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Pollom EL, Sheth VR, Dawes AJ, Holden T. Nonoperative Management for Rectal Cancer. Cancer J 2024; 30:238-244. [PMID: 39042774 DOI: 10.1097/ppo.0000000000000727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2024]
Abstract
ABSTRACT The treatment paradigm for rectal cancer has been shifting toward de-escalated approaches to preserve patient quality of life. Historically, the standard treatment in the United States for locally advanced rectal cancer has standardly comprised preoperative chemoradiotherapy coupled with total mesorectal excision. Recent data challenge this "one-size-fits-all" strategy, supporting the possibility of omitting surgery for certain patients who achieve a clinical complete response to neoadjuvant therapy. Consequently, patients and their physicians must navigate diverse neoadjuvant options, often in the context of pursuing organ preservation. Total neoadjuvant therapy, involving the administration of all chemotherapy and radiation before total mesorectal excision, is associated with the highest rates of clinical complete response. However, questions persist regarding the optimal sequencing of radiation and chemotherapy and the choice between short-course and long-course radiation. Additionally, meticulous response assessment and surveillance are critical for selecting patients for nonoperative management without compromising the excellent cure rates associated with trimodality therapy. As nonoperative management becomes increasingly recognized as a standard-of-care treatment option for patients with rectal cancer, ongoing research in patient selection and monitoring as well as patient-reported outcomes is critical to guide personalized rectal cancer management within a patient-centered framework.
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Affiliation(s)
| | | | | | - Thomas Holden
- Department of Medicine, Stanford University School of Medicine, Stanford, CA
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Cho MS, Bae HW, Chang JS, Yang SY, Kim TH, Koom WS, Shin SJ, Choi GS, Kim NK. Short-Term Outcomes and Cost-Effectiveness between Long-Course Chemoradiation and Short-Course Radiotherapy for Locally Advanced Rectal Cancer. Yonsei Med J 2023; 64:395-403. [PMID: 37226566 DOI: 10.3349/ymj.2023.0042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 04/25/2023] [Accepted: 04/25/2023] [Indexed: 05/26/2023] Open
Abstract
PURPOSE Long-course chemoradiotherapy (LCRT) has been widely recommended in a majority of rectal cancer patients. Recently, encouraging data on short-course radiotherapy (SCRT) for rectal cancer has emerged. In this study, we aimed to compare these two methods in terms of short-term outcomes and cost analysis under the Korean medical insurance system. MATERIALS AND METHODS Sixty-two patients with high-risk rectal cancer, who underwent either SCRT or LCRT followed by total mesorectal excision (TME), were classified into two groups. Twenty-seven patients received 5 Gy×5 with two cycles of XELOX (capecitabine 1000 mg/m² and oxaliplatin 130 mg/m² every 3 weeks) followed by TME (SCRT group). Thirty-five patients received capecitabine-based LCRT followed by TME (LCRT group). Short-term outcomes and cost estimation were assessed between the two groups. RESULTS Pathological complete response was achieved in 18.5% and 5.7% of patients in the SCRT and LCRT groups, respectively (p=0.223). The 2-year recurrence-free survival rate did not show significant difference between the two groups (SCRT vs. LCRT: 91.9% vs. 76.2%, p=0.394). The average total cost per patient for SCRT was 18% lower for inpatient treatment (SCRT vs. LCRT: $18787 vs. $22203, p<0.001) and 40% lower for outpatient treatment (SCRT vs. LCRT: $11955 vs. $19641, p<0.001) compared to LCRT. SCRT was shown to be the dominant treatment option with fewer recurrences and fewer complications at a lower cost. CONCLUSION SCRT was well-tolerated and achieved favorable short-term outcomes. In addition, SCRT showed significant reduction in the total cost of care and distinguished cost-effectiveness compared to LCRT.
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Affiliation(s)
- Min Soo Cho
- The Division of Colon and Rectal Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Hyeon Woo Bae
- The Division of Colon and Rectal Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jee Suk Chang
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Yoon Yang
- The Division of Colon and Rectal Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Hyun Kim
- Graduate School of Public Health, Yonsei University, Seoul, Korea
| | - Woong Sub Koom
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Joon Shin
- The Division of Medical Oncology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Gyu-Seog Choi
- The Division of Colon and Rectal Surgery, Department of Surgery, Kyungpook National University Medical Center, Daegu, Korea
| | - Nam Kyu Kim
- The Division of Colon and Rectal Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea.
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Mei WJ, Wang XZ, Li YF, Sun YM, Yang CK, Lin JZ, Wu ZG, Zhang R, Wang W, Li Y, Zhuang YZ, Lei J, Wan XB, Ren YK, Cheng Y, Li WL, Wang ZQ, Xu DB, Mo XW, Ju HX, Ye SW, Zhao JL, Zhang H, Gao YH, Zeng ZF, Xiao WW, Zhang XP, Zhang X, Xie E, Feng YF, Tang JH, Wu XJ, Chen G, Li LR, Lu ZH, Wan DS, Bei JX, Pan ZZ, Ding PR. Neoadjuvant Chemotherapy With CAPOX Versus Chemoradiation for Locally Advanced Rectal Cancer With Uninvolved Mesorectal Fascia (CONVERT): Initial Results of a Phase III Trial. Ann Surg 2023; 277:557-564. [PMID: 36538627 PMCID: PMC9994847 DOI: 10.1097/sla.0000000000005780] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To compare neoadjuvant chemotherapy (nCT) with CAPOX alone versus neoadjuvant chemoradiotherapy (nCRT) with capecitabine in locally advanced rectal cancer (LARC) with uninvolved mesorectal fascia (MRF). BACKGROUND DATA nCRT is associated with higher surgical complications, worse long-term functional outcomes, and questionable survival benefits. Comparatively, nCT alone seems a promising alternative treatment in lower-risk LARC patients with uninvolved MRF. METHODS Patients between June 2014 and October 2020 with LARC within 12 cm from the anal verge and uninvolved MRF were randomly assigned to nCT group with 4 cycles of CAPOX (Oxaliplatin 130 mg/m2 IV day 1 and Capecitabine 1000 mg/m2 twice daily for 14 d. Repeat every 3 wk) or nCRT group with Capecitabine 825 mg/m² twice daily administered orally and concurrently with radiation therapy (50 Gy/25 fractions) for 5 days per week. The primary end point is local-regional recurrence-free survival. Here we reported the results of secondary end points: histopathologic response, surgical events, and toxicity. RESULTS Of the 663 initially enrolled patients, 589 received the allocated treatment (nCT, n=300; nCRT, n=289). Pathologic complete response rate was 11.0% (95% CI, 7.8-15.3%) in the nCT arm and 13.8% (95% CI, 10.1-18.5%) in the nCRT arm ( P =0.33). The downstaging (ypStage 0 to 1) rate was 40.8% (95% CI, 35.1-46.7%) in the nCT arm and 45.6% (95% CI, 39.7-51.7%) in the nCRT arm ( P =0.27). nCT was associated with lower perioperative distant metastases rate (0.7% vs. 3.1%, P =0.03) and preventive ileostomy rate (52.2% vs. 63.6%, P =0.008) compared with nCRT. Four patients in the nCT arm received salvage nCRT because of local disease progression after nCT. Two patients in the nCT arm and 5 in the nCRT arm achieved complete clinical response and were treated with a nonsurgical approach. Similar results were observed in subgroup analysis. CONCLUSIONS nCT achieved similar pCR and downstaging rates with lower incidence of perioperative distant metastasis and preventive ileostomy compared with nCRT. CAPOX could be an effective alternative to neoadjuvant therapy in LARC with uninvolved MRF. Long-term follow-up is needed to confirm these results.
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Affiliation(s)
| | | | - Yun-Feng Li
- The Third Affiliated Hospital of Kunming Medical University/Yunnan Cancer Hospital
| | - Yue-Ming Sun
- The First Affiliated Hospital of Nanjing Medical University, Nanjing
| | | | | | - Zu-Guang Wu
- Department of Gastrointestinal Surgery, Meizhou People’s Hospital, Meizhou
| | - Rui Zhang
- Liaoning Cancer Hospital & Institute
| | - Wei Wang
- Guangdong Provincial Hospital of Traditional Chinese Medicine
| | - Yong Li
- Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou
| | | | - Jian Lei
- The First Affiliated Hospital of Guangzhou Medical University
| | - Xiang-Bin Wan
- Department of General Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Henan Provincial Cancer Hospital, Zhengzhou
| | - Ying-Kun Ren
- Department of General Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Henan Provincial Cancer Hospital, Zhengzhou
| | - Yong Cheng
- The First Affiliated Hospital of Chongqing Medical University, Chongqing, P. R. China
| | - Wen-Liang Li
- First Affiliated hospital of Kunming Medical University, Kunming
| | | | | | - Xian-Wei Mo
- Guangxi Medical University Cancer Center, Nanning
| | - Hai-Xing Ju
- Cancer Hospital of the University of Chinese Academy of Sciences, Hangzhou
| | | | - Jing-Lin Zhao
- Department of Gastrointestinal Surgery, Jiangmen Central Hospital, Affiliated Jiangmen Hospital of Sun Yat-sen University, Jiangmen
| | - Hong Zhang
- Shengjing Hospital of China Medical University, Shenyang
| | | | | | | | | | - Xuan Zhang
- The Third Affiliated Hospital of Kunming Medical University/Yunnan Cancer Hospital
| | - E Xie
- Shantou Hospital of Traditional Chinese Medicine, Shantou
| | - Yi-Fei Feng
- The First Affiliated Hospital of Nanjing Medical University, Nanjing
| | | | | | | | | | | | | | - Jin-Xin Bei
- Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou Guangdong
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Lorenzo Liñán MÁ, García Armengol J, Martín Martín GP, Martínez Sanjuán V, Roig Vila JV. Validation of pelvic magnetic resonance imaging as the method of choice to determine the distance to the anal margin in rectal cancer. Cir Esp 2022; 100:772-779. [PMID: 36064169 DOI: 10.1016/j.cireng.2022.08.015] [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: 03/17/2021] [Accepted: 07/06/2021] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Distance from anal verge of rectal tumours and their anatomical relationships contribute to determine the multidisciplinary therapeutic strategy based on the combination of radio-chemotherapy and radical surgery. Our aims are to investigate which is the most accurate method for the preoperative measuring of the distance from the anal verge in rectal tumours and if the pelvic MRI can substitute the classical instrumental methods. METHODS Prospective study of diagnostic precision between flexible colonoscopy (FC), preoperative rigid rectosigmoidoscopy (pRR) and pelvic MRI in patients scheduled to radical surgery. Rigid intraoperative rectoscopy (iRR) was considered the reference test. The correlations between the different techniques and their determination coefficient as well as the intraclass correlation coefficient and the degree of agreement between the different tests were analyzed. RESULTS 96 patients (65% males), mean age (SD): 68 (14.1) years were included. 72% received neoadjuvant treatment. The mean distance to the anal margin measured by FC = 103.5 mm, was significantly greater than others, which had similar values: pRR = 81.1; MRI = 77.4; iRR = 82.9 mm (P < .001). A significant intraclass correlation was observed and there was high agreement between all pre- and intraoperative measurements except for the performed by FC, which overestimated the results. MRI provided more individualized and accurate information. CONCLUSIONS There is variability between the measurement methods, being colonoscopy the least reliable. MRI offers objective, comparable, accurate and individualized values that can replace those obtained by pRR for tumours of any location in the rectum.
