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Doroudian S, Osterman E, Glimelius B. Risk Factors for Recurrence After Surgery for Rectal Cancer in a Modern, Nationwide Population-Based Cohort. Ann Surg Oncol 2024; 31:5570-5584. [PMID: 38853216 PMCID: PMC11300512 DOI: 10.1245/s10434-024-15552-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 05/16/2024] [Indexed: 06/11/2024]
Abstract
BACKGROUND The success of modern multimodal treatment in rectal cancer is dependent on risk prediction. Better knowledge of the risk of locoregional and distant recurrence, in relation to preoperative treatment, pathological stage, and commonly used risk factors, is needed when deciding on adjuvant therapy and surveillance. METHODS The Swedish ColoRectal Cancer Registry was used to identify patients diagnosed with rectal adenocarcinoma between 2011 and 2018. Readily available variables, including patient, tumor, and treatment factors were exposures. Cox proportional hazard models were used to identify important risk factors for recurrence and calculate recurrence risks. RESULTS A total of 9428 curatively resected patients were included and followed for a median of 72 months. Eighteen percent had distal recurrence and 3% had locoregional recurrence at 5 years. Risk factors with major impact on distal recurrence were pT4a (hazard ratio [HR] 5.1, 95% confidence interval [CI] 3.3-8.0), pN2b (HR 3.4, 95% CI 2.7-4.2), tumor deposit (HR 1.7, 95% CI 1.5-1.9), lymph node yield (HR 1.5, 95% CI 1.3-1.8), and tumor level 0-5 cm (HR 1.5, 95% CI 1.3-1.8). Pathologic stage and number of risk factors identified groups with markedly different recurrence risks in all neoadjuvant treatment groups. CONCLUSIONS Readily available risk factors, as a complement to stage, are still valid and robust in all neoadjuvant treatment groups. Tumor deposit is important, while circumferential resection margin might no longer be important with improved oncological treatments and high-quality TME surgery. Tailored surveillance is possible in selected groups using risk stratification based on stage and risk factors.
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Affiliation(s)
- Sepehr Doroudian
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden.
- Center for Research and Development, Uppsala University/Region Gävleborg, Gävle, Sweden.
- Department of Surgery, Gävle County Hospital, Gävle, Sweden.
| | - Erik Osterman
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
- Department of Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Bengt Glimelius
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
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Erozkan K, Elamin D, Tasci ME, Liska D, Valente MA, Alipouriani A, Schabl L, Lavryk O, Catalano B, Krishnamurthi S, Miller JA, Purysko AS, Steele SR, Gorgun E. Evaluating complete response rates and predictors in total neoadjuvant therapy for rectal cancer. J Gastrointest Surg 2024:S1091-255X(24)00544-4. [PMID: 39067745 DOI: 10.1016/j.gassur.2024.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 07/18/2024] [Accepted: 07/23/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND There is a paradigm shift in the management of locally advanced rectal cancer (LARC) from conventional neoadjuvant treatment to total neoadjuvant therapy (TNT). Despite its growing acceptance, there are limited studies that have examined its effects on disease presentation. In addition, it is important to determine the factors that play a role in complete response (CR). Our previous data from 119 patients revealed that the CR rate was 37%, and low rectal tumors and the absence of extramural vascular invasion (EMVI) were predictors of CR. Unfortunately, there continues to be a lack of data, and reliable markers are still needed to consistently identify the best respondents. Therefore, this study aimed to determine the factors associated with CR. Moreover, this study hypothesized that both predictive factors and the CR ratio might evolve over time because of the growing patient population. METHODS This retrospective study included patients who completed TNT for LARC at our tertiary care center between 2015 and 2022. The primary outcome was to determine the predictors of CR. The secondary outcomes were the 2-year disease-free survival (DFS) rate and overall survival (OS) rate. CR consists of patients who sustained clinical CR (cCR) for at least 12 months under watch and wait or had pathologic CR (pCR) after surgery. RESULTS Of 339 patients with LARC, 208 (61.3%) successfully completed TNT. Among 208 patients, 57 (27.4%) achieved cCR, and 166 (80.0%) sustained cCR without tumor regrowth after 1 year. The remaining 151 patients (72.6%) underwent surgery, and 42 patients had pCR. The final CR rate was 42.3%. The median age of the patients was 56 years (IQR, 49-66). Moreover, 132 participants (63.5%) were male, whereas 76 participants (36.5%) were female. The median tumor size was 4.95 cm (IQR, 3.60-6.43), with most tumors in the low rectum (119 [57.2%]). Based on the MRI findings, the mesorectal facia (MRF) involvement rate was 25.0% (n = 52), and EMVI was observed in 43 patients (20.7%). Low rectal tumors, the absence of MRF involvement, and the absence of EMVI were predictors of CR. With a median follow-up of 24.7 months, 2-year DFS and OS were significantly higher among patients with CR than among patients with incomplete response (91.3% vs 71.0% [P < .01] and 98.8% vs 90.2% [P = .03], respectively). CONCLUSION An increasing CR rate was observed in our updated dataset compared with that in our previous study. In addition to previously identified predictors, low tumor location, and the absence of EMVI, the absence of MRF involvement was determined as a predictor of CR. Our findings offer valuable insights into clinical practice and help clinicians set clear expectations when counseling patients.
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Affiliation(s)
- Kamil Erozkan
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Doua Elamin
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Muhammed Enes Tasci
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, United States
| | - David Liska
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Michael A Valente
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Ali Alipouriani
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Lukas Schabl
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Olga Lavryk
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Brogan Catalano
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Smitha Krishnamurthi
- Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH, United States
| | - Jacob A Miller
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH, United States
| | - Andrei S Purysko
- Section of Abdominal Imaging and Nuclear Radiology Department, Imaging Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Emre Gorgun
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, United States.
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Kimpe E, Parmentier R, Busschaert SL, De Mey J, Barbé K, De Ridder M, Putman K. Quantifying societal burden of radiation-induced small bowel toxicity in patients with rectal cancer. Front Oncol 2024; 14:1340081. [PMID: 39040451 PMCID: PMC11260702 DOI: 10.3389/fonc.2024.1340081] [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: 11/17/2023] [Accepted: 06/18/2024] [Indexed: 07/24/2024] Open
Abstract
Introduction Advancements in rectal cancer (RC) treatment not only led to an increase in lives saved but also improved quality of life (QoL). Notwithstanding these benefits, RC treatment comes at the price of gastrointestinal morbidity in many patients. Health economic modelling poses an opportunity to explore the societal burden of such side-effects. This study aims to quantify radiation-induced late small bowel (SB) toxicity in survivors of RC for Three-Dimensional Conformal Radiation Therapy (3D-CRT), Intensity Modulated Radiation Therapy (IMRT) and Intensity Modulated Radiation Therapy - Image Guided Radiation Therapy (IMRT/IGRT). Materials and methods Materials and A model-based health economic evaluation was performed. The theoretical cohort consists of a case-mix of survivors of RC aged 25-99 years according to Belgian age-specific incidence rates. A societal perspective was adopted. The base case analysis was complemented with one-way deterministic analyses, deterministic scenario analyses and probabilistic sensitivity analysis (1,000 iterations). Results were presented as mean lifetime incremental cost (€) and utility (QALYs) per patient. Results The analyses showed that the use of innovative radiotherapy (RT) improves lifetime QoL in survivors of RC by 0.11 QALYs and 0.05 QALYs by preferring IMRT/IGRT and IMRT over 3D-CRT, respectively. The use of IMRT/IGRT and IMRT results in an incremental cost-saving of €3,820 and €1,863 per patient, solely by radiation-induced SB toxicity, compared to 3D-CRT. Discussion and conclusion It is important to consider late toxicity effects in decisions regarding investments and reimbursement as our analysis highlighted the potential long-term cost-savings and improved QoL of novel RT techniques in patients with rectal cancer.
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Affiliation(s)
- Eva Kimpe
- Interuniversity Centre for Health Economics Research (I-CHER), Department of Public Health, Vrije Universiteit Brussel, Brussels, Belgium
| | - Riet Parmentier
- Interuniversity Centre for Health Economics Research (I-CHER), Department of Public Health, Vrije Universiteit Brussel, Brussels, Belgium
| | - Sara-Lise Busschaert
- Interuniversity Centre for Health Economics Research (I-CHER), Department of Public Health, Vrije Universiteit Brussel, Brussels, Belgium
| | - Johan De Mey
- Department of Radiology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Kurt Barbé
- Biostatistics and Medical Informatics Research Group (BISI), Department of Public Health, Vrije Universiteit Brussel, Brussels, Belgium
| | - Mark De Ridder
- Department of Radiotherapy, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Koen Putman
- Interuniversity Centre for Health Economics Research (I-CHER), Department of Public Health, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Radiotherapy, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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Noticewala SS, Das P. Current State of Neoadjuvant Therapy for Locally Advanced Rectal Cancer. Cancer J 2024; 30:227-231. [PMID: 39042772 DOI: 10.1097/ppo.0000000000000725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2024]
Abstract
ABSTRACT In locally advanced rectal cancer, neoadjuvant treatment has evolved from no preoperative treatment to the addition of radiation and systemic therapy and ultimately total neoadjuvant therapy. Total neoadjuvant therapy is the completion of preoperative radiation or chemoradiation and chemotherapy before surgery in order to maximize tumor response and improve survival outcomes. This review summarizes the literature of the neoadjuvant approaches related to locally advanced rectal cancer and highlights the nuances of selecting the appropriate treatment.
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Affiliation(s)
- Sonal S Noticewala
- From the Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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Turri G, Ostuzzi G, Vita G, Barresi V, Scarpa A, Milella M, Mazzarotto R, Ruzzenente A, Barbui C, Pedrazzani C. Treatment of Locally Advanced Rectal Cancer in the Era of Total Neoadjuvant Therapy: A Systematic Review and Network Meta-Analysis. JAMA Netw Open 2024; 7:e2414702. [PMID: 38833249 PMCID: PMC11151159 DOI: 10.1001/jamanetworkopen.2024.14702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 03/30/2024] [Indexed: 06/06/2024] Open
Abstract
Importance Treatment of locally advanced rectal cancer (LARC) involves neoadjuvant chemoradiotherapy plus total mesorectal excision and adjuvant chemotherapy. However, total neoadjuvant therapy (TNT) protocols (ie, preoperative chemotherapy in addition to radiotherapy) may allow better adherence and early treatment of distant micrometastases and may increase pathological complete response (pCR) rates. Objective To assess the efficacy and tolerability of TNT protocols for LARC. Data Sources MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science Core Collection electronic databases and ClinicalTrials.gov for unpublished studies were searched from inception to March 2, 2024. Study Selection Randomized clinical trials including adults with LARC who underwent rectal resection as a final treatment were included. Studies including nonoperative treatment (watch-and-wait strategy), treatments other than rectal resection, immunotherapy, or antiangiogenic agents were excluded. Among the initially identified studies, 2.9% met the selection criteria. Data Extraction and Synthesis Two authors independently screened the records and extracted data. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA)-compliant pairwise and network meta-analyses with a random-effects model were performed in a frequentist framework, and the certainty of evidence was assessed according to the confidence in network meta-analysis approach. Main Outcomes and Measures The primary outcome was pCR, defined as the absence of residual tumor at pathological assessment after surgery. Secondary outcomes included tolerability, toxic effects, perioperative outcomes, and long-term survival. Results Of 925 records identified, 27 randomized clinical trials, including 13 413 adults aged 18 years or older (median age, 60.0 years [range, 42.0-63.5 years]; 67.2% male) contributed to the primary network meta-analysis. With regard to pCR, long-course chemoradiotherapy (L-CRT) plus consolidation chemotherapy (relative risk [RR], 1.96; 95% CI, 1.25-3.06), short-course radiotherapy (S-RT) plus consolidation chemotherapy (RR, 1.76; 95% CI, 1.34-2.30), and induction chemotherapy plus L-CRT (RR, 1.57; 95% CI, 1.09-2.25) outperformed standard L-CRT with single-agent fluoropyrimidine-based chemotherapy. Considering 3-year disease-free survival, S-RT plus consolidation chemotherapy (RR, 1.08; 95% CI, 1.01-1.14) and induction chemotherapy plus L-CRT (RR, 1.12; 95% CI, 1.01-1.24) outperformed L-CRT, in spite of an increased 5-year locoregional recurrence rate of S-RT plus consolidation chemotherapy (RR, 1.65; 95% CI, 1.03-2.63). Conclusions and Relevance In this systematic review and network meta-analysis, 3 TNT protocols were identified to outperform the current standard of care in terms of pCR rates, with good tolerability and optimal postoperative outcomes, suggesting they should be recognized as first-line treatments.
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Affiliation(s)
- Giulia Turri
- Division of General and Hepatobiliary Surgery, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Giovanni Ostuzzi
- World Health Organization Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Giovanni Vita
- World Health Organization Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Valeria Barresi
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, Italy
| | - Aldo Scarpa
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, Italy
| | - Michele Milella
- Section of Oncology, Department of Engineering for Innovation Medicine, University of Verona Hospital Trust, Verona, Italy
| | - Renzo Mazzarotto
- Section of Radiotherapy, Department of Medicine, University of Verona Hospital Trust, Verona, Italy
| | - Andrea Ruzzenente
- Division of General and Hepatobiliary Surgery, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Corrado Barbui
- World Health Organization Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Corrado Pedrazzani
- Division of General and Hepatobiliary Surgery, Department of Engineering for Innovation Medicine, University of Verona, Verona, Italy
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O'Brien T, Hospers G, Conroy T, Lenz HJ, Smith JJ, Andrews E, O'Neill B, Leonard G. The role of total neoadjuvant therapy in locally advanced rectal cancer: a survey of specialists attending the All-Ireland Colorectal Cancer Conference 2022 including lead investigators of OPRA, PRODIGE-23 and RAPIDO. Ir J Med Sci 2024; 193:1183-1190. [PMID: 38141097 PMCID: PMC11128399 DOI: 10.1007/s11845-023-03591-4] [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: 12/11/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND The treatment of locally advanced rectal cancer (LARC) has evolved following recent landmark trials of total neoadjuvant therapy (TNT)-the delivery of preoperative chemotherapy sequenced with radiation. AIM To assess the preferences of colorectal surgery (CRS), radiation oncology (RO) and medical oncology (MO) specialists attending the All-Ireland Colorectal Cancer Conference (AICCC) 2022 regarding the neoadjuvant management of LARC. METHODS A live electronic survey explored the preferred treatment approach and TNT regimen for early-, intermediate-, bad-, and advanced-risk categories of rectal cancer according to the European Society of Medical Oncology (ESMO) guidelines. The survey was preceded by an update from lead investigators of TNT trials (OPRA, PRODIGE-23 and RAPIDO), who then participated in a multidisciplinary panel discussion. RESULTS Ten CRS, 7 RO and 15 MO (32 of 45 specialists) participated fully in the survey resulting in a response rate of 71%. Ninety-four percent, 76% and 53% of specialists preferred a TNT approach for patients with advanced, bad, and intermediate-risk rectal cancer, respectively. A consolidation TNT regimen of long-course chemoradiotherapy followed by chemotherapy was the most preferred regimen. Upfront surgery was preferred by 77% for early-risk disease. CONCLUSION This survey illustrated the general acceptance of TNT by rectal cancer specialists attending the AICCC as a valuable treatment strategy for higher-risk category LARC. Whilst the treatment of LARC changes, it remains best practice to individualize care, incorporating the selective use of TNT as discussed by an MDT and in keeping with the patient's goals of care.
