO4, Ivrea Community Hospital, Ivrea, Italy
| | - Giorgio Vellani
- Department of Oncology, ASL TO4, Ivrea Community Hospital, Ivrea, Italy
| | - Maria R La Porta
- Department of Radiation Oncology, ASL TO4, Ivrea Community Hospital, Ivrea, Italy
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25
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Haddad P, Ghalehtaki R, Saeedian A, Farhan F, Babaei M, Aghili M. Current approaches in intensification of long-course chemoradiotherapy in locally advanced rectal cancer: a review. Radiat Oncol J 2021; 39:83-90. [PMID: 34619824 PMCID: PMC8497854 DOI: 10.3857/roj.2021.00108] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 04/01/2021] [Indexed: 12/24/2022] Open
Abstract
Rectal cancer is one of the most prevalent cancers in the world. In many countries, the current standard of care is long-course chemoradiation (CRT), followed by total mesorectal excision. Some efforts have been made by intensifying radiation or chemotherapy components of the neoadjuvant therapy to further decrease the local recurrence and augment surgery’s feasibility and improve the oncological outcomes. This paper reviews recent intensified neoadjuvant interventions in locally advanced rectal cancer (LARC) in terms of efficacy and treatment-related toxicity. Many maneuvers have been made so far to improve the oncological outcomes of rectal cancer with intensified neoadjuvant long-course CRT. Some of these approaches seem compelling and deserve further study, while some have just increased the treatment-related toxicities without evident benefits. Those endeavors with greater pathological complete response than the standard of care may make us await the long-term results on survival rates and chronic treatment-related toxicity. After introduction of neoadjuvant CRT for LARC there have been many efforts to improve its outcomes. Here, this study gathered most of these efforts that intensified the neoadjuvant therapy with some being promising and some being futile.
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Affiliation(s)
- Peiman Haddad
- Radiation Oncology Research Center, Cancer Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Ghalehtaki
- Radiation Oncology Research Center, Cancer Research Institute, Tehran University of Medical Sciences, Tehran, Iran.,Department of Radiation Oncology, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Arefeh Saeedian
- Radiation Oncology Research Center, Cancer Research Institute, Tehran University of Medical Sciences, Tehran, Iran.,Department of Radiation Oncology, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Farshid Farhan
- Radiation Oncology Research Center, Cancer Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Babaei
- Radiation Oncology Research Center, Cancer Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahdi Aghili
- Radiation Oncology Research Center, Cancer Research Institute, Tehran University of Medical Sciences, Tehran, Iran
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26
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Verweij ME, Hoendervangers S, Couwenberg AM, Burbach JPM, Berbee M, Buijsen J, Roodhart J, Reerink O, Pronk A, Consten ECJ, Smits AB, Heikens JT, van Grevenstein WMU, Intven MPW, Verkooijen HM. Impact of dose-escalated chemoradiation on quality of life in patients with locally advanced rectal cancer: two year follow-up of the randomized RECTAL-BOOST trial. Int J Radiat Oncol Biol Phys 2021; 112:694-703. [PMID: 34634436 DOI: 10.1016/j.ijrobp.2021.09.052] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 09/28/2021] [Accepted: 09/30/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Dose-escalated chemoradiation (CRT) for locally advanced rectal cancer (LARC) did not result in higher complete response rates, but initiated more tumor regression in the randomized XXXXX trial (Clinicaltrials.gov XXXXX). This study compared patient reported outcomes (PROs) between patients who received dose-escalated CRT (5 × 3Gy boost + CRT) or standard CRT for two years following randomization. METHODS Patients with LARC, participating in the XXXXX trial, filled out EORTC QLQ-C30 and CR29 questionnaires on quality of life (QoL) and symptoms at baseline, 3, 6, 12, 18 and 24 months following start of treatment. Between-group differences in functional QoL domains were estimated using a linear mixed-effects model and expressed as effect size (ES). Symptom scores were compared using Mann-Whitney U test. RESULTS Patients treated with dose-escalated CRT (boost group, n=51) experienced a significantly stronger decline in global health at 3 and 6 months (ES -0,4 and ES -0,4), physical functioning at 6 months (ES -1,1), role functioning at 3 and 6 months (ES -0,8 and ES -0,6) and social functioning at 6 months (ES -0,6) compared to patients treated with standard CRT (control group, n=64). The boost group reported significantly more fatigue at 3 and 6 months (83% vs. 66% resp. 89% vs. 76%), pain at 3 and 6 months (67% vs. 36% resp. 80% vs. 44%) and diarrhea at 3 months (45% vs. 29%) compared to the control group. From 12 months onwards, QoL and symptoms were similar between groups, apart from more blood/mucus in stool in the boost group. CONCLUSION In patients with LARC, dose-escalated CRT resulted in a transient deterioration in global health, physical, role, and social functioning and more pain, fatigue and diarrhea at 3 and 6 months following start of treatment compared to standard CRT. From 12 months onwards, the impact of dose-escalated CRT on QoL largely resolved.
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Affiliation(s)
- M E Verweij
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - S Hoendervangers
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - A M Couwenberg
- Department of Radiation Oncology, Antoni van Leeuwenhoek Ziekenhuis, Amsterdam, the Netherlands
| | - J P M Burbach
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - M Berbee
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - J Buijsen
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - J Roodhart
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - O Reerink
- Department of Radiation Oncology, Isala Clinic, Zwolle, The Netherlands
| | - A Pronk
- Department of Surgery, Diakonessenhuis, Utrecht, The Netherlands
| | - E C J Consten
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands; Department of Surgery, Meander Medical Center, Amersfoort, The Netherlands
| | - A B Smits
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - J T Heikens
- Department of Surgery, Hospital Rivierenland, Tiel, The Netherlands
| | | | - M P W Intven
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - H M Verkooijen
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
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27
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28
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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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29
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Boldrini L, Intven M, Bassetti M, Valentini V, Gani C. MR-Guided Radiotherapy for Rectal Cancer: Current Perspective on Organ Preservation. Front Oncol 2021; 11:619852. [PMID: 33859937 PMCID: PMC8042309 DOI: 10.3389/fonc.2021.619852] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 02/08/2021] [Indexed: 12/18/2022] Open
Abstract
Online MRI-guided radiotherapy (MRgRT) is one of the most recent technological advances in radiotherapy. MRgRT permits the visualization of tumorous and healthy tissue while the patient is on the treatment table and online daily plan adaptations following the observed anatomical changes. In the context of rectal cancer, online MRgRT is a very promising modality due to the pronounced geographical variability of tumor tissues and the surrounding healthy tissues. This current paper will discuss the possible applications of online MRgRT, in particular, in terms of radiotherapy dose escalation and response prediction in organ preservation approaches for rectal cancer.
