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van den Berg K, Schaap DP, Voogt ELK, Buffart TE, Verheul HMW, de Groot JWB, Verhoef C, Melenhorst J, Roodhart JML, de Wilt JHW, van Westreenen HL, Aalbers AGJ, van 't Veer M, Marijnen CAM, Vincent J, Simkens LHJ, Peters NAJB, Berbée M, Werter IM, Snaebjornsson P, Peulen HMU, van Lijnschoten IG, Roef MJ, Nieuwenhuijzen GAP, Bloemen JG, Willems JMWE, Creemers GJM, Nederend J, Rutten HJT, Burger JWA. Neoadjuvant FOLFOXIRI prior to chemoradiotherapy for high-risk ("ugly") locally advanced rectal cancer: study protocol of a single-arm, multicentre, open-label, phase II trial (MEND-IT). BMC Cancer 2022; 22:957. [PMID: 36068495 PMCID: PMC9446695 DOI: 10.1186/s12885-022-09947-w] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 07/29/2022] [Indexed: 11/14/2022] Open
Abstract
Background The presence of mesorectal fascia (MRF) invasion, grade 4 extramural venous invasion (EMVI), tumour deposits (TD) or extensive or bilateral extramesorectal (lateral) lymph nodes (LLN) on MRI has been suggested to identify patients with indisputable, extensive locally advanced rectal cancer (LARC), at high risk of treatment failure. The aim of this study is to evaluate whether or not intensified chemotherapy prior to neoadjuvant chemoradiotherapy improves the complete response (CR) rate in these patients. Methods This multicentre, single-arm, open-label, phase II trial will include 128 patients with non-metastatic high-risk LARC (hr-LARC), fit for triplet chemotherapy. To ensure a study population with indisputable, unfavourable prognostic characteristics, hr-LARC is defined as LARC with on baseline MRI at least one of the following characteristics; MRF invasion, EMVI grade 4, enlarged bilateral or extensive LLN at high risk of an incomplete resection, or TD. Exclusion criteria are the presence of a homozygous DPD deficiency, distant metastases, any chemotherapy within the past 6 months, previous radiotherapy within the pelvic area precluding standard chemoradiotherapy, and any contraindication for the planned treatment. All patients will be planned for six two-weekly cycles of FOLFOXIRI (5-fluorouracil, leucovorin, oxaliplatin and irinotecan) prior to chemoradiotherapy (25 × 2 Gy or 28 × 1.8 Gy with concomitant capecitabine). A resection will be performed following radiological confirmation of resectable disease after the completion of chemoradiotherapy. A watch and wait strategy is allowed in case of a clinical complete response. The primary endpoint is the CR rate, described as a pathological CR or a sustained clinical CR one year after chemoradiotherapy. The main secondary objectives are long-term oncological outcomes, radiological and pathological response, the number of resections with clear margins, treatment-related toxicity, perioperative complications, health-related costs, and quality of life. Discussion This trial protocol describes the MEND-IT study. The MEND-IT study aims to evaluate the CR rate after intensified chemotherapy prior to concomitant chemoradiotherapy in a homogeneous group of patients with locally advanced rectal cancer and indisputably unfavourable characteristics, defined as hr-LARC, in order to improve their prognosis. Trial registration Clinicaltrials.gov: NCT04838496, registered on 02–04-2021 Netherlands Trial Register: NL9790. Protocol version Version 3 dd 11–4-2022.
