Pre-operative combined 5-FU, low dose leucovorin, and sequential radiation therapy for unresectable rectal cancer

Feasibility of Assessing Prognostic Nutrition Index in Patients With Rectal Cancer Who Receive Preoperative Chemoradiotherapy

BACKGROUND

Malnutrition can adversely affect treatment responses and oncological outcomes in cancer patients. However, among patients with rectal cancer who undergo chemoradiotherapy (CRT), the significance of peri-treatment nutrition assessment as a predictor of treatment response and outcome remains unclear.

OBJECTIVE

The aim of this study was to determine whether the Prognostic Nutrition Index (PNI) based on peri-treatment serum can be used as a predictor of treatment response and outcome in patients with rectal cancer who undergo CRT.

DESIGN, SETTING, AND PATIENTS

We analyzed 114 patients with rectal cancer who received preoperative CRT followed by total mesorectal excision at our institution.

RESULTS

Post-CRT PNI was significantly lower than pre-CRT PNI in rectal cancer patients. Although post-CRT PNI did not significantly correlate with either overall survival or disease-free survival, low pre-CRT PNI was significantly associated with shorter overall survival and disease-free survival in this population and was also an independent risk factor for ineffectiveness of long-course preoperative CRT. Finally, low pre-CRT PNIs were a stronger indicator of poor prognosis and early recurrence in patients with pathological lymph node metastasis (who generally need to receive postoperative chemotherapy), than in those with no pathological lymph node metastasis.

CONCLUSION

Pretreatment PNI could be useful in evaluating and managing patients with rectal cancer who undergo CRT followed by curative resection.

Development of in situ gelling and bio adhesive 5-Fluorouracil enema

In this study, a novel 5-Fluorouracil (5-FU) enema with good bio adhesion and temperature sensitivity was developed using in situ gelling technology. The preparation was formulated as a free-flowing liquid before use, while a layer of gel film was quickly formed when administered in the rectum, with a large contact surface area. It also demonstrated good biocompatibility, appropriate gel strength and bio adhesive force with excellent adhesion to rectal mucosa and prolonged action time, allowing more effective drug absorption and diffusion to surrounding tissues. Poloxamer 407 and poloxamer 188 were applied to adjust the gelling temperature. With the addition of carbopol and polycarbophil (bio adhesive substances), the solubility of 5-FU and gel strength increased, the temperature of gelation and the surface area of drug contact on mucous epithelium decreased. Decreased adhesive force between the preparation and the mucous membrane of the rectum was demonstrated with improving carbopol and polycarbophil's concentration. In vitro release demonstrated that 5-FU in situ gelling enema with different bases had a rapid and almost complete drug release. We used an optimized formulation of P407/P188/polycarbophil/5-FU (17/2.5/0.2/1.0) for animal experiments. The result showed that the drug evenly covered the surface of the rectum and there was no leakage in 6 hours. The in situ gelling enema showed significantly higher rectal tissue levels of 5-FU compared with suppository and intravenous administration, indicating that 5-FU could be well absorbed due to the enlarged releasing area, longer retention time and larger amount of dissolved active ingredients. Systemically, 5-FU levels in the enema group were similar to those in the suppository group and significantly lower than the intravenous group. The enema was not associated with morphological damage to rectal tissue. These results suggest that the bio adhesive and in situ gelling enema could be a more effective rectal delivery system of 5-FU.

Preoperative chemoradiation versus radiation alone for stage II and III resectable rectal cancer

BACKGROUND

Preoperative radiotherapy (RT) decreases local recurrence rate and improves survival in stage II and III rectal cancer patients. The combination of chemotherapy with RT has a sound radiobiological rationale, and phase II trials of combined chemoradiation (CRT) have shown promising activity in rectal cancer.

OBJECTIVES

To compare preoperative RT with preoperative CRT in patients with resectable stage II and III rectal cancer.

SEARCH METHODS

We searched the Cochrane Register of Controlled Trials, Web of Science, Embase.com, and Pubmed from 1975 until June 2012. A manual search was performed of Ann Surg, Arch Surg, Cancer, J Clin Oncol, Int J Radiat Oncol Biol Phys and the proceedings of ASTRO, ECCO and ASCO from 1990 until June 2012.

SELECTION CRITERIA

Relevant studies randomized resectable stage II or III rectal cancer patients to at least one arm of preoperative RT alone or at least one arm of preoperative CRT.

DATA COLLECTION AND ANALYSIS

Primary outcome parameters included overall survival (OS) at 5 years and local recurrence (LR) rate at 5 years. Secondary outcome parameters included disease free survival (DFS) at 5 years, metastasis rate, pathological complete response rate, clinical response rate, sphincter preservation rate, acute toxicity, postoperative mortality and morbidity, and anastomotic leak rate. Outcome parameters were summarized using the Odds Ratio (OR) and associated 95% confidence interval (CI) using the fixed effects model.

MAIN RESULTS

Five trials were identified and included in the meta-analysis. From one of the included trials only preliminary data are reported. The addition of chemotherapy to preoperative RT significantly increased grade III and IV acute toxicity (OR 1.68-10, P = 0.002) and marginally affected postoperative overall morbidity (OR 0.67-1.00, P = 0.05) while no differences were observed in postoperative mortality or anastomotic leak rate. Compared to preoperative RT alone, preoperative CRT significantly increased the rate of complete pathological response (OR 2.12-5.84, P < 0.00001) although this did not translate into a higher sphincter preservation rate (OR 0.92-1.30, P = 0.32). The incidence of local recurrence at five years was significantly lower in the CRT group compared to RT alone (OR 0.39-0.72, P < 0.001). No statistically significant differences were observed in DFS (OR 0.92-1.34, P = 0.27) or OS (OR 0.79-1.14, P = 0.58) at five years.

AUTHORS' CONCLUSIONS

Compared to preoperative RT alone, preoperative CRT enhances pathological response and improves local control in resectable stage II and III rectal cancer, but does not benefit disease free or overall survival. The effects of preoperative CRT on functional outcome and quality of life are incompletely understood and should be addressed in future trials.

