1
|
Salek S, Moazamian E, Mohammadi Bardbori A, Shamsdin SA. The anticancer effect of potential probiotic L. fermentum and L. plantarum in combination with 5-fluorouracil on colorectal cancer cells. World J Microbiol Biotechnol 2024; 40:139. [PMID: 38514489 DOI: 10.1007/s11274-024-03929-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 02/15/2024] [Indexed: 03/23/2024]
Abstract
5-Fluorouracil (5-FU) is an effective chemotherapy drug in the treatment of colorectal cancer (CRC). However, auxiliary or alternative therapies must be sought due to its resistance and potential side effects. Certain probiotic metabolites exhibit anticancer properties. In this study evaluated the anticancer and potential therapeutic activities of cell extracts potential probiotic strains, Limosilactobacillus fermentum and Lactiplantibacillus plantarum isolated from the mule milk and the standard probiotic strain Lacticaseibacillus rhamnosus GG (LGG) against the human colon cancer cell line (HT-29) and the normal cell line (HEK-293) alone or in combination with 5-FU. In this study, L. plantarum and L. fermentum, which were isolated from mule milk, were identified using biochemical and molecular methods. Their probiotic properties were investigated in vitro and compared with the standard probiotic strain of the species L. rhamnosus GG. The MTT assay, acridine orange/ethidium bromide (AO/EB) fluorescent staining, and flow cytometry were employed to measure the viability of cell lines, cell apoptosis, and production rates of Th17 cytokines, respectively. The results demonstrated that the combination of lactobacilli cell extracts and 5-FU decreased cell viability and induced apoptosis in HT-29 cells. Furthermore, this combination protected HEK-293 cells from the cytotoxic effects of 5-FU, enhancing their viability and reducing apoptosis. Moreover, the combination treatment led to an increase in the levels of IL-17A, IFN-γ, and TNF-α, which can enhance anti-tumor immunity. In conclusion, the cell extracts of the lactobacilli strains probably can act as a potential complementary anticancer therapy.
Collapse
Affiliation(s)
- Sanaz Salek
- Department of Microbiology, College of Sciences, Agriculture and Modern Technology, Shiraz Branch, Islamic Azad University, Shiraz, Iran
| | - Elham Moazamian
- Department of Microbiology, College of Sciences, Agriculture and Modern Technology, Shiraz Branch, Islamic Azad University, Shiraz, Iran.
| | - Afshin Mohammadi Bardbori
- Department of Toxicology and Pharmacology, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyedeh Azra Shamsdin
- Gasteroenterohepatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| |
Collapse
|
2
|
Warncke UO, Toma W, Meade JA, Park AJ, Thompson DC, Caillaud M, Bigbee JW, Bryant CD, Damaj MI. Impact of Dose, Sex, and Strain on Oxaliplatin-Induced Peripheral Neuropathy in Mice. FRONTIERS IN PAIN RESEARCH 2021; 2:683168. [PMID: 35295533 PMCID: PMC8915759 DOI: 10.3389/fpain.2021.683168] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 05/11/2021] [Indexed: 12/18/2022] Open
Abstract
Chemotherapy-induced peripheral neuropathy (CIPN) is a common, dose limiting, and long-lasting side effect of chemotherapy treatment. Unfortunately, no treatment has proven efficacious for this side effect. Rodent models play a crucial role in the discovery of new mechanisms underlying the initiation, progression, and recovery of CIPN and the potential discovery of new therapeutics. However, there is limited consistency in the dose, the sex, age, and genetic background of the animal used in these studies and the outcome measures used in evaluation of CIPN rely primarily on noxious and reflexive measures. The main objective of this study was to provide a comprehensive and systematic characterization of oxaliplatin-induced peripheral neuropathy in mice by using a battery of behavioral, sensory, electrophysiological, and morphometric measures in both sexes of the two widely used strains of mice, C57BL/6J and BALB/cJ. Mice received intraperitoneal injections of 3 or 30 mg/kg cumulative doses of oxaliplatin over the course of 2 weeks. Both doses induced long-term and time-dependent mechanical and cold hypersensitivity. Our results show that 30 mg/kg oxaliplatin reduced the locomotor activity in C57BL/6J mice, and C57BL/6J females showed anxiety-like behavior one-week post completion of treatment. In the same dose group, BALB/cJ males and females sustained a larger decrease in sucrose preference than either male or female C57BL/6J mice. Both strains failed to show significant changes in burrowing and nesting behaviors. Two clinically relevant assessments of changes to the peripheral nerve fibers, nerve conduction and intraepidermal nerve fiber density (IENFD) were evaluated. Only BALB/cJ females showed significant reduction in the nerve conduction amplitude 1 week after 30 mg/kg oxaliplatin regimen. Moreover, this dose of the chemo agent reduced the IENF density in both sexes and strains. Our findings suggest that mouse strain, sex, and assay type should be carefully considered when assessing the effects of oxaliplatin and potential therapeutic interventions.
Collapse
Affiliation(s)
- Urszula O Warncke
- Department of Pharmacology and Toxicology, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond, VA, United States
- Wright Center for Clinical and Translational Research, Virginia Commonwealth University, Richmond, VA, United States
| | - Wisam Toma
- Department of Pharmacology and Toxicology, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond, VA, United States
| | - Julie A Meade
- Department of Pharmacology and Toxicology, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond, VA, United States
| | - Abigail J Park
- Department of Pharmacology and Toxicology, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond, VA, United States
| | - Danielle C Thompson
- Department of Pharmacology and Toxicology, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond, VA, United States
| | - Martial Caillaud
- Department of Pharmacology and Toxicology, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond, VA, United States
| | - John W Bigbee
- Department of Anatomy and Neurobiology, School of Medicine, Virginia Commonwealth University, Richmond, VA, United States
| | - Camron D Bryant
- Laboratory of Addiction Genetics, Department of Pharmacology and Experimental Therapeutics and Psychiatry, Boston University School of Medicine, Boston, MA, United States
| | - M Imad Damaj
- Department of Pharmacology and Toxicology, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond, VA, United States
| |
Collapse
|
3
|
Yaghobi Joybari A, Behzadi B, Azadeh P, Alahyari S. The Outcome of Induction Chemotherapy, Followed by Neoadjuvant Chemoradiotherapy and Surgery, in Locally Advanced Rectal Cancer. IRANIAN JOURNAL OF PATHOLOGY 2021; 16:266-273. [PMID: 34306122 PMCID: PMC8298053 DOI: 10.30699/ijp.2021.130482.2441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 12/12/2020] [Indexed: 11/06/2022]
Abstract
Background & Objective Currently, neoadjuvant chemoradiotherapy, followed by surgery, is the standard treatment for locally advanced rectal cancer. The use of induction chemotherapy for this tumor is controversial. In this study, the benefits and side effects of induction chemotherapy in locally advanced rectal cancer are evaluated. Methods Twenty-nine patients with locally advanced rectal cancer in 2018-2019 were enrolled in this study. Initially, they underwent induction chemotherapy (oxaliplatin 130 mg/m2 every 3 weeks and capecitabine 1000 mg/m2 twice a day for 14 days every 3 weeks for 2 courses). Then, neoadjuvant chemoradiotherapy (radiotherapy 50.4 Gy/28 for 5 days a week concomitant with weekly oxaliplatin 50 mg/m2, as well as capecitabine 825 mg/m2/bid on the days of radiotherapy) was administered. After 4 weeks, computed tomography (CT) scan of thorax, pelvis, and abdomen with and without contrast was performed. Total mesorectal surgery was performed 6-8 weeks after the end of radiotherapy. Four courses of adjuvant chemotherapy were applied. Pathologic complete response (pCR), margin, sphincter preservation, and adverse effects were assessed. Results In this study, pCR was present in 6 (20.7%) patients. R0 resection was done in 96.05%. Sphincter was preserved in 44.4% of lower rectal tumors. Two patients (6.9%) did not complete adjuvant treatment. Grade 3 adverse effects were documented in 13.7% of cases during induction chemotherapy and 17.2% of cases during neoadjuvant chemoradiation. Mortality was not reported. Conclusion Induction chemotherapy, followed by neoadjuvant chemoradiotherapy and surgery, would be an effective and safe modality in locally advanced rectal cancer.
Collapse
Affiliation(s)
- Ali Yaghobi Joybari
- Department of Radiation Oncology, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Behnaz Behzadi
- Department of Radiation Oncology, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Payam Azadeh
- Department of Radiation Oncology, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sam Alahyari
- Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| |
Collapse
|
4
|
Lupattelli M, Bellavita R, Natalini G, Giovenali P, Sidoni A, Castagnoli P, Corgna E, Draghini L, Trippolini R, Aristei C. Oxaliplatin with Raltitrexed and Preoperative Radiotherapy in T3-T4 Extraperitoneal Rectal Cancer. A Dose Finding Study. TUMORI JOURNAL 2019; 92:474-80. [PMID: 17260486 DOI: 10.1177/030089160609200602] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aims and background The availability of new drugs offers the opportunity to improve the outcome of locally advanced rectal cancer. Raltitrexed and oxaliplatin are effective in advanced colorectal cancer with acceptable toxicity and can act as radiation enhancers as shown in phase 1-11 studies. The aim of the study was thus to determine the recommended dose of oxaliplatin concomitantly administered with raltitrexed and concurrent preoperative radiotherapy in patients with stage 11-111 extraperitoneal rectal cancer. Methods From September 2001 to September 2002, 18 consecutive patients with T3/T4 rectal cancer were treated at our Institution with preoperative chemoradiation followed by surgery after 6-8 weeks. Pelvic radiotherapy was delivered at a dose of 45 Gy in 25 fractions in 5 weeks followed by a 5.4 Gy boost at 1.8 Gy daily. Concomitant chemotherapy consisted of 3 mg/m2/iv of raltitrexed on days 1, 19, 38 of radiotherapy treatment with incremental doses of oxaliplatin according to dose finding rules (4 dose levels: 65, 85, 110, 130 mg/m2). Dose-limiting toxicity for oxaliplatin was defined as either grade 3-4 hematological or grade 3-4 gastrointestinal or neurological toxicity. We studied a minimum of 3 patients at each dose level. Results Three patients were treated at 65, 85, and 110 mg/m2/iv, respectively, while 9 patients were recruited at the last dose level. Neither grade 3-4 gastrointestinal nor neurological toxicity were documented. Dose-limiting toxicity was documented in 2/9 subjects at the 130 mg/m2 level consisting of grade 3 transient asymptomatic leukopenia. Thirteen patients developed transient increase of one or more liver enzymes (grade 3-4) and 2 patients developed grade 3 perineal dermatitis. All patients received the programmed dose of radiotherapy. The chemotherapy regimen was not completed in 4 cases due to grade 2 protracted leukopenia. Conclusions The maximum tolerated dose of oxaliplatin was not reached at the maximum dose level (IV); 130 mg/m2 can therefore be defined as the recommended dose. The combination of oxaliplatin with raltitrexed and radiotherapy can be considered feasible and well tolerated.
