How often is adjuvant FOLFOX (Adj FOLFOX) discontinued for toxicity among colon cancer patients in the routine care setting?

9530

Background: Although 12 cycles of Adj FOLFOX are recommended for stage III and high risk stage II colon cancer, toxicity may preclude completion of treatment. We used the NCCN Colorectal Cancer Outcomes Database to identify how frequently Adj FOLFOX is discontinued prematurely for toxicity in a non-clinical trial population. Methods: Newly diagnosed stage II-III colon cancer pts treated with Adj FOLFOX at 7 NCI-designated comprehensive cancer centers between 9/05–12/07 were identified. We assessed completion of the prescribed adjuvant chemotherapy (AC) course, including Adj FOLFOX and 5FU-based adjuvant treatment alone subsequent to discontinuation of oxaliplatin (oxal). Dose limiting toxicity (DLT) of Adj FOLFOX was defined as premature discontinuation of Adj FOLFOX due to toxicity. We evaluated potential predictors of Adj FOLFOX DLT, including older age and history of diabetes in a multivariable logistic model controlling for stage and center. We measured the duration of Adj FOLFOX use in weeks, from first to last dose. Results: 293 pts began Adj FOLFOX. Pts who experienced DLT (40%) had a shorter duration of Adj FOLFOX and were less likely to complete AC, even after oxal was discontinued. The only significant predictor of experiencing a DLT was a history of diabetes. Conclusions: Our analysis of patients treated outside of a clinical trial demonstrated a notably high rate of discontinuation of Adj FOLFOX due to DLT, particularly in pts with diabetes. The results underscore the need for systematic assessment of toxicity especially among diabetics.

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Meeting the 12 lymph nodes (LN) benchmark in colorectal cancer surgery: A comparison of NCCN and SEER data

4015

Background: The American College of Pathology has suggested that 12 or more LN be examined from colorectal cancer surgical specimen. Both ASCO and NCCN have considered adopting the 12 LN threshold as a quality metric. The purpose of this study was to determine whether the 12 LN benchmark is achieved at NCCN specialty centers. Methods: Patients with newly diagnosed stage I-III colon or rectal cancer, who had primary surgery at NCCN centers in 2005–6 were selected (n=345). Similarly, data from 14,019 stage I-III colorectal patients diagnosed in 2002 in a SEER region were obtained to determine the extent to which this goal was met in a population-based sample. Patient characteristics of age, gender, location, stage and number of positive nodes were compared for NCCN and SEER data in regards to number of nodes evaluated. Univariate logistic regression models were developed to identify factors associated with the 12 LN target at the NCCN. Factors evaluated were number of positive nodes, age, gender, comorbidity score, ECOG performance status, insurance, location, stage, surgery technique, and NCCN center. Results: As detailed in the Table , 89% of the 2005–6 NCCN sample and 45% of the SEER sample had at least 12 LN evaluated. For patients treated at NCCN centers, stage I compared to stage III (OR=0.20; 95% CI=0.08 to 0.48, p<0.0001) and rectal cancer (OR=0.44; 95% CI=0.22 to 0.88, p=0.02) were each less likely to achieve the 12 LN target. Conclusions: For patients operated on at NCCN centers, at least 12 LN are almost always removed and examined as part of an oncologic resection. In population based samples, this target is achieved in less than half of cases. With longer follow-up we will be able to link this potential quality metric directly to outcomes and thereby better inform whether increasing the number of nodes evaluated is an important priority for cancer control. Table 1 . Characteristics of CRC patients who did and did not have 12 or more LN evaluated at primary resection.

[Table: see text]

No significant financial relationships to disclose.

Incidence of minimally invasive colorectal cancer (CRC) surgery in patients treated at NCCN institutions

