1
|
Kraemer M, Nabiyev S, Kraemer S, Schipmann S. Interrater Agreement of Height Assessment by Rigid Proctoscopy/Rectoscopy for Rectal Carcinoma. Dis Colon Rectum 2024; 67:1018-1023. [PMID: 38701433 PMCID: PMC11250092 DOI: 10.1097/dcr.0000000000003301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
BACKGROUND Some guidelines for rectal carcinoma consider 12 cm, measured by rigid endoscopy, to be the cutoff tumor height for optional neoadjuvant chemoradiation therapy. Measuring differences of only a few centimeters may predetermine the choice of further therapy. However, rigid endoscopy may exhibit similar operator dependence to most other clinical examination methods. OBJECTIVES Evaluation of concordance of rigid rectoscopic tumor height measurements performed by 4 experienced examiners, 2 measuring with patients in the lithotomy position and 2 in the left lateral position. Assessment of tumor palpability and distance of the anal verge to the anocutaneous line were also evaluated. DESIGN This study used a prospective observational design. SETTING This study was conducted at an academic teaching hospital that is a referral center for colorectal surgery. PATIENTS There were 50 patients, of whom 35 were men (70%). The median age was 72.5 years (53-88 years). MAIN OUTCOME MEASURES Interrater agreement of tumor height assessment and tumor height of less than or greater than the 12-cm height limit. RESULTS With an intraclass correlation coefficient of 0.947 (95% CI, 0.918-0.967, p < 0.001), interrater reliability of tumor height assessment was statistically rated "excellent." Despite this, in 26% of patients, there was no agreement regarding the allocation of the tumor <12- or >12-cm height limit. Furthermore, there was also considerable disagreement concerning tumor palpability and the distance of the anal verge to the anocutaneous line. Patient positioning was not found to influence results. LIMITATIONS Single-center study. CONCLUSIONS Rigid rectal endoscopy may not be a sound pivotal basis for the consideration of optional chemoradiation therapy in rectal carcinoma. Application of a universally valid height limit ignores biological variability in body frame, gender, and acquired pelvic descent. Eligibility for neoadjuvant therapy should not rely on height measurements alone. Uniform MRI or CT imaging protocols, based on agreed upon terminology, including factors such as tumor height relative to the pelvic frame and peritoneal reflection, may be an important diagnostic addition to such a decision. See Video Abstract .Clinical trial registration: DRKS00012758 (German National Study Registry), ST-D 406 (German Cancer Society). ACUERDO ENTRE EVALUADORES EN LA EVALUACIN DE LA ALTURA MEDIANTE PROCTO/ RECTOSCOPIA RGIDA PARA EL CARCINOMA DE RECTO ANTECEDENTES:Algunas guías para el carcinoma de recto consideran que 12 cm, medidos mediante endoscopia rígida, es la altura de corte del tumor para la quimiorradiación neoadyuvante opcional. Por lo tanto, una diferencia de medición de sólo unos pocos centímetros puede predeterminar la elección de una terapia adicional. Sin embargo, la endoscopia rígida puede presentar una dependencia del operador similar a la de la mayoría de los demás métodos de examen clínico.OBJETIVOS:Evaluación de la concordancia de las mediciones de la altura del tumor rectoscópico rígido realizadas por cuatro examinadores experimentados, dos en litotomía y dos en posición lateral izquierda. También se evaluó la evaluación de la palpabilidad del tumor y la distancia del borde anal a la línea anocutánea.DISEÑO:Estudio observacional prospectivo.LUGAR:Hospital universitario, centro de referencia para cirugía colorrectal.PACIENTES:50 pacientes, 35 varones (70%), mediana de edad 72,5 años (53-88 años).PRINCIPALES MEDIDAS DE RESULTADOS:Acuerdo entre evaluadores en la evaluación de la altura del tumor y la asignación del tumor por debajo o más allá del límite de altura de 12 cm.RESULTADOS:Con un coeficiente de correlación intraclase de 0,947 (IC del 95%: 0,918-0,967, p < 0,001), la confiabilidad entre evaluadores de la evaluación de la altura del tumor se calificó estadísticamente como "excelente". A pesar de esto, en el 26% de los pacientes no hubo acuerdo sobre la asignación del tumor por debajo o por encima del límite de 12 cm de altura. Además, también hubo un considerable desacuerdo con respecto a la palpabilidad del tumor y la distancia del borde anal a la línea anocutánea. No se encontró que la posición del paciente influyera en los resultados.LIMITACIONES:Estudio unicéntrico.CONCLUSIONES:La endoscopia rectal rígida puede no ser una base sólida y fundamental para considerar la quimiorradiación opcional en el carcinoma de recto. La aplicación de un límite de altura universalmente válido obviamente ignora la variabilidad biológica en la constitución corporal, el género y el descenso pélvico adquirido. La elegibilidad para la terapia neoadyuvante no debe depender únicamente de las mediciones de altura. Los protocolos uniformes de imágenes por resonancia magnética o tomografía computarizada, basados en una terminología acordada, incluidos factores como la altura del tumor en relación con la estructura pélvica y la reflexión peritoneal, pueden ser una adición diagnóstica importante para tal decisión. (Traducción-Yesenia Rojas-Khalil )Clinical trial registration: DRKS00012758 (German National Study Registry), ST-D 406 (German Cancer Society).
Collapse
Affiliation(s)
- Matthias Kraemer
- Department of General and Visceral Surgery, Coloproctology, Academic Teaching Hospital of University of Münster, Münster, Germany
| | - Sarkhan Nabiyev
- Department of General and Visceral Surgery, Coloproctology, Academic Teaching Hospital of University of Münster, Münster, Germany
| | - Silvia Kraemer
- Department of General and Visceral Surgery, Coloproctology, Academic Teaching Hospital of University of Münster, Münster, Germany
| | - Stephanie Schipmann
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
- Medical Faculty, University of Münster, Münster, Germany
| |
Collapse
|
2
|
Janczak J, Ukegjini K, Bischofberger S, Turina M, Müller PC, Steffen T. Quality of Surgical Outcome Reporting in Randomised Clinical Trials of Multimodal Rectal Cancer Treatment: A Systematic Review. Cancers (Basel) 2023; 16:26. [PMID: 38201454 PMCID: PMC10778098 DOI: 10.3390/cancers16010026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/07/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
INTRODUCTION Randomised controlled trials (RCTs) continue to provide the best evidence for treatment options, but the quality of reporting in RCTs and the completeness rate of reporting of surgical outcomes and complication data vary widely. The aim of this study was to measure the quality of reporting of the surgical outcome and complication data in RCTs of rectal cancer treatment and whether this quality has changed over time. METHODS Eligible articles with the keywords ("rectal cancer" OR "rectal carcinoma") AND ("radiation" OR "radiotherapy") that were RCTs and published in the English, German, Polish, or Italian language were identified by reviewing all abstracts published from 1982 through 2022. Two authors independently screened and analysed all studies. The quality of the surgical outcome and complication data was assessed based on fourteen criteria, and the quality of RCTs was evaluated based on a modified Jadad scale. The primary outcome was the quality of reporting in RCTs and the completeness rate of reporting of surgical results and complication data. RESULTS A total of 340 articles reporting multimodal therapy outcomes for 143,576 rectal cancer patients were analysed. A total of 7 articles (2%) met all 14 reporting criteria, 13 met 13 criteria, 27 met from 11 to 12 criteria, 36 met from 9 to 10 criteria, 76 met from 7 to 8 criteria, and most articles met fewer than 7 criteria (mean 5.5 criteria). Commonly underreported criteria included complication severity (15% of articles), macroscopic integrity of mesorectal excision (17% of articles), length of stay (18% of articles), number of lymph nodes (21% of articles), distance between the tumour and circumferential resection margin (CRM) (26% of articles), surgical radicality according to the site of the primary tumour (R0 vs. R1 + R2) (29% of articles), and CRM status (38% of articles). CONCLUSION Inconsistent surgical outcome and complication data reporting in multimodal rectal cancer treatment RCTs is standard. Standardised reporting of clinical and oncological outcomes should be established to facilitate comparing studies and results of related research topics.
Collapse
Affiliation(s)
- Joanna Janczak
- Clinic for General and Visceral Surgery, Hospital for the Region Fürstenland Toggenburg, CH-9500 Wil, Switzerland;
| | - Kristjan Ukegjini
- Department of Surgery, Hospital of the Canton of St. Gallen, CH-9007 St. Gallen, Switzerland; (K.U.); (S.B.)
| | - Stephan Bischofberger
- Department of Surgery, Hospital of the Canton of St. Gallen, CH-9007 St. Gallen, Switzerland; (K.U.); (S.B.)
| | - Matthias Turina
- Department of Surgery and Transplantation, University Hospital Zurich, CH-8091 Zurich, Switzerland;
| | - Philip C. Müller
- Department of Surgery, Clarunis—University Centre for Gastrointestinal and Hepatopancreatobiliary Diseases, CH-4002 Basel, Switzerland;
| | - Thomas Steffen
- Department of Surgery, Hospital of the Canton of St. Gallen, CH-9007 St. Gallen, Switzerland; (K.U.); (S.B.)
| |
Collapse
|
3
|
Mineur L, Vazquez L, Belkacemi M, Toullec C, Bentaleb N, Boustany R, Plat F. Capecitabine/Mitomycin versus 5-Fluorouracil/Mitomycin in Combination with Simultaneous Integrated Boost Intensity-Modulated Radiation Therapy for Anal Cancer. Curr Oncol 2023; 30:8563-8574. [PMID: 37754536 PMCID: PMC10528380 DOI: 10.3390/curroncol30090621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/15/2023] [Accepted: 09/15/2023] [Indexed: 09/28/2023] Open
Abstract
Since EXTRA, a non-randomized phase II trial with 31 patients, explored the use of capecitabine, mitomycin and radiation therapy (RT) in the treatment of localized squamous cell carcinoma of the anal canal (SCCAC), this treatment has been considered as an acceptable alternative to infusional 5-FU. However, the differences in efficacy between capecitabine and 5-FU in chemoradiation therapy (CRT) with simultaneous integrated boost (SIB) radiation therapy (SIB-IMRT) for local SCCAC are not well documented. Patients included in this prospective monocentric cohort study were treated with SIB-RapidArc (a unique RT method treatment for all patients: identical technique, volume and constraints for at-risk organs), mitomycin C and 5-FU each day of RT for 7 weeks (group 1) or capecitabine each day of RT (group 2). Patients treated between July 2009 and August 2017 (group 1) and between November 2012 and April 2018 (group 2) for local SCCAC T2-4 classified as N, M0 or T, N1-3, M0 were included. Primary endpoints were progression-free survival (PFS) and acute toxicities. Results: One hundred forty-seven patients were included, 91 in group 1 and 56 in group 2. The two groups were statistically comparable in terms of sex, Eastern Cooperative Oncology Group Performance Status (ECOG PS) and TNM. With a median duration of follow-up of 53.5 months, the PFS rate at 3 years was 80% for group 1 and 75% for group 2 (p = 0.32). The 3-year colostomy-free survival rate was 92% for group 1 and 85% for group 2 (p = 0.11). The rate of patients with at least one grade 3 or higher acute toxicity was 35.5% in group 1 and 21.4% in group 2 (p = 0.10), with a trend of fewer acute toxicities with capecitabine. Conclusion: Capecitabine/mitomycin in combination with SIB RapidArc radiation therapy for anal cancer seems as effective as 5-FU-based chemotherapy and is well tolerated with minimal toxicity.
Collapse
Affiliation(s)
- Laurent Mineur
- Oncodigestive and Clinical Research Department, Sainte Catherine Institut du Cancer Avignon-Provence, 84918 Avignon, France
| | - Léa Vazquez
- Oncodigestive and Clinical Research Department, Sainte Catherine Institut du Cancer Avignon-Provence, 84918 Avignon, France
| | - Mohamed Belkacemi
- Statistics Department, PRECIS, Nouvelles Technologies, Languedoc Mutualité, 34000 Montpellier, France
| | - Clémence Toullec
- Oncodigestive and Clinical Research Department, Sainte Catherine Institut du Cancer Avignon-Provence, 84918 Avignon, France
| | - Newfel Bentaleb
- Oncodigestive and Clinical Research Department, Sainte Catherine Institut du Cancer Avignon-Provence, 84918 Avignon, France
| | - Rania Boustany
- Oncodigestive and Clinical Research Department, Sainte Catherine Institut du Cancer Avignon-Provence, 84918 Avignon, France
| | - Frederi Plat
- Oncodigestive and Clinical Research Department, Sainte Catherine Institut du Cancer Avignon-Provence, 84918 Avignon, France
| |
Collapse
|
4
|
Gou XX, Shi HY, Li C, Chen ZL, Ouyang W, Sun LY, Diao YK, Wang MD, Yao LQ, Gu LH, Pawlik TM, Lau WY, Shen F, Xue J, Yang T. Association of Adjuvant Radiotherapy with Long-term Overall and Recurrence-free Survival Following Hepatectomy for Hepatocellular Carcinoma: A Multicenter Propensity-matched Study. Int J Radiat Oncol Biol Phys 2022; 114:238-249. [DOI: 10.1016/j.ijrobp.2022.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 05/05/2022] [Accepted: 05/18/2022] [Indexed: 11/25/2022]
|
5
|
Proteinemia as a Prognostic Factor in Colorectal Cancers beyond Surgery and Chemotherapy. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1055/s-0041-1730368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Abstract
Background Globally, 1,096,601, 704,376, and 48,541 new colon, rectum, and anus cancer cases were recorded in 2018, respectively. Besides, 551,269, 310,394 and 19,129 cases of colon, rectum, and anus cancer deaths occurred in the same year. As a result, these cancers ranked in the third level of cancer incidence, and in the second level of cancer mortality. As it is known, all cancer patients are subjected to cancer-induced and therapy-induced nutritional deficiencies (mainly of proteins and calories). The present study aimed to assess proteins level in colorectal cancer (CRC) patients who underwent surgery and chemotherapy.
Methods A combined retrospective and prospective study was performed. The present study enrolled 100 CRC patients with their data on surgical procedures and chemotherapy management. Assessments of the studied samples were conducted as a baseline before receiving chemotherapy and preoperatively as P0, while the period after that was termed as P1. The serum samples were collected to measure protein concentration. Total Protein Kit, Micro was used.
Results The mean age of the patients was 50.7 ± 12.88 years old. Only 8% had a positive CRC family history. Rectosigmoid cancer represented the most frequent site, figured in 41% of the cases, followed by rectum cancer. Multiple sites of CRC metastasis were recorded in 15% of the patients. All patients received chemoradiation. Folinic acid (leucovorin), 5-FU, and oxaliplatin (FOLFOX) was the most used regimen, administered in 40% of the patients. Oxaliplatin and capecitabine (also called Xeloda) (XELOX) were administered in 14% of the patients. Folinic acid (leucovorin), 5-FU, oxaliplatin, and irinotecan (FOLFOXIRI) were administered in 16% of the patients. Single-agent oxaliplatin or carboplatin were administered in 6% of the patients, each. 5-FU plus leucovorin was administered to12% of the patients. Three patients received irinotecan, and oxaliplatin (IROX). One patient received folinic acid (leucovorin), 5-FU and irinotecan (FOLFIRI). Also, Gemzar was administered to two patients only. A total of 80% of the patients underwent several surgical procedures. Anterior perineal resection (APR) and total mesorectal excision (TME) were the most common two surgeries, performed in 20 and in 30% of the patients, respectively. In P0 status, 44% of the patients suffered from low protein levels, and 13% of the patients were within the normal level. These findings were statistically different (p = 0.03). After CRC management (i.e., P1 status), 70% of the patients had protein deficiency. These results have strong significant differences (p = 0.000). The mean of protein concentration declined gradually after management, from 8.82 ± 0.9 μg/L to 6.21 ± 0.78 μg/L, with a strong association between a reduction in proteins levels towards deficiency and surgical procedures and chemotherapy protocols (p = 0.000).
