1
|
Zwart WH, Dijkstra EA, Putter H, Marijnen CAM, Nilsson PJ, van de Velde CJH, van Etten B, Hospers GAP, Glimelius B. Corrigendum to "Authors' reply-Does the RAPIDO trial suggest a benefit of post-operative chemotherapy after preoperative chemoradiation in rectal cancer? No, it does not": [ESMO Open 8 (2023) 101645]. ESMO Open 2023; 8:102042. [PMID: 37866027 PMCID: PMC10598700 DOI: 10.1016/j.esmoop.2023.102042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023] Open
Affiliation(s)
- W H Zwart
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen.
| | - E A Dijkstra
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen
| | - H Putter
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden
| | - C A M Marijnen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam; Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - P J Nilsson
- Department of Surgery, Karolinska University Hospital, Stockholm, Sweden
| | | | - B van Etten
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - G A P Hospers
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen
| | - B Glimelius
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| |
Collapse
|
2
|
Dijkstra EA, Nilsson PJ, Hospers GA, Bahadoer RR, Meershoek-Klein Kranenbarg E, Roodvoets AG, Putter H, Berglund Å, Cervantes A, Crolla RM, Hendriks MP, Capdevila J, Edhemovic I, Marijnen CA, van de Velde CJ, Glimelius B, van Etten B. Locoregional Failure During and After Short-course Radiotherapy Followed by Chemotherapy and Surgery Compared With Long-course Chemoradiotherapy and Surgery: A 5-Year Follow-up of the RAPIDO Trial. Ann Surg 2023; 278:e766-e772. [PMID: 36661037 PMCID: PMC10481913 DOI: 10.1097/sla.0000000000005799] [Citation(s) in RCA: 62] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To analyze risk and patterns of locoregional failure (LRF) in patients of the RAPIDO trial at 5 years. BACKGROUND Multimodality treatment improves local control in rectal cancer. Total neoadjuvant treatment (TNT) aims to improve systemic control while local control is maintained. At 3 years, LRF rate was comparable between TNT and chemoradiotherapy in the RAPIDO trial. METHODS A total of 920 patients were randomized between an experimental (EXP, short-course radiotherapy, chemotherapy, and surgery) and a standard-care group (STD, chemoradiotherapy, surgery, and optional postoperative chemotherapy). LRFs, including early LRF (no resection except for organ preservation/R2 resection) and locoregional recurrence (LRR) after an R0/R1 resection, were analyzed. RESULTS Totally, 460 EXP and 446 STD patients were eligible. At 5.6 years (median follow-up), LRF was detected in 54/460 (12%) and 36/446 (8%) patients in the EXP and STD groups, respectively ( P =0.07), in which EXP patients were more often treated with 3-dimensional-conformed radiotherapy ( P =0.029). In the EXP group, LRR was detected more often [44/431 (10%) vs. 26/428 (6%); P =0.027], with more often a breached mesorectum (9/44 (21%) vs. 1/26 (4); P =0.048). The EXP treatment, enlarged lateral lymph nodes, positive circumferential resection margin, tumor deposits, and node positivity at pathology were the significant predictors for developing LRR. Location of the LRRs was similar between groups. Overall survival after LRF was comparable [hazard ratio: 0.76 (95% CI, 0.46-1.26); P =0.29]. CONCLUSIONS The EXP treatment was associated with an increased risk of LRR, whereas the reduction in disease-related treatment failure and distant metastases remained after 5 years. Further refinement of the TNT in rectal cancer is mandated.