6575

Background: In May 2004 the Clinical Outcomes of Surgical Therapy Study Group published the results of the North American randomized trial demonstrating that oncologic outcome is similar for laparoscopic assisted and open surgery for CRC. This and other studies have shown quicker recovery with laparoscopic CRC surgery including earlier resolution of postoperative ileus, less discomfort, and earlier discharge from the hospital. The extent to which surgeons have adopted the minimally invasive surgical (MIS) approach in CRC is unknown. Methods: Using the NCCN Colon/Rectal Cancer Outcomes Project Database, 715 patients were identified who underwent CRC resection in 2005–6. The distribution of lesions included right colon (39%), left colon (31%), and rectum (30%). The incidence of MIS for CRC and clinicopathologic features associated with this approach were analyzed by logistic regression; results are reported as odd ratio (OR) with 95% confidence intervals (CI), and significance defined at p<0.05 level. Results: A total of 167 (23%) patients underwent MIS colorectal surgery (laparoscopy in 98% and robotic in 2%). Conversion to open surgery was noted in 33 cases (20%). Surgery was performed in outside institutions in 21% of cases prior to patients presenting to NCCN institutions for further treatment. The MIS approach was more common in colon than rectal cancer (30% vs.12%, OR 2.96, CI 1.94–4.51, p<0.0001). Within the colon cancer cohort, right sided lesions were more likely to be approached with MIS techniques rather than left sided lesions (32% vs. 25%; OR 1.42, CI 1.96–2.21, p<0.0001). Stage I tumors were also more likely to be managed with the less invasive approach: Stage I-41%; II-20%; III-21%; IV-19% (Stage I vs. IV, OR=3.00, CI 1.74–5.16 p<0.0001). No differences in surgical approach were noted based on age, gender, race, Charlson comorbidity score, insurance type, or location of surgery (NCCN vs outside facility). Conclusion: The majority of CRC surgery for patients presenting to NCCN institutions is performed by open techniques. Right sided and early stage CRCs were more likely treated with MIS, possibly related to the less demanding nature of the procedure. The adoption of MIS is expected to rise as surgeons become trained in MIS techniques for CRC.

No significant financial relationships to disclose.

Elective groin irradiation is not indicated for patients with adenocarcinoma of the rectum extending to the anal canal

PURPOSE

To evaluate the inguinal nodal failure rate in patients with locally advanced rectal cancer with anal canal involvement (ACI) treated with pelvic chemoradiation without elective inguinal irradiation.

METHODS AND MATERIALS

From 1990 and 1998, 536 patients received preoperative or postoperative chemoradiation for rectal cancer with curative intent; 186 patients had ACI (<4 cm from the anal verge on rigid proctoscopy). Two patients had positive inguinal nodes at presentation. Chemoradiation was delivered preoperatively (45 Gy in 25 fraction) or postoperatively (53 Gy in 29 fractions) with concurrent continuous infusion of 5-fluorouracil (300 mg/m2/d). The inguinal region was specifically irradiated in only 2 patients who had documented inguinal nodal disease.

RESULTS

The median follow-up was 50 months. Only 6 of 184 ACI patients who had clinically negative inguinal nodes at presentation developed inguinal nodal recurrence (5-year actuarial rate 4%); 4 of the 6 cases were isolated. Two patients underwent successful salvage. Only 1 died of uncontrolled groin disease. Local control was achieved in both patients with inguinal nodal disease at presentation, but both died of metastatic disease. Only 3 patients with tumors >4 cm from the verge developed inguinal recurrence (5-year actuarial rate <1%).

CONCLUSIONS

Inguinal nodal failure in rectal cancer patients with ACI treated with neoadjuvant or adjuvant chemoradiation is not high enough to justify routine elective groin irradiation.

Elective groin irradiation is not indicated for patients with adenocarcinoma of the rectum extending to the anal canal

PURPOSE

To evaluate the inguinal nodal failure rate in patients with locally advanced rectal cancer with anal canal involvement (ACI) treated with pelvic chemoradiation without elective inguinal irradiation.

METHODS AND MATERIALS

From 1990 and 1998, 536 patients received preoperative or postoperative chemoradiation for rectal cancer with curative intent; 186 patients had ACI (<4 cm from the anal verge on rigid proctoscopy). Two patients had positive inguinal nodes at presentation. Chemoradiation was delivered preoperatively (45 Gy in 25 fraction) or postoperatively (53 Gy in 29 fractions) with concurrent continuous infusion of 5-fluorouracil (300 mg/m2/d). The inguinal region was specifically irradiated in only 2 patients who had documented inguinal nodal disease.

RESULTS

The median follow-up was 50 months. Only 6 of 184 ACI patients who had clinically negative inguinal nodes at presentation developed inguinal nodal recurrence (5-year actuarial rate 4%); 4 of the 6 cases were isolated. Two patients underwent successful salvage. Only 1 died of uncontrolled groin disease. Local control was achieved in both patients with inguinal nodal disease at presentation, but both died of metastatic disease. Only 3 patients with tumors >4 cm from the verge developed inguinal recurrence (5-year actuarial rate <1%).

CONCLUSIONS

Inguinal nodal failure in rectal cancer patients with ACI treated with neoadjuvant or adjuvant chemoradiation is not high enough to justify routine elective groin irradiation.

T4 rectal cancer treated with preoperative chemoradiation to the posterior pelvis followed by multivisceral resection: patterns of failure and limitations of treatment

PURPOSE

To analyze the overall pattern of treatment failure and sites of pelvic disease recurrence relative to the radiation fields used in treating patients with clinically staged T4 rectal cancer with preoperative chemoradiation followed by multivisceral resection.