Collapse
Affiliation(s)
- Marco Lupattelli
- Radiation Oncology Center, University and Hospital of Perugia, Perugia, Italy.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
5
|
Chang CY, Pan TM. Anticancer and Antimigration Effects of a Combinatorial Treatment of 5-Fluorouracil and Lactobacillus paracasei subsp. paracasei NTU 101 Fermented Skim Milk Extracts on Colorectal Cancer Cells. JOURNAL OF AGRICULTURAL AND FOOD CHEMISTRY 2018; 66:5549-5555. [PMID: 29737161 DOI: 10.1021/acs.jafc.8b01445] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Colorectal cancer (CRC) is one of the most prevalent cancers worldwide. Metabolites of lactic acid bacteria (LAB) have anticancer and antimetastasis capacities. This study aimed to investigate the chemotherapeutic effects of Lactobacillus paracasei subsp. paracasei NTU 101-fermented skim milk (NTU101-FM) extracts in combination with the chemotherapeutic drug 5-fluorouracil (5-FU) in a cellular CRC model. The NTU101-FM extracts effectively reduced CRC cell viability but were not cytotoxic to colon epithelial cells. Moreover, they increased RAW 264.7 cell viability. Notably, the cell viability of CRC cells was decreased by 5-FU in combination with the NTU101-FM extracts; the combinatorial treatment inhibited cell viability significantly more than 5-FU alone ( p < 0.05). An ethanol extract of NTU101-FM effectively attenuated CT26 cell migration. In conclusion, the ethanol extract prepared from NTU101-FM has a potential application as an anticancer agent in CRC.
Collapse
Affiliation(s)
- Chia-Yuan Chang
- Department of Biochemical Science & Technology , National Taiwan University , Number 1, Section 4, Roosevelt Road , Taipei 10617 , Taiwan
| | - Tzu-Ming Pan
- Department of Biochemical Science & Technology , National Taiwan University , Number 1, Section 4, Roosevelt Road , Taipei 10617 , Taiwan
| |
Collapse
|
6
|
Musio D, Raffetto N, Dionisi F, Iannacone E, Dipalma B, Caparrotti F, Meaglia I, Caiazzo R, Bangrazi C, Banelli E. Comparison between Intensified Neoadjuvant Treatment and Standard Preoperative Chemoradiation for Rectal Cancer. TUMORI JOURNAL 2018; 96:11-6. [DOI: 10.1177/030089161009600102] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Objectives The aim of the current study was to compare a neoadjuvant regimen containing oxaliplatin with standard preoperative treatment for rectal cancer. Methods From December 2006 to December 2007, 20 patients with rectal cancer were treated at our Institution with the weekly addition of oxaliplatin (50 mg/m2) to radiotherapy (50.4–54.0 Gy in 28–30 daily fractions) and continuous infusion of 5-fluorouracil (200 mg/m2). The results of the regimen were compared with a historical control group including 21 consecutive patients previously treated with standard 5-fluorouracil treatment from December 2004 to October 2006. Results Both the rate of sphincter preservation in low rectal cancer (91.7% vs 36.4%, P = 0.009) and the rate of downstaging (84.2% vs 47.6%, P = 0.023) were higher in the oxaliplatin group than in the control group. Pathological complete response was achieved in 8 patients (42.1%) in the oxaliplatin group and in 4 patients (19.0%) in the control group (P = 0.172). When ypT0-pT1 stages were analyzed together, the P value was 0.051. Acute toxicity was increased in the oxaliplatin group, with a higher incidence of G3 diarrhea and pelvic pain than in the control group (30.0% vs 14.3%, P = NS). Conclusions Our data seem to correlate the addition of oxaliplatin to the standard treatment for rectal cancer with higher rates of sphincter preservation, down-staging and complete response. Toxicity is increased and requires careful monitoring. However, our results refer to a retrospective comparison of a small series of patients and need to be validated by the large, phase III randomized trial currently ongoing.
Collapse
Affiliation(s)
- Daniela Musio
- Department of Radiation Oncology, University “Sapienza”, Rome, Italy
| | - Nicola Raffetto
- Department of Radiation Oncology, University “Sapienza”, Rome, Italy
| | - Francesco Dionisi
- Department of Radiation Oncology, University “Sapienza”, Rome, Italy
| | - Eva Iannacone
- Department of Radiation Oncology, University “Sapienza”, Rome, Italy
| | | | | | - Ilaria Meaglia
- Department of Radiation Oncology, University “Sapienza”, Rome, Italy
| | - Rossella Caiazzo
- Department of Radiation Oncology, University “Sapienza”, Rome, Italy
| | - Caterina Bangrazi
- Department of Radiation Oncology, University “Sapienza”, Rome, Italy
| | - Enzo Banelli
- Department of Radiation Oncology, University “Sapienza”, Rome, Italy
| |
Collapse
|
7
|
Hüttner FJ, Probst P, Kalkum E, Hackbusch M, Jensen K, Ulrich A, Büchler MW, Diener MK. Addition of platinum derivatives to neoadjuvant single-agent fluoropyrimidine chemoradiotherapy in patients with stage II/III rectal cancer: protocol for a systematic review and meta-analysis (PROSPERO CRD42017073064). Syst Rev 2018; 7:11. [PMID: 29357929 PMCID: PMC5778669 DOI: 10.1186/s13643-018-0678-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Accepted: 01/11/2018] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Neoadjuvant (chemo-)radiation has proven to improve local control compared to surgery alone, but this improvement did not translate into better overall or disease-specific survival. The addition of oxaliplatin to fluoropyrimidine-based neoadjuvant chemoradiotherapy holds the potential of positively affecting survival in this context since it has been proven effective in the palliative and adjuvant setting of colorectal cancer. Thus, the objective of this systematic review is to assess the efficacy, safety, and quality of life resulting from adding a platinum derivative to neoadjuvant single-agent fluoropyrimidine-based chemoradiotherapy in patients with Union for International Cancer Control stage II and III rectal cancer. METHODS MEDLINE, Web of Science, and Cochrane Central Register of Controlled Trials will be systematically searched to identify all randomized controlled trials comparing single-agent fluoropyrimidine-based chemoradiotherapy to combined neoadjuvant therapy including a platinum derivative. Predefined data on trial design, quality, patient characteristics, and endpoints will be extracted. Quality of included trials will be assessed according to the Cochrane Risk of Bias Tool, and the GRADE recommendations will be applied to judge the quality of the resulting evidence. The main outcome parameter will be survival, but also treatment toxicity, perioperative morbidity, and quality of life will be assessed. DISCUSSION The findings of this systematic review and meta-analysis will provide novel insights into the efficacy and safety of combined neoadjuvant chemoradiotherapy including a platinum derivative and may form a basis for future clinical decision-making, guideline evaluation, and research prioritization. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017073064.
Collapse
Affiliation(s)
- Felix J. Hüttner
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
- The Study Center of the German Surgical Society (SDGC), University of Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Pascal Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
- The Study Center of the German Surgical Society (SDGC), University of Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Eva Kalkum
- The Study Center of the German Surgical Society (SDGC), University of Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Matthes Hackbusch
- Institute of Medical Biometry and Informatics (IMBI), University of Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Katrin Jensen
- Institute of Medical Biometry and Informatics (IMBI), University of Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Alexis Ulrich
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - Markus W. Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - Markus K. Diener
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
- The Study Center of the German Surgical Society (SDGC), University of Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| |
Collapse
|
8
|
Dreussi E, Pucciarelli S, De Paoli A, Polesel J, Canzonieri V, Agostini M, Friso ML, Belluco C, Buonadonna A, Lonardi S, Zanusso C, De Mattia E, Toffoli G, Cecchin E. Predictive role of microRNA-related genetic polymorphisms in the pathological complete response to neoadjuvant chemoradiotherapy in locally advanced rectal cancer patients. Oncotarget 2017; 7:19781-93. [PMID: 26934318 PMCID: PMC4991418 DOI: 10.18632/oncotarget.7757] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 02/16/2016] [Indexed: 12/23/2022] Open
Abstract
In rectal cancer, a pathologic complete response (pCR) to pre-operative treatment is a favourable prognostic marker, but is reported in a minority of the patients. We aimed at identifying microRNA-related host genetic polymorphisms predictive of pCR. A panel of 114 microRNA-related tagging polymorphisms was selected and analyzed on 265 locally advanced rectal cancer patients treated with neoadjuvant chemo-radiotherapy. Patients were stratified in two subgroups according to the radiotherapy dose (50.4Gy for 202 patients, 55.0Gy for 78 patients). Interactions among genetic and clinical-pathological variants were investigated by recursive partitioning analysis. Only polymorphisms with a consistent significant effect in the two subgroups of patients were selected as predictive markers of pCR. The results were validated by bootstrap analysis. SMAD3-rs744910, SMAD3-rs745103, and TRBP-rs6088619 were associated to an increased chance of pCR (p=0.0153, p=0.0471, p=0.0125). DROSHA-rs10719 and SMAD3-rs17228212 had an opposite detrimental effect on pathological tumour response (p=0.0274, p=0.0049). Recursive partitioning analysis highlighted that a longer interval time between the end of radiotherapy and surgery increases the chance of pCR in patients with a specific combination of SMAD3-rs744910 and TRBP-rs6088619 genotypes. This study demonstrated that microRNA-related host genetic polymorphisms can predict pCR to neo-adjuvant chemo-radiotherapy, and could be used to personalize the interval time between the end of radiotherapy and surgery.
Collapse
Affiliation(s)
- Eva Dreussi
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico, National Cancer Institute, Aviano, Italy
| | - Salvatore Pucciarelli
- Department of Surgical, Oncological and Gastroenterological Sciences, Section of Surgery, University of Padova, Padua, Italy
| | - Antonino De Paoli
- Radiation Oncology, Centro di Riferimento Oncologico, National Cancer Institute, Aviano, Italy
| | - Jerry Polesel
- Epidemiology and Biostatistics, Centro di Riferimento Oncologico, National Cancer Institute, Aviano, Italy
| | - Vincenzo Canzonieri
- Pathology, Centro di Riferimento Oncologico, National Cancer Institute, Aviano, Italy
| | - Marco Agostini
- Department of Surgical, Oncological and Gastroenterological Sciences, Section of Surgery, University of Padova, Padua, Italy.,Nano Inspired Biomedicine Laboratory, Istituto di Ricerca Pediatrica, Città della Speranza, Padua, Italy.,Department of Nanomedicine, The Methodist Hospital Research Institute, Houston, Texas, USA
| | - Maria Luisa Friso
- Radiation Oncology, Istituto Oncologico Veneto, IRCCS, Padova, Italy
| | - Claudio Belluco
- Surgical Oncology, Centro di Riferimento Oncologico, National Cancer Institute, Aviano, Italy
| | - Angela Buonadonna
- Medical Oncology B, Centro di Riferimento Oncologico, National Cancer Institute, Aviano, Italy
| | - Sara Lonardi
- Medical Oncology 1, Istituto Oncologico Veneto, IRCCS, Padova, Italy
| | - Chiara Zanusso
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico, National Cancer Institute, Aviano, Italy
| | - Elena De Mattia
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico, National Cancer Institute, Aviano, Italy
| | - Giuseppe Toffoli
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico, National Cancer Institute, Aviano, Italy
| | - Erika Cecchin
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico, National Cancer Institute, Aviano, Italy
| |
Collapse
|
9
|
Peng J, Lin J, Zeng Z, Wu X, Chen G, Li L, Lu Z, Ding P, Wan D, Pan Z. Addition of oxaliplatin to capecitabine-based preoperative chemoradiotherapy for locally advanced rectal cancer: Long-term outcome of a phase II study. Oncol Lett 2017; 14:4543-4550. [PMID: 29085451 PMCID: PMC5649637 DOI: 10.3892/ol.2017.6764] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 06/02/2017] [Indexed: 12/18/2022] Open
Abstract
Our previous study reported the favorable short-term outcome and good tolerance of integrating oxaliplatin into capecitabine-based (XELOX regimen) preoperative chemoradiotherapy (CRT) for locally advanced rectal cancer (LARC). The present study reported the long-term oncological outcome of this phase II study. A total of 47 patients with rectal adenocarcinoma (stage II or III) were enrolled and received radiotherapy (46 Gy in 23 fractions) in combination with capecitabine (1,000 mg/m2, twice daily, on days 1–14 and 22–35) and oxaliplatin (130 mg/m2 on days 1 and 22). Overall survival (OS) rate, disease-free survival (DFS) rate and cumulative incidence of recurrences and long-term complications were calculated or observed. As a result, 41 patients underwent surgery after preoperative CRT, and the cumulative OS rates at 1, 3 and 5 years for these patients were 100.0, 84.5 and 81.8%, respectively. For the 38 patients who received R0 resection, the cumulative OS rates at 1, 3 and 5 years were 100.0, 89.0 and 86.2%, respectively, while the cumulative DFS rates at 1, 3 and 5 years were 94.6, 75.3 and 69.7%, respectively. After follow-up at 84 months, the cumulative incidence rates of local and distant recurrences at 5 years were 6.6 and 28.2%, respectively. Oxaliplatin-associated long-term complications were seldom observed. Overall, the addition of oxaliplatin to capecitabine-based preoperative radiotherapy achieved favorable OS and DFS without increased long-term complications in patients with LARC. Therefore, this preoperative CRT strategy is a feasible option for such patients.