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Affiliation(s)
- Luca Boldrini
- Unità Operativa Complessa Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Roma, Italy
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Martijn Intven
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Michael Bassetti
- Department of Human Oncology, University of Wisconsin-Madison, Madison, WI, United States
| | - Vincenzo Valentini
- Unità Operativa Complessa Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Roma, Italy
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Cihan Gani
- Department of Radiation Oncology, Eberhard Karls Universität Tübingen, Tübingen, Germany
- German Cancer Consortium (DKTK), Partner Site, Tübingen, Germany
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30
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Delli Pizzi A, Chiarelli AM, Chiacchiaretta P, d'Annibale M, Croce P, Rosa C, Mastrodicasa D, Trebeschi S, Lambregts DMJ, Caposiena D, Serafini FL, Basilico R, Cocco G, Di Sebastiano P, Cinalli S, Ferretti A, Wise RG, Genovesi D, Beets-Tan RGH, Caulo M. MRI-based clinical-radiomics model predicts tumor response before treatment in locally advanced rectal cancer. Sci Rep 2021; 11:5379. [PMID: 33686147 PMCID: PMC7940398 DOI: 10.1038/s41598-021-84816-3] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 02/22/2021] [Indexed: 02/06/2023] Open
Abstract
Neoadjuvant chemo-radiotherapy (CRT) followed by total mesorectal excision (TME) represents the standard treatment for patients with locally advanced (≥ T3 or N+) rectal cancer (LARC). Approximately 15% of patients with LARC shows a complete response after CRT. The use of pre-treatment MRI as predictive biomarker could help to increase the chance of organ preservation by tailoring the neoadjuvant treatment. We present a novel machine learning model combining pre-treatment MRI-based clinical and radiomic features for the early prediction of treatment response in LARC patients. MRI scans (3.0 T, T2-weighted) of 72 patients with LARC were included. Two readers independently segmented each tumor. Radiomic features were extracted from both the “tumor core” (TC) and the “tumor border” (TB). Partial least square (PLS) regression was used as the multivariate, machine learning, algorithm of choice and leave-one-out nested cross-validation was used to optimize hyperparameters of the PLS. The MRI-Based “clinical-radiomic” machine learning model properly predicted the treatment response (AUC = 0.793, p = 5.6 × 10–5). Importantly, the prediction improved when combining MRI-based clinical features and radiomic features, the latter extracted from both TC and TB. Prospective validation studies in randomized clinical trials are warranted to better define the role of radiomics in the development of rectal cancer precision medicine.
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Affiliation(s)
- Andrea Delli Pizzi
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Via dei Vestini, 66100, Chieti, Italy
| | - Antonio Maria Chiarelli
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Via dei Vestini, 66100, Chieti, Italy
| | - Piero Chiacchiaretta
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Via dei Vestini, 66100, Chieti, Italy.
| | - Martina d'Annibale
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Via dei Vestini, 66100, Chieti, Italy
| | - Pierpaolo Croce
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Via dei Vestini, 66100, Chieti, Italy
| | - Consuelo Rosa
- Department of Radiation Oncology, SS. Annunziata Hospital, "G. D'Annunzio" University of Chieti, Via Dei Vestini, 66100, Chieti, Italy
| | | | - Stefano Trebeschi
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | | | - Francesco Lorenzo Serafini
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Via dei Vestini, 66100, Chieti, Italy
| | - Raffaella Basilico
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Via dei Vestini, 66100, Chieti, Italy
| | - Giulio Cocco
- Unit of Ultrasound in Internal Medicine, Department of Medicine and Science of Aging, "G. D'Annunzio" University, Chieti, Italy
| | - Pierluigi Di Sebastiano
- Department of Innovative Technologies in Medicine and Odontoiatry, "G. D'Annunzio" University, Chieti, Italy
| | - Sebastiano Cinalli
- Division of Pathology, ASST of Valtellina and Alto Lario, Sondrio, Italy
| | - Antonio Ferretti
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Via dei Vestini, 66100, Chieti, Italy
| | - Richard Geoffrey Wise
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Via dei Vestini, 66100, Chieti, Italy
| | - Domenico Genovesi
- Department of Radiation Oncology, SS. Annunziata Hospital, "G. D'Annunzio" University of Chieti, Via Dei Vestini, 66100, Chieti, Italy
| | - Regina G H Beets-Tan
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands.,GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands.,Department of Radiology, University of Southern Denmark, Odense, Denmark
| | - Massimo Caulo
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Via dei Vestini, 66100, Chieti, Italy
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31
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Chiloiro G, Meldolesi E, Giraffa M, Capocchiano ND, Barbaro B, Coco C, Corvari B, De Franco P, D'Ugo D, Alfieri S, Manfredi R, Valentini V, Gambacorta MA. Could the conservative approach be considered safe in the treatment of locally advanced rectal cancer in case of a clinical near-complete or complete response? A retrospective analysis. Clin Transl Radiat Oncol 2021; 28:1-9. [PMID: 33732909 PMCID: PMC7937531 DOI: 10.1016/j.ctro.2021.02.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/18/2021] [Accepted: 02/20/2021] [Indexed: 01/06/2023] Open
Abstract
Background Conservative approach has emerged as an option for the management of rectal cancer (RC) patients with a near or complete clinical response after neoadjuvant chemoradiotherapy (nCRT). The aim of this study is to assess the impact of the conservative approach by comparing patients’ survival outcomes and quality of life with those who had surgical resection. Methods A single-institution and retrospective study including RC patients who reached a near complete or complete clinical response after nCRT from January 2010 to September 2019. Conservative approaches included local excision or watch and wait strategy; surgery approaches included anterior resection or abdominal-perineal resection. Local regrowth (LR), overall survival, disease free survival, metastasis free survival and colostomy free survival were evaluated through Kaplan-Meier curves and compared trough log-rank tests. Quality of life was measured by the following validated questionnaires: EORTC QLC30, EORTC QLQ – CR29 and Fecal Incontinence Quality of Life scale. Results Overall 157 patients were analyzed: 105 (66,9%) underwent radical surgery and 52 (33,1%) had a conservative approach. With a median follow-up of 51 months, 2 patients in the surgical group had a local recurrence and 8 in the conservative group had a LR, respectively. Distance metastasis occurred in 7 and 1 patients of surgical and conservative group, respectively. No differences were detected in terms of survival outcomes except for colostomy free survival (p: 0,01). The conservative group showed better intestinal (p < 0.01) and sexual (p: 0,04) function and emotional status (p: 0,02). Conclusions Conservative approach seems to be safe in terms of survival outcomes with a significant advantage on quality of life in RC patients who achieved clinical complete response after nCRT.