Helical Tomotherapy Significantly Reduces Dose to Normal Tissues When Compared to 3D-CRT for Locally Advanced Rectal Cancer

Combined modality treatment (neoadjuvant chemoradiotherapy followed by surgery) for locally advanced rectal cancer requires special attention to various organs at risk (OAR). As a result, the use of conformal dose delivery methods has become more common in this disease setting. Helical tomotherapy is an image-guided intensity modulated delivery system that delivers dose in a fan-beam manner at 7 degree intervals around the patient and can potentially limit normal tissue from high dose radiation while adequately treating targets. In this study we dosimetrically compare helical tomotherapy to 3D-CRT for stage T3 rectal cancer. The helical tomotherapy plans were optimized in the TomoPlan system to achieve an equivalent uniform dose of 45 Gy for 10 patients with T3N0M0 disease that was at least 5cm from the anal verge. The GTV included the rectal thickening and mass evident on colonoscopy and CT scan as well as with the help of a colorectal surgeon. The CTV included the internal iliac, obturator, and pre-sacral lymphatic chains. The OAR that were outlined included the small bowel, pelvic bone marrow, femoral heads, and bladder. Anatom-e system was used to assist in delineating GTV, CTV and OAR. These 10 plans were then duplicated and optimized into 3-field 3D-CRT plans within the Pinnacle planning system. The V[45], V[40], V[30], V[20], V[10], and mean dose to the OAR were compared between the helical tomotherapy and 3D-CRT plans. Statistically significant differences were achieved in the doses to all OAR, including all volumes and means except for V[10] for the small bowel and the femoral heads. Adequate dosimetric coverage of targets were achieved with both helical tomotherapy and 3D-CRT. Helical tomotherapy reduces the volume of normal tissue receiving high-dose RT when compared to 3D-CRT treatment. Both modalities adequately dose the tumor. Clinical studies addressing the dosimetric benefits are on-going.

Preoperative chemoradiation versus radiation alone for stage II and III resectable rectal cancer

BACKGROUND

Preoperative radiotherapy (RT) decreases local recurrence rate and improves survival in stage II and III rectal cancer patients. The combination of chemotherapy with RT has a sound radiobiological rationale, and phase II trials of combined chemoradiation (CRT) have shown promising activity in rectal cancer.

OBJECTIVES

To compare preoperative RT with preoperative CRT in patients with resectable stage II and III rectal cancer.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials, Web of Science, Embase.com, and Pubmed from 1975 until june 2007. A manual search was performed of Ann Surg, Arch Surg, Cancer, J Clin Oncol, Int J Radiat Oncol Biol Phys and the proceedings of ASTRO, ECCO and ASCO from 1990 until june 2007.

SELECTION CRITERIA

Relevant studies randomized resectable stage II or III rectal cancer patients to at least one arm of preoperative RT alone or at least one arm of preoperative CRT.

DATA COLLECTION AND ANALYSIS

Primary outcome parameters included overall survival (OS) at 5 years and local recurrence (LR) rate at 5 years. Secondary outcome parameters included disease free survival (DFS) at 5 years, metastasis rate, pathological complete response rate, clinical response rate, sphincter preservation rate, acute toxicity, postoperative mortality and morbidity, and anastomotic leak rate. Outcome parameters were summarized using the Odds Ratio (OR) and associated 95% confidence interval (CI) using the fixed effects model.

MAIN RESULTS

Four trials were identified and included in the meta-analysis. The addition of chemotherapy to preoperative RT significantly increased grade III and IV acute toxicity (OR 1.68-10, P = 0.002) while no differences were observed in postoperative morbidity or mortality. Compared to preoperative RT alone, preoperative CRT significantly increased the rate of complete pathological response (OR 2.52-5.27, P < 0.001) although this did not translate into a higher sphincter preservation rate (OR 0.92-1.31, P = 0.29). The incidence of local recurrence at five years was significantly lower in the CRT group compared to RT alone (OR 0.39-0.72, P < 0.001). No statistically significant differences were observed in DFS (OR 0.92-1.34, P = 0.27) or OS (OR 0.79-1.14, P = 0.58) at five years.

AUTHORS' CONCLUSIONS

Compared to preoperative RT alone, preoperative CRT enhances pathological response and improves local control in resectable stage II and III rectal cancer, but does not benefit disease free or overall survival. The effects of preoperative CRT on functional outcome and quality of life are incompletely understood and should be addressed in future trials.

CPT-11 and concomitant hyperfractionated accelerated radiotherapy induce efficient local control in rectal cancer patients: results from a phase II

Patients with rectal cancer are at high risk of disease recurrence despite neoadjuvant radiochemotherapy with 5-Fluorouracil (5FU), a regimen that is now widely applied. In order to develop a regimen with increased antitumour activity, we previously established the recommended dose of neoadjuvant CPT-11 (three times weekly 90 mg m⁻²) concomitant to hyperfractionated accelerated radiotherapy (HART) followed by surgery within 1 week. Thirty-three patients (20 men) with a locally advanced adenocarcinoma of the rectum were enrolled in this prospective phase II trial (1 cT2, 29 cT3, 3 cT4 and 21 cN+). Median age was 60 years (range 43–75 years). All patients received all three injections of CPT-11 and all but two patients completed radiotherapy as planned. Surgery with total mesorectal excision (TME) was performed within 1 week (range 2–15 days). The preoperative chemoradiotherapy was overall well tolerated, 24% of the patients experienced grade 3 diarrhoea that was easily manageable. At a median follow-up of 2 years no local recurrence occurred, however, nine patients developed distant metastases. The 2-year disease-free survival was 66% (95% confidence interval 0.48–0.83). Neoadjuvant CPT-11 and HART allow for excellent local control; however, distant relapse remains a concern in this patient population.

Preoperative hyperfractionated accelerated radiotherapy (HART) and concomitant CPT-11 in locally advanced rectal carcinoma: a phase I study

PURPOSE

Patients with locally advanced rectal carcinoma are at risk for both local recurrence and distant metastases. We demonstrated the efficacy of preoperative hyperfractionated accelerated radiotherapy (HART). In this Phase I trial, we aimed at introducing chemotherapy early in the treatment course with both intrinsic antitumor activity and a radiosensitizer effect.

METHODS AND MATERIALS

Twenty-eight patients (19 males; median age 63, range 28-75) with advanced rectal carcinoma (cT3: 24; cT4: 4; cN+: 12; M1: 5) were enrolled, including 8 patients treated at the maximally tolerated dose. Escalating doses of CPT-11 (30-105 mg/m(2)/week) were given on Days 1, 8, and 15, and concomitant HART (41.6 Gy, 1.6 Gy bid x 13 days) started on Day 8. Surgery was to be performed within 1 week after the end of radiochemotherapy.