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Affiliation(s)
- Timothy O'Brien
- Patrick G Johnston Centre for Cancer Research, Queen's University, Belfast, Northern Ireland.
| | - Geke Hospers
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Thierry Conroy
- Medical Oncology Department, Institut de Cancérologie de Lorraine, Vandoeuvre-Lès-Nancy, Nancy, France
- Université de Lorraine, APEMAC, Équipe MICS, Nancy, France
| | - Heinz-Josef Lenz
- Division of Medical Oncology, Keck School of Medicine, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Jesse Joshua Smith
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering, New York, NY, USA
| | - Emmet Andrews
- Department of Surgery, Cork University Hospital, University College Cork, Cork, Ireland
| | - Brian O'Neill
- Department of Radiation Oncology, St Luke's Radiation Oncology Network, Dublin, Ireland
| | - Gregory Leonard
- Department of Medical Oncology, University Hospital Galway, Newcastle Road, Galway, Ireland
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Medioni M, Cervantes B, Huguet F, Bachet JB, Parc Y, André T, Lefèvre JH, Cohen R. [An update on total neoadjuvant treatment of adenocarcinoma of the rectum]. Bull Cancer 2024; 111:483-495. [PMID: 38553289 DOI: 10.1016/j.bulcan.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 01/23/2024] [Accepted: 02/01/2024] [Indexed: 05/13/2024]
Abstract
A major advance has been made in the management of rectal cancer, with the emergence in 2021 of total neoadjuvant treatment. The main publications from the RAPIDO and PRODIGE-23 trials reported a significant improvement in progression-free survival and the pathological complete response rate. The aim of this review is to synthesize recent data on neoadjuvant treatment of rectal cancer, to explain the long-term results of the RAPIDO and PRODIGE-23 trials, and to put them into perspective, considering current advances in de-escalation strategies. The update of the 5-year survival data from the RAPIDO trial highlights an increased risk of loco-regional relapse, with 11.7% of relapses in the experimental group and 8.1% in the control group, while the update of the PRODIGE-23 trial confirms the benefits of this treatment regimen, with a significant improvement in overall survival. In addition, the results of the OPRA and PROPSPECT trials confirm the benefit of total neoadjuvant treatment with induction chemotherapy, as well as the possibility of surgical de-escalation in the OPRA trial and radiotherapy in the PROSPECT trial. The challenge for the future is to identify patients who require total neoadjuvant treatment with the aim of curative surgery to obtain a cure without local or distant relapse, and those for whom therapeutic de-escalation can be envisaged.
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Affiliation(s)
- Maroussia Medioni
- Sorbonne université, hôpital Saint-Antoine, AP-HP, service d'oncologie médicale, 75012 Paris, France
| | - Baptiste Cervantes
- Sorbonne université, hôpital Saint-Antoine, AP-HP, service d'oncologie médicale, 75012 Paris, France
| | - Florence Huguet
- Sorbonne université, hôpital Tenon, AP-HP, service d'oncologie radiothérapie, Paris, France
| | - Jean-Baptiste Bachet
- Sorbonne université, hôpital Pitié Salpêtrière, AP-HP, service d'hépato-gastroentérologie, Paris, France
| | - Yann Parc
- Sorbonne université, hôpital Saint-Antoine, AP-HP, service de chirurgie générale et digestive, Paris, France
| | - Thierry André
- Sorbonne université, hôpital Saint-Antoine, AP-HP, service d'oncologie médicale, 75012 Paris, France; INSERM URMS_938, centre de recherche Saint-Antoine, SIRIC CURAMUS, équipe instabilité des microsatellites et cancer, équipe labellisée par la Ligue Nationale contre le Cancer, Paris, France
| | - Jérémie H Lefèvre
- Sorbonne université, hôpital Saint-Antoine, AP-HP, service de chirurgie générale et digestive, Paris, France
| | - Romain Cohen
- Sorbonne université, hôpital Saint-Antoine, AP-HP, service d'oncologie médicale, 75012 Paris, France; INSERM URMS_938, centre de recherche Saint-Antoine, SIRIC CURAMUS, équipe instabilité des microsatellites et cancer, équipe labellisée par la Ligue Nationale contre le Cancer, Paris, France.
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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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Li A, Mao M, Chen R, Chi P, Huang Y, Wu J, Xu B. Excluding external iliac node irradiation during neoadjuvant radiotherapy decreases lower intestinal toxicity without compromising efficacy in T4b rectal cancer patients with tumours involving the anterior structures. Discov Oncol 2024; 15:76. [PMID: 38492016 PMCID: PMC10944434 DOI: 10.1007/s12672-024-00885-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 02/07/2024] [Indexed: 03/18/2024] Open
Abstract
PURPOSE To explore the impact of excluding the external iliac node (EIN) from the clinical target volume (CTV) during preoperative radiotherapy in T4b rectal cancer with anterior structure invasion. METHODS We retrospectively identified 132 patients with T4b rectal cancer involving the anterior structures who received radiotherapy followed by surgery between May 2010 and June 2019. Twenty-nine patients received EIN irradiation (EIN group), and 103 did not (NEIN group). Failure patterns, survival and toxicities were compared between the two groups. RESULTS The most common failure was distant metastasis (23.5%). 11 (8.3%) patients developed locoregional recurrence, 10 (9.7%) patients were in the NEIN group, and 1 (3.4%) was in the EIN group (P = 0.34). The EIN region failure was rare (1/132, 0.8%). The locoregional recurrence-free survival (LRFS), distant metastasis-free survival (DMFS), overall survival (OS) and progression-free survival (PFS) rates were 96.3% vs. 90.5%, 82.1% vs.73.7%, 75.9% vs. 78.0% and 72.4% vs. 68.3% (all P > 0.05) for the EIN group and NEIN group, respectively. The incidence of grade 3-4 acute toxicity in the lower intestine was significantly higher in the EIN group than in the NEIN group (13.8% vs. 1.9%, P = 0.02). The Dmax, V35 and V45 of the small bowel was decreased in the NEIN group compared to the EIN group. CONCLUSIONS Exclusion of the EIN from the CTV in T4b rectal cancer with anterior structure invasion could reduce lower intestinal toxicity without compromising oncological outcomes. These results need further evaluation in future studies.
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Affiliation(s)
- Anchuan Li
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Xinquan Road 29, Fuzhou, 350001, China
- Department of Radiation Oncology, College of Clinical Medicine, Fujian Medical University, Fuzhou, 350001, China
- Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for Tumors, Fujian Medical University, Fuzhou, 350001, China
- Clinical Research Center for Radiology and Radiotherapy of Fujian Province (Digestive, Hematological and Breast Malignancies), Fuzhou, 350001, China
| | - Miaobin Mao
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Xinquan Road 29, Fuzhou, 350001, China
- Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for Tumors, Fujian Medical University, Fuzhou, 350001, China
- Clinical Research Center for Radiology and Radiotherapy of Fujian Province (Digestive, Hematological and Breast Malignancies), Fuzhou, 350001, China
| | - Runfan Chen
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Xinquan Road 29, Fuzhou, 350001, China
| | - Pan Chi
- Department of Gastrointestinal Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, China
| | - Ying Huang
- Department of Gastrointestinal Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, China
| | - Junxin Wu
- Department of Radiation Oncology, Fujian Cancer Hospital, Fuma Road 420, Fuzhou, 350014, China.
| | - Benhua Xu
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Xinquan Road 29, Fuzhou, 350001, China.
- Department of Radiation Oncology, College of Clinical Medicine, Fujian Medical University, Fuzhou, 350001, China.
- Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for Tumors, Fujian Medical University, Fuzhou, 350001, China.
- Clinical Research Center for Radiology and Radiotherapy of Fujian Province (Digestive, Hematological and Breast Malignancies), Fuzhou, 350001, China.
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10
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Janczak J, Ukegjini K, Bischofberger S, Turina M, Müller PC, Steffen T. Quality of Surgical Outcome Reporting in Randomised Clinical Trials of Multimodal Rectal Cancer Treatment: A Systematic Review. Cancers (Basel) 2023; 16:26. [PMID: 38201454 PMCID: PMC10778098 DOI: 10.3390/cancers16010026] [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: 11/07/2023] [Revised: 12/07/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
INTRODUCTION Randomised controlled trials (RCTs) continue to provide the best evidence for treatment options, but the quality of reporting in RCTs and the completeness rate of reporting of surgical outcomes and complication data vary widely. The aim of this study was to measure the quality of reporting of the surgical outcome and complication data in RCTs of rectal cancer treatment and whether this quality has changed over time. METHODS Eligible articles with the keywords ("rectal cancer" OR "rectal carcinoma") AND ("radiation" OR "radiotherapy") that were RCTs and published in the English, German, Polish, or Italian language were identified by reviewing all abstracts published from 1982 through 2022. Two authors independently screened and analysed all studies. The quality of the surgical outcome and complication data was assessed based on fourteen criteria, and the quality of RCTs was evaluated based on a modified Jadad scale. The primary outcome was the quality of reporting in RCTs and the completeness rate of reporting of surgical results and complication data. RESULTS A total of 340 articles reporting multimodal therapy outcomes for 143,576 rectal cancer patients were analysed. A total of 7 articles (2%) met all 14 reporting criteria, 13 met 13 criteria, 27 met from 11 to 12 criteria, 36 met from 9 to 10 criteria, 76 met from 7 to 8 criteria, and most articles met fewer than 7 criteria (mean 5.5 criteria). Commonly underreported criteria included complication severity (15% of articles), macroscopic integrity of mesorectal excision (17% of articles), length of stay (18% of articles), number of lymph nodes (21% of articles), distance between the tumour and circumferential resection margin (CRM) (26% of articles), surgical radicality according to the site of the primary tumour (R0 vs. R1 + R2) (29% of articles), and CRM status (38% of articles). CONCLUSION Inconsistent surgical outcome and complication data reporting in multimodal rectal cancer treatment RCTs is standard. Standardised reporting of clinical and oncological outcomes should be established to facilitate comparing studies and results of related research topics.
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Affiliation(s)
- Joanna Janczak
- Clinic for General and Visceral Surgery, Hospital for the Region Fürstenland Toggenburg, CH-9500 Wil, Switzerland;
| | - Kristjan Ukegjini
- Department of Surgery, Hospital of the Canton of St. Gallen, CH-9007 St. Gallen, Switzerland; (K.U.); (S.B.)
| | - Stephan Bischofberger
- Department of Surgery, Hospital of the Canton of St. Gallen, CH-9007 St. Gallen, Switzerland; (K.U.); (S.B.)
| | - Matthias Turina
- Department of Surgery and Transplantation, University Hospital Zurich, CH-8091 Zurich, Switzerland;
| | - Philip C. Müller
- Department of Surgery, Clarunis—University Centre for Gastrointestinal and Hepatopancreatobiliary Diseases, CH-4002 Basel, Switzerland;
| | - Thomas Steffen
- Department of Surgery, Hospital of the Canton of St. Gallen, CH-9007 St. Gallen, Switzerland; (K.U.); (S.B.)
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11
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Chan H, Savoie MB, Munir A, Moslehi J, Anwar M, Laffan A, Rowen T, Salmon R, Varma M, Van Loon K. Multi-Disciplinary Management in Rectal Cancer Survivorship: A Clinical Practice Review. J Gastrointest Cancer 2023; 54:1102-1115. [PMID: 36622517 PMCID: PMC10754749 DOI: 10.1007/s12029-022-00885-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2022] [Indexed: 01/10/2023]
Abstract
Colorectal cancer (CRC) is the third most common cancer in the USA and worldwide. In the USA, nearly one-third of CRC cases are anatomically classified as rectal cancer. Over the past few decades, continued refinement of multimodality treatment and the introduction of new therapeutic agents have enhanced curative treatment rates and quality of life outcomes. As treatments improve and the incidence of young onset rectal cancer rises, the number of rectal cancer survivors grows each year. This trend highlights the growing importance of rectal cancer survivorship. Multimodality therapy with systemic chemotherapy, chemoradiation, and surgery can result in chronic toxicities in multiple organ systems, requiring a multi-disciplinary care model with services ranging from appropriate cancer surveillance to management of long-term toxicities and optimization of modifiable risk factors. Here, we review the evidence on these long-term toxicities and provide management considerations from consensus guidelines. Specific topics include bowel dysfunction from radiation and surgery, oxaliplatin-induced neuropathy, accelerated bone degeneration, the impact of fluoropyrimidines on long-term cardiovascular health, urinary incontinence, sexual dysfunction, and psychosocial distress. Additionally, we review modifiable risk factors to inform providers and rectal cancer survivors of various lifestyle and behavioral changes that can be made to improve their long-term health outcomes.
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Affiliation(s)
- Hilary Chan
- Department of Medicine, Division of Hematology and Oncology, University of California, San Francisco (UCSF), 550 16th Street, Floor 06, Room 6803, Box 3211, San Francisco, CA, 94158, USA
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
| | - Marissa B Savoie
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Amir Munir
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
- Department of Medicine, Division of Cardiology, UCSF, San Francisco, CA, USA
| | - Javid Moslehi
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
- Department of Medicine, Division of Cardiology, UCSF, San Francisco, CA, USA
| | - Mekhail Anwar
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
- Department of Radiation Oncology, UCSF, San Francisco, CA, USA
- Department of Electrical Engineering and Computer Sciences, University of California, Berkeley, Berkeley, CA, USA
| | - Angela Laffan
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
| | - Tami Rowen
- Department of Obstetrics and Gynecology, UCSF, San Francisco, CA, USA
| | - Rebeca Salmon
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
| | - Madhulika Varma
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
- Section of Colorectal Surgery, Department of Surgery, Department of Medicine, UCSF, San Francisco, CA, USA
| | - Katherine Van Loon
- Department of Medicine, Division of Hematology and Oncology, University of California, San Francisco (UCSF), 550 16th Street, Floor 06, Room 6803, Box 3211, San Francisco, CA, 94158, USA.
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA.
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12
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Boustani J, Huguet F, Vendrely V. Practice-changing clinical trials in radiation oncology for gastrointestinal malignancies in 2021-2023. Cancer Radiother 2023; 27:768-777. [PMID: 38415359 DOI: 10.1016/j.canrad.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 08/22/2023] [Indexed: 02/29/2024]
Abstract
Gastrointestinal cancers are one of the most frequent cancers and a leading cause of cancer deaths worldwide. We provide an overview of the most important practice-changing trials that were either published or presented at the international scientific meetings in 2021-2023. Highlights included reports on three phase III trials (CONCORDE/PRODIGE 26, ARTDECO, and a study by Xu et al.) that evaluated dose escalation in the definitive setting for locally advanced oesophageal cancers, as well as two phase III trials that evaluated the role of chemotherapy (neo-AEGIS) and targeted therapy (NRG/RTOG 1010) in the neoadjuvant setting for adenocarcinoma oesophageal cancers or gastroesophageal junction cancer. CheckMate 577 evaluated nivolumab in patients who had residual pathological disease after neoadjuvant chemoradiation followed by complete resection. The use of radiation therapy for borderline and locally advanced pancreatic cancer is also discussed (SMART and CONKO-007 trials). Stereotactic body radiation therapy followed by sorafenib was compared to sorafenib alone in patients with hepatocellular carcinoma in the NRG/RTOG 1112 study. New options in the management of rectal cancer are emerging such as total neoadjuvant treatment (PRODIGE 23, RAPIDO, PROSPECT), organ preservation (OPRA, OPERA), and the role of immunotherapy in patients with DNA mismatch-repair deficient/microsatellite instability. Finally, preliminary results of the ACT 4 trial that evaluated de-escalation in anal cancer are presented.
