Neoadjuvant short-course hyperfractionated accelerated radiotherapy (SC-HART) combined with S-1 for locally advanced rectal cancer

Effect of cognitive behavior therapy combined with exercise intervention on the cognitive bias and coping styles of diarrhea-predominant irritable bowel syndrome patients

BACKGROUND

Irritable bowel syndrome (IBS) is a common digestive system disease with a high incidence rate and is common in women. The cause of IBS remains unclear. Some studies have shown that mental and psychological diseases are independent risk factors for IBS. At present, the treatment of IBS is mainly symptomatic treatment. Clinically, doctors also use cognitive behavioral therapy to improve patients' cognitive ability to diseases and clinical symptoms. In recent years, exercise therapy has attracted more and more attention from scholars. Improving the symptoms of IBS patients through psychosomatic treatment strategy may be a good treatment method.

AIM

To explore the effects of an intervention of cognitive behavioral therapy combined with exercise (CBT+E) on the cognitive bias and coping styles of patients with diarrhea-predominant irritable bowel syndrome (IBS-D); and to provide a theoretical reference for the management of IBS.

METHODS

Sixty IBS-D patients and thirty healthy subjects were selected. The 60 IBS-D patients were randomly divided into experimental and control groups. The experimental group was treated with the CBT+E intervention, while the control group was treated with conventional drugs without any additional intervention. The cognitive bias and coping styles of the participants were evaluated at baseline and after 6 wk, 12 wk and 24 wk using the Automatic Thoughts Questionnaire (ATQ), Dysfunctional Attitudes Scale (DAS) and Pain Coping Style Questionnaire (CSQ) instruments, and the intervention effect was analyzed using SPSS 17.0 statistical software.

RESULTS

At baseline, the scores on the various scales showed that all subjects had cognitive bias and adverse coping styles. The IBS Symptom Severity Scale (IBS-SSS) scores, ATQ total scores, DAS scores and CSQ scores of the two groups were not significantly different (P > 0.05). Compared with baseline, after 6 wk of the CBT+E intervention, there were significant differences in the ATQ scores, the dependence and total scores on the DAS, and the catastrophization, distraction and prayer scores on the CSQ (P < 0.05). After 12 wk, there were significant differences in the scores for perfectionism on the DAS and in the scores for reinterpretation, neglect and pain behavior on the CSQ in the experimental group (P < 0.05). After 24 wk, there were significant differences in the vulnerability, dependence, perfectionism, and total scores on the DAS and in the catastrophization, distraction and prayer scores on the CSQ in the experimental group (P < 0.01). The IBS-SSS scores were negatively correlated with the ATQ and DAS total scores (P < 0.05) but were positively correlated with the CSQ total score (P < 0.05).

CONCLUSION

Intervention consisting of CBT+E can correct the cognitive bias of IBS-D patients and eliminate their adverse coping conditions. CBT+E should be promoted for IBS and psychosomatic diseases.

Pre-operative hyperfractionated concurrent radiochemotherapy for locally advanced rectal cancers: a phase II clinical study

OBJECTIVE

The study was prospectively designed as a single-arm, single-institution prospective trial of pre-operative concomitant hyperfractionated radiotherapy (HART) with co-administration of chemotherapy based on 5-fluorouracil (5FU) in patients with T2/N+ or T3/any N resectable mid-low primary rectal cancer. The aim of the study was to assess the safety and efficacy of accelerated HART with concurrent 5FU-based chemotherapy in patients with locally advanced rectal cancer.

METHODS

Patients with resectable locally advanced (≥T3 or N+) rectal cancer were eligible. The patients received total dose 42 Gy in 28 fractions of 1.5 Gy, two times daily, with at least 8 h of interval, with concurrent chemotherapy: 325 mg m^-2 of 5FU (bolus) on Days 1-3 and Days 16-18 (except for cN0 patients for whom only one cycle on Days 1-3 was prescribed). The primary end point included tolerance, post-operative complication rate and pathological response rate. The secondary end points included locoregional relapse-free survival, metastasis-free survival and overall survival.

RESULTS

Out of 53 enrolled patients; 2 did not undergo surgery. Of the 51 patients evaluable for pathological response, there were 8 (15.6%), 20 (39.3%), 18 (35.3%) and 5 (9.8%) patients with tumour regression grade 0, 1, 2 and 3, respectively. Downstaging of the primary tumour and lymph nodes was observed in 22 (43%) and 25 (49%) patients, respectively. The primary tumour ypCR (ypT0) rate was 15% (8/51). The nodal ypCR rate for cN+ patients was 60% (21/35). The total ypCR (ypT0N0M0) rate was 11% (6/51). Toxicity included: Grade 3 diarrhoea (4/51, 7.8%), Grade 2 diarrhoea (22/51, 43.1%), Grade 2 leukopenia (7/51, 13.7%), Grade 2 neutropenia (6/51, 11.7%) and Grade 1 thrombocytopenia (3/51, 5.9%). No Grade 4 toxicity was reported. Nine patients (18%) presented with post-operative complications (during the 3 months after surgery). There were 6 locoregional relapses (11.8%) and distant metastasis occurred in 11 patients (21.6%). The 2-year cumulative locoregional relapse-free survival, metastasis-free survival and overall survival was 87%, 79% and 89%, respectively.

