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Piringer G, Gruenberger T, Thaler J, Kührer I, Kaczirek K, Längle F, Viragos-Toth I, Amann A, Eisterer W, Függer R, Andel J, Pichler A, Stift J, Sölkner L, Gnant M, Öfner D. LM02 trial Perioperative treatment with panitumumab and FOLFIRI in patients with wild-type RAS, potentially resectable colorectal cancer liver metastases-a phase II study. Front Oncol 2023; 13:1231600. [PMID: 37621684 PMCID: PMC10446765 DOI: 10.3389/fonc.2023.1231600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 07/17/2023] [Indexed: 08/26/2023] Open
Abstract
Background Twenty percent of colorectal cancer liver metastases (CLMs) are initially resectable with a 5-year survival rate of 25%-40%. Perioperative folinic acid, 5-fluorouracil, oxaliplatin (FOLFOX) increases progression-free survival (PFS). In advanced disease, the addition of targeting therapies results in an overall survival (OS) advantage. The aim of this study was to evaluate panitumumab and FOLFIRI as perioperative therapy in resectable CLM. Methods Patients with previously untreated, wild-type Rat sarcoma virus (RAS), and resectable CLM were included. Preoperative four and postoperative eight cycles of panitumumab and folinic acid, 5-fluorouracil, irinotecan (FOLFIRI) were administered. Primary objectives were efficacy and safety. Secondary endpoints included PFS and OS. Results We enrolled 36 patients in seven centers in Austria (intention-to-treat analyses, 35 patients). There were 28 men and seven women, and the median age was 66 years. About 91.4% completed preoperative therapy and 82.9% underwent liver resection. The R0 resection rate was 82.7%. Twenty patients started and 12 patients completed postoperative chemotherapy. The objective radiological response rate after preoperative therapy was 65.7%. About 20% and 5.7% of patients had stable disease and progressive disease, respectively. The most common grade 3 adverse events were diarrhea, rash, and leukopenia during preoperative therapy. One patient died because of sepsis, and one had a pulmonary embolism grade 4. After surgery, two patients died because of hepatic failure. Most common grade 3 adverse events during postoperative therapy were skin toxicities/rash and leukopenia/neutropenia, and the two grade 4 adverse events were stroke and intestinal obstruction. Median PFS was 13.2 months. The OS rate at 12 and 24 months were 85.6% and 73.3%, respectively. Conclusions Panitumumab and FOLFIRI as perioperative therapy for resectable CLM result in a radiological objective response rate in 65.7% of patients with a manageable grade 3 diarrhea rate of 14.3%. Median PFS was 13.2 months, and the 24-month OS rate was 73.3%. These data are insufficient to widen the indication of panitumumab from the unresectable setting to the setting of resectable CLM.
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Affiliation(s)
- Gudrun Piringer
- Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels, Austria
- Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - Thomas Gruenberger
- Department of Surgery, Clinic Favoriten, Hepato-Pancreato-Biliary Center, Health Network Vienna and Sigmund Freud University, Vienna, Austria
| | - Josef Thaler
- Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels, Austria
- Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - Irene Kührer
- Division of General Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Klaus Kaczirek
- Division of General Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Friedrich Längle
- Department of Surgery, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria
| | - Istvan Viragos-Toth
- Department of Surgery, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria
| | - Arno Amann
- Department of Haematology and Oncology, Medical University of Innsbruck, Innsbruck, Austria
| | - Wolfgang Eisterer
- Department of Internal Medicine and Oncology, Klinikum Klagenfurt, Klagenfurt, Austria
| | - Reinhold Függer
- Department of General and Visceral Surgery, Congregation Hospital, Linz, Austria
| | - Johannes Andel
- Department of Internal Medicine II, Landeskrankenhaus Steyr, Steyr, Austria
| | - Angelika Pichler
- Department of Hematology and Oncology, Landeskrankenhaus Hochsteiermark, Leoben, Austria
| | - Judith Stift
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Lidija Sölkner
- Department of Statistics, Austrian Breast and Colorectal Cancer Study Group, Vienna, Austria
| | - Michael Gnant
- Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Dietmar Öfner
- Department of Visceral-, Transplant- and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
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Lee HY, Woo IS. Perioperative Systemic Chemotherapy for Colorectal Liver Metastasis: Recent Updates. Cancers (Basel) 2021; 13:cancers13184590. [PMID: 34572817 PMCID: PMC8464667 DOI: 10.3390/cancers13184590] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 09/10/2021] [Indexed: 12/29/2022] Open
Abstract
Simple Summary The development of cytotoxic chemotherapy, targeted agents and immune check point inhibitors has improved survival outcomes and quality of life in patients diagnosed with metastatic colorectal cancer (CRC). Long-term survival and cure are possible in well-selected CRC patients with liver metastases (LM). The criteria for resectable LM and the eligibility of patients should be evaluated at the time of diagnosis or during the clinical course via a multidisciplinary team approach. The advantages of adjuvant chemotherapy after curative resection of LM are uncertain currently. Systemic preoperative chemotherapy may convert unresectable LM to a resectable type. However, the optimal combination of systemic drugs and treatment strategy has yet to be established. This article summarizes recent reports of perioperative systemic treatment for patients with colorectal liver metastases (CLM). This review provides an update for physicians involved in managing patients with CLM. Abstract The liver is the most common site of metastases for colorectal cancer. Complete resection in some patients with resectable liver metastases (LM) can lead to long-term survival and cure. Adjuvant systemic chemotherapy after complete resection of LM improves recurrence-free survival; however, the overall survival benefit is not clear. In selected patients, preoperative systemic treatment for metastatic colorectal cancer can convert unresectable to resectable cancer. This review will focus on patient selection, and integration of perioperative and postoperative systemic treatment to surgery in resectable and initially unresectable LM. Additionally, new drugs and biomarkers will be discussed.