METHODS AND MATERIALS

Between 1990 and 1998, 45 patients with T4 rectal cancer were treated with preoperative chemoradiation. Clinical staging was according to the system of the American Joint Cancer Committee and was based on endoscopic ultrasonography, chemotherapy (CT), and physical examination. A diagnosis of T4 disease required evidence of invasion of a contiguous structure on CT (n = 31) or endorectal ultrasonography (n = 6), vaginal mucosal involvement on pelvic examination (n = 6), or a combination of these findings (n = 2). Chemoradiation was delivered with 18 MV photons using a 3-field belly-board technique. The median total dose was 45 Gy in all patients (range 45-63). Nine patients received a boost with external beam radiotherapy (EBRT) (n = 5, 1.8-18 Gy), intraoperative RT (n = 3, 10-20 Gy), or interstitial brachytherapy (n = 1, 20 Gy). All patients received concurrent chemotherapy consisting of protracted venous infusion 5-fluorouracil (300 mg/m(2), 5 d/wk). Resection was not performed in 13 (29%) of the 45 patients because of metastases detected before resection or patient refusal. Multivisceral resection and pelvic exenteration was required in 21 (66%) and 11 (34%) of 32 patients, respectively. We compared the location of pelvic disease recurrence with the RT simulation films. The Kaplan-Meier method was used to calculate the 4-year actuarial pelvic and distant recurrent rates and the overall survival rate.

RESULTS

The median length of follow-up was 31.0 months for all patients and 40.0 months for patients alive at last follow-up. When only the resected cases were considered, the local recurrence rate was 20%. Distant metastases occurred in 44% of cases; the overall survival rate was 69%. When all patients were considered, the local recurrence rate was similar (24%), but the rate of distant recurrence (51%) was higher and the overall survival rate lower (50%). Pelvic disease was controlled in all 8 patients whose disease responded well to chemoradiation (either a histologically complete response or microscopic residual disease). Three of 4 patients with close or positive margins had pelvic recurrences despite intraoperative RT and brachytherapy. Nine of the 10 pelvic recurrences occurred in the radiation field. Elective external iliac nodal irradiation was not used, and nodal metastases were not seen in that region. In 1 case, marginal recurrence occurred in a common iliac node at the superior edge of the treatment field.

CONCLUSIONS

Despite aggressive multimodality therapy including multivisceral resection, a high rate of pelvic and distant disease recurrence occurred in patients with clinically staged T4 disease. Regional disease recurred almost exclusively in the radiation field. The intraoperative RT and interstitial brachytherapy doses used did not prevent pelvic disease recurrence in patients with close or positive margins. Novel strategies such as higher preoperative doses of RT with or without altered fractionation or more effective radiosensitizers are needed to improve locoregional control in patients with T4 disease. Future strategies must also include more effective systemic therapy.

Improved overall survival among responders to preoperative chemoradiation for locally advanced rectal cancer

The aim of this study was to determine if the response to preoperative radiation and chemotherapy with continuous infusion 5-fluorouracil (5-FU) was predictive for survival among patients with locally advanced rectal cancer. Preoperative chemoradiation (CTX/XRT) that delivered 45 Gy in 25 fractions over 5 weeks with continuous infusion 5-FU (300 mg/m2/day) was given to 117 patients. The pretreatment stage distribution, as determined by endorectal ultrasound (u), included uT2N0 in 2%, uT3N0 in 47%, uT3N1 in 49%, and uT4N0 in 2% of cases; endorectal ultrasound was not performed in 13% of cases (15 patients). Approximately 6 weeks after completion of CTX/XRT, surgery was performed. Adjuvant chemotherapy, consisting of 400 to 425 mg/m2 of 5-FU plus 20 mg/m2 leucovorin for 5 days, was administered every 28 days for 4 to 6 cycles after surgical resection. Among the 74 patients treated with adjuvant chemotherapy, the preoperative stage of disease was 31 with T3N0 and 43 T3N1. Median follow-up was 46 months (range 2 to 89 months). The pathologic tumor stages were Tis-2N0 in 26%, T2N1 in 5%, T3N0 in 21%, T3N1 in 15%, T4N0 in 5%, and T4N1 in 1%; a complete response (CR) to preoperative CTX/XRT was pathologically confirmed in 32 (27%) of patients. Tumor down-staging occurred in 72 (62%) cases. A sphincter-saving procedure (SP) was possible in 59% of patients. The median DFS and overall survival rates for responders were 46 months and 47 months, respectively; for non-responders these outcome measures were 38 months and 41 months, respectively. Log-rank analysis showed that the distant metastatic-free survival rates improved with any response to CTX/XRT (p < 0.00001), CR to CTX/XRT (p < 0.009) and SP (p < 0.012). Likewise, these parameters also significantly influenced DFS rates (CTX/XRT p < 0.00001; CR p < 0.006; and SP p < 0.008). Control of pelvic disease was influenced by clinical size (p < 0.002) and SP (p < 0.016) on univariate analysis. On multivariate analysis only clinical size (p < 0.002) continued to be a significant factor for local control. Factors on multivariate analysis that resulted in significant improvements in cancer-specific survival included any response to preoperative CTX/XRT (p < 0.017) and administration of adjuvant chemotherapy (p < 0.034). Any response to preoperative CTX/XRT improved distant metastatic-free and disease-free survival rates. Multivariate analysis confirmed that a response to preoperative CTX/XRT predicted for improvements in overall survival among patients with locally advanced rectal cancer. Patients who fail to respond to preoperative 5-FU based chemotherapy given concomitantly with radiation have higher rates of distant metastases with adjuvant 5-FU therapy.