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Affiliation(s)
- K van den Berg
- Department of Medical Oncology, Catharina Hospital, Eindhoven, the Netherlands.,Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - D P Schaap
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - E L K Voogt
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - T E Buffart
- Department of Gastrointestinal Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands.,Department of Medical Oncology, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - H M W Verheul
- Department of Medical Oncology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - J W B de Groot
- Department of Medical Oncology, Isala Oncology Centre, Zwolle, the Netherlands
| | - C Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - J Melenhorst
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - J M L Roodhart
- Department of Medical Oncology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - J H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | | | - A G J Aalbers
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - M van 't Veer
- Department of Research and Education, Catharina Hospital, Eindhoven, 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
| | - J Vincent
- Department of Medical Oncology, Elkerliek Hospital, Helmond, the Netherlands
| | - L H J Simkens
- Department of Medical Oncology, Maxima Medical Centre, Veldhoven, the Netherlands
| | - N A J B Peters
- Department of Medical Oncology, St. Jans Hospital, Weert, the Netherlands
| | - M Berbée
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - I M Werter
- Department of Medical Oncology, Rijnstate Hospital, Arnhem, the Netherlands
| | - P Snaebjornsson
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - H M U Peulen
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - I G van Lijnschoten
- Department of Pathology, PAMM Laboratory for Pathology and Medical Microbiology, Eindhoven, the Netherlands
| | - M J Roef
- Department of Nuclear Medicine, Catharina Hospital, Eindhoven, the Netherlands
| | | | - J G Bloemen
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - J M W E Willems
- Department of Medical Oncology, Anna Hospital, Geldrop, the Netherlands
| | - G J M Creemers
- Department of Medical Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - J Nederend
- Department of Radiology, Catharina Hospital, Eindhoven, the Netherlands
| | - H J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands.,GROW School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
| | - J W A Burger
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands.
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Voogt ELK, Schaap DP, van den Berg K, Nieuwenhuijzen GAP, Bloemen JG, Creemers GJ, Willems J, Cnossen JS, Peulen HMU, Nederend J, van Lijnschoten G, Burger JWA, Rutten HJT. Reply to: Use of induction chemotherapy in locally advanced rectal cancers to increase the response rates: Is it actually helping? Eur J Surg Oncol 2021; 47:2473-2474. [PMID: 34210580 DOI: 10.1016/j.ejso.2021.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 06/18/2021] [Indexed: 10/21/2022] Open
Affiliation(s)
- E L K Voogt
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands.
| | - D P Schaap
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - K van den Berg
- Department of Medical Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | | | - J G Bloemen
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - G J Creemers
- Department of Medical Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - J Willems
- Department of Medical Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - J S Cnossen
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - H M U Peulen
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - J Nederend
- Department of Radiology, Catharina Hospital, Eindhoven, the Netherlands
| | - G van Lijnschoten
- Pathology Department, PAMM Laboratory for Pathology and Medical Microbiology, Eindhoven, the Netherlands
| | - J W A Burger
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - H J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands; GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands
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Voogt ELK, Schaap DP, van den Berg K, Nieuwenhuijzen GAP, Bloemen JG, Creemers GJ, Willems J, Cnossen JS, Peulen HMU, Nederend J, van Lijnschoten G, Burger JWA, Rutten HJT. Improved response rate in patients with prognostically poor locally advanced rectal cancer after treatment with induction chemotherapy and chemoradiotherapy when compared with chemoradiotherapy alone: A matched case-control study. Eur J Surg Oncol 2021; 47:2429-2435. [PMID: 34030921 DOI: 10.1016/j.ejso.2021.05.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 03/04/2021] [Revised: 04/16/2021] [Accepted: 05/07/2021] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION The addition of induction chemotherapy (ICT) to neoadjuvant chemoradiotherapy (CRT) has the potential to improve outcomes in patients with locally advanced rectal cancer (LARC). However, patient selection is essential to prevent overtreatment. This study compared the complete response (CR) rate after treatment with and without ICT of LARC patients with prognostically poor characteristics. METHODS All LARC patients who were treated with neoadjuvant CRT, whether or not preceded by ICT, and who underwent surgery or were considered for a wait-and-see strategy between January 2016 and March 2020 in the Catharina Hospital Eindhoven, were retrospectively selected. LARC was defined as any T4 tumour, or a T2/T3 tumour with extramural venous invasion and/or tumour deposits and/or N2 lymph node status, and/or mesorectal fascia involvement (T3 tumours only). Case-control matching was performed based on the aforementioned characteristics. RESULTS Of 242 patients, 178 (74%) received CRT (CRT-group) and 64 patients (26%) received ICT followed by CRT (ICT-group). In the ICT-group, 3 patients (5%) did not receive the minimum of three cycles. In addition, in this selected cohort, compliance with radiotherapy was 100% in the ICT-group and 97% in the CRT-group. The CR rate was 30% in the ICT-group and 15% in the CRT-group (p = 0.011). After case-control matching, the CR rate was 28% and 9%, respectively (p = 0.013). CONCLUSION Treatment including ICT seemed well tolerated and resulted in a high CR rate. Hence, this treatment strategy may facilitate organ preservation and improve survival in LARC patients with prognostically poor characteristics.