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Statistical aspects in adjuvant and neoadjuvant trials for gastrointestinal cancer in 2020: focus on time-to-event endpoints. Curr Opin Oncol 2020; 32:384-390. [PMID: 32541329 DOI: 10.1097/cco.0000000000000636] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE OF REVIEW Clinical-trial design, analysis, and interpretation entails the use of efficient and reliable endpoints. Statistical issues related to endpoints warrant continued attention, as they may have a substantial impact on the conduct of clinical trials and on interpretation of their results. RECENT FINDINGS We review concepts and discuss recent developments related to the use of time-to-event endpoints in studies on adjuvant and neoadjuvant therapy for colon, pancreatic, and gastric adenocarcinomas. The definition of endpoints has varied to a considerable extent in these settings. Although these variations are relevant in interpreting results from individual trials, they probably have a small impact when considered in aggregate. In terms of surrogacy, most published reports so far have used aggregated data. A few studies based on the preferred method of a metaanalysis of individual-patient data have shown that disease-free survival (DFS) is a surrogate for overall survival in the adjuvant therapy of stage III colon cancer and in gastric cancer, whereas DFS with a landmark of six months is a surrogate for overall survival in the neoadjuvant therapy of adenocarcinoma of the esophagus, gastroesophageal junction, or stomach. SUMMARY Testing novel agents in gastrointestinal cancer requires continued attention to statistical issues related to endpoints.
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4
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Statistical Considerations for Trials in Adjuvant Treatment of Colorectal Cancer. Cancers (Basel) 2020; 12:cancers12113442. [PMID: 33228149 PMCID: PMC7699469 DOI: 10.3390/cancers12113442] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 10/29/2020] [Accepted: 11/17/2020] [Indexed: 12/26/2022] Open
Abstract
The design of the best possible clinical trials of adjuvant interventions in colorectal cancer will entail the use of both time-tested and novel methods that allow efficient, reliable and patient-relevant therapeutic development. The ultimate goal of this endeavor is to safely and expeditiously bring to clinical practice novel interventions that impact patient lives. In this paper, we discuss statistical aspects and provide suggestions to optimize trial design, data collection, study implementation, and the use of predictive biomarkers and endpoints in phase 3 trials of systemic adjuvant therapy. We also discuss the issues of collaboration and patient centricity, expecting that several novel agents with activity in the (neo)adjuvant therapy of colon and rectal cancers will become available in the near future.
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Mise Y, Hasegawa K, Saiura A, Oba M, Yamamoto J, Nomura Y, Takayama T, Hashiguchi Y, Shibasaki M, Sakamoto H, Yamagata S, Aoyanagi N, Kaneko H, Koyama H, Miyagawa S, Shinozaki E, Yoshida S, Nozawa H, Kokudo N. A Multicenter Phase 2 Trial to Evaluate the Efficacy of mFOLFOX6 + Cetuximab as Induction Chemotherapy to Achieve R0 Surgical Resection for Advanced Colorectal Liver Metastases (NEXTO Trial). Ann Surg Oncol 2020; 27:4188-4195. [PMID: 32514802 DOI: 10.1245/s10434-020-08627-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The effect of cetuximab plus mFOLFOX on downsizing of the tumors for curative resection has yet to be assessed for patients with advanced colorectal liver metastases (CRLMs). This study aimed to assess the oncologic benefit of cetuximab plus mFOLFOX for wild-type KRAS patients with advanced CRLMs. METHODS In this multicenter phase 2 trial, patients with technically unresectable tumor and/or five or more CRLMs harboring wild-type KRAS were treated with mFOLFOX plus cetuximab. The patients were assessed for resectability after 4 treatments, and then every 2 months up to 12 treatments. Patients with resectable disease were offered surgery after a waiting period of 1 month. The primary end point of the study was the R0 resection rate. The secondary end points were safety, progression-free survival (PFS), and overall survival (OS). The study is registered with the University Hospital Medical Information Network-Clinical Trials Registry Clinical Trials Registry (no. C000007923). RESULTS Between 2012 and 2015, 50 patients from 13 centers were enrolled in this trial. Two patients were excluded because they had not received induction therapy. The 48 patients had a complete response rate of 0% and a partial response rate of 64.6%. For 26 R0 resections (54.2%) and 5 R1 resections (10.4%), no mortality occurred. During a median follow-up period of 31 months, the median OS for all the patients was calculated to be 41 months (95% confidence interval, 28-not reached). The 3-year OS rate was 59%. CONCLUSION For patients with advanced CRLMs harboring wild-type KRAS, cetuximab administered in combination with mFOLFOX yields high response rates, leading to significantly high R0 resection rates and favorable prognoses.