Collapse
Affiliation(s)
- Jianhong Peng
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, Guangdong 510060, P.R. China
| | - Junzhong Lin
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, Guangdong 510060, P.R. China
| | - Zhifan Zeng
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, Guangdong 510060, P.R. China
| | - Xiaojun Wu
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, Guangdong 510060, P.R. China
| | - Gong Chen
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, Guangdong 510060, P.R. China
| | - Liren Li
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, Guangdong 510060, P.R. China
| | - Zhenhai Lu
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, Guangdong 510060, P.R. China
| | - Peirong Ding
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, Guangdong 510060, P.R. China
| | - Desen Wan
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, Guangdong 510060, P.R. China
| | - Zhizhong Pan
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, Guangdong 510060, P.R. China
| |
Collapse
|
10
|
Capecitabine and Oxaliplatin Prior and Concurrent to Preoperative Pelvic Radiotherapy in Patients With Locally Advanced Rectal Cancer: Long-Term Outcome. Clin Colorectal Cancer 2017; 16:240-245. [DOI: 10.1016/j.clcc.2016.07.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 07/20/2016] [Indexed: 02/04/2023]
|
11
|
Chen M, Song X, Chen LZ, Xu L, Lu YP, Zhang JS. Adjuvant Second-Dose Chemotherapy before Surgery for Patients with Locally Advanced Rectal Malignancy Is Not Beneficial: A Systematic Review and Meta-Analysis. Gastroenterol Res Pract 2017; 2017:1373092. [PMID: 28835750 PMCID: PMC5556998 DOI: 10.1155/2017/1373092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Revised: 06/26/2017] [Accepted: 07/04/2017] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Preoperative chemoradiotherapy is the standard treatment for patients with locally advanced rectal cancer, although tumor responses vary widely; some patients may achieve a pathologic complete response rate (pCR) after chemoradiotherapy. Controversy exists with regard to the efficacy of different preoperative combination chemotherapy regimens and neoadjuvant chemoradiotherapy, compared with chemoradiotherapy alone. METHODS PubMed, the Cochrane Library, and Embase databases were searched for comparative studies of patients with locally advanced rectal cancer that were published between January 1991 and January 2016. Efficacies of different preoperative combination chemotherapy regimens and neoadjuvant chemoradiotherapy (group A) were compared with chemoradiotherapy alone (group B) in a meta-analysis using Review Manager v5.2. RESULTS Three prospective randomized controlled trials and two prospective nonrandomized controlled trials comprising 444 cases were eligible for analysis. No significant difference was detected in the rate of pCR (50/223, 22.4% versus 35/223, 15.7%; relative risk, RR: 1.42 [95% confidence interval, CI: 0.97-2.09], p = 0.07) between the two groups. The rate of tumor regression was similar for both groups (122/203, 60.1% versus 111/203, 54.7%; RR: 1.11 [95% CI: 0.94-1.29], p = 0.22). CONCLUSIONS Adjuvant chemotherapy with preoperative chemoradiotherapy did not significantly improve the rate of pCR nor the rate of T and N downstaging.
Collapse
Affiliation(s)
- Min Chen
- Department of General Surgery, Xiamen Traditional Chinese Medicine (TCM) Hospital Affiliated to Fujian University of TCM, Xiamen 361009, China
| | - Xue Song
- Department of General Surgery, Xiamen Traditional Chinese Medicine (TCM) Hospital Affiliated to Fujian University of TCM, Xiamen 361009, China
| | - Liang-zhou Chen
- Department of General Surgery, Xiamen Traditional Chinese Medicine (TCM) Hospital Affiliated to Fujian University of TCM, Xiamen 361009, China
| | - Lin Xu
- Department of General Surgery, Xiamen Traditional Chinese Medicine (TCM) Hospital Affiliated to Fujian University of TCM, Xiamen 361009, China
| | - Yi-pu Lu
- Department of General Surgery, Xiamen Traditional Chinese Medicine (TCM) Hospital Affiliated to Fujian University of TCM, Xiamen 361009, China
| | - Jin-song Zhang
- Department of General Surgery, Xiamen Traditional Chinese Medicine (TCM) Hospital Affiliated to Fujian University of TCM, Xiamen 361009, China
| |
Collapse
|
12
|
Haddad P, Miraie M, Farhan F, Fazeli MS, Alikhassi A, Maddah-Safaei A, Aghili M, Kalaghchi B, Babaei M. Addition of oxaliplatin to neoadjuvant radiochemotherapy in MRI-defined T3, T4 or N+ rectal cancer: a randomized clinical trial. Asia Pac J Clin Oncol 2017; 13:416-422. [DOI: 10.1111/ajco.12675] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 01/15/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Peiman Haddad
- Radiation Oncology Research Centre; Cancer Institute; Tehran University of Medical Sciences; Tehran Iran
| | - Monir Miraie
- Cancer Research Centre & Radiation Oncology Department; Cancer Institute; Tehran University of Medical Sciences; Tehran Iran
| | - Farshid Farhan
- Cancer Research Centre & Radiation Oncology Department; Cancer Institute; Tehran University of Medical Sciences; Tehran Iran
| | - Mohammad-Sadegh Fazeli
- Colorectal Surgery Department; Imam-Khomeini Hospital; Tehran University of Medical Sciences; Tehran Iran
| | - Afsaneh Alikhassi
- Radiology Department; Cancer Institute; Tehran University of Medical Sciences; Tehran Iran
| | - Afsaneh Maddah-Safaei
- Radiation Oncology Department; Cancer Institute; Tehran University of Medical Sciences; Tehran Iran
| | - Mahdi Aghili
- Radiation Oncology Research Centre & Radiation Oncology Department; Cancer Institute; Tehran University of Medical Sciences; Tehran Iran
| | - Bita Kalaghchi
- Radiation Oncology Department; Cancer Institute; Tehran University of Medical Sciences; Tehran Iran
| | - Mohammad Babaei
- Radiation Oncology Department; Cancer Institute; Tehran University of Medical Sciences; Tehran Iran
| |
Collapse
|
13
|
Sorensen JC, Petersen AC, Timpani CA, Campelj DG, Cook J, Trewin AJ, Stojanovska V, Stewart M, Hayes A, Rybalka E. BGP-15 Protects against Oxaliplatin-Induced Skeletal Myopathy and Mitochondrial Reactive Oxygen Species Production in Mice. Front Pharmacol 2017; 8:137. [PMID: 28443020 PMCID: PMC5385327 DOI: 10.3389/fphar.2017.00137] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 03/06/2017] [Indexed: 12/22/2022] Open
Abstract
Chemotherapy is a leading intervention against cancer. Albeit highly effective, chemotherapy has a multitude of deleterious side-effects including skeletal muscle wasting and fatigue, which considerably reduces patient quality of life and survivability. As such, a defense against chemotherapy-induced skeletal muscle dysfunction is required. Here we investigate the effects of oxaliplatin (OXA) treatment in mice on the skeletal muscle and mitochondria, and the capacity for the Poly ADP-ribose polymerase (PARP) inhibitor, BGP-15, to ameliorate any pathological side-effects induced by OXA. To do so, we investigated the effects of 2 weeks of OXA (3 mg/kg) treatment with and without BGP-15 (15 mg/kg). OXA induced a 15% (p < 0.05) reduction in lean tissue mass without significant changes in food consumption or energy expenditure. OXA treatment also altered the muscle architecture, increasing collagen deposition, neutral lipid and Ca2+ accumulation; all of which were ameliorated with BGP-15 adjunct therapy. Here, we are the first to show that OXA penetrates the mitochondria, and, as a possible consequence of this, increases mtROS production. These data correspond with reduced diameter of isolated FDB fibers and shift in the fiber size distribution frequency of TA to the left. There was a tendency for reduction in intramuscular protein content, albeit apparently not via Murf1 (atrophy)- or p62 (autophagy)- dependent pathways. BGP-15 adjunct therapy protected against increased ROS production and improved mitochondrial viability 4-fold and preserved fiber diameter and number. Our study highlights BGP-15 as a potential adjunct therapy to address chemotherapy-induced skeletal muscle and mitochondrial pathology.
Collapse
Affiliation(s)
- James C Sorensen
- Centre for Chronic Disease, College of Health & Biomedicine, Victoria UniversityMelbourne, VIC, Australia.,Australian Institute for Musculoskeletal ScienceMelbourne, VIC, Australia
| | - Aaron C Petersen
- Institute of Sport, Exercise & Active Living, Victoria UniversityMelbourne, VIC, Australia
| | - Cara A Timpani
- Centre for Chronic Disease, College of Health & Biomedicine, Victoria UniversityMelbourne, VIC, Australia.,Australian Institute for Musculoskeletal ScienceMelbourne, VIC, Australia
| | - Dean G Campelj
- Centre for Chronic Disease, College of Health & Biomedicine, Victoria UniversityMelbourne, VIC, Australia.,Australian Institute for Musculoskeletal ScienceMelbourne, VIC, Australia
| | - Jordan Cook
- Centre for Chronic Disease, College of Health & Biomedicine, Victoria UniversityMelbourne, VIC, Australia
| | - Adam J Trewin
- Institute of Sport, Exercise & Active Living, Victoria UniversityMelbourne, VIC, Australia
| | - Vanesa Stojanovska
- Centre for Chronic Disease, College of Health & Biomedicine, Victoria UniversityMelbourne, VIC, Australia
| | - Mathew Stewart
- Institute of Sustainability and Innovation, Victoria UniversityMelbourne, VIC, Australia
| | - Alan Hayes
- Centre for Chronic Disease, College of Health & Biomedicine, Victoria UniversityMelbourne, VIC, Australia.,Australian Institute for Musculoskeletal ScienceMelbourne, VIC, Australia.,Institute of Sport, Exercise & Active Living, Victoria UniversityMelbourne, VIC, Australia
| | - Emma Rybalka
- Centre for Chronic Disease, College of Health & Biomedicine, Victoria UniversityMelbourne, VIC, Australia.,Australian Institute for Musculoskeletal ScienceMelbourne, VIC, Australia.,Institute of Sport, Exercise & Active Living, Victoria UniversityMelbourne, VIC, Australia
| |
Collapse
|
14
|
Pangeni R, Choi SW, Jeon OC, Byun Y, Park JW. Multiple nanoemulsion system for an oral combinational delivery of oxaliplatin and 5-fluorouracil: preparation and in vivo evaluation. Int J Nanomedicine 2016; 11:6379-6399. [PMID: 27942212 PMCID: PMC5138023 DOI: 10.2147/ijn.s121114] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Oxaliplatin (OXA) is a third-generation cisplatin analog that has been approved as first-line chemotherapy in combination with 5-fluorouracil (5-FU) for the treatment of resectable and advanced colorectal cancer. However, the therapeutic efficacy of oral OXA and 5-FU is limited by their low bioavailability due to poor membrane permeability. The aim of the present study was to develop an oral delivery system for OXA and 5-FU. We constructed an ion-pairing complex of OXA with a deoxycholic acid derivative (Nα-deoxycholyl-l-lysyl-methylester, DCK) (OXA/DCK) as a permeation enhancer. Next, we prepared multiple water-in-oil-in-water nanoemulsions incorporating OXA/DCK and 5-FU to enhance their oral absorption. To evaluate their membrane permeability, we assessed in vitro permeabilities of OXA/DCK and 5-FU through an artificial intestinal membrane and Caco-2 cell monolayer. Finally, oral bioavailability in rats and tumor growth inhibition in the colorectal adenocarcinoma cell (CT26)-bearing mouse model were investigated after oral administration of nanoemulsion containing OXA/DCK and 5-FU. The droplet size of the optimized nanoemulsion was 20.3±0.22 nm with a zeta potential of −4.65±1.68 mV. In vitro permeabilities of OXA/DCK and 5-FU from the nanoemulsion through a Caco-2 cell monolayer were 4.80- and 4.30-fold greater than those of OXA and 5-FU, respectively. The oral absorption of OXA/DCK and 5-FU from the nanoemulsion also increased significantly, and the resulting oral bioavailability values of OXA/DCK and 5-FU in the nanoemulsive system were 9.19- and 1.39-fold higher than those of free OXA and 5-FU, respectively. Furthermore, tumor growth in CT26 tumor-bearing mice given the oral OXA/DCK- and 5-FU-loaded nanoemulsion was maximally inhibited by 73.9%, 48.5%, and 38.1%, compared with tumor volumes in the control group and the oral OXA and 5-FU groups, respectively. These findings demonstrate the therapeutic potential of a nanoemulsion incorporating OXA/DCK and 5-FU as an oral combination therapy for colorectal cancer.