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Affiliation(s)
- Giuditta Chiloiro
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, UOC di Radioterapia, Oncologica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Elisa Meldolesi
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, UOC di Radioterapia, Oncologica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | | | - Nikola Dino Capocchiano
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, UOC di Radioterapia, Oncologica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Brunella Barbaro
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, UOC di Radioterapia, Oncologica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Claudio Coco
- Dipartimento di Chirurgia Generale, Fondazione Policlinico Universitario "A.Gemelli" IRCSS, Roma, Italy
| | - Barbara Corvari
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, UOC di Radioterapia, Oncologica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | | | - Domenico D'Ugo
- Università Cattolica del Sacro Cuore, Roma, Italy.,Dipartimento di Chirurgia Generale, Fondazione Policlinico Universitario "A.Gemelli" IRCSS, Roma, Italy
| | - Sergio Alfieri
- Università Cattolica del Sacro Cuore, Roma, Italy.,Unità di Chirurgia Digestiva, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Riccardo Manfredi
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, UOC di Radioterapia, Oncologica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy.,Università Cattolica del Sacro Cuore, Roma, Italy
| | - Vincenzo Valentini
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, UOC di Radioterapia, Oncologica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy.,Università Cattolica del Sacro Cuore, Roma, Italy
| | - Maria Antonietta Gambacorta
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, UOC di Radioterapia, Oncologica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy.,Università Cattolica del Sacro Cuore, Roma, Italy
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DI Tommaso M, Rosa C, Caravatta L, Augurio A, Borzillo V, DI Santo S, Perrotti F, Taraborrelli M, Cianci R, Innocenti P, DI Sebastiano P, Colasante A, Angelucci D, Basti M, Sindici G, Mazzola L, Pizzicannella G, DI Bartolomeo N, Marchioni M, DI Nicola M, Genovesi D. Treatment Intensification for Locally Advanced Rectal Cancer: Impact on Pathological Complete Response and Outcomes. In Vivo 2021; 34:1223-1233. [PMID: 32354913 DOI: 10.21873/invivo.11896] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 03/10/2020] [Accepted: 03/11/2020] [Indexed: 01/14/2023]
Abstract
AIM Pathological complete response (pCR) and clinical outcomes [overall survival (OS), disease-free survival (DFS), locoregional control (LC)] were evaluated in a single-institution experience of different schedules of neoadjuvant chemoradiotherapy (CRT) for patients with locally advanced rectal cancer (LARC). PATIENTS AND METHODS Data for 322 patients with LARC were retrospectively analyzed. pCR was evaluated according to Mandard tumor regression grade (TRG). The Kaplan-Meier method was used to estimate OS, DFS and LC. RESULTS Three hundred and three (94.1%) patients underwent surgery. pCR was observed in 81 patients (26.7%), with TRG1-2 rate of 41.8%. The 5- and 10-year OS, DFS and LC rates were 82.5%±2.5% and 65.5%±3.8%, 81.2%±2.4% and 79.3%±2.9%, 93.1%±1.7% and 90.5%±2.1%, respectively. CONCLUSION Neoadjuvant CRT in LARC patients resulted in favorable long-term oncological outcomes, with a high pCR rate and acceptable toxicity.
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Affiliation(s)
- Monica DI Tommaso
- Department of Radiation Oncology, SS. Annunziata Hospital, G. D'Annunzio University, Chieti, Italy
| | - Consuelo Rosa
- Department of Radiation Oncology, SS. Annunziata Hospital, G. D'Annunzio University, Chieti, Italy
| | - Luciana Caravatta
- Department of Radiation Oncology, SS. Annunziata Hospital, G. D'Annunzio University, Chieti, Italy
| | - Antonietta Augurio
- Department of Radiation Oncology, SS. Annunziata Hospital, G. D'Annunzio University, Chieti, Italy
| | - Valentina Borzillo
- Department of Radiation Therapy, Istituto Nazionale Tumori-IRCCS-Fondazione G. Pascale, Naples, Italy
| | - Sara DI Santo
- Department of Radiation Oncology, SS. Annunziata Hospital, G. D'Annunzio University, Chieti, Italy
| | - Francesca Perrotti
- Department of Radiation Oncology, SS. Annunziata Hospital, G. D'Annunzio University, Chieti, Italy
| | - Maria Taraborrelli
- Department of Radiation Oncology, SS. Annunziata Hospital, G. D'Annunzio University, Chieti, Italy
| | - Roberta Cianci
- Department of Radiology, SS. Annunziata Hospital, G. D'Annunzio University, Chieti, Italy
| | - Paolo Innocenti
- Division of Surgery, Villa Serena Clinic, Città S. Angelo, Italy
| | - Pierluigi DI Sebastiano
- Department of Medical and Oral Sciences and Biotechnologies, G. D'Annunzio University, Chieti, Italy
| | | | | | - Massimo Basti
- Division of Surgery III, Santo Spirito Hospital, Pescara, Italy
| | - Giulia Sindici
- Division of Pathology, Santo Spirito Hospital, Pescara, Italy
| | | | | | | | - Michele Marchioni
- Laboratory of Biostatistics, Department of Medical, Oral and Biotechnological Sciences, G. D'Annunzio University, Chieti, Italy
| | - Marta DI Nicola
- Laboratory of Biostatistics, Department of Medical, Oral and Biotechnological Sciences, G. D'Annunzio University, Chieti, Italy
| | - Domenico Genovesi
- Department of Radiation Oncology, SS. Annunziata Hospital, G. D'Annunzio University, Chieti, Italy
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Intven M, de Mol van Otterloo S, Mook S, Doornaert P, de Groot-van Breugel E, Sikkes G, Willemsen-Bosman M, van Zijp H, Tijssen R. Online adaptive MR-guided radiotherapy for rectal cancer; feasibility of the workflow on a 1.5T MR-linac: clinical implementation and initial experience. Radiother Oncol 2021; 154:172-178. [DOI: 10.1016/j.radonc.2020.09.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 09/13/2020] [Accepted: 09/14/2020] [Indexed: 10/23/2022]