RESULTS

Twenty-six patients completed all preoperative radiochemotherapy as scheduled; all patients underwent surgery. Dose-limiting toxicity was diarrhea Grade 3 occurring at dose level 6 (105 mg/m(2)). Hematotoxicity was mild, with only 1 patient experiencing Grade 3 neutropenia. Postoperative complications (30 days) occurred in 7 patients, with an anastomotic leak rate of 22%.

CONCLUSIONS

The recommended Phase II dose of CPT-11 in this setting is 90 mg/m(2)/week. Further Phase II exploration at this dose is warranted.

Chemoradiotherapy in the treatment of rectal cancer

The integration of radiotherapy to the adjuvant treatment of rectal cancer was prompted by the predominance of locoregional failures after curative surgery. This characteristic in the pattern of failure is one of the main reasons adjuvant radiotherapy plays a greater role in rectal cancer than in colon cancer. It has been demonstrated that local failure rates after surgery alone for rectal cancer are strongly dependent on the degree of bowel wall invasion, lymph node involvement, and margins of resection. These same locoregional factors are also predictive of distant metastasis and survival. In addition, local failure is associated with devastating symptoms that severely affect the quality of life of patients. For these reasons, locoregional control remains a major issue in the treatment of rectal cancer. This article summarizes the evidence that has established chemoradiotherapy as part of the standard of care for rectal cancer and the techniques used for its delivery.

Influence of irradiation on neutrophilic granulocyte function

BACKGROUND

Neoadjuvant radiotherapy is a common treatment modality for patients with Stage II and III rectal carcinoma but, after surgery, often is complicated by local infections. To define a possible influence of radiotherapy on neutrophilic granulocytes in the neighborhood of tumor cells, the authors investigated their function in vitro.

METHODS

Density gradient-purified granulocytes from healthy donors were used for all tests. These cells were cocultured with the colon carcinoma cell line HRT-18 and irradiated. Their function was assessed by measuring luminol-enhanced chemiluminescence and migration against the chemoattractant formyl-methionyl-leucine-phenylalanine.

RESULTS

Although irradiation decreased, the addition of tumor cells increased reactive-oxygen species release in granulocytes, which was enhanced further by phorbol myristate acid (PMA), even after several hours. All contacts with tumor cells, however, caused immediate radical release that was inversely proportional to the radiation dose. Naïve and irradiated cells were stimulated further by PMA. Migration of granulocytes clearly was inhibited by tumor cells and irradiation, whereas the depth of invasion was enhanced by higher doses of radiation.

CONCLUSIONS

The current data show clearly that the influence of radiotherapy on local defense against colorectal carcinoma is limited and cannot explain the increased rate of infectious complications.

Phase I study of 5-fluorouracil administered by protracted venous infusion, leucovorin, and pelvic radiation therapy

BACKGROUND

This study was designed to assess the toxicity of pelvic radiation therapy, 5-fluorouracil (5-FU) administered by protracted venous infusion, and leucovorin.

METHODS

Pelvic radiation therapy consisted of 50.4-54 gray (Gy) administered in 28-30 fractions. Systemic treatment consisted of leucovorin (10 mg daily) administered orally and protracted venous infusion of 5-FU. The initial daily 5-FU dose was 150 mg/m(2). Dose escalations were planned in increments of 25 mg/m(2).

RESULTS

Forty eligible patients were registered, of whom 37 were evaluable for chemoradiotherapy-related toxicity. Grade 3 or 4 toxicity secondary to radiation therapy, protracted venous infusion of 5-FU, and leucovorin occurred in 2 of 17 patients at a daily 5-FU dose of 150 mg/m(2), in 5 of 10 patients at a daily 5-FU dose of 175 mg/m(2), and in 5 of 10 patients at a daily 5-FU dose of 200 mg/m(2). Diarrhea was dose-limiting in 7 of 8 patients with Grade 4 toxicity. Venous thrombosis, a treatment-related complication not directly related to chemotherapy or radiation therapy, occurred in 5 of the 40 patients entered into this study. Four thromboses occurred at the site of a central catheter. No thrombotic complications occurred in the last 7 patients, who were given warfarin orally (1 mg daily) during treatment.

CONCLUSIONS

Toxicity due to radiation therapy, protracted venous infusion of 5-FU, and leucovorin when 5-FU is given daily at a dose of 150 mg/m(2) is similar to that observed in current chemoradiotherapy regimens for patients with rectal carcinoma. This regimen will be considered as a possible investigational treatment arm of a future trial of adjuvant therapy for rectal carcinoma patients.

Results of external beam radiotherapy alone for incompletely resected carcinoma of rectosigmoid or rectum: Peter MacCallum Cancer Institute experience 1981-1990

PURPOSE

To study the results of external beam radiotherapy treatment for incompletely resected nonmetastatic rectosigmoid and rectal carcinoma.

METHODS AND MATERIALS

A retrospective review was carried out of all patients (57) presenting to Peter MacCallum Cancer Institute from 1981 to 1990 with incompletely resected nonmetastatic rectosigmoid or rectal cancer who were treated with external beam radiotherapy. Three radiotherapy schedules were used: radical (50 to 60 Gy, 27 patients), high-dose palliative (45 Gy, 25 patients), and low-dose palliative (less than 45 Gy, 5 patients). Symptomatic response, overall survival, and the effect of prognostic factors on treatment outcome were evaluated. The median follow-up period for survivors was 49 months.

RESULTS

Symptomatic response rates were 83% and 79% for the radical and high-dose palliative groups respectively. The estimated median survival time from presentation for all patients was 16.4 months (radical 26.1 months, high-dose palliative 15.7 months). Patients with microscopic residual disease survived significantly longer than patients with macroscopic residual disease (estimated median survival time 30.7 months vs. 14.3 months, p = 0.013).

CONCLUSIONS

No dose response effect was seen between the radical group and high-dose palliative group. Microscopic residual disease at presentation was the only significant predictor of better survival. The conventionally fractionated course of 50 to 60 Gy was not significantly better in terms of palliation and overall survival than a shorter palliative course of 45 Gy. In future, preoperative chemoradiation should improve outcome by reducing the number of patients with incompletely resected cancer.

