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Ouyang L, Lin H, Zhuang P, Shao Y, Khosravifarsani M, Guérin B, Zheng Y, Sanche L. DNA radiosensitization by terpyridine-platinum: damage induced by 5 and 10 eV transient anions. NANOSCALE 2023; 15:3230-3242. [PMID: 36722902 DOI: 10.1039/d2nr05403e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Chemoradiation therapy (CRT), which combines a chemotherapeutic drug with ionizing radiation (IR), is the most common cancer treatment. At the molecular level, the binding of Pt-drugs to DNA sensitizes cancer cells to IR, mostly by increasing the damage induced by secondary low-energy (0-20 eV) electrons (LEEs). We investigate such enhancements by binding terpyridine-platinum (Tpy-Pt) to supercoiled plasmid DNA. Fifteen nanometer thick films of Tpy-Pt-DNA complexes in a molar ratio of 5 : 1 were irradiated with monoenergetic electrons of 5 and 10 eV, which principally attach to the DNA bases to form transient anions (TAs) decaying into a multitude of bond-breaking channels. At both energies, the effective yields of crosslinks (CLs), base damage (BD) related CLs, single and double strand breaks (SSBs and DSBs), non-DSB-cluster lesions, loss of supercoiled configuration and base lesions are 6.5 ± 1.5, 8.8± 3.0, 88 ± 11, 5.3 ± 1.3, 9.6 ± 2.2, 106 ± 17, 189 ± 31 × 10-15 per electron per molecule, and 11.9 ± 2.6, 19.9 ± 4.4, 128 ± 18, 7.7 ± 3.0, 13.4 ± 3.9, 144 ± 19, 229 ± 42 × 10-15 per electron per molecule, respectively. DNA damage increased 1.2-4.2-fold due to Tpy-Pt, the highest being for BD-related CLs. These enhancements are slightly higher than those obtained by the conventional Pt-drugs cisplatin, carboplatin and oxaliplatin, apart from BD-related CLs, which are about 3 times higher. Enhancements are related to the strong perturbation of the DNA helix by Tpy-Pt, its high dipole moment and its favorable binding to guanine (G), all of which increase bond-breaking via TA formation. In CRT, Tpy-Pt could considerably enhance crosslinking within genomic DNA and between DNA and other components of the nucleus, causing roadblocks to replication and transcription, particularly within telomeres, where it binds preferentially within G-quadruplexes.
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Affiliation(s)
- Liangde Ouyang
- State Key Laboratory of Photocatalysis on Energy and Environment, Faculty of Chemistry, Fuzhou University, Fuzhou 350116, P.R. China
| | - Hong Lin
- State Key Laboratory of Photocatalysis on Energy and Environment, Faculty of Chemistry, Fuzhou University, Fuzhou 350116, P.R. China
| | - Puxiang Zhuang
- State Key Laboratory of Photocatalysis on Energy and Environment, Faculty of Chemistry, Fuzhou University, Fuzhou 350116, P.R. China
| | - Yu Shao
- State Key Laboratory of Photocatalysis on Energy and Environment, Faculty of Chemistry, Fuzhou University, Fuzhou 350116, P.R. China
| | - Meysam Khosravifarsani
- Department of Nuclear Medicine and Radiobiology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada J1H 5N4.
| | - Brigitte Guérin
- Department of Nuclear Medicine and Radiobiology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada J1H 5N4.
| | - Yi Zheng
- State Key Laboratory of Photocatalysis on Energy and Environment, Faculty of Chemistry, Fuzhou University, Fuzhou 350116, P.R. China
- Department of Nuclear Medicine and Radiobiology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada J1H 5N4.
| | - Léon Sanche
- Department of Nuclear Medicine and Radiobiology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada J1H 5N4.
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Lupattelli M, Bellavita R, Natalini G, Giovenali P, Sidoni A, Castagnoli P, Corgna E, Draghini L, Trippolini R, Aristei C. Oxaliplatin with Raltitrexed and Preoperative Radiotherapy in T3-T4 Extraperitoneal Rectal Cancer. A Dose Finding Study. TUMORI JOURNAL 2019; 92:474-80. [PMID: 17260486 DOI: 10.1177/030089160609200602] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aims and background The availability of new drugs offers the opportunity to improve the outcome of locally advanced rectal cancer. Raltitrexed and oxaliplatin are effective in advanced colorectal cancer with acceptable toxicity and can act as radiation enhancers as shown in phase 1-11 studies. The aim of the study was thus to determine the recommended dose of oxaliplatin concomitantly administered with raltitrexed and concurrent preoperative radiotherapy in patients with stage 11-111 extraperitoneal rectal cancer. Methods From September 2001 to September 2002, 18 consecutive patients with T3/T4 rectal cancer were treated at our Institution with preoperative chemoradiation followed by surgery after 6-8 weeks. Pelvic radiotherapy was delivered at a dose of 45 Gy in 25 fractions in 5 weeks followed by a 5.4 Gy boost at 1.8 Gy daily. Concomitant chemotherapy consisted of 3 mg/m2/iv of raltitrexed on days 1, 19, 38 of radiotherapy treatment with incremental doses of oxaliplatin according to dose finding rules (4 dose levels: 65, 85, 110, 130 mg/m2). Dose-limiting toxicity for oxaliplatin was defined as either grade 3-4 hematological or grade 3-4 gastrointestinal or neurological toxicity. We studied a minimum of 3 patients at each dose level. Results Three patients were treated at 65, 85, and 110 mg/m2/iv, respectively, while 9 patients were recruited at the last dose level. Neither grade 3-4 gastrointestinal nor neurological toxicity were documented. Dose-limiting toxicity was documented in 2/9 subjects at the 130 mg/m2 level consisting of grade 3 transient asymptomatic leukopenia. Thirteen patients developed transient increase of one or more liver enzymes (grade 3-4) and 2 patients developed grade 3 perineal dermatitis. All patients received the programmed dose of radiotherapy. The chemotherapy regimen was not completed in 4 cases due to grade 2 protracted leukopenia. Conclusions The maximum tolerated dose of oxaliplatin was not reached at the maximum dose level (IV); 130 mg/m2 can therefore be defined as the recommended dose. The combination of oxaliplatin with raltitrexed and radiotherapy can be considered feasible and well tolerated.
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Affiliation(s)
- Marco Lupattelli
- Radiation Oncology Center, University and Hospital of Perugia, Perugia, Italy.
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Hüttner FJ, Probst P, Kalkum E, Hackbusch M, Jensen K, Ulrich A, Büchler MW, Diener MK. Addition of platinum derivatives to neoadjuvant single-agent fluoropyrimidine chemoradiotherapy in patients with stage II/III rectal cancer: protocol for a systematic review and meta-analysis (PROSPERO CRD42017073064). Syst Rev 2018; 7:11. [PMID: 29357929 PMCID: PMC5778669 DOI: 10.1186/s13643-018-0678-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Accepted: 01/11/2018] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Neoadjuvant (chemo-)radiation has proven to improve local control compared to surgery alone, but this improvement did not translate into better overall or disease-specific survival. The addition of oxaliplatin to fluoropyrimidine-based neoadjuvant chemoradiotherapy holds the potential of positively affecting survival in this context since it has been proven effective in the palliative and adjuvant setting of colorectal cancer. Thus, the objective of this systematic review is to assess the efficacy, safety, and quality of life resulting from adding a platinum derivative to neoadjuvant single-agent fluoropyrimidine-based chemoradiotherapy in patients with Union for International Cancer Control stage II and III rectal cancer. METHODS MEDLINE, Web of Science, and Cochrane Central Register of Controlled Trials will be systematically searched to identify all randomized controlled trials comparing single-agent fluoropyrimidine-based chemoradiotherapy to combined neoadjuvant therapy including a platinum derivative. Predefined data on trial design, quality, patient characteristics, and endpoints will be extracted. Quality of included trials will be assessed according to the Cochrane Risk of Bias Tool, and the GRADE recommendations will be applied to judge the quality of the resulting evidence. The main outcome parameter will be survival, but also treatment toxicity, perioperative morbidity, and quality of life will be assessed. DISCUSSION The findings of this systematic review and meta-analysis will provide novel insights into the efficacy and safety of combined neoadjuvant chemoradiotherapy including a platinum derivative and may form a basis for future clinical decision-making, guideline evaluation, and research prioritization. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017073064.
