1
|
Vissing M, Pervan M, Pløen J, Schnefeldt M, Rafaelsen SR, Jensen LH, Rody A, Gehl J. Calcium electroporation in cutaneous metastases - A non-randomised phase II multicentre clinical trial. Eur J Surg Oncol 2023; 49:106925. [PMID: 37268521 DOI: 10.1016/j.ejso.2023.04.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 03/14/2023] [Revised: 04/26/2023] [Accepted: 04/30/2023] [Indexed: 06/04/2023]
Abstract
BACKGROUND Cutaneous metastases can cause distressing symptoms and be challenging to treat. Local therapies are essential in management. Calcium electroporation uses calcium and electrical pulses to selectively kill cancer cells. This multicentre study aimed to define response in cutaneous metastases across different cancer types. METHODS Patients with tumours ≤3 cm of any histology were included (stable or progressing on current therapy ≥2 months), at three centres. Tumours were treated with 220 mM calcium chloride injection and manual application of eight 0.1 ms pulses with 1 kV/cm and 1Hz with a handheld electrode, in local or general anaesthesia. Clinical response was evaluated after 1, 2, 3, 4, 5, 6, and 12 months. Primary endpoint was response at two months. The overall response rate (ORR) was partial- and complete responses of treated tumours. MR-imaging and qualitative interviews were performed in respective subsets. RESULTS Nineteen patients with disseminated cancer (breast n = 4, lung n = 5, pancreatic n = 1, colorectal n = 2, gastric n = 1, and endometrial cancer n = 1) were enrolled, and 58 metastases were treated (50 once, 8 retreated). The ORR was 36% (95% CI 22-53) after two months. Best ORR was 51% (CR 42%; PR 9%). Previous irradiation improved outcomes (p = 0.0004). Adverse events were minimal. Median pain score was reduced after two months (p = 0.017). Treatment may relieve symptoms according to qualitative interviews. MRI showed restriction in treated tissue. CONCLUSION The majority of tumours were treated only once with calcium electroporation, achieving an ORR of 36% after two months and best ORR of 51%. Efficacy, symptom-relief and safety support calcium electroporation as a palliative treatment option for cutaneous metastases.
Collapse
Affiliation(s)
- Mille Vissing
- Center for Experimental Drug and Gene Electrotransfer (C∗EDGE), Department of Clinical Oncology and Palliative Care, Zealand University Hospital, Roskilde and Næstved, Ringstedgade 61, 4700, Næstved, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark
| | - Mascha Pervan
- Department of Gynaecology and Obstetrics, University Hospital Schleswig-Holstein, Campus Lübeck, Germany Ratzeburger Allee 160, 23562, Lübeck, Germany
| | - John Pløen
- Department of Oncology, University Hospital of Southern Denmark, Beriderbakken 4, 7100, Vejle, Denmark
| | - Mazen Schnefeldt
- Department of Radiology, University Hospital of Southern Denmark, Beriderbakken 4, 7100, Vejle, Denmark
| | - Søren Rafael Rafaelsen
- Department of Radiology, University Hospital of Southern Denmark, Beriderbakken 4, 7100, Vejle, Denmark
| | - Lars Henrik Jensen
- Department of Oncology, University Hospital of Southern Denmark, Beriderbakken 4, 7100, Vejle, Denmark
| | - Achim Rody
- Department of Gynaecology and Obstetrics, University Hospital Schleswig-Holstein, Campus Lübeck, Germany Ratzeburger Allee 160, 23562, Lübeck, Germany
| | - Julie Gehl
- Center for Experimental Drug and Gene Electrotransfer (C∗EDGE), Department of Clinical Oncology and Palliative Care, Zealand University Hospital, Roskilde and Næstved, Ringstedgade 61, 4700, Næstved, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark.