Collapse
Affiliation(s)
- Esmée A. Dijkstra
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Per J. Nilsson
- Department of Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Geke A.P. Hospers
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Renu R. Bahadoer
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Annet G.H. Roodvoets
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Hein Putter
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, The Netherlands
| | - Åke Berglund
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Andrés Cervantes
- Department of medical oncology, Biomedical Research Institute Incliva, University of Valencia, Valencia, Spain
| | | | | | - Jaume Capdevila
- Department of Medical Oncology, Vall Hebron Institute of Oncology (VHIO), Vall Hebron University Hospital, Autonomous University of Barcelona (UAB), Barcelona, Spain
| | - Ibrahim Edhemovic
- Department of surgical oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Corrie A.M. Marijnen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Bengt Glimelius
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Boudewijn van Etten
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| |
Collapse
|
3
|
Zwart WH, Dijkstra EA, Putter H, Marijnen CAM, Nilsson PJ, van de Velde CJH, van Etten B, Hospers GAP, Glimelius B. Authors' reply-Does the RAPIDO trial suggest a benefit of post-operative chemotherapy after preoperative chemoradiation in rectal cancer? No, it does not. ESMO Open 2023; 8:101645. [PMID: 37713932 PMCID: PMC10511774 DOI: 10.1016/j.esmoop.2023.101645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 08/16/2023] [Indexed: 09/17/2023] Open
Affiliation(s)
- W H Zwart
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
| | - E A Dijkstra
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - H Putter
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - C A M Marijnen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands; Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - P J Nilsson
- Department of Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - C J H van de Velde
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - B van Etten
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - G A P Hospers
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - B Glimelius
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| |
Collapse
|
4
|
Dijkstra EA, Zwart WH, Putter H, Marijnen CAM, Nilsson PJ, van de Velde CJH, van Etten B, Hospers GAP, Glimelius B. Authors' reply-A sensitivity analysis of the RAPIDO clinical trial. Ann Oncol 2023; 34:446-447. [PMID: 36581138 DOI: 10.1016/j.annonc.2022.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/09/2022] [Accepted: 12/17/2022] [Indexed: 12/28/2022] Open
Affiliation(s)
- E A Dijkstra
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | - W H Zwart
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - H Putter
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, The Netherlands
| | - C A M Marijnen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands; Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - P J Nilsson
- Department of Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - C J H van de Velde
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - B van Etten
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - G A P Hospers
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - B Glimelius
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| |
Collapse
|
5
|
Dijkstra EA, Zwart WH, Nilsson PJ, Putter H, Roodvoets AGH, Meershoek-Klein Kranenbarg E, Frödin JE, Nygren P, Østergaard L, Kersten C, Verbiené I, Cervantes A, Hendriks MP, Capdevila J, Edhemovic I, van de Velde CJH, Marijnen CAM, van Etten B, Hospers GAP, Glimelius B. The value of post-operative chemotherapy after chemoradiotherapy in patients with high-risk locally advanced rectal cancer-results from the RAPIDO trial. ESMO Open 2023; 8:101158. [PMID: 36871393 PMCID: PMC10163161 DOI: 10.1016/j.esmoop.2023.101158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 01/20/2023] [Accepted: 02/02/2023] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND Pre-operative chemoradiotherapy (CRT) rather than radiotherapy (RT) has resulted in fewer locoregional recurrences (LRRs), but no decrease in distant metastasis (DM) rate for patients with locally advanced rectal cancer (LARC). In many countries, patients receive post-operative chemotherapy (pCT) to improve oncological outcomes. We investigated the value of pCT after pre-operative CRT in the RAPIDO trial. PATIENTS AND METHODS Patients were randomised between experimental (short-course RT, chemotherapy and surgery) and standard-of-care treatment (CRT, surgery and pCT depending on hospital policy). In this substudy, we compared curatively resected patients from the standard-of-care group who received pCT (pCT+ group) with those who did not (pCT- group). Subsequently, patients from the pCT+ group who received at least 75% of the prescribed chemotherapy cycles (pCT ≥75% group) were compared with patients who did not receive pCT (pCT-/- group). By propensity score stratification (PSS), we adjusted for the following unbalanced confounders: age, clinical extramural vascular invasion, distance to the anal verge, ypT stage, ypN stage, residual tumour, serious adverse event (SAE) and/or readmission within 6 weeks after surgery and SAE related to pre-operative CRT. Cumulative probability of disease-free survival (DFS), DM, LRR and overall survival (OS) was analysed by Cox regression. RESULTS In total, 396/452 patients had a curative resection. The number of patients in the pCT+, pCT >75%, pCT- and pCT-/- groups was 184, 112, 154 and 149, respectively. The PSS-adjusted analyses for all endpoints demonstrated hazard ratios between approximately 0.7 and 0.8 (pCT+ versus pCT-), and 0.5 and 0.8 (pCT ≥75% versus pCT-/-). However, all 95% confidence intervals included 1. CONCLUSIONS These data suggest a benefit of pCT after pre-operative CRT for patients with high-risk LARC, with approximately 20%-25% improvement in DFS and OS and 20%-25% risk reductions in DM and LRR. Compliance with pCT additionally reduces or improves all endpoints by 10%-20%. However, differences are not statistically significant.