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Affiliation(s)
- Yoshihiro Mise
- Department of Hepatobiliary Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Koto City, Japan
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Akio Saiura
- Department of Hepatobiliary Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Koto City, Japan
| | - Masaru Oba
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | | | | | | | | | | | | | | | - Nobuyoshi Aoyanagi
- Kohnodai Hospital, National Center for Global-Health and Medicine, Shinjuku City, Japan
| | | | | | | | - Eiji Shinozaki
- Department of Hepatobiliary Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Koto City, Japan
| | - Shuntaro Yoshida
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hiroaki Nozawa
- Colon and Rectal Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Japan
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Gholami S, Grothey A. EGFR antibodies in resectable metastatic colorectal liver metastasis: more harm than benefit? Lancet Oncol 2020; 21:324-326. [PMID: 32014120 DOI: 10.1016/s1470-2045(20)30003-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 12/20/2019] [Accepted: 01/02/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Sepideh Gholami
- Department of Surgery, University of California, Davis, Sacramento, CA 95817, USA.
| | - Axel Grothey
- West Cancer Center and Research Institute, Germantown, TN, USA
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Abstract
Despite advances over the past 20 years in colorectal cancer (CRC) screening, diagnosis, and treatment, survival outcomes remain suboptimal. Five-year survival for patients with locally advanced CRC is 69%; 5-year survival drops to 12% for patients with metastatic disease. Novel, effective systemic therapies are needed to improve long-term outcomes. In this review, we describe currently available systemic therapies for the treatment of locally advanced and metastatic CRC and discuss emerging therapies, including encouraging advances in identifying novel targeted agents and exciting responses to immunotherapeutic agents.
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Affiliation(s)
- Christine M Veenstra
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - John C Krauss
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
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Poston G, Adam R, Xu J, Byrne B, Esser R, Malik H, Wasan H, Xu J. The role of cetuximab in converting initially unresectable colorectal cancer liver metastases for resection. Eur J Surg Oncol 2017; 43:2001-2011. [DOI: 10.1016/j.ejso.2017.07.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 07/21/2017] [Indexed: 12/15/2022] Open
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Haraldsdottir S, Goldberg RM. Conversion Therapy for Initially Borderline/Unresectable Metastases in Colon Cancer: What Is the Best Neoadjuvant Chemotherapy? CURRENT COLORECTAL CANCER REPORTS 2017. [DOI: 10.1007/s11888-017-0393-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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10
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Pietrantonio F, Di Bartolomeo M, Cotsoglou C, Mennitto A, Berenato R, Morano F, Coppa J, Perrone F, Iacovelli R, Milione M, Alessi A, Vaiani M, Bossi I, Ricchini F, Scotti M, Caporale M, Bajetta E, de Braud F, Mazzaferro V. Perioperative Triplet Chemotherapy and Cetuximab in Patients With RAS Wild Type High Recurrence Risk or Borderline Resectable Colorectal Cancer Liver Metastases. Clin Colorectal Cancer 2017; 16:e191-e198. [DOI: 10.1016/j.clcc.2016.09.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 09/09/2016] [Accepted: 09/22/2016] [Indexed: 12/19/2022]
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11
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Cho H, Kim JE, Kim KP, Yu CS, Kim JC, Kim JH, Lee MA, Jang HS, Oh ST, Kim SY, Oh JH, Kim DY, Hong YS, Kim TW. Phase II Study of Preoperative Capecitabine and Oxaliplatin-based Intensified Chemoradiotherapy With or Without Induction Chemotherapy in Patients With Locally Advanced Rectal Cancer and Synchronous Liver-limited Resectable Metastases. Am J Clin Oncol 2017; 39:623-629. [PMID: 27322695 PMCID: PMC5120770 DOI: 10.1097/coc.0000000000000315] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Supplemental Digital Content is available in the text. Objectives: Controversy surrounds the management of patients with locally advanced rectal cancer with synchronous resectable liver metastases (LMs). This study was designed to improve both systemic and local control in these patients. Methods: Patients with locally advanced rectal cancer (cT3-4N0 or cTanyN1-2) and synchronous resectable liver-limited metastases (cM1a) were randomly assigned to receive either preoperative treatments of induction CapeOx, followed by chemoradiotherapy with CapeOx (CapeOx-RT) (arm A) or CapeOx-RT alone (arm B). Induction CapeOx consisted of oxaliplatin 130 mg/m2 on day 1 and capecitabine 1000 mg/m2 twice daily on days 1 to 14, every 3 weeks for 2 cycles; CapeOx-RT consisted of radiotherapy with 45 Gy/25 daily fractions±5.4 Gy/3 fractions, oxaliplatin 50 mg/m2 weekly for 5 weeks, and capecitabine 825 mg/m2 twice daily on days 1 to 38. Total mesorectal excision and simultaneous liver metastasectomy were planned within 6 weeks after completion of preoperative treatments. The primary endpoint was R0 resection rate of both the primary tumor and LMs. Results: Thirty-eight patients were randomly assigned to the present study, 18 to arm A and 20 to arm B. The overall R0 resection rate for both the primary tumor and LMs was 77.8% in arm A and 70.0% in arm B (P=0.72). The median progression-free survival was 14.2 versus 15.1 months (P=0.422) and the 3-year overall survival rate was 75.0% versus 88.8% (P=0.29), respectively. Conclusions: Both treatment strategies showed considerable R0 resection rates; however, further study will be warranted to apply these intensified strategies in clinical practice.