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Affiliation(s)
- J Boustani
- Department of Radiation Oncology, centre hospitalier universitaire de Besançon, Besançon, France; Inserm, EFS BFC, UMR 1098, RIGHT, Greffon-hôte-tumeur interactions/Ingénierie cellulaire et génique, université de Franche-Comté, Besançon, France.
| | - F Huguet
- Department of Radiation Oncology, hôpital Tenon, AP-HP, Sorbonne université, Paris, France
| | - V Vendrely
- Department of Radiation Oncology, centre hospitalier universitaire de Bordeaux, Bordeaux, France; BoRdeaux Institute of onCology (BRIC), UMR1312, Inserm, université de Bordeaux, 33000, Bordeaux, France
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13
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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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14
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Rouanet P, Castan F, Mazard T, Lemanski C, Nougaret S, Deshayes E, Chalbos P, Gourgou S, Taoum C. GRECCAR 14 - a multicentric, randomized, phase II-III study evaluating the tailored management of locally advanced rectal carcinoma after a favourable response to induction chemotherapy: Study protocol. Colorectal Dis 2023; 25:2078-2086. [PMID: 37697712 DOI: 10.1111/codi.16740] [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] [Received: 05/19/2023] [Revised: 07/27/2023] [Accepted: 08/03/2023] [Indexed: 09/13/2023]
Abstract
AIM Total neoadjuvant treatment (TNT) is becoming standard in patients with locally advanced rectal carcinoma (LARC). Preoperative chemoradiotherapy (CRT) has proven side effects on bowel and genitourinary function. An early tumoral response to induction chemotherapy demonstrates its high prognostic value. Tailored management could be used as an alternative to systematic CRT. The GRECCAR 14 trial will attempt to personalize treatment strategy according to the patient's early tumour response to intensive chemotherapy with the aim of achieving the best toxicity-efficiency ratio. METHOD GRECCAR 14 is a multicentric, randomized, two-arm, phase II-III noninferiority trial. Patients with mid or low LARC with a predictive circumferential resection margin ≤2 mm or T3c-d stage with extramural venous invasion will be included. Evaluation of the tumoral response will be performed after six courses of high-dose FOLFIRINOX chemotherapy. Good responders (GRs) will be defined by a 60% decrease in tumoral volume on magnetic resonance imaging. Patients will be randomized to CRT before surgery. The primary endpoints will be R0 resection for phase II and the 3-year disease-free survival (DFS) for phase III. RESULTS Tailored management of LARC is becoming an exciting challenge for the modality of neoadjuvant treatment and for the type of surgery or its omission. Neoadjuvant FOLFIRINOX has established efficacy, with a significant increase in the 3-year DFS. Better control of systemic disease must be accompanied by the same locoregional control, with the lowest morbidity. Our previous GRECCAR 4 trial demonstrated the high value of the early tumoral response after induction chemotherapy and the long-term safety of tailored management for GRs. CONCLUSION If GRECCAR 14 demonstrates the ability to tailor TNT for LARC, this could lead to changes in clinical practice.
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Affiliation(s)
- Philippe Rouanet
- Institut régional du Cancer de Montpellier (ICM), Montpellier, France
| | - Florence Castan
- Institut régional du Cancer de Montpellier (ICM), Montpellier, France
| | - Thibault Mazard
- Institut régional du Cancer de Montpellier (ICM), Montpellier, France
| | - Claire Lemanski
- Institut régional du Cancer de Montpellier (ICM), Montpellier, France
| | | | - Emmanuel Deshayes
- Institut régional du Cancer de Montpellier (ICM), Montpellier, France
| | - Patrick Chalbos
- Institut régional du Cancer de Montpellier (ICM), Montpellier, France
| | - Sophie Gourgou
- Institut régional du Cancer de Montpellier (ICM), Montpellier, France
| | - Christophe Taoum
- Institut régional du Cancer de Montpellier (ICM), Montpellier, France
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15
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Frerker B, Bock F, Cappel ML, Kriesen S, Klautke G, Hildebrandt G, Manda K. Radiosensitizing Effects of Irinotecan versus Oxaliplatin Alone and in Combination with 5-Fluorouracil on Human Colorectal Cancer Cells. Int J Mol Sci 2023; 24:10385. [PMID: 37373535 DOI: 10.3390/ijms241210385] [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: 05/15/2023] [Revised: 06/15/2023] [Accepted: 06/16/2023] [Indexed: 06/29/2023] Open
Abstract
To date, oxaliplatin and irinotecan are used in combination with 5-flourouracil (5-FU) for metastatic colorectal cancer. In this study it was tested whether oxaliplatin and irinotecan and their combinations with 5-FU have an enhanced effect when treated simultaneously with ionizing radiation. In addition, it should be compared whether one combination therapy is more effective than the other. Colorectal cancer cells (HT-29) were treated with irinotecan or oxaliplatin, both alone and in combination with 5-FU, and subsequently irradiated. The cell growth, metabolic activity and proliferation of cells were investigated, and the clonogenic survival was determined. Furthermore, the assessment of radiation-induced DNA damage and the influence of the drugs and their combinations on DNA damage repair was investigated. Treatment with irinotecan or oxaliplatin in combination with 5-FU inhibited proliferation and metabolic activity as well as clonogenic survival and the DNA damage repair capacity of the tumor cells. The comparison of oxaliplatin and irinotecan with simultaneous irradiation showed the same effect of both drugs. When oxaliplatin or irinotecan was combined with 5-FU, tumor cell survival was significantly lower than with monotherapy; however, there was no superiority of either combination regimen. Our results have shown that the combination of 5-FU and irinotecan is as effective as the combination of 5-FU with oxaliplatin. Therefore, our data support the use of FOLFIRI as a radiosensitizer.
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Affiliation(s)
- Bernd Frerker
- Department of Radiotherapy and Radiation Oncology, University Medical Center Rostock, Suedring 75, 18059 Rostock, Germany
| | - Felix Bock
- Department of Radiotherapy and Radiation Oncology, University Medical Center Rostock, Suedring 75, 18059 Rostock, Germany
| | - Marie-Louise Cappel
- Department of Radiotherapy and Radiation Oncology, University Medical Center Rostock, Suedring 75, 18059 Rostock, Germany
| | - Stephan Kriesen
- Department of Radiotherapy and Radiation Oncology, University Medical Center Rostock, Suedring 75, 18059 Rostock, Germany
| | - Gunther Klautke
- Department of Radiation Oncology, Hospital Chemnitz, Bürgerstrasse 2, 09113 Chemnitz, Germany
| | - Guido Hildebrandt
- Department of Radiotherapy and Radiation Oncology, University Medical Center Rostock, Suedring 75, 18059 Rostock, Germany
| | - Katrin Manda
- Department of Radiotherapy and Radiation Oncology, University Medical Center Rostock, Suedring 75, 18059 Rostock, Germany
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16
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Aoyama R, Hida K, Hasegawa S, Yamaguchi T, Manaka D, Kato S, Yamada M, Yamanokuchi S, Kyogoku T, Kanazawa A, Kawada K, Sakamoto T, Goto S, Sakai Y, Obama K. Long-term results of a phase 2 study of neoadjuvant chemotherapy with molecularly targeted agents for locally advanced rectal cancer. Int J Clin Oncol 2023; 28:392-399. [PMID: 36622469 DOI: 10.1007/s10147-023-02291-4] [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: 07/23/2022] [Accepted: 01/03/2023] [Indexed: 01/10/2023]
Abstract
BACKGROUND We previously reported the feasibility and efficacy of neoadjuvant chemotherapy without radiotherapy for locally advanced rectal cancer. Here, we report the results of a long-term follow-up study. METHODS This was a multi-institutional, prospective phase 2 study of patients with locally advanced rectal cancer. Patients received neoadjuvant chemotherapy with molecularly targeted agents before undergoing total mesorectal excision. Six cycles of modified FOLFOX (mFOLFOX6) with bevacizumab were administered to KRAS-mutant patients, and mFOLFOX6 with cetuximab was administered to KRAS-wild-type patients. Here, we report the secondary end points of overall survival, relapse-free survival, and local recurrence rate. RESULTS Sixty patients were enrolled in this study. R0 resection was achieved in 98.3% (59/60) patients, and pathological complete response was achieved in 16.7% (10/60) patients. After a median follow-up of 5.4 years, the 5 year overall survival was 81.6%, the 5 year relapse-free survival was 71.7%, and the 5 year local recurrence rate was 12.6%. None of the patients who achieved pathological complete response developed recurrence within 5 years. CONCLUSIONS The use of molecularly targeted agents in the neoadjuvant setting for locally advanced rectal cancer has an acceptable prognosis.
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Affiliation(s)
- Ryuhei Aoyama
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Koya Hida
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Suguru Hasegawa
- Department of Gastroenterological Surgery, Fukuoka University, Fukuoka, Japan
| | | | - Dai Manaka
- Department of Surgery, Kyoto Katsura Hospital, Kyoto, Japan
| | - Shigeru Kato
- Department of Gastrointestinal Surgery, Tenri Yorozu Hospital, Nara, Japan
| | | | | | | | - Akiyoshi Kanazawa
- Department of Gastroenterological Surgery and Oncology, Kitano Hospital Medical Research Institute, Osaka, Japan
| | - Kenji Kawada
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takashi Sakamoto
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Saori Goto
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yoshiharu Sakai
- Department of Surgery, Osaka Red Cross Hospital, Osaka, Japan
| | - Kazutaka Obama
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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17
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Grabenbauer A, Aigner T, Göbel H, Leibl BJ, Lamberti C, Grabenbauer GG, Distel LV. Preoperative Radiochemotherapy in Rectal Cancer: Is There an Impact of Oxaliplatin on Pathologic Complete Response and Survival Rates under "Real World" Conditions? Cells 2023; 12:cells12030399. [PMID: 36766741 PMCID: PMC9913152 DOI: 10.3390/cells12030399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 01/19/2023] [Indexed: 01/24/2023] Open
Abstract
This study aimed to evaluate the benefit of additional administration of oxaliplatin during fluorouracil-based neoadjuvant radiochemotherapy (nRCT) in terms of pathologic complete remission (pCR), disease-free survival (DFS), and overall survival (OS) in patients with advanced rectal cancer. Between 2006 and 2021, 669 patients (pts) were diagnosed with locally advanced rectal cancer, of whom a total of 414 pts with nRCT were identified and included in the study. A total of 283 pts were treated by nRCT using concurrent chemotherapy with fluorouracil or capecitabine; 131 pts were treated using a combination of fluorouracil or capecitabine and oxaliplatin. Propensity score matching analyses (PSM) with 114 pts in each group were used to balance the patients' characteristics. OS, DFS, pCR-rate, and potential prognostic factors were compared between the two groups. The median follow-up time was 59.5 weeks in the fluorouracil-group and 43 weeks in the fluorouracil/oxaliplatin group (p = 0.003). After PSM, the pCR-rate (including sustained clinical complete remission) was 27% (31/114 pts) in the fluorouracil/oxaliplatin group and 16% (18/114 pts) in the fluorouracil-group (p = 0.033). There was no difference between these two groups for both 10-year OS and DFS neither before nor after PSM, respectively (OS: 72.6% vs. 55.4%, p = 0.066, and 67.8% vs. 55.1%, p = 0.703, and DFS: 44.8% vs. 46.8%, p = 0.134, and 44.7% vs. 42.3%, p = 0.184). Multivariate analysis identified regression grading according to Dworak grade 4 (HR: 0.659; CI: 0.471-0.921; p = 0.015) and age over 60 years (HR: 2.231; CI: 1.245-4.001; p = 0.007) as independent predictors for OS. In conclusion, the addition of oxaliplatin to fluorouracil during nRCT significantly improved pCR-rate without having an impact on survival.
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Affiliation(s)
- Alexander Grabenbauer
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Thomas Aigner
- Department of Pathology, Coburg Cancer Center, 96450 Coburg, Germany
| | - Holger Göbel
- Department of Gastroenterology, Coburg Cancer Center, 96450 Coburg, Germany
| | - Bernhard J. Leibl
- Department of Abdominal Surgery, Coburg Cancer Center, 96450 Coburg, Germany
| | - Christof Lamberti
- Department of Hematology and Oncology, Coburg Cancer Center, 96450 Coburg, Germany
| | | | - Luitpold V. Distel
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany
- Correspondence: ; Tel.: +49-9131-853-2312; Fax: +49-9131-853-9335
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18
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Morton AJ, Rashid A, Shim JSC, West J, Humes DJ, Grainge MJ. Long-term adverse effects and healthcare burden of rectal cancer radiotherapy: systematic review and meta-analysis. ANZ J Surg 2023; 93:42-53. [PMID: 36189976 DOI: 10.1111/ans.18059] [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: 05/29/2022] [Revised: 09/06/2022] [Accepted: 09/08/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND As rectal cancer survival increases, more patients survive with potentially severe, long-term gastrointestinal and genitourinary complications from radiotherapy. The burden of these complications for patients and healthcare services is unclear, which this review aims to quantify. METHODS Systematic search of Medline and Embase for randomized-controlled trials (RCTs) and multicentre observational studies published since 2000, reporting hospitalization/procedural intervention for long-term (>6 months post-treatment) gastrointestinal or genitourinary complications after radiotherapy and surgery for rectal cancer. Prevalence values were pooled in a meta-analysis assuming random effects. Organ-preservation patients were excluded. RESULTS 4044 records screened; 24 reports from 23 studies included (15 RCTs, 8 Observational), encompassing 15 438 patients. Twenty-one studies (median follow-up 60 months) reported gastrointestinal complications post-radiotherapy: pooled prevalence 11% (95% confidence interval (95% CI) 8-14%). Thirteen reported small bowel obstruction: prevalence 9% (95% CI 6-12%), a 58% increased risk compared with surgery alone (RR 1.58, 95% CI 1.26-1.98, n = 5 studies). Seven reported fistulas: prevalence 1% (95% CI 1-2%). Thirteen reported genitourinary complications: prevalence 4% (95% CI 1-6%); RR 1.10 (95% CI 0.88-1.38, n = 3 studies) compared with surgery alone. CONCLUSIONS Over 10% of patients are hospitalized for long-term complications following rectal cancer radiotherapy. Serious gastrointestinal complications are commonplace; late small bowel obstruction is more common in patients having radiotherapy and surgery compared with surgery alone. Patients and clinicians need to be aware of these risks.
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Affiliation(s)
- Alastair J Morton
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK.,Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Adil Rashid
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK.,Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Joanna S C Shim
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Joe West
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK.,Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK.,Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - David J Humes
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK.,Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Matthew J Grainge
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK.,Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
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O'Brien TN, Shahrokni A, Horgan AM. Total Neoadjuvant Therapy for rectal cancer: Totally Not Translatable to the older patient? J Geriatr Oncol 2023; 14:101348. [PMID: 35882578 DOI: 10.1016/j.jgo.2022.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/14/2022] [Accepted: 07/18/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Timothy N O'Brien
- Medical Oncology Dept., University Hospital Waterford, Ardkeen, Waterford, Ireland.
| | - Armin Shahrokni
- Dept. of Medicine/Geriatrics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Anne M Horgan
- Medical Oncology Dept., University Hospital Waterford, Ardkeen, Waterford, Ireland
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Paszt A, Ottlakan A, Abraham S, Simonka Z, Vas M, Maraz A, Szepes Z, Tiszlavicz L, Nyari T, Olah J, Lazar G. Clinical benefits of oral capecitabine over intravenous 5-fluorouracyl regimen in case of neoadjuvant chemoradiotherapy followed by surgery for locally advanced rectal cancer. Pathol Oncol Res 2022; 28:1610722. [PMID: 36567978 PMCID: PMC9773127 DOI: 10.3389/pore.2022.1610722] [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: 07/20/2022] [Accepted: 11/23/2022] [Indexed: 12/13/2022]
Abstract
Background: During the last decade, one of the most important treatment options for locally advanced, potencially resectable rectal tumours was neoadjuvant chemoradiotherapy (CRT) followed by surgery. Methods: Effects of the neoadjuvant treatment on surgical outcomes were retrospectively analysed in 185 patients with stage T2-T4 and N0-2, resectable rectal tumour among two patient groups defined by radiosensitizer agents. Group 1 (n = 94) involved radiotherapy (RT) with 50.4 Gy total dose (25 × 1.8 Gy + 3 × 1.8 Gy tumour bed boost), and intravenous 5-fluorouracil (5-FU) (350 mg/m2) with leucovorin (20 mg/m2) on the 1-5 and 21-25 days, while Group 2 (n = 91) RT and orally administrated capecitabine (daily 2 × 825 mg/m2) on RT days. Surgery was carried out after 8-10 weeks. Side effects, perioperative complications, type of surgery, number of removed regional lymph nodes, resection margins and tumour regression grade (TRG) were analysed. Results: More favourable side effects were observed in Group 2. Despite the same rate of diarrhoea (Group 1 vs. Group 2: 54.3% vs. 56.0%), Grade 2-3 diarrhoea ratio was lower (p = 0.0352) after capecitabine (Group 2). Weight loss occurred in 17.0% and 2.2% (p = 0.00067), while nausea and vomiting was described in 38.3% and 15.4% (p = 0.00045) with 5-FU treatment and capecitabine respectively. Anaemia was observed in 33.0% and 22.0% (p = 0.0941). Complete tumour regression occurred in 25.3% after oral- and 13.8% after intravenous treatment (p = 0.049). Ratio of sphincter preservation was higher with laparoscopy than open surgery (72.3% vs. 39.7%) (p = 0.00001). Conclusion: The study confirms advantages of neoadjuvant chemoradiotherapy with oral capecitabine for rectal tumours, such as more favourable side effect profile and overall clinical outcome, with increased rate of complete tumour regression.