Conclusion The incidence of CRC is increasing annually, and the chance of being diagnosed with this type of cancer has risen in recent years. In the present study, the male to female ratio was 1:1.5, and the 5th decade of life was the most common age for the diagnosis of CRC. A negative family history and bowel inflammatory diseases (IBD) history did not exclude people from exposure to the incidence of CRC. Colorectal cancer with localized and moderately differentiated adenocarcinoma were the most common types in the present work. Tumor distance from the anal verge seems to be very important and plays a significant role in the choosing of surgical intervention types and chemoradiation protocols. Colorectal cancer acts as a complex condition and, in addition to its management, nutritional state influences it in different mechanisms. Most patients suffered from hypoproteinemia after surgery and chemoradiation. As a result, alteration in the treatment outcomes, delaying in wound healing, and an increase in postoperative complications may occur.
Collapse
|
6
|
Podda M, Sylla P, Baiocchi G, Adamina M, Agnoletti V, Agresta F, Ansaloni L, Arezzo A, Avenia N, Biffl W, Biondi A, Bui S, Campanile FC, Carcoforo P, Commisso C, Crucitti A, De'Angelis N, De'Angelis GL, De Filippo M, De Simone B, Di Saverio S, Ercolani G, Fraga GP, Gabrielli F, Gaiani F, Guerrieri M, Guttadauro A, Kluger Y, Leppaniemi AK, Loffredo A, Meschi T, Moore EE, Ortenzi M, Pata F, Parini D, Pisanu A, Poggioli G, Polistena A, Puzziello A, Rondelli F, Sartelli M, Smart N, Sugrue ME, Tejedor P, Vacante M, Coccolini F, Davies J, Catena F. Multidisciplinary management of elderly patients with rectal cancer: recommendations from the SICG (Italian Society of Geriatric Surgery), SIFIPAC (Italian Society of Surgical Pathophysiology), SICE (Italian Society of Endoscopic Surgery and new technologies), and the WSES (World Society of Emergency Surgery) International Consensus Project. World J Emerg Surg 2021; 16:35. [PMID: 34215310 PMCID: PMC8254305 DOI: 10.1186/s13017-021-00378-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 06/18/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND AIMS Although rectal cancer is predominantly a disease of older patients, current guidelines do not incorporate optimal treatment recommendations for the elderly and address only partially the associated specific challenges encountered in this population. This results in a wide variation and disparity in delivering a standard of care to this subset of patients. As the burden of rectal cancer in the elderly population continues to increase, it is crucial to assess whether current recommendations on treatment strategies for the general population can be adopted for the older adults, with the same beneficial oncological and functional outcomes. This multidisciplinary experts' consensus aims to refine current rectal cancer-specific guidelines for the elderly population in order to help to maximize rectal cancer therapeutic strategies while minimizing adverse impacts on functional outcomes and quality of life for these patients. METHODS The discussion among the steering group of clinical experts and methodologists from the societies' expert panel involved clinicians practicing in general surgery, colorectal surgery, surgical oncology, geriatric oncology, geriatrics, gastroenterologists, radiologists, oncologists, radiation oncologists, and endoscopists. Research topics and questions were formulated, revised, and unanimously approved by all experts in two subsequent modified Delphi rounds in December 2020-January 2021. The steering committee was divided into nine teams following the main research field of members. Each conducted their literature search and drafted statements and recommendations on their research question. Literature search has been updated up to 2020 and statements and recommendations have been developed according to the GRADE methodology. A modified Delphi methodology was implemented to reach agreement among the experts on all statements and recommendations. CONCLUSIONS The 2021 SICG-SIFIPAC-SICE-WSES consensus for the multidisciplinary management of elderly patients with rectal cancer aims to provide updated evidence-based statements and recommendations on each of the following topics: epidemiology, pre-intervention strategies, diagnosis and staging, neoadjuvant chemoradiation, surgery, watch and wait strategy, adjuvant chemotherapy, synchronous liver metastases, and emergency presentation of rectal cancer.
Collapse
Affiliation(s)
- Mauro Podda
- Department of Emergency Surgery, Cagliari University Hospital "D. Casula", Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy.
| | - Patricia Sylla
- Division of Colon and Rectal Surgery, Mount Sinai Hospital, New York, NY, USA
| | - Gianluca Baiocchi
- ASST Cremona, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Michel Adamina
- Department of Colorectal Surgery, Cantonal Hospital of Winterthur, Winterthur - University of Basel, Basel, Switzerland
| | | | - Ferdinando Agresta
- Department of General Surgery, Vittorio Veneto Hospital, AULSS2 Trevigiana del Veneto, Vittorio Veneto, Italy
| | - Luca Ansaloni
- 1st General Surgery Unit, University of Pavia, Pavia, Italy
| | - Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Nicola Avenia
- SC Chirurgia Generale e Specialità Chirurgiche Azienda Ospedaliera Santa Maria, Università degli Studi di Perugia, Terni, Italy
| | - Walter Biffl
- Trauma and Acute Care Surgery, Scripps Memorial Hospital, La Jolla, CA, USA
| | - Antonio Biondi
- Department of General Surgery and Medical - Surgical Specialties, University of Catania, Catania, Italy
| | - Simona Bui
- Department of Medical Oncology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Fabio C Campanile
- Department of Surgery, ASL VT - Ospedale "San Giovanni Decollato - Andosilla", Civita Castellana, Italy
| | - Paolo Carcoforo
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara, University of Ferrara, Ferrara, Italy
| | - Claudia Commisso
- Department of Radiology, University Hospital of Parma, Parma, Italy
| | - Antonio Crucitti
- General and Minimally Invasive Surgery Unit, Cristo Re Hospital and Catholic University, Rome, Italy
| | - Nicola De'Angelis
- Unit of Minimally Invasive and Robotic Digestive Surgery, Regional General Hospital F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - Gian Luigi De'Angelis
- Department of Medicine and Surgery, Gastroenterology and Endoscopy Unit, University of Parma, Parma, Italy
| | | | - Belinda De Simone
- Department of General and Metabolic Surgery, Poissy and Saint Germain en Laye Hospitals, Poissy, France
| | | | - Giorgio Ercolani
- General and Oncologic Surgery, Morgagni-Pierantoni Hospital, AUSL Romagna, Forlì, Italy
| | - Gustavo P Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, SP, Brazil
| | | | - Federica Gaiani
- Department of Medicine and Surgery, Gastroenterology and Endoscopy Unit, University of Parma, Parma, Italy
| | | | | | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ari K Leppaniemi
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Andrea Loffredo
- UOC Chirurgia Generale - AOU san Giovanni di Dio e Ruggi d'Aragona, Università di Salerno, Salerno, Italy
| | - Tiziana Meschi
- Department of Medicine and Surgery, University of Parma Geriatric-Rehabilitation Department, Parma University Hospital, Parma, Italy
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, Denver, USA
| | | | | | - Dario Parini
- Santa Maria della Misericordia Hospital, Rovigo, Italy
| | - Adolfo Pisanu
- Department of Emergency Surgery, Cagliari University Hospital "D. Casula", Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy
| | - Gilberto Poggioli
- Surgery of the Alimentary Tract, Sant'Orsola Hospital, Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Andrea Polistena
- Dipartimento di Chirurgia Pietro Valdoni Policlinico Umberto I, Sapienza Università degli Studi di Roma, Rome, Italy
| | - Alessandro Puzziello
- UOC Chirurgia Generale - AOU san Giovanni di Dio e Ruggi d'Aragona, Università di Salerno, Salerno, Italy
| | - Fabio Rondelli
- SC Chirurgia Generale e Specialità Chirurgiche Azienda Ospedaliera Santa Maria, Università degli Studi di Perugia, Terni, Italy
| | | | | | - Michael E Sugrue
- Letterkenny University Hospital and CPM sEUBP Interreg Project, Letterkenny, Ireland
| | | | - Marco Vacante
- Department of General Surgery and Medical - Surgical Specialties, University of Catania, Catania, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Justin Davies
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge, UK
| | - Fausto Catena
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
| |
Collapse
|
7
|
Bigness A, Imanirad I, Sahin IH, Xie H, Frakes J, Hoffe S, Laskowitz D, Felder S. Locally advanced rectal adenocarcinoma: Treatment sequences, intensification, and rectal organ preservation. CA Cancer J Clin 2021; 71:198-208. [PMID: 33592118 DOI: 10.3322/caac.21661] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 12/14/2020] [Accepted: 12/17/2020] [Indexed: 01/04/2023] Open
Affiliation(s)
- Alec Bigness
- University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Iman Imanirad
- Department of Gastrointestinal Oncology, Medical Oncology Section, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Ibrahim Halil Sahin
- Department of Gastrointestinal Oncology, Medical Oncology Section, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Hao Xie
- Department of Gastrointestinal Oncology, Medical Oncology Section, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Jessica Frakes
- Department of Gastrointestinal Oncology, Radiation Oncology Section, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Sarah Hoffe
- Department of Gastrointestinal Oncology, Radiation Oncology Section, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Danielle Laskowitz
- Department of Gastrointestinal Oncology, Surgical Oncology Section, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Seth Felder
- Department of Gastrointestinal Oncology, Surgical Oncology Section, H. Lee Moffitt Cancer Center, Tampa, Florida
| |
Collapse
|
8
|
Ciseł B, Pietrzak L, Michalski W, Wyrwicz L, Rutkowski A, Kosakowska E, Cencelewicz A, Spałek M, Polkowski W, Jankiewicz M, Styliński R, Bębenek M, Kapturkiewicz B, Maciejczyk A, Sadowski J, Zygulska J, Zegarski W, Jankowski M, Las-Jankowska M, Toczko Z, Żelazowska-Omiotek U, Kępka L, Socha J, Wasilewska-Tesluk E, Markiewicz W, Kładny J, Majewski A, Kapuściński W, Suwiński R, Bujko K. Long-course preoperative chemoradiation versus 5 × 5 Gy and consolidation chemotherapy for clinical T4 and fixed clinical T3 rectal cancer: long-term results of the randomized Polish II study. Ann Oncol 2020; 30:1298-1303. [PMID: 31192355 DOI: 10.1093/annonc/mdz186] [Citation(s) in RCA: 136] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND This trial evaluated whether preoperative short-course radiotherapy and consolidation chemotherapy (CCT) were superior to chemoradiation in rectal cancers with clinical (c)T4 or fixed cT3. Previously, we reported early results showing no differences in the radical surgery rate (primary end point). In the short-course/CCT group, we observed lower acute toxicity of preoperative treatment and better overall survival (OS). We updated results to determine whether the benefit in OS was sustained and to evaluate late complications. PATIENTS AND METHODS Patients with cT4 or fixed cT3 rectal cancer were randomized either to preoperative 5 × 5 Gy and three cycles of FOLFOX4 or to chemoradiation (50.4 Gy with bolus 5-Fu, leucovorin and oxaliplatin). RESULTS Patients (N = 515) were eligible for analysis, 261 in the short-course/CCT group and 254 in the chemoradiation group. The median follow-up was 7.0 years. The difference in OS was insignificant [hazard ratio (HR) 0.90; 95% confidence interval (CI) 0.70-1.15; P = 0.38). However, the difference in early OS favouring short-course/CCT previously reported was observed again, being 9% at 3 years (95% CI 0.5% to 17%). This difference disappeared later; at 8 years OS was 49% in both groups. There was no difference in disease-free survival (HR 0.95; 95% CI 0.75-1.19; P = 0.65) at 8 years 43% versus 41% in the short-course/CCT group versus the chemoradiation group, respectively. The corresponding values for cumulative incidences of local failure and distant metastases did not differ and were HR = 1.08, 95% CI 0.70-1.23, P = 0.60, 35% versus 32% and HR = 1.10, 95% CI 0.68-1.23, P = 0.54, 36% versus 34%, respectively. The rate of late complications was similar (P = 0.66), grade 3+ being 11% versus 9% in the short-course/CCT group versus the chemoradiation group, respectively. CONCLUSION The superiority of preoperative short-course/CCT over chemoradiation was not demonstrated. CLINICAL TRIAL NUMBER The trial is registered as ClinicalTrials.gov number NCT00833131.
Collapse
Affiliation(s)
- B Ciseł
- Department of Surgical Oncology, Medical University of Lublin, Lublin
| | | | | | | | - A Rutkowski
- Gastroenterological Oncology, M. Skłodowska-Curie Memorial Cancer Centre, Warsaw
| | - E Kosakowska
- Gastroenterological Oncology, M. Skłodowska-Curie Memorial Cancer Centre, Warsaw
| | - A Cencelewicz
- Gastroenterological Oncology, M. Skłodowska-Curie Memorial Cancer Centre, Warsaw
| | | | - W Polkowski
- Department of Surgical Oncology, Medical University of Lublin, Lublin
| | - M Jankiewicz
- Department of Surgical Oncology, Medical University of Lublin, Lublin; Department of Radiotherapy, St. John's Cancer Center, Lublin
| | - R Styliński
- 1st Department of General Surgery, Transplantology and Nutritional Therapy Medical University of Lublin
| | | | | | - A Maciejczyk
- Radiotherapy, Silesian Oncological Centre, Wrocław
| | - J Sadowski
- Department of Radiotherapy, Regional Oncological Centre, Kielce
| | - J Zygulska
- Department of Radiotherapy, Beskid Centre of Oncology, Bielsko-Biala
| | | | | | - M Las-Jankowska
- Clinical Oncology, Collegium Medicum Nicolaus Copernicus University and Oncology Centre, Bydgoszcz
| | - Z Toczko
- Department of Surgery, Regional Hospital, Elblag
| | | | - L Kępka
- Department of Radiotherapy, Military Institute of Medicine, Warsaw
| | - J Socha
- Department of Radiotherapy, Military Institute of Medicine, Warsaw; Department of Radiotherapy, Regional Oncology Center, Czestochowa
| | - E Wasilewska-Tesluk
- Radiotherapy Department, Public Health Care Facility of the Ministry of the Interior and Warmian-Masurian Oncology Centre, Olsztyn; Department of Oncology, University of Warmia and Mazury, Olsztyn
| | - W Markiewicz
- Department of Surgery, Regional Cancer Centre, Białystok
| | - J Kładny
- Department of General Surgery and Surgical Oncology First Clinical Hospital of Pomeranian Medical University, Szczecin
| | - A Majewski
- Department of Surgery, Regional Hospital, Wałbrzych
| | - W Kapuściński
- Department of Radiotherapy, Regional Cancer Centre, Copernicus Memorial Hospital of Łódź, Łódź
| | - R Suwiński
- Department of Radiotherapy, M. Skłodowska-Curie Memorial Cancer Centre, Gliwice, Poland
| | - K Bujko
- II Department of Radiotherapy.