Collapse
Affiliation(s)
- E A Dijkstra
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
| | - W H Zwart
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - P J Nilsson
- Department of Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - H Putter
- Departments of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, the Netherlands
| | - A G H Roodvoets
- Departments of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | | | - J E Frödin
- Department of Oncology-Pathology, Karolinska University Hospital, Uppsala
| | - P Nygren
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - L Østergaard
- Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - C Kersten
- Department of Research, Sørlandet Hospital Trust, Kristiansand, Norway
| | - I Verbiené
- Department of Oncology, Uppsala University, Uppsala, Sweden
| | - A Cervantes
- Department of Medical Oncology, Biomedical Research Institute Incliva, University of Valencia, Valencia, Spain
| | - M P Hendriks
- Department of Medical Oncology, Northwest Clinics, Alkmaar, the Netherlands
| | - J Capdevila
- Department of Medical Oncology, Vall Hebron Institute of Oncology (VHIO), Vall Hebron University Hospital. Autonomous University of Barcelona (UAB), Barcelona, Spain
| | - I Edhemovic
- Department of Surgical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - C J H van de Velde
- Departments of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - C A M Marijnen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam; Department of Radiation Oncology, Leiden University Medical Center, Leiden
| | - B van Etten
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - G A P Hospers
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - B Glimelius
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | | |
Collapse
|
6
|
Bahadoer RR, Hospers GA, Marijnen CA, Peeters KC, Putter H, Dijkstra EA, Kranenbarg EMK, Roodvoets AG, van Etten B, Nilsson PJ, Glimelius B, van de Velde CJ. Risk and location of distant metastases in patients with locally advanced rectal cancer after total neoadjuvant treatment or chemoradiotherapy in the RAPIDO trial. Eur J Cancer 2023; 185:139-149. [PMID: 36996624 DOI: 10.1016/j.ejca.2023.02.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 02/18/2023] [Accepted: 02/25/2023] [Indexed: 03/09/2023]
Abstract
INTRODUCTION Although optimising rectal cancer treatment has reduced local recurrence rates, many patients develop distant metastases (DM). The current study investigated whether a total neoadjuvant treatment strategy influences the development, location, and timing of metastases in patients diagnosed with high-risk locally advanced rectal cancer included in the Rectal cancer And Pre-operative Induction therapy followed by Dedicated Operation (RAPIDO) trial. MATERIAL AND METHODS Patients were randomly assigned to short-course radiotherapy followed by 18 weeks of CAPOX or FOLFOX4 before surgery (EXP), or long-course chemoradiotherapy with optional postoperative chemotherapy (SC-G). Assessments for metastatic disease were performed pre- and post-treatment, during surgery, and 6, 12, 24, 36, and 60 months postoperatively. From randomisation, differences in the occurrence of DM and first site of metastasis were evaluated. RESULTS In total, 462 patients were evaluated in the EXP and 450 patients in the SC-G groups. The cumulative probability of DM at 5 years after randomisation was 23% [95% CI 19-27] and 30% [95% CI 26-35] (HR 0.72 [95% CI 0.56-0.93]; P = 0.011) in the EXP and SC-G, respectively. The median time to DM was 1.4 (EXP) and 1.3 years (SC-G). After diagnosis of DM, median survival was 2.6 years [95% CI 2.0-3.1] in the EXP and 3.2 years [95% CI 2.3-4.1] in the SC-G groups (HR 1.39 [95% CI 1.01-1.92]; P = 0.04). First occurrence of DM was most often in the lungs (60/462 [13%] EXP and 55/450 [12%] SC-G) or the liver (40/462 [9%] EXP and 69/450 [15%] SC-G). A hospital policy of postoperative chemotherapy did not influence the development of DM. CONCLUSIONS Compared to long-course chemoradiotherapy, total neoadjuvant treatment with short-course radiotherapy and chemotherapy significantly decreased the occurrence of metastases, particularly liver metastases.
Collapse
|
7
|
Dijkstra EA, Hospers GAP, Kranenbarg EMK, Fleer J, Roodvoets AGH, Bahadoer RR, Guren MG, Tjalma JJJ, Putter H, Crolla RMPH, Hendriks MP, Capdevila J, Radu C, van de Velde CJH, Nilsson PJ, Glimelius B, van Etten B, Marijnen CAM. Quality of life and late toxicity after short-course radiotherapy followed by chemotherapy or chemoradiotherapy for locally advanced rectal cancer - The RAPIDO trial. Radiother Oncol 2022; 171:69-76. [PMID: 35447283 DOI: 10.1016/j.radonc.2022.04.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/06/2022] [Accepted: 04/10/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND PURPOSE The RAPIDO trial demonstrated a decrease in disease-related treatment failure (DrTF) and an increase in pathological complete responses (pCR) in locally advanced rectal cancer (LARC) patients receiving total neoadjuvant treatment (TNT) compared to conventional chemoradiotherapy. This study examines health-related quality of life (HRQL), bowel function, and late toxicity in patients in the trial. MATERIALS AND METHODS Patients were randomized between short-course radiotherapy followed by pre-operative chemotherapy (EXP), or chemoradiotherapy and optional post-operative chemotherapy (STD). The STD group was divided into patients who did (STD+) and did not (STD-) receive post-operative chemotherapy. Three years after surgery patients received HRQL (EORTC QLQ-C30, QLQ-CR29 and QLQ-CIPN20) and LARS questionnaires. Patients who experienced a DrTF event before the toxicity assessments (6, 12, 24, or 36 months) were excluded from analyses. RESULTS Of 574 eligible patients, 495 questionnaires were returned (86%) and 453 analyzed (79% completed within time limits). No significant differences were observed between the groups regarding QLQ-C30, QLQ-CR29 or LARS scores. Sensory-related symptoms occurred significantly more often in the EXP group compared to all STD patients, but not compared to STD+ patients. Any toxicity of any grade and grade ≥ 3 toxicity was comparable between the EXP and STD groups at all time-points. Neurotoxicity grade 1-2 occurred significantly more often in the EXP and STD+ group at all time-points compared to the STD- group. CONCLUSION The results demonstrate that TNT for LARC, yielding improved DrTF and pCRs, does not compromise HRQL, bowel functional or results in more grade ≥3 toxicity compared to standard chemoradiotherapy at three years after surgery in DrTF-free patients.