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Affiliation(s)
- E L K Voogt
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands.
| | - D P Schaap
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - K van den Berg
- Department of Medical Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | | | - J G Bloemen
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - G J Creemers
- Department of Medical Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - J Willems
- Department of Medical Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - J S Cnossen
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - H M U Peulen
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - J Nederend
- Department of Radiology, Catharina Hospital, Eindhoven, the Netherlands
| | - G van Lijnschoten
- Department of Pathology, PAMM Laboratory for Pathology and Medical Microbiology, Eindhoven, the Netherlands
| | - J W A Burger
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - H J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands; GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands
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Schaap DP, Boogerd LSF, Konishi T, Cunningham C, Ogura A, Garcia-Aguilar J, Beets GL, Suzuki C, Toda S, Lee IK, Sammour T, Uehara K, Lee P, Tuynman JB, van de Velde CJH, Rutten HJT, Kusters M. Rectal cancer lateral lymph nodes: multicentre study of the impact of obturator and internal iliac nodes on oncological outcomes. Br J Surg 2021; 108:205-213. [PMID: 33711144 DOI: 10.1093/bjs/znaa009] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [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: 05/18/2020] [Revised: 07/06/2020] [Accepted: 08/29/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND In patients with rectal cancer, enlarged lateral lymph nodes (LLNs) result in increased lateral local recurrence (LLR) and lower cancer-specific survival (CSS) rates, which can be improved with (chemo)radiotherapy ((C)RT) and LLN dissection (LLND). This study investigated whether different LLN locations affect oncological outcomes. METHODS Patients with low cT3-4 rectal cancer without synchronous distant metastases were included in this multicentre retrospective cohort study. All MRI was re-evaluated, with special attention to LLN involvement and response. RESULTS More advanced cT and cN category were associated with the occurrence of enlarged obturator nodes. Multivariable analyses showed that a node in the internal iliac compartment with a short-axis (SA) size of at least 7 mm on baseline MRI and over 4 mm after (C)RT was predictive of LLR, compared with a post-(C)RT SA of 4 mm or less (hazard ratio (HR) 5.74, 95 per cent c.i. 2.98 to 11.05 vs HR 1.40, 0.19 to 10.20; P < 0.001). Obturator LLNs with a SA larger than 6 mm after (C)RT were associated with a higher 5-year distant metastasis rate and lowered CSS in patients who did not undergo LLND. The survival difference was not present after LLND. Multivariable analyses found that only cT category (HR 2.22, 1.07 to 4.64; P = 0.033) and margin involvement (HR 2.95, 1.18 to 7.37; P = 0.021) independently predicted the development of metastatic disease. CONCLUSION Internal iliac LLN enlargement is associated with an increased LLR rate, whereas obturator nodes are associated with more advanced disease with increased distant metastasis and reduced CSS rates. LLND improves local control in persistent internal iliac nodes, and might have a role in controlling systemic spread in persistent obturator nodes.Members of the Lateral Node Study Consortium are co-authors of this study and are listed under the heading Collaborators.