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Affiliation(s)
- Felix J. Hüttner
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
- The Study Center of the German Surgical Society (SDGC), University of Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Pascal Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
- The Study Center of the German Surgical Society (SDGC), University of Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Eva Kalkum
- The Study Center of the German Surgical Society (SDGC), University of Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Matthes Hackbusch
- Institute of Medical Biometry and Informatics (IMBI), University of Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Katrin Jensen
- Institute of Medical Biometry and Informatics (IMBI), University of Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Alexis Ulrich
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - Markus W. Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - Markus K. Diener
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
- The Study Center of the German Surgical Society (SDGC), University of Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
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Resende HM, Jacob LFP, Quinellato LV, Matos D, da Silva EMK. Combination chemotherapy versus single-agent chemotherapy during preoperative chemoradiation for resectable rectal cancer. Cochrane Database Syst Rev 2015; 10:CD008531. [PMID: 35658163 PMCID: PMC8947000 DOI: 10.1002/14651858.cd008531.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Colorectal cancer represents 10% of all cancers and is the third most common cause of death in women and men. Almost two-thirds of all bowel cancers are cancers of the colon and over one-third (34%) are cancers of the rectum, including the anus. Surgery is the cornerstone for curative treatment of rectal cancer. Mesorectal excision decreases the rate of local recurrences; however, it does not improve the overall survival of people with locally advanced rectal cancer. There have been significant research efforts since the mid-1990s to optimise the treatment of rectal cancer. Based on the findings of clinical trials, people with T3/T4 or N+ rectal tumours are now being treated preoperatively with radiation and chemotherapy, mainly fluoropyrimidine. However, the incidence of distant metastases remains as high as 30%. Combination chemotherapy regimens, similar to those used in metastatic disease with the addition of oxaliplatin and irinotecan, have been tested to improve the prognosis of people with rectal cancer. OBJECTIVES To compare outcomes (including overall survival, disease-free survival and toxicity) between two 5-fluorouracil-containing chemotherapy regimens in people with stage II and III rectal cancer who are receiving preoperative chemoradiation. SEARCH METHODS We searched the Cochrane Colorectal Cancer Group Specialised Register (January 2015), the Cochrane Central Register of Controlled Trials (2015, Issue 1), Ovid MEDLINE (1950 to January 2015), Ovid EMBASE (1974 to January 2015) and LILACS (1982 to January 2015). We reviewed the reference lists of included studies, checked clinical trials registers and handsearched relevant journal proceedings. We applied no language or publication restrictions. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing single-agent chemotherapy (fluoropyrimidine) versus combination chemotherapy (fluoropyrimidine plus another agent including, but not limited to, oxaliplatin) during preoperative radiochemotherapy in people with resectable rectal cancer. DATA COLLECTION AND ANALYSIS Two review authors (HMR, EMKS) independently extracted data and assessed trial quality. When necessary, we requested additional information and clarification of published data from the authors of individual trials. MAIN RESULTS We included four RCTs involving 3875 people with resectable rectal cancer. In the preoperative period, the participants of these studies were randomised to receive chemoradiation either with a single fluoropyrimidine agent (capecitabine or 5-fluorouracil) or with a combination of drugs (fluoropyrimidine plus oxaliplatin). The only study that reported overall survival and disease-free survival found no significant differences between the intervention and control groups; we considered this evidence very low quality. For pathological complete response after preoperative treatment (ypCR) there was high quality evidence favouring the intervention group (odds ratio (OR) 1.23, 95% confidence interval (CI) 1.04 to 1.46), but there was also moderate quality evidence suggesting a higher risk for early toxicity in the intervention group (OR 2.07, 95% CI 1.31 to 3.27). Moderate to high quality evidence suggested that the control group had better compliance to radiotherapy (OR 0.32, 95% CI 0.14 to 0.75). There were no significant differences between groups in postoperative mortality within 60 days, postoperative morbidity, resection margins, abdominoperineal resection and Hartmann procedures. AUTHORS' CONCLUSIONS There was very low quality evidence that people with resectable rectal cancer who receive combination preoperative chemotherapy have no improvements in overall survival or disease-free survival. There was high quality evidence that suggested that combination chemotherapy with oxaliplatin may improve local tumour control in people with resectable rectal cancer, but this regimen also caused more toxicity. The review included four RCTs but only one reported survival; therefore, we cannot make robust conclusions or useful clinical recommendations. The publication of more survival data from these studies will contribute to future analyses.
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Affiliation(s)
- Heloisa M Resende
- Escola Paulista de Medicina, Universidade Federal de São PauloPost‐Graduation Program Emergency Medicine and Evidence Based Medicine of the Federal University of São Paulo (UNIFESP)Rua Borges Lagoa 564 cj 64Vl. ClementinoSão PauloBrazil04038‐000
| | | | | | - Delcio Matos
- Escola Paulista de Medicina, Universidade Federal de São PauloDepartment of Gastroenterological SurgeryRua Edison 278, Apto 61Campo BeloSão PauloSão PauloBrazil04618‐031
| | - Edina MK da Silva
- Universidade Federal de São PauloEmergency Medicine and Evidence Based MedicineRua Borges Lagoa 564 cj 64Vl. ClementinoSão PauloSão PauloBrazil04038‐000
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Jones RG, Tan D. How can we determine the best neoadjuvant chemoradiotherapy regimen for rectal cancer? COLORECTAL CANCER 2015. [DOI: 10.2217/crc.15.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
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.
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Affiliation(s)
- Rob Glynne Jones
- Consultant Radiation Oncologist, Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, Middlesex, HA6 2RN, UK
| | - David Tan
- Radiation Oncologist, FRCR, Consultant Radiation Oncologist, National Cancer Centre, Singapore
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Gibbs P, Gebski V, Van Buskirk M, Thurston K, Cade DN, Van Hazel GA. Selective Internal Radiation Therapy (SIRT) with yttrium-90 resin microspheres plus standard systemic chemotherapy regimen of FOLFOX versus FOLFOX alone as first-line treatment of non-resectable liver metastases from colorectal cancer: the SIRFLOX study. BMC Cancer 2014; 14:897. [PMID: 25487708 PMCID: PMC4289171 DOI: 10.1186/1471-2407-14-897] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 12/01/2014] [Indexed: 12/29/2022] Open
Abstract
Background In colorectal cancer (CRC), unresectable liver metastases are linked to poor prognosis. Systemic chemotherapy with regimens such as FOLFOX (combination of infusional 5-fluorouracil, leucovorin and oxaliplatin) is the standard first-line treatment. The SIRFLOX trial was designed to assess the efficacy and safety of combining FOLFOX-based chemotherapy with Selective Internal Radiation Therapy (SIRT or radioembolisation) using yttrium-90 resin microspheres (SIR-Spheres®; Sirtex Medical Limited, North Sydney, Australia). Methods/Design SIRFLOX is a randomised, multicentre trial of mFOLFOX6 chemotherapy ± SIRT as first-line treatment of patients with liver-only or liver-predominant metastatic CRC (mCRC). The trial aims to recruit adult chemotherapy-naïve patients with proven liver metastases with or without limited extra-hepatic disease, a life expectancy of ≥3 months and a WHO performance status of 0–1. Patients will be randomised to receive either mFOLFOX6 or SIRT + mFOLFOX6 (with a reduced dose of oxaliplatin in cycles 1–3 following SIRT). Patients in both arms can receive bevacizumab at investigator discretion. Protocol chemotherapy will continue until there is unacceptable toxicity, evidence of tumour progression, complete surgical resection or ablation of cancerous lesions, or the patient requests an end to treatment. The primary endpoint of the SIRFLOX trial is progression-free survival (PFS). Secondary endpoints include: PFS in the liver; tumour response rate (liver and any site); site of tumour progression; health-related quality of life; toxicity and safety; liver resection rate; and overall survival. Assuming an increase in the median PFS from 9.4 months to 12.5 months with the addition of SIRT to mFOLFOX6, recruiting ≥450 patients will be sufficient for 80% power and 95% confidence. Discussion The SIRFLOX trial will establish the potential role of SIRT + standard systemic chemotherapy in the first-line management of mCRC with non-resectable liver metastases. Trial registration SIRFLOX ClinicalTrials.gov identifier: NCT00724503. Registered 25 July 2008. Electronic supplementary material The online version of this article (doi:10.1186/1471-2407-14-897) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Peter Gibbs
- Royal Melbourne Hospital, Melbourne, Victoria, Australia.
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de-Freitas-Junior JCM, Bastos LG, Freire-Neto CA, Rocher BD, Abdelhay ESFW, Morgado-Díaz JA. N-glycan biosynthesis inhibitors induce in vitro anticancer activity in colorectal cancer cells. J Cell Biochem 2012; 113:2957-66. [DOI: 10.1002/jcb.24173] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Engels B, Gevaert T, Sermeus A, De Ridder M. Current status of intensified neo-adjuvant systemic therapy in locally advanced rectal cancer. Front Oncol 2012; 2:47. [PMID: 22655273 PMCID: PMC3360164 DOI: 10.3389/fonc.2012.00047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Accepted: 04/27/2012] [Indexed: 12/19/2022] Open
Abstract
The addition of 5-fluorouracil (5-FU) or its prodrug capecitabine to radiotherapy (RT) is a standard approach in the neo-adjuvant treatment of patients with rectal tumors extending beyond the muscularis propria (stage II) and/or with clinical evidence of regional lymph node metastases (stage III). According to European randomized trials, the combined treatment modality resulted in favorable local control rates as compared with radiotherapy (RT) alone, but no improvement was found regarding the occurrence of distant metastases or overall survival. In an effort to further enhance the response rates and to decrease the high incidence of distant metastases in locally advanced rectal cancer patients, the addition of other chemotherapeutical drugs and biologic agents as radiation sensitizers to neo-adjuvant 5-FU based chemoradiotherapy (CRT) has been recently investigated. The role of those agents is however questionable as first results from phase III data do not show improvement on pathologic complete remission and circumferential resection margin negative resection rates as compared to 5-FU based CRT, nevertheless an increased toxicity.