| |
Collapse
|
2
|
Nissen H, McIlroy S, Havelund B, Krog C, Pløen J, Berg M. PO-1774: First clinical experiences with MR-only treatment planning and delivery for pelvic cancers. Radiother Oncol 2020. [DOI: 10.1016/s0167-8140(21)01792-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
3
|
Dizdarevic E, Frøstrup Hansen T, Pløen J, Henrik Jensen L, Lindebjerg J, Rafaelsen S, Jakobsen A, Appelt A. Long-Term Patient-Reported Outcomes After High-Dose Chemoradiation Therapy for Nonsurgical Management of Distal Rectal Cancer. Int J Radiat Oncol Biol Phys 2019; 106:556-563. [PMID: 31707122 DOI: 10.1016/j.ijrobp.2019.10.046] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 10/17/2019] [Accepted: 10/25/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE Surgery is standard treatment for rectal cancer, but neoadjuvant chemoradiation therapy (CRT) may result in clinical complete response (cCR) in select patients, allowing for nonsurgical management (NSM). Prospective studies of NSM strategies are sparse, however, and long-term data on quality of life (QoL) are limited. We conducted a single-arm phase 2 trial of high-dose CRT for NSM of distal rectal cancer; we report secondary long-term patient-reported outcomes (PROs), local regrowth, and overall survival in patients managed nonsurgically. METHODS AND MATERIALS Fifty-one patients with resectable, T2 or T3, N0-N1, low adenocarcinoma received 65 Gy (intensity modulated radiation therapy, brachytherapy boost) and oral tegafur-uracil. Patients with cCR 6 weeks after treatment (clinical examination, magnetic resonance imaging, biopsy) were referred for observation and followed closely with clinical examination, endoscopy, positron emission tomography/computed tomography, and PROs for 5 years. Overall colorectal cancer-specific QoL and specific symptom scores were evaluated at baseline and in follow-up and compared between time points. Local regrowth was estimated using cumulative incidence and overall survival using Kaplan-Meier estimates. RESULTS Forty patients achieved cCR after treatment; 29 were in follow-up at 24 months, 21 at 36 months, and 20 at 60 months. PRO questionnaire completion rates were 90% at 24 months, 100% at 36 months, and 85% at 60 months for patients still in follow-up. Average QoL score did not differ between baseline (median 11.1) and 24 months (13.7), 48 months (11.1), or 60 months (6.9). Only rectal bleeding deteriorated from baseline, with bowel- and bladder-related symptom scores otherwise unchanged in follow-up. At median follow-up of 5.0 years, local regrowth rate and overall survival were 31% (95% confidence interval, 15%-47%) and 85% (95% confidence interval, 75%-97%), respectively. CONCLUSIONS Long-term follow-up after NSM of distal rectal cancer showed excellent general colorectal cancer QoL and local symptom scores. Our study results indicate that high-dose CRT followed by organ preservation might be an alternative to standard treatment.
Collapse
Affiliation(s)
- Edina Dizdarevic
- Department of Oncology, Vejle Hospital, University of Southern Denmark, Vejle, Denmark
| | - Torben Frøstrup Hansen
- Department of Oncology, Vejle Hospital, University of Southern Denmark, Vejle, Denmark; Danish Colorectal Cancer Center South, Vejle University Hospital, Vejle, Denmark; Institute of Regional Health Research, University of Southern Denmark, Denmark
| | - John Pløen
- Department of Oncology, Vejle Hospital, University of Southern Denmark, Vejle, Denmark; Danish Colorectal Cancer Center South, Vejle University Hospital, Vejle, Denmark; Institute of Regional Health Research, University of Southern Denmark, Denmark
| | - Lars Henrik Jensen
- Department of Oncology, Vejle Hospital, University of Southern Denmark, Vejle, Denmark; Danish Colorectal Cancer Center South, Vejle University Hospital, Vejle, Denmark; Institute of Regional Health Research, University of Southern Denmark, Denmark
| | - Jan Lindebjerg
- Danish Colorectal Cancer Center South, Vejle University Hospital, Vejle, Denmark; Institute of Regional Health Research, University of Southern Denmark, Denmark; Department of Pathology, Vejle Hospital, University of Southern Denmark, Vejle, Denmark
| | - Søren Rafaelsen
- Danish Colorectal Cancer Center South, Vejle University Hospital, Vejle, Denmark; Institute of Regional Health Research, University of Southern Denmark, Denmark; Department of Radiology, Vejle Hospital, University of Southern Denmark, Vejle, Denmark
| | - Anders Jakobsen
- Department of Oncology, Vejle Hospital, University of Southern Denmark, Vejle, Denmark; Danish Colorectal Cancer Center South, Vejle University Hospital, Vejle, Denmark; Institute of Regional Health Research, University of Southern Denmark, Denmark
| | - Ane Appelt
- Danish Colorectal Cancer Center South, Vejle University Hospital, Vejle, Denmark; Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| |
Collapse
|
4
|
Rønde HS, Wee L, Bokrantz R, Pløen J, Appelt AL. [P168] Volumetric modulated arc therapy using multi-criteria dose plan optimization for anal cancer – Feasibility of selective sparing of organs at risk. Phys Med 2018. [DOI: 10.1016/j.ejmp.2018.06.468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
|
5
|
Appelt A, Havelund B, Rønde H, Pløen J, Vogelius I, Jakobsen A. PO-0798: High dose IMRT for locally advanced rectal cancer – late toxicity and patient-reported outcomes. Radiother Oncol 2018. [DOI: 10.1016/s0167-8140(18)31108-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