Collapse
Affiliation(s)
- Rudra Pangeni
- Department of Pharmacy, College of Pharmacy and Natural Medicine Research Institute, Mokpo National University, Muan-gun
| | - Sang Won Choi
- Department of Pharmacy, College of Pharmacy and Natural Medicine Research Institute, Mokpo National University, Muan-gun
| | - Ok-Cheol Jeon
- Pharosgen R&D Center, Asan Institute for Life Sciences
| | - Youngro Byun
- Department of Molecular Medicine and Biopharmaceutical Science, Graduate School of Convergence Science and Technology, College of Pharmacy, Seoul National University, Seoul, Republic of Korea
| | - Jin Woo Park
- Department of Pharmacy, College of Pharmacy and Natural Medicine Research Institute, Mokpo National University, Muan-gun
| |
Collapse
|
15
|
Peng J, Lin J, Qiu M, Wu X, Lu Z, Chen G, Li L, Ding P, Gao Y, Zeng Z, Zhang H, Wan D, Pan Z. Clinical factors of post-chemoradiotherapy as valuable indicators for pathological complete response in locally advanced rectal cancer. Clinics (Sao Paulo) 2016; 71:449-54. [PMID: 27626475 PMCID: PMC4975783 DOI: 10.6061/clinics/2016(08)07] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 04/26/2016] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES Pathological complete response has shown a better prognosis for patients with locally advanced rectal cancer after preoperative chemoradiotherapy. However, correlations between post-chemoradiotherapy clinical factors and pathologic complete response are not well confirmed. The aim of the current study was to identify post-chemoradiotherapy clinical factors that could serve as indicators of pathologic complete response in locally advanced rectal cancer. METHODS This study retrospectively analyzed 544 consecutive patients with locally advanced rectal cancer treated at Sun Yat-sen University Cancer Center from December 2003 to June 2014. All patients received preoperative chemoradiotherapy followed by surgery. Univariate and multivariate regression analyses were performed to identify post-chemoradiotherapy clinical factors that are significant indicators of pathologic complete response. RESULTS In this study, 126 of 544 patients (23.2%) achieved pathological complete response. In multivariate analyses, increased pathological complete response rate was significantly associated with the following factors: post-chemoradiotherapy clinical T stage 0-2 (odds ratio=2.098, 95% confidence interval=1.023-4.304, p=0.043), post-chemoradiotherapy clinical N stage 0 (odds ratio=2.011, 95% confidence interval=1.264-3.201, p=0.003), interval from completion of preoperative chemoradiotherapy to surgery of >7 weeks (odds ratio=1.795, 95% confidence interval=1.151-2.801, p=0.010) and post-chemoradiotherapy carcinoembryonic antigen ≤2 ng/ml (odds ratio=1.579, 95% confidence interval=1.026-2.432, p=0.038). CONCLUSIONS Post-chemoradiotherapy clinical T stage 0-2, post-chemoradiotherapy clinical N stage 0, interval from completion of chemoradiotherapy to surgery of >7 weeks and post-chemoradiotherapy carcinoembryonic antigen ≤2 ng/ml were independent clinical indicators for pathological complete response. These findings demonstrate that post-chemoradiotherapy clinical factors could be valuable for post-operative assessment of pathological complete response.
Collapse
Affiliation(s)
- Jianhong Peng
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Department of Colorectal Surgery
- #contributed equally to this work
| | - Junzhong Lin
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Department of Colorectal Surgery
- #contributed equally to this work
| | - Miaozhen Qiu
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Department of Medical Oncology
| | - Xiaojun Wu
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Department of Colorectal Surgery
| | - Zhenhai Lu
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Department of Colorectal Surgery
| | - Gong Chen
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Department of Colorectal Surgery
| | - Liren Li
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Department of Colorectal Surgery
| | - Peirong Ding
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Department of Colorectal Surgery
| | - Yuanhong Gao
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Department of Radiation Onology
| | - Zhifan Zeng
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Department of Radiation Onology
| | - Huizhong Zhang
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Department of Pathology, Guangzhou, P.R. China
| | - Desen Wan
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Department of Colorectal Surgery
| | - Zhizhong Pan
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Department of Colorectal Surgery
- E-mail:
| |
Collapse
|
16
|
Resende HM, Jacob LFP, Quinellato LV, Matos D, da Silva EMK. Combination chemotherapy versus single-agent chemotherapy during preoperative chemoradiation for resectable rectal cancer. Cochrane Database Syst Rev 2015; 10:CD008531. [PMID: 35658163 PMCID: PMC8947000 DOI: 10.1002/14651858.cd008531.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Colorectal cancer represents 10% of all cancers and is the third most common cause of death in women and men. Almost two-thirds of all bowel cancers are cancers of the colon and over one-third (34%) are cancers of the rectum, including the anus. Surgery is the cornerstone for curative treatment of rectal cancer. Mesorectal excision decreases the rate of local recurrences; however, it does not improve the overall survival of people with locally advanced rectal cancer. There have been significant research efforts since the mid-1990s to optimise the treatment of rectal cancer. Based on the findings of clinical trials, people with T3/T4 or N+ rectal tumours are now being treated preoperatively with radiation and chemotherapy, mainly fluoropyrimidine. However, the incidence of distant metastases remains as high as 30%. Combination chemotherapy regimens, similar to those used in metastatic disease with the addition of oxaliplatin and irinotecan, have been tested to improve the prognosis of people with rectal cancer. OBJECTIVES To compare outcomes (including overall survival, disease-free survival and toxicity) between two 5-fluorouracil-containing chemotherapy regimens in people with stage II and III rectal cancer who are receiving preoperative chemoradiation. SEARCH METHODS We searched the Cochrane Colorectal Cancer Group Specialised Register (January 2015), the Cochrane Central Register of Controlled Trials (2015, Issue 1), Ovid MEDLINE (1950 to January 2015), Ovid EMBASE (1974 to January 2015) and LILACS (1982 to January 2015). We reviewed the reference lists of included studies, checked clinical trials registers and handsearched relevant journal proceedings. We applied no language or publication restrictions. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing single-agent chemotherapy (fluoropyrimidine) versus combination chemotherapy (fluoropyrimidine plus another agent including, but not limited to, oxaliplatin) during preoperative radiochemotherapy in people with resectable rectal cancer. DATA COLLECTION AND ANALYSIS Two review authors (HMR, EMKS) independently extracted data and assessed trial quality. When necessary, we requested additional information and clarification of published data from the authors of individual trials. MAIN RESULTS We included four RCTs involving 3875 people with resectable rectal cancer. In the preoperative period, the participants of these studies were randomised to receive chemoradiation either with a single fluoropyrimidine agent (capecitabine or 5-fluorouracil) or with a combination of drugs (fluoropyrimidine plus oxaliplatin). The only study that reported overall survival and disease-free survival found no significant differences between the intervention and control groups; we considered this evidence very low quality. For pathological complete response after preoperative treatment (ypCR) there was high quality evidence favouring the intervention group (odds ratio (OR) 1.23, 95% confidence interval (CI) 1.04 to 1.46), but there was also moderate quality evidence suggesting a higher risk for early toxicity in the intervention group (OR 2.07, 95% CI 1.31 to 3.27). Moderate to high quality evidence suggested that the control group had better compliance to radiotherapy (OR 0.32, 95% CI 0.14 to 0.75). There were no significant differences between groups in postoperative mortality within 60 days, postoperative morbidity, resection margins, abdominoperineal resection and Hartmann procedures. AUTHORS' CONCLUSIONS There was very low quality evidence that people with resectable rectal cancer who receive combination preoperative chemotherapy have no improvements in overall survival or disease-free survival. There was high quality evidence that suggested that combination chemotherapy with oxaliplatin may improve local tumour control in people with resectable rectal cancer, but this regimen also caused more toxicity. The review included four RCTs but only one reported survival; therefore, we cannot make robust conclusions or useful clinical recommendations. The publication of more survival data from these studies will contribute to future analyses.