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Affiliation(s)
- Benedikt Engels
- Department of Radiotherapy, UZ Brussel, Vrije Universiteit BrusselBrussels, Belgium
| | - Thierry Gevaert
- Department of Radiotherapy, UZ Brussel, Vrije Universiteit BrusselBrussels, Belgium
| | - Alexandra Sermeus
- Department of Radiotherapy, UZ Brussel, Vrije Universiteit BrusselBrussels, Belgium
| | - Mark De Ridder
- Department of Radiotherapy, UZ Brussel, Vrije Universiteit BrusselBrussels, Belgium
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Hill EJ, Nicolay NH, Middleton MR, Sharma RA. Oxaliplatin as a radiosensitiser for upper and lower gastrointestinal tract malignancies: what have we learned from a decade of translational research? Crit Rev Oncol Hematol 2012; 83:353-87. [PMID: 22309673 DOI: 10.1016/j.critrevonc.2011.12.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2011] [Revised: 12/14/2011] [Accepted: 12/28/2011] [Indexed: 01/08/2023] Open
Abstract
Some of the greatest advances in the treatment of solid malignancies have resulted from the combination of chemotherapy and radiotherapy treatments. This article comprehensively reviews the current clinical evidence for oxaliplatin-based chemo-radiotherapy that may improve local control and survival. In order to understand how clinical studies should be designed, the pre-clinical evidence for the use of oxaliplatin chemotherapy as a radiosensitising agent is appraised. Particular focus is placed on oxaliplatin's biological mechanisms of action, including cell cycle effects, the formation of DNA adducts and interstrand cross-links and the role of DNA repair proteins. At a clinical level, there is currently no evidence to suggest that oxaliplatin provides an additional benefit to concurrent chemo-radiation regimes that utilise fluoropyrimidines; we evaluate the reasons for this observation, the limitations of clinical trial design and the opportunities that currently exist to design clinical trials which are underpinned by an understanding of the basic biology.
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Affiliation(s)
- Esme J Hill
- Gray Institute of Radiation Oncology and Biology, Oncology Department, Old Road Campus Research Building, Oxford OX3 7DQ, UK
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A phase II study of oxaliplatin with 5-FU/folinic acid and concomitant radiotherapy as a preoperative treatment in patients with locally advanced rectal cancer. Biomed Imaging Interv J 2011; 7:e25. [PMID: 22279502 PMCID: PMC3265185 DOI: 10.2349/biij.7.4.e25] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2011] [Revised: 08/10/2011] [Accepted: 08/16/2011] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To evaluate the activity and safety of adding oxaliplatin to a standard chemoradiotherapy schema, including 5-fluorouracil (5-FU)/folinic acid (FA), in locally-advanced rectal cancer (LARC). METHODS Two cycles of oxaliplatin 130 mg/m(2) plus FA 20 mg/m(2) bolus for 5 days and 5-FU 350 mg/m(2) continuous infusion for 5 days were given during week 1 and 4 of pelvic radiotherapy 46 Gy. Patients with a T3/4 and/or node-positive rectal tumour were eligible. Surgery was performed 4-6 weeks after radiotherapy. The primary endpoint was to determine the rate of pathological response. Secondary endpoints were to assess the rate of clinical response and the safety profile. RESULTS Between March 2005 and January 2009, a total of 35 patients were enrolled. The pathological down-staging rate was 79% with a pathological complete response rate of 17%. The overall clinical response rate (assessed by computed tomography or transrectal ultrasound) was 77%. Grade 3 diarrhoea and Grade 3 neutropaenia were reported in 14% and 11% of the patients, respectively. Eleven patients did not undergo surgery: four of them refused the operation, and seven patients were inoperable due to disease progression. In 24 patients who had surgery, a sphincter-preserving procedure could be performed in 29%. At the median follow-up time of 28.1 months, 25 patients (71%) survived with no evidence of disease. CONCLUSION The promising results in terms of pathological response, and the associated good safety profile of a regimen of oxaliplatin plus 5-FU/FA with concomitant radiotherapy, suggest that the regimen could be used in LARC.
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Thukral A, Metz J, Hwang WT, O'Dwyer P, Plastaras J, Both S, Bar-Ad V, Ad VB. Toxicity data for preoperative concurrent chemoradiotherapy with oxaliplatin and continuous infusion 5-fluorouracil for locally advanced esophageal cancer. Dis Esophagus 2011; 24:330-6. [PMID: 21143694 DOI: 10.1111/j.1442-2050.2010.01145.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The purpose of this retrospective analysis was to characterize the feasibility and tolerability of oxaliplatin/5-fluorouracil (5-FU) given concurrently with radiotherapy for patients with locally advanced esophageal cancer. Between July 2005 and March 2009, 15 patients with clinical stage T3/T4 and/or N1/M1a lower esophageal or gastroesophageal junction adenocarcinoma were treated with preoperative chemoradiotherapy using oxaliplatin every 2 weeks and continuous infusion 5-FU. The main treatment-related toxicities were oral mucositis and dysphagia. During the first 2 weeks of treatment, 20% of patients presented with grade 1-2 oral mucositis, and one patient developed grade 1 dysphagia. In weeks 3-4, 53% of the patients experienced grade 1-2 mucositis, and 40% experienced grade 1-2 dysphagia. One patient only experienced grade 3 mucositis in week 4. Three patients (20%) had grade 3-4 dysphagia in weeks 3-4 and were continued on intravenous fluids and pain medications. During the last 2 weeks of chemoradiotherapy, 53% of patients reported grade 1-2 oral mucositis, mostly grade 1 and 73% of patients experienced grade 1-2 dysphagia and 26% patients experienced grade 3-4 dysphagia. Other toxicities included fatigue, nausea, neuropathy, and diarrhea. Only one patient experienced > 10% weight loss. The whole group was treated with aggressive supportive care during radiotherapy. Five (33%) patients achieved a pathological complete response. No patients developed locoregional failure. Sixty percent of the patients developed distant metastases and the 2-year disease-free survival was 53%. The median survival was 3.2 years with the 2-year overall survival of 73%. Preoperative oxaliplatin/5-FU-based chemoradiotherapy for locally advanced esophageal cancer is feasible, but associated with substantial gastrointestinal toxicity. A careful attention to nutrition and hydration throughout the course of therapy is required.
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Affiliation(s)
- A Thukral
- Department of Radiation OncologyDepartment of Biostatistics and EpidemiologyDepartment of Hematology-Oncology, University of Pennsylvania, Philadelphia, USA
| | - J Metz
- Department of Radiation OncologyDepartment of Biostatistics and EpidemiologyDepartment of Hematology-Oncology, University of Pennsylvania, Philadelphia, USA
| | - W-T Hwang
- Department of Radiation OncologyDepartment of Biostatistics and EpidemiologyDepartment of Hematology-Oncology, University of Pennsylvania, Philadelphia, USA
| | - P O'Dwyer
- Department of Radiation OncologyDepartment of Biostatistics and EpidemiologyDepartment of Hematology-Oncology, University of Pennsylvania, Philadelphia, USA
| | - J Plastaras
- Department of Radiation OncologyDepartment of Biostatistics and EpidemiologyDepartment of Hematology-Oncology, University of Pennsylvania, Philadelphia, USA
| | - S Both
- Department of Radiation OncologyDepartment of Biostatistics and EpidemiologyDepartment of Hematology-Oncology, University of Pennsylvania, Philadelphia, USA
| | - V Bar-Ad
- Department of Radiation OncologyDepartment of Biostatistics and EpidemiologyDepartment of Hematology-Oncology, University of Pennsylvania, Philadelphia, USA
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Aschele C, Cionini L, Lonardi S, Pinto C, Cordio S, Rosati G, Artale S, Tagliagambe A, Ambrosini G, Rosetti P, Bonetti A, Negru ME, Tronconi MC, Luppi G, Silvano G, Corsi DC, Bochicchio AM, Chiaulon G, Gallo M, Boni L. Primary tumor response to preoperative chemoradiation with or without oxaliplatin in locally advanced rectal cancer: pathologic results of the STAR-01 randomized phase III trial. J Clin Oncol 2011; 29:2773-80. [PMID: 21606427 DOI: 10.1200/jco.2010.34.4911] [Citation(s) in RCA: 551] [Impact Index Per Article: 42.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To investigate oxaliplatin combined with fluorouracil-based chemoradiotherapy as preoperative treatment for locally advanced rectal cancer. PATIENTS AND METHODS Seven hundred forty-seven patients with resectable, locally advanced (cT3-4 and/or cN1-2) adenocarcinoma of the mid-low rectum were randomly assigned to receive pelvic radiation (50.4 Gy in 28 daily fractions) and concomitant infused fluorouracil (225 mg/m(2)/d) either alone (arm A, n = 379) or combined with oxaliplatin (60 mg/m(2) weekly × 6; arm B, n = 368). Overall survival is the primary end point. A protocol-planned analysis of response to preoperative treatment is reported here. RESULTS Grade 3 to 4 adverse events during preoperative treatment were more frequent with oxaliplatin plus fluorouracil and radiation than with radiation and fluorouracil alone (24% v 8% of treated patients; P < .001). In arm B, 83% of the patients treated with oxaliplatin had five or more weekly administrations. Ninety-one percent, compared with 97% in the control arm, received ≥ 45 Gy (P < .001). Ninety-six percent versus 95% of patients underwent surgery with similar rates of abdominoperineal resections (20% v 18%, arm A v arm B). The rate of pathologic complete responses was 16% in both arms (odds ratio = 0.98; 95% CI, 0.66 to 1.44; P = .904). Twenty-six percent versus 29% of patients had pathologically positive lymph nodes (arm A v arm B; P = .447), 46% versus 44% had tumor infiltration beyond the muscularis propria (P = .701), and 7% versus 4% had positive circumferential resection margins (P = .239). Intra-abdominal metastases were found at surgery in 2.9% versus 0.5% of patients (arm A v arm B; P = .014). CONCLUSION Adding oxaliplatin to fluorouracil-based preoperative chemoradiotherapy significantly increases toxicity without affecting primary tumor response. Longer follow-up is needed to assess the impact on efficacy end points.
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Affiliation(s)
- Carlo Aschele
- Istituto Nazionale per la Ricerca sul Cancro, Genova, Italy.