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Affiliation(s)
- Miguel Ángel Lorenzo Liñán
- Servicio de Cirugía General y Digestiva, Hospital Universitario Torrecárdenas, Almería, Spain; Servicio de Cirugía General y del Aparato Digestivo, Consorcio Hospital General Universitario de Valencia, Valencia, Spain.
| | - Juan García Armengol
- Centro Europeo de Cirugía Colorrectal, Hospital Vithas Valencia 9 de Octubre, Valencia, Spain; Servicio de Cirugía General y del Aparato Digestivo, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - Gonzalo Pablo Martín Martín
- Cirugía, Centro Médico Teknon, Barcelona, Spain; Servicio de Cirugía General y del Aparato Digestivo, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - Vicente Martínez Sanjuán
- Servicio de Radiología y Resonancia Magnética, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - José Vicente Roig Vila
- Centro Europeo de Cirugía Colorrectal, Hospital Vithas Valencia 9 de Octubre, Valencia, Spain; Servicio de Cirugía General y del Aparato Digestivo, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
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Jácome AA, Peixoto RD, Gil MV, Ominelli J, Prolla G, Dienstmann R, Eng C. Biologics in rectal cancer. Expert Opin Biol Ther 2022; 22:1245-1257. [PMID: 35912589 DOI: 10.1080/14712598.2022.2108700] [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: 11/11/2022]
Abstract
INTRODUCTION Despite the use of multimodality therapy, locally advanced rectal cancer (LARC) still presents high rates of disease recurrence. Fluoropyrimidine-based chemotherapy concurrently with radiation therapy (RT) remains the cornerstone of neoadjuvant therapy of LARC, and novel therapies are urgently needed in order to improve the clinical outcomes. AREAS COVERED We aim to summarize data from completed and ongoing clinical trials addressing the role of biological therapies, including monoclonal antibodies, immune checkpoint inhibitors (ICIs), antibody-drug conjugates, bispecific antibodies, and gene therapies in the systemic therapy of rectal cancer. EXPERT OPINION Deeper understanding of the molecular biology of colorectal cancer (CRC) has allowed meaningful advances in the systemic therapy of metastatic disease in the past few years. The larger applicability of biological therapy in CRC, including genome-guided targeted therapy, antiangiogenics, and immunotherapy, gives us optimism for the personalized management of rectal cancer. Microsatellite instability (MSI) tumors have demonstrated high sensitivity to ICIs, and preliminary findings in the neoadjuvant setting of rectal cancer are promising. To date, antiangiogenic and anti-EGFR therapies in LARC have not demonstrated the same benefit seen in metastatic disease. The outstanding results accomplished by biomarker-guided therapy in metastatic CRC will guide future developments of biological therapy in LARC.
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Affiliation(s)
- Alexandre A Jácome
- Department of Gastrointestinal Medical Oncology, Oncoclínicas, Belo Horizonte, Brazil
| | | | - Mariana V Gil
- Department of Gastrointestinal Medical Oncology, Oncoclínicas, Rio de Janeiro, Brazil
| | - Juliana Ominelli
- Department of Gastrointestinal Medical Oncology, Oncoclínicas, Rio de Janeiro, Brazil
| | - Gabriel Prolla
- Department of Gastrointestinal Medical Oncology, Oncoclínicas, Porto Alegre, Brazil
| | | | - Cathy Eng
- Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, USA
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Domínguez Tristancho JL. Organ preservation in rectal cancer, the desire of a new paradigm. Cir Esp 2022; 100:389-391. [PMID: 35525484 DOI: 10.1016/j.cireng.2021.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 07/31/2021] [Indexed: 06/14/2023]
Affiliation(s)
- José Luis Domínguez Tristancho
- Unidad de Coloproctología y Terapia Celular, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Fundación, Jiménez Díaz, Madrid, Spain.
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Ohue M, Iwasa S, Mizusawa J, Kanemitsu Y, Shiozawa M, Nishizawa Y, Ueno H, Katsumata K, Yasui M, Tsukamoto S, Katayama H, Fukuda H, Shimada Y. A randomized controlled trial comparing perioperative vs. postoperative mFOLFOX6 for lower rectal cancer with suspected lateral pelvic lymph node metastasis (JCOG1310): a phase II/III randomized controlled trial. Jpn J Clin Oncol 2022; 52:850-858. [PMID: 35640246 PMCID: PMC9354501 DOI: 10.1093/jjco/hyac080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 04/29/2022] [Indexed: 11/17/2022] Open
Abstract
Objective The optimal perioperative chemotherapy for lower rectal cancer with lateral pelvic lymph node metastasis remains unclear. We evaluated the efficacy and safety of perioperative mFOLFOX6 in comparison with postoperative mFOLFOX6 for rectal cancer patients undergoing total mesorectal excision with lateral lymph node dissection. Methods We conducted an open label randomized phase II/III trial in 18 Japanese institutions. We enrolled patients with histologically proven lower rectal adenocarcinoma with clinical pelvic lateral lymph node metastasis who were randomly assigned (1:1) to receive postoperative mFOLFOX6 (12 courses of intravenous oxaliplatin [85 mg/m2] with L-leucovorin [200 mg/m2] followed by 5-fluorouracil [400 mg/m2, bolus and 2400 mg/m2, continuous infusion, repeated every 2 weeks]) or perioperative mFOLFOX6 (six courses each preoperatively and postoperatively). The primary endpoint was overall survival (OS). The trial is registered with Japan Registry of Clinical Trials, number jRCTs031180230. Results Between May 2015, and May 2019, 48 patients were randomized to the postoperative arm (n = 26) and the perioperative arm (n = 22). The trial was terminated prematurely due to poor accrual. The 3-year OS in the postoperative and perioperative groups were 66.1 and 84.4%, respectively (HR 0.58, 95% CI [0.14–2.45], one-sided P = 0.23). The pathological complete response rate in the perioperative group was 9.1%. Grade 3 postoperative surgical complications were more frequently observed in the perioperative arm (50.0 vs. 12.0%). One treatment-related death due to sepsis from pelvic infection occurred in the postoperative group. Conclusions Perioperative mFOLFOX6 may be an insufficient treatment to improve survival of lower rectal cancer with lateral pelvic lymph node metastasis.
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Affiliation(s)
- Masayuki Ohue
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Satoru Iwasa
- Gastrointestinal Medical Oncology Division, National Cancer Center Hospital, Tokyo, Japan
| | - Junki Mizusawa
- Japan Clinical Oncology Group Data Center/Operations Office, National Cancer Center Hospital, Tokyo, Japan
| | - Yukihide Kanemitsu
- Department of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Manabu Shiozawa
- Department of Surgery, Kanagawa Cancer Center, Yokohama, Japan
| | - Yusuke Nishizawa
- Department of Surgery, Saitama Prefecture Cancer Center, Saitama, Japan
| | - Hideki Ueno
- Department of Surgery, National Defense Medical College, Saitama, Japan
| | - Kenji Katsumata
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Masayoshi Yasui
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Shunsuke Tsukamoto
- Department of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroshi Katayama
- Japan Clinical Oncology Group Data Center/Operations Office, National Cancer Center Hospital, Tokyo, Japan
| | - Haruhiko Fukuda
- Japan Clinical Oncology Group Data Center/Operations Office, National Cancer Center Hospital, Tokyo, Japan
| | - Yasuhiro Shimada
- Clinical Oncology Division, Kochi Health Sciences Center, Kochi, Japan
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The Evolving Neoadjuvant Treatment Paradigm for Patients with Locoregional mismatch Repair Proficient Rectal Cancer. Curr Treat Options Oncol 2022; 23:453-473. [PMID: 35312962 DOI: 10.1007/s11864-022-00961-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2022] [Indexed: 12/29/2022]
Abstract
OPINION STATEMENT The standard of care for locally advanced rectal cancer (LARC) has included preoperative chemoradiation, total mesorectal excision surgery and post operative adjuvant chemotherapy based on histopathology. The current therapeutic landscape in LARC has many different options with different directions of travel - depending on the goal of treatment. Enthusiasm for delivering total neoadjuvant therapy (TNT) for patients with locally advanced rectal cancer (LARC) is increasing in the light of recently published randomised phase III trials - RAPIDO and PRODIGE-23. There is a wide diversity of different potential schedules and a multitude of approaches, which include induction neoadjuvant chemotherapy (NACT) with a range of chemotherapy options (CAPEOX, FOLFOX, FOLFOXIRI) and a varying duration of 6-18 weeks, or consolidation NACT. These schedules either precede or follow short-course preoperative radiation therapy (SCPRT) using 5 × 5Gy or long-course chemoradiation (LCCRT) using 45-60Gy respectively. The different strategies of induction and consolidation neoadjuvant chemotherapy have been compared and have similar long-term outcomes, but consolidation chemotherapy may facilitate organ-sparing. The results are driving novel paradigms with both intensification and de-intensification treatment strategies. The ideal combination, sequence or duration of such a TNT approach remains undefined. As yet, there are no robust clinical, genetic, molecular, immune or imaging features (alone or integrated), which either direct or aid these choices. Currently, the selection of neoadjuvant treatment is driven by the impact on avoidance or feasibility of surgery or reducing the risk of metastases rather than prevention of local recurrence. Most believe that TNT will improve overall survival, despite the present lack of evidence. Both the inherent heterogeneity in LARC and the observed range of different responses underline the need for response biomarkers to individually tailor therapy rather than 'a one size fits all' approach.
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Deng X, Wu Q, Bi L, Yu Y, Huang S, He D, Wu B, Gou H, Meng W, Qiu M, He Y, Wang Z. Early response to upfront neoadjuvant chemotherapy (CAPOX) alone in low- and intermediate-risk rectal cancer: a single-arm phase II trial. Br J Surg 2021; 109:121-128. [PMID: 34792107 PMCID: PMC10364694 DOI: 10.1093/bjs/znab388] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 10/09/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND With local recurrence of rectal cancer continuing to decrease, distant recurrence is becoming a major concern, especially for patients with low- and intermediate-risk stage II/III rectal cancer. Therefore, a new treatment strategy is warranted for these patients. This single-arm phase II trial aimed to assess the effect of neoadjuvant chemotherapy (NCT) in low- and intermediate-risk stage II/III rectal cancer and explore candidate radiological and clinical parameters for early prediction of tumour response after two cycles of CAPOX. METHODS Patients with mid-low stage II/III rectal cancer with low and intermediate risk were examined. The primary outcome was defined as a clinicopathological response by integrating tumour longitudinal length reduction (TLLR) on MRI into pathological tumour regression grade (TRG). After completing NCT, patients with TRG0-2 and TRG3 with a TLLR rate greater than 30 per cent were considered to be responders. Secondary outcomes included pathological complete response (pCR), adverse events and local and distant recurrence. RESULTS This study enrolled 61 eligible patients. No patient was converted to neoadjuvant chemoradiotherapy owing to tumour progression. The clinicopathological response and pCR rates were 78.7 and 21.3 per cent respectively. After two cycles of CAPOX, TLLR, TRG on MRI, and mucosal lesion regression grade on endoscopy had potential discriminative ability (area under the curve greater than 0.7) for predicting both clinicopathological and pathological response. CONCLUSION NCT alone achieves good tumour response rates in patients with low- and intermediate-risk stage II/III rectal cancer, and predicting tumour response to NCT is feasible at an early treatment phase. REGISTRATION NUMBER NCT03666442 (http://www.clinicaltrials.gov).
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Affiliation(s)
- Xiangbing Deng
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Qingbin Wu
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Liang Bi
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China.,Department of Colorectal Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Yongyang Yu
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Shuo Huang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Du He
- Department of Pathology, West China Hospital, Sichuan University, Chengdu, China
| | - Bing Wu
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
| | - Hongfeng Gou
- Department of Abdominal Cancer, West China Hospital, Sichuan University, Chengdu, China
| | - Wenjian Meng
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Meng Qiu
- Department of Abdominal Cancer, West China Hospital, Sichuan University, Chengdu, China
| | - Yazhou He
- Department of Oncology, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Ziqiang Wang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
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Ng SP, Ngan SY, Leong T. Current State of Neoadjuvant Radiotherapy for Rectal Cancer. Clin Colorectal Cancer 2021; 21:63-70. [PMID: 34852972 DOI: 10.1016/j.clcc.2021.10.008] [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: 09/28/2021] [Revised: 10/27/2021] [Accepted: 10/31/2021] [Indexed: 11/11/2022]
Abstract
Colorectal cancer is the third most commonly diagnosed cancer, with rectal cancer accounting for 30% of cases. The current standard of care curative treatment for locally advanced rectal cancer is (chemo)radiotherapy followed by surgery and adjuvant chemotherapy. Although neoadjuvant radiotherapy has reduced the risk of local recurrence to less than 10%, the risk of distant metastasis remained high at 30% affecting patient survival. In addition, there is a recognition that there is heterogeneity in tumor biology and treatment response with good responders potentially suitable for treatment de-escalation. Therefore, new treatment sequencing and regimens were investigated. Here, we reviewed the evidence for current neoadjuvant treatment options in patients with locally advanced rectal adenocarcinoma, and highlight the new challenges in this new treatment landscape.