Collapse
Affiliation(s)
- Heloisa M Resende
- Escola Paulista de Medicina, Universidade Federal de São PauloPost‐Graduation Program Emergency Medicine and Evidence Based Medicine of the Federal University of São Paulo (UNIFESP)Rua Borges Lagoa 564 cj 64Vl. ClementinoSão PauloBrazil04038‐000
| | | | | | - Delcio Matos
- Escola Paulista de Medicina, Universidade Federal de São PauloDepartment of Gastroenterological SurgeryRua Edison 278, Apto 61Campo BeloSão PauloSão PauloBrazil04618‐031
| | - Edina MK da Silva
- Universidade Federal de São PauloEmergency Medicine and Evidence Based MedicineRua Borges Lagoa 564 cj 64Vl. ClementinoSão PauloSão PauloBrazil04038‐000
| | | |
Collapse
|
17
|
Fedeli U, Zorzi M, Urso ED, Gennaro N, Dei Tos AP, Saugo M. Impact of fecal immunochemical test-based screening programs on proximal and distal colorectal cancer surgery rates: A natural multiple-baseline experiment. Cancer 2015; 121:3982-9. [DOI: 10.1002/cncr.29623] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 06/15/2015] [Accepted: 07/20/2015] [Indexed: 01/27/2023]
Affiliation(s)
- Ugo Fedeli
- Regional Epidemiological Department; Veneto Region Padua Italy
| | - Manuel Zorzi
- Veneto Tumour Registry; Veneto Region Padua Italy
| | - Emanuele D.L. Urso
- First Surgical Department; University of Padua Medical Center; Padua Italy
| | - Nicola Gennaro
- Regional Epidemiological Department; Veneto Region Padua Italy
| | - Angelo P. Dei Tos
- Veneto Tumour Registry; Veneto Region Padua Italy
- Department of Pathology; Treviso General Hospital; Treviso Italy
| | - Mario Saugo
- Regional Epidemiological Department; Veneto Region Padua Italy
| |
Collapse
|
18
|
Fan WH, Wang FL, Lu ZH, Pan ZZ, Li LR, Gao YH, Chen G, Wu XJ, Ding PR, Zeng ZF, Wan DS. Surgery with versus without preoperative concurrent chemoradiotherapy for mid/low rectal cancer: an interim analysis of a prospective, randomized trial. CHINESE JOURNAL OF CANCER 2015; 34:394-403. [PMID: 26111932 PMCID: PMC4593338 DOI: 10.1186/s40880-015-0024-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 04/02/2015] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Multimodality therapy, including preoperative chemoradiotherapy (CRT) and total mesorectal excision (TME), has effectively reduced local recurrence rates of rectal cancer over the past decade. However, the benefits and risks of the addition of neoadjuvant CRT to surgery need to be evaluated. This study was to compare the efficacy of TME with versus without preoperative concurrent chemoradiotherapy (CCRT) involving XELOX regimen (oxaliplatin plus capecitabine) in Chinese patients with stages II and III mid/low rectal adenocarcinoma. METHODS We randomly assigned patients to the TME group (TME without preoperative CCRT) or CCRT + TME group (TME with preoperative CCRT). The primary endpoint was disease-free survival (DFS); the secondary endpoints were overall survival (OS), local and distant recurrence, tumor response to CRT, toxicity, sphincter preservation, and surgical complications. An interim analysis of the potential inferiority of DFS in the CCRT + TME group was planned when the first 180 patients had been followed up for at least 6 months. RESULTS A total of 94 patients in the TME group and 90 patients in the CCRT + TME group were able to be evaluated. The 3-year DFS and OS rates were 86.3 % and 91.5 % in the whole cohort, respectively. The 3-year DFS rates of the TME and CCRT + TME groups were 85.7% and 87.9 % (P = 0.766), respectively, and the 3-year OS rates were 90.7 % and 92.3 % (P = 0.855), respectively. The functional sphincter preservation rates of the TME and CCRT + TME groups were 71.3 % and 70.0 % (P = 0.849), respectively. In the TME group, 16 (17.0 %) patients were proven to have pTNM stage I disease after surgery. In the CCRT + TME group, 32 (35.6 %) patients achieved a pathologic complete response (pCR). CONCLUSIONS Preliminary results indicated no significant differences in the DFS, OS, or functional sphincter preservation rates between the TME and CCRT + TME groups. However, preoperative CCRT with XELOX yielded a high pCR rate. Newer techniques are needed to improve the staging accuracy, and further investigation is warranted. CLINICAL TRIAL REGISTRATION NUMBER Chi CTR-TRC-08000122.
Collapse
Affiliation(s)
- Wen-Hua Fan
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, P. R. China. .,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, P. R. China.
| | - Fu-Long Wang
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, P. R. China. .,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, P. R. China.
| | - Zhen-Hai Lu
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, P. R. China. .,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, P. R. China.
| | - Zhi-Zhong Pan
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, P. R. China. .,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, P. R. China.
| | - Li-Ren Li
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, P. R. China. .,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, P. R. China.
| | - Yuan-Hong Gao
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, P. R. China. .,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, P. R. China.
| | - Gong Chen
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, P. R. China. .,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, P. R. China.
| | - Xiao-Jun Wu
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, P. R. China. .,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, P. R. China.
| | - Pei-Rong Ding
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, P. R. China. .,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, P. R. China.
| | - Zhi-Fan Zeng
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, P. R. China. .,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, P. R. China.
| | - De-Sen Wan
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, P. R. China. .,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, P. R. China.
| |
Collapse
|
19
|
AlGizawy SM, Essa HH, Ahmed BM. Chemotherapy Alone for Patients With Stage II/III Rectal Cancer Undergoing Radical Surgery. Oncologist 2015; 20:752-7. [PMID: 26040621 DOI: 10.1634/theoncologist.2015-0038] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 03/23/2015] [Indexed: 01/01/2023] Open
Abstract
PURPOSE The purpose of this prospective pilot study was to determine the efficacy of preoperative chemotherapy with six cycles of FOLFOX 6 (without radiation therapy) followed by radical surgery followed by six additional cycles of FOLFOX 6 for patients with stage II/III rectal cancer. PATIENTS AND METHODS From January 2010 to January 2014, patients with locally advanced rectal cancer who met the eligibility criteria were enrolled in this study. Patients received FOLFOX 6 chemotherapy comprising oxaliplatin and leucovorin calcium i.v. over 2 hours on day 1, then bolus, and then continuous fluorouracil i.v. over 46 hours on days 1 and 2. Treatment was repeated every 14 days for 6 courses followed by radical surgery followed by additional 6 cycles of FOLFOX 6. RESULTS In total, 45 patients were enrolled in this study. In the preoperative re-evaluation, the overall response rate was 68.8% (clinical complete response was 4.4%, and the partial response was 64.4%). There were 14 cases (31.2%) of stable disease. No patients had progressive disease. Postoperatively, the pathologic complete response rate was 8 of 45 (17.8%; 95% confidence interval [CI]: 8.9%-28.9%). The median follow-up was 29 months (range 9-54 months). The actuarial 3-year overall survival and disease-free survival rates for all patients were 80.8% (standard error, 1.877; 95% CI: 69.3%-92.3%) and 67.9% (standard error, 2.319; 95% CI: 54.3%-81.5%), respectively. CONCLUSION Neoadjuvant chemotherapy (FOLFOX) without radiotherapy is active and safe but cannot be considered a standard of care until the results of prospective randomized phase III trials are available. IMPLICATIONS FOR PRACTICE Neoadjuvant radiotherapy of rectal cancer represents the current standard of care. However, its use is also associated with short-term toxicity and long-term morbidity. With the increasing use of total mesorectal resection resulting in better local control and advances in systemic therapy for colorectal cancer, this study highlights the question of whether radiation is a necessary component of neoadjuvant therapy for all patients with rectal cancer or whether select patients could be spared the additional toxicities and inconvenience of radiotherapy. This study suggests that neoadjuvant FOLFOX without radiotherapy is active and safe, but it could not be considered a standard of care till now.
Collapse
Affiliation(s)
- Samy M AlGizawy
- Department of Clinical Oncology, Faculty of Medicine, and Department of Surgical Oncology, South Egypt Cancer Institute, Assiut University, Assiut, Egypt
| | - Hoda H Essa
- Department of Clinical Oncology, Faculty of Medicine, and Department of Surgical Oncology, South Egypt Cancer Institute, Assiut University, Assiut, Egypt
| | - Badawy M Ahmed
- Department of Clinical Oncology, Faculty of Medicine, and Department of Surgical Oncology, South Egypt Cancer Institute, Assiut University, Assiut, Egypt
| |
Collapse
|
20
|
Jin T, Zhu Y, Luo JL, Zhou N, Li DC, Ju HX, Fan YT, Liu Y, Zhu YP, Feng HY, Liu LY. Prospective phase II trial of nimotuzumab in combination with radiotherapy and concurrent capecitabine in locally advanced rectal cancer. Int J Colorectal Dis 2015; 30:337-45. [PMID: 25564344 DOI: 10.1007/s00384-014-2097-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/11/2014] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim of the study was to evaluate the safety and efficacy of adding concurrent nimotuzumab to preoperative radiotherapy with concurrent capecitabine in locally advanced rectal cancer. METHODS AND MATERIALS Patients with rectal cancer (clinical stage T3/4 or N+) were scheduled to receive weekly nimotuzumab (400 mg; days -6, 1, 8, 15, 22, and 29). Capecitabine (825 mg/m(2)) was delivered orally twice daily for the duration of radiotherapy. Radiotherapy was administered at 50.4 Gy (45 + 5.4 Gy). The main endpoint was the pathologic complete response (pCR) rate. RESULTS Twenty-one patients with T3 or T4 disease were enrolled; 66.7 % were nodal-positive; the median distance from the anal verge was 5.5 cm. A pCR was achieved in four patients (19.0 %); 71.4 % patients obtained moderate or good tumor regression (Grade 2 and 3). Downstaging occurred in 15/21 (71.4 %) patients by T stage and 11/14 (78.6 %) by N stage. The actual dose intensities (median/mean, %) were nimotuzumab (100, 100) and capecitabine (100, 99.5). The most frequent Grade 1/2 toxicities were radiation dermatitis (57.1 %), nausea/vomiting (52.4 %), leukocytopenia (47.6 %), diarrhea (47.6 %), and proctitis (38.1 %). Grade 3 diarrhea was observed in 9.5 % of patients and Grade 3 leukocytopenia in 4.8 %. CONCLUSION These preliminary results indicate that nimotuzumab can be safely combined with radiotherapy plus concurrent capecitabine. The efficacy of this regimen (pCR = 19.0 %) was significantly higher than that observed in previous phase II trials of preoperative radiotherapy with concurrent capecitabine and cetuximab in rectal cancer. Further investigation of concurrent nimotuzumab with radiotherapy plus capecitabine is warranted.
Collapse
Affiliation(s)
- Ting Jin
- Department of Radiation Oncology, Zhejiang Cancer Hospital, 38 Guang Ji Road, Hangzhou, 310022, Zhejiang, People's Republic of China
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
|
22
|
Jones RG, Tan D. How can we determine the best neoadjuvant chemoradiotherapy regimen for rectal cancer? COLORECTAL CANCER 2015. [DOI: 10.2217/crc.15.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
SUMMARY The current management of patients with clinically defined ‘locally advanced rectal cancer’ often involves fluoropyrimidine-based preoperative chemoradiotherapy (CRT) followed by total mesorectal excision. The focus remains primarily on reducing local recurrence, and improving survival, with organ preservation an increasing target. The best neoadjuvant CRT is the most effective regimen, balanced against the tolerability and late functional consequences, which should be selected for the individual according to their individual risk of local and distant recurrence. Hence, what makes the best neoadjuvant treatment depends on the activity and toxicity of the particular schedule, the aims of treatment, the individual disease characteristics and the individual patient pharmacogenomics. Current research efforts focus on enhancing the efficacy of CRT by integrating additional cytotoxics and biologically targeted agents.