CONCLUSION

The proposed pre-operative HART with co-administration of 5FU had acceptable toxicity profile and provided satisfactory rate of ypCR. This created rationale to initiate a Phase III randomized study that was registered under ClinicalTrials.gov Identifier: NCT01814969. Advances in knowledge: The results of this research show that responders to pre-operative radiochemotherapy have favourable outcome. Tumour regression grade as prognostic clinical feature holds the promise of better classifying patients at high risk of local and systemic recurrence and this issue may be an interesting objective for future research.

Diffusion-weighted magnetic resonance imaging for prediction of tumor response to neoadjuvant chemoradiotherapy using irinotecan plus S-1 for rectal cancer

The purpose of this study was to investigate the clinical value of diffusion-weighted (DW) magnetic resonance imaging (MRI) as a predictor of tumor response in patients receiving neoadjuvant chemoradiotherapy (NA-CRT) for rectal cancer (RC) through measurement of the apparent diffusion coefficient (ADC) value in each tumor. Neoadjuvant radiotherapy with a total dose of 45 Gy in 25 fractions was performed in all 16 patients with RC, combined with irinotecan and S-1. MRI was performed before and after NA-CRT. Multiple factors were assessed to predict the pathological response to NA-CRT. The pathological response rate was determined in 9 patients (56.3%). Statistical analyses indicated that the ADC value prior to NA-CRT was significantly lower in patients with a better response to NA-CRT (P=0.023). A cut-off value of 0.750×10^-3 mm²/sec obtained by a receiver operating characteristic curve analysis indicated a sensitivity of 77.8% and specificity of 85.7% for pathological responders to NA-CRT. In addition, the patients with lower ADC values exhibited a greater pathological response to NA-CRT (P=0.041). In conclusion, the ADC value of MRI of RC patients treated with NA-CRT followed by surgery may provide valuable information to predict the response to NA-CRT.

Feasibility of modified short-course radiotherapy combined with a chemoradiosensitizer for T3 rectal cancer

BACKGROUND

5-Fluorouracil-based chemotherapy is considered to be a radiosensitizer; however, conventional short-course radiotherapy combined with chemotherapy is generally thought to not be feasible because of the prevalence of side effects.

OBJECTIVE

The aim of this study was to evaluate the feasibility of modified short-course radiotherapy combined with a chemoradiosensitizer for T3 rectal cancer.

DESIGN AND SETTINGS

This study was retrospective in nature and used a prospectively collected database.

PATIENTS

Patients with T3 rectal cancer located below the peritoneum reflection were selected.

INTERVENTIONS

A total dose of 25 Gy of radiotherapy was administered in 10 fractions of 2.5 Gy each for 5 days. Radiotherapy was performed with S-1 as a radiosensitizer from day 1 to day 10. Surgery was targeted to be performed 4 weeks after radiotherapy.

MAIN OUTCOME MEASUREMENTS

The morbidity, sphincter-preserving rate, anal function, and long-term outcomes were assessed.

RESULTS

All patients (n = 170) completed the radiotherapy regimen and 166 (97.6%) completed the combination regimen with chemotherapy. A total of 149 patients (87.6%) had sphincter-preserving surgery (double stapling technique (DST), 58 patients; intersphincteric resection (ISR), 91 patients), and postoperative complications were relatively mild (anastomotic leakage, 15.4%; intra-abdominal infection, 8.2%). Among those undergoing sphincter preserving surgery, the 5-year local relapse-free survival rate was 94.3% in the DST group, and 89.8% in the ISR group. With respect to the anal function, the Wexner score the first year after stoma closure for the double-stapling technique group was 6 and that for intersphincteric resection was 15; however, the score for the intersphincteric resection group was improved to 8 at 4 years after stoma closure.

LIMITATIONS

This study had limitations because it was an uncontrolled, 1-arm, retrospective review with a small sample size.

CONCLUSIONS

Modified short-course radiotherapy combined with chemoradiosensitizer is a feasible approach for treating T3 rectal cancer. With the use of the short-course approach, efforts to reduce the incidence of side effects by appropriately prolonging the waiting period enable the administration of combination treatment with short-course radiotherapy and chemotherapy.