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Affiliation(s)
- Sweet Ping Ng
- Department of Radiation Oncology, Olivia Newton-John Cancer Centre, Austin Health, Melbourne, Australia; School of Molecular Sciences, La Trobe University, Melbourne, Australia; Department of Surgery, The University of Melbourne, Melbourne, Australia.
| | - Samuel Y Ngan
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
| | - Trevor Leong
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
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Domínguez Tristancho JL. Organ preservation in rectal cancer, the desire of a new paradigm. Cir Esp 2021; 100:S0009-739X(21)00261-X. [PMID: 34544563 DOI: 10.1016/j.ciresp.2021.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/28/2021] [Accepted: 07/31/2021] [Indexed: 10/20/2022]
Affiliation(s)
- José Luis Domínguez Tristancho
- Unidad de Coloproctología y Terapia Celular, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Fundación Jiménez Díaz, Madrid, España.
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Wu P, Xu HM, Zhu Z. Neoadjuvant chemotherapy without radiation as a potential alternative treatment for locally advanced rectal cancer: A meta-analysis. World J Gastrointest Oncol 2021; 13:1196-1209. [PMID: 34616523 PMCID: PMC8465444 DOI: 10.4251/wjgo.v13.i9.1196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 06/01/2021] [Accepted: 07/19/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Neoadjuvant chemoradiotherapy (Neo-CRT) is the current standard strategy for treating locally advanced rectal cancer. However, it delays the administration of optimal chemotherapy and increases toxicity.
AIM To compare the feasibility and efficacy of neoadjuvant chemotherapy (Neo-CT) and Neo-CRT for patients with locally advanced rectal cancer.
METHODS The Cochrane, EMBASE, and PubMed databases were searched for relevant articles using MESH terms and free words. The hazard ratio of overall survival and the risk ratio (RR) for the pathological complete response, the sphincter preservation rate, and treatment-related adverse events were analyzed.
RESULTS A total of 19 studies of 60870 patients were included in the meta-analysis. There was no significant difference in overall survival [hazard ratio = 1.09, 95% confidence interval (CI) = 0.93–1.24; P = 0.19] or the pathological complete response (RR = 0.79, 95%CI = 0.61–1.03; P = 0.086) between the Neo-CT and Neo-CRT groups. As compared to the Neo-CRT group, the incidences of anastomotic fistula (RR = 0.49, 95%CI = 0.35–0.68; P = 0.000) and temporary colostomy (RR = 0.69, 95%CI = 0.58–0.83; P = 0.000) were significantly lower in the Neo-CT group, with a simultaneous increase in the sphincter preservation rate (RR = 1.07, 95%CI = 1.01–1.13; P = 0.029). However, there was no significant difference in the tumor downstaging rate, overall complications, and urinary complications.
CONCLUSION Neo-CT administration can lower the incidences of anastomotic fistula and temporary colostomy and increase the sphincter preservation rate as to compared to Neo-CRT and could provide an alternative to chemoradiotherapy for locally advanced rectal cancer.
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Affiliation(s)
- Pei Wu
- Department of Gastrointestinal Surgery, Yongchuan Hospital of Chongqing Medical University, Chongqing 402160, China
- Department of Surgical Oncology, The First Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Hui-Mian Xu
- Department of Surgical Oncology, The First Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Zhi Zhu
- Department of Surgical Oncology, The First Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
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13
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High-Resolution Diffusion-Weighted Imaging for Evaluation of Extramural Tumor Invasion in Primary Rectal Cancer. J Comput Assist Tomogr 2021; 45:522-527. [PMID: 34519451 DOI: 10.1097/rct.0000000000001165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The aim of this study was to determine the added value of high-resolution diffusion-weighted imaging (DWI) to T2-weighted imaging (T2WI) for evaluation of extramural tumor invasion (EMTI) in patients with primary rectal cancer. METHODS Seventy-eight patients who had undergone 3.0-T magnetic resonance imaging including DWI (b = 0, 1000 s/mm2, 2 mm iso-voxel) and subsequent surgery were included. Two blinded radiologists independently read the T2WI first and then the combined DWI set. They recorded their confidence level using a 5-point scale. The diagnostic accuracy was calculated by receiver operating characteristic curve analysis based on the histopathological results as the reference. RESULTS The study population consisted of EMTI positive (n = 44) and negative (n = 34). The area under the curve was not significantly increased after adding DWI to T2WI (reader 1, 0.868-0.856, P = 0.5618; reader 2, 0.848-0.865, P = 0.4539). CONCLUSION Adding DWI to T2WI showed no additional diagnostic value for the evaluation of EMTI in patients with primary rectal cancer.
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Lorenzo Liñán MÁ, García Armengol J, Martín Martín GP, Martínez Sanjuán V, Roig Vila JV. Validation of pelvic magnetic resonance imaging as the method of choice to determine the distance to the anal margin in rectal cancer. Cir Esp 2021; 100:S0009-739X(21)00245-1. [PMID: 34493375 DOI: 10.1016/j.ciresp.2021.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 06/30/2021] [Accepted: 07/06/2021] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Distance from anal verge of rectal tumors and their anatomical relationships contribute to determine the multidisciplinary therapeutic strategy based on the combination of radio-chemotherapy and radical surgery. Our aims are to investigate which is the most accurate method for the preoperative measuring of the distance from the anal verge in rectal tumors and if the pelvic MRI can substitute the classical instrumental methods. METHODS Prospective study of diagnostic precision between flexible colonoscopy (FC), preoperative rigid rectosigmoidoscopy (pRR) and pelvic MRI in patients scheduled to radical surgery. Rigid intraoperative rectoscopy (iRR) was considered the reference test. The correlations between the different techniques and their determination coefficient as well as the intraclass correlation coefficient and the degree of agreement between the different tests were analyzed. RESULTS 96 patients (65% males), mean age (SD): 68 (14.1) years were included. 72% received neoadjuvant treatment. The mean distance to the anal margin measured by FC=103.5mm, was significantly greater than others, which had similar values: pRR=81.1; MRI=77.4; iRR=82.9mm (P<.001). A significant intraclass correlation was observed and there was high agreement between all pre- and intraoperative measurements except for the performed by FC, which overestimated the results. MRI provided more individualized and accurate information. CONCLUSIONS There is variability between the measurement methods, being colonoscopy the least reliable. MRI offers objective, comparable, accurate and individualized values that can replace those obtained by pRR for tumors of any location in the rectum.
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Affiliation(s)
- Miguel Ángel Lorenzo Liñán
- Servicio de Cirugía General y Digestiva, Hospital Universitario Torrecárdenas, , Almería, España; La filiación de Miguel Ángel Lorenzo Liñán, Juan García Armengol, Gonzalo Pablo Martin Martin y José Vicente Roig Vila en el momento de la realización de este artículo era: Servicio de Cirugía General y del Aparato Digestivo, Consorcio Hospital General Universitario de Valencia, Valencia, España.
| | - Juan García Armengol
- Centro Europeo de Cirugía Colorrectal, Hospital Vithas Valencia 9 de Octubre, Valencia, España; La filiación de Miguel Ángel Lorenzo Liñán, Juan García Armengol, Gonzalo Pablo Martin Martin y José Vicente Roig Vila en el momento de la realización de este artículo era: Servicio de Cirugía General y del Aparato Digestivo, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - Gonzalo Pablo Martín Martín
- Cirugía, Centro Médico Teknon, Barcelona, España; La filiación de Miguel Ángel Lorenzo Liñán, Juan García Armengol, Gonzalo Pablo Martin Martin y José Vicente Roig Vila en el momento de la realización de este artículo era: Servicio de Cirugía General y del Aparato Digestivo, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - Vicente Martínez Sanjuán
- Servicio de Radiología y Resonancia Magnética, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - José Vicente Roig Vila
- Centro Europeo de Cirugía Colorrectal, Hospital Vithas Valencia 9 de Octubre, Valencia, España; La filiación de Miguel Ángel Lorenzo Liñán, Juan García Armengol, Gonzalo Pablo Martin Martin y José Vicente Roig Vila en el momento de la realización de este artículo era: Servicio de Cirugía General y del Aparato Digestivo, Consorcio Hospital General Universitario de Valencia, Valencia, España
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15
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Abdalla S, Benoist S, Lefèvre JH, Penna C, Brouquet A. New treatment strategies for non-metastatic rectal cancer. J Visc Surg 2021; 158:497-505. [PMID: 33926836 DOI: 10.1016/j.jviscsurg.2021.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The most widely practiced (standard) treatment of non-metastatic rectal cancer is based on proctectomy with mesorectal excision (partial or total according to the location of the tumor and commonly called TME). Surgery is preceded by CAP50-type chemoradiotherapy (capecitabineand 50 Grays radiation) and performed 6-8 weeks after the end of chemoradiotherapy. The development of new endoscopic, surgical, radiation-based and chemotherapeutic modalities leads surgeons to envisage customized treatment to find the best compromise between functional and oncologic results according to the locoregional extension of the tumor. Superficial lesions are amenable to transanal excision. T2-3 tumors<4cm are amenable to rectal preservation when neoadjuvant treatment obtains a complete response, allowing local excision or close surveillance. Intensification endocavitary radiotherapy and induction and consolidation chemotherapy regimens to avoid recourse to salvage abdomino-perineal resection (APR) are under investigation. For locally advanced rectal cancers (T3-4 and all N+ irrespective of T), the following scenarios can be envisaged: for initially resectable tumors (T3N0, T1-T3N+, circumferential resection margin>2mm), neoadjuvant chemotherapy alone aims to minimize the risk of local recurrence while avoiding the sequelae of radiotherapy. In case of initially non-resectable tumors (T4, circumferential resection margin<1mm), induction chemotherapy before chemoradiotherapy and consolidation chemotherapy after short course radiotherapy provide better results than standard treatment in terms of complete response and recurrence-free survival, and should be routinely proposed in this indication.
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Affiliation(s)
- S Abdalla
- Department of digestive and oncological surgery, Bicêtre hospital, Paris Sud university hospital Group, Assistance Publique-Hôpitaux de Paris, 63, rue Gabriel-Péri, 94275 Le Kremlin Bicêtre, France; Paris Sud Faculty of Medicine, Paris Saclay university, 94275 Le Kremlin-Bicêtre, France
| | - S Benoist
- Department of digestive and oncological surgery, Bicêtre hospital, Paris Sud university hospital Group, Assistance Publique-Hôpitaux de Paris, 63, rue Gabriel-Péri, 94275 Le Kremlin Bicêtre, France; Paris Sud Faculty of Medicine, Paris Saclay university, 94275 Le Kremlin-Bicêtre, France
| | - J H Lefèvre
- General and Digestive Surgery Department, Saint Antoine Hospital, Assistance Publique-Hôpitaux de Paris, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France; Faculty of Medicine Sorbonne University Paris VI, Paris, France
| | - C Penna
- Department of digestive and oncological surgery, Bicêtre hospital, Paris Sud university hospital Group, Assistance Publique-Hôpitaux de Paris, 63, rue Gabriel-Péri, 94275 Le Kremlin Bicêtre, France; Paris Sud Faculty of Medicine, Paris Saclay university, 94275 Le Kremlin-Bicêtre, France
| | - A Brouquet
- Department of digestive and oncological surgery, Bicêtre hospital, Paris Sud university hospital Group, Assistance Publique-Hôpitaux de Paris, 63, rue Gabriel-Péri, 94275 Le Kremlin Bicêtre, France; Paris Sud Faculty of Medicine, Paris Saclay university, 94275 Le Kremlin-Bicêtre, France.
