Neoadjuvant chemotherapy without radiation as a potential alternative treatment for locally advanced rectal cancer: A meta-analysis

Re-evaluating the role of pelvic radiation in the age of modern precision medicine and systemic therapy

The efficacy of pelvic radiation in the management of locally advanced stage rectal cancer has come under scrutiny in the context of modern precision medicine and systemic therapy as evidenced by recent clinical trials such as FOWARC (J Clin Oncol 2019; 37: 3223-3233), NCT04165772 (N Engl J Med 2022; 386: 2363-2376), and PROSPECT (N Engl J Med 2023; 389: 322-334). In this review, we comprehensively assess these pivotal trials and offer additional insights into the evolving role of pelvic radiation in contemporary oncology.

GRECCAR 14 - a multicentric, randomized, phase II-III study evaluating the tailored management of locally advanced rectal carcinoma after a favourable response to induction chemotherapy: Study protocol

AIM

Total neoadjuvant treatment (TNT) is becoming standard in patients with locally advanced rectal carcinoma (LARC). Preoperative chemoradiotherapy (CRT) has proven side effects on bowel and genitourinary function. An early tumoral response to induction chemotherapy demonstrates its high prognostic value. Tailored management could be used as an alternative to systematic CRT. The GRECCAR 14 trial will attempt to personalize treatment strategy according to the patient's early tumour response to intensive chemotherapy with the aim of achieving the best toxicity-efficiency ratio.

METHOD

GRECCAR 14 is a multicentric, randomized, two-arm, phase II-III noninferiority trial. Patients with mid or low LARC with a predictive circumferential resection margin ≤2 mm or T3c-d stage with extramural venous invasion will be included. Evaluation of the tumoral response will be performed after six courses of high-dose FOLFIRINOX chemotherapy. Good responders (GRs) will be defined by a 60% decrease in tumoral volume on magnetic resonance imaging. Patients will be randomized to CRT before surgery. The primary endpoints will be R0 resection for phase II and the 3-year disease-free survival (DFS) for phase III.

RESULTS

Tailored management of LARC is becoming an exciting challenge for the modality of neoadjuvant treatment and for the type of surgery or its omission. Neoadjuvant FOLFIRINOX has established efficacy, with a significant increase in the 3-year DFS. Better control of systemic disease must be accompanied by the same locoregional control, with the lowest morbidity. Our previous GRECCAR 4 trial demonstrated the high value of the early tumoral response after induction chemotherapy and the long-term safety of tailored management for GRs.

CONCLUSION

If GRECCAR 14 demonstrates the ability to tailor TNT for LARC, this could lead to changes in clinical practice.

Effect of Glutamine on Short-term Surgical Outcomes in Rectal Cancer Patients Receiving Neoadjuvant Therapy: A Propensity Score Matching Study

The effect of glutamine on postoperative complications and postoperative recovery in rectal cancer (RC) patients receiving neoadjuvant therapy (NT) is unclear. This study aimed to investigate the effects of intravenous glutamine supplementation on short-term postoperative outcomes in these patients. This retrospective study included patients with RC who received NT and underwent radical surgery between January 2013 and July 2022 and were either administered glutamine (glutamine group) or not administered glutamine (non-glutamine group). Propensity score matching method was used to analyze and compare postoperative complications and other outcome indicators. A total of 208 patients were reviewed, and 53 were included in each group post matching. While no significant difference in the time to first solid food intake between the two groups was observed, the glutamine group had a significantly reduced incidence of postoperative complications, shorter length of hospital stay, and shorter time to first defecation, first exhaust, and first fluid diet intake than those of the control group. Moreover, glutamine alleviated the reduction in albumin and prealbumin levels. Perioperative parenteral glutamine supplementation effectively reduces the incidence of postoperative complications, promotes postoperative recovery, and improves albumin levels in patients undergoing RC surgery and receiving NT.

Effect of Neoadjuvant Therapy on the Functional Outcome of Patients With Rectal Cancer: A Systematic Review and Meta-Analysis

AIMS

The impact of neoadjuvant therapy on the functional outcome of patients with resectable rectal cancer is still controversial. The aim of the present study was to explore the effects of neoadjuvant therapy on anorectal function (ARF), urinary function and sexual function in relevant patients.

MATERIALS AND METHODS

PubMed, Embase, Web of Science and the Cochrane Library were searched systematically. All English-language studies, published from January 2000 to July 2021, that explored the (postoperative) effects of neoadjuvant therapy versus upfront surgery on ARF, urinary function and sexual function of patients were included (PROSPERO 2021: CRD42021281617).

RESULTS

The data in this study were derived from 37 articles based on 33 studies; in total, 17 917 patients were enrolled. The meta-analysis revealed that the incidence of anorectal dysfunction in the neoadjuvant therapy group was significantly higher than that in the group of upfront surgery, which was manifested by a higher incidence of major low anterior resection syndrome (odds ratio = 3.09, 95% confidence interval = 2.48, 3.84; P < 0.001), reduction of mean squeeze pressure and mean resting pressure, and other manifestations, including clustering of stools, incontinence, urgency and use of pads. With the extension of follow-up time, the adverse effects of neoadjuvant therapy on major low anterior resection syndrome existed. Compared with patients undergoing upfront surgery, neoadjuvant therapy increased the risk of urinary incontinence (odds ratio = 1.31, 95% confidence interval = 1.00, 1.72; P = 0.05) and erectile dysfunction (odds ratio = 1.77, 95% confidence interval = 1.27, 2.45; P < 0.001).

CONCLUSION

Compared with upfront surgery, neoadjuvant therapy is not only associated with impairment of ARF, but also with increased incidence of urinary incontinence and male erectile dysfunction. However, the influence of confounding factors (e.g. surgical method, tumour stage) needs to be considered.