| | | |
Collapse
|
9
|
Hong YS, Kim SY, Lee JS, Nam BH, Kim KP, Kim JE, Park YS, Park JO, Baek JY, Kim TY, Lee KW, Ahn JB, Lim SB, Yu CS, Kim JC, Yun SH, Kim JH, Park JH, Park HC, Jung KH, Kim TW. Oxaliplatin-Based Adjuvant Chemotherapy for Rectal Cancer After Preoperative Chemoradiotherapy (ADORE): Long-Term Results of a Randomized Controlled Trial. J Clin Oncol 2019; 37:3111-3123. [PMID: 31593484 DOI: 10.1200/jco.19.00016] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
PURPOSE We evaluated the role of oxaliplatin as adjuvant chemotherapy in patients with rectal cancer who received preoperative chemoradiotherapy (CRT) with fluoropyrimidine monotherapy and total mesorectal excision (TME). METHODS The ADORE trial (adjuvant oxaliplatin in rectal cancer) is a multicenter, randomized trial in patients with postoperative ypStage II (ypT3-4N0) or III (ypTanyN1-2) rectal cancer after fluoropyrimidine-based preoperative CRT and TME. Patients were randomly assigned (1:1) to receive adjuvant chemotherapy either with FL (fluorouracil 380 mg/m2 and leucovorin 20 mg/m2) or FOLFOX (oxaliplatin 85 mg/m2, leucovorin 200 mg/m2, and fluorouracil bolus 400 mg/m2 on day 1, fluorouracil infusion 2,400 mg/m2 for 46 hours). Stratification factors included ypStage and participating center. Primary end point was disease-free survival (DFS). RESULTS A total of 321 patients were enrolled between November 19, 2008, and June 12, 2012. Six-year DFS rates were 68.2% in the FOLFOX arm versus 56.8% in the FL arm, with a stratified hazard ratio of 0.63 (95% CI, 0.43 to 0.93; P = .018) by intention-to-treat analysis. In the subgroup analysis for DFS, FOLFOX was favorable versus FL in patients with ypStage III, ypN1b, ypN2, high-grade histology, minimally regressed tumor, and an absence of lymphovascular or perineural invasion. Six-year overall survival rate was 78.1% in the FOLFOX arm versus76.4% in the FL arm (hazard ratio, 0.73; 95% CI, 0.45 to 1.19; P = .21). In the subgroup analysis for OS, FOLFOX was favorable versus FL in patients with ypN2 and minimally regressed tumor. CONCLUSION Adjuvant FOLFOX improved DFS in patients with rectal cancer with ypStage II and III disease after preoperative CRT. Adjuvant FOLFOX may be considered on the basis of the postoperative pathologic stage in those who received preoperative CRT and TME.
Collapse
Affiliation(s)
- Yong Sang Hong
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sun Young Kim
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ji Sung Lee
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Byung-Ho Nam
- The Institute of Advanced Clinical and Biomedical Research, Seoul, Republic of Korea
| | - Kyu-Pyo Kim
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jeong Eun Kim
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young Suk Park
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Joon Oh Park
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ji Yeon Baek
- Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Tae-You Kim
- Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Keun-Wook Lee
- Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Joong Bae Ahn
- Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seok-Byung Lim
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chang Sik Yu
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jin Cheon Kim
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seong Hyeon Yun
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jong Hoon Kim
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jin-Hong Park
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hee Chul Park
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyung Hae Jung
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Tae Won Kim
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
10
|
Postoperative XELOX therapy for patients with curatively resected high-risk stage II and stage III rectal cancer without preoperative chemoradiation: a prospective, multicenter, open-label, single-arm phase II study. BMC Cancer 2019; 19:929. [PMID: 31533662 PMCID: PMC6751668 DOI: 10.1186/s12885-019-6122-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 09/02/2019] [Indexed: 12/18/2022] Open
Abstract
Background Preoperative 5-FU-based chemoradiation is currently a standard treatment for advanced rectal cancer, particularly in Western countries. Although it reduced the local recurrence, it could not necessarily improve overall survival. Furthermore, it can also produce adverse effects and long-term sphincter function deficiency. Adjuvant oxaliplatin plus capecitabine (XELOX) is a recommended regimen for patients with curatively resected colon cancer. However, the efficacy of postoperative adjuvant therapy for rectal cancer patients who have not undergone preoperative chemoradiation remains unknown. We aimed to evaluate the efficacy of surgery and postoperative XELOX without preoperative chemoradiation for treating rectal cancer. Methods We performed a prospective, multicenter, open-label, single arm phase II study. Patients with curatively resected high-risk stage II and stage III rectal cancer who had not undergone preoperative therapy were treated with a 120 min intravenous infusion of oxaliplatin (130 mg/m2) on day 1 and capecitabine (2000 mg/m2/day) in 2 divided doses for 14 days of a 3-week cycle, for a total of 8 cycles (24 weeks). The primary endpoint was 3-year disease-free survival (DFS). Results Between August 2012 and June 2015, 60 men and 47 women with a median age was 63 years (range: 29–77 years) were enrolled. Ninety-three patients had Eastern Cooperative Oncology Group performance status scores of ‘0’ and 14 had scores of ‘1’. Tumors were located in the upper and lower rectums in 54 and 48 patients, respectively; 8 patients had stage II disease and 99 had stage III. The 3-year DFS was 70.1% (95% confidence interval, 60.8–78.0%) and 33 patients (31%) experienced recurrence, most commonly in the lung (16 patients) followed by local recurrence (9) and hepatic recurrence (7). Conclusions Postoperative XELOX without preoperative chemoradiation is effective for rectal cancer and provides adequate 3-year DFS prospects. Trial registration This clinical trial was registered in the University Hospital Medical Information Network registry system as UMIN000008634 at Aug 06, 2012.
Collapse
|
11
|
Barzi A, Hershman DL, Till C, Barlow WE, Ramsey S, Lenz HJ, Hochster HS, Unger JM. Osteoporosis in colorectal cancer survivors: analysis of the linkage between SWOG trial enrollees and Medicare claims. Arch Osteoporos 2019; 14:83. [PMID: 31352608 PMCID: PMC6852789 DOI: 10.1007/s11657-019-0629-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 07/02/2019] [Indexed: 02/03/2023]
Abstract
UNLABELLED To explore the rates of osteoporosis (diagnosis and screening) and fractures in colorectal cancer survivors (CRCS), records of clinical trial enrollees was linked to Medicare. Female/male risk of fracture in CRCS is 74% higher than general population. Less than 30% of male and female CRCS receive osteoporosis screening. Osteoporosis is a significant morbidity in CRCS. INTRODUCTION In the USA, the population of colorectal cancer survivors (CRCS) is on the rise. Calcium and vitamin D are the common thread between colorectal cancer and osteoporosis. We set to explore the patterns and prevalence of osteoporosis (OP) and osteoporotic fractures (OF) in CRCS who received fluorouracil-based therapy on SWOG trials. METHODS Data for CRCS from three SWOG phase III treatment trials between 1994 and 2000 (N = 3775) were linked to Medicare claims (N = 1233). OP was identified using ICD9 and HCPCS codes; OF was defined using a more restricted set of codes. We compared patterns of OP, OF, and screening for OP by gender in CRCS. Given the gender disparities in the rates of OP and OF, we used data from the National Health Interview Survey (NHIS) and the National Hospital Discharge Survey (NHDS) to assess the ratio of OF in females and males in general population. RESULTS Forty-seven percent of females and 15% of men CRCS had OP claims. Female CRCS were more likely than males to have OP (HR = 4.76 [3.77-6.01], p < 0.0001) and OF (HR = 2.64 [2.04-3.42], p < 0.0001). In the general population, the female to male ratio of OF was 1.67 as opposed to 2.90 in CRCS, indicating a significantly larger gender disparity of OF in CRCS (p < 0.001). Only 7% of men and 27% of women CRCS had OP screening. CONCLUSION Despite a low rate of OP screening, the gender disparity of OF in CRCS is more pronounced than the general population. These findings provide an impetus for studying OP and OF in CRCS.
Collapse
Affiliation(s)
| | | | | | | | - Scott Ramsey
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | | | | |
Collapse
|
12
|
Abstract
The management of locally-advanced rectal cancer involves a combination of chemotherapy, chemoradiation, and surgical resection to provide excellent local tumor control and overall survival. However, aspects of this multimodality approach are associated with significant morbidity and long-term sequelae. In addition, there is growing evidence that patients with a clinical complete response to chemotherapy and chemoradiation treatments may be safely offered initial non-operative management in a rigorous surveillance program. Weighed against the morbidity and significant sequelae of rectal resection, recognizing how to best optimize non-operative strategies without compromising oncologic outcomes is critical to our understanding and treatment of this disease.
Collapse
Affiliation(s)
- Iris H Wei
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering, New York, NY, USA -
| | - Julio Garcia-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering, New York, NY, USA
| |
Collapse
|
13
|
Qi F, Zheng Z, Yan Q, Liu J, Chen Y, Zhang G. Comparisons of Efficacy, Safety, and Cost of Chemotherapy Regimens FOLFOX4 and FOLFIRINOX in Rectal Cancer: A Randomized, Multicenter Study. Med Sci Monit 2018; 24:1970-1979. [PMID: 29614063 PMCID: PMC5896363 DOI: 10.12659/msm.906934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background The currently available chemotherapeutic regimens do not use a specifically designed drug delivery system. The objective of this study was to compare outcome measures, adverse effects, and cost of FOLFOX4 and FOLFIRINOX treatments in rectal cancer patients. Material/Methods We enrolled patients who, after surgery, did not undergo chemotherapy or radiotherapy (Control group); were administered 200 mg/m2 folinic acid, 400 mg/m2 fluorouracil, and 85 mg/m2 oxaliplatin (FFO group); or were administered 400 mg/m2 folinic acid, 400 mg/m2 fluorouracil, 180 mg/m2 irinotecan, and 85 mg/m2 oxaliplatin (FFIO group). We recorded tumor and nodal staging, carbohydrate antigen 19-9, serum carcinoembryonic antigen, total cost of treatment, disease recurrence, overall survival, and adverse effects. We used the 2-tailed paired t test following Turkey post hoc test for adverse effects, recurrence analysis, and cost of treatment at 95% of confidence level. Results Surgery (p=0.00089), FOLFOX4 (p=0.000167), and FOLFIRINOX (p=0.00013) improved disease-free conditions. Only surgery failed to maintain carbohydrate antigen and carcinoembryonic antigen 19-9 levels. The cost of chemotherapeutic treatments was in the order of FFIO group > FFO group > Control group. Non-fatal treatment-emergent adverse effects were due to chemotherapeutic drugs. However, fatal chemotherapeutic treatment-emergent adverse effects were observed only in the FFIO group. Overall survival, irrespective of cancerous condition, was higher in the FFO group. Conclusions FOLFIRINOX had less total cancer recurrence than FOLFOX4. However, FOLFIRINOX had more fatal treatment-emergent adverse effects and excessive cost of treatment than FOLFOX4 regimen.
Collapse
Affiliation(s)
- Fei Qi
- Department of Anorectal Surgery, Huzhou Central Hospital, Huzhou, Zhejiang, China (mainland)
| | - Zhaozheng Zheng
- Department of Anorectal Surgery, Huzhou Central Hospital, Huzhou, Zhejiang, China (mainland)
| | - Qiang Yan
- Department of Hepatobiliary Surgery, Huzhou Central Hospital, Huzhou, Zhejiang, China (mainland)
| | - Jian Liu
- Department of Anorectal Surgery, Huzhou Central Hospital, Huzhou, Zhejiang, China (mainland)
| | - Yan Chen
- Department of Anorectal Surgery, Huzhou Central Hospital, Huzhou, Zhejiang, China (mainland)
| | - Guiyang Zhang
- Department of Anorectal Surgery, Huzhou Central Hospital, Huzhou, Zhejiang, China (mainland)
| |
Collapse
|
14
|
Cèfaro GA, Genovesi D, Vinciguerra A, Augurio A, Di Tommaso M, Marchese R, Borzillo V, Tasciotti L, Taraborrelli M, Innocenti P, Colecchia G, Di Nicola M. Effects of Preoperative Radiochemotherapy with Capecitabine for Resectable Locally Advanced Rectal Cancer in Elderly Patients. TUMORI JOURNAL 2018; 98:622-9. [DOI: 10.1177/030089161209800513] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Aims and background Rectal cancer is a common disease of elderly people. However, patients over 70 years of age are often not included in clinical trials. There is a lack of data concerning the use of radiochemotherapy with capecitabine in elderly patients. The aim of this study was to retrospectively evaluate the impact of preoperative radiochemotherapy with capecitabine on downstaging and sphincter preservation and to assess treatment compliance and toxicity in elderly patients. Methods Twenty-six patients with resectable locally advanced rectal cancer (stage II-III/TNM) aged >70 years received preoperative radiotherapy and concurrent oral capecitabine 825 mg/m2 twice daily during the whole period of radiotherapy. Two patients who refused surgery after chemoradiation therapy were excluded from the analysis. Results Eighty-one percent of patients underwent anterior resection and 18.1% underwent abdominoperineal resection. Overall tumor downstaging, considering both T and N categories, was observed in 18/24 patients (75%). Treatment compliance was good and toxicity rates were similar to those of younger people. Conclusions Age is not a contraindication to any therapy and elderly patients who can tolerate radiochemotherapy should be treated like younger patients. Preoperative radiochemotherapy with capecitabine for patients aged >70 years has a good impact on tumor downstaging, increases the feasibility of sphincter-preserving surgery, and is also safe and well tolerated.
Collapse
Affiliation(s)
| | - Domenico Genovesi
- Radiation Oncology Department, G d'Annunzio University, Chieti, Italy
| | | | | | - Monica Di Tommaso
- Radiation Oncology Department, G d'Annunzio University, Chieti, Italy
| | - Rita Marchese
- Radiation Oncology Department, G d'Annunzio University, Chieti, Italy
| | | | - Lucia Tasciotti
- Radiation Oncology Department, G d'Annunzio University, Chieti, Italy
| | | | - Paolo Innocenti
- Surgery Department, G. d'Annunzio University, Chieti, G d'Annunzio University, Chieti, Italy
| | - Giuseppe Colecchia
- Surgery Department, Santo Spirito Hospital, Pescara, G d'Annunzio University, Chieti, Italy
| | - Marta Di Nicola
- Laboratory of Biostatistics, Department of Biomedical Science, G d'Annunzio University, Chieti, Italy
| |
Collapse
|
15
|
Roselló S, Papaccio F, Roda D, Tarazona N, Cervantes A. The role of chemotherapy in localized and locally advanced rectal cancer: A systematic revision. Cancer Treat Rev 2018; 63:156-171. [PMID: 29407455 DOI: 10.1016/j.ctrv.2018.01.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 01/07/2018] [Accepted: 01/09/2018] [Indexed: 12/28/2022]
Abstract
Curative treatment of rectal cancer depends on an optimal surgical resection, with the addition of neoadjuvant radiotherapy (RT) with or without concomitant chemotherapy (ChT) in more advanced tumors. The role of adjuvant ChT is controversial and a more intensified neoadjuvant approach with the addition of ChT before or after RT, or even as single modality, is currently being explored in trials. A systematic review selecting randomised phase II and III trials on the role of ChT in localized rectal cancer was performed. Data show that neoadjuvant ChRT improves locoregional control in resected rectal cancer. Short-course RT (SCRT) could give similar outcomes to ChRT. The addition of oxaliplatin to neoadjuvant ChRT marginally increases the pathological complete remission rate without improving survival and increasing toxicity. A more intensified approach remains investigational as trials to date have not shown significant advantages. Adjuvant ChT trials after preoperative ChRT are contentious, although the addition of oxaliplatin in high risk patients may benefit outcomes. Despite a wide heterogeneity in the target population, different staging procedures and diverse treatment approaches among different trials, this systematic review confirms the role of ChT in combination with neoadjuvant long-course RT. Adjuvant ChT could be of value in selected patients with high-risk features, mainly if they do not respond to neoadjuvant RT. Further investigation is warranted on more intensified neoadjuvant regimens including ChT for MRI-defined high-risk patients.