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15
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Gerard JP, Francois E, Freyer G, Milano G, Aschele C. Rectal Cancer: Rectal Preservation Is an Important End Point. J Clin Oncol 2010. [DOI: 10.1200/jco.2010.30.2059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | | | - Carlo Aschele
- Istituto Nazionale per la Ricerca sul Cancro, Genoa, Italy
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16
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Flatmark K, Ree AH. Radiosensitizing Drugs: Lessons to Be Learned From the Oxaliplatin Story. J Clin Oncol 2010; 28:e577-8; author reply e581-3. [DOI: 10.1200/jco.2010.30.0921] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Kjersti Flatmark
- Clinic of Cancer and Surgery, Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Anne Hansen Ree
- Akershus University Hospital, Lørenskog; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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17
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Vergo M, Nimeiri H, Benson AB. Adjuvant chemotherapy after neoadjuvant chemoradiation and surgery: A quest to improve survival for stage II and III rectal cancer. CURRENT COLORECTAL CANCER REPORTS 2009. [DOI: 10.1007/s11888-009-0022-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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18
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Concomitant chemo-radiotherapy in clinical trials: To promote step by step rational development. Crit Rev Oncol Hematol 2009; 70:206-15. [DOI: 10.1016/j.critrevonc.2008.09.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2008] [Revised: 07/25/2008] [Accepted: 09/17/2008] [Indexed: 11/22/2022] Open
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19
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Katz D, Ito E, Liu FF. On the path to seeking novel radiosensitizers. Int J Radiat Oncol Biol Phys 2009; 73:988-96. [PMID: 19251086 DOI: 10.1016/j.ijrobp.2008.12.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2008] [Revised: 11/29/2008] [Accepted: 12/02/2008] [Indexed: 10/21/2022]
Abstract
Radiation therapy is a highly effective cancer treatment modality, and extensive investigations have been undertaken over the years to augment its efficacy in the clinic. This review summarizes the current understanding of the biologic bases underpinning many of the clinically used radiosensitizers. In addition, this review illustrates how the advent of innovative, high-throughput technologies with integration of different disciplines could be harnessed for an expeditious discovery process for novel radiosensitizers, providing an exciting future for such pursuits in radiation biology and oncology.
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Affiliation(s)
- David Katz
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
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20
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Lawson JD, Kauh J, Koshy M, Staley C, Landry J. Early clinical results from chemoradiation with 5-fluorouracil and oxaliplatin for locally advanced rectal cancer. Clin Colorectal Cancer 2009; 7:325-30. [PMID: 18794065 DOI: 10.3816/ccc.2008.n.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE Preoperative chemoradiation with 5-fluorouracil (5-FU) has improved local control and resectability in patients with locally advanced rectal adenocarcinoma. The possible benefit of adding oxaliplatin is being investigated. We present background on the use of oxaliplatin as well as institutional experience assessing treatment tolerability and early outcome data. PATIENTS AND METHODS From August 2001 to August 2006, 15 patients were treated with concurrent 5-FU, oxaliplatin, and radiation. Each had locally advanced rectal carcinoma with staging as follows: T3 (10 patients), T4 (5 patients), N1 (3 patients), and M1 (1 patient). Three patients were treated for local recurrence; 2 had received previous radiation therapy. All patients received continuous-infusion 5-FU at 225 mg/m2 per day. The oxaliplatin dose was 70 mg/m2 in 1 patient and 85 mg/m2 in the others, administered every other week x 3 weeks starting on day 1 of radiation. Resection followed completion of radiation by 6 weeks. RESULTS The treatment was tolerable, with the most frequent hematologic toxicity being grade 1/2 anemia. Twelve patients were evaluable, with 11 treated preoperatively. All were able to undergo resection with negative margins, with T stage at resection as follows: T4 (2 patients, 1 with 5% viable tumor), T3 (4 patients), T2 (1 patient), T1 (2 patients); there were pathologic complete responses in 4 patients. At resection, 2 patients had N2 disease; 1 of these was also found to have a peritoneal metastasis. Two patients with clinical N1 disease initially were N0 at resection. With median follow-up of 13 months (range, 4-36 months), 9 patients have clinically no evidence of disease. There have been no local recurrences and 1 death from disease. CONCLUSION We present tolerability and early clinical efficacy data for patients treated with concurrent 5-FU and oxaliplatin chemoradiation. The oxaliplatin-based regimen was tolerable. All patients were able to undergo resection with negative margins, with encouraging downstaging, local control, and survival.
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Affiliation(s)
- Joshua D Lawson
- Department of Radiation Oncology, Emory University, Atlanta, GA 30322, USA.
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21
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Capdevila J, Elez E, Peralta S, Macarulla T, Ramos FJ, Tabernero J. Oxaliplatin-based chemotherapy in the management of colorectal cancer. Expert Rev Anticancer Ther 2008; 8:1223-36. [PMID: 18699761 DOI: 10.1586/14737140.8.8.1223] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Oxaliplatin is the only third-generation platinum derivative compound that has found a place in the routine treatment of colorectal cancer (CRC). The appearance of oxaliplatin, as well as irinotecan, in the CRC treatment armamentarium has offered new standards for adjuvant treatment and greater hopes in metastatic disease. Moreover, the combination of oxaliplatin-based chemotherapy with new targeted drugs has improved response rates and survival of these patients. Despite these new approaches, the prognosis of CRC remains poor and a better understanding of the molecular pathways is needed to optimize the use of these new approaches. In this review, the authors examine the development of oxaliplatin as well as the main trials that have positioned oxaliplatin as a key drug in the treatment of CRC.
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Affiliation(s)
- Jaume Capdevila
- Medical Oncology Department, Vall d'Hebron University Hospital, Barcelona, Spain.
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22
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Multi-center phase II trial of chemo-radiotherapy with 5-fluorouracil, leucovorin and oxaliplatin in locally advanced esophageal cancer. Cancer Chemother Pharmacol 2008; 63:1111-9. [DOI: 10.1007/s00280-008-0834-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2008] [Accepted: 09/08/2008] [Indexed: 12/23/2022]
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23
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Capecitabine, Irinotecan, Oxaliplatin (CAPIRINOX) and Concomitant Irradiation in Advanced Rectal Cancer: The Lyon R-02-01 Phase I Trial. Clin Oncol (R Coll Radiol) 2008; 20:369-74. [DOI: 10.1016/j.clon.2008.02.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2007] [Revised: 01/30/2008] [Accepted: 02/26/2008] [Indexed: 01/10/2023]
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24
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Irinotecan+5-fluorouracil with concomitant pre-operative radiotherapy in locally advanced non-resectable rectal cancer: a phase I/II study. Br J Cancer 2008; 98:1210-6. [PMID: 18349840 PMCID: PMC2359647 DOI: 10.1038/sj.bjc.6604292] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
In the UK, 10% of patients diagnosed with rectal cancer have inoperable disease at presentation. This study ascertained whether the resectability rate of inoperable locally advanced rectal cancer was improved by administration of intravenous irinotecan, 5-fluorouracil (5-FU) and pelvic radiotherapy. During phase I of the trial (n=12), the dose of irinotecan was escalated in three-patient cohorts from 50 mg m−2 to 60 mg m−2 to 70 mg m−2 to identify the maximum tolerated dose (60 mg m−2). In phase II, 31 patients with non-resectable disease received 45 Gy radiotherapy and 5-FU infusions (200 mg m−2 per day) for 5 weeks. Irinotecan (60 mg m−2) was given on days 1, 8, 15 and 22. After treatment, patients were operated on if possible. Thirty patients completed the protocol, 28 underwent surgery. Before surgery, MRI restaging of 24 patients showed that 19 (79%) had a reduction in tumour stage after treatment (seven complete clinical response and 12 partial). Of 27 patients followed up after surgery, 22 (81%) had clear circumferential resection margins. Disease-free and overall survival estimates at 3 years were 65 and 90%, respectively. The regimen was well tolerated. Irinotecan, 5-FU and radiotherapy results in tumour downgrading, allowing resection of previously inoperable tumour with acceptable toxicity.
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Folkvord S, Flatmark K, Seierstad T, Røe K, Rasmussen H, Ree AH. Inhibitory effects of oxaliplatin in experimental radiation treatment of colorectal carcinoma: does oxaliplatin improve 5-fluorouracil-dependent radiosensitivity? Radiother Oncol 2008; 86:428-34. [DOI: 10.1016/j.radonc.2007.10.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2007] [Accepted: 10/11/2007] [Indexed: 11/29/2022]
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26
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Dolinsky CM, Mahmoud NN, Mick R, Sun W, Whittington RW, Solin LJ, Haller DG, Giantonio BJ, O'Dwyer PJ, Rosato EF, Fry RD, Metz JM. Effect of time interval between surgery and preoperative chemoradiotherapy with 5-fluorouracil or 5-fluorouracil and oxaliplatin on outcomes in rectal cancer. J Surg Oncol 2007; 96:207-12. [PMID: 17443718 DOI: 10.1002/jso.20815] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVES Preoperative chemoradiotherapy for locally advanced rectal cancer is now considered "standard of care." However, the optimal time interval for resection after neoadjuvant therapy is unknown. METHODS Between 11/90 and 11/04, 107 patients with rectal adenocarcinoma underwent preoperative chemo/RT at the University of Pennsylvania. Fifty-six percent had LAR and 40% had APR. Chemotherapy consisted of 5-FU/oxaliplatin in 28% and 5-FU in 72% of patients. All patients received preoperative RT. RESULTS A longer time interval between chemo/RT and surgery was associated with tumor downstaging (OR 1.24, P = 0.02). A longer time interval was not associated with: nodal downstaging (OR 1.00, P = 0.98); pathologic complete response (PCR) (OR 0.97, P = 0.80); likelihood of performing an LAR (OR 0.90, P = 0.47); improved disease free survival (DFS), local control, or distant control (HR 1.05, P = 0.49; HR 1.14, P = 0.22; HR 1.06, P = 0.52, respectively). The PCR rate was 34.5% in the 5-FU/oxaliplatin/radiation group, and 13.7% in the 5-FU/radiation group. If patients with microscopic CR were excluded, then the PCR rate for 5FU/OX was 21.4% and for 5-FU was 12.2%. CONCLUSIONS Time interval between surgery and chemo/RT appeared to have little effect on PCR or LAR rates. Patients receiving 5 FU/oxaliplatin/RT had a high PCR rate. A prospective randomized trial to test superiority of 5 FU/oxaliplatin is warranted.