Collapse
Affiliation(s)
- Esmée A Dijkstra
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, the Netherlands.
| | - Geke A P Hospers
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, the Netherlands
| | | | - Joke Fleer
- Department of Health Sciences, Section Health Psychology, University Medical Center Groningen, University of Groningen, the Netherlands
| | | | - Renu R Bahadoer
- Department of Surgery, Leiden University Medical Center, the Netherlands
| | | | - Jolien J J Tjalma
- Department of General Practice, University Medical Center Groningen, University of Groningen, the Netherlands
| | - Hein Putter
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, the Netherlands
| | | | - Mathijs P Hendriks
- Department of Medical Oncology, Northwest Clinics, Alkmaar, the Netherlands
| | - Jaume Capdevila
- Department of Medical Oncology, Vall Hebron Institute of Oncology (VHIO), Vall Hebron University Hospital, Autonomous University of Barcelona (UAB), Spain
| | - Calin Radu
- Department of Immunology, Genetics and Pathology, Uppsala University, Sweden
| | | | - Per J Nilsson
- Department of Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Bengt Glimelius
- Department of Immunology, Genetics and Pathology, Uppsala University, Sweden
| | - Boudewijn van Etten
- Department of Surgery, University Medical Center Groningen, University of Groningen, the Netherlands
| | - Corrie A M Marijnen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands; Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
| |
Collapse
|
8
|
Dijkstra EA, Mul VEM, Hemmer PHJ, Havenga K, Hospers GAP, Muijs CT, van Etten B. Re-Irradiation in Patients with Recurrent Rectal Cancer is Safe and Feasible. Ann Surg Oncol 2021; 28:5194-5204. [PMID: 34023946 PMCID: PMC8349344 DOI: 10.1245/s10434-021-10070-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 03/11/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND There is no consensus yet for the best treatment regimen in patients with recurrent rectal cancer (RRC). This study aims to evaluate toxicity and oncological outcomes after re-irradiation in patients with RRC in our center. Clinical (cCR) and pathological complete response (pCR) rates and radicality were also studied. METHODS Between January 2010 and December 2018, 61 locally advanced RRC patients were treated and analyzed retrospectively. Patients received radiotherapy at a dose of 30.0-30.6 Gy (reCRT) or 50.0-50.4 Gy chemoradiotherapy (CRT) in cases of no prior irradiation because of low-risk primary rectal cancer. In both groups, patients received capecitabine concomitantly. RESULTS In total, 60 patients received the prescribed neoadjuvant (chemo)radiotherapy followed by surgery, 35 patients (58.3%) in the reRCT group and 25 patients (41.7%) in the long-course CRT group. There were no significant differences in overall survival (p = 0.82), disease-free survival (p = 0.63), and local recurrence-free survival (p = 0.17) between the groups. Patients in the long-course CRT group reported more skin toxicity after radiotherapy (p = 0.040). No differences were observed in late toxicity. In the long-course CRT group, a significantly higher cCR rate was observed (p = 0.029); however, there was no difference in the pCR rate (p = 0.66). CONCLUSIONS The treatment of RRC patients with re-irradiation is comparable to treatment with long-course CRT regarding toxicity and oncological outcomes. In the reCRT group, less cCR was observed, although there was no difference in pCR. The findings in this study suggest that it is safe and feasible to re-irradiate RRC patients.