Effective pelvic symptom control using initial chemoradiation without colostomy in metastatic rectal cancer

PURPOSE

To assess pelvic chemoradiotherapy (CXRT) without colostomy as a component of the multidisciplinary management of patients presenting with metastatic rectal cancer.

METHODS AND MATERIALS

Eighty patients with synchronous distant metastases from rectal cancer were treated with initial CXRT. Hypofractionated radiotherapy was administered usually with concurrent 5-FU (92%, 300 mg/m(2)/day, M-F). Three-field belly-board technique was used in 89%. Group 1 had CXRT alone (n = 55). Group 2 (n = 25) patients were selected for primary disease resection, and sometimes HAI chemotherapy (n = 10) or hepatic resection (n = 5). Subsequently, 78% received systemic chemotherapy.

RESULTS

Symptoms from primary tumor resolved in 94%. Endoscopic complete clinical response rate was 36%. Two-year survival (11% vs. 46%, p < 0.0001) and symptomatic pelvic control (PC, 81% vs. 91%, p = 0.111) were higher in Group 2, but colostomy-free rate (CFR) was lower (79% vs. 51% p = 0.02). CFR was 87% in Group 1 patients managed initially without fecal diversion (n = 50). Examining all patients using multivariate analysis, pelvic pain at presentation (p < 0.00001), BED (biologic equivalent dose at 2 Gy/fraction) < 35 Gy (p = 0.077), and poor differentiation (0.079) predicted worse PC. Poor differentiation (p = 0.017) and selection for CXRT alone (p < 0.0001) predicted worse survival. There were 4 RTOG of Grade 3 or greater acute complications, 5 severe perioperative complications, and no significant late treatment-related complications.

CONCLUSION

Durable PC can be safely achieved without colostomy in most patients presenting with primary rectal cancer and synchronous systemic metastases using hypofractionated pelvic chemoradiation. A BED greater than 35 Gy is recommended. Selected patients appear to benefit from resection of primary disease. Higher doses should be investigated in patients with pelvic pain.

Major surgery to manage definitively severe complications of salvage cryotherapy for prostate cancer

PURPOSE

Severe complications of salvage cryotherapy may be debilitating and chronic but these complications may be managed by definitive extirpative surgical procedures. We evaluated the effectiveness of the major surgical procedures performed to manage these complications, and assessed patient survival and complications after extirpative surgery.

MATERIALS AND METHODS

Between 1992 and 1995 salvage cryotherapy was performed in 150 men with biopsy proved, locally recurrent prostate cancer after radiotherapy and/or systemic therapy. We retrospectively reviewed patient charts to assess the complications managed by extirpative surgery.

RESULTS

Extirpative surgery was performed in 6 of the 150 patients for serious complications, including uncontrollable hematuria, osteitis pubis, rectourethral fistula, refractory perineal pain, bladder outlet obstruction and complete urinary incontinence. Cystoprostatectomy was done in 4 patients, of whom 3 also underwent en bloc pubic symphysectomy. In the remaining 2 men salvage prostatectomy was performed with bladder neck closure and continent catheterizable stomal creation. Surgery successfully managed severe cryotherapy complications in all 6 cases. The complications of extirpative surgery included superficial wound infection in 1 patient and 3 incisional hernias in another. Prostate specific antigen was undetectable in 4 of the 6 men at 36, 38, 39 and 42 months, and detectable in 2 at 31 and 41 months, respectively.