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16
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Deschner BW, VanderWalde NA, Grothey A, Shibata D. Evolution and Current Status of the Multidisciplinary Management of Locally Advanced Rectal Cancer. JCO Oncol Pract 2021; 17:383-402. [PMID: 33881906 DOI: 10.1200/op.20.00885] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
The management of locally advanced rectal cancer has grown in both complexity and quality since the first proctectomy. What once was a malignancy with a fairly consistent treatment algorithm for decades, a recent paradigm shift in the care of these patients has led to a more personalized, multidisciplinary approach with variations in timing, sequence, duration, and potential exclusion of multimodality therapies. This review summarizes the most important evidence behind these developing overarching concepts to provide a context for this paradigm shift.
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Affiliation(s)
- Benjamin W Deschner
- Division of Surgical Oncology, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Noam A VanderWalde
- Radiation Oncology and Medical Oncology, West Cancer Center and Research Institute, Memphis, TN
| | - Axel Grothey
- Radiation Oncology and Medical Oncology, West Cancer Center and Research Institute, Memphis, TN
| | - David Shibata
- Division of Surgical Oncology, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
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17
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Park H. Predictive factors for early distant metastasis after neoadjuvant chemoradiotherapy in locally advanced rectal cancer. World J Gastrointest Oncol 2021; 13:252-264. [PMID: 33889277 PMCID: PMC8040066 DOI: 10.4251/wjgo.v13.i4.252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 01/11/2021] [Accepted: 03/16/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Distant relapse is the leading cause of cancer-related death in locally advanced rectal cancer. Neoadjuvant chemoradiation (NACRT) followed by surgery inevitably delays delivery of systemic treatment. Some patients show early distant metastasis before systemic treatment.
AIM To identify the most effective treatments. We investigated prognostic factors for distant metastasis, especially early distant metastasis, using the standard treatment paradigm to identify the most effective treatments according to recurrence risk.
METHODS From January 2015 through December 2019, rectal cancer patients who underwent NACRT for having clinical T 3-4 or clinical N 1-2 disease according to the 8th American Joint Committee on Cancer staging system were included. Radiotherapy was delivered to the whole pelvis with concomitant chemotherapy. Patients received surgery 6-8 wk after completion of NACRT. Adjuvant chemotherapy was administered at the physician’s discretion.
RESULTS A total of 127 patients received NACRT. Ninety-three patients (73.2%) underwent surgery. The R0 resection rate was 89.2% in all patients. Pathologic tumor and node downstaging rates were 41.9% and 76.3%. Half the patients (n = 69) received adjuvant chemotherapy after surgery. The 3-year distant metastasis-free survival (DMFS) and overall survival (OS) rates were 81.7% and 83.5%. On univariate analyses, poorly differentiated tumors, > 5 cm, involvement of mesorectal fascia (MRF), or presence of extramural involvement (EMVI) were associated with worse DMFS and OS. Five patients showed distant metastasis at their first evaluation after NACRT. Patients with early distant metastasis were more likely to have poorly differentiated tumor (P = 0.025), tumors with involved MRF (P = 0.002), and EMVI (P = 0.012) than those who did not.
CONCLUSION EMVI, the involvement of MRF, and poor histologic grade were associated with early distant metastasis. In order to control distant metastasis and improve treatment outcome, selective use of neoadjuvant treatment according to individualized risk factors is necessary. Future studies are required to determine effective treatment strategies for patients at high risk for distant metastasis.
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Affiliation(s)
- Hyojung Park
- Departments of Radiation Oncology, Dankook University Hospital, Dankook University College of Medicine, Cheonan 46115, South Korea
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Cienfuegos JA, Rodríguez J, Baixauli J, Chopitea Ortega A, García-Consuegra A, Abengózar M, Sánchez Justicia C, Hernández Lizoain JL. Neoadjuvant chemotherapy without radiotherapy for patients with locally advanced rectal cancer. Oncologic outcomes. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2021; 112:16-22. [PMID: 31729235 DOI: 10.17235/reed.2019.6454/2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND the standard treatment for locally advanced rectal cancer is neoadjuvant chemo-radiotherapy, surgery and adjuvant chemotherapy. Only 50% of patients receive the adjuvant treatment due to the surgical complications and toxicity of radiotherapy. Recently, neoadjuvant chemotherapy has been investigated in the locally advanced rectal cancer setting, with the aim of guaranteeing an uninterrupted systemic treatment. The objective of the present study was to assess the safety and efficacy of neoadjuvant chemotherapy in locally advanced rectal cancer. METHODS AND PATIENTS patients treated with neoadjuvant chemotherapy and surgery were identified from a prospective database of patients with rectal cancer (cII-III). The primary outcomes were the assessment of the number of R0 resections, the degree of pathologic response, patterns of recurrence and overall and disease-free survival. Treatment schedule: patients received 6-8 cycles of oxaliplatin and fluoropyrimides based chemotherapy. RESULTS twenty-seven patients who received neoadjuvant chemotherapy were identified. Twenty-six anterior resections and one Hartmann intervention were performed. An R0 resection was performed in 27 (100%) patients and no involvement of the circumferential margin was observed. Complete pathologic response (ypT0N0) was confirmed in four (14.8%) patients. The median follow-up was 35 months (range: 10-81) and four distant recurrences were recorded. Overall and disease-free survival at five years was 85% and 84.7%, respectively. Twenty-seven (100%) patients received all the cycles of chemotherapy, with a mean of six cycles (range 5-8) per patient. CONCLUSIONS neoadjuvant chemotherapy is a promising alternative in the locally advanced rectal cancer setting and further phase III clinical trials are clearly warranted.
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Affiliation(s)
- Javier A Cienfuegos
- Cirugía General / Apoyo Investigación, Clinica Universidad de Navarra, España
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19
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Zhou Y, Guo Z, Wu Z, Shi J, Zhou C, Sun J, Hidasa I, Lu X, Lu C. The efficacy and safety of adding bevacizumab in neoadjuvant therapy for locally advanced rectal cancer patients: A systematic review and meta-analysis. Transl Oncol 2020; 14:100964. [PMID: 33248411 PMCID: PMC7704460 DOI: 10.1016/j.tranon.2020.100964] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 11/15/2020] [Accepted: 11/16/2020] [Indexed: 01/11/2023] Open
Abstract
Background Patients with locally advanced rectal cancer (LARC) are more likely to suffer local recurrence and distant metastases, contributing to worse prognoses. Considering the provided dramatic reduction of local recurrences, neoadjuvant CRT (nCRT) followed by curative resection with total mesorectal excision (TME) and adjuvant chemotherapy has been established as standard therapy for LARC patients. However, the efficacy of adding bevacizumab in neoadjuvant therapy, especially in induction therapy-containing nCRT for LARC patients remains uncertain. Materials PubMed, Embase, and Web of Science were searched to retrieve records on the application of bevacizumab in a neoadjuvant setting for LARC patients. The endpoints of interest were pCR and the rates of patients suffering Grade 3/4 bevacizumab-specific adverse events, namely bleeding, wound healing complications, and gastrointestinal perforation. Results 29 cohorts covering 1134 subjects were included in this systematic review. The pooled pCR rate for bevacizumab-relevant cohorts was 21% (95% confidence interval (95% CI), 17–25%; I2 = 61.8%), the pooled estimates of Grade 3/4 bleeding, Grade 3/4 wound healing complication, Grade 3/4 gastrointestinal perforation were 1% (95% CI, 0–3%; I2 = 0%), 2% (95% CI, 1–5%; I2 = 4.7%), and 2% (95% CI, 0–5%; I2 = 0%), respectively. Conclusion The addition of bevacizumab in the nCRT, especially in the TNT, for LARC patients provides promising efficacy and acceptable safety. However, the results should be interpreted cautiously due to the small amount of relevant data and need further confirmation by future studies.
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Affiliation(s)
- Yue Zhou
- Department of Medical Oncology, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang 110001, China
| | - Zhexu Guo
- Department of Surgical Oncology and General Surgery, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, China
| | - Zhonghua Wu
- Department of Surgical Oncology and General Surgery, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, China
| | - Jinxin Shi
- Department of Surgical Oncology and General Surgery, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, China
| | - Cen Zhou
- Department of Surgical Oncology and General Surgery, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, China
| | - Jie Sun
- Department of Surgical Oncology and General Surgery, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, China
| | - Iko Hidasa
- Department of Surgical Oncology and General Surgery, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, China
| | - Xuefei Lu
- Department of Pediatrics, People's Hospital of Yifeng County, 24 Chengnanmen Road, Yifeng County, Yichun 336300, China
| | - Chong Lu
- Department of Surgical Oncology and General Surgery, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, China.
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Bhudia J, Glynne-Jones R, Smith T, Hall M. Neoadjuvant Chemotherapy without Radiation in Colorectal Cancer. Clin Colon Rectal Surg 2020; 33:287-297. [PMID: 32968364 PMCID: PMC7500967 DOI: 10.1055/s-0040-1713746] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In colon cancer, primary surgery followed by postoperative chemotherapy represents the standard of care. In rectal cancer, the standard of care is preoperative radiotherapy or chemoradiation, which significantly reduces local recurrence but has no impact on subsequent metastatic disease or overall survival. The administration of neoadjuvant chemotherapy (NACT) before surgery can increase the chance of a curative resection and improves long-term outcomes in patients with liver metastases. Hence, NACT is being explored in both primary rectal and colon cancers as an alternative strategy to shrink the tumor, facilitate a curative resection, and simultaneously counter the risk of metastases. Yet, this lack of clarity regarding the precise aims of NACT (downstaging, maximizing response, or improving survival) is hindering progress. The appropriate cytotoxic agents, the optimal regimen, the number of cycles, or duration of NACT prior to surgery or in the postoperative setting remains undefined. Several potential strategies for integrating NACT are discussed with their advantages and disadvantages.
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Affiliation(s)
- Jyotsna Bhudia
- Department of Radiotherapy, Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, United Kingdom
| | - Rob Glynne-Jones
- Department of Radiotherapy, Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, United Kingdom
| | - Thomas Smith
- Department of Radiotherapy, Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, United Kingdom
| | - Marcia Hall
- Department of Medical Oncology, Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, United Kingdom
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21
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Barzi A, Choi A, Tsao-Wei D, Iqbal S, El-Khoueiry A, Agafitei DR, Cologne KG, Lenz HJ. Phase II Trial of Neoadjuvant Bevacizumab with Modified FOLFOX7 in Patients with Stage II and III Rectal Cancer. Oncologist 2020; 25:e1879-e1885. [PMID: 32649004 DOI: 10.1634/theoncologist.2020-0642] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/28/2020] [Indexed: 01/04/2023] Open
Abstract
LESSONS LEARNED Neoadjuvant bevacizumab with modified FOLFOX7 without radiation failed to meet the goal of pathological complete response rate; however, the low number of recurrence and disease-free survival in this population, with predominantly stage III, is encouraging and worth further exploration. The racial distribution of the patient population, as well as a wait time of more than 4 weeks after last chemotherapy, may have contributed to the findings. BACKGROUND Combination chemotherapy in lieu of radiation in rectal adenocarcinoma is under exploration in multiple trials. We evaluated the efficacy of neoadjuvant FOLFOX + bevacizumab in patients (pts) with clinical stage II and III disease. METHODS Pts received six cycles of bevacizumab (5 mg/kg) and modified FOLFOX7 (oxaliplatin 85 mg/m2 , leucovorin 20 mg/m2 , and fluorouracil [5-FU] 2,400 mg/m2 ). Surgical resection was performed 6-8 weeks after completion of treatment and upon confirmation of nonmetastatic disease. We employed a Simon two-stage design and required three pathological complete responses (pCR) in the first 18 pts, with a prespecified pCR rate of 25% before moving to the next stage. RESULTS Seventeen pts enrolled; 65% at stage III. Median age was 57 (35-79), 65% were male, 47% were Hispanic, 35% were white, and 18% were Asian. All pts but one completed six cycles of therapy. One pCR was observed (6%), and 11 of 17 (65%) pts had pathological downstaging. One patient experienced systemic recurrence and remains on treatment. Probability of disease-free survival (DFS) at 5 years is 0.94 (SE, 0.06). CONCLUSION The study failed to meet the required three pCRs in the first 18 pts. The DFS in this population is encouraging and supports the hypothesis that select pts with rectal cancer may be spared from radiation.