How can we determine the best neoadjuvant chemoradiotherapy regimen for rectal cancer?

SUMMARY 

The current management of patients with clinically defined ‘locally advanced rectal cancer’ often involves fluoropyrimidine-based preoperative chemoradiotherapy (CRT) followed by total mesorectal excision. The focus remains primarily on reducing local recurrence, and improving survival, with organ preservation an increasing target. The best neoadjuvant CRT is the most effective regimen, balanced against the tolerability and late functional consequences, which should be selected for the individual according to their individual risk of local and distant recurrence. Hence, what makes the best neoadjuvant treatment depends on the activity and toxicity of the particular schedule, the aims of treatment, the individual disease characteristics and the individual patient pharmacogenomics. Current research efforts focus on enhancing the efficacy of CRT by integrating additional cytotoxics and biologically targeted agents.

Organ preservation in rectal cancer: have all questions been answered?

Improved treatment strategies have eliminated local control as the major problem in rectal cancer. With increasing awareness of long-term toxic effects in survivors of rectal cancer, organ-preservation strategies are becoming more popular. After chemoradiotherapy, both watchful waiting and local excision are used as possible alternatives for radical surgery. Although these seem attractive strategies, many issues about the safety of organ preservation remain. Additionally, radiotherapy strategies are mainly aimed at intermediate and high-risk rectal tumours, and adaptation of this standard practice for a completely new treatment indication has yet to start. This Review will discuss the options and problems of organ preservation, and address the research questions that need to be answered in the coming years, with a specific focus on radiotherapy.

The timing of surgery after preoperative short-course S-1 chemoradiotherapy with delayed surgery for T3 lower rectal cancer

PURPOSE

The purpose of this study was to analyze the influence of variations in clinical practice regarding the timing of surgery with short-course chemoradiotherapy with delayed surgery (SCRT-delay) for lower rectal cancer.

METHODS

A total of 171 patients with T3 N0-2 lower rectal cancer treated with SCRT-delay (25 Gy/10 fractions/5 days (S-1); days 1-10) were retrospectively evaluated. The median waiting period of 30 days was used as a discriminator (group A: waiting period, ≤30 days; group B: waiting period, ≥31 days). Preoperative treatment responses and oncological outcomes were analyzed.

RESULTS

The mean waiting periods for groups A and B were 24.4 ± 5.3 and 41.4 ± 12.3 days, respectively. There were no statistically significant differences between the two groups in any of the clinical variables. The clinicopathological outcomes were as follows: T downstaging (43.5 vs 37.2 %; p = 0.400), negative yp N (67.1 vs 75.6 %; p = 0.218), pCR (7.1 vs 1.2 %; p = 0.119). The 5-year local recurrence-free survival (89.3 vs 87.6 %; p = 0.956), the recurrence-free survival (82.2 vs 78.8 %; p = 0.662), and the overall survival (88.5 vs 84.4 %; p = 0.741), all of which were similar between the two groups.

CONCLUSIONS

The longer waiting period did not increase the tumor downstaging and not improve the oncological outcomes for T3 lower rectal cancer treated with SCRT-delay. In addition, considering that the impaired leukocyte response occurred during the sub-acute period, any time after the sub-acute period (day 12) up to 30 days after radiotherapy would be a suitable waiting period.

A'high tie'confers an increased risk of anastomotic leakage for lower rectal cancer surgery in patients treated with preoperative radiotherapy

PURPOSE

This study aimed at analyzing retrospectively the risk factors for anastomotic leakage for lower rectal cancer treated with preoperative radiotherapy.

METHODS

The subjects were 108 patients with T3 lower rectal cancer, who underwent curative resection following preoperative radiotherapy. All patients had a diverting stoma made. Univariate and multivariate analyses were conducted for the independent clinical variables.

RESULTS

Anastomotic leakage developed in 19 (17.6 %) patients. Univariate analysis of the risk factors for anastomotic leakage revealed that arterial ligation with a high tie (p = 0.001), undifferentiated tumor type (p = 0.002), a shorter distance from the anal verge (p = 0.086), and a longer hospital stay (p = 0.0002) were significant predictors of leakage. Multivariate analysis revealed that a high tie [hazard ratio 12.22 (95 % confidence interval 2.83-87.94); p = 0.0003], undifferentiated tumor type [91.15 (5.98-3128.03); p = 0.0008], and a long hospital stay [13.03 (2.86-104.93); p = 0.0004] were independently associated with anastomotic leakage.

CONCLUSION

Our data suggest that preoperative radiotherapy and a high tie for lower rectal cancer are independent risk factors for anastomotic leakage.