CONCLUSIONS

Extirpative surgery may successfully alleviate severe salvage cryotherapy complications without major additive morbidity. Long survival duration justifies extirpative surgery in select patients with severe complications of salvage cryotherapy.

Phase I study of preoperative oral uracil and tegafur plus leucovorin and radiation therapy in rectal cancer

PURPOSE

Preoperative combined-modality therapy for rectal cancer may allow for sphincter preservation, while decreasing recurrence rates and improving the overall prognosis. Oral chemotherapy with uracil and tegafur (UFT) plus leucovorin (LV) may reduce costs and complications associated with protracted infusions of fluorouracil. Our goal was to evaluate the safety of UFT plus LV combined with preoperative radiation and determine the maximum-tolerated dose (MTD) and dose-limiting toxicity (DLT) of UFT plus LV in this setting.

PATIENTS AND METHODS

Patients with tumor-node-metastasis stage II or III rectal cancer received escalating doses of UFT (starting at 250mg/m(2)/d, with 50-mg/m(2)/d increments between consecutive cohorts) and fixed doses of LV (90 mg/d). The UFT and LV combination was given 5 days per week concurrently with a 5-week course of preoperative radiation totaling 45 Gy (1.8 Gy/fraction). Surgery was performed 4 to 6 weeks after radiation and was followed by four 35-day cycles of fixed doses of UFT and LV (28 days of therapy each cycle).

RESULTS

Fifteen patients were treated, and 13 received the full preoperative chemotherapy. All planned radiation was delivered successfully. The MTD of UFT with radiation was 350 mg/m(2)/d with 90 mg/d of LV. Diarrhea was the DLT. Sphincter-preserving surgery was performed in 12 of 14 patients. One patient had progressive disease before surgery. Pathologic evaluation of 14 resected specimens showed a complete response in three cases.

CONCLUSION

Preoperative chemoradiation with oral UFT plus LV is feasible and well tolerated and should be further investigated.

A phase I study. Preoperative UFT/leucovorin and radiation therapy in rectal cancer

The use of combined modality regimens has been well established in the treatment of stages II and III rectal cancer. The most common chemotherapy regimens used include continuous-infusion 5-FU delivered with the help of a central venous catheter and the use of portable pumps. These regimens are expensive and can potentially develop line problems. The availability of the oral agent UFT in combination with oral leucovorin prompted the development of an all-oral chemotherapy regimen that could be combined with radiotherapy. At The University of Texas M. D. Anderson Cancer Center, we routinely use combined chemotherapy and radiotherapy preoperatively for the treatment of rectal cancers, and decided to conduct a phase I trial in which UFT and leucovorin was used instead of the conventional 5-FU. The preliminary results are encouraging and seem to demonstrate the feasibility of this approach.

Avoidance of colostomy placement in advanced colorectal cancer with twice weekly hypofractionated radiation plus continuous infusion 5-fluorouracil

The purpose of this study was to determine the efficacy of twice weekly hypo-fractionated radiation therapy (RT) plus continuous infusion 5-fluorouracil for unresectable or locally advanced colorectal cancer with synchronous metastases. Palliative radiation consisting of 30 Gy/6 fractions/3 weeks was administered to 87 patients from 1982-1995 with 3 field belly board technique. Diverting colostomy was required for obstruction in 14 (16%) prior to radiation; 47 patients (54%) had recurrent disease following prior resection and 58 (66%) had distant metastases on presentation. Median follow-up was 12 months (1-104 months). Stabilization/regression of pelvic disease was accomplished in 65 patients (75%). Complete resection of the pelvic disease was accomplished in 5 patients (6%), all of whom had synchronous metastases. Diverting colostomy was required in only 11 patients after chemoradiation because of progressive pelvic tumor; 2 of these 11 patients (18%) had isolated progression of pelvic disease. Overall, colostomy was not required in 48 of the 72 patients (67%) who did not present with a stoma. Median survival was 11 months if metastatic disease was present and only 6 months when disease was limited to the pelvis. Grade 3 acute radiation toxicities occurred in <10% and no grade 4 acute toxicities were observed. No significant late radiation effects were noted. Twice weekly hypofractionated RT is well tolerated and provides durable palliation of symptoms related to locally advanced primary or recurrent colorectal cancer with metastatic disease.

Prospective trial of preoperative concomitant boost radiotherapy with continuous infusion 5-fluorouracil for locally advanced rectal cancer

RATIONALE

To evaluate the response to a concomitant boost given during standard chemoradiation for locally advanced rectal cancer.