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Affiliation(s)
- Afsaneh Barzi
- Department of Medicine, USC Norris Comprehensive Cancer Center, Los Angeles, California
- City of Hope National Medical Center, Duarte, California
| | - April Choi
- Department of Medicine, USC Norris Comprehensive Cancer Center, Los Angeles, California
| | - Denice Tsao-Wei
- Department of Preventive Medicine, USC Norris Comprehensive Cancer Center, Los Angeles, California
| | - Syma Iqbal
- Department of Medicine, USC Norris Comprehensive Cancer Center, Los Angeles, California
| | - Anthony El-Khoueiry
- Department of Medicine, USC Norris Comprehensive Cancer Center, Los Angeles, California
| | - Dana Raluca Agafitei
- Department of Medicine, USC Norris Comprehensive Cancer Center, Los Angeles, California
| | - Kyle G Cologne
- Department of Surgery, Keck School of Medicine, Los Angeles, California
| | - Heinz-Josef Lenz
- Department of Medicine, USC Norris Comprehensive Cancer Center, Los Angeles, California
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22
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Nishimura J, Hasegawa J, Noura S, Ikeda K, Yasui M, Komori T, Tsujie M, Yasumasa K, Shingai T, Uemura M, Hata T, Matsuda C, Mizushima T, Ikeda M, Doki Y, Mori M. Adjuvant Chemotherapy after Neoadjuvant Chemotherapy and Long-term Outcomes of CAPOX Plus Bevacizumab Followed by TME for High-risk Localized Rectal Cancer. JOURNAL OF THE ANUS RECTUM AND COLON 2020; 4:108-113. [PMID: 32743112 PMCID: PMC7390618 DOI: 10.23922/jarc.2019-042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 03/19/2020] [Indexed: 11/30/2022]
Abstract
Objectives: We previously reported the feasibility of neoadjuvant capecitabine and oxaliplatin plus bevacizumab as a treatment for locally advanced rectal cancer (UMIN000003219). The aim of this study is to investigate the prognostic relevance of neoadjuvant chemotherapy followed by total mesorectal resection (TME). Methods: Twenty-five patients of our prior multicenter prospective study of neoadjuvant chemotherapy followed by TME enrolled to this study. We analyzed the adjuvant chemotherapy regimen, and the duration between surgery and initial chemotherapy treatment. Five-year progression-free survival and overall survival were estimated using the Kaplan-Meier method. Results: Among survivors, the median follow-up time was 66 months. Recurrence occurred in six patients, all of whom had suboptimal tumor regression after neoadjuvant chemotherapy. Five patients died from other causes. The rate of local recurrence and distant metastasis was 17.4% and 8.7%, respectively. Five-year progression-free survival was 70.0%, and 5 year overall survival was 84.0%. Conclusions: We report the long-term survival of patients who received neoadjuvant chemotherapy without radiation followed by TME, revealing a generally favorable prognosis.
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Affiliation(s)
- Junichi Nishimura
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | | | - Shingo Noura
- Department of Surgery, Osaka Rosai Hospital, Sakai, Japan
| | - Kimimasa Ikeda
- Department of Surgery, Minoh City Hospital, Minoh, Japan
| | - Masayoshi Yasui
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Takamichi Komori
- Department of Surgery, Osaka General Medical Center, Osaka, Japan
| | - Masaki Tsujie
- Department of Surgery, Sakai City Medical Center, Sakai, Japan
| | - Keigo Yasumasa
- Department of Surgery, JCHO Osaka Hospital, Osaka, Japan
| | | | - Mamoru Uemura
- Department of Gastroenterological Surgery, Osaka University, Suita, Japan
| | - Taishi Hata
- Department of Gastroenterological Surgery, Osaka University, Suita, Japan
| | - Chu Matsuda
- Department of Gastroenterological Surgery, Osaka University, Suita, Japan
| | | | - Masataka Ikeda
- Department of Surgery, National Hospital Organization, Osaka National Hospital, Osaka, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Osaka University, Suita, Japan
| | - Masaki Mori
- Department of Surgery and Science, Kyushu University, Fukuoka, Japan
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Brouquet A, Bachet JB, Huguet F, Karoui M, Artru P, Sabbagh C, Lefèvre JH, Vernerey D, Mariette C, Vicaut E, Benoist S. NORAD01-GRECCAR16 multicenter phase III non-inferiority randomized trial comparing preoperative modified FOLFIRINOX without irradiation to radiochemotherapy for resectable locally advanced rectal cancer (intergroup FRENCH-GRECCAR- PRODIGE trial). BMC Cancer 2020; 20:485. [PMID: 32471382 PMCID: PMC7257230 DOI: 10.1186/s12885-020-06968-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 05/17/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Preoperative radiochemotherapy (RCT) is recommended in France prior to total mesorectal excision in patients with mid or low locally advanced rectal cancer (LARC) (cT3/T4 and/or N+) because it has been shown to improve local control. Preoperative RCT has also disadvantages including the absence of proven impact on metastatic recurrence and the risk of late side effects on bowel and genitourinary function. In patients with primarily resectable LARC, preoperative systemic chemotherapy without pelvic irradiation could be used as an alternative to RCT. METHODS This study is a multicenter, open-label randomized, 2-arm phase III non-inferiority trial. Patients with mid or low resectable LARC (cT3N0 or cT1-T3N+ with circumferential resection margin [CRM] > 2 mm on pretreatment MRI) will be randomized to either modified FOLFIRINOX for 3 months or RCT (Cap50 intensified-modulated radiotherapy). All patients have restaging MRI after preoperative treatment. The primary endpoint is 3-year progression-free survival (PFS) from the time to randomization including progression during preoperative treatment. Secondary endpoints are treatment related toxicity, treatment compliance, R0 resection rate, sphincter saving surgery rate, postoperative morbidity and mortality rates, loco-regional recurrence free survival, overall survival, bowel and sexual functions at diagnosis, quality of life, radiologic and pathologic response after preoperative treatment. The number of patients required is 574. DISCUSSION The choice of modified FOLFIRINOX for preoperative chemotherapy is supported by recent and consistent data on safety and efficacy of this regimen on rectal cancer. The use of preoperative chemotherapy instead of RCT could be associated with pronounced advantages in terms of functional results and quality of life in cancer survivors. However and first of all, the non-inferiority of preoperative chemotherapy compared to RCT on oncologic outcome has to be validated. If this study demonstrates the non-inferiority of chemotherapy compared to RCT, this can lead to a crucial change in clinical practice in a large subset of rectal cancer patients. TRIAL REGISTRATION ClinicalTrials.gov NCT03875781 (March 15, 2019). Version 1.1.
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Affiliation(s)
- Antoine Brouquet
- Service de Chirurgie Digestive et Oncologique, Hôpital Bicêtre, Groupe Hospitalier Universitaire Paris Sud, Assistance Publique, Hôpitaux de Paris, 63, rue Gabriel Péri, Le Kremlin Bicetre, 94275, France. .,Faculté de Médecine Paris Sud, Université Paris Saclay, Lrekmlin Bicêtre, 94275, France.
| | - Jean-Baptiste Bachet
- Service d'Oncologie Digestive, Hôpital de la Pitié Salpétrière, Assistance Publique, Hôpitaux de Paris, Paris, 75013, France
| | - Florence Huguet
- Service de Radiothérapie, Hôpital Tenon, Assistance Publique, Hôpitaux de Paris, Paris, 75020, France
| | - Mehdi Karoui
- Service de Chirurgie Digestive, Hôpital Européen Georges Pompidou, Assistance Publique, Hôpitaux de Paris, Paris, 75015, France
| | | | - Charles Sabbagh
- Service de Chirurgie Digestive, CHU Amiens, Amiens, 60000, France
| | - Jérémie H Lefèvre
- Service de Chirurgie Générale et Digestive, Hôpital Saint Antoine, Assistance Publique, Hôpitaux de Paris, Paris, 75012, France
| | | | - Christophe Mariette
- Service de Chirurgie Digestive et Oncologique, CHU Lille, Lille, 59000, France
| | - Eric Vicaut
- Unité de Recherche Clinique Paris VII, Assistance Publique, Hôpitaux de Paris, Paris, 75010, France
| | - Stephane Benoist
- Service de Chirurgie Digestive et Oncologique, Hôpital Bicêtre, Groupe Hospitalier Universitaire Paris Sud, Assistance Publique, Hôpitaux de Paris, 63, rue Gabriel Péri, Le Kremlin Bicetre, 94275, France.,Faculté de Médecine Paris Sud, Université Paris Saclay, Lrekmlin Bicêtre, 94275, France
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24
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Zhang YX, Liu HY, Jiang B, Wang WY, Wang HB, Lu YJ. Stepwise neoadjuvant chemoradiotherapy in the management of mid-low locally advanced rectal cancer. Eur J Surg Oncol 2020; 46:410-414. [DOI: 10.1016/j.ejso.2019.10.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 08/25/2019] [Accepted: 10/10/2019] [Indexed: 02/06/2023] Open
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25
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Jia AY, Narang A, Safar B, Zaheer A, Murphy A, Azad NS, Gearhart S, Fang S, Efron J, Warczynski T, Hacker-Prietz A, Meyer J. Sequential short-course radiation therapy and chemotherapy in the neoadjuvant treatment of rectal adenocarcinoma. Radiat Oncol 2019; 14:147. [PMID: 31426827 PMCID: PMC6700789 DOI: 10.1186/s13014-019-1358-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 08/12/2019] [Indexed: 01/13/2023] Open
Abstract
Background There is continued debate regarding the optimal combinations of radiation therapy and chemotherapy in the preoperative treatment of locally advanced rectal adenocarcinomas. We report our single-institution experience of feasibility and early oncologic outcomes of short-course preoperative radiation therapy (5 Gy X 5 fractions) followed by consolidation neoadjuvant chemotherapy. Methods We reviewed the records of 26 patients with locally advanced rectal adenocarcinoma. All patients underwent short course radiotherapy (5 Gy X 5 fractions) followed by chemotherapy [either modified infusional and bolus 5-fluorouracail and oxalipatin (mFOLFOX6) or capecitabine and oxaliplatin] prior to consideration for surgery. A full course of chemotherapy was defined as at least 8 weeks of chemotherapy. Results There were five clinical (c) T2, 16 cT3, and five cT4 rectal tumors, with 88% cN+. Twenty-five patients received a median of 4 cycles (range 3 to 8) of mFOLFOX6 (with one cycle defined as a two-week period); one patient received 3 cycles of capecitabine and oxaliplatin. All patients completed SCRT; 81% completed the full course of neoadjuvant chemotherapy with 19% requiring dose reductions in chemotherapy, most commonly due to neuropathy. Nineteen patients underwent post-treatment endoscopic evaluation, and nine patients were noted to achieve a complete clinical response (CCR). Six of the nine patients who achieved CCR opted for a non-operative approach of watch-and-wait. Twenty patients underwent surgical resection; pathologic complete response was observed in seven (35%) of these twenty. The main radiation-associated toxicity was proctitis with CTCAE Grade 2 proctitis observed in seven patients (27%). Post-operative Clavien-Dindo Grade 3 complications within 30 days of surgery were identified in six patients (30%), with no Grade 4 or 5 adverse events. Median length of hospital stay was 4.5 days (range 2–16 days); three patients were readmitted within a 30 day period. Conclusions Short course preoperative radiotherapy followed by neoadjuvant chemotherapy was well-tolerated and achieved oncologic outcomes that compare favorably with short-course radiation therapy alone or long-course chemoradiotherapy. This regimen is associated with high rates of clinical and pathologic complete response.