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Affiliation(s)
- Hyungwoo Cho
- *Department of Internal Medicine, Asan Medical Center Departments of †Oncology ‡Surgery §Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine Departments of ∥Medical Oncology ¶Radiation Oncology #Colorectal Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul **Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
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12
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Weledji EP. Centralization of Liver Cancer Surgery and Impact on Multidisciplinary Teams Working on Stage IV Colorectal Cancer. Oncol Rev 2017; 11:331. [PMID: 28814999 PMCID: PMC5538223 DOI: 10.4081/oncol.2017.331] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 12/15/2016] [Accepted: 07/17/2017] [Indexed: 12/17/2022] Open
Abstract
Surgical resection is the most effective treatment approach for colorectal liver metastases but only a minority of patients is suitable for upfront surgery. The treatment strategies of stage IV colorectal cancer have shifted towards a continuum of care in which medical and surgical treatment combinations are tailored to the clinical setting of the individual patient. The optimization of treatment through appropriate decision-making and multimodal therapy for stage IV colorectal cancer require a joint multidisciplinary meeting in a centralized liver cancer unit.
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Nishioka Y, Shindoh J, Yoshioka R, Gonoi W, Abe H, Okura N, Yoshida S, Sakamoto Y, Hasegawa K, Fukayama M, Kokudo N. Clinical Impact of Preoperative Chemotherapy on Microscopic Cancer Spread Surrounding Colorectal Liver Metastases. Ann Surg Oncol 2017; 24:2326-2333. [PMID: 28349338 DOI: 10.1245/s10434-017-5845-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND A potentially favorable effect of chemotherapy on the incidence of micrometastases has been reported in patients with colorectal liver metastases (CLMs); however, the actual influence of chemotherapy on the distribution of micrometastases and surgical curability remains unclear. METHOD The clinical impact of preoperative chemotherapy on the incidence and distribution of micrometastases was assessed in 191 patients with 357 CLM nodules. Potential radiologic measures for predicting the extent of microscopic cancer spread and surgical curability were then sought among the size-based and non-size-based radiologic response criteria. RESULTS Multivariate analysis estimated a reduced incidence of micrometastases in patients receiving preoperative chemotherapy (odds ratio [OR] 0.45, 95% confidence interval [CI] 0.26-0.76, p = 0.003). Furthermore, the addition of biologic agents to the preoperative chemotherapy regimen was correlated with a reduced incidence of microscopic cancer spread beyond a width of 1 mm from the margin of the main tumor (OR 0.28, 95% CI 0.11-0.74, p = 0.010 for bevacizumab; and OR 0.29, 95% CI 0.09-0.99, p = 0.048 for anti-epidermal growth factor receptor antibody). Receiver operating characteristic analyses revealed that the computed tomography (CT) morphologic response showed a moderate predictive power for the distribution of micrometastases, with an area under the curve of 0.687, while size-based response criteria were not reliable for estimating the extent of microscopic cancer spread. CONCLUSION Notwithstanding the potential selection of patients after preoperative chemotherapy, the incidence and distribution of micrometastases may be reduced by preoperative chemotherapy. CT morphologic response may be a reliable predictor of both the degree of microscopic cancer spread and the curability of surgery.
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Affiliation(s)
- Yujiro Nishioka
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Hepatobiliary-Pancreatic Surgery Division, Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
| | - Junichi Shindoh
- Hepatobiliary-Pancreatic Surgery Division, Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan. .,Okinaka Memorial Institute for Medical Disease, Tokyo, Japan.
| | - Ryuji Yoshioka
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Wataru Gonoi
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Abe
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Naoki Okura
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shuntaro Yoshida
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshihiro Sakamoto
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masashi Fukayama
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
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14
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Veen T, Søreide K. Can molecular biomarkers replace a clinical risk score for resectable colorectal liver metastasis? World J Gastrointest Oncol 2017; 9:98-104. [PMID: 28344745 PMCID: PMC5348630 DOI: 10.4251/wjgo.v9.i3.98] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 11/25/2016] [Accepted: 12/28/2016] [Indexed: 02/05/2023] Open
Abstract
In resectable colorectal liver metastasis (CRLM) the role and use of molecular biomarkers is still controversial. Several biomarkers have been linked to clinical outcomes in CRLM, but none have so far become routine for clinical decision making. For several reasons, the clinical risk score appears to no longer hold the same predictive value. Some of the reasons include the ever expanding indications for liver resection, which now increasingly tend to involve extrahepatic disease, such as lung metastases (both resectable and non-resectable) and the shift in indication from “what is taken out” (e.g., how much liver has to be resected) to “what is left behind” (that is, how much functional liver tissue the patient has after resection). The latter is amenable to modifications by using adjunct techniques of portal vein embolization and the associating liver partition and portal vein ligation for staged hepatectomy techniques to expand indications for liver resection. Added to this complexity is the increasing number of molecular markers, which appear to hold important prognostic and predictive information, for which some will be discussed here. Beyond characteristics of tissue-based genomic profiles will be liquid biopsies derived from circulating tumor cells and cell-free circulating tumor DNA in the blood. These markers are present in the peripheral circulation in the majority of patients with metastatic cancer disease. Circulating biomarkers may represent more readily available methods to monitor, characterize and predict cancer biology with future implications for cancer care.