Collapse
Affiliation(s)
- Esmée A Dijkstra
- Department of Medical Oncology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Véronique E M Mul
- Department of Radiation Oncology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Patrick H J Hemmer
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Klaas Havenga
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Geke A P Hospers
- Department of Medical Oncology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Christina T Muijs
- Department of Radiation Oncology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Boudewijn van Etten
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.
| |
Collapse
|
9
|
Dijkstra EA, Mul VEM, Hemmer PHJ, Havenga K, Hospers GAP, Kats-Ugurlu G, Beukema JC, Berveling MJ, El Moumni M, Muijs CT, van Etten B. Clinical selection strategy for and evaluation of intra-operative brachytherapy in patients with locally advanced and recurrent rectal cancer. Radiother Oncol 2021; 159:91-97. [PMID: 33741470 DOI: 10.1016/j.radonc.2021.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 03/05/2021] [Accepted: 03/08/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE A radical resection of locally advanced rectal cancer (LARC) or recurrent rectal cancer (RRC) can be challenging. In case of increased risk of an R1 resection, intra-operative brachytherapy (IOBT) can be applied. We evaluated the clinical selection strategy for IOBT. MATERIALS AND METHODS Between February 2007 and May 2018, 132 LARC/RRC patients who were scheduled for surgery with IOBT standby, were evaluated. By intra-operative inspection of the resection margin and MR imaging, it was determined whether a resection was presumed to be radical. Frozen sections were taken on indication. In case of a suspected R1 resection, IOBT (1 × 10 Gy) was applied. Histopathologic evaluation, treatment and toxicity data were collected from medical records. RESULTS Tumour was resected in 122 patients. IOBT was given in 42 patients of whom 54.8% (n = 23) had a histopathologically proven R1 resection. Of the 76 IOBT-omitted R0 resected patients, 17.1% (n = 13) had a histopathologically proven R1 resection. In 4 IOBT-omitted patients, a clinical R1/2 resection was seen. In total, correct clinical judgement occurred in 72.6% (n = 88) of patients. In LARC, 58.3% (n = 14) of patients were overtreated (R0, with IOBT) and 10.9% (n = 5) were undertreated (R1, without IOBT). In RRC, 26.5% (n = 9) of patients were undertreated. CONCLUSION In total, correct clinical judgement occurred in 72.6% (n = 88). However, in 26.5% (n = 9) RRC patients, IOBT was unjustifiedly omitted. IOBT is accompanied by comparable and acceptable toxicity. Therefore, we recommend IOBT to all RRC patients at risk of an R1 resection as their salvage treatment.
Collapse
Affiliation(s)
- Esmée A Dijkstra
- University of Groningen, University Medical Centre Groningen, Department of Medical Oncology, the Netherlands
| | - Véronique E M Mul
- University of Groningen, University Medical Centre Groningen, Department of Radiation Oncology, the Netherlands
| | - Patrick H J Hemmer
- University of Groningen, University Medical Centre Groningen, Department of Surgery, the Netherlands
| | - Klaas Havenga
- University of Groningen, University Medical Centre Groningen, Department of Surgery, the Netherlands
| | - Geke A P Hospers
- University of Groningen, University Medical Centre Groningen, Department of Medical Oncology, the Netherlands
| | - Gursah Kats-Ugurlu
- University of Groningen, University Medical Centre Groningen, Department of Pathology and Medical Biology, the Netherlands
| | - Jannet C Beukema
- University of Groningen, University Medical Centre Groningen, Department of Radiation Oncology, the Netherlands
| | - Maaike J Berveling
- University of Groningen, University Medical Centre Groningen, Department of Radiation Oncology, the Netherlands
| | - Mostafa El Moumni
- University of Groningen, University Medical Centre Groningen, Department of Surgery, the Netherlands
| | - Christina T Muijs
- University of Groningen, University Medical Centre Groningen, Department of Radiation Oncology, the Netherlands
| | - Boudewijn van Etten
- University of Groningen, University Medical Centre Groningen, Department of Surgery, the Netherlands.
| |
Collapse
|
10
|
Bahadoer RR, Dijkstra EA, van Etten B, Marijnen CAM, Putter H, Kranenbarg EMK, Nilsson PJ, Glimelius B, van de Velde CJH, Hospers GAP. Interpreting the RAPIDO trial: factors to consider - Authors' reply. Lancet Oncol 2021; 22:e90-e91. [PMID: 33662297 DOI: 10.1016/s1470-2045(21)00087-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 02/08/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Renu R Bahadoer
- Department of Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Esmée A Dijkstra
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen 9700 RB, Netherlands
| | - Boudewijn van Etten
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen 9700 RB, Netherlands
| | - Corrie A M Marijnen
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, Netherlands; Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Hein Putter
- Department of Biomedical Datasciences, Leiden University Medical Center, Leiden, Netherlands
| | | | - Per J Nilsson
- Department of Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Bengt Glimelius
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | | | - Geke A P Hospers
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen 9700 RB, Netherlands.