6
|
Rønde HS, Wee L, Pløen J, Appelt AL. Feasibility of preference-driven radiotherapy dose treatment planning to support shared decision making in anal cancer. Acta Oncol 2017; 56:1277-1285. [PMID: 28447539 DOI: 10.1080/0284186x.2017.1315174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE/OBJECTIVE Chemo-radiotherapy is an established primary curative treatment for anal cancer, but clinically equal rationale for different target doses exists. If joint preferences (physician and patient) are used to determine acceptable tradeoffs in radiotherapy treatment planning, multiple dose plans must be simultaneously explored. We quantified the degree to which different toxicity priorities might be incorporated into treatment plan selection, to elucidate the feasible decision space for shared decision making in anal cancer radiotherapy. MATERIAL AND METHODS Retrospective plans were generated for 22 anal cancer patients. Multi-criteria optimization handles dynamically changing priorities between clinical objectives while meeting fixed clinical constraints. Four unique dose distributions were designed to represent a wide span of clinically relevant objectives: high-dose preference (60.2 Gy tumor boost and 50.4 Gy to elective nodes with physician-defined order of priorities), low-dose preference (53.75 Gy tumor boost, 45 Gy to elective nodes, physician-defined priorities), bowel sparing preference (lower dose levels and priority for bowel avoidance) and bladder sparing preference (lower dose levels and priority for bladder avoidance). RESULTS Plans satisfied constraints for target coverage. A senior oncologist approved a random subset of plans for quality assurance. Compared to a high-dose preference, bowel sparing was clinically meaningful at the lower prescribed dose [median change in V45Gy: 234 cm3; inter-quartile range (66; 247); p < .01] and for a bowel sparing preference [median change in V45Gy: 281 cm3; (73; 488); p < .01]. Compared to a high-dose preference, bladder sparing was clinically meaningful at the lower prescribed dose [median change in V35Gy: 13.7%-points; (0.3; 30.6); p < .01] and for a bladder sparing preference [median change in V35Gy: 30.3%-points; (12.4; 43.1); p < .01]. CONCLUSIONS There is decision space available in anal cancer radiotherapy to incorporate preferences, although tradeoffs are highly patient-dependent. This study demonstrates that preference-informed dose planning is feasible for clinical studies utilizing shared decision making.
Collapse
Affiliation(s)
- Heidi S. Rønde
- Department of Medical Physics, Vejle Hospital, Vejle, Denmark
| | - Leonard Wee
- MAASTRO Clinic, School of Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands
- Danish Colorectal Cancer Centre South, Vejle Hospital, and Institute of Regional Health Research, University of Southern Denmark, Denmark
| | - John Pløen
- Danish Colorectal Cancer Centre South, Vejle Hospital, and Institute of Regional Health Research, University of Southern Denmark, Denmark
- Department of Oncology, Vejle Hospital, Vejle, Denmark
| | - Ane L. Appelt
- Danish Colorectal Cancer Centre South, Vejle Hospital, and Institute of Regional Health Research, University of Southern Denmark, Denmark
- Leeds Institute of Cancer and Pathology, University of Leeds, and Leeds Cancer Centre, St. James' University Hospital, Leeds, UK
| |
Collapse
|
7
|
Jakobsen A, Andersen F, Fischer A, Jensen LH, Jørgensen JCR, Larsen O, Lindebjerg J, Pløen J, Rafaelsen SR, Vilandt J. Neoadjuvant chemotherapy in locally advanced colon cancer. A phase II trial. Acta Oncol 2015; 54:1747-53. [PMID: 25920359 DOI: 10.3109/0284186x.2015.1037007] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Neoadjuvant chemotherapy has proven valuable in several tumors, but it has not been elucidated in colon cancer. The present phase II trial addressed the issue in high-risk patients selected by computed tomography (CT) scan. MATERIAL AND METHODS Patients with resectable colon cancer fulfilling the following criteria were offered inclusion; Histopathological verification of adenocarcinoma, T3 tumor on CT scan with extramural tumor invasion > 5 mm or T4 tumor, age ≥ 18 years, PS ≤ 2, adequate hematology, and informed consent. Patients with KRAS, BRAF or PIK3CA mutation or unknown mutational status received three cycles of capecitabine 2000 mg/m(2) days 1-14 q3w and oxaliplatin 130 mg iv day 1 q3w. Wild-type patients received the same chemotherapy supplemented with panitumumab 9 mg/kg iv q3w. After the operation, patients fulfilling the international criteria for adjuvant chemotherapy, i.e. high-risk stage II and III patients, received five cycles of the same chemotherapy without panitumumab. Patients not fulfilling the criteria were offered follow-up only. The primary endpoint was the fraction of patients not fulfilling the criteria for adjuvant chemotherapy (converted patients). Secondary endpoints were recurrence rate, disease-free survival (DFS), and toxicity. RESULTS The study included 77 patients. The conversion rate was 42% in the wild-type group compared to 51% in patients with a mutation. The cumulative recurrence rate in converted versus unconverted patients was 6% versus 32% (p = 0.005) translating into a three-year DFS of 94% versus 63% (p = 0.005). CONCLUSION Neoadjuvant chemotherapy in colon cancer is feasible and the results suggest that a major part of the patients can be spared adjuvant chemotherapy. Validation in a randomized trial is warranted.