METHODS AND MATERIALS

Concomitant boost radiotherapy was administered preoperatively to 45 patients with locally advanced rectal cancer in a prospective trial. Treatment consisted of 45 Gy to the pelvis with 18 mV photons at 1.8 Gy/fraction using a 3-field belly board technique with continuous infusion 5FU chemotherapy (300mg/m(2)) 5 days per week. The boost was given during the last week of therapy with a 6-hour inter-fraction interval to the tumor plus a 2-3 cm margin. The boost dose equaled 7.5 Gy/5 fractions (1.5 Gy/fraction); a total dose of 52.5 Gy/5 weeks was given to the primary tumor. Pretreatment tumor stage, determined by endorectal ultrasound and CT scan, included 29 with T3N0 [64%], 11 T3N1, 1 T3Nx, 2 T4N0, 1 T4N3, and 1 with TxN1 disease. Mean distance from the anal verge was 5 cm (range 0-13 cm). Median age was 55 years (range 33-77 years). The population consisted of 34 males and 11 females. Median time of follow-up is 8 months (range 1-24 months).

RESULTS

Sphincter preservation (SP) has been accomplished in 33 of 42 (79%) patients resected to date. Three patients did not undergo resection because of the development of metastatic disease in the interim between the completion of chemoradiation (CTX/XRT) and preoperative evaluation. The surgical procedures included proctectomy and coloanal anastomosis (n = 16), low anterior resection (n = 13), transanal resection (n = 4). Tumor down-staging was pathologically confirmed in 36 of the 42 (86%) resected patients, and 13 (31%) achieved a pathologic CR. Among the 28 tumors (67%) located <6 cm from the anal verge, SP was accomplished in 21 cases (75%). Although perioperative morbidity was higher, toxicity rates during CTX/XRT were comparable to that seen with conventional fractionation. Compared to our contemporary experience with conventional CTX/XRT (45Gy; 1.8 Gy per fraction), improvements were seen in SP (79% vs. 59%; p = 0.02), SP for tumors <6 cm from the anal verge (75% vs. 42%; p = 0.003), and down-staging (86% vs. 62%; p = 0.003).

CONCLUSION

The SP rate with concomitant boost radiation has been highly favorable with rates of response which are higher than those previously reported for chemoradiation without administration of a boost. Further evaluation of this radiotherapeutic strategy appears warranted.

Rationale for bladder-sparing surgery in patients with locally advanced colorectal carcinoma

BACKGROUND

Total pelvic exenteration (TPE) with urinary diversion is a standard surgical approach for patients with locally advanced rectal carcinoma. Because only approximately 50% of patients undergoing TPE have tumor involving the bladder, the authors evaluated the feasibility of bladder salvage in this setting. The current study presents the results of a retrospective study of patients with advanced colorectal carcinoma (classification of >/= T3) to formulate criteria for selecting patients for bladder-sparing procedures.

METHODS

The charts of 81 patients with rectal carcinoma classified as >/= T3 were reviewed for age, gender, computed tomography (CT) findings, results of intraoperative examination under anesthesia, final pathologic evaluation, urologic complications, local recurrence, and patient survival.

RESULTS

Among the 46 patients who underwent TPE, final pathologic evaluation demonstrated tumor involvement of the bladder in 58% of patients. Preoperative identification of a bladder mucosal abnormality accurately predicted bladder involvement in only 57% of the 30 patients who underwent cystoscopy. CT and intraoperative palpation of the bladder individually predicted the final pathologic findings in 69% and 70% of patients, respectively; of the 21 patients in whom both were positive, 90% had bladder involvement. Of the 35 patients (26 females and 9 males) who underwent bladder-sparing procedures, 22 had complete sparing of the bladder, 9 underwent partial cystectomy (5 with ureteroneocystostomy), 4 underwent ureteroneocystostomy alone, and 2 underwent prostatectomy alone. Ninety-four percent of these 35 patients had negative histologic margins. There was no difference in the incidence rate of urinary complications between patients who underwent TPE and those who underwent a bladder-sparing surgery (17% each). The incidence rates of local recurrence (14% vs. 17%) and the 3-year survival rates (49% vs. 39%) did not differ significantly between the 2 groups.

CONCLUSIONS

Bladder-sparing surgery to treat patients with locally invasive colorectal carcinoma provides good local control without sacrificing survival. Women, whose reproductive organs act as a natural barrier, and selected men in whom CT and intraoperative evaluation identify only localized involvement of the prostate or bladder appear to be reasonable candidates for bladder-sparing procedures.

Tumor downstaging and sphincter preservation with preoperative chemoradiation in locally advanced rectal cancer: the M. D. Anderson Cancer Center experience

PURPOSE

To evaluate the rates of tumor downstaging after preoperative chemoradiation for locally advanced rectal cancer.

