Adjuvant intraportal chemotherapy for Dukes B2 and C colorectal cancer also receiving systemic treatment: results of a multicenter randomized trial. Groupe Régional d'Etude du Cancer Colo-Rectal (Belgium)

Efficacy of various adjuvant chemotherapy methods in preventing liver metastasis from potentially curative colorectal cancer: A systematic review network meta-analysis of randomized clinical trials

PURPOSE

Various chemotherapy administration methods have been used to prevent liver metastasis (LM) in patients with colorectal cancer (CRC). This network meta-analysis evaluated the efficacy of these different methods in preventing LM in CRC patients who underwent curative surgery.

METHOD

A systematic search of randomized controlled trials reporting the efficacy of various adjuvant chemotherapy methods in patients with colorectal cancer who underwent curative surgery was conducted. The primary outcome was the LM rate.

RESULTS

This network meta-analysis included 19 studies reporting on 12,588 participants, comparing portal vein infusion chemotherapy (PVIC) versus hepatic arterial infusion chemotherapy (HAIC) versus systematic chemotherapy (SC) versus surgery alone. The HAIC group had the lowest LM rate when compared to the other three groups (odds ratio [OR] of PVIC vs. HAIC: 1.86; OR of SC vs. HAIC: 1.98; and HAIC vs. surgery alone: 0.43). The LM rate did not differ significantly between PVIC, SC, and surgery alone. The recurrence rates were lower for PVIC and HAIC than for surgery alone (the ORs for PVIC and HAIC were 0.73 [95% CI: 0.58-0.92] and 0.45 [95% CI: 0.26-0.77]). The mortality rates of patients undergoing PVIC and HAIC were lower than that of patients undergoing surgery alone (the ORs for PVIC and HAIC were 0.77 [95% CI: 0.64-0.93] and 0.49 [95% CI: 0.24-0.98]). Anastomotic leakage, cardiopulmonary leakage, diarrhea, nausea and vomiting, oral ulceration, wound infection, or ileus did not differ significantly between the four groups. PVIC showed the highest hepatic toxicity rate compared to those for SC, HAIC, and surgery alone.

CONCLUSION

HAIC might be a satisfactory method for preventing LM in patients with CRC undergoing curative surgery.

Endpoints in Adjuvant Treatment Trials: A Systematic Review of the Literature in Colon Cancer and Proposed Definitions for Future Trials

Disease-free survival is increasingly being used as the primary endpoint of most trials testing adjuvant treatments in cancer. Other frequently used endpoints include overall survival, recurrence-free survival, and time to recurrence. These endpoints are often defined differently in different trials in the same type of cancer, leading to a lack of comparability among trials. In this Commentary, we used adjuvant studies in colon cancer as a model to address this issue. In a systematic review of the literature, we identified 52 studies of adjuvant treatment in colon cancer published in 1997-2006 that used eight other endpoints in addition to overall survival. Both the definition of these endpoints and the starting point for measuring time to the events that constituted these endpoints varied widely. A panel of experts on clinical research on colorectal cancer then reached consensus on the definition of each endpoint. Disease-free survival--defined as the time from randomization to any event, irrespective of cause--was considered to be the most informative endpoint for assessing the effect of treatment and therefore the most relevant to clinical practice. The proposed guidelines may add to the quality and cross-comparability of future studies of adjuvant treatments for cancer.

Can biliary carcinoembryonic antigen identify colorectal cancer patients with occult hepatic metastases?

BACKGROUND

Twenty-five percent of radically treated colorectal cancer patients already have occult hepatic metastases (OHM) that will later be observed during postoperative follow-up. Instrumental examinations, i.e., intraoperative ultrasound or Doppler perfusion index, have not improved diagnosis. As carcinoembyonic antigen (CEA) levels are useful to reveal hepatic metastases from colorectal cancer, determination of CEA in the bile rather than the blood may allow preclinical diagnosis of OHM thanks to the reduced volume of bile.