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Affiliation(s)
- C M Dolinsky
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
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Wallace MH, Glynne-Jones R. Saving the sphincter in rectal cancer: are we prepared to change practice? Colorectal Dis 2007; 9:302-8; discussion 308-9. [PMID: 17432980 DOI: 10.1111/j.1463-1318.2006.01108.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Total mesorectal excision and preoperative radiation with or without chemotherapy has led to a reduction in local recurrence rates in patients with rectal cancer. This article examines the effect such treatment has on the rate of sphincter preservation in patients with rectal cancers close to the anal sphincter mechanism and looks at the evidence for changing clinical practice.
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Affiliation(s)
- M H Wallace
- Department of Surgery, West Herts NHS Trust, Watford General Hospital, Watford, UK.
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28
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Sharma RA, Van Hazel GA, Morgan B, Berry DP, Blanshard K, Price D, Bower G, Shannon JA, Gibbs P, Steward WP. Radioembolization of liver metastases from colorectal cancer using yttrium-90 microspheres with concomitant systemic oxaliplatin, fluorouracil, and leucovorin chemotherapy. J Clin Oncol 2007; 25:1099-106. [PMID: 17369573 DOI: 10.1200/jco.2006.08.7916] [Citation(s) in RCA: 220] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Liver metastases represent the principal cause of death in patients with advanced colorectal cancer (CRC). Injection of resin microspheres (SIR Spheres)--containing the beta-emitter, yttrium-90--into the arterial supply of the liver can cause radioembolization of metastases. This treatment has not been tested with the radiosensitizing chemotherapy, oxaliplatin, which appears synergistic in the treatment of CRC when combined with fluorouracil and leucovorin (FOLFOX). PATIENTS AND METHODS A phase I study of SIR-Spheres therapy with modified FOLFOX4 systemic chemotherapy was conducted in patients with inoperable liver metastases from CRC who had not previously received chemotherapy for metastatic disease. Oxaliplatin (30 to 85 mg/m2) was administered for the first three cycles with full FOLFOX4 doses from cycle 4 until cycle 12. The primary end point was toxicity. RESULTS Twenty patients were enrolled onto the study. Five patients experienced National Cancer Institute (NCI; Bethesda, MD) grade 3 abdominal pain, two of whom had microsphere-induced gastric ulcers. The dose-limiting toxicity was grade 3 or 4 neutropenia, which was recorded in 12 patients. One episode of transient grade 3 hepatotoxicity was recorded. Mean splenic volume increased by 92% following 6 months of protocol therapy. Partial responses were demonstrated in 18 patients and stable disease in two patients. Two patients underwent partial hepatic resection following protocol therapy. Median progression-free survival was 9.3 months, and median time to progression in the liver was 12.3 months. CONCLUSION The maximum-tolerated dose was 60 mg/m2 of oxaliplatin for the first three cycles, with full FOLFOX4 doses thereafter. This chemoradiation regime merits evaluation in phase II-III trials.
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Affiliation(s)
- Ricky A Sharma
- Department of Radiation Oncology and Biology, University of Oxford, Churchill Hospital, Oxford, UK.
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29
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Abstract
Cancers of the colon and rectum will affect 1 in 17 North Americans during their lifetime. The progress witnessed in the treatment of these cancers in recent years has been remarkable. Improvements have been realized in surgical technique, radiation therapy, and systemic therapies, particularly with the addition of oxaliplatin and irinotecan to the previously limited armamentarium of fluorouracil alone. Targeted therapies directed at the vascular endothelial growth factor pathway and the epidermal growth factor pathway are now key players in the treatment of colorectal cancer. With current-day therapies, more than 75% of patients with localized disease are recurrence free at 3 years, and up to 50% of patients with advanced unresectable disease are alive at 2 years. This review focuses on the evidence supporting the current role of chemotherapy and radiation therapy in the adjuvant management of colorectal cancers and the strategy of combining chemotherapy and biological therapy in the treatment of metastatic disease.
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30
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Aschele C, Lonardi S. Addition of Weekly Oxaliplatin to Standard Preoperative Chemoradiation for Locally Advanced Rectal Cancer. J Clin Oncol 2007; 25:602-3; author reply 603. [PMID: 17290071 DOI: 10.1200/jco.2006.09.2171] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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31
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Abstract
Cancers of the colon and rectum will affect 1 in 17 North Americans during their lifetime. The progress witnessed in the treatment of these cancers in recent years has been remarkable. Improvements have been realized in surgical technique, radiation therapy, and systemic therapies, particularly with the addition of oxaliplatin and irinotecan to the previously limited armamentarium of fluorouracil alone. Targeted therapies directed at the vascular endothelial growth factor pathway and the epidermal growth factor pathway are now key players in the treatment of colorectal cancer. With current-day therapies, more than 75% of patients with localized disease are recurrence free at 3 years, and up to 50% of patients with advanced unresectable disease are alive at 2 years. This review focuses on the evidence supporting the current role of chemotherapy and radiation therapy in the adjuvant management of colorectal cancers and the strategy of combining chemotherapy and biological therapy in the treatment of metastatic disease.
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Affiliation(s)
- Sharlene Gill
- Department of Medical Oncology, British Columbia Cancer Agency, Vancouver, British Columbia
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32
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Pucciarelli S, Urso E, DeSalvo GL, Aschele C, Friso ML, Rugge M, Toppan P, Bruttocao A, Fabris G, Ferraro B, Lonardi S, Frego M, Finco C, Lise M, Nitti D. 5-fluorouracil and weekly oxaliplatin combined with radiotherapy for locally advanced rectal cancer: surgical complications and long-term results. Arch Med Res 2006; 37:860-5. [PMID: 16971226 DOI: 10.1016/j.arcmed.2006.04.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2005] [Accepted: 04/03/2006] [Indexed: 11/22/2022]
Abstract
BACKGROUND We undertook this study to evaluate early surgical complications and long-term results after preoperative radiotherapy and chemotherapy (RCT) using 5-fluorouracil (5-FU) and oxaliplatin (OXA) for rectal cancer. METHODS Forty six TNM stage II-III rectal cancer patients were studied, who were given preoperative RT (50.4 Gy/28 fractions) combined with 5-FU (200-225 mg/m(2)/day by continuous venous infusion) and weekly OXA (25-60 mg/m(2)). Major complications and reoperations were recorded overall, whereas outcome analyses were performed only for patients who received the recommended regimen dosage. RESULTS Forty three patients (M:F, 25:18; median age 59 years) were available for analysis. All patients received the planned RT dose. There were no postoperative deaths; seven patients had early major surgical complications, four requiring re-operation. One additional patient had a second surgical procedure due to a duodenal fistula complicating the resection of an aortic aneurysm performed concomitantly with rectal cancer surgery. At a median follow-up of 49 months, two of the 23 patients treated at the recommended doses developed recurrence (one local, and one local and distant), and two died of cancer progression. Following the Kaplan-Meier method, the estimated 5-year overall and disease-free survival rates were 92 and 89%, respectively. CONCLUSIONS The preoperative RCT regimen used in the present study incurs a low rate of recurrence with an acceptable surgical morbidity.
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Affiliation(s)
- Salvatore Pucciarelli
- Clinica Chirurgica II, Dipartimento di Scienze Oncologiche e Chirurgiche, Policlinico, Padova, Italy.
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Meadows K, Morris CG, Rout WR, Zlotecki RA, Hochwald SN, Marsh RD, Copeland EM, Mendenhall WM. Preoperative Radiotherapy Alone or Combined With Chemotherapy Followed by Transanal Excision for Rectal Adenocarcinoma. Am J Clin Oncol 2006; 29:430-4. [PMID: 17023774 DOI: 10.1097/01.coc.0000217830.87635.83] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the efficacy of preoperative radiotherapy (RT) and chemoradiation (CRT) followed by transanal excision (TAE) for rectal adenocarcinoma. METHODS Thirty-two patients were treated between July 1988 and April 2004 and followed from 2 to 123 months (median, 27 months). RESULTS The 3-year outcomes were: locoregional control, 79%; distant metastasis-free survival, 80%; cause-specific survival, 88%; and overall survival, 75%. Outcomes were better for patients with T1-T2 tumors and those who experienced a complete response to preoperative RT or CRT. Two patients (6%) had chronic RT proctitis after treatment. CONCLUSION A select subset of patients with T2/T3 tumors will experience similar outcomes after preoperative RT or CRT and TAE compared with radical proctectomy. Reliably predictive clinicopathologic features to define this subgroup would best be elicited in the context of large prospective randomized trials, as would the optimal combination and schedule of systemic agents delivered in conjunction with preoperative RT. Patients who experience a complete response (cCR) after preoperative CRT are excellent candidates for TAE; those with less than a cCR have a less-favorable prognosis and are probably better treated with a low anterior resection or abdominal-perineal resection.
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Affiliation(s)
- Kenyon Meadows
- Department of Radiation Oncology, University of Florida, Gainesville, FL 32510-0385, USA
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Abstract
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.