| |
Collapse
|
11
|
Bahadoer RR, Dijkstra EA, van Etten B, Marijnen CAM, Putter H, Kranenbarg EMK, Roodvoets AGH, Nagtegaal ID, Beets-Tan RGH, Blomqvist LK, Fokstuen T, Ten Tije AJ, Capdevila J, Hendriks MP, Edhemovic I, Cervantes A, Nilsson PJ, Glimelius B, van de Velde CJH, Hospers GAP. Short-course radiotherapy followed by chemotherapy before total mesorectal excision (TME) versus preoperative chemoradiotherapy, TME, and optional adjuvant chemotherapy in locally advanced rectal cancer (RAPIDO): a randomised, open-label, phase 3 trial. Lancet Oncol 2021; 22:29-42. [PMID: 33301740 DOI: 10.1016/s1470-2045(20)30555-6] [Citation(s) in RCA: 619] [Impact Index Per Article: 206.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/09/2020] [Accepted: 09/11/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Systemic relapses remain a major problem in locally advanced rectal cancer. Using short-course radiotherapy followed by chemotherapy and delayed surgery, the Rectal cancer And Preoperative Induction therapy followed by Dedicated Operation (RAPIDO) trial aimed to reduce distant metastases without compromising locoregional control. METHODS In this multicentre, open-label, randomised, controlled, phase 3 trial, participants were recruited from 54 centres in the Netherlands, Sweden, Spain, Slovenia, Denmark, Norway, and the USA. Patients were eligible if they were aged 18 years or older, with an Eastern Cooperative Oncology Group (ECOG) performance status of 0-1, had a biopsy-proven, newly diagnosed, primary, locally advanced rectal adenocarcinoma, which was classified as high risk on pelvic MRI (with at least one of the following criteria: clinical tumour [cT] stage cT4a or cT4b, extramural vascular invasion, clinical nodal [cN] stage cN2, involved mesorectal fascia, or enlarged lateral lymph nodes), were mentally and physically fit for chemotherapy, and could be assessed for staging within 5 weeks before randomisation. Eligible participants were randomly assigned (1:1), using a management system with a randomly varying block design (each block size randomly chosen to contain two to four allocations), stratified by centre, ECOG performance status, cT stage, and cN stage, to either the experimental or standard of care group. All investigators remained masked for the primary endpoint until a prespecified number of events was reached. Patients allocated to the experimental treatment group received short-course radiotherapy (5 × 5 Gy over a maximum of 8 days) followed by six cycles of CAPOX chemotherapy (capecitabine 1000 mg/m2 orally twice daily on days 1-14, oxaliplatin 130 mg/m2 intravenously on day 1, and a chemotherapy-free interval between days 15-21) or nine cycles of FOLFOX4 (oxaliplatin 85 mg/m2 intravenously on day 1, leucovorin [folinic acid] 200 mg/m2 intravenously on days 1 and 2, followed by bolus fluorouracil 400 mg/m2 intravenously and fluorouracil 600 mg/m2 intravenously for 22 h on days 1 and 2, and a chemotherapy-free interval between days 3-14) followed by total mesorectal excision. Choice of CAPOX or FOLFOX4 was per physician discretion or hospital policy. Patients allocated to the standard of care group received 28 daily fractions of 1·8 Gy up to 50·4 Gy or 25 fractions of 2·0 Gy up to 50·0 Gy (per physician discretion or hospital policy), with concomitant twice-daily oral capecitabine 825 mg/m2 followed by total mesorectal excision and, if stipulated by hospital policy, adjuvant chemotherapy with eight cycles of CAPOX or 12 cycles of FOLFOX4. The primary endpoint was 3-year disease-related treatment failure, defined as the first occurrence of locoregional failure, distant metastasis, new primary colorectal tumour, or treatment-related death, assessed in the intention-to-treat population. Safety was assessed by intention to treat. This study is registered with the EudraCT, 2010-023957-12, and ClinicalTrials.gov, NCT01558921, and is now complete. FINDINGS Between June 21, 2011, and June 2, 2016, 920 patients were enrolled and randomly assigned to a treatment, of whom 912 were eligible (462 in the experimental group; 450 in the standard of care group). Median follow-up was 4·6 years (IQR 3·5-5·5). At 3 years after randomisation, the cumulative probability of disease-related treatment failure was 23·7% (95% CI 19·8-27·6) in the experimental group versus 30·4% (26·1-34·6) in the standard of care group (hazard ratio 0·75, 95% CI 0·60-0·95; p=0·019). The most common grade 3 or higher adverse event during preoperative therapy in both groups was diarrhoea (81 [18%] of 460 patients in the experimental group and 41 [9%] of 441 in the standard of care group) and neurological toxicity during adjuvant chemotherapy in the standard of care group (16 [9%] of 187 patients). Serious adverse events occurred in 177 (38%) of 460 participants in the experimental group and, in the standard of care group, in 87 (34%) of 254 patients without adjuvant chemotherapy and in 64 (34%) of 187 with adjuvant chemotherapy. Treatment-related deaths occurred in four participants in the experimental group (one cardiac arrest, one pulmonary embolism, two infectious complications) and in four participants in the standard of care group (one pulmonary embolism, one neutropenic sepsis, one aspiration, one suicide due to severe depression). INTERPRETATION The observed decreased probability of disease-related treatment failure in the experimental group is probably indicative of the increased efficacy of preoperative chemotherapy as opposed to adjuvant chemotherapy in this setting. Therefore, the experimental treatment can be considered as a new standard of care in high-risk locally advanced rectal cancer. FUNDING Dutch Cancer Foundation, Swedish Cancer Society, Spanish Ministry of Economy and Competitiveness, and Spanish Clinical Research Network.