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15
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Abstract
Resection of colorectal liver metastases is a treatment standard because patients experience long-term disease-free survival or are even cured after undergoing this procedure. Improved surgical techniques for liver resection in combination with downsizing liver metastases by chemotherapy, interventions to induce liver hypertrophy before resection, and the use of ablative techniques have allowed us to expand the indications for liver surgery and local treatment in situations with limited metastatic colorectal cancer. Resectability and identification of patients who might benefit from liver surgery and local ablative techniques are key factors for the treatment of patients with colorectal cancer. Despite the wide acceptance of liver surgery and ablative techniques, there are many open questions on the management of limited metastatic disease, such as which patients benefit from an aggressive surgical approach, what the indications for ablative and other local techniques are, and what the role of chemotherapy is for patients with resectable or resected disease. Unfortunately, results of randomized trials are only available for a limited number of these questions.
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Affiliation(s)
- Gunnar Folprecht
- From the University Hospital Carl Gustav Carus, University Cancer Center, Medical Department I, Dresden, Germany
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16
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Jones RP, Kokudo N, Folprecht G, Mise Y, Unno M, Malik HZ, Fenwick SW, Poston GJ. Colorectal Liver Metastases: A Critical Review of State of the Art. Liver Cancer 2016; 6:66-71. [PMID: 27995090 PMCID: PMC5159727 DOI: 10.1159/000449348] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Over 50% of patients with colorectal cancer will develop liver metastases. Only a minority of patients present with technically resectable disease. Around 40% of those undergoing surgical resection are alive five years after their diagnosis compared with less than 1% for those with disseminated disease treated with systemic chemotherapy. Surgical resection remains the only possibility for long-term survival for these patients and great efforts have been made to increase the rates of resection whilst improving long-term outcomes. SUMMARY This review considers current technical and oncological criteria for resection, as well as targeted approaches to stratify underlying tumor biology in order to better predict long-term benefit. The role of neoadjuvant and perioperative systemic chemotherapy is critically reviewed, with suggestions for patient stratification in order to identify those who are likely to derive the greatest benefit. The key role of multidisciplinary assessment and decision making for these complex patients is also discussed. KEY MESSAGES Surgery remains the optimal treatment for colorectal liver metastases (CRLM). Despite the curative intent of surgical resection, the majority of patients develop recurrence. Surgical strategies should therefore be adopted to maximize the potential for repeat resections in the event of recurrence. Although a number of preoperative prognostic markers have been identified, none are absolute contraindications to resection. In order to reduce postoperative recurrence, neo-adjuvant chemotherapy is now the standard of care in a number of countries. The evidence base for this approach is contentious, and the potential benefit of such a strategy is likely to be greatest in patients with high oncological risk disease. Multidisciplinary care is essential to ensure the optimal management of these complex patients. In addition, all patients with CRLM should be discussed with specialist hepatobiliary surgeons.
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Affiliation(s)
- Robert P Jones
- School of Cancer Studies, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom,North Western Hepatobiliary Unit, Aintree University Hospital, Liverpool, United Kingdom,*Robert Jones, BSc(Hons), MBChB, PhD School of Cancer Studies, Institute of Translational Medicine, University of Liverpool, Liverpool L69 3GA (United Kingdom), Tel. +44 0 7813 845562, E-Mail
| | | | - Gunnar Folprecht
- University Hospital Carl Gustav Carus, University Cancer Center, Dresden, Germany
| | - Yoshihiro Mise
- Department of Surgery, University of Tokyo, Tokyo, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hassan Z Malik
- North Western Hepatobiliary Unit, Aintree University Hospital, Liverpool, United Kingdom
| | - Stephen W Fenwick
- North Western Hepatobiliary Unit, Aintree University Hospital, Liverpool, United Kingdom
| | - Graeme J Poston
- North Western Hepatobiliary Unit, Aintree University Hospital, Liverpool, United Kingdom
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17
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Starlinger P, Assinger A, Brostjan C, Gruenberger T. Liver surgery for metastatic colorectal cancer: the surgical oncologist perspective. COLORECTAL CANCER 2016. [DOI: 10.2217/crc-2016-0004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Neoadjuvant/conversion chemotherapy has emerged as an indispensable tool to achieve resectability of initially unresectable metastatic colorectal cancer and improves oncological outcomes. In parallel, surgical strategy has adopted a more aggressive treatment approach to achieve complete tumor clearance. However, chemotherapy affects liver function and combined with extensive liver resection, morbidity has increased, thereby compromising oncological outcome. There is an imperative need for careful patient selection to optimize patient management. In this review, we discuss available evidence and indications for neoadjuvant treatment in the management of colorectal cancer liver metastases, on preoperative patient selection and identification of high-risk patients, potential treatment strategies to promote postoperative liver regeneration to avoid postoperative morbidity and potentially deleterious side effects of these therapies on tumor growth.