MATERIALS AND METHODS

Preoperative chemoradiotherapy (CTX/XRT) that delivered 45 Gy in 25 fractions over 5 weeks with continuous infusion 5-fluorouracil (300 mg/m2/day) was given to 117 patients. The pretreatment stage distribution, as determined by endorectal ultrasound (u), included uT2N0 in 2%, uT3N0 in 47%, uT3N1 in 49%, and uT4N0 in 2% of cases; endorectal ultrasound was not performed in 13% of cases (15 patients). Approximately 6 weeks after completion of CTX/XRT, surgery was performed.

RESULTS

The pathological tumor stages were Tis-2N0 in 26%, T2N1 in 5%, T3N0 in 21%, T3N1 in 15%, T4N0 in 5%, and T4NI in 1%; a complete response (CR) to preoperative CTX/XRT was pathologically confirmed in 32 (27%) of patients. Tumor downstaging occurred in 72 (62%) cases. Only 3% of cases had pathologic evidence of progressive disease. Pretreatment tumor size (< 5 cm vs. > or = 5 cm) was the only factor predictive of tumor downstaging (p < 0.04). A decrease of > 1 T-stage level was accomplished in 45% of those downstaged. Overall, a sphincter-saving (SP) procedure was possible in 59% of patients and an abdominoperineal resection (APR) was required in 41 % of cases. Factors predictive of SP included downstaging (p < 0.03), age > 40 years (p < 0.007), pretreatment tumor distance, 3 to 6 cm from the anal verge (p < 0.00001), tumor size <6 cm (p < 0.02), mobility (p < 0.004), tumor stage <T4 (p < 0.01), and uN negative (p < 0.008). SP was performed in 23 patients (72%) with a CR and in 48 (67%) of downstaged cases. Among the 69 tumors located < 6 cm from the anal verge, 29 (42%) were resected with a SP. The level of response was important for tumors located < 6 cm from the anal verge because a SP was performed in 9 of the 17 (53%) CRs in this group while only 20 of 52 patients (38%) had a SP when residual disease was present after CTX/XRT. For tumors located > 6 cm from the anal verge, SP was performed in 14 of the 15 (93%) patients with a CR and 32 of 33 (97%) of patients with residual disease (p < 0.00004).

CONCLUSIONS

Significant tumor downstaging results from preoperative chemoradiation allowing sphincter sparing surgery in over 40% of patients whose tumors were located < 6 cm from the anal verge and who otherwise would have required colostomy.

Preoperative UFT and calcium folinate and radiotherapy in rectal cancer

Protracted infusions of 5-fluorouracil (5-FU) combined with pelvic radiotherapy have been associated with improved survival and decreased local and distant metastases in the adjuvant therapy of rectal cancer. However, this method of 5-FU infusion requires the inconvenience and expense of central venous line placement and care, infusion pumps, and treatment of catheter-related complications. We previously demonstrated that a completely oral therapy with UFT (uracil plus tegafur in a 4:1 molar ratio) plus oral calcium folinate (Orzel) can achieve pharmacokinetic parameters similar to those associated with protracted 5-FU infusions. This trial examines the feasibility of using UFT plus oral calcium folinate both during preoperative pelvic radiation and postoperatively, and shows that patients can be treated safely and effectively with a completely oral chemotherapy program combining UFT plus oral calcium folinate with pelvic radiation therapy.

Survival factors in 186 patients younger than 40 years old with colorectal adenocarcinoma

BACKGROUND

We sought to determine the clinical factors and tumor characteristics associated with the reported poor prognosis in young patients with carcinoma of the colon and rectum.

STUDY DESIGN

A retrospective review was performed of 186 patients younger than 40 years of age who were treated for primary colorectal adenocarcinoma. The median age was 34.3 years, and the median follow-up period was 9.4 years. Clinical and tumor histopathologic parameters were analyzed.

RESULTS

Regional lymph node metastases, distant metastases, or both, were seen at first examination in 65.6 percent of young patients. Histopathologic indicators of more aggressive tumor biology were present at a significantly higher frequency in young patients compared with patients older than 40 years (p < 0.001). Poorly differentiated tumor grade was present in 41.0 percent, signet-ring cell tumors were found in 11.1 percent, and infiltrating tumor leading edges were present in 69.0 percent of young patients. Among young patients with stage II disease, vascular invasion was a significant negative prognostic variable (p < 0.05).