Collapse
Affiliation(s)
- Renu R Bahadoer
- Department of Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Esmée A Dijkstra
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Boudewijn van Etten
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Corrie A M Marijnen
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, Netherlands; Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Hein Putter
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, Netherlands
| | | | - Annet G H Roodvoets
- Department of Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Iris D Nagtegaal
- Department of Pathology, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Lennart K Blomqvist
- Department of Imaging and Physiology, Karolinska University Hospital, Stockholm, Sweden
| | - Tone Fokstuen
- Department of Oncology and Pathology, Karolinska University Hospital, Stockholm, Sweden
| | | | - Jaume Capdevila
- Department of Medical Oncology, Vall Hebron Institute of Oncology, Vall Hebron University Hospital, Autonomous University of Barcelona, Barcelona, Spain
| | | | - Ibrahim Edhemovic
- Department of Surgical Oncology, Institute of Oncology Ljubljana, University of Ljubljana Faculty of Medicine, Ljubljana, Slovenia
| | - Andrés Cervantes
- Department of Medical Oncology, Biomedical Research Institute Incliva, University of Valencia, Valencia, Spain
| | - Per J Nilsson
- Department of Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Bengt Glimelius
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | | | - Geke A P Hospers
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.
| |
Collapse
|
12
|
van der Valk MJM, Marijnen CAM, van Etten B, Dijkstra EA, Hilling DE, Meershoek-Klein Kranenbarg E, Putter H, Roodvoets AGH, Bahadoer RR, Fokstuen T, Jan Ten Tije A, Capdevila J, Hendriks MP, Edhemovic I, Cervantes AMR, de Groot DJA, Nilsson PJ, Glimelius B, van de Velde CJH, Hospers GAP. Erratum to "Compliance and tolerability of short-course radiotherapy followed by preoperative chemotherapy and surgery for high-risk rectal cancer - Results of the international randomized RAPIDO-trial" [Radiother. Oncol. 147 (2020) 75-83]. Radiother Oncol 2020; 147:e1. [PMID: 32564889 DOI: 10.1016/j.radonc.2020.06.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
| | - Corrie A M Marijnen
- Department of Radiotherapy, Netherlands Cancer Institute, Amsterdam, The Netherlands; Department of Radiotherapy, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Boudewijn van Etten
- Department of Surgery, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Esmée A Dijkstra
- Department of Medical Oncology, University of Groningen, The Netherlands
| | - Denise E Hilling
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Hein Putter
- Department of Medical Statistics, Leiden University Medical Center, The Netherlands
| | - Annet G H Roodvoets
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Renu R Bahadoer
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Tone Fokstuen
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
| | | | - Jaume Capdevila
- Department of Medical Oncology, Vall Hebron University Hospital, Vall Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Mathijs P Hendriks
- Department of Medical Oncology, Northwest Clinics, Alkmaar, The Netherlands
| | - Ibrahim Edhemovic
- Department of Surgical Oncology, Institute of Oncology Ljubljana, Slovenia
| | - Andrès M R Cervantes
- Department of Medical Oncology, Hospital Clínico Universitario de Valencia, Spain
| | | | - Per J Nilsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Bengt Glimelius
- Department of Immunology, Genetics and Pathology, Uppsala University, Sweden
| | | | - Geke A P Hospers
- Department of Medical Oncology, University of Groningen, The Netherlands.