Collapse
Affiliation(s)
- Rob Glynne Jones
- Consultant Radiation Oncologist, Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, Middlesex, HA6 2RN, UK
| | - David Tan
- Radiation Oncologist, FRCR, Consultant Radiation Oncologist, National Cancer Centre, Singapore
| |
Collapse
|
23
|
Gibbs P, Gebski V, Van Buskirk M, Thurston K, Cade DN, Van Hazel GA. Selective Internal Radiation Therapy (SIRT) with yttrium-90 resin microspheres plus standard systemic chemotherapy regimen of FOLFOX versus FOLFOX alone as first-line treatment of non-resectable liver metastases from colorectal cancer: the SIRFLOX study. BMC Cancer 2014; 14:897. [PMID: 25487708 PMCID: PMC4289171 DOI: 10.1186/1471-2407-14-897] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 12/01/2014] [Indexed: 12/29/2022] Open
Abstract
Background In colorectal cancer (CRC), unresectable liver metastases are linked to poor prognosis. Systemic chemotherapy with regimens such as FOLFOX (combination of infusional 5-fluorouracil, leucovorin and oxaliplatin) is the standard first-line treatment. The SIRFLOX trial was designed to assess the efficacy and safety of combining FOLFOX-based chemotherapy with Selective Internal Radiation Therapy (SIRT or radioembolisation) using yttrium-90 resin microspheres (SIR-Spheres®; Sirtex Medical Limited, North Sydney, Australia). Methods/Design SIRFLOX is a randomised, multicentre trial of mFOLFOX6 chemotherapy ± SIRT as first-line treatment of patients with liver-only or liver-predominant metastatic CRC (mCRC). The trial aims to recruit adult chemotherapy-naïve patients with proven liver metastases with or without limited extra-hepatic disease, a life expectancy of ≥3 months and a WHO performance status of 0–1. Patients will be randomised to receive either mFOLFOX6 or SIRT + mFOLFOX6 (with a reduced dose of oxaliplatin in cycles 1–3 following SIRT). Patients in both arms can receive bevacizumab at investigator discretion. Protocol chemotherapy will continue until there is unacceptable toxicity, evidence of tumour progression, complete surgical resection or ablation of cancerous lesions, or the patient requests an end to treatment. The primary endpoint of the SIRFLOX trial is progression-free survival (PFS). Secondary endpoints include: PFS in the liver; tumour response rate (liver and any site); site of tumour progression; health-related quality of life; toxicity and safety; liver resection rate; and overall survival. Assuming an increase in the median PFS from 9.4 months to 12.5 months with the addition of SIRT to mFOLFOX6, recruiting ≥450 patients will be sufficient for 80% power and 95% confidence. Discussion The SIRFLOX trial will establish the potential role of SIRT + standard systemic chemotherapy in the first-line management of mCRC with non-resectable liver metastases. Trial registration SIRFLOX ClinicalTrials.gov identifier: NCT00724503. Registered 25 July 2008. Electronic supplementary material The online version of this article (doi:10.1186/1471-2407-14-897) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Peter Gibbs
- Royal Melbourne Hospital, Melbourne, Victoria, Australia.
| | | | | | | | | | | | | |
Collapse
|
24
|
Wong SJ, Moughan J, Meropol NJ, Anne PR, Kachnic LA, Rashid A, Watson JC, Mitchell EP, Pollock J, Lee RJ, Haddock M, Erickson BA, Willett CG. Efficacy endpoints of radiation therapy group protocol 0247: a randomized, phase 2 study of neoadjuvant radiation therapy plus concurrent capecitabine and irinotecan or capecitabine and oxaliplatin for patients with locally advanced rectal cancer. Int J Radiat Oncol Biol Phys 2014; 91:116-23. [PMID: 25446610 DOI: 10.1016/j.ijrobp.2014.09.031] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Revised: 09/01/2014] [Accepted: 09/23/2014] [Indexed: 01/25/2023]
Abstract
PURPOSE To report secondary efficacy endpoints of Radiation Therapy Oncology Group protocol 0247, primary endpoint analysis of which demonstrated that preoperative radiation therapy (RT) with capecitabine plus oxaliplatin achieved a pathologic complete remission prespecified threshold (21%) to merit further study, whereas RT with capecitabine plus irinotecan did not (10%). METHODS AND MATERIALS A randomized, phase 2 trial evaluated preoperative RT (50.4 Gy in 1.8-Gy fractions) with 2 concurrent chemotherapy regimens: (1) capecitabine (1200 mg/m(2)/d Monday-Friday) plus irinotecan (50 mg/m(2)/wk × 4); and (2) capecitabine (1650 mg/m(2)/d Monday-Friday) plus oxaliplatin (50 mg/m(2)/wk × 5) for clinical T3 or T4 rectal cancer. Surgery was performed 4 to 8 weeks after chemoradiation, then 4 to 6 weeks later, adjuvant chemotherapy (oxaliplatin 85 mg/m(2); leucovorin 400 mg/m(2); 5-fluorouracil 400 mg/m(2); 5-fluorouracil 2400 mg/m(2)) every 2 weeks × 9. Disease-free survival (DFS) and overall survival (OS) were estimated univariately by the Kaplan-Meier method. Local-regional failure (LRF), distant failure (DF), and second primary failure (SP) were estimated by the cumulative incidence method. No statistical comparisons were made between arms because each was evaluated individually. RESULTS A total of 104 patients (median age, 57 years) were treated; characteristics were similar for both arms. Median follow-up for RT with capecitabine/irinotecan arm was 3.77 years and for RT with capecitabine/oxaliplatin arm was 3.97 years. Four-year DFS, OS, LRF, DF, and SP estimates for capecitabine/irinotecan arm were 68%, 85%, 16%, 24%, and 2%, respectively. The 4-year DFS, OS, LRF, DF, and SP failure estimates for capecitabine/oxaliplatin arm were 62%, 75%, 18%, 30%, and 6%, respectively. CONCLUSIONS Efficacy results for both arms are similar to other reported studies but suggest that pathologic complete remission is an unsuitable surrogate for traditional survival metrics of clinical outcome. Although it remains uncertain whether the addition of a second cytotoxic agent enhances the effectiveness of fluorouracil plus RT, these results suggest that further study of irinotecan may be warranted.
Collapse
Affiliation(s)
| | - Jennifer Moughan
- Radiation Therapy Oncology Group Statistical Center, Philadelphia, Pennsylvania
| | - Neal J Meropol
- University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio.
| | - Pramila Rani Anne
- Department of Radiation Oncology and Medical Oncology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Lisa A Kachnic
- Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Asif Rashid
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - James C Watson
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Edith P Mitchell
- Department of Radiation Oncology and Medical Oncology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | | | | | - Michael Haddock
- Division of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Christopher G Willett
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| |
Collapse
|
25
|
Kim D. More Treatment is not Necessarily Better - Limited Options for Chemotherapeutic Radiosensitization. COLORECTAL CANCER 2014. [DOI: 10.1002/9781118337929.ch12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
26
|
Lu JY, Xiao Y, Qiu HZ, Wu B, Lin GL, Xu L, Zhang GN, Hu K. Clinical outcome of neoadjuvant chemoradiation therapy with oxaliplatin and capecitabine or 5-fluorouracil for locally advanced rectal cancer. J Surg Oncol 2013; 108:213-9. [PMID: 23913795 DOI: 10.1002/jso.23394] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Accepted: 07/12/2013] [Indexed: 02/06/2023]
Affiliation(s)
- Jun-Yang Lu
- Department of Surgery; Peking Union Medical College Hospital; Peking Union Medical College; Chinese Academy of Medical Sciences; Beijing China
| | - Yi Xiao
- Department of Surgery; Peking Union Medical College Hospital; Peking Union Medical College; Chinese Academy of Medical Sciences; Beijing China
| | - Hui-Zhong Qiu
- Department of Surgery; Peking Union Medical College Hospital; Peking Union Medical College; Chinese Academy of Medical Sciences; Beijing China
| | - Bin Wu
- Department of Surgery; Peking Union Medical College Hospital; Peking Union Medical College; Chinese Academy of Medical Sciences; Beijing China
| | - Guo-Le Lin
- Department of Surgery; Peking Union Medical College Hospital; Peking Union Medical College; Chinese Academy of Medical Sciences; Beijing China
| | - Lai Xu
- Department of Surgery; Peking Union Medical College Hospital; Peking Union Medical College; Chinese Academy of Medical Sciences; Beijing China
| | - Guan-Nan Zhang
- Department of Surgery; Peking Union Medical College Hospital; Peking Union Medical College; Chinese Academy of Medical Sciences; Beijing China
| | - Ke Hu
- Department of Radiation; Peking Union Medical College Hospital; Peking Union Medical College; Chinese Academy of Medical Sciences; Beijing China
| |
Collapse
|
27
|
Wolff HA, Conradi LC, Beissbarth T, Leha A, Hohenberger W, Merkel S, Fietkau R, Raab HR, Tschmelitsch J, Hess CF, Becker H, Wittekind C, Sauer R, Rödel C, Liersch T. Gender affects acute organ toxicity during radiochemotherapy for rectal cancer: long-term results of the German CAO/ARO/AIO-94 phase III trial. Radiother Oncol 2013; 108:48-54. [PMID: 23768685 DOI: 10.1016/j.radonc.2013.05.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Revised: 04/26/2013] [Accepted: 05/02/2013] [Indexed: 01/27/2023]
Abstract
INTRODUCTION The CAO/ARO/AIO-94 phase-III-trial demonstrated a significant improvement of preoperative chemoradiotherapy (CRT) versus postoperative CRT on local control for UICC stage II/III rectal cancer patients, but no effect on long-term survival. In this add-on evaluation, we investigated the association of gender and age with acute toxicity and outcome. PATIENTS AND METHODS According to actual treatment analyses, 654 of 799 patients had received pre- (n=406) or postoperative CRT (n=248); in 145 patients postoperative CRT was not applied. Gender, age and clinicopathological parameters were correlated with CRT-associated acute toxicity and survival. RESULTS The 10-year survival was higher in women than in men, with 72.4% versus 65.6% for time to recurrence (p=0.088) and 62.7% versus 58.4% for overall-survival (OS) (p=0.066), as expected. For patients receiving CRT, women showed higher hematologic (p<0.001) and acute organ toxicity (p<0.001) in the entire cohort as well as in subgroup analyses according to pre- (p=0.016) and postoperative CRT (p<0.001). Lowest OS was seen in patients without acute toxicity (p=0.0271). Multivariate analyses for OS showed that acute organ toxicity (p=0.034) was beneficial while age (p<0.001) was associated with worse OS. DISCUSSION Female gender is significantly associated with CRT-induced acute toxicity in rectal cancer. Acute toxicity during CRT may be associated with improved long-term outcome.
Collapse
|
28
|
Ricardi U, Racca P, Franco P, Munoz F, Fanchini L, Rondi N, Dongiovanni V, Gabriele P, Cassoni P, Ciuffreda L, Morino M, Filippi AR, Aglietta M, Bertetto O. Prospective phase II trial of neoadjuvant chemo-radiotherapy with Oxaliplatin and Capecitabine in locally advanced rectal cancer (XELOXART). Med Oncol 2013; 30:581. [PMID: 23606239 DOI: 10.1007/s12032-013-0581-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Accepted: 04/11/2013] [Indexed: 01/25/2023]
Abstract
Neo-adjuvant chemo-radiotherapy (CT-RT) has been shown to decrease local recurrence rate in locally advanced rectal cancer. This multicenter phase II trial was conducted to evaluate the feasibility, safety and effectiveness of a combination of pre-operative radiotherapy and concurrent Capecitabine plus Oxaliplatin (XELOXART Trial). From October 2008 to May 2011, fifty consecutive patients affected with T3/T4 and/or N+ rectal cancer were enrolled. Treatment protocol consisted of 50.4 Gy in 28 fractions, Oxaliplatin 60 mg/m(2) once a week for 6 weeks and oral Capecitabine 825 mg/m(2) twice daily from day 1 to 14 and from day 22 to 35. Surgery was planned 6-8 weeks after. Main endpoints were pathological complete response rate (pCR) and the type of surgery performed compared to the planned one at diagnosis. 50 patients were included; pCR (ypT0N0M0) was achieved in 6 patients (12 %). Tumour downstaging was observed in 27 patients (54 %), and nodal downstaging in 32 patients (64 %). A total of 32 patients had lower rectal cancer, with 24 candidate for abdominal-perineal resection. At the end of CT-RT, a total of 12/24 (50 %) underwent conservative surgery. Grade 3 toxicity (fatigue and diarrhoea) occurred in 4 % of patients; grade 4 sensory neuropathy occurred in 2 % of patients. Perioperative complications of any grade occurred in 10 % of patients. Pre-operative CT-RT with Capecitabine-Oxaliplatin was well tolerated and resulted in an encouraging sphincter preservation and tumour downstaging rate. No improvements in terms of pathological complete response rate were shown.