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Affiliation(s)
- Angela Y Jia
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amol Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bashar Safar
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Atif Zaheer
- Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Adrian Murphy
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nilofer S Azad
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Susan Gearhart
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sandy Fang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan Efron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tam Warczynski
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amy Hacker-Prietz
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jeffrey Meyer
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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The treatment of rectal cancer with synchronous liver metastases: A matter of strategy. Crit Rev Oncol Hematol 2019; 139:91-95. [DOI: 10.1016/j.critrevonc.2019.05.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 05/07/2019] [Accepted: 05/08/2019] [Indexed: 12/14/2022] Open
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Buccafusca G, Proserpio I, Tralongo AC, Rametta Giuliano S, Tralongo P. Early colorectal cancer: diagnosis, treatment and survivorship care. Crit Rev Oncol Hematol 2019; 136:20-30. [PMID: 30878125 DOI: 10.1016/j.critrevonc.2019.01.023] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 12/29/2018] [Accepted: 01/29/2019] [Indexed: 12/11/2022] Open
Abstract
CRC is the third most commonly diagnosed malignancy and the fourth leading cause of cancer-related death in the world. With advances in treatment, colorectal cancer is being transformed from a deadly disease to an illness that is increasingly curable. With this transformation has come increased interest in the unique problems, risks, needs, and concerns of survivors who have completed treatment and are cancer-free. They often suffer late/long-term side effects of therapies that may compromise their QoL such as fatigue, sleep difficulty, fear of recurrence, anxiety, depression, negative body image, sensory neuropathy, gastrointestinal problems, urinary incontinence, and sexual dysfunction. In this review, we discuss what is known about early colorectal diagnosis, staging, treatments and their long-term effects on quality of life and survivorship care.
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Affiliation(s)
- Gabriella Buccafusca
- UOC Oncologia Medica, Ospedale Umberto I, Via Giuseppe Testaferrata 1, 96100, Siracusa, Italy
| | - Ilaria Proserpio
- UOC Oncologia Medica, ASST Settelaghi, Ospedale di Circolo e Fondazione Macchi, Via Francesco Guicciardini 9, 21100, Varese, Italy
| | - Antonino Carmelo Tralongo
- UOC Oncologia Medica, ASST Settelaghi, Ospedale di Circolo e Fondazione Macchi, Via Francesco Guicciardini 9, 21100, Varese, Italy
| | | | - Paolo Tralongo
- UOC Oncologia Medica, Ospedale Umberto I, Via Giuseppe Testaferrata 1, 96100, Siracusa, Italy.
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Bachet J, Lucidarme O, Levache C, Barbier E, Raoul J, Lecomte T, Desauw C, Brocard F, Pernot S, Breysacher G, Lagasse J, Di Fiore F, Etienne P, Dupuis O, Aleba A, Lepage C, Taieb J, Dahan L, Auby D, Khemissa F, Ghiringhelli F, Nguyen S, Bedjaoui A, Terrebonne E, Thaury J, Baconnier M. FOLFIRINOX as induction treatment in rectal cancer patients with synchronous metastases: Results of the FFCD 1102 phase II trial. Eur J Cancer 2018; 104:108-116. [DOI: 10.1016/j.ejca.2018.09.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 08/20/2018] [Accepted: 09/09/2018] [Indexed: 01/29/2023]
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Koizumi M, Yamada T, Shinji S, Yokoyama Y, Takahashi G, Iwai T, Takeda K, Hara K, Ohta K, Uchida E, Yoshida H. Feasibility of Neoadjuvant FOLFOX Therapy Without Radiotherapy for Baseline Resectable Rectal Cancer. In Vivo 2018; 32:937-943. [PMID: 29936483 DOI: 10.21873/invivo.11332] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 05/08/2018] [Accepted: 05/09/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND/AIM The combination of oxaliplatin, leucovorin and fluorouracil (FOLFOX) has been established as postoperative adjuvant chemotherapy for stage III colon cancer. However, the safety and efficacy of neoadjuvant FOLFOX in patients with rectal cancer are still controversial. This prospective pilot study aimed to evaluate the feasibility of neoadjuvant FOLFOX therapy without radiation for baseline resectable rectal cancer (RC). PATIENTS AND METHODS The study included 30 patients with clinical stage II/III RC between February 2012 and December 2015. The patients were treated with six cycles of FOLFOX followed by elective surgery. The primary endpoint was the R0 resection rate. The secondary endpoints were the scheduled treatment completion rate, adverse events, pathological response and the disease-free survival (DFS) rate. RESULTS All the patients underwent elective R0 resection after neoadjuvant FOLFOX therapy. The completion rate of the 6-cycle regimen was 93.3% (28/30 patients). Grade 3-4 adverse events occurred in seven patients (23.3%). Pathological complete response was noted in two patients (6.7%). The 3-year DFS rate was 77.5% (95% confidence interval, 61.4%-93.7%). CONCLUSION Neoadjuvant FOLFOX therapy without radiation is a feasible therapeutic strategy for baseline resectable RC.
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Affiliation(s)
- Michihiro Koizumi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Takeshi Yamada
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Seiichi Shinji
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Yasuyuki Yokoyama
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Goro Takahashi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Takuma Iwai
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Kohki Takeda
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Keisuke Hara
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Keiichiro Ohta
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Eiji Uchida
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Hiroshi Yoshida
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
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Glynne-Jones R, Hall M, Lopes A, Pearce S, Goh V, Bosompem S, Bridgewater J, Chau I, Wasan H, Moran B, Melcher L, West N, Quirke P, Wong WL, Beare S, Hava N, Duggan M, Harrison M. BACCHUS: A randomised non-comparative phase II study of neoadjuvant chemotherapy (NACT) in patients with locally advanced rectal cancer (LARC). Heliyon 2018; 4:e00804. [PMID: 30258994 PMCID: PMC6151852 DOI: 10.1016/j.heliyon.2018.e00804] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 08/06/2018] [Accepted: 09/13/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Chemoradiation (CRT) or short-course radiotherapy (SCRT) are standard treatments for locally advanced rectal cancer (LARC). We evaluated the efficacy/safety of two neoadjuvant chemotherapy (NACT) regimens as an alternative prior to total mesorectal excision (TME). METHODS/DESIGN This multi-centre, phase II trial in patients with magnetic resonance imaging (MRI) defined high-risk LARC (>cT3b, cN2+ or extramural venous invasion) randomised patients (1:1) to FOLFOX + Bevacizumab (Arm 1) or FOLFOXIRI + bevacizumab (Arm 2) every 14 days for 6 cycles prior to surgery. Patients were withdrawn if positron emission tomography (PET) standardised uptake value (SUV) after 3 cycles failed to decrease by >30% or increased compared to baseline. Primary endpoint was pathological complete response rate (pCR). Secondary endpoints included adverse events (AE) and toxicity. Neoadjuvant rectal (NAR) scores based on "T" and "N" downstaging were calculated. FINDINGS Twenty patients aged 18-75 years were randomised. The trial stopped early because of poor accrual. Seventeen patients completed all 6 cycles of NACT. One stopped due to myocardial infarction, 1 poor response on PET (both received CRT) and 1 committed suicide. 11 patients had G3 AE, 1 G4 AE (neutropenia), and 1 G5 (suicide). pCR (the primary endpoint) was 0/10 for Arm 1 and 2/10 for Arm 2 i.e. 2/20 (10%) overall. Median NAR score was 14·9 with 5 (28%), 7 (39%), and 6 (33%) having low, intermediate, or high scores. Surgical morbidity was acceptable (1/18 wound infection, no anastomotic leak/pelvic sepsis/fistulae). The 24-month progression-free survival rate was 75% (95% CI: 60%-85%). INTERPRETATION The primary endpoint (pCR rate) was not met. However, FOLFOXIRI and bevacizumab achieved promising pCR rates, low NAR scores and was well-tolerated. This regimen is suitable for testing as the novel arm against current standards of SCRT and/or CRT in a future trial.
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Affiliation(s)
- R. Glynne-Jones
- Radiotherapy Department, Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, UK
| | - M.R. Hall
- Radiotherapy Department, Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, UK
| | - A. Lopes
- Cancer Research UK & University College London Cancer Trials Centre, London, UK
| | - S. Pearce
- Cancer Research UK & University College London Cancer Trials Centre, London, UK
| | - V. Goh
- Division of Imaging Sciences & Biomedical Engineering, Kings College London, Department of Radiology, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, SE1 7EH, UK
| | - S. Bosompem
- Pharmacy Department, Milton Keynes University Hospital NHS Trust, Milton Keynes, United Kingdom
| | - J. Bridgewater
- University College, London Cancer Institute, 72 Huntley St., London, WC1E 6AA, UK
| | - I. Chau
- Department of Medical Oncology, Royal Marsden Hospital, London & Surrey, UK
| | - H. Wasan
- Department of Cancer Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - B. Moran
- Department of Surgery, Hampshire Hospitals Foundation Trust, Basingstoke, Hampshire, UK
| | - L. Melcher
- Radiotherapy Department, North Middlesex Hospital, Sterling Way, London, N18 1QX, UK
| | - N.P. West
- Leeds Institute of Cancer and Pathology, School of Medicine, University of Leeds, Leeds, United Kingdom
| | - P. Quirke
- Leeds Institute of Cancer and Pathology, School of Medicine, University of Leeds, Leeds, United Kingdom
| | - W.-L. Wong
- Department of Radiology, Paul Strickland Scanner Centre, Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, UK
| | - S. Beare
- Cancer Research UK & University College London Cancer Trials Centre, London, UK
| | - N. Hava
- Cancer Research UK & University College London Cancer Trials Centre, London, UK
| | - M. Duggan
- Cancer Research UK & University College London Cancer Trials Centre, London, UK
| | - M. Harrison
- Radiotherapy Department, Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, UK
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Lin XL, Xiao XY. Progress in neoadjuvant drug therapy of rectal cancer. Shijie Huaren Xiaohua Zazhi 2018; 26:1340-1347. [DOI: 10.11569/wcjd.v26.i22.1340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Rectal cancer is one of the most common malignant tumors of the digestive system. A portion of patients have had locally advanced disease at the time of diagnosis and have lost the chance of radical surgery. How to increase the R0 resection rate has always been a major difficulty in clinical practice. Some studies have shown that for some patients, neoadjuvant drug therapy can achieve reduction of clinical stage, increase the R0 resection rate and anus-preserving rate, reduce the local recurrence and micro-metastasis, and prolong the survival time of patients. This article mainly reviews the progress in neoadjuvant drug therapy of rectal cancer.
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Affiliation(s)
- Xiao-Lin Lin
- Department of Oncology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Xiu-Ying Xiao
- Department of Oncology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
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Narang AK, Meyer J. Neoadjuvant Short-Course Radiation Therapy for Rectal Cancer: Trends and Controversies. Curr Oncol Rep 2018; 20:68. [DOI: 10.1007/s11912-018-0714-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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KOIZUMI MICHIHIRO, YAMADA TAKESHI, SHINJI SEIICHI, YOKOYAMA YASUYUKI, TAKAHASHI GORO, IWAI TAKUMA, TAKEDA KOHKI, HARA KEISUKE, OHTA KEIICHIRO, UCHIDA EIJI, YOSHIDA HIROSHI. Feasibility of Neoadjuvant FOLFOX Therapy Without Radiotherapy for Baseline Resectable Rectal Cancer. In Vivo 2018. [PMID: 29936483 PMCID: PMC6117778 DOI: 10.21873/invivo.112332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND/AIM The combination of oxaliplatin, leucovorin and fluorouracil (FOLFOX) has been established as postoperative adjuvant chemotherapy for stage III colon cancer. However, the safety and efficacy of neoadjuvant FOLFOX in patients with rectal cancer are still controversial. This prospective pilot study aimed to evaluate the feasibility of neoadjuvant FOLFOX therapy without radiation for baseline resectable rectal cancer (RC). PATIENTS AND METHODS The study included 30 patients with clinical stage II/III RC between February 2012 and December 2015. The patients were treated with six cycles of FOLFOX followed by elective surgery. The primary endpoint was the R0 resection rate. The secondary endpoints were the scheduled treatment completion rate, adverse events, pathological response and the disease-free survival (DFS) rate. RESULTS All the patients underwent elective R0 resection after neoadjuvant FOLFOX therapy. The completion rate of the 6-cycle regimen was 93.3% (28/30 patients). Grade 3-4 adverse events occurred in seven patients (23.3%). Pathological complete response was noted in two patients (6.7%). The 3-year DFS rate was 77.5% (95% confidence interval, 61.4%-93.7%). CONCLUSION Neoadjuvant FOLFOX therapy without radiation is a feasible therapeutic strategy for baseline resectable RC.