Collapse
Affiliation(s)
- Anders Jakobsen
- a Department of Oncology , Vejle Hospital , Vejle , Denmark
- i Institute for Regional Health Research, University of Southern Denmark , Odense , Denmark
| | - Fahimeh Andersen
- e Department of Oncology , Hillerød Hospital , Hillerød , Denmark
| | - Anders Fischer
- h Department of Surgical Gastroenterology , Herlev Hospital , Herlev , Denmark
| | - Lars H Jensen
- a Department of Oncology , Vejle Hospital , Vejle , Denmark
| | | | - Ole Larsen
- g Department of Oncology , Herlev Hospital , Herlev , Denmark
| | - Jan Lindebjerg
- b Department of Pathology , Vejle Hospital , Vejle , Denmark
| | - John Pløen
- a Department of Oncology , Vejle Hospital , Vejle , Denmark
| | - Søren R Rafaelsen
- c Department of Radiology , Vejle Hospital , Vejle , Denmark
- i Institute for Regional Health Research, University of Southern Denmark , Odense , Denmark
| | - Jesper Vilandt
- f Department of Surgery , Hillerød Hospital , Hillerød , Denmark
| |
Collapse
|
8
|
Rafaelsen SR, Vagn-Hansen C, Sørensen T, Lindebjerg J, Pløen J, Jakobsen A. Elastography and diffusion-weighted MRI in patients with rectal cancer. Br J Radiol 2015; 88:20150294. [PMID: 26402215 DOI: 10.1259/bjr.20150294] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE The current literature has described the usefulness of elastography and diffusion-weighted MRI in patients with cancer, but to the best of our knowledge so far none of them has compared the two new methods. The tumour cell density is related to the MRI-measured apparent diffusion-weighted coefficient (ADC). The purpose of the present study was to compare quantitative elastography based on ultrasound shear wave measurements with MRI ADC. METHODS We prospectively examined 52 patients with histopathologically proven rectal cancer. The mean age was 67 years (range 42-90 years). Males: 39, females: 13. Tumour elasticity was measured transgluteally using the acoustic radiation force impulse (ARFI) to generate information on the mechanical properties of the tissue. The objective quantitative elastography shear wave velocity was blindly compared with the ADC measurements using a 1.5-T MRI system. RESULTS The mean tumour elasticity was 3.05 m s(-1) [standard deviation (SD): 0.79], and the mean ADC was 0.69 × 10(-3) mm(2) s(-1) (SD: 0.27). Elasticity was inversely strongly correlated with ADC, r = -0.65 (Salkin scale). ARFI = 4.392 - 1.949 × ADC, R(2) = 0.43, p < 0.0001. Intercept = 4.392 (95% CI: 3.92 to 4.86), slope = -1.949 (95% CI: -1.31 to -2.59), p < 0.0001. CONCLUSION Elasticity correlates with the estimated diffusion restriction by MRI ADC measurements in rectal tumours. The relationship between ARFI and ADC measurement was linear in our study population. ADVANCES IN KNOWLEDGE This work describes a correlation between tissue elasticity and diffusion in rectal cancer.
Collapse
Affiliation(s)
- Søren R Rafaelsen
- 1 Department of Radiology, CCE, Vejle Hospital, Vejle, Denmark.,2 Danish Colorectal Cancer Group South, Institute of Regional Health Research, CCE, University of Southern Denmark, Vejle, Denmark
| | | | - Torben Sørensen
- 1 Department of Radiology, CCE, Vejle Hospital, Vejle, Denmark
| | - Jan Lindebjerg
- 3 Department of Pathology, CCE, Vejle Hospital, Vejle, Denmark
| | - John Pløen
- 4 Department of Oncology, CCE, Vejle Hospital, Vejle, Denmark
| | - Anders Jakobsen
- 2 Danish Colorectal Cancer Group South, Institute of Regional Health Research, CCE, University of Southern Denmark, Vejle, Denmark.,4 Department of Oncology, CCE, Vejle Hospital, Vejle, Denmark
| |
Collapse
|
9
|
Appelt AL, Pløen J, Harling H, Jensen FS, Jensen LH, Jørgensen JCR, Lindebjerg J, Rafaelsen SR, Jakobsen A. High-dose chemoradiotherapy and watchful waiting for distal rectal cancer: a prospective observational study. Lancet Oncol 2015; 16:919-27. [PMID: 26156652 DOI: 10.1016/s1470-2045(15)00120-5] [Citation(s) in RCA: 364] [Impact Index Per Article: 40.4] [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: 04/01/2015] [Revised: 05/08/2015] [Accepted: 05/12/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Abdominoperineal resection is the standard treatment for patients with distal T2 or T3 rectal cancers; however, the procedure is extensive and mutilating, and alternative treatment strategies are being investigated. We did a prospective observational trial to assess whether high-dose radiotherapy with concomitant chemotherapy followed by observation (watchful waiting) was successful for non-surgical management of low rectal cancer. METHODS Patients with primary, resectable, T2 or T3, N0-N1 adenocarcinoma in the lower 6 cm of the rectum were given chemoradiotherapy (60 Gy in 30 fractions to tumour, 50 Gy in 30 fractions to elective lymph node volumes, 5 Gy endorectal brachytherapy boost, and oral tegafur-uracil 300 mg/m(2)) every weekday for 6 weeks. Endoscopies and biopsies of the tumour