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Affiliation(s)
- Attila Paszt
- Department of Surgery, University of Szeged, Szeged, Hungary,*Correspondence: Attila Paszt,
| | - Aurel Ottlakan
- Department of Surgery, University of Szeged, Szeged, Hungary
| | | | - Zsolt Simonka
- Department of Surgery, University of Szeged, Szeged, Hungary
| | - Marton Vas
- Department of Surgery, University of Szeged, Szeged, Hungary
| | - Aniko Maraz
- Department of Oncotherapy, University of Szeged, Szeged, Hungary
| | - Zoltan Szepes
- 1st Department of Internal Medicine, University of Szeged, Szeged, Hungary
| | | | - Tibor Nyari
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Judit Olah
- Department of Oncotherapy, University of Szeged, Szeged, Hungary
| | - Gyorgy Lazar
- Department of Surgery, University of Szeged, Szeged, Hungary
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Eng L, Brual J, Nagee A, Mok S, Fazelzad R, Chaiton M, Saunders D, Mittmann N, Truscott R, Liu G, Bradbury P, Evans W, Papadakos J, Giuliani M. Reporting of tobacco use and tobacco-related analyses in cancer cooperative group clinical trials: a systematic scoping review. ESMO Open 2022; 7:100605. [PMID: 36356412 PMCID: PMC9646674 DOI: 10.1016/j.esmoop.2022.100605] [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: 08/14/2022] [Revised: 09/21/2022] [Accepted: 09/23/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Continued smoking after a diagnosis of cancer negatively impacts cancer outcomes, but the impact of tobacco on newer treatments options is not well established. Collecting and evaluating tobacco use in clinical trials may advance understanding of the consequences of tobacco use on treatment modalities, but little is known about the frequency of reporting and analysis of tobacco use in cancer cooperative clinical trial groups. PATIENTS AND METHODS A comprehensive literature search was conducted to identify cancer cooperative group clinical trials published from January 2017-October 2019. Eligible studies evaluated either systemic and/or radiation therapies, included ≥100 adult patients, and reported on at least one of: overall survival, disease/progression-free survival, response rates, toxicities/adverse events, or quality-of-life. RESULTS A total of 91 studies representing 90 trials met inclusion criteria with trial start dates ranging from 1995 to 2015 with 14% involving lung and 5% head and neck cancer patients. A total of 19 studies reported baseline tobacco use; 2 reported collecting follow-up tobacco use. Seven studies reported analysis of the impact of baseline tobacco use on clinical outcomes. There was significant heterogeneity in the reporting of baseline tobacco use: 7 reported never/ever status, 10 reported never/ex-smoker/current smoker status, and 4 reported measuring smoking intensity. None reported verifying smoking status or second-hand smoke exposure. Trials of lung and head and neck cancers were more likely to report baseline tobacco use than other disease sites (83% versus 6%, P < 0.001). CONCLUSIONS Few cancer cooperative group clinical trials report and analyze trial participants' tobacco use. Significant heterogeneity exists in reporting tobacco use. Routine standardized collection and reporting of tobacco use at baseline and follow-up in clinical trials should be implemented to enable investigators to evaluate the impact of tobacco use on new cancer therapies.
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Affiliation(s)
- L. Eng
- Division of Medical Oncology and Hematology, Department of Medicine, Princess Margaret Cancer Centre/University Health Network and University of Toronto, Toronto, Canada,Prof L. Eng, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, Ontario M5G 2M9, Canada. Tel: +1-416-946-2953; Fax: +1-416-946-6546 @Lawson_Eng@MeredithGiulia1@PMcancercentre
| | - J. Brual
- Cancer Education Program, Princess Margaret Cancer Centre, Toronto, Canada
| | - A. Nagee
- Cancer Education Program, Princess Margaret Cancer Centre, Toronto, Canada
| | - S. Mok
- Cancer Education Program, Princess Margaret Cancer Centre, Toronto, Canada
| | - R. Fazelzad
- Library and Information Services, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - M. Chaiton
- Centre for Addiction and Mental Health, University of Toronto, Toronto, Canada
| | - D.P. Saunders
- Northeast Cancer Centre of Health Sciences North, Northern Ontario School of Medicine, Sudbury, Canada
| | - N. Mittmann
- Canadian Agency for Drugs and Technologies in Health, Toronto, Canada
| | - R. Truscott
- Division of Prevention Policy and Stakeholder Engagement, Ontario Health (Cancer Care Ontario), Toronto, Canada
| | - G. Liu
- Division of Medical Oncology and Hematology, Department of Medicine, Princess Margaret Cancer Centre/University Health Network and University of Toronto, Toronto, Canada
| | - P.A. Bradbury
- Division of Medical Oncology and Hematology, Department of Medicine, Princess Margaret Cancer Centre/University Health Network and University of Toronto, Toronto, Canada
| | - W.K. Evans
- Department of Oncology, McMaster University, Hamilton, Canada
| | - J. Papadakos
- Cancer Education Program, Princess Margaret Cancer Centre, Toronto, Canada,Patient Education, Ontario Health (Cancer Care Ontario), Toronto, Canada
| | - M.E. Giuliani
- Cancer Education Program, Princess Margaret Cancer Centre, Toronto, Canada,Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Canada,Correspondence to: Prof M. Giuliani, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, Ontario M5G 2M9, Canada. Tel: +1-416-946-2983; Fax: +1-416-946-6546
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Ma Z, Tan L, Liu ZL, Xiao JW. Total neoadjuvant therapy or standard chemoradiotherapy for locally advanced rectal cancer: A systematic review and meta-analysis. Front Surg 2022; 9:911538. [PMID: 36090336 PMCID: PMC9458916 DOI: 10.3389/fsurg.2022.911538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 08/10/2022] [Indexed: 11/29/2022] Open
Abstract
Background and Aim The effectiveness of total neoadjuvant therapy (TNT) on patients with locally advanced rectal cancer (LARC) is controversy. This study aims to compare the prognostic value of TNT with standard neoadjuvant chemoradiotherapy (CRT) for LARC. Methods We searched databases (Embase [Ovid], Medline [Ovid], PubMed, Cochrane Library, and Web of Science) for articles published between January 1, 2000, and March 10, 2022. Studies on evaluating the effects of TNT and standard CRT on the prognosis of LARC were included. The primary outcomes were overall survival (OS) and disease-free survival (DFS). Results 19 primary studies, involving 10 randomized controlled trials, 3 prospective studies and 6 retrospective studies, with data on 5,074 patients treated for LARC were included in the meta-analysis. Statistical analyses revealed that, compared with standard CRT, TNT significantly improved OS (hazard ratio [HR]=0.77, 95% confidence interval [CI]=0.65–0.90, I2 = 30%, P = 0.17), DFS (HR = 0.85, 95% CI = 0.74–0.97, I² = 11%, P = 0.35), distant metastases-free survival (DMFS, HR = 0.76, 95% CI = 0.65–0.90, I² = 0%, P = 0.50), pathological complete response rate (pCR, OR = 1.89, 95% CI = 1.61–2.22, I² = 0%, P = 0.47), and R0 resection rate (OR = 1.33, 95% CI = 1.07–1.67, I² = 16%, P = 0.28), but local recurrence-free survival (LRFS, HR = 1.12, 95% CI = 0.90–1.39, I² = 4%, P = 0.37). Conclusions Comprehensive literature research shows that TNT showed excellent short-term efficacy in terms of pCR and R0 resection rate while also improved the long-term outcomes of OS, DFS and DMFS, might become a new standard of treatment in patients with LARC. Even so, more studies and longer follow-up were still warranted.
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Affiliation(s)
- Zhou Ma
- Department of Gastrointestinal Surgery, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
- Department of Gastrointestinal Surgery, BaZhong Central Hospital, Bazhong, China
| | - Ling Tan
- Department of Urology, People's Hospital Affiliated to Chongqing Three Gorges Medical College, Chongqing, China
| | - Zi-lin Liu
- Department of Gastrointestinal Surgery, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Jiang-wei Xiao
- Department of Gastrointestinal Surgery, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
- Correspondence: Jiang-wei Xiao
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Larrouy A, Giraud N, Huguet F, Vendrely V. [Organ preservation for rectal cancer: What are the arguments in favor of radiotherapy?]. Cancer Radiother 2022; 26:766-770. [PMID: 35995720 DOI: 10.1016/j.canrad.2022.06.013] [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: 06/10/2022] [Revised: 06/14/2022] [Accepted: 06/17/2022] [Indexed: 11/28/2022]
Abstract
Standard care for rectal cancers relies on both tumor (location relative to the sphincter, T and N stage, sphincter involvement) and patients characteristics. Radical surgery (total mesorectal excision) following short-course radiotherapy (RT) or standard chemo-radiotherapy, associated with induction or consolidation chemotherapy (total neoadjuvant treatment), remains the cornerstone of locally advanced rectal cancer (T3cd, T4 and/or N+) treatment. Nevertheless, for early stages, this radical resection could be avoided in favor of conservative approaches combining RT (external, contact, brachytherapy) with or without chemotherapy (concurrent, induction or consolidative), or even be limited, for good responders, to a local excision with view of organ-preservation strategies. This conservative approach could also be offered selectively to patients with complete clinical response after the induction sequence, irrespective of initial tumor characteristics. The Watch and Wait strategy relies on clinical, endoscopic and radiological evaluations, as well as sustained surveillance. Ongoing studies aim to improve response rates, either with chemotherapy intensification, or RT boost dose escalation with brachytherapy or contact-therapy.
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Affiliation(s)
- A Larrouy
- Institut cancérologie Paris Nord, service d'oncologie radiothérapie, avenue Charles-Péguy, 95200 Sarcelles, France.
| | - N Giraud
- Service d'oncologie radiothérapie, hôpital Haut-Lévêque, CHU de Bordeaux, Bordeaux, France
| | - F Huguet
- Assistance publique-Hôpitaux de Paris, service d'oncologie radiothérapie, hôpital Tenon, AP-HP, Sorbonne université, Paris, France
| | - V Vendrely
- Service d'oncologie radiothérapie, hôpital Haut-Lévêque, CHU de Bordeaux, Bordeaux, France; U1312-BRIC, eq BioGO, Inserm, université de Bordeaux, 33000 Bordeaux, France
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Gerard JP, Montagne L, Thamphya B, Doyen J, Schiappa R, Benezery K, Gourgou S, Dejean C, Hannoun-Levi JM. Propensity score analysis of radical proctectomy versus organ preservation using contact X-ray brachytherapy for rectal cancer. Clin Transl Radiat Oncol 2022; 33:70-76. [PMID: 35118202 PMCID: PMC8791854 DOI: 10.1016/j.ctro.2021.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 12/14/2021] [Accepted: 12/19/2021] [Indexed: 11/25/2022] Open
Abstract
Key objective: the goal provides data to evaluate the oncological risk of performing a planned- conservative strategy in selected patients presenting early T2-T3 rectal adenocarcinoma. Knowledge generated: This propensity score analysis on 72 patients, comparing neoadjuvant chemoradiotherapy followed by radical surgery with planned organ preservation using combined chemoradiotherapy and contact X-ray brachytherapy boost, showed no detrimental oncological safety results after 5 year follow-up. Relevance: This study supplies additional arguments in favor of organ preservation for selected early rectal T2-T3.
Introduction Radical proctectomy (RP-TME) with neo adjuvant chemoradiotherapy (nCRT) remains the standard treatment for T2-T3 rectal cancer. Organ preservation (OP) using CRT and a “watch and wait” strategy (W&W) is a field of research. Planned organ preservation can be proposed for early T1-T3 using contact X-ray brachytherapy (CXB). We compared the oncological outcomes of both approaches using a propensity score matched-cohort analysis. Material and methods For comparative analyses between patients with nCRT + RP-TME and patients with CXB + CRT, propensity scores were calculated with logistic regression and multiple imputations for missing data. The variables included in the propensity score model were PS status, T-N stage and rectal circumference extension. Patients were matched 1:1 using the nearest neighbor method with a 0.1 caliper restriction. The 5-year Cancer Specific survival was the primary end point. Results The Accord 12 phase III trial included 584 patients who treated with nCRT + RP-TME. The CXB cohort included 71 patients with a planned OP. To select OP patient candidate, T4, tumor with extension >66% circumference were eliminated and only patients treated with CXB + CRT were analyzed in the CXB cohort resulting in a total of 374 patients. A one to one paired cohort with 36 patients in each group was derived. These two cohorts were well matched for all confounding factors except for age. The 5-year cancer specific rate showed no significant difference between the two groups (89% in Accord 12 vs 82% in CXB; p = 0.84). At 5 years, rate of metastasis (15% vs 22%, p = 0.54) showed no significant difference. In the CXB group 33/36 patients preserved their rectum. Conclusion The organ preservation strategy using CXB boost yielded a 5-year cancer specific survival rate similar to patients treated with RP-TME. In selected early T2-3 rectal adenocarcinoma an organ preservation strategy could be offered as a reasonable option.