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Patel UB, Cervantes A, Fernández-Martos C, Sclafani F, Cunningham D, Nilsson P, Brown G. Session 2: Are we ready for primary chemotherapy in rectal cancer: who, when, why? Colorectal Dis 2018; 20 Suppl 1:56-60. [PMID: 29878678 DOI: 10.1111/codi.14081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The potential of preoperative chemotherapy in rectal cancer is the subject of investigation in a number of global randomized trials. In this overview and expert discussion, Professor Cervantes summarizes the findings of numerous Phase II trials testing neoadjuvant chemotherapy. The crucial points in the next phase of trials include: patient selection, whether radiotherapy can be omitted altogether and whether chemotherapy can be used to augment the initial response to chemoradiotherapy. Finally, with the emergence of Magnetic Resonance Tumour Regression Grade a reliable method for assessing response after initial chemoradiotherapy, we ask if this can be used to drive the use of further selective chemotherapy to augment response.
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Affiliation(s)
- U B Patel
- London North-West HealthCare NHS Trust, London, UK
| | | | | | - F Sclafani
- The Royal Marsden NHS Foundation Trust, London, UK
| | - D Cunningham
- NIHR Biomedical Research Centre, The Royal Marsden NHS Foundation Trust, London, UK
| | - P Nilsson
- Karolinkska Institute, Stockholm, Sweden
| | - G Brown
- The Royal Marsden NHS Foundation Trust, London, UK.,Imperial College London, London, UK
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Qin Q, Wang L. Neoadjuvant therapy and subsequent treatment in rectal cancer: balance between oncological and functional outcomes. JOURNAL OF THE ANUS RECTUM AND COLON 2018; 2:47-58. [PMID: 31583321 PMCID: PMC6768820 DOI: 10.23922/jarc.2017-049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 02/09/2018] [Indexed: 12/21/2022]
Abstract
Current practice of neoadjuvant therapy and total mesorectal excision (TME) in rectal cancer bears the weakness in systemic disease control and long-term functional outcomes. With increasing concerns of the balance between cure and quality of life, new strategies are developed to better oncological outcomes at least cost of function damage. Attractive options to adjust neoadjuvant modality include escalation of radiotherapy, intensification of chemotherapy, and chemoradiotherapy with consolidation or full-course chemotherapy. Subsequently, organ-preserving strategies have gained the popularity. Surgical or nonsurgical approaches that spare the rectum are used as possible alternatives for radical surgery, though high-quality TME remains the last resort to offer reliable local disease control. This review discusses new strategies of neoadjuvant therapy and subsequent management, with a specific focus on the balance between oncological and functional outcomes.
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Affiliation(s)
- Qiyuan Qin
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Lei Wang
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Sun Yat-sen University, Guangzhou, Guangdong, China
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36
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Martella A, Willett C, Palta M, Czito B. The Selective Use of Radiation Therapy in Rectal Cancer Patients. Curr Oncol Rep 2018; 20:43. [DOI: 10.1007/s11912-018-0689-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Abstract
Purpose of Review Pathological complete response is seen in approximately one fifth of rectal cancer patients following neoadjuvant chemoradiation. Since these patients have excellent oncological outcomes, there has been a rapidly growing interest in organ preservation for those who develop a clinical complete response. We review the watch-and-wait strategy and focus on all aspects of this hot topic, including who should be considered for this approach, how should we identify treatment response and what are the expected outcomes. Recent Findings The major challenges in interpreting the data on watch-and-wait are the significant heterogeneity of patients selected for this approach and of methods employed to identify them. The evidence available comes mostly from retrospective cohort studies, but has shown good oncological outcomes, including the rate of successful salvage surgery, locoregional control and overall survival. Summary There is currently not enough and not robust enough evidence to support watch-and-wait as a standard approach, outside a clinical trial, for patients achieving clinical complete response following neoadjuvant chemoradiation. Furthermore, there is a lack of data on long-term outcomes. However, the results we have so far are promising, and there is therefore an urgent need for randomised control studies such as the TRIGGER trial to confirm the safety of this strategy.
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Zhong X, Wu Z, Gao P, Shi J, Sun J, Guo Z, Wang Z, Song Y. The efficacy of adding targeted agents to neoadjuvant therapy for locally advanced rectal cancer patients: a meta-analysis. Cancer Med 2018; 7:565-582. [PMID: 29464874 PMCID: PMC5852374 DOI: 10.1002/cam4.1298] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 11/22/2017] [Accepted: 11/26/2017] [Indexed: 12/19/2022] Open
Abstract
Patients with locally advanced rectal cancer (LARC) are at tremendous risk of metastatic diseases. To improve the prognoses of LARC patients, the efficacy of adding targeted agents to neoadjuvant therapy has been investigated by many researchers but remains controversial. A literature search of relevant databases was conducted through December 2016, 804 studies were identified and 32 investigations were ultimately included. A total of 1196 patients from 31 cohorts of 29 studies were eligible for quantitative synthesis in this single‐arm setting meta‐analysis. As pathologic complete response (pCR) shows promise as a prognosis indicator, we focused on pCR rates to evaluate whether adding targeted agents to neoadjuvant therapies improves the outcome of LARC patients. In our study, we revealed pooled estimates of pCR of 27% (95%CI, 21–34%) and 14% (95%CI, 9–21%) for bevacizumab‐relevant cohorts and cetuximab‐relevant cohorts, respectively. The safety of adding targeted agents to neoadjuvant therapy was also evaluated by pooling the data of Grade 3/4 toxicity. In conclusion, our study revealed that adding bevacizumab to the neoadjuvant therapy regimens provides appreciable pCR for LARC patients. Meanwhile, the efficacy of cetuximab remains inconclusive, RCTs with larger scale and better study design that stress more on mutational status are needed.
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Affiliation(s)
- Xi Zhong
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang, 110001, China
| | - Zhonghua Wu
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang, 110001, China
| | - Peng Gao
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang, 110001, China
| | - Jinxin Shi
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang, 110001, China
| | - Jingxu Sun
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang, 110001, China
| | - Zhexu Guo
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang, 110001, China
| | - Zhenning Wang
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang, 110001, China
| | - Yongxi Song
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang, 110001, China
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Nacion AJD, Park YY, Kim NK. Contemporary management of locally advanced rectal cancer: Resolving issues, controversies and shifting paradigms. Chin J Cancer Res 2018; 30:131-146. [PMID: 29545727 DOI: 10.21147/j.issn.1000-9604.2018.01.14] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Advancements in rectal cancer treatment have resulted in improvement only in locoregional control and have failed to address distant relapse, which is the predominant mode of treatment failure in rectal cancer. As the efficacy of conventional chemoradiotherapy (CRT) followed by total mesorectal excision (TME) reaches a plateau, the need for alternative strategies in locally advanced rectal cancer (LARC) has grown in relevance. Several novel strategies have been conceptualized to address this issue, including: 1) neoadjuvant induction and consolidation chemotherapy before CRT; 2) neoadjuvant chemotherapy alone to avoid the sequelae of radiation; and 3) nonoperative management for patients who achieved pathological or clinical complete response after CRT. This article explores the issues, recent advances and paradigm shifts in the management of LARC and emphasizes the need for a personalized treatment plan for each patient based on tumor stage, location, gene expression and quality of life.
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Affiliation(s)
- Aeris Jane D Nacion
- Department of Surgery, Eastern Visayas Regional Medical Center, Tacloban City 6500, Philippines
| | - Youn Young Park
- Department of Surgery, Eastern Visayas Regional Medical Center, Tacloban City 6500, Philippines
| | - Nam Kyu Kim
- Department of Surgery, Eastern Visayas Regional Medical Center, Tacloban City 6500, Philippines
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Patel UB, Brown G, Machado I, Santos-Cores J, Pericay C, Ballesteros E, Salud A, Isabel-Gil M, Montagut C, Maurel J, Ramón-Ayuso J, Martin N, Estevan R, Fernandez-Martos C. MRI assessment and outcomes in patients receiving neoadjuvant chemotherapy only for primary rectal cancer: long-term results from the GEMCAD 0801 trial. Ann Oncol 2017; 28:344-353. [PMID: 28426108 DOI: 10.1093/annonc/mdw616] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background Primary chemotherapy has been tested as a possible approach for patients with high risk features but predicted clear mesorectal margins on preoperative MRI assessment. This study investigates the prognostic relevance of baseline and post-treatment MRI and pathology staging in rectal cancer patients undergoing primary chemotherapy. Patients and methods Forty-six patients with T3 tumour > =2 mm from the mesorectal fascia were prospectively treated with Neoadjuvant Capecitabine, Oxaliplatin and Bevacizumab prior to surgery between 2009 and 2011. The baseline and post-treatment MRI: T, Nodal and Extra-mural venous invasion (EMVI) status were recorded as well as post-treatment MRI Tumour regression grade (TRG) and modified-RECIST assessment of tumour length. The post-treatment pathology (yp) assessments of T3 substage, N, EMVI and TRG status were also recorded. Three-year disease-free survival (DFS) and cumulative incidence of recurrence were estimated by using the Kaplan-Meier product-limit method, and Cox proportional hazards models were used to determine associations between staging and response on MRI and pathology with survival outcomes. Results About 46 patients underwent neoadjuvant chemotherapy alone for high risk margin safe primary rectal cancer. The median follow-up was 41 months, 5 patients died and 11 patients experienced relapse (2 local, 8 distant and 1 both). In total 23/46 patients were identified with MRI features of EMVI at baseline. mrEMVI positive status carried independent prognostic significance for DFS (P = 0.0097) with a hazard ratio of 31.33 (95% CI: 2.3-425.4). The histopathologic factor that was of independent prognostic importance was a final ypT downstage of ypT3a or less, hazard ratio: 14.0 (95% CI: 1.5-132.5). Conclusions mrEMVI is an independent prognostic factor at baseline for poor outcomes in rectal cancer treated with neoadjuvant chemotherapy while ≤ypT3a is associated with an improvement in DFS. Future preoperative therapy evaluation in rectal cancer patients will need to stratify treatment according to baseline EMVI status as a crucial risk factor for recurrence in patients with predicted CRM clear rectal cancer.