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Affiliation(s)
- Patrick Starlinger
- Department of Surgery, Medical University of Vienna, General Hospital, Vienna, Austria
| | - Alice Assinger
- Center for Physiology & Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Christine Brostjan
- Department of Surgery, Medical University of Vienna, General Hospital, Vienna, Austria
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18
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Jones RP, Poston GJ. Resection of Liver Metastases in Colorectal Cancer in the Era of Expanding Systemic Therapy. Annu Rev Med 2016; 68:183-196. [PMID: 27686016 DOI: 10.1146/annurev-med-062415-093510] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
About 25% of patients with colorectal cancer develop liver metastases after resection of the primary tumor, and surgical resection of the metastases offers the only opportunity for long-term survival. However, only 20% of patients present with resectable disease. Deciding which patients should be offered surgery, and which should receive additional treatment in the form of perioperative chemotherapy, is complex. For the majority of patients who present with technically irresectable liver-limited disease, systemic downsizing chemotherapy offers the only opportunity to reach surgery and potential cure. Molecular analysis of tumor tissue is improving patient stratification, allowing more appropriate treatment selection, but is not yet a regular part of clinical practice. Decision making is limited by a lack of clear prospective evidence, and so multidisciplinary team assessment is essential to optimize outcomes.
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Affiliation(s)
- Robert P Jones
- North Western Hepatobiliary Unit, Aintree University Hospital, Liverpool L9 7AL, United Kingdom; .,School of Cancer Studies, Institute of Translational Medicine, University of Liverpool, Liverpool L69 3BX, United Kingdom;
| | - Graeme J Poston
- North Western Hepatobiliary Unit, Aintree University Hospital, Liverpool L9 7AL, United Kingdom;
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19
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Thariat J, Vignot S. [Not Available]. Bull Cancer 2016; 103:S48-54. [PMID: 27494974 DOI: 10.1016/s0007-4551(16)30145-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OLIGOMETASTASIS AND OLIGOPROGRESSION Oligometastic progression (or solitary metastases) can justify ablative treatment for metastatic treatment. When such a strategy is discussed, it is important to notice that definition of oligometastases is not consensual both in terms of clinical presentation than on the biological basis. Does a specific biological background truly exist and are there markers that could predict for additional occult disease and its oligo or polymetastatic profile in individuals with demonstrated oligometastasis. This article provides a summary of the state of the art in this field and highlights some current areas of controversies.
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Affiliation(s)
- Juliette Thariat
- Service de radiothérapie, Centre Antoine Lacassagne, 33, avenue Valombrose, 06189 Nice.
| | - Stéphane Vignot
- Service oncologie et hématologie, Hôpitaux de Chartres, hôpital Louis-Pasteur, 4, rue Claude Bernard, 28630 Le Coudray
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20
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Pugh SA, Bowers M, Ball A, Falk S, Finch-Jones M, Valle JW, O'Reilly DA, Siriwardena AK, Hornbuckle J, Rees M, Rees C, Iveson T, Hickish T, Maishman T, Stanton L, Dixon E, Corkhill A, Radford M, Garden OJ, Cunningham D, Maughan TS, Bridgewater JA, Primrose JN. Patterns of progression, treatment of progressive disease and post-progression survival in the New EPOC study. Br J Cancer 2016; 115:420-4. [PMID: 27434036 PMCID: PMC4985352 DOI: 10.1038/bjc.2016.208] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 06/02/2016] [Accepted: 06/13/2016] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The addition of cetuximab (CTX) to perioperative chemotherapy (CT) for operable colorectal liver metastases resulted in a shorter progression-free survival. Details of disease progression are described to further inform the primary study outcome. METHODS A total of 257 KRAS wild-type patients were randomised to CT alone or CT with CTX. Data regarding sites and treatment of progressive disease were obtained for the 109 (CT n=48, CT and CTX n=61) patients with progressive disease at the cut-off date for analysis of November 2012. RESULTS The liver was the most frequent site of progression (CT 67% (32/48); CT and CTX 66% (40/61)). A higher proportion of patients in the CT and group had multiple sites of progressive disease (CT 8%, 4/48; CT and CTX 23%, 14/61 P=0.04). Further treatment for progressive disease is known for 84 patients of whom 69 received further CT, most frequently irinotecan based. Twenty-two patients, 11 in each arm, received CTX as a further line agent. CONCLUSIONS Both the distribution of progressive disease and further treatment are as expected for such a cohort. The pattern of disease progression seen is consistent with failure of systemic micrometastatic disease control rather than failure of local disease control following liver surgery.