Collapse
Affiliation(s)
- Susana Roselló
- CIBERONC, Department of Medical Oncology, Biomedical Research Institute INCLIVA, University of Valencia, Valencia, Spain
| | - Federica Papaccio
- Oncologia Medica, Dipartimento di Internistica Clinica e Sperimentale "F. Magrassi", Università degli Studi della Campania Luigi Vanvitelli, Napoli, Italy
| | - Desamparados Roda
- CIBERONC, Department of Medical Oncology, Biomedical Research Institute INCLIVA, University of Valencia, Valencia, Spain
| | - Noelia Tarazona
- CIBERONC, Department of Medical Oncology, Biomedical Research Institute INCLIVA, University of Valencia, Valencia, Spain
| | - Andrés Cervantes
- CIBERONC, Department of Medical Oncology, Biomedical Research Institute INCLIVA, University of Valencia, Valencia, Spain.
| |
Collapse
|
16
|
McCleary NJ, Benson AB, Dienstmann R. Personalizing Adjuvant Therapy for Stage II/III Colorectal Cancer. Am Soc Clin Oncol Educ Book 2017; 37:232-245. [PMID: 28561714 DOI: 10.1200/edbk_175660] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This review focuses on three areas of interest with respect to the treatment of stage II and III colon and rectal cancer, including (1) tailoring adjuvant therapy for the geriatric population, (2) the controversy as to the optimal adjuvant therapy strategy for patients with locoregional rectal cancer and for patients with colorectal resectable metastatic disease, and (3) discussion of the microenvironment, molecular profiling, and the future of adjuvant therapy. It has become evident that age is the strongest predictive factor for receipt of adjuvant chemotherapy, duration of treatment, and risk of treatment-related toxicity. Although incorporating adjuvant chemotherapy for patients who have received neoadjuvant chemoradiation and surgery would appear to be a reasonable strategy to improve survivorship as an extrapolation from stage III colon cancer adjuvant trials, attempts at defining the optimal rectal cancer population that would benefit from adjuvant therapy remain elusive. Similarly, the role of adjuvant chemotherapy for patients after resection of metastatic colorectal cancer has not been clearly defined because of very limited data to provide guidance. An understanding of the biologic hallmarks and drivers of metastatic spread as well as the micrometastatic environment is expected to translate into therapeutic strategies tailored to select patients. The identification of actionable targets in mesenchymal tumors is of major interest.
Collapse
Affiliation(s)
- Nadine Jackson McCleary
- From the Dana-Farber Cancer Institute, Boston, MA; Division of Hematology/Oncology, Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL; Oncology Data Science Group, Vall d'Hebron Institute of Oncology, Barcelona, Spain; Sage Bionetworks, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Al B Benson
- From the Dana-Farber Cancer Institute, Boston, MA; Division of Hematology/Oncology, Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL; Oncology Data Science Group, Vall d'Hebron Institute of Oncology, Barcelona, Spain; Sage Bionetworks, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Rodrigo Dienstmann
- From the Dana-Farber Cancer Institute, Boston, MA; Division of Hematology/Oncology, Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL; Oncology Data Science Group, Vall d'Hebron Institute of Oncology, Barcelona, Spain; Sage Bionetworks, Fred Hutchinson Cancer Research Center, Seattle, WA
| |
Collapse
|
17
|
Wu Y, Liu H, Du XL, Wang F, Zhang J, Cui X, Li E, Yang J, Yi M, Zhang Y. Impact of neoadjuvant and adjuvant radiotherapy on disease-specific survival in patients with stages II-IV rectal cancer. Oncotarget 2017; 8:106913-106925. [PMID: 29290999 PMCID: PMC5739784 DOI: 10.18632/oncotarget.22460] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 10/12/2017] [Indexed: 12/15/2022] Open
Abstract
Objectives The purposes of this study were to determine whether neoadjuvant or adjuvant radiotherapy affected disease-specific survival (DSS) in patients with rectal cancer and whether stratification by tumor stage affected the results. Results 55.5% patients had neoadjuvant-radiotherapy (NRT), and 18.3% patients had adjuvant- radiotherapy (ART). Multivariable models showed that treatment type was independently associated with DSS. Patients with stages III/IV tumors who received ART plus chemotherapy had significantly worse DSS than did those who received NRT plus chemotherapy (NCRT) (P = 0.03). Among patients with stage II tumors, those who received ART plus chemotherapy and those who received NCRT had similar DSS. Further stratification by risk group revealed that patients with stage IIIA tumors who received ART plus chemotherapy had significantly better DSS than did those who received NCRT (P = 0.04). The ART plus chemotherapy and NCRT groups had similar DSS in patients with stage IIA tumors. Among high-risk patients (T3N+/T4), the NCRT group had significantly better DSS than did the ART plus chemotherapy group. Patients who underwent surgery only had the worst DSS of all the treatment groups. Materials and Methods From the Surveillance, Epidemiology, and End Results database, patients diagnosed with stages II-IV rectal cancer from 2004-2014 were identified. Clinicopathologic features, treatments, and DSS in different treatment groups were compared. Conclusions NCRT or ART plus chemotherapy can reduce deaths from rectal cancer. Patients with stage IIIA tumors will benefit most from ART plus chemotherapy, whereas NCRT should be recommended to patients with stages II, IIIB, or higher tumors.
Collapse
Affiliation(s)
- Yinying Wu
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, People's Republic of China
| | - Haiyang Liu
- Department of Radiation Imaging, Shangluo Central Hospital, Shangluo, Shaanxi, People's Republic of China
| | - Xianglin L Du
- Department of Epidemiology, Human Genetics and Environmental Sciences, The University of Texas School of Public Health, Houston, TX, USA
| | - Fan Wang
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, People's Republic of China
| | - Jing Zhang
- Second Department of Thoracic Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, People's Republic of China
| | - Xiaohai Cui
- Second Department of Thoracic Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, People's Republic of China
| | - Enxiao Li
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, People's Republic of China
| | - Jin Yang
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, People's Republic of China
| | - Min Yi
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, People's Republic of China.,Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yunfeng Zhang
- Second Department of Thoracic Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, People's Republic of China
| |
Collapse
|
18
|
Idasiak A, Galwas-Kliber K, Behrendt K, Wziętek I, Kryj M, Stobiecka E, Chmielik E, Suwiński R. Pre-operative hyperfractionated concurrent radiochemotherapy for locally advanced rectal cancers: a phase II clinical study. Br J Radiol 2017; 90:20160731. [PMID: 28466686 DOI: 10.1259/bjr.20160731] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE The study was prospectively designed as a single-arm, single-institution prospective trial of pre-operative concomitant hyperfractionated radiotherapy (HART) with co-administration of chemotherapy based on 5-fluorouracil (5FU) in patients with T2/N+ or T3/any N resectable mid-low primary rectal cancer. The aim of the study was to assess the safety and efficacy of accelerated HART with concurrent 5FU-based chemotherapy in patients with locally advanced rectal cancer. METHODS Patients with resectable locally advanced (≥T3 or N+) rectal cancer were eligible. The patients received total dose 42 Gy in 28 fractions of 1.5 Gy, two times daily, with at least 8 h of interval, with concurrent chemotherapy: 325 mg m-2 of 5FU (bolus) on Days 1-3 and Days 16-18 (except for cN0 patients for whom only one cycle on Days 1-3 was prescribed). The primary end point included tolerance, post-operative complication rate and pathological response rate. The secondary end points included locoregional relapse-free survival, metastasis-free survival and overall survival. RESULTS Out of 53 enrolled patients; 2 did not undergo surgery. Of the 51 patients evaluable for pathological response, there were 8 (15.6%), 20 (39.3%), 18 (35.3%) and 5 (9.8%) patients with tumour regression grade 0, 1, 2 and 3, respectively. Downstaging of the primary tumour and lymph nodes was observed in 22 (43%) and 25 (49%) patients, respectively. The primary tumour ypCR (ypT0) rate was 15% (8/51). The nodal ypCR rate for cN+ patients was 60% (21/35). The total ypCR (ypT0N0M0) rate was 11% (6/51). Toxicity included: Grade 3 diarrhoea (4/51, 7.8%), Grade 2 diarrhoea (22/51, 43.1%), Grade 2 leukopenia (7/51, 13.7%), Grade 2 neutropenia (6/51, 11.7%) and Grade 1 thrombocytopenia (3/51, 5.9%). No Grade 4 toxicity was reported. Nine patients (18%) presented with post-operative complications (during the 3 months after surgery). There were 6 locoregional relapses (11.8%) and distant metastasis occurred in 11 patients (21.6%). The 2-year cumulative locoregional relapse-free survival, metastasis-free survival and overall survival was 87%, 79% and 89%, respectively. CONCLUSION The proposed pre-operative HART with co-administration of 5FU had acceptable toxicity profile and provided satisfactory rate of ypCR. This created rationale to initiate a Phase III randomized study that was registered under ClinicalTrials.gov Identifier: NCT01814969. Advances in knowledge: The results of this research show that responders to pre-operative radiochemotherapy have favourable outcome. Tumour regression grade as prognostic clinical feature holds the promise of better classifying patients at high risk of local and systemic recurrence and this issue may be an interesting objective for future research.
Collapse
Affiliation(s)
- Adam Idasiak
- 1 Radiotherapy and Chemotherapy Clinic and Teaching Hospital, Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice, Poland
| | - Katarzyna Galwas-Kliber
- 1 Radiotherapy and Chemotherapy Clinic and Teaching Hospital, Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice, Poland
| | - Katarzyna Behrendt
- 1 Radiotherapy and Chemotherapy Clinic and Teaching Hospital, Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice, Poland
| | - Iwona Wziętek
- 2 Radiotherapy Department, Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice, Poland
| | - Mariusz Kryj
- 3 Department of Surgery, Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice, Poland
| | - Ewa Stobiecka
- 4 Department of Pathology, Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice, Poland
| | - Ewa Chmielik
- 4 Department of Pathology, Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice, Poland
| | - Rafał Suwiński
- 1 Radiotherapy and Chemotherapy Clinic and Teaching Hospital, Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice, Poland
| |
Collapse
|
19
|
An update on the multimodality of localized rectal cancer. Crit Rev Oncol Hematol 2016; 108:23-32. [PMID: 27931837 DOI: 10.1016/j.critrevonc.2016.10.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 07/12/2016] [Accepted: 10/12/2016] [Indexed: 12/15/2022] Open
Abstract
New strategies have reduced the local recurrence (LR) rate and extended the duration of overall survival (OS) in patients with localized rectal cancer (RC) in recent decades. The mainstay of curative treatment remains radical surgery; however, downsizing the tumor by neo-adjuvant chemo-radiotherapy and adjuvant cytotoxic therapy for systemic disease has shown significant additional benefit. The standardization of total mesorectal excision (TME), radiation treatment (RT) dose and fractionation, and optimal timing and sequencing of treatment modalities with the use of prolonged administration of fluoropyrimidine concurrent with RT have significantly decreased the rates of LR in locally advanced rectal cancer (LARC) patients. This review focuses on the optimization of multi-modality therapies in patients with localized RC.
Collapse
|
20
|
Bujko K, Wyrwicz L, Rutkowski A, Malinowska M, Pietrzak L, Kryński J, Michalski W, Olędzki J, Kuśnierz J, Zając L, Bednarczyk M, Szczepkowski M, Tarnowski W, Kosakowska E, Zwoliński J, Winiarek M, Wiśniowska K, Partycki M, Bęczkowska K, Polkowski W, Styliński R, Wierzbicki R, Bury P, Jankiewicz M, Paprota K, Lewicka M, Ciseł B, Skórzewska M, Mielko J, Bębenek M, Maciejczyk A, Kapturkiewicz B, Dybko A, Hajac Ł, Wojnar A, Leśniak T, Zygulska J, Jantner D, Chudyba E, Zegarski W, Las-Jankowska M, Jankowski M, Kołodziejski L, Radkowski A, Żelazowska-Omiotek U, Czeremszyńska B, Kępka L, Kolb-Sielecki J, Toczko Z, Fedorowicz Z, Dziki A, Danek A, Nawrocki G, Sopyło R, Markiewicz W, Kędzierawski P, Wydmański J. Long-course oxaliplatin-based preoperative chemoradiation versus 5 × 5 Gy and consolidation chemotherapy for cT4 or fixed cT3 rectal cancer: results of a randomized phase III study. Ann Oncol 2016; 27:834-42. [PMID: 26884592 DOI: 10.1093/annonc/mdw062] [Citation(s) in RCA: 271] [Impact Index Per Article: 33.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 02/08/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Improvements in local control are required when using preoperative chemoradiation for cT4 or advanced cT3 rectal cancer. There is therefore a need to explore more effective schedules. PATIENTS AND METHODS Patients with fixed cT3 or cT4 cancer were randomized either to 5 × 5 Gy and three cycles of FOLFOX4 (group A) or to 50.4 Gy in 28 fractions combined with two 5-day cycles of bolus 5-Fu 325 mg/m(2)/day and leucovorin 20 mg/m(2)/day during the first and fifth week of irradiation along with five infusions of oxaliplatin 50 mg/m(2) once weekly (group B). The protocol was amended in 2012 to allow oxaliplatin to be then foregone in both groups. RESULTS Of 541 entered patients, 515 were eligible for analysis; 261 in group A and 254 in group B. Preoperative treatment acute toxicity was lower in group A than group B, P = 0.006; any toxicity being, respectively, 75% versus 83%, grade III-IV 23% versus 21% and toxic deaths 1% versus 3%. R0 resection rates (primary end point) and pathological complete response rates in groups A and B were, respectively, 77% versus 71%, P = 0.07, and 16% versus 12%, P = 0.17. The median follow-up was 35 months. At 3 years, the rates of overall survival and disease-free survival in groups A and B were, respectively, 73% versus 65%, P = 0.046, and 53% versus 52%, P = 0.85, together with the cumulative incidence of local failure and distant metastases being, respectively, 22% versus 21%, P = 0.82, and 30% versus 27%, P = 0.26. Postoperative and late complications rates in group A and group B were, respectively, 29% versus 25%, P = 0.18, and 20% versus 22%, P = 0.54. CONCLUSIONS No differences were observed in local efficacy between 5 × 5 Gy with consolidation chemotherapy and long-course chemoradiation. Nevertheless, an improved overall survival and lower acute toxicity favours the 5 × 5 Gy schedule with consolidation chemotherapy. CLINICAL TRIAL NUMBER The trial is registered as ClinicalTrials.gov number NCT00833131.