CONCLUSIONS

We have demonstrated an increased incidence of three biological indicators of aggressive and potentially metastatic tumor biology in 186 young patients with carcinoma of the colon and rectum: signet-ring cell carcinoma, infiltrating tumor edges, and aggressive histologic grade in the primary adenocarcinoma. The increased incidence of these three histologic measures of more aggressive carcinoma of the colon and rectum in part accounts for the higher rate of advanced disease at presentation in patients younger than 40.

Transcriptional activation of the urokinase receptor gene in invasive colon cancer

The plasminogen activator urokinase promotes tumor invasion by converting plasminogen into plasmin, which degrades several extracellular matrix components. Urokinase can bind to a specific cell surface receptor, which leads to accelerated plasmin production. While there is good evidence indicating a role for this binding site in tumor invasion/metastasis, there is little information concerning the regulation of urokinase receptor expression in invasive cancer. To address this question a series of colon cancer cell lines, which demonstrate either a high or low ability to invade an extracellular matrix-coated porous filter, was characterized for receptor expression at the transcriptional and post-transcriptional levels. The invasive cell lines possessed 10-fold more receptors than their non-invasive counterparts as shown by cross-linking experiments and by Western blotting. Northern blotting indicated that this disparity in receptor number could be largely accounted for by a different amount of steady-state mRNA encoding the binding site. However, neither gene amplification nor enhanced mRNA stability could account for the augmented receptor protein observed for the invasive colon cancer cell types. In contrast, nuclear run-on experiments with representative cell lines revealed that the 10-fold difference in receptor display between the invasive-competent and invasive-deficient cells could be largely accounted for by differences in transcription rates. Transcription of the u-PAR gene in the receptor-deficient GEO cells, but not in the receptor-rich RKO cells, could be augmented by protein kinase C stimulation. These findings provide a clear rationale for studies to determine if the urokinase receptor promoter in invasive colon cancer is activated in cis or in trans.

Patterns of residual disease after preoperative chemoradiation in ultrasound T3 rectal carcinoma

BACKGROUND

Rectal carcinoma tends to recur locally, with invasion of adjacent organs and significant pelvic pain. Both radiation therapy alone and combined chemoradiation have been used in an attempt to decrease the local recurrence rate and thereby improve survival. Although preoperative chemoradiation can clinically downstage rectal tumors, the pathologic extent of the residual disease has not been studied.

METHODS

Thirty-seven patients with T3 rectal cancer diagnosed by transrectal ultrasonography (uT3) received 45 Gy with continuous infusion 5-fluorouracil (300 mg/m2/day). Proctoscopy with mucosal/submucosal biopsy was performed in patients (16 of 37) posttreatment and before definitive surgery.

RESULTS

Microscopic evaluation of the 37 resected specimens showed a 30% (11 patients) pathologic complete remission rate. The pattern of residual disease in the remaining 26 patients showed that nine (25%) had microscopic residual tumor without evidence of mucosal involvement. Of the 14 patients with a negative proctoscopic evaluation and biopsy only, five (36%) had no residual tumor on final pathology.

CONCLUSIONS

After chemoradiation, the pathologic presentation of rectal cancer may be altered, making endoscopic procedures and mucosal/submucosal biopsies unreliable in detection of residual disease. Despite the relatively good pathologic complete remission rate noted in this study, all patients undergoing chemoradiation for uT3 rectal carcinomas need definitive surgical resection to confirm a complete clinical remission.

Interleukin-2 administration causes reversible hemodynamic changes and left ventricular dysfunction similar to those seen in septic shock

Interleukin-2, a lymphocyte product, has well demonstrated antitumor activity in humans. Early clinical studies showed hemodynamic alterations in patients receiving the drug as antitumor immunotherapy. We serially assessed interleukin-2-associated hemodynamic parameters and left ventricular ejection fractions in five patients with neoplastic diseases unresponsive to conventional therapies. By day 4 of therapy, compared with baseline (preinterleukin-2), all patients developed tachycardia (p less than 0.01), decreased mean arterial blood pressure (p less than 0.05), increased cardiac index (p less than 0.05), and decreased systemic vascular resistance (p less than 0.01). In addition, left ventricular ejection fraction fell from 58.0 +/- 4.7 to 36.4 +/- 4.0 percent (0.05 less than p less than 0.10), which was associated with a trend toward left ventricular dilatation manifested by an increase in left ventricular end-diastolic volume index. Transient renal dysfunction was noted in all five patients, and one developed transient respiratory failure; both types of organ dysfunction recovered to baseline values after cessation of immunotherapy. Thus, interleukin-2 induces multiple reversible cardiovascular abnormalities that are similar to the hemodynamic manifestations of human septic shock.