Efficacy and Safety of High-Dose Vitamin C Combined with Total Neoadjuvant Chemoradiotherapy in Locally Advanced Rectal Cancer (HCCSC R02 Study)

PURPOSE/OBJECTIVE(S)

Forpatients with locally advanced rectal cancer (LARC), the standard treatment is fluoropyrimidine (FU) -based neoadjuvant chemoradiotherapy (NCRT) combined with curative surgery. The CAO/ARO/AIO-04 trial and FORWARC trial reported that the addition of oxaliplatin to FU -based NCRT contributed to improve pathologic complete response (pCR), nevertheless, increased the acute therapeutic toxicity. Some studies showed that vitamin C (VitC) had potential benefits on anti-tumor therapy and anti-inflammatory response. Therefore, we conducted this HCCSC R02 study to explore the efficacy and safety of adding a high-dose intravenous VitC to mFOLFOX6/XELOX -based NCRT in LARC.

MATERIALS/METHODS

HCCSCR02 study was designed as a prospective, single-center phase II trial, which including pts aged 18-75 years with stage II/III rectal adenocarcinoma, distance from anus ≤12cm. The enrollment criteria included: staged with MRI as cT3/cT4 or cN1/2, or mesorectal fascia involvement (MRF+), or difficult to preserve the anus. Patients with glucose-6-phosphate dehydrogenase enzyme(G6PD) deficiency were excluded. Pelvic intensity modulated radiation therapy (IMRT) was given in 45-50.4Gy/25-28 fractions. Concurrently, two cycles of chemotherapy (mFOLFOX6 or XELOX) were administered during IMRT, as well as intravenous VitC (24g) delivered daily after the end of each radiation therapy. Additional 2-3 cycles of mFOLFOX6 / XELOX were adopted between the completion of radiotherapy and surgery. The primary endpoint was pCR rate. The secondary endpoints included radiation-related toxicities, overall survival (OS) and disease-free survival (DFS). This study is still recruiting.

RESULTS

From May 15, 2021 to Feb 8, 2023, 19 pts were recruited and finished all the scheduled NCRT, of which the proportion of cT4, cT3, cN2, cN1 were 31.6%, 63.2%, 52.6%, 36.8%, respectively. In addition, 10 pts (52.6%) were diagnosed as MRF+ initially, and 8 pts (42.1%) had a lower primary tumor(≤5cm) who were considered difficult for anal preservation before NCRT. All subjects enrolled were confirmed to be proficient mismatch repair (pMMR). As a result, 18 pts underwent a total mesorectal excision (TME) all with R0-resection, and 8 pts were evaluated as pCR (44.4%, 8/18, confidence interval: 0.246-0.663), 11 as major pathological response rate (MPR) (61.6%, 11/18), respectively. The anus preservation rate in patients with lower diseases was 87.5% (7/8). One case accepted a watch-and-wait strategy because of clinical complete response (cCR). Overall, grade 3 toxicities were observed in 4 pts, including 3 leucopenia (15.8%, 3/19), 2 neutropenia (10.5%, 2/19) and 1 diarrhea (5.3%, 1/19). No grade 4 adverse event was observed.

CONCLUSION

The addition of high-dose VitC to the mFOLFOX6/XELOX-based NCRT in LARC showed a promising pCR, well tolerance, particularly low rate of diarrhea, thus warrants further investigation.

CLINICAL TRIAL INFORMATION

NCT04801511.

[Study on the correlation between PPG and HVPG in patients with portal hypertension]