| | | |
Collapse
|
13
|
van der Valk MJM, Marijnen CAM, van Etten B, Dijkstra EA, Hilling DE, Kranenbarg EMK, Putter H, Roodvoets AGH, Bahadoer RR, Fokstuen T, Ten Tije AJ, Capdevila J, Hendriks MP, Edhemovic I, Cervantes AMR, de Groot DJA, Nilsson PJ, Glimelius B, van de Velde CJH, Hospers GAP. Compliance and tolerability of short-course radiotherapy followed by preoperative chemotherapy and surgery for high-risk rectal cancer - Results of the international randomized RAPIDO-trial. Radiother Oncol 2020; 147:75-83. [PMID: 32240909 DOI: 10.1016/j.radonc.2020.03.011] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 03/01/2020] [Accepted: 03/07/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Preoperative chemoradiotherapy (CRT) followed by total mesorectal excision is widely accepted as the standard of care for high-risk rectal cancer. Adjuvant chemotherapy is advised in several international guidelines, although the survival benefit remains unclear and compliance is poor. The current multidisciplinary approach has led to major improvements in local control, yet the occurrence of distant metastases has not decreased accordingly. The combination of short-course radiotherapy (SCRT) and chemotherapy in the waiting period before surgery might have several benefits, including higher compliance, downstaging and better effect of systemic therapy. METHODS This is an investigator-initiated, international multicentre randomized phase III trial. High-risk rectal cancer patients were randomized to SCRT followed by chemotherapy (6 cycles CAPOX or alternatively 9 cycles FOLFOX4) and subsequent surgery, or long-course radiotherapy (25-28 × 2-1.8 Gy) with concomitant capecitabine followed by surgery and optional postoperative chemotherapy (8 cycles CAPOX or 12 cycles FOLFOX4) according to local institutions' policy. The primary endpoint is time to disease-related treatment failure. Here, we report the compliance, toxicity and postoperative complications in both study groups. FINDINGS Between June 2011 and June 2016, 920 patients were enrolled. Of these, 901 were evaluable (460 in the experimental arm and 441 in the standard arm). All patients in the experimental arm received 5 × 5 Gy radiotherapy, and 84% of all patients received at least 75% of the prescribed chemotherapy. In the standard arm, the compliance for CRT was 93% and 58% for postoperative chemotherapy. Toxicity ≥grade 3 occurred in 48% of patients in the experimental arm, compared to 25% of patients in the standard arm during preoperative treatment and 35% of patients during postoperative chemotherapy. No statistically significant differences in surgical procedures or postoperative complications were observed. INTERPRETATION High compliance (84%) of preoperative systemic treatment could be achieved with the experimental approach. Although considerable toxicity was observed during preoperative therapy, this did not lead to differences in surgical procedures or postoperative complications. Longer follow-up time is needed to assess the primary endpoint and related outcomes.
Collapse
Affiliation(s)
| | - Corrie A M Marijnen
- Department of Radiotherapy, Leiden University Medical Center, The Netherlands; Department of Radiotherapy, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Boudewijn van Etten
- Department of Surgery, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Esmée A Dijkstra
- Department of Medical Oncology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Denise E Hilling
- Department of Surgery, Leiden University Medical Center, The Netherlands
| | | | - Hein Putter
- Department of Medical Statistics, Leiden University Medical Center, The Netherlands
| | | | - Renu R Bahadoer
- Department of Surgery, Leiden University Medical Center, The Netherlands
| | - Tone Fokstuen
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
| | | | - Jaume Capdevila
- Department of Medical Oncology, Vall Hebron University Hospital, Vall Hebron Institute of Oncology (VHIO). Barcelona, Spain
| | - Mathijs P Hendriks
- Department of Medical Oncology, Northwest Clinics, Alkmaar, The Netherlands
| | - Ibrahim Edhemovic
- Department of Surgical Oncology, Institute of Oncology Ljubljana, Slovenia
| | - Andrès M R Cervantes
- Department of Medical Oncology, Hospital Clínico Universitario de Valencia, Spain
| | - Derk Jan A de Groot
- Department of Medical Oncology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Per J Nilsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Bengt Glimelius
- Department of Immunology, Genetics and Pathology, Uppsala University, Sweden
| | | | - Geke A P Hospers
- Department of Medical Oncology, University of Groningen, University Medical Center Groningen, The Netherlands.
| | | |
Collapse
|
14
|
Abstract
To determine the rheobase and the chronaxie of excitable cells from strength-duration curves both constant-current pulses and constant-voltage pulses are applied. Since the complex impedance of the electrode-tissue interface varies with both the pulsewidth and the stimulation voltage, chronaxie values estimated from voltage-duration measurements will differ from the proper values as determined from current-duration measurements. To allow a comparison of chronaxie values obtained by the two stimulation methods, voltage-duration curves were measured in human subjects with a deep brain stimulation electrode implanted, while the current and the load impedance of the stimulation circuit were determined in vitro as a function of both stimulation voltage and pulsewidth. Chronaxie values calculated from voltage-duration data were shown to be 30-40% below those estimated from current-duration data. It was also shown that in the normal range of stimulation amplitudes (up to 7 V) the load impedance increases almost linearly with the pulsewidth. This result led us to present a simple method to convert voltage-duration data into current-duration data, thereby reducing the error in the calculated chronaxie values to approximately 6%. For this purpose voltage-duration data have to be measured for pulses up to 10-20 times the expected chronaxie.
Collapse
Affiliation(s)
- J Holsheimer
- Department of Electrical Engineering, Institute for Biomedical Technology, University of Twente, PO Box 217, NL-7500 AE, Enschede, The Netherlands.
| | | | | | | |
Collapse
|