were done at baseline, throughout the course of treatment (weeks 2, 4, and 6), and 6 weeks after the end of treatment. We allocated patients with complete clinical tumour regression, negative tumour site biopsies, and no nodal or distant metastases on CT and MRI 6 weeks after treatment to the observation group (watchful waiting). We referred all other patients to standard surgery. Patients under observation were followed up closely with endoscopies and selected-site biopsies, with surgical resection given for local recurrence. The primary endpoint was local tumour recurrence 1 year after allocation to the observation group. This study is registered with ClinicalTrials.gov, number NCT00952926. Enrolment is closed, but follow-up continues for secondary endpoints. FINDINGS Between Oct 20, 2009, and Dec 23, 2013, we enrolled 55 patients. Patients were recruited from three surgical units throughout Denmark and treated in one tertiary cancer centre (Vejle Hospital, Vejle, Denmark). Of 51 patients who were eligible, 40 had clinical complete response and were allocated to observation. Median follow-up for local recurrence in the observation group was 23·9 months (IQR 15·3-31·0). Local recurrence in the observation group at 1 year was 15·5% (95% CI 3·3-26·3). The most common acute grade 3 adverse event during treatment was diarrhoea, which affected four (8%) of 51 patients. Sphincter function in the observation group was excellent, with 18 (72%) of 25 patients at 1 year and 11 (69%) of 16 patients at 2 years reporting no faecal incontinence at all and a median Jorge-Wexner score of 0 (IQR 0-0) at all timepoints. The most common late toxicity was bleeding from the rectal mucosa; grade 3 bleeding was reported in two (7%) in 30 patients at 1 year and one (6%) of 17 patients at 2 years. There were no unexpected serious adverse reactions or treatment-related deaths. INTERPRETATION High-dose chemoradiotherapy and watchful waiting might be a safe alternative to abdominoperineal resection for patients with distal rectal cancer. FUNDING CIRRO-The Lundbeck Foundation Center for Interventional Research in Radiation Oncology and The Danish Council for Strategic Research.
Collapse
Affiliation(s)
- Ane L Appelt
- Danish Colorectal Cancer Center South, Vejle Hospital, Vejle, Denmark; Department of Oncology, Section of Radiotherapy, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - John Pløen
- Danish Colorectal Cancer Center South, Vejle Hospital, Vejle, Denmark
| | - Henrik Harling
- Digestive Disease Center, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Frank S Jensen
- Department of Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Lars H Jensen
- Danish Colorectal Cancer Center South, Vejle Hospital, Vejle, Denmark
| | | | - Jan Lindebjerg
- Danish Colorectal Cancer Center South, Vejle Hospital, Vejle, Denmark
| | - Søren R Rafaelsen
- Danish Colorectal Cancer Center South, Vejle Hospital, Vejle, Denmark
| | - Anders Jakobsen
- Danish Colorectal Cancer Center South, Vejle Hospital, Vejle, Denmark
| |
Collapse
|
10
|
Dam C, Lund-Rasmussen V, Pløen J, Jakobsen A, Rafaelsen SR. Computed tomography assessment of early response to neoadjuvant therapy in colon cancer. Dan Med J 2015; 62:A5103. [PMID: 26183044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
INTRODUCTION Using multidetector computed tomography, we aimed to assess the early response of neoadjuvant drug therapy for locally advanced colon cancer. METHODS Computed tomography with IV contrast was acquired from 67 patients before and after up to three cycles of preoperative treatment. All patients had histologically confirmed colon cancer, a T4 or T3 tumour with extramural invasion ≥ 5 mm and no distant metastases or peritoneal nodules. The patients were treated with oxaliplatin and capecitabine. In addition, those with no mutations in the KRAS, BRAF and PIK3CA genes were also treated with panitumumab. Before and after treatment, we measured the tumour diameter in two different planes, the extension of the extramural tumour invasion, and the number and size of enlarged lymph nodes. RESULTS The mean tumour length was 7.8 cm (95% confidence interval (CI): 5.3-10.4) at baseline and 4.34 cm (95% CI: 4.0-4.9) after treatment. The mean extramural tumour invasion was 10.6 mm (95% CI: 9.5-11.8) at baseline and 5.7 mm (95% CI: 4.7-6.7) after treatment. The mean number of enlarged lymph nodes was 4.1 (95% CI: 3.4-4.9) at baseline and 2.1 (95% CI: 1.4-2.7) after treatment. According to RECIST 1.1, 45% (95% CI: 34-57) of the patients had a response and 55% (95% CI: 43-67) had stable disease. None of the patients showed progressive disease. CONCLUSION Using CT, we demonstrated a significant reduction in tumour size, extramural tumour invasion, number and size of enlarged lymph nodes following neoadjuvant treatment. FUNDING not relevant. TRIAL REGISTRATION Registered with ClinicalTrials.gov (NCT 01108107).