Prognostic implications of downstaging following preoperative radiation therapy for operable T3-T4 rectal cancer

PURPOSE

To evaluate the prognostic value of tumor downstaging after preoperative radiation for resectable rectal cancer.

METHODS AND MATERIALS

Eighty-eight patients with non-metastatic resectable rectal cancers (76 T3 and 12 T4) were treated with preoperative irradiation. Median dose was 40 Gy (30-46 Gy) delivered over 32 days (range 11-40). Seventeen patients received preoperative chemotherapy, two courses of 5-fluorouracil (5FU) 350 mg/m2/day and folinic acid 20 mg/m2/day; 5 days per week during the first and fifth weeks of radiotherapy. Surgery was performed with a mean delay of 46 days after completion of irradiation and included 66 abdominoperineal resections and 22 anal sphincter-preserving procedures. Postoperative chemotherapy was administered in 44 patients.

RESULTS

Histological tumor stages were: complete histological response in 7%, pT2N0 in 19%, pT3N0 in 46%, and pT2-3N1 in 28%. Tumor downstaging occurred in 26%. No predictive factor of downstaging was statistically significant. The median follow-up was 33 months. The 3- and 5-year cancer-specific survival rates were 100% for the pT0N0 and pT2N0, respectively, 89% and 68% for pT3N0, and 64% and 0% for pT2T3N1. After preoperative irradiation, the pathological tumor stages remained a prognostic factor. Patients with downstaging (pT0T2N0) had significantly higher cancer-specific survival rates than the group without downstaging: 100% and 80% at 3 years, and 100% and 45% at 5 years; respectively (p = 0.011). The 3- and 5-year recurrence free-survival rates were 94% for the group with downstaging and 56% and 50%, respectively, for the group without downstaging (p = 0.002).

CONCLUSION

Downstaging after preoperative irradiation in this retrospective study results in an improvement in local control and survival.

[Phase II study on preoperative radio-chemo-thermotherapy in locally advanced rectal carcinoma]

BACKGROUND

Recent studies show that preoperative radio-chemotherapy can increase resectability and local control of locally advanced rectal carcinomas. Additional regional hyperthermia might increase remission rates and tumor response. We therefore tested regional hyperthermia together with radio-chemotherapy in a phase-II study on locally advanced rectal carcinomas.

PATIENTS AND METHODS

Thirty-seven patients with primary advanced stage uT3/T4 rectal carcinomas were treated with preoperative radio-chemo-thermo-therapy. The initial tumor depth was determined using endosonography, CT, and MRI. Radiotherapy was carried out in prone position (on a belly board) using standard techniques, with 5 x 1.8 Gy per week up to 45 Gy at the reference point. 5-Fluorouracil (300 to 500 mg/m2) was administered with low doses of leucovorin (50 mg) on days 1 to 5 and 22 to 28. The patients were treated with regional hyperthermia each week prior to radiotherapy and simultaneously with chemotherapy, using the Sigma 60 ring from the BSD-2000 system. Temperature/position curves and temperature/time curves were recorded in endocavitary (endorectal) catheters in tumor contact and as well in bladder and vagina. Following endosonographic restaging, the operation was carried out 4 to 6 weeks after the end of preoperative therapy and adjuvant chemotherapy continued in four cycles. In cases where tumors were non-resectable, a boost up to 64 Gy was aimed.

RESULTS

Thirty-one of the 37 patients (84%) with primary carcinoma proved locally R0-resectable. In addition we had 1 R1-resection (3%) and 5 non-resectable tumors (13%). Among the resected tumors, 53% experienced a reduction of depth infiltration from the initial endosonographic stage during preoperative therapy. The actuarial survival rate after 4 years is 65% (free of progression 57%). The actuarial 4-year survival rate was particularly favorable for the group of responders. Overall, the preoperative multimodal therapy was well tolerated, and premature termination was only necessary in 1 case (3%). Grade III/IV toxicities in the intestine and skin were reduced as far as possible by field blockings and cooling of the perineal region. They occurred only in 5/37 patients (13%) at the intestine and in 6/37 patients (16%) at the skin. The thermal data were subjected to a statistical analysis. The quality of temperature distribution (T90, cum min T90 > or = 40.5 degrees C) depends on the power level and relative power density. The response (reduction of tumor size or depth infiltration) correlated significantly with quality parameters of the temperature distributions. This dependency is found as a trend for progression-free survival, too.

CONCLUSIONS

Preoperative radio-chemo-thermo-therapy proved to be practical and effective, with encouraging remission rates and excellent local control rates. For this reason, a phase-III study to test regional hyperthermia has been initiated. At the same time, certain technical improvements are still under development for regional hyperthermia.

Risk factors associated with mucositis in cancer patients receiving 5-fluorouracil

Oral mucositis is a dose-limiting toxicity of 5-fluorouracil (5-FU). This prospective cohort study investigated factors associated with mucositis in patients receiving 5-FU for cancer of the digestive tract. Sixty-three patients (mean age 65 years) completed self-administered questionnaires and had interviews, oral examinations and unstimulated whole salivary flow measurements at baseline and follow-up appointments. The duration of follow-up was 2 months. Predictor variables included sociodemographic data, body surface area, diabetes, smoking, alcohol consumption, salivary flow, oral hygiene, presence of prostheses, performance status, regimen of cytotoxic drugs, hematological data, and herpes simplex virus antibody titer. Forty-six per cent of patients developed at least one episode of oral mucositis during cytotoxic treatment. Pearson's chi-square analysis showed that mucositis was significantly associated with xerostomia at baseline, xerostomia during chemotherapy, and lower baseline neutrophil counts (P < or = 0.05). Multiple logistic regression analysis indicated that xerostomia at baseline (odds ratio, OR = 10.0), or baseline neutrophil level under 4000 cells/mm3 (OR = 3.9) were significant predictors of mucositis. Taking into account the effect of neutrophil level at baseline, xerostomia during chemotherapy (OR = 4.5) was also a significant predictor of mucositis. The results showed that xerostomia and lower baseline neutrophil levels are significantly associated with oral mucositis. These variables should be taken into consideration in the design of intervention studies to reduce the frequency and severity of mucositis. More research is required to investigate the role of saliva and neutrophils in the pathogenesis of chemotherapy-induced mucositis.

