Radiotherapy and Oral Capecitabine in the Preoperative Treatment of Patients with Rectal Cancer: Rationale, Preliminary Results and Perspectives

Comparison between Intensified Neoadjuvant Treatment and Standard Preoperative Chemoradiation for Rectal Cancer

Objectives

The aim of the current study was to compare a neoadjuvant regimen containing oxaliplatin with standard preoperative treatment for rectal cancer.

Methods

From December 2006 to December 2007, 20 patients with rectal cancer were treated at our Institution with the weekly addition of oxaliplatin (50 mg/m2) to radiotherapy (50.4–54.0 Gy in 28–30 daily fractions) and continuous infusion of 5-fluorouracil (200 mg/m2). The results of the regimen were compared with a historical control group including 21 consecutive patients previously treated with standard 5-fluorouracil treatment from December 2004 to October 2006.

Results

Both the rate of sphincter preservation in low rectal cancer (91.7% vs 36.4%, P = 0.009) and the rate of downstaging (84.2% vs 47.6%, P = 0.023) were higher in the oxaliplatin group than in the control group. Pathological complete response was achieved in 8 patients (42.1%) in the oxaliplatin group and in 4 patients (19.0%) in the control group (P = 0.172). When ypT0-pT1 stages were analyzed together, the P value was 0.051. Acute toxicity was increased in the oxaliplatin group, with a higher incidence of G3 diarrhea and pelvic pain than in the control group (30.0% vs 14.3%, P = NS).

Conclusions

Our data seem to correlate the addition of oxaliplatin to the standard treatment for rectal cancer with higher rates of sphincter preservation, down-staging and complete response. Toxicity is increased and requires careful monitoring. However, our results refer to a retrospective comparison of a small series of patients and need to be validated by the large, phase III randomized trial currently ongoing.

Capecitabine: a new adjuvant option for colorectal cancer

Colorectal cancer continues to pose a major public health threat in the United States. Without postsurgical adjuvant therapy, approximately 50% of patients will have recurrent disease and die within five years. Since 1990, five new chemotherapy agents have been added to the therapeutic armamentarium for management of colorectal cancer, and agents traditionally used to treat metastatic and advanced disease increasingly are being applied in the adjuvant setting. One such treatment, capecitabine, offers patients the benefit of oral dosing and permits at-home self-management. A phase III randomized trial, Xeloda in Adjuvant Colorectal Cancer Treatment, demonstrated that treatment with single-agent capecitabine was equivalent to bolus 5-fluorouracil with leucovorin with respect to disease-free survival and overall survival, with significantly less diarrhea, stomatitis, neutropenia, nausea and vomiting, and alopecia. This article reviews the findings and discusses how oncology nurses can help provide effective education and monitoring for patients using oral treatment in the adjuvant setting.

New and emerging radiosensitizers and radioprotectors

The combination of chemotherapy and radiation has led to clinical breakthroughs in several disease sites, and current work continues to define optimum combinations of proven chemotherapy as well as more recently available, noncytotoxic agents. Administration of systemic therapies allows modulation of radiation response to improve tumor control (radiosensitization) or to prevent normal tissue toxicity (radioprotection). Substantial progress has been made in identifying the targets of standard chemotherapeutic radiation sensitizers and protectors as well as in the introduction of a new generation of molecularly targeted therapies in combination with radiation. We have reviewed the most recent, predominantly early phase clinical trials combining systemic agents with radiation. Although the proof of an improved schedule ultimately needs to come from well-run Phase III trials, the search among schedules could be shortened by the use of surrogate endpoints such as presence of active drug metabolites in the tumor. This has been accomplished only in a few cases and needs to become a more standard part of radiation sensitizer and protector trials.

Phase III trial of fluorouracil-based chemotherapy regimens plus radiotherapy in postoperative adjuvant rectal cancer: GI INT 0144

PURPOSE

Adjuvant chemoradiotherapy after or before resection of high-risk rectal cancer improves overall survival (OS) and pelvic control. We studied three postoperative fluorouracil (FU) radiochemotherapy regimens.