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34
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D'Alimonte L, Bao QR, Spolverato G, Capelli G, Del Bianco P, Albertoni L, De Paoli A, Guerrieri M, Mantello G, Gambacorta MA, Canzonieri V, Valentini V, Coco C, Pucciarelli S. Long-Term Outcomes of Local Excision Following Neoadjuvant Chemoradiotherapy for Locally Advanced Rectal Cancer. Ann Surg Oncol 2020; 28:2801-2808. [PMID: 33125570 PMCID: PMC8043910 DOI: 10.1245/s10434-020-09243-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 08/28/2020] [Indexed: 12/24/2022]
Abstract
Background Local excision might represent an alternative to total mesorectal excision for patients with locally advanced rectal cancer who achieve a major or complete clinical response after neoadjuvant chemoradiotherapy. Methods Between August 2005 and July 2011, 63 patients with mid-low rectal adenocarcinoma who had a major/complete clinical response after neoadjuvant chemoradiotherapy were enrolled in a multicenter prospective phase 2 trial and underwent transanal full thickness local excision. The main endpoint of this study was to evaluate the 5- and 10-year overall, relapse-free, local, and distant relapse-free survival, which were calculated by applying the Kaplan–Meier method. The rate of patients with rectum preserved and without stoma were also calculated. Results Of 63 patients, 38 (60%) were male and 25 (40%) were female, with a median (range) age of 64 (25–82) years. At baseline, the following clinical stages were found: cT2, n = 21 (33.3%); cT3, n = 42 (66.6%), 39 (61.9%) patients were cN+. At a median (range) follow-up of 108 (32–166) months, the estimated cumulative 5- and 10-year overall survival, relapse-free survival, local recurrence-free survival, and distant recurrence-free survival were 87% (95% CI 76–93) and 79% (95% CI 66–87), 89% (95% CI 78–94) and 82% (95% CI 66–91), both 91% (95% CI 81–96), and 90% (95% CI 80–95) and 86% (95% CI 73–93), respectively. Overall, 49 (77.8%) patients had their rectum preserved, and 54 (84.1%) were stoma-free. Conclusion In highly selected patients, the local excision approach after neoadjuvant chemoradiotherapy is associated with excellent long-term outcomes, high rates of rectum preservation and absence of permanent stoma.
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Affiliation(s)
- Lucrezia D'Alimonte
- Department of Surgical, Oncological, and Gastroenterological Sciences, First Surgical Clinic, University of Padua, Padua, Italy
| | - Quoc Riccardo Bao
- Department of Surgical, Oncological, and Gastroenterological Sciences, First Surgical Clinic, University of Padua, Padua, Italy
| | - Gaya Spolverato
- Department of Surgical, Oncological, and Gastroenterological Sciences, First Surgical Clinic, University of Padua, Padua, Italy.
| | - Giulia Capelli
- Department of Surgical, Oncological, and Gastroenterological Sciences, First Surgical Clinic, University of Padua, Padua, Italy
| | - Paola Del Bianco
- Clinical Research Unit, Istituto Oncologico Veneto IOV - IRCCS, Padua, Italy
| | - Laura Albertoni
- Surgical Pathology and Cytopathology Unit, Department of Medicine-DIMED, University of Padua, Padua, Italy
| | - Antonino De Paoli
- Department of Radiation Oncology, National Cancer Institute, Aviano, Italy
| | - Mario Guerrieri
- General Surgery, Marche Polytechnic University, Ancona, Italy
| | | | | | | | | | - Claudio Coco
- Department of Surgical Sciences, Catholic University of Rome, Rome, Italy
| | - Salvatore Pucciarelli
- Department of Surgical, Oncological, and Gastroenterological Sciences, First Surgical Clinic, University of Padua, Padua, Italy
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Gambacorta MA, Masciocchi C, Chiloiro G, Meldolesi E, Macchia G, van Soest J, Peters F, Collette L, Gérard JP, Ngan S, Rödel CC, Damiani A, Dekker A, Valentini V. Timing to achieve the highest rate of pCR after preoperative radiochemotherapy in rectal cancer: a pooled analysis of 3085 patients from 7 randomized trials. Radiother Oncol 2020; 154:154-160. [PMID: 32966845 DOI: 10.1016/j.radonc.2020.09.026] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 09/01/2020] [Accepted: 09/12/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE Optimal timing of surgery after neoadjuvant chemoradiotherapy (Nad-CRT) is still controversial in locally advanced rectal cancer (LARC). The primary goal of this study was to determine the best surgical interval (SI) to achieve the highest rate of pathological complete response (pCR) and secondly to evaluate the effect on survival outcomes according to the SI. PATIENTS AND METHODS Patients data were extracted from the international randomized trials: Accord12/0405, EORTC22921, FFCD9203, CAO/ARO/AIO-94, CAO-ARO-AIO-04, INTERACT and TROG01.04. Inclusion criteria were: age≥ 18, cT3-T4 and cN0-2, no clinical evidence of distant metastasis at diagnosis, Nad-CRT followed by surgery. Pearson's Chi-squared test with Yates' continuity correction for categorical variables, the Mann-Whitney test for continuous variables, Mann-Kendall test, Kaplan-Meier curves with log-rank test, univariate and multivariate logistic regression model was used for data analysis. RESULTS 3085 patients met the inclusion criteria. Overall, the pCR rate was 14% at a median SI of 6 weeks (range 1-31). The cumulative pCR rate increased significantly when SI lengthened, with 95% of pCR events within 10 weeks from Nad-CRT. At univariate and multivariate logistic regression analysis, lengthening of SI (p< 0.01), radiotherapy dose (p< 0.01), and the addition of oxaliplatin to Nad-CRT (p< 0.01) had a favorable impact on pCR. Furthermore, lengthening of SI was not impact on local recurrences, distance metastases, and overall survival. CONCLUSION This pooled analysis suggests that the best time to achieve pCR in LARC is at 10 weeks, considering that the lengthening of SI is not detrimental concerning survival outcomes.