METHODS

One hundred radically treated colorectal cancer patients were enrolled in the study. Bile was withdrawn from the gallbladder intraoperatively and biliary CEA levels determined using an immuno-enzymatic method (normal value 0-5 ng/ml). Eighty-nine fully evaluable patients were followed up for three years postoperatively to monitor hepatic metastases. Preoperative blood CEA, lymph node metastases and biliary CEA were compared in order to assess which procedure was more efficient in identifying patients who would develop hepatic metastases.

RESULTS

Eleven of the 89 evaluable patients developed hepatic metastases: 9/11 presented elevated biliary CEA levels (mean: 12.73; range: 5.1-26.2); 8/11 had high preoperative blood CEA values; and 9/11 were at anatomopathological stage N+. In the 78 patients who did not develop hepatic metastases, biliary CEA was within normal limits in 73/78, preoperative blood CEA was normal in 60/78, and 58/78 patients were at anatomopathological stage N-. Hence, the sensitivity of biliary CEA was 81.8%, specificity was 93.6%, and diagnostic accuracy was 92.1%.

CONCLUSIONS

Determination of biliary CEA seems to be more efficient in identifying patients presenting OHM who require frequent clinical examinations or adjuvant cancer treatment.

Adjuvant therapy for stage II colon cancer: a systematic review from the Cancer Care Ontario Program in evidence-based care's gastrointestinal cancer disease site group

PURPOSE

To develop a systematic review that would address the following question: Should patients with stage II colon cancer receive adjuvant therapy?

METHODS

A systematic review was undertaken to locate randomized controlled trials comparing adjuvant therapy to observation.

RESULTS

Thirty-seven trials and 11 meta-analyses were included. The evidence for stage II colon cancer comes primarily from a trial of fluorouracil plus levamisole and a meta-analysis of 1,016 patients comparing fluorouracil plus folinic acid versus observation. Neither detected an improvement in disease-free or overall survival for adjuvant therapy. A recent pooled analysis of data from seven trials observed a benefit for adjuvant therapy in a multivariate analysis for both disease-free and overall survival. The disease-free survival benefits appeared to extend to stage II patients; however, no P values were provided. A meta-analysis of chemotherapy by portal vein infusion has also shown a benefit in disease-free and overall survival for stage II patients. A meta-analysis was conducted using data on stage II patients where data were available (n = 4,187). The mortality risk ratio was 0.87 (95% CI, 0.75 to 1.01; P =.07).

CONCLUSION

There is preliminary evidence indicating that adjuvant therapy is associated with a disease-free survival benefit for patients with stage II colon cancer. These benefits are small and not necessarily associated with improved overall survival. Patients should be made aware of these results and encouraged to participate in active clinical trials. Additional investigation of newer therapies and more mature data from the presently available trials should be pursued.

Regional chemotherapeutic techniques for liver tumors: current knowledge and future directions

After a rather long period of stagnation, intra-arterial therapeutic approaches for treating liver tumors are currently progressing rapidly. These new modalities will increase the resectability of initially unresectable liver tumors after dramatic responses. At the same time, resectability rates are increasing with the assistance of local ablative physical treatments such as radiofrequency, resulting in an improvement of patients' median survival rates and quality of life.

Adjuvant chemotherapy for colon cancer

Colorectal cancer is one of the most frequent cancers in the world, especially in occidental countries. The primary curative therapy is surgical resection of the tumour. Within the last 15 years, appropriately powered prospective randomized trials have demonstrated that adjuvant post-operative chemotherapy should be the standard treatment for stage III cancers (node-positive disease). 5-Fluorouracil(5FU)/levamisole was used in the early 1990s but has now been replaced by 5FU/leucovorin. The recommended duration of treatment is 6 months. Combining levamisole with 5FU/leucovorin does not improve efficacy. In patients with stage II colon cancer it is still unclear whether adjuvant chemotherapy is effective. In an attempt to define groups of stage II cases that may benefit from adjuvant chemotherapy, considerable efforts have been made to determine molecular genetic factors (tumour-ploidy and mutations or alterations in oncogenes and tumour-suppressor genes). Regional therapy (particularly portal vein infusion) is one of the other therapeutic strategies still considered to be investigational. Current clinical trials are evaluating the role of non-fluorinated pyrimidine agents in an adjuvant setting.