PATIENTS AND METHODS

After resection of T3-4, N0, M0 or T1-4, N1, 2M0 rectal adenocarcinoma, 1,917 patients were randomly assigned to arm 1, with bolus FU in two 5-day cycles every 28 days before and after radiotherapy (XRT) plus FU via protracted venous infusion (PVI) 225 mg/m2/d during XRT; arm 2 (PVI-only arm), with PVI 42 days before and 56 days after XRT + PVI; or arm 3 (bolus-only arm), with bolus FU + leucovorin (LV) in two 5-day cycles before and after XRT, plus bolus FU + LV (levamisole was administered each cycle before and after XRT). Patients were stratified by operation type, T and N stage, and time from surgery.

RESULTS

Median follow-up was 5.7 years. Lethal toxicity was less than 1%, with grade 3 to 4 hematologic toxicity in 49% to 55% of the bolus arms versus 4% in the PVI arm. No disease-free survival (DFS) or OS difference was detected (3-year DFS, 67% to 69% and 3-year OS, 81% to 83% in all arms). Locoregional failure (LRF) at first relapse was 8% in arm 1, 4.6% in arm 2, and 7% in arm 3. LRF in T1-2, N1-2, and T3, N0-2 primaries who received low anterior resection (those most suitable for primary resection) was 5% in arm 1, 3% in arm 2, and 5% in arm 3.

CONCLUSION

All arms provide similar relapse-free survival and OS, with different toxicity profiles and central catheter requirements. LRF with postoperative therapy is low, justifying initial resection for T1-2, N0-2 and T3, and N0-2 anterior resection candidates.

Long-Term Clinical Response in Leptomeningeal Metastases from Breast Cancer Treated with Capecitabine Monotherapy: A Case Report

Brain and leptomeningeal metastases from breast cancer carry a poor prognosis and are often less responsive to systemic therapy. It is often thought that systemic therapy has a minimal role in the management of central nervous system (CNS) metastases because of the impermeability of the blood-brain barrier. However, treatments directed to the CNS such as radiation or intrathecal chemotherapy are not effective in managing concurrent non-CNS metastases. We report the long-term control of a woman receiving capecitabine with brain and leptomeningeal metastases. After 3.7 years of capecitabine therapy after whole-brain radiation, the patient remains without neurologic symptoms or deficits, has no evidence of disease on neuroimaging studies, but has a persistent positive cytology. This case report demonstrates that, in principle, systemic therapy can provide long-term complete responses for some patients with CNS metastases. The significance of persistent circulating tumor cells in the CNS in patients without evidence of disease is unclear but should be investigated further.

Evaluation of TS-1 based treatment and expression of thymidylate synthase and dihydropyrimidine dehydrogenase on oral squamous cell carcinoma

Seventeen oral squamous cell carcinoma (SCC) patients underwent chemotherapy with TS-1 (8 males and 9 females, mean age; 75.1 years, range; 47-102 years). TS-1 permitted five cases of oral chemotherapy on an outpatient basis and 8 cases in elder patients over 80-years of age. Excepting five patients who underwent TS-1 therapy as post-operative adjuvant chemotherapy, the therapeutic efficacy of TS-1 in 12 patients with or without irradiation, surgery or chemotherapy resulted in 3 cases of complete response (CR), 6 cases of partial response (PR), 3 cases of stable disease (SD), with no progressive disease (PD) cases (overall response rate; 75%). SCC samples obtained from biopsy were immunohistochemically stained with anti-TS and DPD polyclonal antibody. Although the statistical significance was not clear, the expression of TS and DPD for CR cases was lower than that for SD cases. TS-1 therapy improved quality of life (QOL) especially in elder patients with oral SCC, and our immunohistochemical results suggested the predictive possibilities of TS and DPD expression in response to TS-1.