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Affiliation(s)
- Maria Antonietta Gambacorta
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS - Roma, Italy; Istituto di Radiologia, Università Cattolica del Sacro Cuore - Roma, Italy
| | - Carlotta Masciocchi
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS - Roma, Italy
| | - Giuditta Chiloiro
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS - Roma, Italy; Istituto di Radiologia, Università Cattolica del Sacro Cuore - Roma, Italy.
| | - Elisa Meldolesi
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS - Roma, Italy
| | | | - Johan van Soest
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht University, Medical Centre+, The Netherlands
| | - Fenke Peters
- Department of Radiation Oncology, Leiden University Medical Center, The Netherlands
| | | | - Jean-Pierre Gérard
- Department of Radiation Oncology, Centre Antoine Lacassagne, Nice Côte-d'Azur University, France
| | - Samuel Ngan
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - C Claus Rödel
- Department of Radiotherapy and Oncology, University Hospital Frankfurt, Goethe University, Germany
| | - Andrea Damiani
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS - Roma, Italy
| | - Andre Dekker
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht University, Medical Centre+, The Netherlands
| | - Vincenzo Valentini
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS - Roma, Italy; Istituto di Radiologia, Università Cattolica del Sacro Cuore - Roma, Italy
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Hearn N, Bugg W, Chan A, Vignarajah D, Cahill K, Atwell D, Lagopoulos J, Min M. Manual and semi-automated delineation of locally advanced rectal cancer subvolumes with diffusion-weighted MRI. Br J Radiol 2020; 93:20200543. [PMID: 32877210 DOI: 10.1259/bjr.20200543] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES To evaluate interobserver agreement for T2 weighted (T2W) and diffusion-weighted MRI (DW-MRI) contours of locally advanced rectal cancer (LARC); and to evaluate manual and semi-automated delineations of restricted diffusion tumour subvolumes. METHODS 20 cases of LARC were reviewed by 2 radiation oncologists and 2 radiologists. Contours of gross tumour volume (GTV) on T2W, DW-MRI and co-registered T2W/DW-MRI were independently delineated and compared using Dice Similarity Coefficient (DSC), mean distance to agreement (MDA) and other metrics of interobserver agreement. Restricted diffusion subvolumes within GTVs were manually delineated and compared to semi-automatically generated contours corresponding to intratumoral apparent diffusion coefficient (ADC) centile values. RESULTS Observers were able to delineate subvolumes of restricted diffusion with moderate agreement (DSC 0.666, MDA 1.92 mm). Semi-automated segmentation based on the 40th centile intratumoral ADC value demonstrated moderate average agreement with consensus delineations (DSC 0.581, MDA 2.44 mm), with errors noted in image registration and luminal variation between acquisitions. A small validation set of four cases with optimised planning MRI demonstrated improvement (DSC 0.669, MDA 1.91 mm). CONCLUSION Contours based on co-registered T2W and DW-MRI could be used for delineation of biologically relevant tumour subvolumes. Semi-automated delineation based on patient-specific intratumoral ADC thresholds may standardise subvolume delineation if registration between acquisitions is sufficiently accurate. ADVANCES IN KNOWLEDGE This is the first study to evaluate the feasibility of semi-automated diffusion-based subvolume delineation in LARC. This approach could be applied to dose escalation or 'dose painting' protocols to improve delineation reproducibility.
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Affiliation(s)
- Nathan Hearn
- Department of Radiation Oncology, Sunshine Coast University Hospital, Birtinya, QLD, Australia.,ICON Cancer Centre, Maroochydore, QLD, Australia.,University of the Sunshine Coast, Sippy Downs, QLD, Australia
| | - William Bugg
- Department of Medical Imaging, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - Anthony Chan
- Department of Medical Imaging, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - Dinesh Vignarajah
- Department of Radiation Oncology, Sunshine Coast University Hospital, Birtinya, QLD, Australia.,ICON Cancer Centre, Maroochydore, QLD, Australia
| | - Katelyn Cahill
- Department of Radiation Oncology, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - Daisy Atwell
- Department of Radiation Oncology, Sunshine Coast University Hospital, Birtinya, QLD, Australia.,ICON Cancer Centre, Maroochydore, QLD, Australia.,University of the Sunshine Coast, Sippy Downs, QLD, Australia
| | - Jim Lagopoulos
- University of the Sunshine Coast, Sippy Downs, QLD, Australia.,Sunshine Coast Mind and Neuroscience - Thompson Institute, University of the Sunshine Coast, Birtinya, QLD, Australia
| | - Myo Min
- Department of Radiation Oncology, Sunshine Coast University Hospital, Birtinya, QLD, Australia.,ICON Cancer Centre, Maroochydore, QLD, Australia.,University of the Sunshine Coast, Sippy Downs, QLD, Australia
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Kosakowska E, Pietrzak L, Michalski W, Kepka L, Polkowski W, Jankiewicz M, Cisel B, Krynski J, Zwolinski J, Wyrwicz L, Rutkowski A, Stylinski R, Nawrocki G, Sopylo R, Szczepkowski M, Tarnowski W, Bujko K. Neoadjuvant chemotherapy with or without oxaliplatin after short-course radiotherapy in high-risk rectal cancer: A subgroup analysis from a prospective study. Rep Pract Oncol Radiother 2020; 25:1017-1022. [PMID: 33390858 DOI: 10.1016/j.rpor.2020.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/28/2020] [Accepted: 08/11/2020] [Indexed: 02/08/2023] Open
Abstract
Aim To evaluate the role of oxaliplatin in neoadjuvant chemotherapy delivered after short-course irradiation. Background Using oxaliplatin in the above setting is uncertain. Patients and methods A subgroup of 136 patients managed by short-course radiotherapy and 3 cycles of consolidation chemotherapy within the framework of a randomised study was included in this post-hoc analysis. Sixty-seven patients received FOLFOX4 (oxaliplatin group) while oxaliplatin was omitted in the second period of accrual in 69 patients because of protocol amendment (fluorouracil-only group). Results Grade 3+ acute toxicity from neoadjuvant treatment was observed in 30% of patients in the oxaliplatin group vs. 16% in the fluorouracil-only group (p = 0.053). The corresponding proportions of patients having radical surgery or achieving complete pathological response were 72% vs. 77% (odds ratio [OR] = 0.88; 95% confidence interval [CI]: 0.39-1.98; p = 0.75) and 15% vs. 7% (OR = 2.25; 95% CI: 0.83-6.94; p = 0.16), respectively. The long-term outcomes were similar in the two groups. Overall and disease-free survival rates at 5 years were 63% vs. 56% (p = 0.78) and 49% vs. 44% (p = 0.59), respectively. The corresponding numbers for cumulative incidence of local failure or distant metastases were 33% vs. 38% (hazard ratio [HR] = 0.89; 95% CI: 0.52-1.52; p = 0.68) and 33% vs. 33% (HR = 0.78; 95% CI: 0.43-1.40; p = 0.41), respectively. Conclusion Our findings do not support adding oxaliplatin to three cycles of chemotherapy delivered after short-course irradiation.