Preoperative radiation with concurrent 5-fluorouracil continuous infusion for locally advanced unresectable rectal cancer

BACKGROUND AND PURPOSE

To determine the percentage of complete responders and the resectability rate for patients with locally advanced carcinoma of the rectum treated by 5-fluorouracil (5-FU) infusional chemotherapy and pelvic radiation.

MATERIALS AND METHODS

Between October 1992 and June 1996, 29 patients with a diagnosis of locally advanced unresectable rectal cancer received preoperative 5 FU by continuous intravenous infusion at a dose of 225 mg/m2/day concurrent with pelvic radiation (median 54 Gy/28 fractions). All patients were clinical stage T4 on the bases of organ invasion or tumor fixation. Median time for surgical resection was 6 weeks.

RESULTS

Median follow-up for the group was 28 months (range 5-57 months). Six patients were felt to be persistently unresectable or developed distant metastases and did not undergo surgical resection. Of the 29 patients, 23 proceeded to surgery, 18 were resectable for cure, 13 by abdominoperineal resection, 3 by anterior resection and 2 by local excision. Of the 29 patients, 4 (13%) had a complete response, and 90% were clinically downstaged. Of the 18 resected patients, 1 has died of his disease, 17 are alive, and 15 disease-free. The regimen was well tolerated; there was only one treatment-related complication, a wound dehiscence.

CONCLUSION

The combination of 5 FU infusion and pelvic radiation in the management of locally advanced rectal cancer is well tolerated and provides a baseline for comparison purposes with future combinations of newer systemic agents and radiation.

Preoperative hyperthermia combined with radiochemotherapy in locally advanced rectal cancer: a phase II clinical trial

OBJECTIVE

A prospective phase II study was performed to determine the feasibility and efficacy in terms of response rate, resectability, and morbidity in patients with locally advanced rectal cancer who received preoperative regional hyperthermia combined with radiochemotherapy (HRCT).

SUMMARY BACKGROUND DATA

Recent studies suggest that preoperative radiochemotherapy in locally advanced rectal cancer can induce downstaging, but after resection the incidence of local recurrences remains high. Hyperthermia (HT) may add tumoricidal effects and improve the efficacy of radiochemotherapy in a trimodal approach.

PATIENTS AND METHODS

Thirty-seven patients with histologically proven rectal cancer and T3 or T4 lesions, as determined by endorectal ultrasound and computed tomography, entered the trial. 5-Fluorouracil (300-350 mg/m2) and leucovorin (50 mg) were administered on days 1 to 5 and 22 to 26. Regional HT using the SIGMA 60 applicator (BSD-2000) was given once a week before radiotherapy (45 Gy with 1.8-Gy fractions for 5 weeks). Surgery followed 4 to 6 weeks after completion of HRCT.

RESULTS

Preoperative treatment was generally well tolerated, with 16% of patients developing grade III toxicity. No grade IV complications were observed. The overall resectability rate was 32 of 36 patients (89%), and 31 resection specimens had negative margins (R0). One patient refused surgery. In 5 patients (14%), the histopathologic report confirmed no evidence of residual tumor (pCR). A partial remission (PR) was observed in 17 patients (46%). The survival rate after 38 months was 86%. In none of the patients was local recurrence detected after R0(L), but five patients developed distant metastases.

CONCLUSION

Preoperative HRCT is feasible and effective and may contribute to locoregional tumor control of advanced rectal cancer, which is to be proven in an ongoing phase III trial.

[Effect radiotherapy on postoperative staging and residual tumor cell density in rectal cancers]

PURPOSE

To determine predictive factors and prognostic value of tumor downstaging and sterilization after preoperative radiotherapy for rectal cancer.

PATIENTS AND METHODS

Between 1977 and 1994, 167 patients with a histologically proven adenocarcinoma underwent preoperative radiotherapy (median dose, 44 Gy; mean time before surgery, 5 weeks). Pathologic specimens were reviewed by the same pathologist in order to specify the modified Astler Coller classification (MAC) and to quantify residual tumor cell density (RTCD).

RESULTS

According to the MAC, there were nine stage 0 (5%), 10 stage A (6%), 103 stage B1-B3 (62%) and 45 stage C1-C3 (27%) tumors. Seventeen per cent and 56% of the patients who received a dose > or = 44 Gy presented with stage 0-A and stage B1-B3 tumors, respectively, compared to 4 and 69% of those who received a dose < 44 Gy (P = 0.04). Tumor differentiation and a longer interval before surgery were significantly associated with more frequent downstaging. According to the RTCD, 62 tumors (37%) showed no or only rare foci of residual tumor cells; 62 (37%) showed an intermediate RTCD and 43 (26%) a high RTCD. No predictive factor of RTCD was statistically significant. Only post-operative staging was a significant prognostic factor (P < 0.01).

CONCLUSION

The favourable influence of higher doses of preoperative radiotherapy on pathologic stage has been observed. Tumor differentiation and time before surgery were the other significant predictive factors of tumor downstaging. Even after preoperative radiotherapy, post-operative staging retained its prognostic value.

Pre-operative radiotherapy and chemotherapy for non-resectable rectal cancer

BACKGROUND

The treatment results of combined pre-operative radiotherapy and chemotherapy followed by surgery for patients with initially non-resectable primary rectal cancer were reviewed.

METHODS

Thirteen patients with locally advanced non-resectable rectal cancer were treated with pre-operative irradiation consisting of 50.4-54 Gy plus concomitant 5-fluorouracil (5-FU) delivered during the 1st and 5th weeks of radiotherapy.

RESULTS

Following pre-operative therapy, the resectability rate was 91%, with all but one patient undergoing complete resection. The pathologic complete response rate was 10%. The overall peri-operative and postoperative complication rate was 0.8 complications per patient. There was no postoperative mortality.

CONCLUSIONS

This early experience indicates that high resectability rates are achievable with pre-operative radiotherapy and chemotherapy for non-resectable rectal cancer while maintaining acceptable postoperative morbidity.

The role of adjuvant radiation therapy in the treatment of colorectal cancer

Radiation therapy in conjunction with 5-FU chemotherapy is an effective method in the adjuvant treatment of both colon and rectal cancer.

Preliminary results of preoperative 5-fluorouracil, low-dose leucovorin, and concurrent radiation therapy for clinically resectable T3 rectal cancer

PURPOSE

We report the downstaging, sphincter preservation, acute toxicity, and preliminary local control and survival results of preoperative 5-fluorouracil (5-FU), low-dose leucovorin (LV), and concurrent radiation therapy followed by postoperative LV/5-FU for treatment of patients with clinically resectable T3 rectal cancer.