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Affiliation(s)
- Aaron C Spalding
- Department of Radiation Oncology, University of Michigan Medical School, Ann Arbor, Michigan 48109-0010, USA
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35
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Pasetto LM. Preoperative versus postoperative treatment for locally advanced rectal carcinoma. Future Oncol 2006; 1:209-20. [PMID: 16555993 DOI: 10.1517/14796694.1.2.209] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
EPIDEMIOLOGY Overall mortality of rectal cancer at 5 years is approximately 40%. This cancer is commonly diagnosed at an early stage, but because of local relapse and/or metastatic disease, only half of radically resected patients can be considered disease free. COMMON TREATMENT The value of adding radiotherapy to surgery in the treatment of patients with resectable rectal cancer has been assessed in trials using either preoperative or postoperative irradiation. IMPROVEMENTS IN TREATMENT Preoperative radiotherapy and complete resection are established modalities for Stage II and III rectal cancer whilst data reporting improvement of survival by preoperative chemoradiotherapy are still not available. At present, the improved results reported by Phase II trials in terms of local control, sphincter saving and tumor regression grade make neoadjuvant treatment the 'standard' therapy only in North America and some other countries, but the concept of preoperative combined modality treatment is not supported globally.
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Affiliation(s)
- Lara Maria Pasetto
- Azienda Ospedale - Università, Medical Oncology Division, Via Gattamelata 64, 35128 Padova, Italy.
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Abstract
The currently available evidence from randomized clinical trials clearly supports the use of adjuvant therapy in general and preoperative combined modality therapy in particular as effective means of decreasing the rates of local recurrence, improving sphincter preservation rates, and probably im-proving overall survival when managing patients with locally advanced adenocarcinomas of the lower two thirds of the rectum. A radical surgical approach with adequately performed, sharp TME remains the standard of care for those patients. There is clearly a need to develop and validate surrogate biomarkers for the identification of patients who respond favorably to preoperative treatment. There is still a significant fraction of rectal cancer patients who ultimately die from their disease. The armamentarium of avail-able therapies is evolving rapidly, and hopefully local control rates and overall survival of rectal cancer patients will continue to improve in the near future.
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Affiliation(s)
- J Pablo Arnoletti
- Section of Surgical Oncology, Department of Surgery, University of Alabama at Birmingham, 1922 7th Avenue South, KB321, Birmingham, AL 35294, USA
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37
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Ortholan C, Francois E, Thomas O, Benchimol D, Baulieux J, Bosset JF, Gerard JP. Role of radiotherapy with surgery for T3 and resectable T4 rectal cancer: evidence from randomized trials. Dis Colon Rectum 2006; 49:302-10. [PMID: 16456638 DOI: 10.1007/s10350-005-0263-x] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE The main treatment for resectable rectal cancer T2-T4 N0-N2 M0 is surgery. The benefit of preoperative or postoperative radiation therapy can be analyzed in terms of improvement of local control, sphincter preservation, and survival weighted against increased toxicity. METHODS Only randomized trials can provide strong evidence of a positive cost-benefit ratio of such combined approach. The most recent trials were reviewed. RESULTS Three randomized trials, including the latest German CAO-ARO trial, have demonstrated the superiority of preoperative radiotherapy with or without chemotherapy (vs. postoperative) in terms of local control and toxicity. The Ducth TME trial showed that even with modern standard surgery, preoperative radiotherapy improved local control. Preoperative irradiation using a high dose in a small volume and a long interval before surgery may improve sphincter preservation (Lyon trials). Concurrent chemoradiation (FFCD 9203, EORTC 22921, did not significantly improve sphincter preservation or survival but significantly reduced the local recurrence rate. CONCLUSIONS In 2005 examination of randomized trials provides evidence for the benefit of preoperative chemoradiation in improving local control and probably sphincter preservation in rectal cancer. Randomized trials should be designed to further demonstrate improved sphincter preservation and to increase survival using adjuvant medical treatments.
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Affiliation(s)
- Cecile Ortholan
- Department of Radiotherapy, Centre Antoine-Lacassagn, Nice, France
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38
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Chau I, Brown G, Cunningham D, Tait D, Wotherspoon A, Norman AR, Tebbutt N, Hill M, Ross PJ, Massey A, Oates J. Neoadjuvant capecitabine and oxaliplatin followed by synchronous chemoradiation and total mesorectal excision in magnetic resonance imaging-defined poor-risk rectal cancer. J Clin Oncol 2006; 24:668-74. [PMID: 16446339 DOI: 10.1200/jco.2005.04.4875] [Citation(s) in RCA: 336] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To evaluate neoadjuvant capecitabine/oxaliplatin before chemoradiotherapy (CRT) and total mesorectal excision (TME) in newly diagnosed patients with magnetic resonance imaging (MRI) -defined poor-risk rectal cancer. PATIENTS AND METHODS MRI criteria for poor-risk rectal cancer were tumors within 1 mm of mesorectal fascia (ie, circumferential resection margin threatened), T3 tumors at or below levators, tumors extending > or = 5 mm into perirectal fat, T4 tumors, and T1-4N2 tumors. Patients received 12 weeks of neoadjuvant capecitabine/oxaliplatin followed by concomitant capecitabine and radiotherapy. TME was planned 6 weeks after CRT. Postoperatively, patients received another 12 weeks of capecitabine. RESULTS Between November 2001 and August 2004, 77 eligible patients were recruited. After neoadjuvant capecitabine/oxaliplatin, the radiologic response rate was 88%. In addition, 86% of patients had symptomatic responses in a median of 32 days (ie, just over one cycle of capecitabine/oxaliplatin). After CRT, the tumor response rate was increased to 97%. Three patients remained inoperable. Sixty-seven patients proceeded to TME, and all but one patient had R0 resection. Pathologic complete response was observed in 16 patients (24%; 95% CI, 14% to 36%), and in an additional 32 patients (48%), only microscopic tumor foci were found on surgical specimens. Four deaths occurred during neoadjuvant capecitabine/oxaliplatin therapy as a result of pulmonary embolism, ischemic heart disease, sudden death with history of chest pain, and neutropenic colitis. CONCLUSION Capecitabine/oxaliplatin before synchronous CRT and TME results in substantial tumor regression, rapid symptomatic response, and achievement of R0 resection.
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Affiliation(s)
- Ian Chau
- Department of Medicine, Royal Marsden Hospital, London, United Kingdom
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Kjellström J, Kjellén E, Johnsson A. In vitro radiosensitization by oxaliplatin and 5-fluorouracil in a human colon cancer cell line. Acta Oncol 2006; 44:687-93. [PMID: 16227158 DOI: 10.1080/02841860500247552] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The current study was designed to compare the radiosensitizing effects of oxaliplatin and 5-fluorouracil (5FU) in a human colon cancer cell line. A human colon cancer cell line (S1) was treated with various doses of oxaliplatin, 5FU, radiation, and combinations thereof. Various clinically used schedules were mimicked. 5FU was either incubated during 1 h ("bolus") or 24 h ("continuous infusion"). When combining oxaliplatin and 5FU, an isobologram analysis revealed synergistic effects, regardless of 5FU schedule. The IC(10) and IC(50)-doses for the drugs where then combined with radiotherapy. With equitoxic drug doses (IC(50)), radiosensitization was observed in the following order: oxaliplatin > 5FU 24 h > 5FU 1 h exposure. The degree of potentiation corresponded to approximately 0.8 Gy, 0.7 Gy, and 0.2 Gy, respectively. In this experimental setting, oxaliplatin seemed to be a better radiosensitizer than 5FU, and longer incubation time with 5FU was better than short exposure.
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40
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Thomas CT, Ammar A, Farrell JJ, Elsaleh H. Radiation Modifiers: Treatment Overview and Future Investigations. Hematol Oncol Clin North Am 2006; 20:119-39. [PMID: 16580560 DOI: 10.1016/j.hoc.2006.01.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Many radiosensitizers are in current clinical use. In addition, a myriad of potential new targeted therapies, which may also interact with radiation, are in clinical development. The clinical utility of new targeted therapies, in combination with existing radiation sensitizers (chemotherapies) requires further evaluation, as does the understanding of their acute and late radiation effects. Free radical scavengers appear to show promise as radioprotectors, but data for mucoprotection are less convincing.