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Affiliation(s)
- Ewa Kosakowska
- Department of Gastroenterological Oncology, Maria Sklodowska-Curie National, Research Institute of Oncology, Warsaw, Poland
| | - Lucyna Pietrzak
- I Department of Radiotherapy, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Wojciech Michalski
- Department of Computational Oncology, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Lucyna Kepka
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland
| | | | | | - Bogumila Cisel
- Department of Surgical Oncology, Medical University of Lublin, Poland
| | - Jacek Krynski
- Department of Gastroenterological Oncology, Maria Sklodowska-Curie National, Research Institute of Oncology, Warsaw, Poland
| | - Jacek Zwolinski
- Department of Gastroenterological Oncology, Maria Sklodowska-Curie National, Research Institute of Oncology, Warsaw, Poland
| | - Lucjan Wyrwicz
- Department of Oncology and Radiotherapy, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Andrzej Rutkowski
- Department of Gastroenterological Oncology, Maria Sklodowska-Curie National, Research Institute of Oncology, Warsaw, Poland
| | - Roman Stylinski
- 1st Department of General Surgery, Transplantology and Nutritional Therapy, Medical University of Lublin, Poland
| | - Grzegorz Nawrocki
- Department of Surgery, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Rafal Sopylo
- Department of Surgery, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Marek Szczepkowski
- Clinical Department of Colorectal, General and Oncological Surgery, Centre of Postgraduate Medical Education, Bielanski Hospital, Warsaw, Poland
| | - Wieslaw Tarnowski
- Department of General, Oncologic and Digestive Tract Surgery, Medical Centre of Postgraduate Education, Orlowski Hospital, Warsaw, Poland
| | - Krzysztof Bujko
- I Department of Radiotherapy, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
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Hearn N, Atwell D, Cahill K, Elks J, Vignarajah D, Lagopoulos J, Min M. Neoadjuvant Radiotherapy Dose Escalation in Locally Advanced Rectal Cancer: a Systematic Review and Meta-analysis of Modern Treatment Approaches and Outcomes. Clin Oncol (R Coll Radiol) 2020; 33:e1-e14. [PMID: 32669228 DOI: 10.1016/j.clon.2020.06.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 05/15/2020] [Accepted: 06/05/2020] [Indexed: 01/10/2023]
Abstract
AIMS Improving pathological complete response (pCR) rates after neoadjuvant chemoradiotherapy for locally advanced rectal cancer may facilitate surgery-sparing treatment paradigms. Radiotherapy boost has been linked to higher rates of pCR; however, outcomes in moderately escalated inverse-planning studies have not been systematically evaluated. We therefore carried out a systematic review and meta-analysis of radiation dose-escalation studies in the context of neoadjuvant therapy for locally advanced rectal cancer. MATERIALS AND METHODS A systematic search of Pubmed, EMBASE and Cochrane databases for synonyms of 'rectal cancer', 'radiotherapy' and 'boost' was carried out. Studies were screened for radiotherapy prescription >54 Gy. Prespecified quality assessment was carried out for meta-analysis inclusion suitability. Pooled estimates of pCR, acute toxicity (grade ≥3) and R0 resection rates were determined with random-effects restricted maximum-likelihood estimation. Heterogeneity was assessed with Higgins I2 and Cochran Q statistic. Subset analysis examined outcomes in modern inverse-planning studies. Meta-regression with permutation correction was carried out for each outcome against radiation dose, radiotherapy technique, boost technique, chemotherapy intensification and other patient- and treatment-related cofactors. RESULTS Forty-nine primary and three follow-up publications were included in the systematic review. Pooled estimates of pCR, toxicity and R0 resection across 37 eligible publications (n = 1817 patients) were 24.1% (95% confidence interval 21.2-27.4%), 11.2% (95% confidence interval 7.2-17.0%) and 90.7% (95% confidence interval 87.9-93.8%). Within inverse-planning studies (17 publications, n = 959 patients), these rates were 25.7% (95% confidence interval 21.0-31.1%), 9.8% (95% confidence interval 4.6-19.7%) and 95.3% (95% confidence interval 91.6-97.4%). Regression analysis did not identify any significant predictor of pCR (P > 0.05). CONCLUSIONS Radiotherapy dose escalation above 54 Gy is associated with high rates of pCR and does not seem to increase the risk of acute grade ≥3 toxicity events. pCR rates approaching 25% may be achievable utilising moderate escalation (54-60 Gy) with modern inverse-planning techniques; however, a clear dose-response relationship was not identified in regression analysis and additional evidence is awaited given the prevalence of heterogenous single-arm studies to date.