Collapse
Affiliation(s)
| | - L Wyrwicz
- Department of Gastroenterological Oncology
| | | | | | | | - J Kryński
- Department of Gastroenterological Oncology
| | - W Michalski
- Department of Bioinformatics and Biostatistics Unit, M. Skłodowska-Curie Memorial Cancer Centre, Warsaw
| | - J Olędzki
- Department of Colorectal Surgery, Medical University, Warsaw
| | - J Kuśnierz
- Department of Gynecology, M. Skłodowska-Curie Memorial Cancer Centre, Warsaw
| | - L Zając
- Department of Gastroenterological Oncology
| | | | - M Szczepkowski
- Department of Rehabilitation, Jozef Piłsudski University of Physical Education, Warsaw Clinical Department of General and Colorectal Surgery, Bielański Hospital, Warsaw
| | - W Tarnowski
- Department of General, Oncologic and Digestive Tract Surgery, Medical Centre of Postgraduate Education, Orłowski Hospital, Warsaw
| | | | | | - M Winiarek
- Department of Gastroenterological Oncology
| | | | | | | | - W Polkowski
- Department of Surgical Oncology, Medical University of Lublin, Lublin
| | - R Styliński
- First Department of General Surgery, Transplantology and Nutritional Therapy, Medical University of Lublin, Lublin
| | | | - P Bury
- II Chair and Department of General and Gastrointestinal Surgery and Surgical Oncology of the Alimentary Tract, Medical University, Lublin
| | - M Jankiewicz
- Department of Surgical Oncology, Medical University of Lublin, Lublin Department of Radiotherapy, St John's Cancer Center, Lublin
| | - K Paprota
- Department of Radiotherapy, St John's Cancer Center, Lublin
| | - M Lewicka
- Department of Surgical Oncology, Medical University of Lublin, Lublin
| | - B Ciseł
- Department of Surgical Oncology, Medical University of Lublin, Lublin
| | - M Skórzewska
- Department of Surgical Oncology, Medical University of Lublin, Lublin
| | - J Mielko
- Department of Surgical Oncology, Medical University of Lublin, Lublin
| | | | | | | | | | | | - A Wojnar
- Pathology, Silesian Oncological Centre, Wroclaw
| | - T Leśniak
- Department of Surgery, Beskid Centre of Oncology, Bielsko-Biala
| | - J Zygulska
- Department of Radiotherapy, Beskid Centre of Oncology, Bielsko-Biala
| | - D Jantner
- Department of Surgery, Beskid Centre of Oncology, Bielsko-Biala
| | - E Chudyba
- Department of Radiotherapy, Beskid Centre of Oncology, Bielsko-Biala
| | - W Zegarski
- Department of Oncological Surgery, Collegium Medicum Nicolaus Copernicus University and Oncology Centre, Bydgoszcz
| | - M Las-Jankowska
- Department of Oncological Surgery, Collegium Medicum Nicolaus Copernicus University and Oncology Centre, Bydgoszcz
| | - M Jankowski
- Department of Oncological Surgery, Collegium Medicum Nicolaus Copernicus University and Oncology Centre, Bydgoszcz
| | | | - A Radkowski
- Department of Radiotherapy, Regional Cancer Centre, Tarnów
| | | | - B Czeremszyńska
- Department Radiotherapy, Independent Public Health Care Facility of the Ministry of the Interior and Warmian-Masurian Oncology Centre, Olsztyn
| | - L Kępka
- Department Radiotherapy, Independent Public Health Care Facility of the Ministry of the Interior and Warmian-Masurian Oncology Centre, Olsztyn
| | - J Kolb-Sielecki
- Department Radiotherapy, Independent Public Health Care Facility of the Ministry of the Interior and Warmian-Masurian Oncology Centre, Olsztyn
| | - Z Toczko
- Department of Surgery, Regional Hospital, Elbląg
| | - Z Fedorowicz
- Department of Surgery, Regional Hospital, Elbląg
| | - A Dziki
- Department of Surgery, Medical University, Lódź
| | | | - G Nawrocki
- Department of Surgery, M. Skłodowska-Curie Memorial Cancer Centre, Warsaw
| | - R Sopyło
- Department of Surgery, M. Skłodowska-Curie Memorial Cancer Centre, Warsaw
| | - W Markiewicz
- Department of Surgery, Regional Cancer Centre, Białystok
| | - P Kędzierawski
- Department of Radiotherapy, Regional Oncological Centre, Kielce
| | - J Wydmański
- Department of Radiotherapy, M. Skłodowska-Curie Memorial Cancer Centre, Gliwice, Poland
| | | |
Collapse
|
21
|
Russo S, Steele S, Fredman E, Biswas T. Current topics in the multimodality treatment of locally advanced rectal cancer. Future Oncol 2016; 12:963-79. [PMID: 26880222 DOI: 10.2217/fon.16.12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The multimodality approach to the treatment of locally advanced rectal cancer has evolved to include neoadjuvant radiotherapy with or without concurrent chemotherapy, total mesorectal excision and adjuvant fluoropyrimidine-based chemotherapy. Though this broad strategy has yielded improvements in local control compared with historical data, overall survival remains largely unchanged. Current investigations focus on improving patient selection through new imaging modalities, improving surgical techniques, incorporating more aggressive systemic treatment regimens and the selective use of radiation. Here, we review emerging data regarding newer staging techniques, neoadjuvant chemotherapy, optimal timing of surgery, selective use of radiation and nonoperative approaches to the management of locally advanced rectal cancers.
Collapse
Affiliation(s)
- Suzanne Russo
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH, USA
| | - Scott Steele
- Department of Surgery, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH, USA
| | - Elisha Fredman
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH, USA
| | - Tithi Biswas
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH, USA
| |
Collapse
|
22
|
Milinis K, Thornton M, Montazeri A, Rooney PS. Adjuvant chemotherapy for rectal cancer: Is it needed? World J Clin Oncol 2015; 6:225-236. [PMID: 26677436 PMCID: PMC4675908 DOI: 10.5306/wjco.v6.i6.225] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 08/01/2015] [Accepted: 09/08/2015] [Indexed: 02/06/2023] Open
Abstract
Adjuvant chemotherapy has become a standard treatment of advanced rectal cancer in the West. The benefits of adjuvant chemotherapy after surgery alone have been well established. However, controversy surrounds the use adjuvant chemotherapy in patients who received preoperative chemoradiotherapy, despite it being recommended by a number of international guidelines. Results of recent multicentre randomised control trials showed no benefit of adjuvant chemotherapy in terms of survival and rates of distant metastases. However, concerns exist regarding the quality of the studies including inadequate staging modalities, out-dated chemotherapeutic regimens and surgical approaches and small sample sizes. It has become evident that not all the patients respond to adjuvant chemotherapy and more personalised approach should be employed when considering the benefits of adjuvant chemotherapy. The present review discusses the strengths and weaknesses of the current evidence-base and suggests improvements for future studies.
Collapse
|
23
|
Bergsland EK. Is more not better?: combination therapies in colorectal cancer treatment. Hematol Oncol Clin North Am 2015; 29:85-116. [PMID: 25475574 DOI: 10.1016/j.hoc.2014.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The treatment of colorectal cancer has evolved dramatically in recent years with the availability of new chemotherapeutic agents and inhibitors of the vascular endothelial growth factor- and epidermal growth factor-signaling pathways. The incremental benefit of each individual line of therapy for advanced disease is relatively small. Advances in our ability to select patients should improve the cost-effectiveness of our treatment strategies (avoiding unnecessary toxicity in the patients who are unlikely to benefit and accepting the potential for adverse events in the patients who stand to benefit the most from a given regimen).
Collapse
Affiliation(s)
- Emily K Bergsland
- Department of Medicine, Division of Hematology and Oncology, UCSF Helen Diller Family Comprehensive Cancer Center, 1600 Divisadero Street, A727, San Francisco, CA 94115, USA.
| |
Collapse
|
24
|
Valdivieso M, Corn BW, Dancey JE, Wickerham DL, Horvath LE, Perez EA, Urton A, Cronin WM, Field E, Lackey E, Blanke CD. The Globalization of Cooperative Groups. Semin Oncol 2015; 42:693-712. [PMID: 26433551 DOI: 10.1053/j.seminoncol.2015.07.003] [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: 12/18/2022]
Abstract
The National Cancer Institute (NCI)-supported adult cooperative oncology research groups (now officially Network groups) have a longstanding history of participating in international collaborations throughout the world. Most frequently, the US-based cooperative groups work reciprocally with the Canadian national adult cancer clinical trial group, NCIC CTG (previously the National Cancer Institute of Canada Clinical Trials Group). Thus, Canada is the largest contributor to cooperative groups based in the United States, and vice versa. Although international collaborations have many benefits, they are most frequently utilized to enhance patient accrual to large phase III trials originating in the United States or Canada. Within the cooperative group setting, adequate attention has not been given to the study of cancers that are unique to countries outside the United States and Canada, such as those frequently associated with infections in Latin America, Asia, and Africa. Global collaborations are limited by a number of barriers, some of which are unique to the countries involved, while others are related to financial support and to US policies that restrict drug distribution outside the United States. This article serves to detail the cooperative group experience in international research and describe how international collaboration in cancer clinical trials is a promising and important area that requires greater consideration in the future.
Collapse
Affiliation(s)
- Manuel Valdivieso
- Division of Hematology/Oncology, University of Michigan; and SWOG, Executive Officer, Quality Assurance and International Initiatives, Ann Arbor, MI.
| | - Benjamin W Corn
- Institute of Radiotherapy, Tel Aviv Medical Center, Tel Aviv, Israel; and Department of Radiation Oncology, Jefferson Medical College, Philadelphia, PA
| | - Janet E Dancey
- Director, NCIC Clinical Trials Group; Scientific Director Canadian Cancer Clinical Trials Network; Program Leader, High Impact Clinical Trials, Ontario Institute for Cancer Research; Professor of Oncology, Queen's University, Kingston, Ontario, Canada
| | - D Lawrence Wickerham
- Deputy Chairman, NRG Oncology, Pittsburgh, PA; Department of Human Oncology, Pittsburgh Campus, Drexel University School of Medicine; Allegheny Cancer Center at Allegheny General Hospital, Pittsburgh, PA
| | - L Elise Horvath
- Executive Officer, Alliance for Clinical Trials in Oncology, Chicago, IL
| | - Edith A Perez
- Deputy Director at Large, Mayo Clinic Cancer Center; Group Vice Chair, Alliance for Clinical Trials in Oncology; Hematology/Oncology and Cancer Biology Mayo Clinic, Jacksonville, FL
| | - Alison Urton
- Group Administrator, NCIC Clinical Trials Group, Queen's University, Kingston, Ontario, Canada
| | - Walter M Cronin
- Associate Director, NRG Oncology Statistics and Data Management Center (SDMC); Associate Director, Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | - Erica Field
- Project Specialist III, RTOG, Philadelphia, PA
| | - Evonne Lackey
- Coordinating Center Manager, SWOG Statistical Center, Seattle, WA
| | - Charles D Blanke
- Chair, SWOG; Department of Medicine, Division of Hematology and Medical Oncology, Oregon Health & Science University and Knight Cancer Institute, Portland, OR
| |
Collapse
|
25
|
Smith JJ, Garcia-Aguilar J. Advances and challenges in treatment of locally advanced rectal cancer. J Clin Oncol 2015; 33:1797-808. [PMID: 25918296 DOI: 10.1200/jco.2014.60.1054] [Citation(s) in RCA: 129] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Dramatic improvements in the outcomes of patients with rectal cancer have occurred over the past 30 years. Advances in surgical pathology, refinements in surgical techniques and instrumentation, new imaging modalities, and the widespread use of neoadjuvant therapy have all contributed to these improvements. Several questions emerge as we learn of the benefits or lack thereof for components of the current multimodality treatment in subgroups of patients with nonmetastatic locally advanced rectal cancer (LARC). What is the optimal surgical technique for distal rectal cancers? Do all patients need postoperative chemotherapy? Do all patients need radiation? Do all patients need surgery, or is a nonoperative, organ-preserving approach warranted in selected patients? Answering these questions will lead to more precise treatment regimens, based on patient and tumor characteristics, that will improve outcomes while preserving quality of life. However, the idea of shifting the treatment paradigm (chemoradiotherapy, total mesorectal excision, and adjuvant therapy) currently applied to all patients with LARC to a more individually tailored approach is controversial. The paradigm shift toward organ preservation in highly selected patients whose tumors demonstrate clinical complete response to neoadjuvant treatment is also controversial. Herein, we highlight many of the advances and resultant controversies that are likely to dominate the research agenda for LARC in the modern era.
Collapse
|
26
|
Onyeuku NE, Ayala-Peacock DN, Russo SM, Blackstock AW. The multidisciplinary approach to the treatment of rectal cancer: 2015 update. Expert Rev Gastroenterol Hepatol 2015; 9:507-17. [PMID: 25431898 DOI: 10.1586/17474124.2015.987753] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The multidisciplinary approach to the management of rectal cancer continues to evolve with developments in surgery, radiation therapy as well as systemic chemotherapy. Refinement of surgical techniques to improve organ preservation, selective use of neoadjuvant (or adjuvant) therapies, improvements in staging modalities and emerging criteria for the selection of tailored therapies are some of the advancements made over the last three decades. In addition, neoadjuvant treatment alternatives, multimodality sequencing and adaptive therapies based on treatment response continue to be a subject of clinical investigation. The current article reviews the salient topics related to the multidisciplinary treatment of resectable rectal cancer.
Collapse
Affiliation(s)
- Nasarachi E Onyeuku
- Comprehensive Cancer Center of Wake Forest University, Winston-Salem, NC, USA
| | | | | | | |
Collapse
|
27
|
Fazeli MS, Keramati MR. Rectal cancer: a review. Med J Islam Repub Iran 2015; 29:171. [PMID: 26034724 PMCID: PMC4431429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 12/24/2014] [Indexed: 11/22/2022] Open
Abstract
Rectal cancer is the second most common cancer in large intestine. The prevalence and the number of young patients diagnosed with rectal cancer have made it as one of the major health problems in the world. With regard to the improved access to and use of modern screening tools, a number of new cases are diagnosed each year. Considering the location of the rectum and its adjacent organs, management and treatment of rectal tumor is different from tumors located in other parts of the gastrointestinal tract or even the colon. In this article, we will review the current updates on rectal cancer including epidemiology, risk factors, clinical presentations, screening, and staging. Diagnostic methods and latest treatment modalities and approaches will also be discussed in detail.
Collapse
Affiliation(s)
- Mohammad Sadegh Fazeli
- 1 Associate Professor of Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.
| | - Mohammad Reza Keramati
- 2 Assistant Professor of Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.
| |
Collapse
|
28
|
Chronomodulated capecitabine and adjuvant radiation in intermediate-risk to high-risk rectal cancer: a phase II study. Am J Clin Oncol 2015; 37:545-9. [PMID: 23428953 DOI: 10.1097/coc.0b013e31827ecd1d] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the feasibility and tolerability of capecitabine administration according to a specific time schedule, combined with adjuvant radiation therapy, in intermediate-risk to high-risk rectal cancer patients treated with an upfront surgery. The primary endpoint was the rate of grade 3 to 4 diarrhea during chemoradiation (CRT). MATERIALS AND METHODS Stage II and III rectal cancer patients received, after total mesorectal excision, 2 cycles of XELOX regimen (oxaliplatin 130 mg/m(2) on day 1; capecitabine 1000 mg/m(2) bid on day 1 to 14, q21), followed by capecitabine (800 mg/m(2) bid daily; 20% dose at 12:00 AM and 80% dose at 12:00 PM) administered continuously during pelvic radiation (total 50.4 Gy in 28 fractions, 1.8 Gy daily dose between 2:00 and 4:00 PM). Four additional cycles of XELOX were administered after chemoradiotherapy. RESULTS Fifty-one radically resected rectal cancer patients were enrolled. All, but one, cases were evaluated for safety of CRT. We reported a grade 3 and 4 diarrhea rate of 14% (7 of 50 patients), whereas no grade 3 and 4 leukopenia was observed. Grade 1 and 2 proctitis was observed in 26 (52%) cases, whereas grade 1 and 2 cystitis in 5 (10%) patients. Only 2 cases of grade 3 proctitis and cystitis were reported, respectively. The CRT phase was feasible and was completed by 43 (84%) patients. Three patients developed actinic enteritis 60 days after the end of the radiotherapy program. CONCLUSIONS Capecitabine timetable administration combined with adjuvant radiation therapy of rectal cancer is well tolerated and feasible. Further investigation of this chronomodulated schedule in terms of efficacy is warranted in neoadjuvant setting.