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Affiliation(s)
- C T Thomas
- Department of Radiation Oncology, David Geffen School of Medicine at University of California Los Angeles, 200 Medical Plaza, Suite B265, Los Angeles, CA 90095, USA
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41
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Sebag-Montefiore D, Glynne-Jones R, Falk S, Meadows HM, Maughan T. A phase I/II study of oxaliplatin when added to 5-fluorouracil and leucovorin and pelvic radiation in locally advanced rectal cancer: a Colorectal Clinical Oncology Group (CCOG) study. Br J Cancer 2005; 93:993-8. [PMID: 16249791 PMCID: PMC2361684 DOI: 10.1038/sj.bjc.6602818] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The purpose of this study was to evaluate the maximum tolerated dose (MTD) and recommended dose of oxaliplatin given synchronously with 5-fluorouracil (5FU), leucovorin (LV) and preoperative pelvic radiation for primary unresectable, locally advanced, rectal cancer. Preoperative pelvic radiotherapy using a three- or four-field technique and megavoltage photons comprised 45 Gy given in 25 fractions, 1.8 Gy per fraction, and delivered with escalating doses of oxaliplatin in combination with low-dose LV and 5FU. Chemotherapy was given synchronously with radiotherapy in weeks 1 and 5. Escalating doses of oxaliplatin (85, 130 and 150 mg m(-2)) were given on days 2 and 30, followed by low-dose LV (20 mg m(-2)) and 5FU (350 mg m(-2)), both given on days 1-5 and 29-33. Surgery was performed 6-10 weeks later. The MTD was determined as the dose causing more than a third of patients to have a dose-limiting toxicity (DLT). Once the MTD was reached, a further 14 patients were treated at the dose level below the MTD. In all, 32 patients received oxaliplatin at the three dose levels, median age 60 years (range 31-79), 24 males and eight females. The MTD was reached at 150 mg m(-2) when four out of six patients experienced DLT. Dose-limiting grade 3 or 4 diarrhoea was reported in two out of six patients at 85 mg m(-2), 5 out of 20 at 130 mg m(-2) and four out of 6 at 150 mg m(-2). Grade 3 neuropathy was reported at 130 mg m(-2) (1 out of 20) and at 150 mg m(-2) (two out of six), and serious haematological toxicity was minimal; one grade 3 anaemia at 150 mg m(-2). In all, 28 out of 32 patients completed all treatments as planned; three had radiotherapy interrupted and three a chemotherapy dose reduction. Four patients did not proceed to surgery due to the presence of metastatic disease (two), unfitness (one) or patient refusal (one). Also, 28 patients underwent surgical resection. Histopathology demonstrated histopathological complete response (pCR) 2 out of 27 (7%), Tmic 3 out of 27 (11%), pCR+Tmic 5 out of 27 (19%), pT0-2 6 out of 27 (22%) and histologically confirmed clear circumferential resection margins in 22 out of 27 (81%). Dose-limiting toxicity with oxaliplatin is 150 mg m(-2) given days 2 and 30 when added to the described 5FU LV and 45 Gy radiation preoperatively. The acceptable toxicity and compliance at 130 mg m(-2) recommend testing this dose in future phase II studies. The tumour downstaging and complete resection rates are encouragingly high for this very locally advanced group.
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Affiliation(s)
- D Sebag-Montefiore
- Cookridge Hospital, Hospital Lane, Cookridge, West Yorkshire LS16 6QB, UK.
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42
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François E, Ychou M, Ducreux M, Bertheault-Cvitkovic F, Giovannini M, Conroy T, Lemanski C, Thomas O, Magnin V. Combined radiotherapy, 5-fluorouracil continuous infusion and weekly oxaliplatin in advanced rectal cancer: A phase I study. Eur J Cancer 2005; 41:2861-7. [PMID: 16297614 DOI: 10.1016/j.ejca.2005.08.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2005] [Revised: 08/17/2005] [Accepted: 08/18/2005] [Indexed: 11/28/2022]
Abstract
The aim of this study was to determine the maximum-tolerated dose (MTD) of weekly oxaliplatin combined with 5-fluorouracil (5FU) continuous infusion administered concomitantly with fractionated radiotherapy in patients presenting advanced rectal cancer. Forty-three patients with rectal cancer (stage T3/T4 (n = 24), metastatic (n = 17) and 2 with local recurrence), were included. The radiotherapy dose delivered was 45 Gy over 5 weeks (1.8 Gy/fraction/day, 5 days per week). The initial weekly oxaliplatin dosage was 30 mg/m2 and the 5FU dosage 150 mg/m2/d. The oxaliplatin and 5FU doses were escalated. Eight dose levels were tested. At dose level 8 (oxaliplatin 80 mg/m2, 5FU 225 mg/m2/d), 2 patients out of 4 presented dose-limiting toxicity (severe diarrhoea with dehydration and fatal shock, rectovesical fistula). At dose level 7, 2 further patients presented with grade 3 diarrhoea. The main toxicity of the combination was diarrhoea. The hematological and neurological toxicities were not severe and were not dose-limiting. Out of the 30 patients undergoing surgery, 4 (13.3%) presented with pathological complete response and 4 (13.3%) only presented with microscopic residual disease. The results from this study enabled determination of the recommended weekly oxaliplatin dose (60 mg/m2) combined with 5FU continuous infusion (225 mg/m2) and fractionated radiotherapy (45 Gy) in the pre-operative treatment of advanced rectal cancer. The good safety profile of the regimen, associated with promising results in terms of histological response, suggest that the regimen could be developed in future phase II/III studies.
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Affiliation(s)
- Eric François
- Department of Medical Oncology, Centre Antoine-Lacassagne, Avenue de Valombrose, 06189 Nice, Cedex 2, France.
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43
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Machiels JP, Duck L, Honhon B, Coster B, Coche JC, Scalliet P, Humblet Y, Aydin S, Kerger J, Remouchamps V, Canon JL, Van Maele P, Gilbeau L, Laurent S, Kirkove C, Octave-Prignot M, Baurain JF, Kartheuser A, Sempoux C. Phase II study of preoperative oxaliplatin, capecitabine and external beam radiotherapy in patients with rectal cancer: the RadiOxCape study. Ann Oncol 2005; 16:1898-905. [PMID: 16219623 DOI: 10.1093/annonc/mdi406] [Citation(s) in RCA: 112] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Preoperative radiotherapy has been shown to decrease the local recurrence rate of patients with locally advanced rectal cancer. Capecitabine and oxaliplatin are both active anticancer agents in the treatment of patients with advanced colorectal cancer and have radiosensitizing properties. Therefore, these drugs would be expected to improve effectiveness of preoperative radiotherapy in terms of local control and prevention of distant metastases. PATIENTS AND METHODS Forty patients with rectal cancer (T3-T4 and/or N+) received radiotherapy (1.8 Gy, 5 days a week over 5 weeks, total dose 45 Gy, 3D conformational technique) in combination with intravenous oxaliplatin 50 mg/m2 once weekly for 5 weeks and oral capecitabine 825 mg/m2 twice daily on each day of radiation. Surgery was performed 6-8 weeks after completion of radiotherapy. The main end points were safety and efficacy as assessed by the pathological complete response (pCR). RESULTS The most frequent grade 3/4 adverse event was diarrhea, occurring in 30% of patients. pCR was found in five (14%) patients. According to Dworak's classification, good regression was found in six (18%) additional patients. CONCLUSIONS Combination of preoperative radiotherapy with capecitabine and oxaliplatin is feasible for downstaging rectal cancer.
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Affiliation(s)
- J-P Machiels
- Clinique des Pathologies Tumorales du Colon et du Rectum, Centre du Cancer, Université Catholique de Louvain, Brussels, Belgium.
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44
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Lordick F, Lorenzen S, Stollfuss J, Vehling-Kaiser U, Kullmann F, Hentrich M, Zumschlinge R, Dietzfelbinger H, Thoedtmann J, Hennig M, Seroneit T, Bredenkamp R, Duyster J, Peschel C. Phase II study of weekly oxaliplatin plus infusional fluorouracil and folinic acid (FUFOX regimen) as first-line treatment in metastatic gastric cancer. Br J Cancer 2005; 93:190-4. [PMID: 16012522 PMCID: PMC2361546 DOI: 10.1038/sj.bjc.6602697] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Oxaliplatin plus fluorouracil/folinic acid (5-FU/FA) every 2 weeks has shown promising activity in advanced gastric cancer. This study assessed the efficacy and safety of weekly oxaliplatin plus 5-FU/FA (FUFOX regimen) in the metastatic setting. Patients with previously untreated metastatic gastric cancer received oxaliplatin (50 mg m−2) plus FA (500 mg m−2, 2-h infusion) followed by 5-FU (2000 mg m−2, 24-h infusion) given on days 1, 8, 15 and 22 of a 5-week cycle. The primary end point of this multicentre phase II study was the response rate according to RECIST criteria. A total of 48 patients were enrolled. Median age was 62 years and all patients had metastatic disease, with a median number of three involved organs. The most common treatment-related grade 3/4 adverse events were diarrhoea (17%), deep vein thrombosis (15%), neutropenia (8%), nausea (6%), febrile neutropenia (4%), fatigue (4%), anaemia (4%), tumour bleeding (4%), emesis (2%), cardiac ischaemia (2%) and pneumonia (2%). Grade 1/2 sensory neuropathy occurred in 67% of patients but there were no episodes of grade 3 neuropathy. Intent-to-treat analysis showed a response rate of 54% (95% CI, 39–69%), including two complete responses. At a median follow-up of 18.1 months (range 11.2–26.2 months), median survival is 11.4 months (95% CI, 8.0–14.9 months) and the median time to progression is 6.5 months (95% CI, 3.9–9.2 months). The weekly FUFOX regimen is well tolerated and shows notable activity as first-line treatment in metastatic gastric cancer.