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Affiliation(s)
- N Hearn
- Department of Radiation Oncology, Sunshine Coast University Hospital, Birtinya, Queensland, Australia; ICON Cancer Centre, Maroochydore, Queensland, Australia; University of the Sunshine Coast, Sippy Downs, Queensland, Australia.
| | - D Atwell
- Department of Radiation Oncology, Sunshine Coast University Hospital, Birtinya, Queensland, Australia; ICON Cancer Centre, Maroochydore, Queensland, Australia; University of the Sunshine Coast, Sippy Downs, Queensland, Australia
| | - K Cahill
- Department of Radiation Oncology, Sunshine Coast University Hospital, Birtinya, Queensland, Australia; University of the Sunshine Coast, Sippy Downs, Queensland, Australia
| | - J Elks
- University of the Sunshine Coast, Sippy Downs, Queensland, Australia
| | - D Vignarajah
- Department of Radiation Oncology, Sunshine Coast University Hospital, Birtinya, Queensland, Australia; ICON Cancer Centre, Maroochydore, Queensland, Australia
| | - J Lagopoulos
- University of the Sunshine Coast, Sippy Downs, Queensland, Australia; Sunshine Coast Mind and Neuroscience - Thompson Institute, University of the Sunshine Coast, Birtinya, Queensland, Australia
| | - M Min
- Department of Radiation Oncology, Sunshine Coast University Hospital, Birtinya, Queensland, Australia; ICON Cancer Centre, Maroochydore, Queensland, Australia; University of the Sunshine Coast, Sippy Downs, Queensland, Australia
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De Mattia E, Roncato R, Palazzari E, Toffoli G, Cecchin E. Germline and Somatic Pharmacogenomics to Refine Rectal Cancer Patients Selection for Neo-Adjuvant Chemoradiotherapy. Front Pharmacol 2020; 11:897. [PMID: 32625092 PMCID: PMC7311751 DOI: 10.3389/fphar.2020.00897] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 06/02/2020] [Indexed: 12/25/2022] Open
Abstract
Neoadjuvant chemoradiotherapy (nCRT) followed by radical surgery is the standard of care for patients with Locally Advanced Rectal Cancer (LARC). Current selection for nCRT is based on clinical criteria regardless of any molecular marker. Pharmacogenomics may be a useful strategy to personalize and optimize nCRT in LARC. This review aims to summarize the most recent and relevant findings about the role of germline and somatic pharmacogenomics in the prediction of nCRT outcome in patients with LARC, discussing the state of the art of their application in the clinical practice. A systematic literature search of the PubMed database was completed to identify relevant English-language papers published up to January 2020. The chemotherapeutic backbone of nCRT is represented by fluoropyrimidines, mainly metabolized by DPD (Dihydro-Pyrimidine Dehydrogenase, DPYD). The clinical impact of testing DPYD*2A, DPYD*13, c.2846A > T and c.1236G > A-HapB3 before a fluoropyrimidines administration to increase treatment safety is widely acknowledged. Other relevant target genes are TYMS (Thymidylate Synthase) and MTHFR (Methylene-Tetrahydro-Folate Reductase), whose polymorphisms were mainly studied as potential markers of treatment efficacy in LARC. A pivotal role of a TYMS polymorphism in the gene promoter region (rs34743033) was reported and was pioneeringly used to guide nCRT treatment in a phase II study. The pharmacogenomic analysis of other pathways mostly involved in the cellular response to radiation damage, as the DNA repair and the activation of the inflammatory cascade, provided less consistent results. A high rate of somatic mutation in genes belonging to PI3K (Phosphatidyl-Inositol 3-Kinase) and MAPK (Mitogen-Activated Protein Kinase) pathways, as BRAF (V-raf murine sarcoma viral oncogene homolog B1), KRAS (Kirsten Rat Sarcoma viral oncogene homolog), NRAS (Neuroblastoma RAS viral (v-ras) oncogene homolog), PIK3CA (Phosphatidyl-Inositol-4,5-bisphosphate 3-Kinase, Catalytic Subunit Alpha), as well as TP53 (Tumor Protein 53) was reported in LARC. Their pharmacogenomic role, already defined in colorectal cancer, is under investigation in LARC with promising results concerning specific somatic mutations in KRAS and TP53, as predictors of tumor response and prognosis. The availability of circulating tumor DNA in plasma may also represent an opportunity to monitor somatic mutations in course of therapy.
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Affiliation(s)
- Elena De Mattia
- Clinical and Experimental Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
| | - Rossana Roncato
- Clinical and Experimental Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
| | - Elisa Palazzari
- Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Giuseppe Toffoli
- Clinical and Experimental Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
| | - Erika Cecchin
- Clinical and Experimental Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
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Basics and Frontiers on Pancreatic Cancer for Radiation Oncology: Target Delineation, SBRT, SIB technique, MRgRT, Particle Therapy, Immunotherapy and Clinical Guidelines. Cancers (Basel) 2020; 12:cancers12071729. [PMID: 32610592 PMCID: PMC7407382 DOI: 10.3390/cancers12071729] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 06/11/2020] [Accepted: 06/17/2020] [Indexed: 12/17/2022] Open
Abstract
Pancreatic cancer represents a modern oncological urgency. Its management is aimed to both distal and local disease control. Resectability is the cornerstone of treatment aim. It influences the clinical presentation’s definitions as up-front resectable, borderline resectable and locally advanced (unresectable). The main treatment categories are neoadjuvant (preoperative), definitive and adjuvant (postoperative). This review will focus on (i) the current indications by the available national and international guidelines; (ii) the current standard indications for target volume delineation in radiotherapy (RT); (iii) the emerging modern technologies (including particle therapy and Magnetic Resonance [MR]-guided-RT); (iv) stereotactic body radiotherapy (SBRT), as the most promising technical delivery application of RT in this framework; (v) a particularly promising dose delivery technique called simultaneous integrated boost (SIB); and (vi) a multimodal integration opportunity: the combination of RT with immunotherapy.