MATERIALS AND METHODS

A total of 32 patients received two monthly cycles of preoperative LV/5-FU (bolus daily X 5). Radiation therapy (5,040 cGy) began concurrently on day 1. Postoperatively, patients received a median of two monthly cycles of LV/5-FU (range, 0-10).

RESULTS

The complete response rate was 9 percent pathologic and 13 percent clinical, for a total of 22 percent. Total Grade 3+ acute toxicity during the preoperative combined modality segment was 25 percent (8/32). Of the 20 patients who were thought to initially require an abdominoperineal resection and for whom the intent of treatment was sphincter preservation, 17 (85 percent) were able to undergo sphincter-preserving surgery. With a median follow-up of 22 (3-59) months, none have developed local failure, and the three-year actuarial disease-free survival rate was 60 percent.

CONCLUSION

Our data reveal encouraging downstaging, sphincter preservation and acute toxicity with this regimen. Additional follow-up is needed to assess the long-term local control and survival rates.

Preoperative radiotherapy (RT) for rectal cancer: predictive factors of tumor downstaging and residual tumor cell density (RTCD): prognostic implications

PURPOSE

To determine predictive factors and prognostic value of tumor downstaging and tumor sterilization after preoperative RT for rectal cancer.

METHODS AND MATERIALS

Between 1977 and 1994, 167 patients with a histologically proven adenocarcinoma (70 T2, 65 T3, 29 T4, and 3 local recurrences) underwent preoperative RT. Median dose was 44 Gy (5-73 Gy). Surgery was performed in a mean time of 5 weeks after RT. Pathologic specimens have been reviewed by the same pathologist in order to specify the modified Astler Coller classification (MAC), and to quantify the residual tumor cell density (RTCD).

RESULTS

According to the MAC, there was 9 stage 0 (5%), 10 stage A (6%), 103 stage B1-B3 (62%), and 45 stage C1-C3 (27%) tumors. Seventeen percent and 56% of the patients who received a dose > or = 44 Gy had respectively a 0-A and a B tumor, compared to 4 and 69% in those who received a dose < 44 Gy (p = 0.04). Tumor differentiation and a longer interval before surgery were significantly associated with a more frequent downstaging, and preoperative staging correlated well to the postoperative pathological findings. According to the RTCD, 62 tumors (37%) showed no or only rare foci of residual tumor cells (Group 1); 62 (37%) showed an intermediate RTCD (Group 2); and 43 (26%) a high RTCD (Group 3). No predictive factor of RTCD was statistically significant. In univariate analysis, postoperative staging was a significant prognostic factor, with corresponding 5-year overall survival rates in 0-A, B, and C stages of 92, 67, and 26% (p < 0.01). RTCD was not a prognostic factor. However, overall and disease-free survival rates for patients with complete pathologic response of 83% at 2 and 5 years suggested a better outcome in this subgroup of patients.

CONCLUSION

The favorable influence of higher doses of preoperative RT on pathologic stage has been observed. Tumor differentiation, preoperative classification and time before surgery were the other predictive factors of tumor downstaging. However, there was no predictive factor of complete pathologic response. Even after preoperative RT, postoperative staging remained a prognostic factor.

Preoperative 5-FU, low-dose leucovorin, and radiation therapy for locally advanced and unresectable rectal cancer

PURPOSE

We report the local control and survival of two Phase I dose escalation trials of combined preoperative 5-fluorouracil (5-FU), low-dose leucovorin (LV), and radiation therapy followed by postoperative LV/5-FU for the treatment of patients with locally advanced and unresectable rectal cancer.

METHODS AND MATERIALS

A total of 36 patients (30 primary and 6 recurrent) received two monthly cycles of LV/5-FU (bolus daily x 5). Radiation therapy (50.40 Gy) began on day 1 in the 25 patients who received concurrent treatment and on day 8 in the 11 patients who received sequential treatment. Postoperatively, patients received a median of four monthly cycles of LV/5-FU.

RESULTS

The resectability rate with negative margins was 97%. The complete response rate was 11% pathologic and 14% clinical for a total of 25%. The 4-year actuarial disease-free survival was 67% and the overall survival was 76%. The crude local failure rate was 14% and the 4-year actuarial local failure rate was 30%. Crude local failure was lower in the four patients who had a pathologic complete response (0%) compared with those who either did not have a pathologic complete response (16%) or who had a clinical complete response (20%).

CONCLUSION

Our preliminary data with the low-dose LV regimen reveal encouraging downstaging, local control, and survival rates. Additional follow-up is needed to determine the 5-year results. The benefit of downstaging on local control is greatest in patients who achieve a pathologic complete response.

Suppository delivery of 5-fluorouracil in rectal cancer

BACKGROUND

Preoperative radiotherapy with concomitant intravenous 5-fluorouracil (5-FU-i.v.) is effective in shrinking locally advanced rectal cancers and facilitating subsequent surgery. Topical 5-FU application may enhance its radiosensitizing and cytotoxic effects. Suppository and intravenous 5-FU administration were compared with respect to myelo-suppression and tissue concentrations.

METHODS

Rats received 120 mg/kg 5-FU-i.v. or via suppository (5-FU-S). White blood cell count, serum albumin, alkaline phosphatase, creatinine, and aspartate aminotransferase (AST) were determined before and serially after 5-FU administration. In a separate experiment, rats received 5-FU-S or 5-FU-i.v. as already described. Portal and systemic blood, rectal, iliac lymph node, liver, and lung tissue were harvested for high-performance liquid chromatography determination of 5-FU concentrations 30 min, 1, 3, 6, and 12 h after drug administration.

RESULTS

No toxicity was observed in 5-FU-S animals, whereas 63% of 5-FU-IV animals had diarrhea. Weight loss and myelosuppression occurred only in 5-FU-i.v. animals. Rectal drug concentrations were significantly higher in the 5-FU-S animals compared with 5-FU-i.v. animals, 0.5-6 h after drug administration. Blood, liver, and lung 5-FU concentrations with 5-FU-S were comparable to those with 5-FU-i.v.

CONCLUSIONS

5-FU suppositories are associated with fewer systemic side effects and higher rectal 5-FU concentrations than with 5-FU-i.v. administration.