Collapse
Affiliation(s)
- Claus Dam
- Radiologisk Afdeling, Vejle Hospital, Kabbeltoft 25, 7100 Vejle, Denmark.
| | | | | | | | | |
Collapse
|
11
|
Appelt AL, Vogelius IR, Pløen J, Rafaelsen SR, Lindebjerg J, Havelund BM, Bentzen SM, Jakobsen A. Long-term results of a randomized trial in locally advanced rectal cancer: no benefit from adding a brachytherapy boost. Int J Radiat Oncol Biol Phys 2014; 90:110-8. [PMID: 25015203 DOI: 10.1016/j.ijrobp.2014.05.023] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 05/07/2014] [Accepted: 05/16/2014] [Indexed: 01/08/2023]
Abstract
PURPOSE/OBJECTIVE(S) Mature data on tumor control and survival are presented from a randomized trial of the addition of a brachytherapy boost to long-course neoadjuvant chemoradiation therapy (CRT) for locally advanced rectal cancer. METHODS AND MATERIALS Between March 2005 and November 2008, 248 patients with T3-4N0-2M0 rectal cancer were prospectively randomized to either long-course preoperative CRT (50.4 Gy in 28 fractions, per oral tegafur-uracil and L-leucovorin) alone or the same CRT schedule plus a brachytherapy boost (10 Gy in 2 fractions). The primary trial endpoint was pathologic complete response (pCR) at the time of surgery; secondary endpoints included overall survival (OS), progression-free survival (PFS), and freedom from locoregional failure. RESULTS Results for the primary endpoint have previously been reported. This analysis presents survival data for the 224 patients in the Danish part of the trial. In all, 221 patients (111 control arm, 110 brachytherapy boost arm) had data available for analysis, with a median follow-up time of 5.4 years. Despite a significant increase in tumor response at the time of surgery, no differences in 5-year OS (70.6% vs 63.6%, hazard ratio [HR] = 1.24, P=.34) and PFS (63.9% vs 52.0%, HR=1.22, P=.32) were observed. Freedom from locoregional failure at 5 years were 93.9% and 85.7% (HR=2.60, P=.06) in the standard and in the brachytherapy arms, respectively. There was no difference in the prevalence of stoma. Explorative analysis based on stratification for tumor regression grade and resection margin status indicated the presence of response migration. CONCLUSIONS Despite increased pathologic tumor regression at the time of surgery, we observed no benefit on late outcome. Improved tumor regression does not necessarily lead to a relevant clinical benefit when the neoadjuvant treatment is followed by high-quality surgery.
Collapse
Affiliation(s)
- Ane L Appelt
- Department of Oncology, Vejle Hospital, Vejle, Denmark; Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.
| | - Ivan R Vogelius
- Department of Radiation Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - John Pløen
- Danish Colorectal Cancer Group South, Vejle Hospital, Vejle, Denmark
| | - Søren R Rafaelsen
- Danish Colorectal Cancer Group South, Vejle Hospital, Vejle, Denmark
| | - Jan Lindebjerg
- Danish Colorectal Cancer Group South, Vejle Hospital, Vejle, Denmark
| | | | - Søren M Bentzen
- Division of Biostatistics and Bioinformatics, University of Maryland Greenebaum Cancer Center, and Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Anders Jakobsen
- Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark; Danish Colorectal Cancer Group South, Vejle Hospital, Vejle, Denmark
| |
Collapse
|
12
|
Hansen TF, Andersen RF, Pallisgaard N, Spindler KLG, Pløen J, Keldsen N, Lindebjerg J, Sørensen FB, Jakobsen A. A 3-weekly schedule of irinotecan and panitumumab for wild-type KRAS metastatic colorectal cancer. Colorectal Cancer 2014. [DOI: 10.2217/crc.13.85] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
SUMMARY Aim: We investigated the combination of irinotecan and panitumumab as a 3-weekly schedule in patients with wild-type KRAS metastatic colorectal cancer, who had progressed after standard chemotherapy. Material & methods: Patients received concomitant irinotecan (350 mg/m2) and panitumumab (9 mg/kg) once every 3 weeks. The primary end point was response rate. Secondary end points included progression-free survival (PFS), overall survival (OS) and translational research. Results: Inclusion was stopped early owing to lack of efficacy (n = 31). The response rate was 16%, median PFS and OS was 2.0 months (95% CI: 1.9–4.0) and 7.8 months (95% CI: 4.6–8.8), respectively. The most commonly encountered adverse event was skin rash (84% any grade). Pretreatment cell-free DNA levels were significantly related to disease control (p = 0.04), PFS (p = 0.04) and OS (p = 0.002), respectively. Conclusion: The present treatment regimen was less effective than expected and is not recommended. The clinical importance of cell-free DNA deserves further research.