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Affiliation(s)
- U B Patel
- Radiology Department, London North-West Healthcare NHS Trust, London
| | - G Brown
- Radiology Department, The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - I Machado
- Department of Pathology, Valencia Institute of Oncology, Valencia, Spain
| | - J Santos-Cores
- Department of Radiology, Fundacion InstitutoValenciano de Oncologia, Valencia, Spain
| | - C Pericay
- Department of Medical Oncology, Corporació Sanitària Parc Taulí, Parc Taulí, 1, Sabadell, Barcelona, Spain
| | - E Ballesteros
- Department of Radiology, Corporación Sanitaria Parc Taulí, Sabadell, Barcelona, Spain
| | - A Salud
- Department of Medical Oncology, Corporació Sanitària Parc Taulí, Parc Taulí, 1, Sabadell, Barcelona, Spain
| | - M Isabel-Gil
- Department of Radiology, Hospital Universitari Arnau de Vilanova, Lleida
| | - C Montagut
- Department of Medical Oncology Department, Hospital del Mar, Barcelona
| | - J Maurel
- Department of Medical Oncology, Corporació Sanitària Parc Taulí, Parc Taulí, 1, Sabadell, Barcelona, Spain
| | - J Ramón-Ayuso
- Department of Radiology, Hospital Clinic de Barcelona, Barcelona
| | - N Martin
- Department of Pivotal, Madrid, Fundacion Instituto Valenciano de Oncologia, Valencia, Spain
| | - R Estevan
- Department of Surgery, Fundacion Instituto Valenciano de Oncologia, Valencia, Spain
| | - C Fernandez-Martos
- Department of Medical Oncology, Fundacion Instituto Valenciano de Oncologia, Valencia, Spain
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Santos DA, Alseidi A, Shannon VR, Messick C, Song G, Ledet CR, Lee H, Ngo-Huang A, Francis GJ, Asher A. Management of surgical challenges in actively treated cancer patients. Curr Probl Surg 2017; 54:612-654. [DOI: 10.1067/j.cpsurg.2017.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Tailored Treatment Strategy for Locally Advanced Rectal Carcinoma Based on the Tumor Response to Induction Chemotherapy: Preliminary Results of the French Phase II Multicenter GRECCAR4 Trial. Dis Colon Rectum 2017; 60:653-663. [PMID: 28594714 DOI: 10.1097/dcr.0000000000000849] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Preoperative radiochemotherapy and total mesorectal excision are the standard-of-care for locally advanced rectal carcinoma, but some patients could be over- or undertreated. OBJECTIVE This study aimed to assess the feasibility of radiochemotherapy tailored based on the tumor response to induction chemotherapy (FOLFIRINOX) to obtain a minimum R0 resection rate of 90% in the 4 arms of the study. DESIGN This study is a multicenter randomized trial (NCT01333709). SETTING This study was conducted at 16 French cancer specialty centers. PATIENTS Two hundred six patients with locally advanced rectal carcinoma were enrolled between 2011 and 2014. INTERVENTIONS Good responders (≥75% tumor volume reduction) were randomly assigned to immediate surgery (arm A) or standard radiochemotherapy (Cap 50: 50 Gy irradiation and 1600 mg/m oral capecitabine daily) plus surgery (arm B). Poor responders were randomly assigned to Cap 50 (arm C) or intensive radiochemotherapy (Cap 60, 60 Gy irradiation, arm D) before surgery. OUTCOME MEASURES The primary end point was a R0 resection rate (circumferential resection margin >1 mm). STATISTICAL CONSIDERATIONS The experimental strategies were to be considered effective if at least 28 successes (R0 resection) among 31 patients in each arm of stratum I and 34 successes among 40 patients in each arm of stratum II were reported (Simon 2-stage design). RESULTS After induction treatment (good compliance), 194 patients were classified as good (n = 30, 15%) or poor (n = 164, 85%) responders who were included in arms A and B (16 and 14 patients) and arms C and D (113 and 51 patients). The trial was prematurely stopped because of low accrual in arms A and B and recruitment completion in arms C and D. Data from 133 randomly assigned patients were analyzed: 11, 19, 52, and 51 patients in arms A, B, C, and D. Good responders had smaller tumors than poor responders (23 cm vs 45 cm; p < 0.001). The surgical procedure was similar among groups. The R0 resection rates [90% CI] were 100% [70-100], 100% [85-100], 83% [72-91], and 88% [77-95]. Among the first 40 patients, 34 successes were reported in arms C and D (85% R0 resection rate). The circumferential resection margin ≤1 rates were 0%, 0%, 12%, and 5% in arms A, B, C, and D. The rate of transformation from positive to negative circumferential resection margin was 93%. LIMITATIONS There was low accrual in arms A and B. CONCLUSION Tailoring preoperative radiochemotherapy based on the induction treatment response appears safe for poor responders and promising for good responders. Long-term clinical results are needed to confirm its efficacy. See Video Abstract at http://links.lww.com/DCR/A359.
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Optimal Sequencing of Neoadjuvant Therapies (NAT) in Rectal Cancer: Upfront Chemotherapy vs. Upfront Chemoradiation. CURRENT COLORECTAL CANCER REPORTS 2017. [DOI: 10.1007/s11888-017-0358-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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SEOM Clinical Guideline of localized rectal cancer (2016). Clin Transl Oncol 2016; 18:1163-1171. [PMID: 27905053 PMCID: PMC5138264 DOI: 10.1007/s12094-016-1591-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 11/15/2016] [Indexed: 02/06/2023]
Abstract
Localized rectal adenocarcinoma is a heterogeneous disease and current treatment recommendations are based on a preoperative multidisciplinary evaluation. High-resolution magnetic resonance imaging and endoscopic ultrasound are complementary to do a locoregional accurate staging. Surgery remains the mainstay of treatment and preoperative therapies with chemoradiation (CRT) or short-course radiation (SCRT) must be considered in more locally advanced cases. Novel strategies with induction chemotherapy alone or preceding or after CRT (SCRT) and surgery are in development.
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Millard T, Kunk PR, Ramsdale E, Rahma OE. Current debate in the oncologic management of rectal cancer. World J Gastrointest Oncol 2016; 8:715-724. [PMID: 27795811 PMCID: PMC5064049 DOI: 10.4251/wjgo.v8.i10.715] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Revised: 07/01/2016] [Accepted: 08/29/2016] [Indexed: 02/05/2023] Open
Abstract
Despite the considerable amount of research in the field, the management of locally advanced rectal cancer remains a subject to debate. To date, effective treatment centers on surgical resection with the standard approach of total mesorectal resection. Radiation therapy and chemotherapy have been incorporated in order to decrease local and systemic recurrence. While it is accepted that a multimodality treatment regimen is indicated, there remains significant debate for how best to accomplish this in regards to order, dosing, and choice of agents. Preoperative radiation is the standard of care, yet remains debated with the option for chemoradiation, short course radiation, and even ongoing studies looking at the possibility of leaving radiation out altogether. Chemotherapy was traditionally incorporated in the adjuvant setting, but recent reports suggest the possibility of improved efficacy and tolerance when given upfront. In this review, the major studies in the management of locally advanced rectal cancer will be discussed. In addition, future directions will be considered such as the role of immunotherapy and ongoing trials looking at timing of chemotherapy, inclusion of radiation, and non-operative management.
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Kataoka M, Kanda M, Ishigure K, Matsuoka H, Sato Y, Takahashi T, Tanaka C, Deguchi T, Shibata Y, Sato M, Inagaki H, Matsui T, Kondo A, Takano N, Tanaka H, Sakamoto J, Oba K, Kondo K. The COMET Open-label Phase II Study of Neoadjuvant FOLFOX or XELOX Treatment Combined with Molecular Targeting Monoclonal Antibodies in Patients with Resectable Liver Metastasis of Colorectal Cancer. Ann Surg Oncol 2016; 24:546-553. [PMID: 27638675 DOI: 10.1245/s10434-016-5557-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Advantages of neoadjuvant chemotherapy combined with monoclonal antibodies for treating patients with resectable colorectal cancer liver metastasis (CLM) have not been established. The purpose of this study was to evaluate the efficacy and safety of oxaliplatin-based regimen (FOLFOX or XELOX) plus monoclonal antibodies (cetuximab or bevacizumab) treatment in patients with resectable CLM. METHODS A single-arm, open-label, multicenter, phase II trial was conducted for patients aged ≥ 20 years with resectable and untreated CLM. Patients received preoperative FOLFOX (6 cycles) or XELOX (4 cycles). Cetuximab or bevacizumab was administered to patients with wild-type or mutated KRAS codons 12 and 13, respectively. The primary endpoint was progression-free survival (PFS). RESULTS Between January 2010 and June 2012, 47 patients were enrolled from 12 institutions. Wild-type or mutant KRAS sequences were examined in 32 and 15 patients, respectively. Twenty-one (45 %) patients experienced Grades 3/4 adverse events, and 55 % of all patients responded to therapy. The sizes of tumors of patients in the wild-type KRAS group were significantly reduced compared with those of the mutant KRAS group. The overall rates of liver resection and postoperative morbidity were 83 and 14 %, respectively, and the median PFS was 15.6 months. The median PFS times of the KRAS wild-type and mutant groups were 22.5 months and 10.5 months, respectively. CONCLUSIONS Neoadjuvant therapy using FOLFOX/XELOX combined with monoclonal antibodies did not improve PFS, although it was administered safely and had less adverse effects after liver resection.
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Affiliation(s)
- Masato Kataoka
- Department of Surgery, Nagoya National Hospital, Nagoya, Japan
| | - Mitsuro Kanda
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | | | - Hiroshi Matsuoka
- Department of Surgery, Fujita Health University School of Medicine, Aichi, Japan
| | - Yusuke Sato
- Department of Surgery, Tosei Hospital, Seto, Japan
| | - Takao Takahashi
- Department of Surgical Oncology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Chihiro Tanaka
- Department of Surgery, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Tomohiro Deguchi
- Department of Surgery, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Yoshihisa Shibata
- Department of Surgery, Toyohashi Municipal Hospital, Toyohashi, Japan
| | - Mikinori Sato
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Hitoshi Inagaki
- Department of Surgery, Yokoyama Hospital for Gastroenterological Diseases, Nagoya, Japan
| | - Takanori Matsui
- Department of Gastroenterological Surgery, Aichi Cancer Center Aichi Hospital, Okazaki, Japan
| | - Akinobu Kondo
- Department of Surgery, Saiseikai Matsusaka General Hospital, Matsusaka, Japan
| | - Nao Takano
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Haruyoshi Tanaka
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | | | - Koji Oba
- Department of Biostatistics, School of Public Health, Tokyo University Graduate School of Medicine, Tokyo, Japan.,Interfaculty Initiative in Information Studies, Tokyo University, Tokyo, Japan
| | - Ken Kondo
- Department of Surgery, Nagoya National Hospital, Nagoya, Japan
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Kalyan A, Rozelle S, Benson A. Neoadjuvant treatment of rectal cancer: where are we now? Gastroenterol Rep (Oxf) 2016; 4:206-9. [PMID: 27412436 PMCID: PMC4976683 DOI: 10.1093/gastro/gow017] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 05/12/2016] [Indexed: 12/13/2022] Open
Affiliation(s)
- Aparna Kalyan
- Developmental Therapeutics Program of Division of Hematology & Oncology, Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL USA Division of Hematology & Oncology, Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL USA
| | - Shaina Rozelle
- Division of Hematology & Oncology, Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL USA
| | - Al Benson
- Division of Hematology & Oncology, Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL USA
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Sclafani F, Chau I. Timing of Therapies in the Multidisciplinary Treatment of Locally Advanced Rectal Cancer: Available Evidence and Implications for Routine Practice. Semin Radiat Oncol 2016; 26:176-85. [PMID: 27238468 DOI: 10.1016/j.semradonc.2016.02.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
A multimodality disciplinary approach is paramount for the management of locally advanced rectal cancer. Over the last decade, (chemo)radiotherapy followed by surgery plus or minus adjuvant chemotherapy has represented the mainstay of treatment for this disease. Nevertheless, robust evidence suggesting the optimal timing and sequence of therapies in this setting has been overall limited. A number of questions are still unsolved including the length of the interval between neoadjuvant radiotherapy and surgery or the timing of systemic chemotherapy. Interestingly, emerging data support the contention that altering sequence or timing or both of the components of this multimodality approach may provide an opportunity to implement treatment strategies that far better address the risk and expectations of individual patients. In this article, we review the available evidence on timing of therapies in the multidisciplinary treatment of locally advanced rectal cancer and discuss the potential implications for routine practice that may derive from a change of the currently accepted treatment paradigm.
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Affiliation(s)
- Francesco Sclafani
- Department of Medicine, The Royal Marsden NHS Foundation Trust, London and Surrey, UK
| | - Ian Chau
- Department of Medicine, The Royal Marsden NHS Foundation Trust, London and Surrey, UK.
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50
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Abstract
According to current guidelines, the standard treatment for locally advanced rectal cancer patients is preoperative (chemo)radiotherapy followed by total mesorectal excision surgery and adjuvant chemotherapy. Improvements in surgical techniques, imaging modalities, chemotherapy regimens, and radiotherapy delivery have reduced local recurrence rates to less than 10%. The current challenge in rectal cancer treatment lies in the prevention of distant metastases, which still occur in more than 25% of the patients. The decrease in local recurrence rates, the need for more effective systemic treatments, and the increased awareness of treatment-induced toxicity raise the question as to whether a more selective use of radiotherapy is advocated.
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