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Dudani S, Marginean H, Gotfrit J, Tang PA, Monzon JG, Dennis K, Kennecke HF, Powell ED, Babak S, Cheung WY, Vickers MM. The Impact of Chronic Kidney Disease in Patients With Locally Advanced Rectal Cancer Treated With Neoadjuvant Chemoradiation. Dis Colon Rectum 2021; 64:1471-1478. [PMID: 34657078 PMCID: PMC8568328 DOI: 10.1097/dcr.0000000000002116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Patients with chronic kidney disease are commonly excluded from clinical trials. The impact of chronic kidney disease on outcomes in patients with locally advanced rectal cancer has not been previously studied. OBJECTIVE This study aimed to investigate the impact of chronic kidney disease on outcomes in patients with locally advanced rectal cancer. DESIGN This is a multi-institutional, retrospective cohort study. SETTINGS This study was conducted at academic and community cancer centers participating in the Canadian Health Outcomes Research Database Consortium Rectal Cancer Database. PATIENTS Consecutive patients with locally advanced rectal cancer undergoing neoadjuvant chemoradiation before curative-intent surgery from 2005 to 2013 were selected. MAIN OUTCOME MEASURES Disease-free survival, overall survival, pathologic complete response, and neoadjuvant chemotherapy/radiotherapy completion rate were the primary outcomes measured. RESULTS A total of 1254 patients were included. Median age was 62, and 29%/69% had clinical stage II and III disease. Median estimated creatinine clearance was 93 mL/min, with 11% <60 mL/min (n = 136). There was no significant difference in the completion rate of neoadjuvant chemotherapy (82% vs 85%, p = 0.36) or radiotherapy (93% vs 95%, p = 0.45) between patients with and without chronic kidney disease. Patients with chronic kidney disease were less likely to receive adjuvant chemotherapy (63% vs 77%, p < 0.01). On multivariate analysis, patients with chronic kidney disease had decreased disease-free survival (HR, 1.37; 95% CI, 1.03-1.82; p = 0.03) but not overall survival (HR, 1.23; 95% CI, 0.88-1.75; p = 0.23) or pathologic complete response (OR, 0.83; 95% CI, 0.50-1.39; p = 0.71). LIMITATIONS This study was limited by its retrospective design and by limited events for overall survival analysis. CONCLUSIONS In patients with locally advanced rectal cancer undergoing neoadjuvant chemoradiation, baseline chronic kidney disease was associated with less use of adjuvant chemotherapy and decreased disease-free survival. Chronic kidney disease was not independently associated with neoadjuvant chemotherapy/radiotherapy completion rate, pathologic complete response, or overall survival. These data suggest that patients with locally advanced rectal cancer with chronic kidney disease may have distinct outcomes and, accordingly, the results of landmark clinical trials may not be generalizable to this population. See Video Abstract at http://links.lww.com/DCR/B694. LA REPERCUSIN DE LA ENFERMEDAD RENAL CRNICA EN PACIENTES CON CNCER DE RECTO LOCALMENTE AVANZADO TRATADOS CON QUIMIORRADIOTERAPIA NEOADYUVANTE ANTECEDENTES:Los pacientes con enfermedad renal crónica generalmente se excluyen de los ensayos clínicos. La repercusión de la enfermedad renal crónica en el desenlace en pacientes con cáncer de recto localmente avanzado no se ha estudiado previamente.OBJETIVO:Investigar la repercusión de la enfermedad renal crónica en los desenlaces en pacientes con cáncer de recto localmente avanzado.DISEÑO:Estudio de cohorte retrospectivo multiinstitucional.ESCENARIO:Centros oncológicos académicos y comunitarios que participan en la base de datos de cáncer rectal del consorcio CHORD.PACIENTES:Pacientes consecutivos con cáncer de recto localmente avanzado, tratados con quimiorradioterapia neoadyuvante, previa a la cirugía con intención curativa del 2005 al 2013.PRINCIPALES VARIABLES EVALUADAS:Sobrevida libre de enfermedad, sobrevida global, respuesta patológica completa, tasa de conclusión de quimioterapia / radioterapia neoadyuvante.RESULTADOS:Se incluyeron 1254 pacientes. El promedio de edad fue de 62, y el 29% / 69% tenían enfermedad en estadio clínico II y III, respectivamente. El promedio de la depuración de creatinina estimada fue de 93 mililitros / minuto, con un 11% <60 mililitros / minuto (n = 136). No hubo diferencias significativas en la tasa de conclusión de la quimioterapia neoadyuvante (82% vs 85%, p = 0,36) o radioterapia (93% vs 95%, p = 0,45) entre pacientes con y sin enfermedad renal crónica. Los pacientes con enfermedad renal crónica tenían menos probabilidades de recibir quimioterapia adyuvante (63% contra el 77%, p <0,01). En el análisis multivariado, los pacientes con enfermedad renal crónica tenían una sobrevida libre de enfermedad menor (HR 1,37, IC 95% 1,03-1,82, p = 0,03) pero no en la sobrevida global (HR 1,23, IC 95% 0,88-1,75, p = 0,23) o respuesta patológica completa (OR 0,83, IC 95% 0,50-1,39, p = 0,71).LIMITACIONES:Diseño retrospectivo y acontecimientos limitados para el análisis de sobrevida global.CONCLUSIONES:En pacientes con cáncer de recto localmente avanzado tratados con quimiorradioterapia neoadyuvante, la enfermedad renal crónica de base se asoció con un menor uso de quimioterapia adyuvante y una menor sobrevida libre de enfermedad. La enfermedad renal crónica no se asoció de forma independiente con la tasa de conclusión de la quimioterapia / radioterapia neoadyuvante, la respuesta patológica completa o la sobrevida global. Estos datos sugieren que los pacientes con cáncer de recto localmente avanzado con enfermedad renal crónica pueden tener resultados distintos y, en consecuencia, los resultados de los ensayos clínicos de referencia pueden no ser generalizables a esta población. Consulte Video Resumen en http://links.lww.com/DCR/B694.
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Affiliation(s)
- Shaan Dudani
- The Ottawa Hospital Cancer Centre/University of Ottawa, Ottawa, Ontario, Canada
| | - Horia Marginean
- The Ottawa Hospital Cancer Centre/University of Ottawa, Ottawa, Ontario, Canada
| | - Joanna Gotfrit
- The Ottawa Hospital Cancer Centre/University of Ottawa, Ottawa, Ontario, Canada
| | - Patricia A. Tang
- Alberta Health Services/University of Calgary, Calgary, Alberta, Canada
| | | | - Kristopher Dennis
- The Ottawa Hospital Cancer Centre/University of Ottawa, Ottawa, Ontario, Canada
| | | | - Erin D. Powell
- Dr. H Bliss Murphy Cancer Centre, St. John’s, Newfoundland, Canada
| | - Sam Babak
- Alberta Health Services/University of Calgary, Calgary, Alberta, Canada
| | - Winson Y. Cheung
- British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Michael M. Vickers
- The Ottawa Hospital Cancer Centre/University of Ottawa, Ottawa, Ontario, Canada
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Des Guetz G, Landre T, Bollet MA, Mathonnet M, Quéro L. Is There a Benefit of Oxaliplatin in Combination with Neoadjuvant Chemoradiotherapy for Locally Advanced Rectal Cancer? An Updated Meta-Analysis. Cancers (Basel) 2021; 13:6035. [PMID: 34885147 PMCID: PMC8657124 DOI: 10.3390/cancers13236035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 11/15/2021] [Accepted: 11/26/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Neoadjuvant fluoropyrimidine (5FU or capecitabine)-based chemoradiotherapy (CRT) has been considered the standard of care for locally advanced rectal cancer (LARC). Whether addition of oxaliplatin (OXP) will further improve clinical outcomes is still unclear. METHODS To identify clinical trials combining oxaliplatin in preoperative CRT or perioperative chemotherapy for LARC published until March 2021, we searched PubMed and the Cochrane Library. We also searched for relevant ASCO conference abstracts. The primary endpoint was disease-free survival (DFS). Data were extracted from every study to perform a meta-analysis using Review Manager (version 5.3). RESULTS A total of seven randomized clinical trials (ACCORD-12, CARO-AIO-04, FOWARC, JIAO, NSABP, PETACC-6, and STAR-01) with 5782 stage II or III rectal cancer patients were analyzed, including 2727 patients with OXP + 5FU regimen and 3055 patients with 5FU alone. Compared with the 5FU alone group, the OXP + 5FU regimen improved DFS (HR = 0.90, 95% CI: 0.81-0.99, p = 0.03) and pathologic complete response (pCR) (OR = 1.21, 95% CI: 1.07-1.37, p = 0.002). Patients treated with the OXP + 5FU regimen had significantly less metastatic progression (OR = 0.79; 95% CI, 0.67 to 0.94; p = 0.007). Considering adverse events (AEs), there was more grade 3-4 diarrhea with OXP + 5FU (OR = 2.41, 95% CI: 1.74-3.32, p < 0.00001). However, there were no significant differences grade 3-4 hematologic AEs (OR = 1.16, 95% CI: 0.87-1.57, p = 0.31). CONCLUSIONS Our meta-analysis with long-term results from the randomized studies showed a benefit of the addition of OXP + 5FU regiment in terms of DFS, metastatic progression, and pCR rate that did not translate to improved OS.
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Affiliation(s)
- Gaëtan Des Guetz
- Medical Oncology Department, Delafontaine Hospital, 93200 St Denis, France
- Department of Surgery, Faculty of Medicine, University of Limoges, 87032 Limoges, France;
| | - Thierry Landre
- Unité de Coordination en Onco-Gériatrie, Hôpitaux Universitaires Paris Seine-St-Denis, AP-HP, 93270 Sevran, France;
| | - Marc A. Bollet
- Centre de Radiothérapie Hartmann, 92300 Levallois-Perret, France;
| | - Muriel Mathonnet
- Department of Surgery, Faculty of Medicine, University of Limoges, 87032 Limoges, France;
- Department of Surgery, University Hospital of Limoges, 87032 Limoges, France
| | - Laurent Quéro
- INSERM U1160, Université de Paris, 75010 Paris, France;
- Radiation Oncology Department, Saint-Louis University Hospital, AP-HP, 75010 Paris, France
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Hofheinz RD. [Locally advanced rectal cancer - Standards and new multimodality treatment concepts]. Dtsch Med Wochenschr 2021; 146:1478-1487. [PMID: 34741293 DOI: 10.1055/a-1391-5302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Treatment strategies for locally advanced rectal cancer are changing dramatically. The treatment recommended in the guidelines for locally advanced tumors of neoadjuvant radio(chemo)therapy (RChT), followed by surgery and, if necessary, adjuvant therapy, are increasingly be abandoned in favor of the following concepts: (i) prolonged neoadjuvant (RChT (i. e. "more chemotherapy before resection", referred to as total neoadjuvant therapy, TNT); (ii) omission of radiotherapy in tumors with a low risk of local recurrence; (iii) organ preservation in patients with a complete clinical response after neoadjuvant radiochemotherapy. Herein, current strategies and study concepts are to be discussed based on the guideline-based status quo.
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Sheng X, Li S, Zhang Y, Geng J, Wang H, Zhu X, Quan J, Li Y, Cai Y, Wang W. One to Two Cycles of Consolidation Chemotherapy With Capecitabine After Neoadjuvant Chemoradiotherapy Does Not Benefit Low-Risk Patients With Locally Advanced Middle-Low Rectal Cancer. Front Oncol 2021; 11:695726. [PMID: 34660266 PMCID: PMC8515850 DOI: 10.3389/fonc.2021.695726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 09/06/2021] [Indexed: 12/21/2022] Open
Abstract
Background and Objective Organ preservation can enable locally advanced rectal cancer (LARC) patients with clinical complete response (cCR) after neoadjuvant treatment to maintain quality of life. In this study, we aimed to evaluate whether one or two cycles of capecitabine after neoadjuvant chemoradiotherapy (NCRT) without extending the interval between the end of NCRT and surgery could increase the complete response (CR) rate in low-risk middle-low LARC patients. Material and Methods We retrospectively evaluated middle-low LARC patients with low risk defined as clinical T2-3b, mesorectal fascia-clear, and extramural vascular invasion-negative by magnetic resonance imaging (MRI), treated between January 2015 and July 2019. Patients were divided into two groups according to whether consolidation chemotherapy was administered after NCRT. Patients in the consolidation chemotherapy group received one or two cycles of capecitabine (1000 mg/m2 twice daily from days 1 to 14). The main outcome was the CR rate, including pathological CR (pCR) and cCR. Results A total of 169 patients, 105 in the consolidation chemotherapy group and 64 in the non-consolidation chemotherapy group, were included in the study, and the median follow-up was 37.2 months (range, 0.4–71.2 months). Seventeen patients achieved cCR and the remaining 152 underwent surgery after neoadjuvant treatment. There was no significant difference in the CR rate (39.0% vs. 35.9%, p=0.686), ypT0-2N0 rate (65.2% vs. 63.3%, p=0.812), or ypN0 rate (83.7% vs. 88.3%, p=0.503) between the consolidation chemotherapy and non-consolidation chemotherapy groups. Among the patients achieved cCR, 3 (17.6%) experienced regrowth in the rectum and 2 (11.8%) experienced distant metastasis. There was also no significant difference in the 3-year disease-free survival (87.4% vs 85.9%, p=0.971) in patients who underwent surgery between the two groups. Multivariate logistic regression analysis indicated that normal Carcinoma Embryonic Antigen (CEA) levels (p = 0.001) were associated with a higher CR rate. Moreover, there were no significant differences in the incidences of grade ≥2 acute toxicities during neoadjuvant treatment. Conclusion Although there was no increase in treatment-related toxicities between the two groups, simply adding one or two cycles of capecitabine after NCRT might be insufficient to benefit low-risk middle-low LARC patients.
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Affiliation(s)
- Xueqing Sheng
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing, China
| | - Shuai Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing, China
| | - Yangzi Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing, China
| | - Jianhao Geng
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing, China
| | - Hongzhi Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing, China
| | - Xianggao Zhu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing, China
| | - Jizhong Quan
- Department of Radiation Oncology, Jilin Guowen Hospital, Gongzhuling, China
| | - Yongheng Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing, China
| | - Yong Cai
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing, China
| | - Weihu Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing, China
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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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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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Dou R, He S, Deng Y, Wang J. Comparison of guidelines on rectal cancer: exception proves the rule? Gastroenterol Rep (Oxf) 2021; 9:290-298. [PMID: 34567560 PMCID: PMC8460091 DOI: 10.1093/gastro/goab034] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/14/2021] [Accepted: 07/07/2021] [Indexed: 12/19/2022] Open
Abstract
The standard of care for early or locally advanced rectal cancer is promoted by multiple clinical practice guidelines globally, but the considerable differences between the guidelines may cause confusion. We compared the latest updated clinical practice guidelines from five professional societies/authorities: National Comprehensive Cancer Network, American Society of Colorectal Surgeons, European Society of Medical Oncology, Chinese National Health Commission, and Chinese Society of Clinical Oncology. Key evidence is discussed for a better understanding of some seemingly contradictory recommendations.
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Affiliation(s)
- Ruoxu Dou
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Siqi He
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Yanhong Deng
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China.,Department of Medical Oncology, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Jianping Wang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China.,Department of Gastrointestinal Surgery, Foresea Life Insurance Guangzhou General Hospital, Guangzhou, Guangdong, P. R. China
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32
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Kataoka T, Mori T, Suzuki J, Kawaki Y, Kito Y, Hotta Y, Kawade Y, Maeda Y, Kimura K. Oxaliplatin, an Anticancer Agent, Causes Erectile Dysfunction in Rats due to Endothelial Dysfunction. J Sex Med 2021; 18:1337-1345. [PMID: 37057457 DOI: 10.1016/j.jsxm.2021.06.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 06/07/2021] [Accepted: 06/13/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Chemotherapeutics, one of the standard treatment options for cancer worldwide, have various adverse effects, including erectile dysfunction (ED). AIM To investigate erectile function in an animal model after administration of the anticancer agent oxaliplatin (L-OHP). METHODS Male Wistar/ST rats were divided into 2 groups: L-OHP rats (n = 21), which were intravenously administered L-OHP (4 mg/kg; twice a week for 4 weeks), and Control rats (n = 21), which were injected with the same volume of 5% glucose solution, using the same dosing schedule. At the end of the study period, erectile function was evaluated by measuring intracavernous pressure (ICP) and mean arterial pressure (MAP) after cavernous nerve stimulation (n = 9-10). Endothelial function was evaluated with an isometric tension study using corpus cavernosum strips (n = 11). Western blot analysis was used to assess neuronal nitric oxide (nNOS) and endothelial NO synthase (eNOS) protein levels (n = 7). Real-time quantitative polymerase chain reaction (qRT-PCR) was used to assess the expression of inflammation- and oxidative stress-related markers (nicotinamide adenine dinucleotide phosphate oxidase-1, p22phox, interleukin [IL]-6, and nuclear factor-kappa B) (n = 6). Statistical significance was determined using the Student's t-test. OUTCOMES The L-OHP group had a significantly lower ICP:MAP ratio than the control group (P < .05). Compared to the Control group, the L-OHP group exhibited significantly lower responses to ACh and eNOS protein levels and significantly higher inflammatory biomarker levels. CLINICAL TRANSLATION The results based on this animal model indicate that use of the anticancer agent L-OHP should be considered as a risk factor for ED occurring via reduction of NO bioavailability in humans; our results provide possible treatment strategies for maintaining the erectile function of cancer survivors. STRENGTHS AND LIMITATIONS Our study showed that the anticancer agent L-OHP has the propensity to cause ED in rats. A major limitation of this study is the lack of an established cure for ED associated with L-OHP and the lack of clinical evidence. CONCLUSIONS L-OHP causes ED in rats via reduction of NO bioavailability caused by endothelial dysfunction. Kataoka T, Mori T, Suzuki J, et al. Oxaliplatin, an Anticancer Agent, Causes Erectile Dysfunction in Rats due to Endothelial Dysfunction. J Sex Med 2021;18:1337-1345.