Objective: To explore the correlation between portal vein pressure gradient (PPG) and hepatic vein pressure gradient (HVPG) in patients with portal hypertension (PHT). Methods: 752 cases with portal hypertension (PHT) who underwent transjugular intrahepatic portosystemic shunt (TIPS) and met the enrollment criteria between January 2016 to December 2019 were analyzed for hepatic vein, inferior vena cava and portal vein pressure. Paired t-test was used for analysis. Pearson correlation test was used to estimate correlation coefficient and coefficient of determination. P<0.05 were considered statistically significant. Results: Wedged hepatic vein pressure (WHVP), portal vein pressure (PVP), correlation coefficient, and coefficient of determination were 27.98±8.95 mmHg, 33.85±7.33 mmHg, 0.329 (P<0.001), and 0.108, respectively. HVPG, PPG,correlation coefficient, and coefficient of determination were 16.84±7.97 mmHg, 25.11±6.95 mmHg (P<0.001), 0.145, and 0.021 (P<0.001), respectively. The difference between HVPG and PPG was greater than 5 mmHg in 524 cases, accounting for 69.7%. The difference between HVPG and PPG was within 5 mmHg or basically equal in 228 cases, accounting for 30.3%. The correlation coefficient between free hepatic venous pressure (FHVP) and inferior vena cava pressure (IVCP) was 0.568 (P<0.001), and the coefficient of determination was 0.323. According to the presence or absence of hepatic venous collaterals after balloon occluded hepatic angiography, they were divided into two groups: 157 (20.9%) cases in the group with hepatic venous collaterals, and 595 (79.1%) cases in the group without hepatic venous collaterals. The parameters of the two groups were compared: WHVP (15.73±3.63) mmHg vs. (31.22±6.90) mmHg, P<0.001; PVP (31.69±8.70) mmHg vs. (34.42±6.81) mmHg, P<0.001; HVPG (7.18±4.40) mmHg vs. (19.40±6.62) mmHg, P<0.001; PPG (24.24±8.11) mmHg vs. (25.34±6.60) mmHg, P<0.001; free hepatic venous pressure (FHVP) (8.58±3.37) mmHg vs. (11.82±5.07) mmHg , P<0.001; inferior vena cava pressure (IVCP) (7.45±3.29) mmHg vs. (9.09±4.14) mmHg, P<0.001. Conclusion: The overall correlation is poor between HVPG and PPG. HVPG of most patients is not an accurate representation of PPG, and the former is lower than the latter. Hepatic venous collateral formation is one of the important reasons for the serious underestimation of HVPG values.

[Establishment of a nomogram model for predicting lymph node metastasis in patients with cN0 gastric cancer based on combination of preoperative C-reactive protein/albumin ratio]

Objective: To investigate the relationship between systemic inflammatory markers such as neutrophil/lymphocyte ratio (NLR) and C-reactive protein/albumin ratio (CAR), and lymph node metastasis in patients with cN0 gastric cancer. To establish a nomogram model to predict the risk of lymph node metastasis in patients with cN0 gastric cancer. Methods: The preoperative systemic inflammatory markers and clinical data of 134 patients with cN0 gastric cancer were retrospectively analyzed, and these markers of patients with negative (pN0) or positive (pN+ ) lymph node metastasis in postoperative pathological diagnosis were compared. The receiver operating characteristic (ROC) curve was used to evaluate the predictive effect of preoperative systemic inflammatory markers on lymph node metastasis. The influencing factors for lymph node metastasis were assessed by univariate analysis and multivariate logistic regression analysis. A nomogram subsequently established by R software was validated by Bootstrap resampling as internal validation. Results: Compared with pN0 group, NE (P=0.022), CRP (P<0.001), NLR (P<0.001), PLR (P=0.003) and CAR (P<0.001) were higher, LY (P=0.003) and Alb (P=0.042) were lower in pN+ group. ROC curve analysis showed that the area under the curve (AUC) of postoperative pathological lymph node metastasis in patients with cN0 gastric cancer diagnosed by NLR, PLR and CAR were 0.687, 0.651 and 0.694, respectively, and the best cutoff values were 2.12, 113.59 and 0.02, respectively. The corresponding sensitivity and specificity were 62.9% and 72.2%, 77.4% and 48.6%, 74.2% and 58.3%, respectively. Univariate analysis showed that tumor size, depth of invasion, NLR, PLR and CAR were associated with lymph node metastasis in cN0 gastric cancer patients (all P<0.05). Multivariate analysis showed that depth of invasion, NLR and CAR were independent influencing factors of lymph node metastasis in patients with cN0 gastric cancer. OR were 8.084, 3.540 and 3.092, respectively (all P<0.05). The C-index of the nomogram model was 0.847 (95% CI: 0.782-0.915). The predicting calibration curve was properly fit with the ideal curve in calibration chart. Conclusion: Combination of NLR and CAR to establish a nomogram model has a good consistency and can accurately predict the risk of lymph node metastasis in patients with cN0 gastric cancer.