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Affiliation(s)
- Siân A Pugh
- University Surgery and Cancer Sciences Division, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK
| | - Megan Bowers
- Southampton Clinical Trials Unit, Southampton, UK
| | | | - Stephen Falk
- Bristol Cancer Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Meg Finch-Jones
- Bristol Cancer Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Department of Upper Gastrointestinal Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Juan W Valle
- University of Manchester/The Christie NHS Foundation Trust, Manchester, UK
| | - Derek A O'Reilly
- Department of Hepatopancreatobiliary Surgery, Central Manchester NHS Foundation Trust, Manchester, UK
- Institute of Cancer Sciences, University of Manchester, Manchester, UK
| | | | - Joanne Hornbuckle
- Specialised Cancer Services, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Myrddin Rees
- Hepatobiliary Surgery, Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
| | - Charlotte Rees
- Department of Medical Oncology, Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
| | - Tim Iveson
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Tamas Hickish
- Bournemouth University, Bournemouth, UK
- Poole Hospital, Poole, UK
| | - Tom Maishman
- Southampton Clinical Trials Unit, Southampton, UK
| | | | | | | | - Mike Radford
- Southampton Clinical Trials Unit, Southampton, UK
| | - O James Garden
- Department of Clinical Surgery, The University of Edinburgh, Edinburgh, UK
| | - David Cunningham
- Department of Medicine, Gastrointestinal and Lymphoma Units, The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Tim S Maughan
- Department of Oncology, University of Oxford, Oxford, UK
| | | | - John N Primrose
- University Surgery and Cancer Sciences Division, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK
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21
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Tanis E, Caballero C, Collette L, Verleye L, den Dulk M, Lacombe D, Schuhmacher C, Werutsky G. The European Organization for Research and Treatment for Cancer (EORTC) strategy for quality assurance in surgical clinical research: Assessment of the past and moving towards the future. Eur J Surg Oncol 2016; 42:1115-22. [DOI: 10.1016/j.ejso.2016.04.052] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 03/31/2016] [Accepted: 04/20/2016] [Indexed: 11/24/2022] Open
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22
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Khoo E, O'Neill S, Brown E, Wigmore SJ, Harrison EM. Systematic review of systemic adjuvant, neoadjuvant and perioperative chemotherapy for resectable colorectal-liver metastases. HPB (Oxford) 2016; 18:485-93. [PMID: 27317952 PMCID: PMC4913134 DOI: 10.1016/j.hpb.2016.03.001] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 03/02/2016] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The role of systemic chemotherapy in patients with resectable colorectal liver metastases (CRLM) is ambiguous. The aim of this review was to compare the outcomes of regimens using systemic neoadjuvant, adjuvant or perioperative (combination of pre and postoperative) chemotherapy, for the treatment of resectable CRLM. METHODS MEDLINE was searched for articles investigating the use of chemotherapy for adults with resectable CRLM. Randomized controlled trials reporting overall survival (OS), disease-free survival (DFS) and grade 3-4 adverse events (AEs) were screened for inclusion. PROSPERO record: CRD42015020609. RESULTS Four trials met the inclusion criteria (1098 patients). No significant improvement in median OS was achieved with chemotherapy/surgery compared with surgery-alone. Two trials demonstrated a significant improvement in DFS with chemotherapy/surgery compared to surgery-alone (Hazard ratio 0.78 (0.61-0.99) p = 0.04 and HR 0.66 (0.46-0.96) p = 0.03). Fluorouracil/folinic acid alone had a lower incidence of AEs than combination therapies, and the addition of cetuximab shortened DFS in one trial (HR 1.48 (1.04-2.12) p = 0.03). CONCLUSION There is a lack of adequately powered trials of chemotherapy in combination with liver resection for CRLM, partly due to difficulties in recruitment. In an unselected patient group, FOLFOX in combination with liver resection appears to improve DFS compared to surgery-alone, but trials are underpowered for OS. Future trials will require prospective stratification of patients based on biomarkers predictive of response.
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Affiliation(s)
- Emily Khoo
- Department of Clinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK
| | - Stephen O'Neill
- Department of Clinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK
| | - Ewan Brown
- Edinburgh Cancer Centre, University of Edinburgh, Western General Hospital, Crewe Road South, Edinburgh EH4 2XR, UK
| | - Stephen J. Wigmore
- Department of Clinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK
| | - Ewen M. Harrison
- Department of Clinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK,Correspondence: Ewen M. Harrison, Department of Clinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK. Tel.: +44 7974420495.Department of Clinical SurgeryUniversity of EdinburghRoyal Infirmary of Edinburgh51 Little France CrescentEdinburghEH16 4SAUK
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23
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Current and Future Approaches to Target the Epidermal Growth Factor Receptor and Its Downstream Signaling in Metastatic Colorectal Cancer. Clin Colorectal Cancer 2015; 14:203-18. [DOI: 10.1016/j.clcc.2015.05.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 05/20/2015] [Accepted: 05/22/2015] [Indexed: 01/27/2023]
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24
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25
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Köhne CH. Is Progression-Free Survival the Right End Point in Trials of Patients With Clearly Resectable, Borderline Resectable, and Unresectable Liver-Limited Colorectal Cancer? J Clin Oncol 2015; 33:2406-7. [DOI: 10.1200/jco.2014.60.7044] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Claus-Henning Köhne
- University Campus Klinikum Oldenburg, Carl von Ossietzky University, North-West-German Cancer Center, Oldenburg, Germany
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26