Collapse
Affiliation(s)
- Torben Frøstrup Hansen
- Department of Oncology, Vejle Hospital part of Lillebaelt Hospital, Vejle, Denmark
- Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | | | - Niels Pallisgaard
- Department of Biochemistry, Vejle Hospital part of Lillebaelt Hospital, Vejle, Denmark
| | - Karen-Lise Garm Spindler
- Department of Oncology, Vejle Hospital part of Lillebaelt Hospital, Vejle, Denmark
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - John Pløen
- Department of Oncology, Vejle Hospital part of Lillebaelt Hospital, Vejle, Denmark
| | - Nina Keldsen
- Department of Oncology, Herning Hospital, Herning, Denmark
| | - Jan Lindebjerg
- Department of Clinical Pathology, Vejle Hospital part of Lillebaelt Hospital, Vejle, Denmark
| | - Flemming Brandt Sørensen
- Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Department of Clinical Pathology, Vejle Hospital part of Lillebaelt Hospital, Vejle, Denmark
| | - Anders Jakobsen
- Department of Oncology, Vejle Hospital part of Lillebaelt Hospital, Vejle, Denmark
- Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
13
|
Nørgaard A, Dam C, Jakobsen A, Pløen J, Lindebjerg J, Rafaelsen SR. Selection of colon cancer patients for neoadjuvant chemotherapy by preoperative CT scan. Scand J Gastroenterol 2014; 49:202-8. [PMID: 24279811 DOI: 10.3109/00365521.2013.862294] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Preoperative staging is essential to plan correct treatment of colon cancer and calls for objective, accurate methods for the introduction of neoadjuvant chemotherapy, which represents a new treatment option. PURPOSE To evaluate the diagnostic accuracy of multislice computed tomography (CT) in local staging of colon cancer correlated with histopathological parameters, including criteria for adjuvant chemotherapy. MATERIAL AND METHODS A total of 74 included patients had preoperative CT scans and surgical resection of their colon tumors. Tumor stage (T-stage), extramural tumor invasion (ETI), nodal stage (N-stage), extramural venous invasion (EVI) and the distance from tumor to nearest retroperitoneal fascia (DRF) were retrospectively assessed on the CT scan and compared blindly with the results of the pathological examination, including evaluation of the criteria for adjuvant chemotherapy. Advanced tumors were defined as T3 with ETI ≥5 mm or T4. RESULTS Sixty-nine percent of the tumors were correctly T-staged by CT, 7% were overstaged and 24% were understaged. As to correct recognition of ETI on the CT scan, the observer was 73% accurate compared with histology (70% sensitivity (95% CI: 53-82%), 78% specificity (95% CI: 60-90%), 81% positive predictive value (PPV) (95% CI: 63-91%) and 66% negative predictive value (NPV) (95% CI: 49-80%). N-stage, EVI and DRF had poor accuracy: 53%, 53% and 64%. All patients with advanced tumors on CT fulfilled the criteria for adjuvant chemotherapy. Positive predictive value: 100% (95% CI: 88-100%). CONCLUSION CT has a potential in the preoperative selection of advanced tumors suitable for neoadjuvant chemotherapy without overtreatment of low-risk patients.
Collapse
Affiliation(s)
- Anne Nørgaard
- Department of Radiology, Vejle Hospital , Kabbeltoft 25, DK-7100 Vejle , Denmark
| | | | | | | | | | | |
Collapse
|
14
|
Appelt A, Mortensen B, Pløen J, Spindler K. PO-1041: MRI-guided brachytherapy for rectal cancer: A treatment planning study with a shieldable multicatheter applicator. Radiother Oncol 2014. [DOI: 10.1016/s0167-8140(15)31159-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
15
|
Olling K, Appelt A, Pløen J. EP-1258: Targeted high dose electron treatment of early stage anal cancers ñ toxicity and initial outcomes in a case series. Radiother Oncol 2014. [DOI: 10.1016/s0167-8140(15)31376-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
16
|
Rafaelsen SR, Vagn-Hansen C, Sørensen T, Lindebjerg J, Pløen J, Jakobsen A. Ultrasound elastography in patients with rectal cancer treated with chemoradiation. Eur J Radiol 2013; 82:913-7. [PMID: 23410908 DOI: 10.1016/j.ejrad.2012.12.030] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 12/27/2012] [Accepted: 12/28/2012] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The current literature has described several predictive markers in rectal cancer patients treated with chemoradiation, but so far none of them have been validated for clinical use. The purpose of the present study was to compare quantitative elastography based on ultrasound measurements in the course of chemoradiation with tumor response based on T stage classification and the Mandard tumor regression grading (TRG). MATERIALS AND METHODS We prospectively examined 31 patients with rectal cancer planned for high dose radiochemotherapy. The tumor and the mesorectal fat elasticity were measured using the Acoustic Radiation Force Impulse to generate information on the mechanical properties of the tissue. The objective quantitative elastography shear wave velocity was compared to the T stage classification and TRG. RESULTS The baseline mean tumor elasticity was 3.13 m/s. Two and six weeks after the start of chemoradiation the velocities were 2.17 m/s and 2.11 m/s, respectively. The difference between baseline velocity and velocities during the treatment course was statistically significant, (p<0.0001). Patients with tumor confined to the rectal wall at histopathology (ypT1-2) had a mean elasticity measurement after two weeks of treatment of 1.95 m/s, whereas tumors invading the mesorectal fat (ypT3-4) had a velocity of 2.47 m/s, (p<0.05). The mean elasticity tended to be lower (1.99m/s) after two weeks in patients with TRG 1-2 responses in contrast to 2.24 m/s in those with TRG 3-4. CONCLUSION Ultrasound elastography after two weeks of chemoradiation seems to hold early predictive information to the pathological T stage.