Collapse
Affiliation(s)
- Umberto Ricardi
- Department of Oncology, Radiation Oncology, University of Torino, via Genova 3, 10126 Turin, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Li YH, Li XF, Li JL, Zhu XG, Xu B, Cai Y. Therapeutic effect of postoperative radiotherapy in combination with oxaliplatin and 5-Fu in patients with stage Ⅱ/Ⅲ rectal cancer. Shijie Huaren Xiaohua Zazhi 2013; 21:729-733. [DOI: 10.11569/wcjd.v21.i8.729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the dose limited toxicity (DLT), maximal tolerated dose (MTD) and recommended dose (RD) of oxaliplatin weekly administered with 5FU/leucovorin in combination with concurrent postoperative radiotherapy in patients with stage Ⅱ/Ⅲ rectal cancer.
METHODS: Patients with stage Ⅱ/Ⅲ rectal cancer after radical excision were enrolled. A modified 3+3 dose-escalation design was used for evaluating 3 dose levels (40 mg/m2, 50 mg/m2 and 60 mg/m2) of oxaliplatin and fixed-dose 5-FU/leucovorin given once weekly, with 50 Gy XRT delivered in 25 fractions of 2 Gy, five times per week over 5 weeks. Patients received oxaliplatin at the assigned dose level, and 5-FU and leucovorin doses were fixed at 600 mg/m2 and 200 mg/m2 for all cohorts, respectively. Dose-limiting toxicity (DLT) was defined as any grade 4 hematologic toxicity (including grade 3 thrombocytopenia) or grade 3 non-hematologic toxicity (except for alopecia).
RESULTS: Nine evaluable patients were enrolled, including 3 treated at 40 mg/m2, 3 at 50 mg/m2 and 3 at 60 mg/m2. At dose level 3, 2 of 3 patients experienced dose-limiting diarrhea and hypodynamia. Another 14 patients received the dose of 50 mg/m2 in a phase 2 study. Main toxicities were hematologic, primarily affecting neutrophils and platelets. The most common non-hematologic toxicities were gastrointestinal. None experienced grade 3 or 4 acute toxicities. The 3- and 5-year overall survival (OS) rates were 86.1% and 63.3%, respectively. The rates of 5-year progression-free survival, local failure and metastasis were 56.9%, 8.5% and 22.3%, respectively.
CONCLUSION: The MTD and RD of oxaliplatin are 60 mg/m2 and 50 mg/m2, respectively. The DLT includes diarrhea and hypodynamia. The combination of oxaliplatin and 5-Fu weekly with postoperative radiotherapy was well tolerated and demonstrated encouraging efficacy in patients with stage II/III rectal cancer after radical excision.
Collapse
|
30
|
Short term results of neoadjuvant chemoradiotherapy with fluoropyrimidine alone or in combination with oxaliplatin in locally advanced rectal cancer: A meta analysis. Eur J Cancer 2013; 49:843-51. [PMID: 23063351 DOI: 10.1016/j.ejca.2012.09.026] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Revised: 08/28/2012] [Accepted: 09/18/2012] [Indexed: 01/31/2023]
|
31
|
Restivo A, Zorcolo L, Cocco IMF, Manunza R, Margiani C, Marongiu L, Casula G. Elevated CEA levels and low distance of the tumor from the anal verge are predictors of incomplete response to chemoradiation in patients with rectal cancer. Ann Surg Oncol 2012; 20:864-71. [PMID: 23010737 DOI: 10.1245/s10434-012-2669-8] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Indexed: 12/18/2022]
Abstract
BACKGROUND The objective of this study was to evaluate pretreatment clinical parameters as predictive factors for complete pathological response after long-term chemoradiotherapy (RCT) for rectal cancer. Tumor downstaging after RCT for rectal cancer can be obtained in half of cases, whereas a complete pathological response (CPR) is reported to range between 15 and 30%. It is not possible to foresee before therapies who will respond. METHODS Patients with stage II-III rectal cancer that had undergone RCT and rectal resection between January 1995 and October 2010 were considered. Patients were divided in those who achieved a CPR, "CR" group, and those who did not achieve a CPR, "NCR" group. Univariate and multivariate analyses between groups were performed considering the clinical parameters: gender, age, ASA score, preoperative hematic CEA, tumor grading; distance of the tumor from the anal verge, maximum tumor diameter, TNM stage, and neoadjuvant treatment details. RESULTS Among 260 patients, 43 (16.5%) achieved a CPR. The two groups resulted homogeneous for age, sex, pretreatment status, and tumor stage. A CEA <5 ng/dl and distance from anal verge >5 cm were correlated with CPR at multivariate analysis. Patients with both these conditions presented a significantly higher CPR rate (30.6%) as well as improved 5-year survival. CPR was also correlated with improved survival. CONCLUSIONS Very low tumors with a high serum CEA are very unlikely to reach a CPR. The predictive value of these easily available clinical factors should not be underestimated, and better therapeutic strategies for these tumors are needed.
Collapse
Affiliation(s)
- Angelo Restivo
- Department of Surgery, Colorectal Surgery Center, University of Cagliari, Cagliari, Italy.
| | | | | | | | | | | | | |
Collapse
|
32
|
Abstract
Neoadjuvant short-course radiotherapy and long-course chemoradiation (CRT) reduce local recurrence rates when compared to surgery alone and remain widely accepted as standard of care for patients with locally advanced rectal cancer. However, surgery is not without complications and a non-surgical approach in carefully selected patients warrants evaluation. A pathological complete response to CRT is associated with a significant improvement in survival and it has been suggested that a longer time interval between the completion of CRT and surgery increases tumor downstaging. Intensification of neoadjuvant treatment regimens to increase tumor downstaging has been evaluated in a number of clinical trials and more recently the introduction of neoadjuvant chemotherapy prior to CRT has demonstrated high rates of radiological tumor regression. Careful selection of patients using high-resolution MRI may allow a non-surgical approach in a subgroup of patients achieving a complete response to neoadjuvant therapies after an adequate time period. Clearly this needs prospective evaluation within a clinical trial setting, incorporating modern imaging techniques, and tissue biomarkers to allow accurate prediction and assessment of response.
Collapse
|
33
|
Schirmer MA, Mergler CPN, Rave-Fränk M, Herrmann MK, Hennies S, Gaedcke J, Conradi LC, Jo P, Beissbarth T, Hess CF, Becker H, Ghadimi M, Brockmöller J, Christiansen H, Wolff HA. Acute Toxicity of Radiochemotherapy in Rectal Cancer Patients: A Risk Particularly for Carriers of the TGFB1 Pro25 variant. Int J Radiat Oncol Biol Phys 2012; 83:149-57. [DOI: 10.1016/j.ijrobp.2011.05.063] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Revised: 05/19/2011] [Accepted: 05/26/2011] [Indexed: 01/10/2023]
|
34
|
Dewdney A, Cunningham D, Tabernero J, Capdevila J, Glimelius B, Cervantes A, Tait D, Brown G, Wotherspoon A, Gonzalez de Castro D, Chua YJ, Wong R, Barbachano Y, Oates J, Chau I. Multicenter randomized phase II clinical trial comparing neoadjuvant oxaliplatin, capecitabine, and preoperative radiotherapy with or without cetuximab followed by total mesorectal excision in patients with high-risk rectal cancer (EXPERT-C). J Clin Oncol 2012; 30:1620-7. [PMID: 22473163 DOI: 10.1200/jco.2011.39.6036] [Citation(s) in RCA: 286] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
PURPOSE To evaluate the addition of cetuximab to neoadjuvant chemotherapy before chemoradiotherapy in high-risk rectal cancer. PATIENTS AND METHODS Patients with operable magnetic resonance imaging-defined high-risk rectal cancer received four cycles of capecitabine/oxaliplatin (CAPOX) followed by capecitabine chemoradiotherapy, surgery, and adjuvant CAPOX (four cycles) or the same regimen plus weekly cetuximab (CAPOX+C). The primary end point was complete response (CR; pathologic CR or, in patients not undergoing surgery, radiologic CR) in patients with KRAS/BRAF wild-type tumors. Secondary end points were radiologic response (RR), progression-free survival (PFS), overall survival (OS), and safety in the wild-type and overall populations and a molecular biomarker analysis. RESULTS One hundred sixty-five eligible patients were randomly assigned. Ninety (60%) of 149 assessable tumors were KRAS or BRAF wild type (CAPOX, n = 44; CAPOX+C, n = 46), and in these patients, the addition of cetuximab did not improve the primary end point of CR (9% v 11%, respectively; P = 1.0; odds ratio, 1.22) or PFS (hazard ratio [HR], 0.65; P = .363). Cetuximab significantly improved RR (CAPOX v CAPOX+C: after chemotherapy, 51% v 71%, respectively; P = .038; after chemoradiation, 75% v 93%, respectively; P = .028) and OS (HR, 0.27; P = .034). Skin toxicity and diarrhea were more frequent in the CAPOX+C arm. CONCLUSION Cetuximab led to a significant increase in RR and OS in patients with KRAS/BRAF wild-type rectal cancer, but the primary end point of improved CR was not met.
Collapse
Affiliation(s)
- Alice Dewdney
- Department of Medicine, Royal Marsden Hospital, Surrey, UK
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Safety and outcome of chemoradiotherapy in elderly patients with rectal cancer: results from two French tertiary centres. Dig Liver Dis 2012; 44:350-4. [PMID: 22119617 DOI: 10.1016/j.dld.2011.10.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2011] [Revised: 10/17/2011] [Accepted: 10/20/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND The risks of chemoradiotherapy in elderly patients with rectal cancer have not yet been well-characterised. METHODS We retrospectively reviewed the charts of patients with rectal cancer over 70 years old who were treated with chemoradiotherapy in two French university hospitals. RESULTS A total of 125 patients were evaluated. Mean age was 75.1 ± 4.1 years and ranged from 70 to 90 years. Adverse effects ≥ grade 2 were observed in 32% of the patients and adverse effects ≥ grade 3 in 15%. Dose reduction for toxicity was performed in 18% of the patients and chemoradiotherapy discontinuation was necessary in 9%. Postoperative morbidity was 16% with two treatment-related deaths. Two-year survival rate was 84%. No variables had any influence on treatment-related adverse events. CONCLUSIONS In selected elderly patients, chemoradiotherapy is well-tolerated, without any significant increase in adverse events, and the results are similar to those recorded in younger patients.