Collapse
|
29
|
Bohanes P, Rankin CJ, Blanke CD, Winder T, Ulrich CM, Smalley SR, Rich TA, Martensen JA, Benson AB, Mayer RJ, Cripps CM, Danenberg K, Makar KW, Zhang W, Benedetti JK, Lenz HJ. Pharmacogenetic Analysis of INT 0144 Trial: Association of Polymorphisms with Survival and Toxicity in Rectal Cancer Patients Treated with 5-FU and Radiation. Clin Cancer Res 2015; 21:1583-90. [PMID: 25589620 DOI: 10.1158/1078-0432.ccr-14-0857] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Accepted: 12/12/2014] [Indexed: 12/16/2022]
Abstract
PURPOSE We tested whether 18 polymorphisms in 16 genes (GSTP1, COX2, IL10, EGFR, EGF, FGFR4, CCDN1, VEGFR2, VEGF, CXCR2, IL8, MMP3, ICAM1, ERCC1, RAD51, and XRCC3) would predict disease-free survival (DFS), overall survival (OS), and toxicity in the INT0144 trial, which was designed to investigate different postoperative regimens of 5-fluorouracil (5-FU)-based chemoradiation (CRT) in locally advanced rectal cancers: Arm 1 consisted of bolus 5-FU followed by 5-FU protracted venous infusion (PVI) with radiotherapy; arm 2 was induction and concomitant PVI 5-FU with radiotherapy and arm 3 was induction and concomitant bolus 5-FU with radiotherapy. EXPERIMENTAL DESIGN DNA from 746 stage II/III rectal patients enrolled in the Southwest Oncology Group (SWOG) S9304 phase III trial was analyzed. Genomic DNA was extracted from formalin-fixed, paraffin-embedded (FFPE) tumor tissue. The polymorphisms were analyzed using direct DNA-sequencing or polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). RESULTS GSTP1-Ile105Val (rs1695) was significantly associated with DFS and OS and its effect did not vary by treatment arm. The five-year DFS and OS were 53% and 58%, respectively, for G/G, 66% and 72% for G/A, and 57% and 66% for A/A patients. In arm 2, IL8-251A/A genotype (rs4073) was associated with a lower risk of toxicities (P = 0.04). The VEGFR2 H472Q Q/Q genotype (rs1870377) was associated with a higher risk of grade 3-5 proximal upper gastrointestinal tract (PUGIT) mucositis (P = 0.04) in arm 2. However, in arm 1, this genotype was associated with a lower risk of PUGIT mucositis (P = 0.004). CONCLUSION rs1695 may be prognostic in patients with rectal cancer treated with adjuvant CRT. rs4073 and rs1870377 may exhibit different associations with toxicity, according to the 5-FU schedule.
Collapse
Affiliation(s)
- Pierre Bohanes
- University of Southern California/Norris Comprehensive Cancer Center, Los Angeles, California
| | | | - Charles D Blanke
- SWOG Group Chair's Office/Oregon Health & Science University, Portland, Oregon
| | - Thomas Winder
- University of Southern California/Norris Comprehensive Cancer Center, Los Angeles, California
| | - Cornelia M Ulrich
- University of Washington and Fred Hutchinson Cancer Research Center, Seattle, Washington; and Division of Preventive Oncology at the National Center of Tumor Diseases, Heidelberg, Germany
| | | | - Tyvin A Rich
- University of Virginia Health System, Charlottesville, Virginia
| | | | | | | | | | | | - Karen W Makar
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Wu Zhang
- University of Southern California/Norris Comprehensive Cancer Center, Los Angeles, California
| | | | - Heinz-Josef Lenz
- University of Southern California/Norris Comprehensive Cancer Center, Los Angeles, California.
| |
Collapse
|
30
|
Ulrich CM, Rankin C, Toriola AT, Makar KW, Altug-Teber Ö, Benedetti JK, Holmes RS, Smalley SR, Blanke CD, Lenz HJ. Polymorphisms in folate-metabolizing enzymes and response to 5-fluorouracil among patients with stage II or III rectal cancer (INT-0144; SWOG 9304). Cancer 2014; 120:3329-3337. [PMID: 25041994 PMCID: PMC4259283 DOI: 10.1002/cncr.28830] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 04/08/2014] [Accepted: 04/11/2014] [Indexed: 01/03/2023]
Abstract
BACKGROUND Recurrence and toxicity occur commonly among patients with rectal cancer who are treated with 5-fluorouracil (5-FU). The authors hypothesized that genetic variation in folate-metabolizing genes could play a role in interindividual variability. The objective of the current study was to evaluate the associations between genetic variants in folate-metabolizing genes and clinical outcomes among patients with rectal cancer treated with 5-FU. METHODS The authors investigated 8 functionally significant polymorphisms in 6 genes (methylenetetrahydrofolate reductase [MTHFR] [C677T, A1298C], SLC19A1 [G80A], SHMT1 [C1420T], dihydrofolate reductase [DHFR] [Del19bp], TS 1494del,and TSER) involved in folate metabolism in 745 patients with TNM stage II or III rectal cancer enrolled in a phase 3 adjuvant clinical trial of 3 regimens of 5-FU and radiotherapy (INT-0144 and SWOG 9304). RESULTS There were no statistically significant associations noted between polymorphisms in any of the genes and overall survival, disease-free survival (DFS), and toxicity in the overall analyses. Nevertheless, there was a trend toward worse DFS among patients with the variant allele of MTHFR C677T compared with wild-type, particularly in treatment arm 2, in which patients with the MTHFR C677T TT genotype had worse overall survival (hazards ratio, 1.76; 95% confidence interval, 1.06-2.93 [P = .03]) and DFS (hazards ratio, 1.84; 95% confidence interval, 1.12-3.03 [P = .02]) compared with those with homozygous wild-type. In addition, there was a trend toward reduced hematological toxicity among patients with variants of SLC19A1 G80A in treatment arm 1 (P for trend, .06) and reduced esophagitis/stomatitis noted among patients with variants of TSER in treatment arm 3 (P for trend, .06). CONCLUSIONS Genetic variability in folate-metabolizing enzymes was found to be associated only to a limited degree with clinical outcomes among patients with rectal cancer treated with 5-FU.
Collapse
Affiliation(s)
- Cornelia M Ulrich
- Division of Preventive Oncology, National Center for Tumor Diseases, Heidelberg, Germany
- German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research (DKTK), Heidelberg, Germany
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Cathryn Rankin
- Southwest Oncology Group Statistical Center, Seattle, WA
| | - Adetunji T Toriola
- Department of Surgery, Division of Public Health Sciences and Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO
| | - Karen W Makar
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Özge Altug-Teber
- Division of Preventive Oncology, National Center for Tumor Diseases, Heidelberg, Germany
- German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research (DKTK), Heidelberg, Germany
| | | | | | | | | | | |
Collapse
|
31
|
Fung-Kee-Fung SD. Therapeutic approaches in the management of locally advanced rectal cancer. J Gastrointest Oncol 2014; 5:353-61. [PMID: 25276408 DOI: 10.3978/j.issn.2078-6891.2014.067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 08/11/2014] [Indexed: 12/18/2022] Open
Abstract
Combined-modality therapy, using radiotherapy and chemotherapy with surgery, has been the traditional therapeutic algorithm for locally advanced rectal cancer. Standard of care in the United States has evolved to include neoadjuvant concurrent chemotherapy and radiotherapy followed by surgical excision and adjuvant chemotherapy. This approach has led to a significant improvement in local recurrences (LR), to the point where distant sites are the more common site of failure. Further improvements in local control have failed to improve overall survival. This article reviews historical trials that shifted the treatment paradigm to the current standard of care, as well as recent research trials, which have sought to incorporate new treatment methodologies, and treatment agents to improve outcomes. Finally this article describes ongoing studies and their potential impact on the future of therapeutic management of locally-advanced rectal cancer.
Collapse
|
32
|
Kye BH, Cho HM. Overview of radiation therapy for treating rectal cancer. Ann Coloproctol 2014; 30:165-74. [PMID: 25210685 PMCID: PMC4155135 DOI: 10.3393/ac.2014.30.4.165] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2014] [Accepted: 07/23/2014] [Indexed: 12/13/2022] Open
Abstract
A major outcome of importance for rectal cancer is local control. Parallel to improvements in surgical technique, adjuvant therapy regimens have been tested in clinical trials in an effort to reduce the local recurrence rate. Nowadays, the local recurrence rate has been reduced because of both good surgical techniques and the addition of radiotherapy. Based on recent reports in the literature, preoperative chemoradiotherapy is now considered the standard of care for patients with stages II and III rectal cancer. Also, short-course radiotherapy appears to provide effective local control and the same overall survival as more long-course chemoradiotherapy schedules and, therefore, may be an appropriate choice in some situations. Capecitabine is an acceptable alternative to infusion fluorouracil in those patients who are able to manage the responsibilities inherent in self-administered, oral chemotherapy. However, concurrent administration of oxaliplatin and radiotherapy is not recommended at this time. Radiation therapy has long been considered an important adjunct in the treatment of rectal cancer. Although no prospective data exist for several issues, we hope that in the near future, patients with rectal cancer can be treated by using the best combination of surgery, radiation therapy, and chemotherapy in near future.
Collapse
Affiliation(s)
- Bong-Hyeon Kye
- Department of Surgery, St. Vincent Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea
| | - Hyeon-Min Cho
- Department of Surgery, St. Vincent Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea
| |
Collapse
|
33
|
Predictors of recurrence free survival for patients with stage II and III colon cancer. BMC Cancer 2014; 14:336. [PMID: 24886281 PMCID: PMC4029910 DOI: 10.1186/1471-2407-14-336] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Accepted: 05/09/2014] [Indexed: 12/15/2022] Open
Abstract
Background The aim of this study was to evaluate clinico-pathologic specific predictors of recurrence for stage II/III disease. Improving recurrence prediction for resected stage II/III colon cancer patients could alter surveillance strategies, providing opportunities for more informed use of chemotherapy for high risk individuals. Methods 871 stage II and 265 stage III patients with colon cancers were included. Features studied included surgery date, age, gender, chemotherapy, tumor location, number of positive lymph nodes, tumor differentiation, and lymphovascular and perineural invasion. Time to recurrence was evaluated, using Cox’s proportional hazards models. The predictive ability of the multivariable models was evaluated using the concordance (c) index. Results For stage II cancer patients, estimated recurrence-free survival rates at one, three, five, and seven years following surgery were 98%, 92%, 90%, and 89%. Only T stage was significantly associated with recurrence. Estimated recurrence-free survival rates for stage III patients at one, three, five, and seven years following surgery were 94%, 78%, 70%, and 66%. Higher recurrence rates were seen in patients who didn’t receive chemotherapy (p = 0.023), with a higher number of positive nodes (p < 0.001). The c-index for the stage II model was 0.55 and 0.68 for stage III. Conclusions Current clinic-pathologic information is inadequate for prediction of colon cancer recurrence after resection for stage II and IIII patients. Identification and clinical use of molecular markers to identify the earlier stage II and III colon cancer patients at elevated risk of recurrence are needed to improve prognostication of early stage colon cancers.
Collapse
|
34
|
Kim H, Chie EK, Ahn YC, Kim K, Park W, Yoon WS, Huh SJ, Ha SW. Impact on Loco-regional Control of Radiochemotherapeutic Sequence and Time to Initiation of Adjuvant Treatment in Stage II/III Rectal Cancer Patients Treated with Postoperative Concurrent Radiochemotherapy. Cancer Res Treat 2014; 46:148-57. [PMID: 24851106 PMCID: PMC4022823 DOI: 10.4143/crt.2014.46.2.148] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 06/20/2013] [Indexed: 12/27/2022] Open
Abstract
Purpose This study was designed to evaluate the impact of radiochemotherapeutic sequence and time to initiation of adjuvant treatment on loco-regional control for resected stage II and III rectal cancer. Materials and Methods Treatment outcomes for rectal cancer patients from two hospitals with different sequencing strategies regarding adjuvant concurrent radiochemotherapy (CRCT) were compared retrospectively. Pelvic radiotherapy was administered concurrently on the first (early CRCT, n=180) or the third cycle of chemotherapy (late CRCT, n=180). During radiotherapy, two cycles of fluorouracil were provided to patients in both groups. In the early CRCT group, median six cycles of fluorouracil and leucovorin were prescribed during the post-CRCT period. In the late CRCT group, two cycles of fluorouracil were administered in the pre- and post-CRCT periods. Results No significant differences in the 5-year loco-regional recurrence-free survival (LRRFS) (92.5% vs. 95.6%, p=0.43) or overall survival and disease-free survival were observed between groups. Patients who began receiving adjuvant treatment later than five weeks after surgery had lower LRRFS than patients who received adjuvant treatment within five weeks following surgery (79% vs. 91%, p<0.01). The risk of loco-regional recurrence increased as the time to initiation of adjuvant treatment was delayed. Conclusion In the current study, treatment outcomes were not significantly influenced by the sequence of adjuvant treatment but by the delay of adjuvant treatment for more than five weeks. Timely administration of adjuvant treatment is deemed important in achieving loco-regional tumor control for stage II/III rectal cancer patients.
Collapse
Affiliation(s)
- Haeyoung Kim
- Department of Radiation Oncology, Hallym University Dongtan Sacred Heart Hospital, Hwasung, Korea
| | - Eui Kyu Chie
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
| | - Yong Chan Ahn
- Department of Radiation Oncology, Samsung Comprehensive Cancer Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyubo Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
| | - Won Park
- Department of Radiation Oncology, Samsung Comprehensive Cancer Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Won Sup Yoon
- Department of Radiation Oncology, Korea University Ansan Hospital, Ansan, Korea
| | - Seung Jae Huh
- Department of Radiation Oncology, Samsung Comprehensive Cancer Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung W Ha
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
35
|
Yoney A, Isikli L. Preoperative chemoradiation in locally advanced rectal cancer: a comparison of bolus 5-fluorouracil/leucovorin and capecitabine. Saudi J Gastroenterol 2014; 20:102-7. [PMID: 24705147 PMCID: PMC3987149 DOI: 10.4103/1319-3767.129474] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
PURPOSE To compare the acute toxicities, pathologic response, surgical margins, downstaging, local control, disease-free survival (DFS), and overall survival (OS) in locally advanced rectal cancer patients with preoperative radiotherapy (RT) with either concurrent bolus 5-fluorouracil (5-FU)/leucovorin (LV) or capecitabine (CA). MATERIALS AND METHODS Sixty patients who presented to our department with a diagnosis of locally advanced rectal cancer were treated with surgery following preoperative RT with either concurrent 5-FU/LV or CA between January 2008 and December 2011 were analyzed. RESULTS Median follow-up period was 38 months (range 3-61). Four patients (6.7%) had grade 3 gastrointestinal (GIS) toxicity during the course of chemoradiotherapy. The pathologic complete response rates were 8% with 5-FU/LV and 8.6% with CA (P = 0.844). Also, 60% of the patients treated with 5-FU/LV and 37.1% with CA had downstaging of the T stage after chemoradiotherapy (P = 0.026). The 5-year local control (P = 0.510), distant control (P = 0.721), DFS (P = 0.08), and OS (P = 0.09) rates were 80%, 80%, 59.4%, and 64.4%, respectively, for patients treated with 5-FU/LV and 85.7%, 82.9%, 74.8%, and 75.1%, respectively, for patients treated with CA. CONCLUSION No significant differences were seen in the local control and distant recurrences and the survival among patients treated with pre-op RT and concurrent 5-FU/LV compared with those treated with pre-op RT and concurrent CA, except toxicities.