Hyperthermia in the multimodal therapy of advanced rectal carcinomas

The synergistic effects of hyperthermia (raising temperatures to 40 degrees C and above) when combined with radiotherapy and cytotoxic drugs and a modulation of immunological phenomena have been demonstrated in the laboratory. Pre-clinical data relating to hyperthermia are summed up, along with their implications for clinical application. Controlled studies of local and regional hyperthermia have been performed during recent years, and these show us that the adjunction of hyperthermia provides at least an improvement of local control compared with radiotherapy alone. Current clinical results are summarized. Therapy systems based on radiowave irradiation have been commercially available for regional hyperthermia of the pelvis since the mid 1980s. This technology allows us to perform sufficiently tolerable and effective regional hyperthermia on rectal carcinomas. Used as part of curative preoperative and postoperative multimodal therapeutic strategies, hyperthermia can lead to improvement in local control (resectability, down-staging, progression-free time, recurrence rate), at least for certain risk groups. The preoperative radio-chemo-thermotherapy of advanced primary and recurring rectal carcinoma, uT3/4, was tested in a phase-I/II study of 20 patients. Therapy procedure, acute toxicity, thermal parameters, and response are described and discussed for this patient group. The regimen proved to be sufficiently tolerable, and complications did not occur. Tumor resection was performed on 14 of the 20 patients; 13 of the procedures were R0-resections and one was an R2 resection. In 64% of the resected rectal carcinomas, histopathological down-staging of the pretherapeutic endosonographical stadium was achieved; in three of the patients, despite continued non-resectability, local control has now been maintained for more than 12 months. In two patients with nonresectable rectal carcinomas, local progress was seen during the neoadjuvant combination therapy.

Preoperative and postoperative radiotherapy in rectal carcinoma

Surgery is the initial treatment of choice for most patients with rectal neoplasms. The objectives are to remove of tumor and drain the primary nodes. In stage I disease the surgical approach is though to be sufficiently effective. However, at least in the case of abdominoperineal resection, this causes considerable morbidity. Therefore, at the present time, there are efforts to reduce the extent of the resection by applying other treatment modalities in stage I disease. After curative resection in stage II/III disease a considerable number of patients suffer from local recurrence or distant metastases. In these patients adjuvant therapy is currently recommended. In locally advanced disease, primary resection is not feasible. Different treatment settings which apply combinations of all treatment modalities are possible. The article reviews the literature and shows future directions.

Constipation and diarrhea: the neglected symptoms

OBJECTIVE

To review the symptom experience of constipation and diarrhea related to cancer and its treatment.

DATA SOURCES

Published articles and book chapters relating to constipation and diarrhea in patients with cancer.

CONCLUSIONS

Constipation and diarrhea often represent a major concern and source of discomfort for the cancer patients. Research is needed to establish prevention and treatment protocols for patients at risk for constipation or diarrhea.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses are in an excellent position to recognize individuals who are at high risk for constipation and diarrhea. Preventive strategies and treatment protocols are of utmost importance.

A pilot study of a new therapeutic approach in the treatment of locally advanced stages of rectal cancer: neoadjuvant radiation, chemotherapy and regional hyperthermia

The synergistic effects of hyperthermia (temperatures > or = 41 degrees C) when combined with radiotherapy or cytotoxic drugs, as well as a modulation of tumour-related immunological phenomena have been demonstrated preclinically. Local or regional hyperthermia in combination with radiation or chemotherapy has been studied in patients during recent years, and has convincingly demonstrated that hyperthermia is feasible and tolerated by patients. Furthermore, there is strong evidence that hyperthermia may provide an improvement in local control as compared with radiotherapy or chemotherapy alone. Systems based on radiowave irradiation allow sufficiently tolerable and effective regional hyperthermic therapy in patients with rectal carcinomas. Used as part of curative pre-operative and postoperative multimodal therapeutic strategies in high-risk patients with locally advanced rectal carcinomas, hyperthermia may result in improved local control and a higher rate of sphincter-sparing procedures. 20 patients with non-resectable, locally advanced primary or recurring rectal carcinoma T3/4 entered a phase I/II study of pre-operative radiochemothermotherapy with folinic acid and 5-fluorouracil, radiation (45 Gy HD), as well as regional hyperthermia once a week followed by chemotherapy after surgery. The regimen proved to be sufficiently tolerable. Acute grade III or IV toxicities did not occur after hyperthermia. Tumour resections were performed on 14 of the 20 patients, with 13 being complete. In 9 of the carcinomas, downstaging compared with the pretherapeutic stage was achieved. In 3 of 6 patients with persistent non-resectable tumours, local control has now been maintained for more than 12 months. One patient progressed locally during neoadjuvant combination therapy. These results prompted the initiation of a prospective randomised study to evaluate the relative importance of regional hyperthermia in this setting.

Preoperative infusional chemoradiation and surgery with or without an electron beam intraoperative boost for advanced primary rectal cancer

PURPOSE

To compare the multimodality treatment results of surgical resection plus preoperative radiotherapy with concomitant protracted infusion chemotherapy (preop-chemoXRT), with or without an electron beam intraoperative radiotherapy (EB-IORT) boost, in 37 patients having advanced primary rectal cancer, with the results of a protocol using only preoperative radiotherapy (preop-XRT) plus surgical resection in a historic control group of 36 patients.

METHODS AND MATERIALS

Thirty-eight patients with tethered T3 or T4 primary rectal cancer were treated with 45 Gy delivered in 25 fractions over 5 weeks plus infusional chemotherapy. Thirty-seven patients underwent surgical resection: 13 (35%) had restorative operations, and the remainder had either abdomino-perineal resection (APR) or pelvic exenteration (PE). Electron beam intraoperative radiotherapy (EB-IORT) was used in doses of 10-20 Gy for 11 patients with adherent pelvic tumor. In the 36 historic control patients, the preop-XRT dose was 45 Gy, and 93% of them had APR or PE.

RESULTS

The local recurrence rate was 3% for the preop-chemoXRT group and 33% for the historic control group. The 3-year survival rate for patients treated with preop-chemoXRT plus resection was 82% compared with 62% for the historic control group. Distant metastases occurred more frequently in patients treated with an EB-IORT boost than in patients who were not (64% vs. 19%, p < 0.05), and the overall 3-year survival rate was lower for the former (67% vs. 96%, p < 0.05). Acute and late toxicities were acceptable.