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Primrose JN, Cunningham D, Garden OJ, Maughan TS, Pugh SA, Stanton L, Falk SJ, Rees M, Finch-Jones M, Valle JW, O'Reilly D, Hornbuckle J, Hickish T, Bridgewater JA. Cetuximab Is Contraindicated in the Perioperative Treatment of Colorectal Liver Metastases. J Clin Oncol 2015; 33:2405-6. [PMID: 26033821 DOI: 10.1200/jco.2014.60.1344] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - David Cunningham
- The Royal Marsden Hospital National Health Service Foundation Trust, London, United Kingdom
| | | | - Tim S Maughan
- Gray Institute for Radiation Oncology and Biology, University of Oxford, Oxford, United Kingdom
| | - Siân A Pugh
- University of Southampton, Southampton, United Kingdom
| | | | - Stephen J Falk
- University Hospitals Bristol National Health Service Foundation Trust, Bristol, United Kingdom
| | - Myrddin Rees
- Basingstoke and North Hampshire Hospital, Basingstoke, United Kingdom
| | - Meg Finch-Jones
- University Hospitals Bristol National Health Service Foundation Trust, Bristol, United Kingdom
| | - Juan W Valle
- The Christie National Health Service Foundation Trust, Manchester, United Kingdom
| | - Derek O'Reilly
- Central Manchester University Hospitals National Health Service Foundation Trust, Manchester, United Kingdom
| | - Joanne Hornbuckle
- Sheffield Teaching Hospitals National Health Service Foundation Trust, Sheffield, United Kingdom
| | - Tamas Hickish
- Poole Hospital National Health Service Trust, Poole, United Kingdom
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27
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Papadimitriou K, Rolfo C, Dewaele E, Van De Wiel M, Van den Brande J, Altintas S, Huizing M, Specenier P, Peeters M. Incorporating anti-VEGF pathway therapy as a continuum of care in metastatic colorectal cancer. Curr Treat Options Oncol 2015; 16:18. [PMID: 25813037 DOI: 10.1007/s11864-015-0333-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Metastatic cancer was previously treated with distinctive lines of chemotherapy regimens upon disease progression or toxicity, yet the choices of therapy are actually interrelated, with the selection of a first-line regimen in part determining the choices available for subsequent treatment. Lately the therapeutic approach based on separate lines of treatment, tends to be replaced from a perspective strategical approach, that of the "continuum of care". This strategy targets to an improved overall survival, improved of quality of life and minimization of toxicity through upfront design of treatment selection and sequencing, exposure to all available drugs and minimization of unnecessary treatment. Anti-VEGF treatment has a well-documented role in this approach. Bevacizumab should be included in upfront treatment regimens for all mCRC patients independently of RAS status, unless contraindicated. Upfront bevacizumab could be combined with all available regimens since the optimal choice of backbone chemotherapy is yet to be defined. In RAS wild-type population, when metastasectomy is the target, an anti-EGFR combination is also a valid approach. Maintenance with bevacizumab and fluoropyrimidines should be considered upon intolerance of induction treatment and/or disease stabilization; maintenance with bevacizumab monotherapy should be avoided. In highly selected patients, complete treatment cessation could be also an option. Continuation with bevacizumab upon first progression and switch of the "backbone" chemotherapy is a validated approach. Patients progressing after first-line oxaliplatin regimen including bevacizumab combinations could be treated with an aflibercept-irinotecan combination. When no more options are available, regorafenib monotherapy should be the following choice. Combinations of anti-VEGF and anti-EGFR treatment have no place in this approach and are not indicated.
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28
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Nordlinger BM, Poston GJ, Goldberg RM. Reply to J.N. Primrose et al and C.-H. Köhne. J Clin Oncol 2015; 33:2408-9. [PMID: 26033799 DOI: 10.1200/jco.2014.60.4751] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Bernard M Nordlinger
- Hôpital Ambroise Paré, Boulogne; and Assistance Publique Hôpitaux de Paris, Université de Versailles, Versailles, France
| | - Graeme J Poston
- Aintree University Hospital; and Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Richard M Goldberg
- The James Cancer Hospital and Solove Research Institute, The Ohio State University James Comprehensive Cancer Center, Columbus, OH
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29
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Abstract
The role of antiangiogenic and anti-epidermal growth factor receptor (EGFR) agents has been investigated extensively in colorectal cancer in the palliative, adjuvant, and neoadjuvant settings. Although the role of biologic agents has become well-defined in the first, second, and subsequent lines of treatment of metastatic colorectal cancer (mCRC), considerable debate continues around the optimal sequencing and around optimal patient selection. The benefits from integrating bevacizumab or cetuximab in the adjuvant setting have been investigated in several randomized phase III clinical trials in stage II/III disease, all with disappointing results. Neoadjuvant approaches incorporating biologic therapy in patients with liver metastatic disease have led to mixed results. Although the current evidence does suggest increased down-staging and increased resectability with the addition of cetuximab in patients with initially unresectable or borderline resectable liver metastases, a positive effect of anti-EGFR therapy on the overall survival (OS) in this setting is not conclusive. Patients with resectable liver metastases derive no benefit and may experience potential harm from the addition of cetuximab to neoadjuvant chemotherapy. Similarly, there is neither rationale nor adequate data to support the addition of bevacizumab to neoadjuvant chemotherapy in patients with resectable liver metastases. In this review, we examine the role of antiangiogenesis and anti-EGFR therapies across the spectrum of adjuvant, neoadjuvant, and metastatic disease.
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Affiliation(s)
- Marwan Fakih
- From the City of Hope Comprehensive Cancer Center, Duarte, CA
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