Collapse
Affiliation(s)
- Adnan Yoney
- Department of Radiation Oncology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey,Address for correspondence: Dr. Adnan Yoney, Department of Radiation Oncology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey. E-mail:
| | - Levent Isikli
- Okmeydani Training and Research Hospital, Istanbul, Turkey
| |
Collapse
|
36
|
Nelamangala Ramakrishnaiah VP, Thomas CT, Sundar E, Reddy KS, Krishnamachari S. Preoperative radiotherapy in carcinoma rectum. Indian J Surg Oncol 2013; 3:302-7. [PMID: 24293967 DOI: 10.1007/s13193-012-0181-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Accepted: 07/31/2012] [Indexed: 10/28/2022] Open
Abstract
The present study was undertaken to address the various concerns that has limited the use of preoperative radiotherapy in rectal cancer in our institution. All patients diagnosed as having carcinoma rectum between August 2005 and July 2007 were included in the study. Group 1 patients consisted of those presenting with T2, T3 and T4 who received preoperative radiation of 25 Gy. Group 2 consisted of those with T4 tumours, who received Long course radiotherapy. Complication of radiation like dermatitis, enteritis and proctitis were noted. Before surgery CT scan and TRUS were repeated. In the postoperative period a record of abdominal, perineal wound complications and other complications were noted. The results were compared with a similar group of patients who did not receive preoperative radiotherapy. There were 21 patients (12males) with a mean age of 48.4 years (Range 18-70) in the radiotherapy group. Sixteen patients received short course (25 Gy) and five patients received long course of preoperative radiotherapy. Fourteen patients underwent definitive surgery in the form of abdominoperineal resection (APR) or anterior resection (AR). In the non-RT group there were 17 patients (8 males) with a mean age of 50.2 year. Fourteen patients underwent definitive surgery like APR (11) and AR (3). In the RT group CT scan and TRUS failed show any significant downsizing or down staging of tumour. In the RT group, incidence of acute skin toxicity was 23.8 % (5/21), all were seen in those who received long course of radiotherapy (Group 2). Grade 2 or 3 lower G I symptoms occurred in 3 (18.6 %) patients of Group 1 and 1(20 %) patient of group 2. There was higher incidence of perineal wound complication in the RT group (19.0 % vs 5.9 %). Preoperative long course of radiotherapy may be associated with high rates of dermatitis and perineal wound infection. Short course may be associated with lower G I toxicity.
Collapse
|
37
|
Díaz Beveridge R, Aparicio J, Tormo A, Estevan R, Artes J, Giménez A, Segura Á, Roldán S, Palasí R, Ramos D. Long-term results with oral fluoropyrimidines and oxaliplatin-based preoperative chemoradiotherapy in patients with resectable rectal cancer. A single-institution experience. Clin Transl Oncol 2013; 14:471-80. [PMID: 22634537 DOI: 10.1007/s12094-012-0826-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Neoadjuvant 5-FU-based chemoradiotherapy in resectable rectal cancer (RC) is a standard of treatment. The use of oral fluoropyrimidines and new agents such as oxaliplatin may improve efficacy and tolerance. MATERIAL AND METHODS Between 1999 and 2009, 126 RC patients with T3-T4 and/or N+ disease were given three successive protocols: UFT (32), UFT-oxaliplatin (75) and capecitabine-oxaliplatin (19), alongside 45 Gy of radiotherapy; with surgery 4-6 weeks after. Adjuvant treatment was given in all patients. The primary objective was pathologic complete response (pCR). RESULTS Preoperative therapy was well tolerated, with no toxic deaths and a 15% grade 3-4 toxicity rate. Eighty-five percent of patients received the full chemotherapy dose, 56% had an abdominoperineal resection, 6% reinterventions and 57% received the full adjuvant chemotherapy planned. The pCR rate was 13%. The downstaging rate was 80%; 8% had progression of disease. The relapse rate was 20%, with local relapse in 6%. By 5 years of followup, 92% of relapses had occurred. Median follow-up was 73 months, 5- and 10-year disease-free survival rates were 75% and 50%, and 5- and 10-year overall survival rates were 79% and 66% respectively. There was no benefit from the use of oxaliplatin regarding survival or pCR rates. Older patients had worse long-term outcomes. CONCLUSIONS Neoadjuvant chemoradiotherapy with oral fluoropyrimidines and oxaliplatin is feasible and well tolerated. The risk of early progression is low. However, there was no added benefit with the use of oxaliplatin. There were no relapses in patients with pCR. The role of adjuvant chemotherapy is unclear.
Collapse
Affiliation(s)
- Robert Díaz Beveridge
- Medical Oncology Department, University Hospital La Fe, C/ Bulevar Sur, s/n, ES-46026 Valencia, Spain.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Pusceddu C, Sotgia B, Melis L, Fele RM, Meloni GB. Painful pelvic recurrence of rectal cancer: percutaneous radiofrequency ablation treatment. ACTA ACUST UNITED AC 2013; 38:1225-33. [PMID: 23736888 DOI: 10.1007/s00261-013-0012-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
PURPOSE To retrospectively evaluate the feasibility and efficacy of computed tomography (CT)-guided radiofrequency thermal ablation (RFA) in reducing the pain in patients with painful pelvic recurrence of rectal cancer ineligible for surgical resection. MATERIAL AND METHODS Twelve consecutive patients (10 men and 2 women; mean age 67 ± 10 years) with painful pelvic recurrence of rectal cancer underwent CT-guided RFA treatments under conscious sedation. At baseline, in all patients pelvic-sacral pain was classified as severe by Visual Analog Scale (VAS; VAS score ≥75 mm). The tumor density and carcinoembryionic antigen (CEA) serum level averages were 46 ± 7 HU and 15.7 ± 9.3 ng/mL, respectively. Clinical outcome was evaluated by VAS with a mean follow-up period of 23 months. RESULTS All RFA sessions were completed and well tolerated. Morbidity consisted of recto-vesical fistula (8 %) and rectal abscess (8 %). 1 month after RFA procedure, complete lack of enhancement was obtained in 7 cases (58 %). A significant difference in HU and CEA serum level averages between baseline and 1 month post-RFA was revealed (p < 0.000 and p < 0.002, respectively). A significant reduction in pain was obtained: VAS score was significantly different between baseline and the clinical evaluations at week 1 and month 3, 6, 12, and 22) (p < 0.000). At the end of follow-up, 11 patients (92 %) were symptom free. CONCLUSIONS CT-guided RFA of painful pelvic recurrence of rectal cancer can be considered as a feasible and effective treatment for reducing the pain in selected cases.
Collapse
Affiliation(s)
- Claudio Pusceddu
- Division of Interventional Radiology, Department of Oncologic Radiology, Businco Hospital, Regional Referral Center for Oncologic Disease, 09100, Cagliari, Italy,
| | | | | | | | | |
Collapse
|
39
|
Fu KI, Konuma H, Ueyama H, Saga T. Invasive rectal cancer treated with a combination of endoscopic submucosal dissection and chemoradiation. Dig Endosc 2013; 25 Suppl 2:37-40. [PMID: 23617647 DOI: 10.1111/den.12095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Accepted: 02/15/2013] [Indexed: 02/08/2023]
Abstract
A 68-year-old man underwent total colonoscopy because of a positive fecal occult blood test. A polypoid lesion (Is + IIa), 20 mm in size, was detected in the very lower part of the rectum. A large reddish nodule suggesting invasive carcinoma was seen on conventional view. Magnifying chromoendoscopy, however, disclosed a non-invasive pit pattern in that part. Moreover, magnifying narrow band imaging showed a type IIIA capillary pattern. Therefore, endoscopic submucosal dissection was successfully conducted for en bloc resection. Histologically, it was a rectal submucosal invasive carcinoma deeply invading into the submucosal layer with vascular invasion. Although additional surgical treatment was suggested, the patient refused the proposal and received chemoradiation therapy to avoid a permanent colostomy. Periodic evaluation revealed no local or distant metastasis 3 years thereafter.
Collapse
Affiliation(s)
- Kuang I Fu
- Department of Gastroenterology, Juntendo University Nerima Hospital, Tokyo, Japan.
| | | | | | | |
Collapse
|
40
|
Pagliuca MDG, Turri L, Munoz F, Melano A, Bacigalupo A, Franzone P, Sciacero P, Tseroni V, Vitali ML, Delmastro E, Scolaro T, Marziano C, Orsatti M, Tessa M, Rossi A, Ballarè A, Moro G, Grasso R, Krengli M. Patterns of Practice in the Radiation Therapy Management of Rectal Cancer: Survey of the Interregional Group Piedmont, Valle d'Aosta and Liguria of the “Associazione Italiana di Radioterapia Oncologica (AIRO)”. TUMORI JOURNAL 2013; 99:61-7. [DOI: 10.1177/030089161309900111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aims and background To report the survey about the main aspects on the use of radiotherapy for the treatment of rectal cancer in Piedmont and Liguria. Methods and study design Sixteen centers (11 from Piedmont and 5 from Liguria) received and answered by email a questionnaire data base about clinical and technical aspects of the treatment of rectal cancer. All data were incorporated in a single data base and analyzed. Results Data regarding 593 patients who received radiotherapy for rectal cancer during the year 2009 were collected and analyzed. Staging consisted in colonoscopy, thoracic and abdominal CT, pelvic MRI and endoscopic ultrasound. PET/CT was employed to complete staging and in the treatment planning in 12/16 centers (75%). Neoadjuvant radiotherapy was employed more frequently than adjuvant radiotherapy (50% vs 36.4%), using typically a total dose of 45 Gy with 1.8 Gy/fraction. Concurrent chemoradiation with 5-fluorouracil or capecitabine was mainly employed in neoadjuvant and adjuvant settings, whereas oxaliplatin alone or in combination with 5-FU or capecitabine and leucovorin was commonly employed as the adjuvant agent. The median interval from neoadjuvant treatment to surgery was 7 weeks after long-course radiotherapy and 8 days after short-course radiotherapy. The pelvic total dose of 45 Gy in the adjuvant setting was the same in all the centers. Doses higher than 45 Gy were employed with a radical intent or in case of positive surgical margins. Hypofractionated regimens (2.5, 3 Gy to a total dose of 35–30 Gy) were used in the palliative setting. No relevant differences were observed in target volume definition and patient setup. Twenty-six patients (4.4%) developed grade 3 acute toxicity. Follow-up was scheduled in a similar way in all the centers. Conclusions No relevant differences were found among the centers involved in the survey. The approach can help clinicians to address important clinical questions and to improve consistency and homogeneity of treatments.
Collapse
Affiliation(s)
| | - Lucia Turri
- Radiotherapy, University Hospital Maggiore della Carità, Novara
| | - Fernando Munoz
- Radiotherapy University Hospital San Giovanni Battista, Turin
| | | | - Almalina Bacigalupo
- Department of Radiation Oncology, IRCCS San Martino, National Institute for Cancer Research and University, Genoa
| | - Paola Franzone
- Radiotherapy, Hospital SS Antonio and Biagio, Alessandria
| | | | | | | | - Elena Delmastro
- Radiotherapy, Institute for Cancer Research and Treatment, Candiolo, Turin
| | | | | | - Marco Orsatti
- Radiotherapy, Hospital Sanremo, Asl 1 Imperiese, Sanremo
| | - Maria Tessa
- Radiotherapy, Hospital Cardinal Massaia, Asti
| | | | | | | | - Rachele Grasso
- Radiotherapy, University Hospital Maggiore della Carità, Novara
| | - Marco Krengli
- Radiotherapy, University Hospital Maggiore della Carità, Novara
| |
Collapse
|
41
|
Jones WE, Thomas CR, Herman JM, Abdel-Wahab M, Azad N, Blackstock W, Das P, Goodman KA, Hong TS, Jabbour SK, Konski AA, Koong AC, Rodriguez-Bigas M, Small W, Zook J, Suh WW. ACR appropriateness criteria® resectable rectal cancer. Radiat Oncol 2012; 7:161. [PMID: 23006527 PMCID: PMC3488966 DOI: 10.1186/1748-717x-7-161] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Accepted: 09/09/2012] [Indexed: 12/12/2022] Open
Abstract
The management of resectable rectal cancer continues to be guided by clinical trials and advances in technique. Although surgical advances including total mesorectal excision continue to decrease rates of local recurrence, the management of locally advanced disease (T3-T4 or N+) benefits from a multimodality approach including neoadjuvant concomitant chemotherapy and radiation. Circumferential resection margin, which can be determined preoperatively via MRI, is prognostic. Toxicity associated with radiation therapy is decreased by placing the patient in the prone position on a belly board, however for patients who cannot tolerate prone positioning, IMRT decreases the volume of normal tissue irradiated. The use of IMRT requires knowledge of the patterns of spreads and anatomy. Clinical trials demonstrate high variability in target delineation without specific guidance demonstrating the need for peer review and the use of a consensus atlas. Concomitant with radiation, fluorouracil based chemotherapy remains the standard, and although toxicity is decreased with continuous infusion fluorouracil, oral capecitabine is non-inferior to the continuous infusion regimen. Additional chemotherapeutic agents, including oxaliplatin, continue to be investigated, however currently should only be utilized on clinical trials as increased toxicity and no definitive benefit has been demonstrated in clinical trials. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every two years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
Collapse
Affiliation(s)
- William E Jones
- UT Health Science Center San Antonio, San Antonio, Texas, USA
| | - Charles R Thomas
- Knight Cancer Institute at Oregon Health and Science University, Portland, Oregon, US
| | - Joseph M Herman
- Sidney Kimmel Cancer Center at Johns Hopkins, Baltimore, Maryland, USA
| | | | - Nilofer Azad
- Sidney Kimmel Cancer Center at Johns Hopkins, American Society of Clinical Oncology, Baltimore, Maryland, USA
| | | | - Prajnan Das
- MD Anderson Cancer Center, Houston, Texas, USA
| | - Karyn A Goodman
- Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | | | - Salma K Jabbour
- Cancer Institute of New Jersey, University of Medicine and Dentistry of New Jersey, New Brunswick, New Jersey, USA
| | - Andre A Konski
- Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Albert C Koong
- Stanford University Medical Center, Stanford, California, USA
| | | | - William Small
- The Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, Illinois, USA
| | - Jennifer Zook
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - W Warren Suh
- Cancer Center of Santa Barbara, Santa Barbara, California, USA
| |
Collapse
|
42
|
Fernández-Martos C, Nogué M, Cejas P, Moreno-García V, Machancoses AH, Feliu J. The role of capecitabine in locally advanced rectal cancer treatment: an update. Drugs 2012; 72:1057-73. [PMID: 22621694 DOI: 10.2165/11633870-000000000-00000] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Preoperative infusional 5-fluorouracil (5-FU) and concurrent radiation therapy (RT) followed by total mesorectal surgery is the current standard of care for locally advanced rectal cancer (LAR). When compared with postoperative 5-FU-based chemoradiation, this strategy is associated with significantly lower rates of local relapse, lower toxicity and better compliance. Capecitabine is a rationally designed oral prodrug that is converted into 5-FU by intracellular thymidine phosphorylase. Substitution of infusional 5-FU with capecitabine is an attractive option that provides a more convenient administration schedule and, possibly, increased efficacy. Indeed, incorporation of capecitabine in combined modality neoadjuvant therapy for LAR has been under intense investigation during the last 10 years. Phase I and II clinical trials showed that a regimen consisting of capecitabine 825mg/m(2) twice daily for 7 days/week continuous oral administration in combination with RT is an active and well tolerated regimen, thereby being the preferred concurrent regimen. The definitive demonstration that efficacy of capecitabine/RT is similar to 5-FU/RT has been provided by the NSABP-R-04 and the German Margit trials. One approach to improve outcomes in rectal cancer is to deliver a second RT-sensitizing drug with effective systemic activity. Oxaliplatin and irinotecan are therefore good candidates. However, two phase III trials demonstrated that incorporation of oxaliplatin to capecitabine with RT did not improve early outcomes and, by contrast, increased toxicity. Capecitabine has also been combined with irinotecan. This regimen showed encouraging results in phase I and II clinical trials, which led to an ongoing phase III clinical trial. New strategies with induction chemotherapy with or without chemoradiation prior to surgery are currently under investigation. Whether or not capecitabine has a role in this setting is being investigated in ongoing trials. Incorporation of agents directed towards new targets, such as anti-epidermal growth factor receptor (EGFR) antibodies or antiangiogenic agents, in combination preoperative regimens, is being hampered by results of early trials in which efficacy outcomes with cetuximab were poor and an excessive rate of surgical complications with bevacizumab was observed. The lack of improvements in efficacy with the addition of cetuximab or bevacizumab in the adjuvant treatment of colon cancer led to concerns about further development of these agents in rectal cancer. The role of capecitabine in the postoperative adjuvant setting is the aim of the ongoing Dutch SCRIPT trial. The prediction of response associated with capecitabine has been based on expression of thymidylate synthase and dihydropyrimidine dehydrogenase, as well as on gene expression arrays. All these procedures require further validation and should be considered as investigational. In conclusion, capecitabine can safely and effectively replace intravenous continuous infusion of 5-FU in the preoperative chemoradiation setting for rectal cancer management. The addition of other new antineoplastic agents to a fluoropyrimidine-based regimen remains investigational.