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Efficacy of Dose-Escalated Chemoradiation on Complete Tumor Response in Patients with Locally Advanced Rectal Cancer (RECTAL-BOOST): A Phase 2 Randomized Controlled Trial. Int J Radiat Oncol Biol Phys 2020; 108:1008-1018. [PMID: 32565319 DOI: 10.1016/j.ijrobp.2020.06.013] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 05/28/2020] [Accepted: 06/04/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE Pathologic complete tumor response after chemoradiation in patients with locally advanced rectal cancer (LARC) is associated with a favorable prognosis and allows organ-sparing treatment strategies. In the RECTAL-BOOST trial, we aimed to investigate the effect of an external radiation boost to the tumor before chemoradiation on pathologic or sustained clinical complete tumor response in LARC. METHODS AND MATERIALS This multicenter, nonblinded, phase 2 randomized controlled trial followed the trials-within-cohorts design, which is a pragmatic trial design allowing cohort participants to be randomized for an experimental intervention. Patients in the intervention group are offered the intervention (and can either accept or refuse this), whereas patients in the control group are not notified about the randomization. Participants of a colorectal cancer cohort referred for chemoradiation of LARC to either of 2 radiation therapy centers were eligible. Patients were randomized to no boost or an external radiation boost (5 × 3 Gy) without concurrent chemotherapy, directly followed by standard pelvic chemoradiation (25 × 2 Gy with concurrent capecitabine). The primary outcome was pathologic complete response (ie, ypT0N0) in patients with planned surgery at 12 weeks, or, as surrogate for pathologic complete response, a 2-year sustained clinical complete response for patients treated with an organ preservation strategy. Analyses were intention to treat. The study was registered with ClinicalTrials.gov, number NCT01951521. RESULTS Between September 2014 and July 2018, 128 patients were randomized. Fifty-one of the 64 (79.7%) patients in the intervention group accepted and received a boost. Compared with the control group, fewer patients in the intervention group had a cT4 stage and a low rectal tumor (31.3% vs 17.2% and 56.3% vs 45.3%, respectively), and more patients had a cN2 stage (59.4% vs 70.3%, respectively). Rate of pathologic or sustained clinical complete tumor response was similar between the groups: 23 of 64 (35.9%; 95% confidence interval [CI], 24.3-48.9) in the intervention group versus 24 of 64 (37.5%; 95% CI, 25.7-50.5) in the control group (odds ratio [OR] = 0.94; 95% CI, 0.46-1.92). Near-complete or complete tumor regression was more common in the intervention group (34 of 49; 69.4%) than in the control group (24 of 53; 45.3%; (OR = 2.74, 95% CI 1.21-6.18). Grade ≥3 acute toxicity was comparable: 6 of 64 (9.4%) in the intervention group versus 5 of 64 (7.8%) in the control group (OR = 1.22; 95% CI, 0.35-4.22). CONCLUSIONS Dose escalation with an external radiation therapy boost to the tumor before neoadjuvant chemoradiation did not increase the pathologic or sustained clinical complete tumor response rate in LARC.
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Cecchin E, De Mattia E, Dreussi E, Montico M, Palazzari E, Navarria F, Bergamo F, Belluco C, Quartuccio L, De Vita S, Canzonieri V, Gagno S, Zanusso C, Buonadonna A, Pucciarelli S, De Paoli A, Toffoli G. Immunogenetic markers in IL17F predict the risk of metastases spread and overall survival in rectal cancer patients treated with neoadjuvant chemoradiotherapy. Radiother Oncol 2020; 149:30-37. [PMID: 32387487 DOI: 10.1016/j.radonc.2020.04.055] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 04/28/2020] [Accepted: 04/29/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND PURPOSE The role of the immune system in tumor response to chemo-radiotherapy (CRT) is an emerging issue. This work aimed at identifying predictive and prognostic immunogenetic variants in LARC patients after preoperative (po)-CRT and surgery. MATERIALS AND METHODS A set of 192 polymorphisms in 34 candidate genes involved in the regulation of the immune response signalling network, was selected and analyzed in 370 LARC patients treated with po-CRT and surgery, split into a Test Set (n = 233) and a Validation Set (n = 137). Immunogenetic markers were selected based on a concordant significant effect on 2-year relapse-free survival (2-yrRFS) (bootstrapped P < 0.05) in both patients Sets. The effect of the selected immunogenetic variants on 5-year metastases-free (5yrMFS), 5-year disease-free (5yrDFS), and 10-year overall (10yrOS) survival was tested in the entire Set of 370 patients. RESULTS Two immunogenetic IL17F (IL17F-rs641701 and IL17F-rs9463772) markers predictive of 2yrRFS, 5yrDFS, 5yrMFS, and 10yrOS were identified. The combination of tumor regression grade (TRG) and patients genotype for IL17F-rs641701 and IL17F-rs9463772 allowed the identification of subgroups of patients with differential prognosis in term of both 5yrDFS (HR 11.29, P-value <0.001, and HR 5.86, P-value = 0.001, respectively) and 10yrOS (HR 7.07, P-value = 0.005, and HR 6.05, P-value = 0.002, respectively). CONCLUSION IL17F-rs641701 and IL17F-rs9463772 were highlighted as promising immunogenetic markers significantly associated with the prognosis of LARC patients. After a prospective validation of the herein reported findings, the combination of TRG and patients genotype should be considered to provide additional stratification criteria for the selection of a personalized multimodality treatment.
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Affiliation(s)
- Erika Cecchin
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy.
| | - Elena De Mattia
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Eva Dreussi
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Marcella Montico
- Scientific Direction, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Italy
| | - Elisa Palazzari
- Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Italy
| | - Federico Navarria
- Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Italy
| | | | - Claudio Belluco
- Surgical Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Italy
| | - Luca Quartuccio
- Department of Medical Area (DAME), Rheumatology Clinic, Santa Maria della Misericordia University Hospital, Udine (UD), Italy
| | - Salvatore De Vita
- Department of Medical Area (DAME), Rheumatology Clinic, Santa Maria della Misericordia University Hospital, Udine (UD), Italy
| | - Vincenzo Canzonieri
- Pathology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Italy; Department of Medical, Surgical and Health Sciences, University of Trieste, Italy
| | - Sara Gagno
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Chiara Zanusso
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Angela Buonadonna
- Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Italy
| | | | - Antonino De Paoli
- Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Italy
| | - Giuseppe Toffoli
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
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