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Affiliation(s)
- D P Schaap
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - L S F Boogerd
- Department of Surgery, Amsterdam University Medical Centres, Location VUmc, Amsterdam, the Netherlands
| | - T Konishi
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - C Cunningham
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - A Ogura
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - J Garcia-Aguilar
- Department of Surgery, Memorial Sloan Kettering Cancer Centre, New York, USA
| | - G L Beets
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - C Suzuki
- Department of Radiology, Karolinska Institutet, Stockholm, Sweden
| | - S Toda
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
| | - I K Lee
- Department of Surgery, Seoul St Mary's Hospital, Catholic University of Korea, Seoul, Korea
| | - T Sammour
- Department of Surgery, Royal Adelaide Hospital and University of Adelaide, Adelaide, South Australia, Australia
| | - K Uehara
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - P Lee
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District and Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - J B Tuynman
- Department of Surgery, Amsterdam University Medical Centres, Location VUmc, Amsterdam, the Netherlands
| | - C J H van de Velde
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - H J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
- Maastricht University, GROW, School of Oncology and Developmental Biology, Maastricht, the Netherlands
| | - M Kusters
- Department of Surgery, Amsterdam University Medical Centres, Location VUmc, Amsterdam, the Netherlands
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Schaap DP, de Valk KS, Deken MM, Meijer RPJ, Burggraaf J, Vahrmeijer AL, Kusters M. Carcinoembryonic antigen-specific, fluorescent image-guided cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for metastatic colorectal cancer. Br J Surg 2020; 107:334-337. [PMID: 31960953 PMCID: PMC7079046 DOI: 10.1002/bjs.11523] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 11/27/2019] [Accepted: 01/09/2020] [Indexed: 12/29/2022]
Affiliation(s)
- D P Schaap
- Department of Surgery, Catharina Hospital, Eindhoven, Netherlands
| | - K S de Valk
- Centre for Human Drug Research, Leiden, Netherlands.,Department of Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | - M M Deken
- Centre for Human Drug Research, Leiden, Netherlands.,Department of Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | - R P J Meijer
- Centre for Human Drug Research, Leiden, Netherlands.,Department of Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | - J Burggraaf
- Centre for Human Drug Research, Leiden, Netherlands
| | - A L Vahrmeijer
- Department of Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | - M Kusters
- Department of Surgery, Amsterdam University Medical Centres, location VUmc, Amsterdam, Netherlands
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Schaap DP, Ogura A, Nederend J, Maas M, Cnossen JS, Creemers GJ, van Lijnschoten I, Nieuwenhuijzen GAP, Rutten HJT, Kusters M. Prognostic implications of MRI-detected lateral nodal disease and extramural vascular invasion in rectal cancer. Br J Surg 2018; 105:1844-1852. [PMID: 30079958 DOI: 10.1002/bjs.10949] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [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: 02/12/2018] [Revised: 06/13/2018] [Accepted: 06/18/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Lateral nodal disease in rectal cancer remains a subject of debate and is treated differently in the East and the West. The predictive value of lateral lymph node and MRI-detected extramural vascular invasion (mrEMVI) features on oncological outcomes was assessed in this study. METHODS In this retrospective cohort study, data on patients with cT3-4 rectal cancer within 8 cm from the anal verge were considered over a 5-year period (2009-2013). Lateral lymph node size, malignant features and mrEMVI features were evaluated and related to oncological outcomes. RESULTS In total, 192 patients were studied, of whom 30 (15·6 per cent) underwent short-course radiotherapy and 145 (75·5 per cent) received chemoradiotherapy. A lateral lymph node short-axis size of 10 mm or more was associated with a significantly higher 5-year lateral/presacral local recurrence rate of 37 per cent, compared with 7·7 per cent in nodes smaller than 10 mm (P = 0·041). Enlarged nodes did not result in a higher 5-year rate of distant metastasis (23 per cent versus 27·7 per cent in nodes smaller than 10 mm; P = 0·563). However, mrEMVI positivity was related to more metastatic disease (5-year rate 43 versus 26·3 per cent in the mrEMVI-negative group; P = 0·014), but not with increased lateral/presacral recurrence. mrEMVI occurred in 46·6 per cent of patients with nodes smaller than 10 mm, compared with 29 per cent in patients with nodes of 10 mm or larger (P = 0·267). CONCLUSION Although lateral nodal disease is more a local problem, mrEMVI mainly predicts distant recurrence. The results of this study showed an unacceptably high local recurrence rate in patients with a short axis of 10 mm or more, despite neoadjuvant (chemo)radiotherapy.
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Affiliation(s)
- D P Schaap
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | - A Ogura
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
- Department of Surgery, Division of Surgical Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - J Nederend
- Department of Radiology, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | - M Maas
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - J S Cnossen
- Department of Radiation Oncology, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | - G J Creemers
- Department of Medical Oncology, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | - I van Lijnschoten
- Pathology Department, Laboratory for Pathology and Medical Microbiology (PAMM), Eindhoven, the Netherlands
| | | | - H J T Rutten
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
- School for Oncology and Developmental Biology (GROW), Maastricht University, Maastricht, the Netherlands
| | - M Kusters
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
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