Collapse
|
43
|
Salazar R, Navarro M, Losa F, Alonso V, Gallén M, Rivera F, Benavides M, Escudero P, González E, Massutí B, Gómez A, Majem M, Aranda E. Phase II study of preoperative radiotherapy and concomitant weekly intravenous oxaliplatin combined with oral capecitabine for stages II–III rectal cancer. Clin Transl Oncol 2012; 14:592-8. [DOI: 10.1007/s12094-012-0846-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Accepted: 11/02/2011] [Indexed: 01/03/2023]
|
44
|
Kaiser AM, Klaristenfeld D, Beart RW. Preoperative versus postoperative radiotherapy for rectal cancer in a decision analysis and outcome prediction model. Ann Surg Oncol 2012; 19:4150-60. [PMID: 22766982 DOI: 10.1245/s10434-012-2445-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2010] [Indexed: 12/15/2022]
Abstract
PURPOSE Reduction of local recurrences has been achieved by radiotherapy, but also by improved surgical technique (total mesorectal excision). Radiotherapy has adverse effects and cannot exceed local dose limits. Neoadjuvant radiotherapy may result in overtreatment. We aimed to define the minimum local benefit that would have to be postulated for radiotherapy in order to bring a benefit to the overall cohort. We hypothesized that saving radiotherapy as treatment for a subset of patients with high-risk tumors and local recurrences improves the outcome of the overall cohort. We sought to simulate preoperative versus postoperative radiotherapy in theoretical decision analysis model based on published recurrence rates, with overall survival being the primary end point. METHODS Computerized literature search for studies published between 1996 and 2011, supplemented by manual review of the retrieved reference lists. RESULTS Postoperative radiotherapy evolved as preferred strategy with cure rates of 65.6 % vs. 63.7 % for postoperative and neoadjuvant radiotherapy, respectively, and a decrease of radiation exposure to 42.9 % of the cohort. The system was sensitive to (1) the fraction of stage I cancers included in the cohort, (2) the difference between local recurrence rates (LRR) for neoadjuvant radiotherapy, adjuvant radiotherapy, or surgery-only approach, and (3) the compliance with the postoperative radiotherapy. If the surgery-only recurrence was set to the published 10 %, 13 %, and 27 %, respectively, adjuvant radiotherapy had to achieve LRR below the threshold values of 6.3 %, 8.5 %, and 18.3 % to reverse the impact of compliance. CONCLUSIONS Radiotherapy only improves cancer-specific survival of the cohort if there is a large difference in LRR with versus without it. Routine treatment may therefore be inferior to a tailored radiotherapy regimen.
Collapse
Affiliation(s)
- Andreas M Kaiser
- Department of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | | | | |
Collapse
|
45
|
Samuelian JM, Callister MD, Ashman JB, Young-Fadok TM, Borad MJ, Gunderson LL. Reduced Acute Bowel Toxicity in Patients Treated With Intensity-Modulated Radiotherapy for Rectal Cancer. Int J Radiat Oncol Biol Phys 2012; 82:1981-7. [DOI: 10.1016/j.ijrobp.2011.01.051] [Citation(s) in RCA: 135] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2010] [Revised: 01/12/2011] [Accepted: 01/26/2011] [Indexed: 12/12/2022]
|
46
|
Bai X, Li S, Yu B, Su H, Jin W, Chen G, DU J, Zuo F. Sphincter-preserving surgery after preoperative radiochemotherapy for T3 low rectal cancers. Oncol Lett 2012; 3:1336-1340. [PMID: 22783445 DOI: 10.3892/ol.2012.656] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2012] [Accepted: 03/19/2012] [Indexed: 12/15/2022] Open
Abstract
The aim of this study was to evaluate the feasibility and the effectiveness of preoperative radiochemotherapy followed by total mesorectal excision (TME) and sphincter-preserving procedures for T3 low rectal cancer. Patients with rectal cancer and T3 tumors located within 1-6 cm of the dentate line received preoperative radiochemotherapy. Concurrent 5-fluorouracil-based radiochemotherapy was used. Radical resection with TME and sphincter-preserving procedures were performed during the six to eight weeks following radiotherapy. Survival was analyzed using the Kaplan-Meier method. The anal function was evaluated using the Wexner score. The clinical response rate was 83.5%, overall downstaging of T classification was 75.3% and pathological complete response was 15.3%. The anastomotic fistula rate was 4.7%. A median follow-up of 30 months showed the local recurrence rate to be 4.7% and the distant metastasis rate to be 5.9%. The three-year overall survival rate was 87%. The degree of anal incontinence as measured using the Wexner score decreased over time, and the anal sphincter function in the majority of patients gradually improved. Preoperative radiochemotherapy was found to improve tumor downstaging, reduces local recurrence, increase the sphincter preservation rate, and is therefore of benefit to patients with T3 low rectal cancer.
Collapse
Affiliation(s)
- Xue Bai
- Department of General Surgery, The Military General Hospital of Beijing PLA, Beijing 100700, P.R. China
| | | | | | | | | | | | | | | |
Collapse
|
47
|
Updates on Rectal Cancer. CURRENT COLORECTAL CANCER REPORTS 2011. [DOI: 10.1007/s11888-011-0097-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
48
|
McRee AJ, Cowherd S, Wang AZ, Goldberg RM. Chemoradiation therapy in the management of gastrointestinal malignancies. Future Oncol 2011; 7:409-26. [PMID: 21417904 DOI: 10.2217/fon.11.7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Concurrent administration of chemotherapy and radiotherapy has been increasingly used in cancer treatment, leading to improvements in survival as well as quality of life. Currently, it is a feasible preference, often regarded as the standard therapeutic option, for many locally confined solid tumors, including anal, bladder, cervical, esophageal, gastric, head and neck, lung, pancreatic and rectal cancers. In patients with these tumors, combined modality therapy improves local tumor control and survival while, in some instances, obviating the need for surgical removal of the organ of origin. The scientific rationale for the use of chemoradiation derives from the preclinical and clinical observations of synergistic interactions between radiotherapy and chemotherapy. When chemotherapy and radiotherapy are administered together, the chemotherapeutic agents can sensitize the cancer cells to the effects of ionizing radiation, leading to increased tumor-killing effects within the radiotherapy field. This, in turn, can improve local control of the primary tumor and, in some cancers, render surgical resection unnecessary. In other cases, patients with tumors that were initially considered unresectable are able to undergo curative interventions after completing chemoradiation. The chemotherapy component can address any potential micrometastatic disease that, without therapy, leads to an increased risk of distant recurrence. A large body of evidence exists that supports the use of chemoradiotherapy in gastrointestinal cancers. In fact, one of the first tumor types in which the superior efficacy of chemoradiation was described was anal cancer. Since then, chemoradiotherapy has been explored in other gastrointestinal malignancies with superior outcomes when compared with either radiation or chemotherapy alone. This article aims to recapitulate the clinical evidence supporting the use of chemoradiotherapy in a variety of gastrointestinal tumor types.
Collapse
Affiliation(s)
- Autumn J McRee
- Department of Hematology/Oncology, University of North Carolina School of Medicine, NC, USA
| | | | | | | |
Collapse
|
49
|
Kennecke H, Berry S, Wong R, Zhou C, Tankel K, Easaw J, Rao S, Post J, Hay J. Pre-operative bevacizumab, capecitabine, oxaliplatin and radiation among patients with locally advanced or low rectal cancer: a phase II trial. Eur J Cancer 2011; 48:37-45. [PMID: 21664123 DOI: 10.1016/j.ejca.2011.05.016] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Revised: 05/04/2011] [Accepted: 05/10/2011] [Indexed: 12/31/2022]
Abstract
BACKGROUND To evaluate the safety and efficacy of pre-operative chemoradiation, using capecitabine, oxaliplatin and bevacizumab with standard doses of radiation, in patients with high-risk rectal cancer. METHODS Patients with locally advanced or low rectal cancer were treated with capecitabine 825 mg/m(2) twice daily on days 1-14 and 22-35, oxaliplatin 50mg/m(2) on days 1, 8, 22 and 29, bevacizumab 5mg/kg on days 14, 1, 15 and 29, and radiation 50.4 Gy in 28 fractions including boost. Total mesorectal excision was performed 7-9 weeks after chemoradiation. The primary end-point was complete tumour regression (ypT0NX) by central review. FINDINGS Forty-two evaluable patients were enrolled, and 38 proceeded to definitive surgery. Eighteen patients (43%) had clinical T4 tumours and/or N2 tumours. Mean relative dose intensity was >90% for all systemic agents, and 97% for radiation. Grade 3/4 diarrhoea occurred in 10 patients (24%) and pain in 4 patients (10%) pre-operatively, while grade 3/4 pain, fatigue and infection were each reported among 5 patients (13%) post-operatively. Re-operation due to complications occurred in 4 patients (11%). Complete tumour regression (ypT0) was seen in 9 patients (23.7%) of which two had N1 disease and the pathological complete response (pCR) rate (ypT0N0) was 18.4%. Central review changed pathologic stage in six cases (16%). INTERPRETATION In this study, pre-operative bevacizumab added to oxaliplatin, capecitabine and radiation was safe and resulted in a promising tumour regression rate. Surgical complications were closely monitored and occurred with the expected frequency. Central pathology review should be considered for trials with pathologic response as the primary end-point. FUNDING British Columbia Cancer Agency, Hoffmann-La Roche Canada and Sanofi-Aventis.
Collapse
Affiliation(s)
- Hagen Kennecke
- BC Cancer Agency, 600 West 10th Avenue, Vancouver, BC, Canada V5Z 4E6.
| | | | | | | | | | | | | | | | | |
Collapse
|
50
|
Cellier P, Leduc B, Martin L, Vié B, Chevelle C, Vendrely V, Salemkour A, Carrie C, Calais G, Burtin P, Campion L, Boisdron-Celle M, Morel A, Berger V, Gamelin E. Phase II study of preoperative radiation plus concurrent daily tegafur-uracil (UFT) with leucovorin for locally advanced rectal cancer. BMC Cancer 2011; 11:98. [PMID: 21410976 PMCID: PMC3070684 DOI: 10.1186/1471-2407-11-98] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2010] [Accepted: 03/16/2011] [Indexed: 12/16/2022] Open
Abstract
Background Considerable variation in intravenous 5-fluorouracil (5-FU) metabolism can occur due to the wide range of dihydropyrimidine dehydrogenase (DPD) enzyme activity, which can affect both tolerability and efficacy. The oral fluoropyrimidine tegafur-uracil (UFT) is an effective, well-tolerated and convenient alternative to intravenous 5-FU. We undertook this study in patients with locally advanced rectal cancer to evaluate the efficacy and tolerability of UFT with leucovorin (LV) and preoperative radiotherapy and to evaluate the utility and limitations of multicenter staging using pre- and post-chemoradiotherapy ultrasound. We also performed a validated pretherapy assessment of DPD activity and assessed its potential influence on the tolerability of UFT treatment. Methods This phase II study assessed preoperative UFT with LV and radiotherapy in 85 patients with locally advanced T3 rectal cancer. Patients with potentially resectable tumors received UFT (300 mg/m/2/day), LV (75 mg/day), and pelvic radiotherapy (1.8 Gy/day, 45 Gy total) 5 days/week for 5 weeks then surgery 4-6 weeks later. The primary endpoints included tumor downstaging and the pathologic complete response (pCR) rate. Results Most adverse events were mild to moderate in nature. Preoperative grade 3/4 adverse events included diarrhea (n = 18, 21%) and nausea/vomiting (n = 5, 6%). Two patients heterozygous for dihydropyrimidine dehydrogenase gene (DPYD) experienced early grade 4 neutropenia (variant IVS14+1G > A) and diarrhea (variant 2846A > T). Pretreatment ultrasound TNM staging was compared with postchemoradiotherapy pathology TN staging and a significant shift towards earlier TNM stages was observed (p < 0.001). The overall downstaging rate was 42% for primary tumors and 44% for lymph nodes. The pCR rate was 8%. The sensitivity and specificity of ultrasound for staging was poor. Anal sphincter function was preserved in 55 patients (65%). Overall and recurrence-free survival at 3 years was 86.1% and 66.7%, respectively. Adjuvant chemotherapy was administered to 36 node-positive patients (mean duration 118 days). Conclusion Preoperative chemoradiotherapy using UFT with LV plus radiotherapy was well tolerated and effective and represents a convenient alternative to 5-FU-based chemoradiotherapy for the treatment of resectable rectal cancer. Pretreatment detection of DPD deficiency should be performed to avoid severe adverse events.
Collapse
|