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Affiliation(s)
- Tomoya Kataoka
- Department of Clinical Pharmaceutics, Graduate School of Medical Sciences, Nagoya City University, Mizuho-cho, Mizuho-ku, Nagoya, Japan.
| | - Taiki Mori
- Department of Hospital Pharmacy, Graduate School of Pharmaceutical Sciences, Nagoya City University, Mizuho-ku, Nagoya, Japan
| | - Jun Suzuki
- Department of Hospital Pharmacy, Graduate School of Pharmaceutical Sciences, Nagoya City University, Mizuho-ku, Nagoya, Japan
| | - Yuto Kawaki
- Department of Hospital Pharmacy, Graduate School of Pharmaceutical Sciences, Nagoya City University, Mizuho-ku, Nagoya, Japan
| | - Yohei Kito
- Department of Hospital Pharmacy, Graduate School of Pharmaceutical Sciences, Nagoya City University, Mizuho-ku, Nagoya, Japan
| | - Yuji Hotta
- Department of Hospital Pharmacy, Graduate School of Pharmaceutical Sciences, Nagoya City University, Mizuho-ku, Nagoya, Japan
| | - Yoshihiro Kawade
- Department of Hospital Pharmacy, Graduate School of Pharmaceutical Sciences, Nagoya City University, Mizuho-ku, Nagoya, Japan
| | - Yasuhiro Maeda
- Department of Hospital Pharmacy, Graduate School of Pharmaceutical Sciences, Nagoya City University, Mizuho-ku, Nagoya, Japan
| | - Kazunori Kimura
- Department of Clinical Pharmaceutics, Graduate School of Medical Sciences, Nagoya City University, Mizuho-cho, Mizuho-ku, Nagoya, Japan; Department of Hospital Pharmacy, Graduate School of Pharmaceutical Sciences, Nagoya City University, Mizuho-ku, Nagoya, Japan.
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Okada Y, Ozawa T, Hayama T, Ohno K, Tsukamoto M, Fukushima Y, Shimada R, Nozawa K, Matsuda K, Hashiguchi Y. Impact of Fluoropyrimidine and Oxaliplatin-based Chemoradiotherapy in Patients With Locally Advanced Rectal Cancer. In Vivo 2021; 35:593-601. [PMID: 33402514 DOI: 10.21873/invivo.12296] [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: 10/25/2020] [Revised: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM To evaluate the benefits of the addition of oxaliplatin (OX) to fluoropyrimidine (FP)-based neoadjuvant chemoradiotherapy (CRT) for patients with locally advanced rectal cancers (LARCs). PATIENTS AND METHODS We performed retrospective analyses comparing the pathological complete response (pCR) rate, overall survival (OS), recurrence-free survival (RFS), and local recurrence-free survival (LRFS) between FP-based and FP+OX-based CRT groups and for patients who had completed the CRT. RESULTS One hundred patients were included in the analyses: the pCR rate, OS, RFS, and LRFS were similar between these groups. The FP+OX group showed significantly more frequent incompleteness of the CRT compared to the FP group (p=0.049). Among the patients who had completed the CRT, the FP+OX group demonstrated significantly improved LRFS compared to the FP group (p=0.048). CONCLUSION The addition of OX to an FP regimen in neoadjuvant CRT for LARC may reduce local recurrence in patients who have achieved good compliance to CRT.
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Affiliation(s)
- Yuka Okada
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Tsuyoshi Ozawa
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Tamuro Hayama
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Kohei Ohno
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Mitsuo Tsukamoto
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | | | - Ryu Shimada
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Keijiro Nozawa
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Keiji Matsuda
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Yojiro Hashiguchi
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
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Meillan N, Orthuon A, Chauchat P, Atlani D, Bouche O, Chaulin B, David C, Deberne M, Debrigode C, Kao W, Keller A, Laharie H, Lamezec B, Lemanski C, Magné N, Mahé MA, Mere P, Moureau-Zabotto L, Peiffert D, Pointreau Y, Quéro L, Racadot S, Roca S, Sargos P, Servagi S, Tang E, Vendrely V, Doyen J, Huguet F. Locoregional relapses in the ACCORD 12/0405-PRODIGE 02 study: Dosimetric study and risk factors. Radiother Oncol 2021; 161:198-204. [PMID: 34144078 DOI: 10.1016/j.radonc.2021.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 05/21/2021] [Accepted: 06/02/2021] [Indexed: 11/19/2022]
Abstract
PURPOSE The aim of this study is to correlate locoregional relapse with radiation therapy volumes in patients with rectal cancer treated with neoadjuvant chemoradiation in the ACCORD 12/0405-PRODIGE 02 trial. PATIENTS AND METHODS We identified patients who had a locoregional relapse included in ACCORD 12's database. We studied their clinical, radiological, and dosimetric data to analyze the dose received by the area of relapse. RESULTS 39 patients (6.5%) presented 54 locoregional relapses. Most of the relapses were in-field (n = 21, 39%) or marginal (n = 13, 24%) with only six out-of-field (11%), 14 could not be evaluated. Most of them happened in the anastomosis, the perirectal space, and the usual lymphatic drainage areas (presacral and posterior lateral lymph nodes). Only patients treated for a lower rectum adenocarcinoma had a relapse outside of the treated volume. 2 patients with T4 tumors extending into anterior pelvic organs had relapses in anterior lateral and external iliac lymph nodes. CONCLUSIONS Lowering the upper limit of the treatment field for low rectal tumors increased the risk of out of the field recurrence. For very low tumors, including the inguinal lymph nodes in the treated volume should be considered. Recording locoregional involvement, treated volumes, and relapse areas in future prospective trials would be of paramount interest to refine delineation guidelines.
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Affiliation(s)
- Nicolas Meillan
- APHP, Pitié-Salpêtrière Hospital, Department of Radiation Oncology, Paris, France; Sorbonne Université, AP-HP, Pitié Salpêtrière Hospital, Department of Radiation Oncology, Paris, France.
| | | | - Paul Chauchat
- APHP, Pitié Salpêtrière Hospital, Department of Medical Physics, Paris, France
| | - David Atlani
- Department of Radiation Oncology, Civil Colmar Hospital, Colmar, France
| | - Olivier Bouche
- Department of Gastroenterology, Reims University Hospital, France
| | - Bertrand Chaulin
- Department of Radiation Oncology, Bordeaux Nord Aquitaine Polyclinic, France
| | - Céline David
- Department of Medical Physics, Mulhouse and South Alsace Hospital, France
| | - Mélanie Deberne
- Department of Radiation Oncology, South Lyon Hospital, France
| | | | - William Kao
- Department of Radiation Oncology, François Baclesse Cancer Center, Caen, France
| | - Audrey Keller
- Department of Radiation Oncology, ICANS, Strasbourg, France
| | - Hortense Laharie
- Department of Radiation Oncology, Tivoli Ducos Clinic, Bordeaux, France
| | - Bruno Lamezec
- Department of Radiation Oncology, Armorican Radiation Therapy, Radiology and Oncology Center, Plérin, France
| | - Claire Lemanski
- Department of Radiation Oncology, Montpellier-Val d'Aurelles Cancer Institute, France
| | - Nicolas Magné
- Department of Radiation Oncology, Loire Cancer Institute Saint-Priest-en-Jarez France
| | - Marc-André Mahé
- Department of Radiation Oncology, Western Cancer Institute, Nantes, France
| | - Pascale Mere
- Department of Radiation Oncology, Jean Mermoz Private Hospital, Lyon, France
| | | | - Didier Peiffert
- Department of Radiation Oncology, Lorraine Cancer Institute, Nancy, France
| | - Yoann Pointreau
- Department of Radiation Oncology, Inter-régionaL Cancer Institute (ILC) - Jean Bernard Center-Victor Hugo Clinic, Le Mans, France
| | - Laurent Quéro
- Department of Radiation Oncology, Saint-Louis Hospital, APHP, Paris, France
| | - Séverine Racadot
- Department of Radiation Oncology, Léon Bérard Center, Lyon, France
| | - Sophie Roca
- Department of Medical Oncology, Sainte-Anne Clinic, Langon, France
| | - Paul Sargos
- Department of Radiation Oncology, Bergonié Institute, Bordeaux, France
| | - Stéphanie Servagi
- Department of Radiation Oncology, Jean Godinot Institute, Reims, France
| | - Eliane Tang
- Hôpitaux Universitaires Henri Mondor, APHP, Henri Mondor Hospital, Department of Radiation Oncology, Paris, France
| | - Véronique Vendrely
- Department of Radiation Oncology, Bordeaux University Hospital, France; INSERM 1035, University of Bordeaux, France
| | - Jérôme Doyen
- Department of Radiation Oncology, Antoine Lacassagne Center, Nice, France
| | - Florence Huguet
- Sorbonne Université, AP-HP, Pitié Salpêtrière Hospital, Department of Radiation Oncology, Paris, France; UMR_S 938, Centre de Recherche de Saint Antoine, Paris, France; APHP, Tenon Hospital, Department of Radiation Oncology, Paris, France
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35
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[Neoadjuvant treatment for rectal cancer]. Bull Cancer 2021; 108:855-867. [PMID: 34140155 DOI: 10.1016/j.bulcan.2021.03.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/22/2021] [Accepted: 03/30/2021] [Indexed: 02/01/2023]
Abstract
The management of patients with locally advanced rectal cancer has improved significantly in the past few years with preoperative radiotherapy (RT) and total mesorectal excision. The rate of local recurrence is now around 5 % while the risk of metastatic recurrence has not been reduced which is about 30 %. The benefit of adjuvant chemotherapy remains questionable apart from patients with ypN+tumor after preoperative chemoradiotherapy (CRT) for whom FOLFOX is an option. In recent years, several therapeutic trials have evaluated the benefit of extending the time between the end of RT and surgery and/or the benefit of neoadjuvant chemotherapy, administered as induction (before RT) or in consolidation (after RT and before surgery). The first results of two positive phase 3 trials, PRODIGE 23 and RAPIDO, have been reported in 2020. The two regimens evaluated in these trials are markedly different but have shown that neoadjuvant chemotherapy significantly reduces the risk of distant metastasis. Current developments largely related to a de-escalation of therapy: organ conservation according to a "Watch and Wait" strategy or local resection of the scar, administration of neoadjuvant chemotherapy without RT. These therapeutic strategies have not yet been validated but should be in the news tomorrow. The purpose of this review is to present recent data reported in patients with locally advanced rectal cancer.
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Lin H, Wang L, Zhong X, Zhang X, Shao L, Wu J. Meta-analysis of neoadjuvant chemotherapy versus neoadjuvant chemoradiotherapy for locally advanced rectal cancer. World J Surg Oncol 2021; 19:141. [PMID: 33952287 PMCID: PMC8101236 DOI: 10.1186/s12957-021-02251-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 04/21/2021] [Indexed: 02/06/2023] Open
Abstract
Background and purpose With the advent of more intensive chemotherapy regimens, neoadjuvant chemoradiotherapy (NACRT) for patients with locally advanced rectal cancer (LARC) has always been questioned due to its inevitable radiation toxicity. Hence, we conducted a meta-analysis to compare the clinical efficacy of neoadjuvant chemotherapy (NAC) and NACRT. Materials and methods Eligible studies were searched using PubMed, MEDLINE, Embase, the Cochrane Library, and Web of Science up to 31 July 2020, comparing the clinical efficacy of NAC versus NACRT for LARC. Short- and long-term outcomes were determined using the odds ratio (OR) with 95% confidence interval (CI). Results Six studies with 12,812 patients were eligible for this meta-analysis, including 677 patients in the NAC group and 12,135 patients in the NACRT group. There were no significant differences between the two groups in terms of pathological complete response rate (OR=0.62, 95%CI=0.27~1.41), N down-staging rate (OR=1.20, 95%CI=0.25~5.79), R0 resection rate (OR=1.24, 95%CI=0.78~1.98), and local relapse rate (OR=1.12, 95%CI=0.58~2.14). The pooled OR for the total response rate and T down-staging were in favor of NACRT (OR=0.41, 95%CI=0.22~0.76 versus OR=0.67 95%CI=0.52~0.87). However, the pooled OR for the sphincter preservation rate favored NAC compared with NACRT (OR=1.87, 95%CI=1.24~2.81). Moreover, NAC was found to be superior to NACRT in terms of distant metastasis (14.3% vs. 20.4%), but the difference was not significant (OR=0.84, 95%CI=0.31~2.27). Conclusion We concluded that NAC was superior to NACRT in terms of the sphincter preservation rate, and non-inferior to NACRT in terms of pCR, N down-staging, R0 resection, local relapse, and distant metastasis. However, the conclusion warrants further validation. Supplementary Information The online version contains supplementary material available at 10.1186/s12957-021-02251-0.
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Affiliation(s)
- Huaqin Lin
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, China
| | - Lei Wang
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, China
| | - Xiaohong Zhong
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, China
| | - Xueqing Zhang
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, China
| | - Lingdong Shao
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, China.
| | - Junxin Wu
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, China.
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Abdalla S, Benoist S, Lefèvre JH, Penna C, Brouquet A. New treatment strategies for non-metastatic rectal cancer. J Visc Surg 2021; 158:497-505. [PMID: 33926836 DOI: 10.1016/j.jviscsurg.2021.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The most widely practiced (standard) treatment of non-metastatic rectal cancer is based on proctectomy with mesorectal excision (partial or total according to the location of the tumor and commonly called TME). Surgery is preceded by CAP50-type chemoradiotherapy (capecitabineand 50 Grays radiation) and performed 6-8 weeks after the end of chemoradiotherapy. The development of new endoscopic, surgical, radiation-based and chemotherapeutic modalities leads surgeons to envisage customized treatment to find the best compromise between functional and oncologic results according to the locoregional extension of the tumor. Superficial lesions are amenable to transanal excision. T2-3 tumors<4cm are amenable to rectal preservation when neoadjuvant treatment obtains a complete response, allowing local excision or close surveillance. Intensification endocavitary radiotherapy and induction and consolidation chemotherapy regimens to avoid recourse to salvage abdomino-perineal resection (APR) are under investigation. For locally advanced rectal cancers (T3-4 and all N+ irrespective of T), the following scenarios can be envisaged: for initially resectable tumors (T3N0, T1-T3N+, circumferential resection margin>2mm), neoadjuvant chemotherapy alone aims to minimize the risk of local recurrence while avoiding the sequelae of radiotherapy. In case of initially non-resectable tumors (T4, circumferential resection margin<1mm), induction chemotherapy before chemoradiotherapy and consolidation chemotherapy after short course radiotherapy provide better results than standard treatment in terms of complete response and recurrence-free survival, and should be routinely proposed in this indication.
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Affiliation(s)
- S Abdalla
- Department of digestive and oncological surgery, Bicêtre hospital, Paris Sud university hospital Group, Assistance Publique-Hôpitaux de Paris, 63, rue Gabriel-Péri, 94275 Le Kremlin Bicêtre, France; Paris Sud Faculty of Medicine, Paris Saclay university, 94275 Le Kremlin-Bicêtre, France
| | - S Benoist
- Department of digestive and oncological surgery, Bicêtre hospital, Paris Sud university hospital Group, Assistance Publique-Hôpitaux de Paris, 63, rue Gabriel-Péri, 94275 Le Kremlin Bicêtre, France; Paris Sud Faculty of Medicine, Paris Saclay university, 94275 Le Kremlin-Bicêtre, France
| | - J H Lefèvre
- General and Digestive Surgery Department, Saint Antoine Hospital, Assistance Publique-Hôpitaux de Paris, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France; Faculty of Medicine Sorbonne University Paris VI, Paris, France
| | - C Penna
- Department of digestive and oncological surgery, Bicêtre hospital, Paris Sud university hospital Group, Assistance Publique-Hôpitaux de Paris, 63, rue Gabriel-Péri, 94275 Le Kremlin Bicêtre, France; Paris Sud Faculty of Medicine, Paris Saclay university, 94275 Le Kremlin-Bicêtre, France
| | - A Brouquet
- Department of digestive and oncological surgery, Bicêtre hospital, Paris Sud university hospital Group, Assistance Publique-Hôpitaux de Paris, 63, rue Gabriel-Péri, 94275 Le Kremlin Bicêtre, France; Paris Sud Faculty of Medicine, Paris Saclay university, 94275 Le Kremlin-Bicêtre, France.