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Affiliation(s)
- F Lordick
- Clinic Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
- Clinic Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany. E-mail:
| | - S Lorenzen
- Clinic Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - J Stollfuss
- Clinic Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - U Vehling-Kaiser
- Oncological Outpatient Clinic, Heilig-Geist-Gasse 411, 84028 Landshut, Germany
| | - F Kullmann
- University Clinic of Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - M Hentrich
- Clinic Harlaching, Sanatoriumsplatz 2, 81545 Munich, Germany
| | - R Zumschlinge
- Clinic Traunstein, Cuno-Niggl-Str. 3, 83278 Traunstein, Germany
| | | | - J Thoedtmann
- Clinic Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - M Hennig
- Clinic Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - T Seroneit
- Sanofi-Aventis Group, Potsdamer Str. 8, 10785 Berlin, Germany
| | - R Bredenkamp
- Center for Clinical Studies, Ismaninger Str. 22, 81675 Munich, Germany
| | - J Duyster
- Clinic Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - C Peschel
- Clinic Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
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45
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Aschele C, Friso ML, Pucciarelli S, Lonardi S, Sartor L, Fabris G, Urso EDL, Del Bianco P, Sotti G, Lise M, Monfardini S. A phase I-II study of weekly oxaliplatin, 5-fluorouracil continuous infusion and preoperative radiotherapy in locally advanced rectal cancer. Ann Oncol 2005; 16:1140-6. [PMID: 15894548 DOI: 10.1093/annonc/mdi212] [Citation(s) in RCA: 119] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Oxaliplatin (OXA) significantly enhanced the antitumour activity of 5-fluorouracil (FUra) in patients with advanced colorectal cancer and displayed radiosensitising properties in preclinical studies. This study was thus performed to test the feasibility, identify the recommended doses (RDs) and explore preliminarily the clinical activity of weekly OXA and infused FUra combined with preoperative pelvic radiotherapy. PATIENTS AND METHODS Forty-six patients with recurrent or locally advanced (cT3-4 and/or N+) adenocarcinomas of the mid-low rectum were treated with escalating doses of OXA (25, 35, 45, 60 mg/m2, weekly for 6 weeks) and FUra (200-225 mg/m2/day, 6-week infusion) concurrent to preoperative pelvic radiotherapy (50.4 Gy/28 fractions). The RDs for the phase II part of the study were immediately below the level resulting in dose-limiting toxicities in more than one third of the patients, or corresponded to the last planned dose level. RESULTS In the escalation phase, dose-limiting toxicities only occurred in one patient at the fourth level and one of six patients treated at the last planned dose level (grade III diarrhoea). OXA 60 mg/m2 and FUra 225 mg/m2/day are therefore the RDs for the regimen. Among 25 patients globally treated at these doses (phase II part), the incidence of grade III diarrhoea was 16% with no grade IV toxicity. Neurotoxicity did not exceed grade II (12%). All patients completed radiotherapy and were operated on as scheduled. Twenty-one of 25 patients had the tumour down-staged after chemoradiation with seven (28%) pathological complete responses and 12 (48%) residual tumours limited to ypT1-2N0. CONCLUSIONS Weekly OXA, at doses potentially active systemically, can be combined with full-dose, infused FUra and radiotherapy. Given the low toxicity and promising activity, this regimen is being compared to standard FUra-based pelvic chemoradiation in a randomised study.
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Affiliation(s)
- C Aschele
- Department of Medical Oncology, Radiotherapy and Surgery, Padova University Hospital, Padova.
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46
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Rich TA, Crane C, Lawson JD, Landry J. Chemoradiotherapy for gastrointestinal cancers. Curr Oncol Rep 2005; 7:196-202. [PMID: 15847710 DOI: 10.1007/s11912-005-0073-2] [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: 11/30/2022]
Abstract
New combinations of chemotherapy with radiotherapy for gastrointestinal cancers are showing evidence that improved outcomes may result from toxicity profiles associated with "targeted" systemic radiosensitizing agents. These new agents are also clinically attractive owing to such factors as oral bioavailability and patient dosing schedules, making them practical and convenient compared with older intravenous administration requirements. Several new classes of radiosensitizing agents are discussed here and underscore aspects of molecular activation in tumors rather than normal tissues because of differences in pathways of metabolism or based on the process of tumor-associated angiogenesis.
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Affiliation(s)
- Tyvin A Rich
- Department of Radiation Oncology, University of Virginia, PO Box 800383, Charlottesville, VA 22908, USA.
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Pasetto LM, Pucciarelli S, Agostini M, Rossi E, Monfardini S. Neoadjuvant treatment for locally advanced rectal carcinoma. Crit Rev Oncol Hematol 2005; 52:61-71. [PMID: 15363467 DOI: 10.1016/j.critrevonc.2004.07.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2004] [Indexed: 01/27/2023] Open
Abstract
Rectal cancer is one of the most common neoplasms of Western Countries. Overall mortality at 5 years is about 40%. This cancer is commonly diagnosed at a precocious stage, but because of local relapse and/or metastatic disease, only half of radically resected patients can be considered disease free. The value of adding radiotherapy to surgery in the treatment of patients with resectable rectal cancer has been assessed in trials using either preoperative or postoperative irradiation. Preoperative irradiation is more "dose-effective" than postoperative radiotherapy; that is, a higher dose is needed postoperatively to reduce rates of local recurrence to the same extent as preoperative radiation. Nevertheless, preoperative treatment has not been routinely recommended, mainly because it has not been shown to improve overall survival and because in some trials it has been associated with increased postoperative mortality. This paper critically reviews clinical trials of chemoradiotherapy on whether an optimal combination exists for locally advanced rectal cancer. Even if in the latest years, recent advances in surgery have improved the local control of disease, the next steps in rectal cancer care should aim at the improvement of local cure rates and the enhancement of systemic control. New approaches to CT treatment are necessary. Patient enrollment into rigorous and well-conducted clinical trials will generate new information regarding investigational therapies and it will offer improved therapies for patients with this disease.
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Affiliation(s)
- Lara Maria Pasetto
- Medical Oncology Division, Azienda Ospedale--Università, Via Gattamelata 64, 35128 Padova, Italy.
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48
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Loi S, Ngan SYK, Hicks RJ, Mukesh B, Mitchell P, Michael M, Zalcberg J, Leong T, Lim-Joon D, Mackay J, Rischin D. Oxaliplatin combined with infusional 5-fluorouracil and concomitant radiotherapy in inoperable and metastatic rectal cancer: a phase I trial. Br J Cancer 2005; 92:655-61. [PMID: 15700033 PMCID: PMC2361867 DOI: 10.1038/sj.bjc.6602413] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The aim of this study was to define the recommended dose of oxaliplatin when combined with infusional 5-fluorouracil (5-FU) and concurrent pelvic radiotherapy. Eligible patients had inoperable rectal cancer, or symptomatic primary rectal cancer with metastasis. Oxaliplatin was given on day 1 of weeks 1, 3 and 5 of radiotherapy. Dose level 1 was oxaliplatin 70 mg m(-2) with 5-FU 200 mg m(-2) day(-1) continuous infusion 96 h week(-1). On dose level 2, the oxaliplatin dose was increased to 85 mg m(-2). On dose level 3, the duration of the 5-FU was increased to 168 h per week. Pelvic radiotherapy was 45 Gray (Gy) in 25 fractions over 5 weeks with a boost of 5.4 Gy. Fluorine-18 fluoro deoxyglucose and Fluorine-18 fluoro misonidazole positron emission tomography (FDG-PET and FMISO-PET) were used to assess metabolic tumour response and hypoxia. In all, 16 patients were accrued. Dose-limiting toxicities occurred in one patient at level 2 (grade 3 chest infection), and two patients at level 3 (grade 3 diarrhoea). Dose level 2 was declared the recommended dose level. FDG-PET imaging showed metabolic responses in 11 of the 12 primary tumours assessed. Four of six tumours had detectable hypoxia on FMISO-PET scans. The addition of oxaliplatin to infusional 5-FU chemoradiotherapy was feasible and generally well tolerated. For future trials, oxaliplatin 85 mg m(-2) and 5-FU 200 mg m(-2) day(-1) continuous infusion 96 h week(-1) is the recommended dose when combined with 50.4 Gy of pelvic radiotherapy.
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Affiliation(s)
- S Loi
- Division of Haematology and Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - S Y K Ngan
- Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - R J Hicks
- Centre for Molecular Imaging, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - B Mukesh
- Centre for Biostatistics and Clinical Trials, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - P Mitchell
- Cancer Services, Austin and Repatriation Hospital, Heidelberg, Victoria, Australia
| | - M Michael
- Division of Haematology and Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - J Zalcberg
- Division of Haematology and Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - T Leong
- Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - D Lim-Joon
- Cancer Services, Austin and Repatriation Hospital, Heidelberg, Victoria, Australia
| | - J Mackay
- Division of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - D Rischin
- Division of Haematology and Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Division of Haematology and Medical Oncology, PeterMacCallum Cancer Centre, University of Melbourne, Locked Bag 1, A'Beckett Street, Melbourne, Victoria 8006, Australia. E-mail:
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Abstract
Significant gains have been achieved in the integration of radiation therapy (RT) and chemotherapy with surgery in the management of patients with localized rectal cancer. Treatment combinations of RT and chemotherapy with surgery have evolved to neoadjuvant approaches of these modalities to enhance sphincter preservation, tumor control, and reduction of acute and late treatment-related morbidity. Although 5-fluorouracil (5-FU)-based chemotherapy in combination with RT remains the standard adjuvant therapy for rectal cancer, the integration of novel chemotherapeutic agents and biologic modulators is being actively investigated.
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Affiliation(s)
- Andrew X Zhu
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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50
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Reerink O, Mulder NH, Szabo BG, Sluiter WJ, Wiggers T, Bongaerts AHH, Hospers GAP. Developments in treatment of primary irresectable rectal cancer. Colorectal Dis 2004; 6:406-17. [PMID: 15521928 DOI: 10.1111/j.1463-1318.2004.00602.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Abstract The treatment options for primary irresectable rectal cancers are discussed. Assessment of tumour stage is the first step for an appropriate choice of treatment. Following a diagnosis of rectal cancer, a vast array of diagnostic procedures is available to determine its stage, and thereby its best treatment options. From the many (new) diagnostic options the merits and drawbacks are discussed. If a diagnosis of irresectability is made, further treatment options should include radiotherapy in most cases, some aspects of timing and application, i.e. intra-operative treatment are discussed. Chemotherapy options are manifold, the results are discussed and some new options are explored.
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Affiliation(s)
- O Reerink
- Department of Radiation Oncology, University Hospital Groningen, 9700 RB Groningen, the Netherlands
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