Collapse
Affiliation(s)
- S R Rafaelsen
- Department of Radiology, DCCG South, Vejle Hospital, 7100 Vejle, Denmark.
| | | | | | | | | | | |
Collapse
|
17
|
Havelund BM, Sørensen FB, Pløen J, Lindebjerg J, Spindler KLG, Jakobsen A. Immunohistological expression of HIF-1α, GLUT-1, Bcl-2 and Ki-67 in consecutive biopsies during chemoradiotherapy in patients with rectal cancer. APMIS 2012; 121:127-38. [PMID: 23030583 DOI: 10.1111/j.1600-0463.2012.02949.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Accepted: 06/22/2012] [Indexed: 12/16/2022]
Abstract
The aim of this study was to describe the dynamics of HIF-1α, GLUT-1, Bcl-2 and Ki-67 during chemoradiotherapy (CRT) of rectal cancer, and to investigate the fluctuation of these biomarkers in relation to pathological response to CRT. The study included 86 patients with rectal adenocarcinoma receiving preoperative CRT (>50.4 Gy and Uracil/Tegafur). Immunohistological expressions of HIF-1α, GLUT-1, Bcl-2 and Ki-67 were investigated in biopsies taken before treatment, after 2, 4 and 6 weeks of CRT and in specimens from the operation. Decreasing expressions of HIF-1α, Bcl-2 and Ki-67 were observed during CRT, whereas GLUT-1 overall was unchanged. No significant changes of the markers were observed in the interval between CRT and surgery. A significant association was observed between the presence of residual carcinoma after 6 weeks of treatment and pathological response to CRT, but no association was seen between the fluctuations of any of the markers and response to CRT. This unique material containing specimens before, after and during CRT for rectal cancer demonstrated biological dynamics in HIF-1α, Bcl-2 and Ki-67, but not GLUT-1, expression during CRT, and a significant association was seen between the presence of residual carcinoma after 6 weeks of treatment and pathological response to CRT.
Collapse
|
18
|
Appelt AL, Pløen J, Vogelius IR, Bentzen SM, Jakobsen A. Radiation dose-response model for locally advanced rectal cancer after preoperative chemoradiation therapy. Int J Radiat Oncol Biol Phys 2012; 85:74-80. [PMID: 22763027 DOI: 10.1016/j.ijrobp.2012.05.017] [Citation(s) in RCA: 190] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Revised: 05/03/2012] [Accepted: 05/08/2012] [Indexed: 12/13/2022]
Abstract
PURPOSE Preoperative chemoradiation therapy (CRT) is part of the standard treatment of locally advanced rectal cancers. Tumor regression at the time of operation is desirable, but not much is known about the relationship between radiation dose and tumor regression. In the present study we estimated radiation dose-response curves for various grades of tumor regression after preoperative CRT. METHODS AND MATERIALS A total of 222 patients, treated with consistent chemotherapy and radiation therapy techniques, were considered for the analysis. Radiation therapy consisted of a combination of external-beam radiation therapy and brachytherapy. Response at the time of operation was evaluated from the histopathologic specimen and graded on a 5-point scale (TRG1-5). The probability of achieving complete, major, and partial response was analyzed by ordinal logistic regression, and the effect of including clinical parameters in the model was examined. The radiation dose-response relationship for a specific grade of histopathologic tumor regression was parameterized in terms of the dose required for 50% response, D50,i, and the normalized dose-response gradient, γ50,i. RESULTS A highly significant dose-response relationship was found (P=.002). For complete response (TRG1), the dose-response parameters were D50,TRG1=92.0 Gy (95% confidence interval [CI] 79.3-144.9 Gy), γ50,TRG1=0.982 (CI 0.533-1.429), and for major response (TRG1-2) D50,TRG1&2=72.1 Gy (CI 65.3-94.0 Gy), γ50,TRG1&2=0.770 (CI 0.338-1.201). Tumor size and N category both had a significant effect on the dose-response relationships. CONCLUSIONS This study demonstrated a significant dose-response relationship for tumor regression after preoperative CRT for locally advanced rectal cancer for tumor dose levels in the range of 50.4-70 Gy, which is higher than the dose range usually considered.
Collapse
Affiliation(s)
- Ane L Appelt
- Department of Oncology, Vejle Hospital, Vejle, Denmark.
| | | | | | | | | |
Collapse
|