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Conroy T, Bosset JF, Etienne PL, Rio E, François É, Mesgouez-Nebout N, Vendrely V, Artignan X, Bouché O, Gargot D, Boige V, Bonichon-Lamichhane N, Louvet C, Morand C, de la Fouchardière C, Lamfichekh N, Juzyna B, Jouffroy-Zeller C, Rullier E, Marchal F, Gourgou S, Castan F, Borg C. Neoadjuvant chemotherapy with FOLFIRINOX and preoperative chemoradiotherapy for patients with locally advanced rectal cancer (UNICANCER-PRODIGE 23): a multicentre, randomised, open-label, phase 3 trial. Lancet Oncol 2021; 22:702-715. [PMID: 33862000 DOI: 10.1016/s1470-2045(21)00079-6] [Citation(s) in RCA: 515] [Impact Index Per Article: 171.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/01/2021] [Accepted: 02/04/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Treatment of locally advanced rectal cancer with chemoradiotherapy, surgery, and adjuvant chemotherapy controls local disease, but distant metastases remain common. We aimed to assess whether administering neoadjuvant chemotherapy before preoperative chemoradiotherapy could reduce the risk of distant recurrences. METHODS We did a phase 3, open-label, multicentre, randomised trial at 35 hospitals in France. Eligible patients were adults aged 18-75 years and had newly diagnosed, biopsy-proven, rectal adenocarcinoma staged cT3 or cT4 M0, with a WHO performance status of 0-1. Patients were randomly assigned (1:1) to either the neoadjuvant chemotherapy group or standard-of-care group, using an independent web-based system by minimisation method stratified by centre, extramural extension of the tumour into perirectal fat according to MRI, tumour location, and stage. Investigators and participants were not masked to treatment allocation. The neoadjuvant chemotherapy group received neoadjuvant chemotherapy with FOLFIRINOX (oxaliplatin 85 mg/m2, irinotecan 180 mg/m2, leucovorin 400 mg/m2, and fluorouracil 2400 mg/m2 intravenously every 14 days for 6 cycles), chemoradiotherapy (50 Gy during 5 weeks and 800 mg/m2 concurrent oral capecitabine twice daily for 5 days per week), total mesorectal excision, and adjuvant chemotherapy (3 months of modified FOLFOX6 [intravenous oxaliplatin 85 mg/m2 and leucovorin 400 mg/m2, followed by intravenous 400 mg/m2 fluorouracil bolus and then continuous infusion at a dose of 2400 mg/m2 over 46 h every 14 days for six cycles] or capecitabine [1250 mg/m2 orally twice daily on days 1-14 every 21 days]). The standard-of-care group received chemoradiotherapy, total mesorectal excision, and adjuvant chemotherapy (for 6 months). The primary endpoint was disease-free survival assessed in the intention-to-treat population at 3 years. Safety analyses were done on treated patients. This trial was registered with EudraCT (2011-004406-25) and ClinicalTrials.gov (NCT01804790) and is now complete. FINDINGS Between June 5, 2012, and June 26, 2017, 461 patients were randomly assigned to either the neoadjuvant chemotherapy group (n=231) or the standard-of-care group (n=230). At a median follow-up of 46·5 months (IQR 35·4-61·6), 3-year disease-free survival rates were 76% (95% CI 69-81) in the neoadjuvant chemotherapy group and 69% (62-74) in the standard-of-care group (stratified hazard ratio 0·69, 95% CI 0·49-0·97; p=0·034). During neoadjuvant chemotherapy, the most common grade 3-4 adverse events were neutropenia (38 [17%] of 225 patients) and diarrhoea (25 [11%] of 226). During chemoradiotherapy, the most common grade 3-4 adverse event was lymphopenia (59 [28%] of 212 in the neoadjuvant chemotherapy group vs 67 [30%] of 226 patients in the standard-of-care group). During adjuvant chemotherapy, the most common grade 3-4 adverse events were lymphopenia (18 [11%] of 161 in the neoadjuvant chemotherapy group vs 42 [27%] of 155 in the standard-of-care group), neutropenia (nine [6%] of 161 vs 28 [18%] of 155), and peripheral sensory neuropathy (19 [12%] of 162 vs 32 [21%] of 155). Serious adverse events occurred in 63 (27%) of 231 participants in the neoadjuvant chemotherapy group and 50 (22%) of 230 patients in the standard-of-care group (p=0·167), during the whole treatment period. During adjuvant therapy, serious adverse events occurred in 18 (11%) of 163 participants in the neoadjuvant chemotherapy group and 36 (23%) of 158 patients in the standard-of-care group (p=0·0049). Treatment-related deaths occurred in one (<1%) of 226 patients in the neoadjuvant chemotherapy group (sudden death) and two (1%) of 227 patients in the standard-of-care group (one sudden death and one myocardial infarction). INTERPRETATION Intensification of chemotherapy using FOLFIRINOX before preoperative chemoradiotherapy significantly improved outcomes compared with preoperative chemoradiotherapy in patients with cT3 or cT4 M0 rectal cancer. The significantly improved disease-free survival in the neoadjuvant chemotherapy group and the decreased neurotoxicity indicates that the perioperative approach is more efficient and better tolerated than adjuvant chemotherapy. Therefore, the PRODIGE 23 results might change clinical practice. FUNDING Institut National du Cancer, Ligue Nationale Contre le Cancer, and R&D Unicancer.
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Affiliation(s)
- Thierry Conroy
- Institut de Cancérologie de Lorraine, Université de Lorraine, Nancy, France; APEMAC, Université de Lorraine, Nancy, France.
| | - Jean-François Bosset
- Hôpital Nord Franche-Comté, Montbéliard, France; University Hospital of Besançon, Besançon, France
| | | | - Emmanuel Rio
- Institut de Cancérologie de l'Ouest-Site René Gauducheau, Saint-Herblain, France
| | | | | | - Véronique Vendrely
- Centre Hospitalier et Universitaire de Bordeaux, Hôpital Haut-Lévêque, Pessac, France
| | - Xavier Artignan
- Centre Hospitalier Privé Saint-Grégoire, Saint-Grégoire, France
| | | | | | | | | | | | - Clotilde Morand
- Centre Hospitalier Départemental, Site de la Roche-sur-Yon, La Roche-sur-Yon, France
| | | | | | | | | | - Eric Rullier
- Centre Hospitalier et Universitaire de Bordeaux, Hôpital Haut-Lévêque, Pessac, France
| | - Frédéric Marchal
- Institut de Cancérologie de Lorraine, Université de Lorraine, Nancy, France
| | - Sophie Gourgou
- Institut Régional du Cancer de Montpellier, Université de Montpellier, Montpellier, France
| | - Florence Castan
- Institut Régional du Cancer de Montpellier, Université de Montpellier, Montpellier, France
| | - Christophe Borg
- Hôpital Nord Franche-Comté, Montbéliard, France; University Hospital of Besançon, Besançon, France
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Neumann PA, Berlet MW, Friess H. Surgical oncology in the age of multimodality therapy for cancer of the upper and lower gastrointestinal tract. Expert Rev Anticancer Ther 2021; 21:511-522. [PMID: 33355020 DOI: 10.1080/14737140.2021.1868991] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION To date, all efforts to fight gastrointestinal cancer, regardless of its origin and entity, have resulted in complex therapeutic regimens involving a combination of systemic therapy, radiation therapy and surgery. It is generally accepted across all disciplines that not one, but the combination and the proper timing of all modalities result in the best oncologic outcome. AREAS COVERED Here, we provide insight into the current and future value of multimodal therapeutic approaches for upper and lower gastrointestinal cancer. Various aspects of treatment as well as open questions regarding indication and timing of multimodal strategies are addressed in this review. EXPERT OPINION In order to further improve the survival and quality of life of patients with gastrointestinal tumors in the future, scientifically proven multimodal therapy concepts are needed first and foremost. In addition, markers are pivotal to assign individual patients to a specific concept and to monitor the success of therapy. The main question is in which situation a neoadjuvant, perioperative or adjuvant radio-, chemo- or immunotherapy is superior. In fact, almost every curatively intended concept still contains surgical resection. Thus, improvement in surgical technique is also critical for multimodality concepts.
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Affiliation(s)
| | | | - Helmut Friess
- Department of Surgery, School of Medicine, Technical University of Munich, Germany
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Siegel R. Verbessert die zusätzliche Gabe von Oxaliplatin in der prä- und postoperativen Behandlung das Überleben beim lokal fortgeschrittenen Rektumkarzinom? Ergebnisse der PETACC 6 Studie. COLOPROCTOLOGY 2021. [DOI: 10.1007/s00053-020-00512-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Body A, Prenen H, Lam M, Davies A, Tipping-Smith S, Lum C, Liow E, Segelov E. Neoadjuvant Therapy for Locally Advanced Rectal Cancer: Recent Advances and Ongoing Challenges. Clin Colorectal Cancer 2021; 20:29-41. [PMID: 33531256 DOI: 10.1016/j.clcc.2020.12.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 12/11/2020] [Accepted: 12/31/2020] [Indexed: 12/12/2022]
Abstract
Locally advanced rectal cancer has a rising global incidence. Over the last 4 decades, advances first in surgery and later in radiotherapy and chemoradiotherapy have improved outcomes, particularly with regard to local recurrence. Unfortunately, distant metastases remain a significant problem. In clinical trials of patients with stage II and III disease, distant relapse occurs in 25% to 30% of patients regardless of the treatment approach. Recent phase 3 trials have therefore focused on intensification of systemic therapy for localized disease, with an aim of reducing the distant relapse rate. Early results of trials of total neoadjuvant therapy with combination systemic therapy provided in the neoadjuvant setting are promising; for the first time, a significant improvement in the rate of distant relapse has been noted. Longer-term follow-up is eagerly awaited. On the other hand, trimodal therapy with chemotherapy, radiotherapy, and surgery is toxic. Several trials are currently assessing the feasibility of a watch-and-wait approach, omitting surgery in those with complete response to neoadjuvant treatment, in an attempt to reduce the burden of treatment on patients. The future for rectal cancer patients is likely to be highly personalized, with more intense approaches for high-risk patients and omission of unnecessary therapy for those whose disease responds well to initial treatment. Biomarkers such as circulating tumor DNA will help to more accurately stratify patients into risk groups. Improvements in survival and quality of life are expected as the results of ongoing research become available throughout the next decade.
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Affiliation(s)
- Amy Body
- Medical Oncology, Monash Medical Centre, Clayton, Australia; School of Clinical Sciences, Monash University, Clayton, Australia.
| | - Hans Prenen
- Medical Oncology, Monash Medical Centre, Clayton, Australia; Oncology Department, University Hospital Antwerp, Antwerp, Belgium
| | - Marissa Lam
- Medical Oncology, Monash Medical Centre, Clayton, Australia
| | - Amy Davies
- Medical Oncology, Monash Medical Centre, Clayton, Australia
| | | | - Caroline Lum
- Medical Oncology, Monash Medical Centre, Clayton, Australia
| | - Elizabeth Liow
- Medical Oncology, Monash Medical Centre, Clayton, Australia; School of Clinical Sciences, Monash University, Clayton, Australia
| | - Eva Segelov
- Medical Oncology, Monash Medical Centre, Clayton, Australia; School of Clinical Sciences, Monash University, Clayton, Australia
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Kosmala R, Fokas E, Flentje M, Sauer R, Liersch T, Graeven U, Fietkau R, Hohenberger W, Arnold D, Hofheinz RD, Ghadimi M, Ströbel P, Staib L, Grabenbauer GG, Folprecht G, Kirste S, Uter W, Gall C, Rödel C, Polat B. Quality of life in rectal cancer patients with or without oxaliplatin in the randomised CAO/ARO/AIO-04 phase 3 trial. Eur J Cancer 2020; 144:281-290. [PMID: 33383348 DOI: 10.1016/j.ejca.2020.11.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 11/03/2020] [Accepted: 11/15/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND The CAO/ARO/AIO trial has shown that oxaliplatin added to preoperative chemoradiotherapy and postoperative chemotherapy significantly improved disease-free survival in locally advanced rectal cancer (LARC). Here, we present a post-hoc analysis of quality of life (QoL) in disease-free patients. PATIENTS AND METHODS Between 2006 and 2010, 1236 patients with LARC were randomly assigned either to preoperative chemoradiotherapy followed by total mesorectal excision and postoperative chemotherapy (N = 623) or combined with oxaliplatin (N = 613). QoL questionnaires (EORTC QLQ-C30, colorectal module CR38) were completed at baseline, after postoperative chemotherapy and during follow-up. Analysis was performed according intent-to-treat. RESULTS Available questionnaires (baseline) were 82% (N = 512) in the control and 84% (N = 513) in the investigational group. Response rates were 49% (533 of 1086) at 1 year and 43% (403 of 928) at 3 years. Global health status (GHS) for disease-free patients was stable in both groups (range 0-100). At baseline: standard arm 62.0 (mean, SD 21.6; N = 491) versus oxaliplatin arm 63.2 (mean, SD 22; N = 503); at 3 years: 69.4 (SD 19.3; N = 187) versus 65.4 (SD 22.2; N = 202). After treatment and at 3 years, no significant differences (≥10 points) between groups were found in QoL subscales. Disease-free patients experiencing neurotoxic side-effects (grade 1-4) showed reduced GHS at 3 years versus patients without neurotoxicity (mean 59.2 versus 69.3; P < 0.001), while grade 3-4 rate was low. CONCLUSION The addition of oxaliplatin was not associated with worse overall QoL. This information is of interest to patients in many ongoing rectal cancer trials. TRIAL REGISTRATION INFORMATION NCT00349076.
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Affiliation(s)
- Rebekka Kosmala
- Department of Radiation Oncology, University Hospital Würzburg, Würzburg, Germany.
| | - Emmanouil Fokas
- Department of Radiotherapy, University of Frankfurt, Germany; Frankfurt Cancer Institute, Germany; German Cancer Research Centre (DKFZ), Heidelberg, Germany; German Cancer Consortium (DKTK) Partner Site, Frankfurt, Germany
| | - Michael Flentje
- Department of Radiation Oncology, University Hospital Würzburg, Würzburg, Germany
| | - Rolf Sauer
- Department of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany
| | - Torsten Liersch
- Department of General, Visceral and Paediatric Surgery, University Medical Centre Göttingen, Göttingen, Germany
| | - Ullrich Graeven
- Department of Haematology/Oncology and Gastroenterology, Kliniken Maria Hilf GmbH, Mönchengladbach, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany
| | | | - Dirk Arnold
- Department of Oncology, Haematology and Palliative Care, Asklepios Klinik Altona, Asklepios Tumorzentrum Hamburg, Hamburg
| | - Ralf-Dieter Hofheinz
- Interdisciplinary Tumour Center, University Hospital Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Michael Ghadimi
- Department of General, Visceral and Paediatric Surgery, University Medical Centre Göttingen, Göttingen, Germany
| | - Philipp Ströbel
- Institute of Pathology, University Medical Center Göttingen, Göttingen, Germany
| | - Ludger Staib
- Department of Surgery, Klinikum Esslingen, Esslingen, Germany
| | - Gerhard G Grabenbauer
- Department of Radiation Oncology and Radiotherapy, DiaCura & Klinikum Coburg, Coburg, Germany
| | - Gunnar Folprecht
- Medical Department I, University Cancer Centre, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Simon Kirste
- Department of Radiation Oncology, University Hospital Freiburg, Freiburg, Germany
| | - Wolfgang Uter
- Department of Medical Informatics, Biometry and Epidemiology, University Erlangen-Nürnberg, Erlangen, Germany
| | - Christine Gall
- Department of Medical Informatics, Biometry and Epidemiology, University Erlangen-Nürnberg, Erlangen, Germany
| | - Claus Rödel
- Department of Radiotherapy, University of Frankfurt, Germany; Frankfurt Cancer Institute, Germany; German Cancer Research Centre (DKFZ), Heidelberg, Germany; German Cancer Consortium (DKTK) Partner Site, Frankfurt, Germany
| | - Bülent Polat
- Department of Radiation Oncology, University Hospital Würzburg, Würzburg, Germany.