CONCLUSIONS

Preop-chemoXRT for advanced primary rectal cancer results in better control of pelvic disease and better overall survival rates than does preop-XRT alone. With preop-chemoXRT, acute chemoradiation toxicity is increased whereas late morbidity is unchanged compared with preop-XRT alone. Local control in patients with areas of residual or clinically adherent disease is improved by the use of EB-IORT; however, patients treated with EB-IORT had poorer survival rates than those treated without EB-IORT.

The rationale to switch from postoperative hyperfractionated accelerated radiotherapy to preoperative hyperfractionated accelerated radiotherapy in rectal cancer

PURPOSE

To demonstrate the feasibility of preoperative Hyperfractionated Accelerated RadioTherapy (preop-HART) in rectal cancer and to explain the rationales to switch from postoperative HART to preoperative HART.

METHODS AND MATERIALS

Fifty-two consecutive patients were introduced in successive Phase I trials since 1989. In trial 89-01, postoperative HART (48 Gy in 3 weeks) was applied in 20 patients. In nine patients with locally advanced rectal cancer, considered unresectable by the surgeon, 32 Gy in 2 weeks was applied prior to surgery (trial 89-02). Since 1991, 41.6 Gy in 2.5 weeks has been applied preoperatively to 23 patients with T3-T4 any N rectal cancer immediately followed by surgery (trial 91-01). All patients were irradiated at the department of radiation-oncology with a four-field box technique (1.6 Gy twice a day and with at least a 6-h interval between fractions). The minimal accelerating potential was 6 MV. Acute toxicity was scored according to the World Health Organization (WHO for skin and small bowel) and the Radiation Therapy Oncology Group criteria (RTOG for bladder). This was done weekly during treatment and every 3 months thereafter. Small bowel volume was estimated by a modified "Gallagher's" method.

RESULTS

Acute toxicity was acceptable both in postoperative and preoperative setup. The mean acute toxicity was significantly lower in trial 91-01 compared to 89-01. This difference was due to the smaller amount of small bowel in irradiation field and lower total dose in trial 91-01. Moreover, there was a significantly reduced delay between surgery and radiotherapy favoring trial 91-01 (median delay 4 days compared to 46 days in trial 89-01). Nearly all patients in trial 89-02 and 91-01 underwent surgery (31 out of 32; 97%). Resection margins were negative in 29 out of 32. Hospitalization duration in trial 91-01 was not significantly different from trial 89-01 (19 vs. 21 days, respectively).

CONCLUSIONS

Hyperfractionated accelerated radiotherapy immediately followed by surgery is feasible as far as acute toxicity is concerned. Preoperative HART is favored by a significantly lower acute toxicity related, in part, to a smaller amount of irradiated small bowel, and a shorter duration of the delay between radiotherapy and surgery. Moreover, the hospital stay after preoperative HART is not significantly increased.

Efficacy of postoperative 5-FU, high-dose leucovorin, and sequential radiation therapy for clinically resectable rectal cancer

We report the local control and survival in a previously reported phase I dose escalation trial of combined postoperative 5-FU, high dose leucovorin (LV), and sequential radiation therapy followed by maintenance LV/5-FU for the treatment of patients with clinically resectable rectal cancer. Following surgery for stages T3-4N0-2M0 primary (21) or recurrent (4) rectal cancer, 25 patients received 5-FU/LV x 1 cycle. Radiation therapy (5040 cGy) began on day 8. A second cycle of 5-FU/LV was given concurrent with the fourth week of radiation. Patients received an additional 10 cycles of LV/5-FU. The median follow-up was 40 months (range 18-52). The incidence of grade 3+ acute toxicity in the 9 patients who received the recommended dose of 5-FU was 44%. The local failure rate was 28%. Abdominal and distant failure rates were 24%. The 3-year actuarial disease-free survival was 74% and the overall survival was 80%. Our preliminary data reveal reasonable local control and survival rates. However, further follow-up is needed to assess our results at 5 years. Postoperative combined modality therapy with high-dose LV may be an option for the adjuvant treatment of patients with resectable rectal cancer.

Preoperative 5-fluorouracil, low-dose leucovorin, and concurrent radiation therapy for rectal cancer

BACKGROUND

A Phase I trial was performed to determine the maximum tolerated dose of concurrent preoperative radiation therapy (5040 cGy) and 2 cycles (bolus daily times 5) of 5-fluorouracil (5-FU) and low-dose leucovorin (LV) (20 mg/m2), followed by surgery and 10 cycles of postoperative 5-FU/LV in patients with primary or recurrent rectal cancer.

METHODS

Twenty-four patients were entered into the study. Preoperatively, the initial dose of 5-FU was 325 mg/m2. 5-FU was escalated 50 mg/m2, while the dose of LV and radiation therapy remained constant. Chemotherapy and radiation began concurrently on day 1. The postoperative chemotherapy was not dose escalated; 5-FU, 425 mg/m2, and LV, 20 mg/m2. The median follow-up was 10 months (range, 4-19 months).

RESULTS

The resectability rate with negative margins in the 23 patients who underwent surgery was 100%. One patient refused surgery. The pathologic complete response rate was 13% (3 of 23). An additional four patients had negative nodes and a microscopic foci of tumor in the bowel wall. Therefore, the total clinical complete response rate was 30% (7 of 23). The maximum tolerated dose of 5-FU for the preoperative combined modality segment was 375 mg/m2; therefore, the recommended Phase II dose level is 325 mg/m2. The incidence of Grade 3+ toxicity for the 22 patients treated at the recommended 5-FU dose level (325 mg/m2) during the preoperative combined modality segment was as follows: diarrhea, 14%; erythema, 5%; hematologic, 10%; and total, 18%. The median nadir counts were leukocyte count, 3.7 (range, 1.5-5.9); hemoglobin count, 12.2 (range, 10.2-14.3); and platelet count (times 1000), 165 (range, 92-237).

CONCLUSIONS

With this regimen, the recommended doses of chemotherapy in the combined modality segment are slightly higher than those recommended in arm 2 of the Intergroup postoperative adjuvant rectal trial 0114. This regimen will serve both as the preoperative arm of the Intergroup randomized trial of preoperative versus postoperative combined modality therapy for resectable rectal cancer (INT R9401) as well as the basis for the combined modality segment of NSABP RO-3.