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Abstract
PURPOSE OF REVIEW The value of adjuvant chemotherapy in rectal cancer is controversial with opinions varying from 'not be used' since randomized trials have not shown significant gains to 'be used as in colon cancer' as the need is the same and colon and rectal cancers are quite similar. This review will look upon data critically and with open eyes. RECENT FINDINGS With the exception of one randomized phase II trial (ADORE) revealing a significant gain in disease-free survival using one more effective regimen (mFOLFOX) than bolus 5-fluorouracil leucovorin, no new data have been presented. However, bringing up aspects in previous trials, either considered irrelevant for the present situation or overall negative, of what adjuvant treatment can achieve, a small reduction (hazard ratio about 0.8) in the risk of recurrence is present. This reduction is not fundamentally different from that in colon cancer considering that adjuvant treatment for rectal cancer cannot be initiated as rapidly as it can after a colon cancer diagnosis. SUMMARY Adjuvant chemotherapy after rectal cancer surgery reduces recurrence risks but the benefit is limited and for most patients not clinically relevant. Neoadjuvant therapy can be more effective but results from randomized trials are not yet available.
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Garant A, Kavan P, Martin AG, Azoulay L, Vendrely V, Lavoie C, Vasilevsky CA, Boutros M, Faria J, Nguyen TN, Ferland E, Des Groseilliers S, Cloutier AS, Diec H, Drolet S, Richard C, Batist G, Vuong T. Optimizing treatment sequencing of chemotherapy for patients with rectal cancer: The KIR randomized phase II trial. Radiother Oncol 2020; 155:237-245. [PMID: 33220397 DOI: 10.1016/j.radonc.2020.11.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 11/04/2020] [Accepted: 11/08/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Randomized studies have shown low compliance to adjuvant chemotherapy in rectal cancer patients receiving preoperative chemotherapy and external beam radiation (CT/EBRT) with total mesorectal excision. We hypothesize that giving neoadjuvant CT before local treatment would improve CT compliance. METHODS Between 2010-2017, 180 patients were randomized (2:1) to either Arm A (AA) with FOLFOX x6 cycles prior to high dose rate brachytherapy (HDRBT) and surgery plus adjuvant FOLFOX x6 cycles, or Arm B (AB), with neoadjuvant HDRBT with surgery and adjuvant FOLFOX x12 cycles. The primary endpoint was CT compliance to ≥85% of full-dose CT for the first six cycles. Secondary endpoints were ypT0N0, five-year disease free survival (DFS), local control and overall survival (OS). RESULTS Patients were randomized to either AA (n = 120, median age (MA) 62 years) or AB (n = 60, MA 63 years). 175/180 patients completed HDRBT as planned (97.2%). In AA, two patients expired during CT; three patients post-randomization received short course EBRT because of progression under CT (n = 2, AA) or personal preference (n = 1, AB). ypT0N0 was 31% in AA and 28% in AB (p = 0.7). CT Compliance was 80% in AA and 53% in AB (p = 0.0002). Acute G3/G4 toxicity was 35.8% in AA and 27.6% in AB (p = 0.23). With a median follow-up of 48.5 months (IQR 33-72), the five-year DFS was 72.3% with AA and 68.3% with AB (p = 0.74), the five-year OS 83.8% for AA and 82.2% for AB (p = 0.53), and the five-year local recurrence was 6.3% for AA and 5.8% for AB (p = 0.71). CONCLUSION We confirmed improved compliance to neoadjuvant CT in this study. Although there is no statistical difference in ypT0N0 rate, local recurrence, and DFS between the two arms, a trend towards favourable oncological outcomes is observed.
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Affiliation(s)
- Aurelie Garant
- Department of Oncology, Division of Radiation Oncology, Sir Mortimer B. Davis Jewish General Hospital, Montreal, Canada
| | - Petr Kavan
- Department of Oncology, Sir Mortimer B. Davis Jewish General Hospital, Montreal, Canada
| | - André-Guy Martin
- Department of Radiation Oncology, Centre hospitalier universitaire de Québec, Université Laval, Quebec City, Canada
| | - Laurent Azoulay
- Department of Epidemiology, Biostatistics, and Occupational Health, and Gerald Bronfman Department of Oncology, McGill University, Montreal, Canada
| | - Véronique Vendrely
- Department of Oncology, Division of Radiation Oncology, Sir Mortimer B. Davis Jewish General Hospital, Montreal, Canada
| | - Caroline Lavoie
- Department of Radiation Oncology, Centre hospitalier universitaire de Québec, Université Laval, Quebec City, Canada
| | - Carol-Ann Vasilevsky
- Department of Surgery, Division of Colon and Rectal Surgery, Sir Mortimer B. Davis Jewish General Hospital, Montreal, Canada
| | - Marylise Boutros
- Department of Surgery, Division of Colon and Rectal Surgery, Sir Mortimer B. Davis Jewish General Hospital, Montreal, Canada
| | - Julio Faria
- Department of Surgery, Division of General Surgery and Oncology, Sir Mortimer B. Davis Jewish General Hospital, Montreal, Canada
| | - Trung Nghia Nguyen
- Department of Hematology, Medical Oncology, Hôpital Charles-LeMoyne, Greenfield Park, Canada
| | - Emery Ferland
- Department of Hematology, Medical Oncology, Hôpital Pierre-Boucher, Longueuil, Canada
| | | | | | - Hugo Diec
- Department of Surgery, Hôpital Pierre-Boucher, Longueuil, Canada
| | - Sébastien Drolet
- Department Surgery, Division of Colorectal Surgery, Hôpital Saint-François D'Assise, Quebec City, Canada
| | - Carole Richard
- Department of Surgery, Division of Colon and Rectal Surgery, Centre hospitalier de l'Université de Montréal, Montreal, Canada
| | - Gerald Batist
- Department of Oncology, Sir Mortimer B. Davis Jewish General Hospital, Montreal, Canada
| | - Té Vuong
- Department of Oncology, Division of Radiation Oncology, Sir Mortimer B. Davis Jewish General Hospital, Montreal, Canada.
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Total Neoadjuvant Therapy for Rectal Cancer: Current Status and Future Directions. CURRENT COLORECTAL CANCER REPORTS 2020. [DOI: 10.1007/s11888-020-00461-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Fichtner-Feigl S. Biology-and Location-Oriented Precision Treatment of Rectal Cancer: Present and Future. Visc Med 2020; 36:381-387. [PMID: 33178735 PMCID: PMC7590750 DOI: 10.1159/000510488] [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: 06/29/2020] [Accepted: 07/27/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The surgical approach in rectal cancer treatment has evolved in the last decades and a standardized surgical technique for tumor resection - total mesorectal excision - has been established. SUMMARY In a multidisciplinary effort with the use of total mesorectal excision in combination with adjuvant and neoadjuvant treatments to compliment surgery disease management can achieve excellent long-term local control and improved patient survival. Further improvements in imaging techniques and the ability to identify prognostic factors such as tumor regression, extramural venous invasion, and threatened margins have introduced the concept of decision-making based on preoperative staging information. KEY MESSAGE Therefore, in the modern era treatment algorithms are based on high-resolution imaging to plan neoadjuvant therapy and precision surgery followed by pathological and molecular analysis to stratify patients for the need of adjuvant chemotherapy. Despite excellent results with guideline structured treatment pathways, there is still a need to improve long-term results especially for individuals with locally advanced or metastatic tumors.
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Affiliation(s)
- Stefan Fichtner-Feigl
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Freiburg, Freiburg, Germany
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How to improve clinical research in a department of radiation oncology. Bull Cancer 2020; 107:991-998. [PMID: 32950241 DOI: 10.1016/j.bulcan.2020.06.007] [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: 04/14/2020] [Revised: 06/15/2020] [Accepted: 06/18/2020] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Radiation therapy is a core modality for cancer treatment. Around 40% of cancer cures include the use of radiotherapy, either as a single strategy or combined with other treatments. In the past decade, substantial technical advances and novel insights into radiobiological properties have considerably improved patients' outcomes. This study overviewed the landscape of clinical research at our radiotherapy department. METHODS We surveyed our institutional database of clinical trials to collect information for completed or ongoing radiation therapy clinical trials, from 2005 to December 2017 at the Lucien Neuwirth cancer institute. RESULTS A total of 31 clinical trials were undertaken during the study period, of which 4 studies (12.9%) were industry-sponsored and 3 studies (9.7%) were launched by our radiotherapy unit. The vast majority of clinical trials (83.9%) were dedicated to unique organ localization, especially urological cancer (prostate or bladder) (42%). We also observed a shift towards more phase II trials during the study period as well as a special focus on elderly population. Over the last decade, the number of included patients increased by a 5.3 fold input, with 135 inclusions before 2011 and 720 inclusions after 2011. DISCUSSION This study provided an observational and comprehensive analysis of radiotherapy research. From a monocentric point-of-view, these results reflected the on-going progress of worldwide radiotherapy research. Based on a 13-years' experience, this study aimed at highlighting essential cues to ensure efficient and perennial research.
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Meng Y, Wan L, Zhang C, Wang C, Ye F, Li S, Zou S, Cheng J, Xu K, Zhou C, Zhang H. The Predictive Value of Pre-/Postneoadjuvant Chemoradiotherapy MRI Characteristics for Patient Outcomes in Locally Advanced Rectal Cancer. Acad Radiol 2020; 27:e233-e243. [PMID: 31780392 DOI: 10.1016/j.acra.2019.10.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 10/27/2019] [Accepted: 10/27/2019] [Indexed: 01/18/2023]
Abstract
RATIONALE AND OBJECTIVES This study aimed to investigate the predictive value of pre-/postneoadjuvant chemoradiotherapy (nCRT) magnetic resonance imaging (MRI) characteristics for the long-term survival outcomes in patients with locally advanced rectal cancer (LARC). MATERIALS AND METHODS We retrospectively evaluated pre- and post-nCRT MRI and clinicopathologic characteristics of LARC patients. The 3-year disease-free survival (DFS) was estimated using the Kaplan-Meier product-limit method. Associations between MRI variabilities and survival outcomes were assessed using Cox proportional hazards model. RESULTS In total, 171 LARC patients (112 men and 59 women) with a median age of 55 years (range, 27-82 years) treated with nCRT were evaluated. The median follow-up was 47.6 months, and the 3-, 4-, and 5-year DFS in the overall cohort was 76.6%, 74.5%, and 73.7%, respectively. MRI assessment of extramural venous invasion (mrEMVI) positivity was a significant independent adverse factor of long-term survival (hazard ratio [HR] = 2.589, 95% confidence interval [CI] = 1.398-4.794, p = 0.002) on multivariate analysis. Patients with positive mrEMVI had significantly lower 3-year DFS than those with negative mrEMVI (52.6 months vs 65.1 months; p = 0.003). Moreover, the tumor regression grade on MRI (mrTRG) also significantly correlated with survival outcomes in patients with LARC. Patients with partial response on post-nCRT MRI (mrPR) showed short DFS than those with complete response (mrCR; HR = 4.914, 95% CI = 1.176-20.533, p = 0.029). The 3-year DFS of mrCR and mrPR patients were 74.3 months and 58.9 months, respectively (p = 0.011). CONCLUSION The pre-/post-nCRT MRI characteristics may be used to long-term survival stratification in LARC patients. mrEMVI positivity was an independent adverse prognostic indicator for 3-year DFS. Further, mrTRG may also be a predictive factor for the prognosis of LARC patients. The pre-/post-nCRT MR imaging may offer more information for providing individualized treatment.
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Affiliation(s)
- Yankai Meng
- Department of Radiology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, Province, PR China; College of Medical Imaging, Xuzhou Medical University, Xuzhou, Jiangsu, Province, PR China
| | - Lijuan Wan
- Department of Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17 Panjiayuannanli, Chaoyang District, Beijing 100021, PR China
| | - Chongda Zhang
- Tandon school of Engineering, New York university, New York, USA
| | - Chen Wang
- Department of Radiology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, Province, PR China
| | - Feng Ye
- Department of Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17 Panjiayuannanli, Chaoyang District, Beijing 100021, PR China
| | - Shaodong Li
- Department of Radiology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, Province, PR China
| | - Shuangmei Zou
- Department of Pathology, National Cancer Center/ National Clinical Research Center for Cancer /Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jyh Cheng
- College of Medical Imaging, Xuzhou Medical University, Xuzhou, Jiangsu, Province, PR China.; Department of Biomedical and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan
| | - Kai Xu
- Department of Radiology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, Province, PR China; College of Medical Imaging, Xuzhou Medical University, Xuzhou, Jiangsu, Province, PR China..
| | - Chunwu Zhou
- Department of Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17 Panjiayuannanli, Chaoyang District, Beijing 100021, PR China.
| | - Hongmei Zhang
- Department of Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17 Panjiayuannanli, Chaoyang District, Beijing 100021, PR China.
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The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Rectal Cancer. Dis Colon Rectum 2020; 63:1191-1222. [PMID: 33216491 DOI: 10.1097/dcr.0000000000001762] [Citation(s) in RCA: 152] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Marmorino F, Boccaccino A, Germani MM, Falcone A, Cremolini C. Immune Checkpoint Inhibitors in pMMR Metastatic Colorectal Cancer: A Tough Challenge. Cancers (Basel) 2020; 12:E2317. [PMID: 32824490 PMCID: PMC7465130 DOI: 10.3390/cancers12082317] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 08/13/2020] [Accepted: 08/14/2020] [Indexed: 12/14/2022] Open
Abstract
The introduction of checkpoint inhibitors provided remarkable achievements in several solid tumors but only 5% of metastatic colorectal cancer (mCRC) patients, i.e., those with bearing microsatellite instable (MSI-high)/deficient DNA mismatch repair (dMMR) tumors, benefit from this approach. The favorable effect of immunotherapy in these patients has been postulated to be due to an increase in neoantigens due to their higher somatic mutational load, also associated with an abundant infiltration of immune cells in tumor microenvironment (TME). While in patients with dMMR tumors checkpoint inhibitors allow achieving durable response with dramatic survival improvement, current results in patients with microsatellite stable (MSS or MSI-low)/proficient DNA mismatch repair (pMMR) tumors are disappointing. These tumors show low mutational load and absence of "immune-competent" TME, and are intrinsically resistant to immune checkpoint inhibitors. Modifying the interplay among cancer cells, TME and host immune system is the aim of multiple lines of research in order to enhance the immunogenicity of pMMR mCRC, and exploit immunotherapy also in this field. Here, we focus on the rationale behind ongoing clinical trials aiming at extending the efficacy of immunotherapy beyond the MSI-high/dMMR subgroup with particular regard to academic no-profit studies.
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Affiliation(s)
- Federica Marmorino
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, via Risorgimento 36, 56126 Pisa, Italy; (F.M.); (A.B.); (M.M.G.); (A.F.)
- Unit of Medical Oncology, Azienda Ospedaliera Universitaria Pisana, Via Roma 67, 56126 Pisa, Italy
| | - Alessandra Boccaccino
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, via Risorgimento 36, 56126 Pisa, Italy; (F.M.); (A.B.); (M.M.G.); (A.F.)
- Unit of Medical Oncology, Azienda Ospedaliera Universitaria Pisana, Via Roma 67, 56126 Pisa, Italy
| | - Marco Maria Germani
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, via Risorgimento 36, 56126 Pisa, Italy; (F.M.); (A.B.); (M.M.G.); (A.F.)
- Unit of Medical Oncology, Azienda Ospedaliera Universitaria Pisana, Via Roma 67, 56126 Pisa, Italy
| | - Alfredo Falcone
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, via Risorgimento 36, 56126 Pisa, Italy; (F.M.); (A.B.); (M.M.G.); (A.F.)
- Unit of Medical Oncology, Azienda Ospedaliera Universitaria Pisana, Via Roma 67, 56126 Pisa, Italy
| | - Chiara Cremolini
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, via Risorgimento 36, 56126 Pisa, Italy; (F.M.); (A.B.); (M.M.G.); (A.F.)
- Unit of Medical Oncology, Azienda Ospedaliera Universitaria Pisana, Via Roma 67, 56126 Pisa, Italy
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