Collapse
|
36
|
Zorcolo L, Rosman AS, Restivo A, Pisano M, Nigri GR, Fancellu A, Melis M. Complete pathologic response after combined modality treatment for rectal cancer and long-term survival: a meta-analysis. Ann Surg Oncol 2012; 19:2822-32. [PMID: 22434243 DOI: 10.1245/s10434-011-2209-y] [Citation(s) in RCA: 173] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2011] [Indexed: 02/05/2023]
Abstract
BACKGROUND Complete pathologic response (CPR) after neoadjuvant chemoradiotherapy (combined modality treatment, CMT) for rectal cancer seems associated with improved survival compared to partial or no response (NPR). However, previous reports have been limited by small sample size and single-institution design. METHODS A systematic literature review was conducted to detect studies comparing long-term results of patients with CPR and NPR after CMT for rectal cancer. Variables were pooled only if evaluated by 3 or more studies. Study end points included rates of CPR, local recurrence (LR), distant recurrence (DR), 5-year overall survival (OS), and disease-free survival (DFS). RESULTS Twelve studies (1,913 patients) with rectal cancer treated with CMT were included. CPR was observed in 300 patients (15.6%). CPR and NPR patient groups were similar with respect to age, sex, tumor size, distance of tumor from the anus, and stage of disease before treatment. Median follow-up ranged from 23 to 46 months. CPR patients had lower rates of LR [0.7% vs. 2.6%; odds ratio (OR) 0.45, 95% confidence interval (CI) 0.22-0.90, P = 0.03], DR (5.3% vs. 24.1%; OR 0.15, 95% CI 0.07-0.31, P = 0.0001), and simultaneous LR + DR (0.7% vs. 4.8%; OR 0.32, 95% CI 0.13-0.79, P = 0.01). OS was 92.9% for CPR versus 73.4% for NPR (OR 3.6, 95% CI 1.84-7.22, P = 0.002), and DFS was 86.9% versus 63.9% (OR 3.53, 95% CI 1.62-7.72, P = 0.002). CONCLUSIONS CPR after CMT for rectal cancer is associated with improved local and distal control as well as better OS and DFS.
Collapse
Affiliation(s)
- Luigi Zorcolo
- Department of Surgery, University of Cagliari, Cagliari, Italy
| | | | | | | | | | | | | |
Collapse
|
37
|
Vestermark LW, Jensen HA, Pfeiffer P. High-dose radiotherapy (60 Gy) with oral UFT/folinic acid and escalating doses of oxaliplatin in patients with non-resectable locally advanced rectal cancer (LARC): a phase I trial. Acta Oncol 2012; 51:311-7. [PMID: 22248062 DOI: 10.3109/0284186x.2011.652740] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Consensus is that patients with locally advanced rectal cancer (LARC) should receive long-term chemoradiotherapy (CRT) before surgery. With the intent to offer the patients intensified concomitant chemotherapy (CT) to improve outcome and to assess tolerability and toxicity of oxaliplatin (Ox) a phase I trial of high dose pelvic radiotherapy (RT), fixed dose of oral UFT/l-leucovorin and increasing doses of weekly Ox were performed. METHODS Pelvic RT with 48.6 Gy/27 fractions was given to the primary tumour and the regional lymph nodes and a concurrent boost of 5.4 Gy/27 fractions with a final boost of 6 Gy/3 fractions was given to the gross tumour volume (GTV) (60 Gy/30 fractions). Concurrent with RT patients received a daily dose of UFT 300 mg/m(2) plus fixed dose l-leucovorin 22.5 mg 5/7 days and increasing weekly doses of Ox with 10 mg/m(2)/week from a start dose of 30 mg/m(2)/week to a maximum of 60 mg/m(2)/week. In addition, before and after CRT the patients received one course of TEGAFOX (UFT 300 mg/m(2) with l/leucovorin 22.5 mg Days 1-14 and Ox 130 mg/m(2) given on Day 1). Surgery was planned at least six weeks after the completion of the CRT. RESULTS From May 2005 to March 2009, 18 patients with LARC (16 primary, two recurrent) were included in this phase I trial. Toxicity was low with only 5-17% grade 3-4 toxicity. Fifteen patients (83%) were operated (14 R0 resection and 1 R1 resection) after completion of CRT. Five (33%) patients had a pathological complete response (ypCR). When ypCR was combined with yp few residual cells, the rate was 60%. Thirteen patients are still alive December 2011. CONCLUSION Preoperative high-dose RT and concomitant UFT with increasing doses of Ox up to 60 mg/m(2)/week was feasible with low toxicity, high ypCR rates and promising OS in patients with non-resectable LARC.
Collapse
Affiliation(s)
- Lene W Vestermark
- Department of Oncology, Odense University Hospital, Odense, Denmark.
| | | | | |
Collapse
|
38
|
Hill EJ, Nicolay NH, Middleton MR, Sharma RA. Oxaliplatin as a radiosensitiser for upper and lower gastrointestinal tract malignancies: what have we learned from a decade of translational research? Crit Rev Oncol Hematol 2012; 83:353-87. [PMID: 22309673 DOI: 10.1016/j.critrevonc.2011.12.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2011] [Revised: 12/14/2011] [Accepted: 12/28/2011] [Indexed: 01/08/2023] Open
Abstract
Some of the greatest advances in the treatment of solid malignancies have resulted from the combination of chemotherapy and radiotherapy treatments. This article comprehensively reviews the current clinical evidence for oxaliplatin-based chemo-radiotherapy that may improve local control and survival. In order to understand how clinical studies should be designed, the pre-clinical evidence for the use of oxaliplatin chemotherapy as a radiosensitising agent is appraised. Particular focus is placed on oxaliplatin's biological mechanisms of action, including cell cycle effects, the formation of DNA adducts and interstrand cross-links and the role of DNA repair proteins. At a clinical level, there is currently no evidence to suggest that oxaliplatin provides an additional benefit to concurrent chemo-radiation regimes that utilise fluoropyrimidines; we evaluate the reasons for this observation, the limitations of clinical trial design and the opportunities that currently exist to design clinical trials which are underpinned by an understanding of the basic biology.
Collapse
Affiliation(s)
- Esme J Hill
- Gray Institute of Radiation Oncology and Biology, Oncology Department, Old Road Campus Research Building, Oxford OX3 7DQ, UK
| | | | | | | |
Collapse
|
39
|
Thariat J, Mazeron JJ. About the 53rd meeting of the American Society for Therapeutic Radiology and Oncology (ASTRO). Bull Cancer 2011; 98:bdc.2011.1508. [PMID: 22240261 DOI: 10.1684/bdc.2011.1508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Juliette Thariat
- Institut universitaire de la face et du cou, université de Nice - Sophia-Antipolis, centre Antoine-Lacassagne, département de radiothérapie, 33, avenue Valombrose, 06189 Nice Cedex 2, France
| | | |
Collapse
|
40
|
Fischkoff KN, Ruby JA, Guillem JG. Nonoperative Approach to Locally Advanced Rectal Cancer After Neoadjuvant Combined Modality Therapy: Challenges and Opportunities From a Surgical Perspective. Clin Colorectal Cancer 2011; 10:291-7. [DOI: 10.1016/j.clcc.2011.06.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2010] [Revised: 12/16/2010] [Accepted: 12/21/2010] [Indexed: 12/22/2022]
|
41
|
Wolff HA, Wagner DM, Conradi LC, Hennies S, Ghadimi M, Hess CF, Christiansen H. Irradiation with protons for the individualized treatment of patients with locally advanced rectal cancer: a planning study with clinical implications. Radiother Oncol 2011; 102:30-7. [PMID: 22112780 DOI: 10.1016/j.radonc.2011.10.018] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Revised: 09/20/2011] [Accepted: 10/17/2011] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND PURPOSE Ongoing clinical trials aim to improve local control and overall survival rates by intensification of therapy regimen for patients with locally advanced rectal cancer. It is well known that whenever treatment is intensified, risk of therapy-related toxicity rises. An irradiation with protons could possibly present an approach to solve this dilemma by lowering the exposure to the organs-at-risk (OAR) without compromising tumor response. MATERIAL AND METHODS Twenty five consecutive patients were treated from 04/2009 to 5/2010. For all patients, four different treatment plans including protons, RapidArc, IMRT and 3D-conformal-technique were retrospectively calculated and analyzed according to dosimetric aspects. RESULTS Detailed DVH-analyses revealed that protons clearly reduced the dose to the OAR and entire normal tissue when compared to other techniques. Furthermore, the conformity index was significantly better and target volumes were covered consistent with the ICRU guidelines. CONCLUSIONS Planning results suggest that treatment with protons can improve the therapeutic tolerance for the irradiation of rectal cancer, particularly for patients scheduled for an irradiation with an intensified chemotherapy regimen and identified to be at high risk for acute therapy-related toxicity. However, clinical experiences and long-term observation are needed to assess tumor response and related toxicity rates.
Collapse
Affiliation(s)
- Hendrik Andreas Wolff
- Department of Radiotherapy and Radiooncology, University Medical Center, Göttingen, Germany.
| | | | | | | | | | | | | |
Collapse
|
42
|
Pinto C, Di Fabio F, Maiello E, Pini S, Latiano T, Aschele C, Garufi C, Bochicchio A, Rosati G, Aprile G, Giaquinta S, Torri V, Bardelli A, Gion M, Martoni A. Phase II study of panitumumab, oxaliplatin, 5-fluorouracil, and concurrent radiotherapy as preoperative treatment in high-risk locally advanced rectal cancer patients (StarPan/STAR-02 Study). Ann Oncol 2011; 22:2424-2430. [DOI: 10.1093/annonc/mdq782] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
43
|
Wong SJ, Winter K, Meropol NJ, Anne PR, Kachnic L, Rashid A, Watson JC, Mitchell E, Pollock J, Lee RJ, Haddock M, Erickson BA, Willett CG. Radiation Therapy Oncology Group 0247: a randomized Phase II study of neoadjuvant capecitabine and irinotecan or capecitabine and oxaliplatin with concurrent radiotherapy for patients with locally advanced rectal cancer. Int J Radiat Oncol Biol Phys 2011; 82:1367-75. [PMID: 21775070 DOI: 10.1016/j.ijrobp.2011.05.027] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Revised: 05/02/2011] [Accepted: 05/12/2011] [Indexed: 12/14/2022]
Abstract
PURPOSE To evaluate the rate of pathologic complete response (pCR) and the toxicity of two neoadjuvant chemoradiotherapy (chemoRT) regimens for Stage T3-T4 rectal cancer in a randomized Phase II study. METHODS AND MATERIALS Patients with Stage T3 or T4 rectal cancer of <12 cm from the anal verge were randomized to preoperative RT (50.4 Gy in 1.8-Gy fractions) with concurrent capecitabine (1,200 mg/m(2)/d Mondays through Friday) and irinotecan (50 mg/m(2) weekly in four doses) (Arm 1) or concurrent capecitabine (1,650 mg/m(2)/d Monday through Friday) and oxaliplatin (50 mg/m(2) weekly in five doses) (Arm 2). Surgery was performed 4-8 weeks after chemoRT, and adjuvant chemotherapy 4-6 weeks after surgery. The primary endpoint was the pCR rate, requiring 48 evaluable patients per arm. RESULTS A total of 146 patients were enrolled. The protocol chemotherapy was modified because of excessive gastrointestinal toxicity after treatment of 35 patients; 96 were assessed for the primary endpoint-the final regimen described above. The patient characteristics were similar for both arms. After chemoRT, the rate of tumor downstaging was 52% and 60% and the rate of nodal downstaging (excluding N0 patients) was 46% and 40%, for Arms 1 and 2, respectively. The pCR rate for Arm 1 was 10% and for Arm 2 was 21%. For Arm 1 and 2, the preoperative chemoRT rate of Grade 3-4 hematologic toxicity was 9% and 4% and the rate of Grade 3-4 nonhematologic toxicity was 26% and 27%, respectively. CONCLUSIONS Preoperative chemoRT with capecitabine plus oxaliplatin for distal rectal cancer has significant clinical activity (10 of 48 pCRs) and acceptable toxicity. This regimen is currently being evaluated in a Phase III randomized trial (National Surgical Adjuvant Breast and Bowel Project R04).
Collapse
|
44
|
McRee AJ, Cowherd S, Wang AZ, Goldberg RM. Chemoradiation therapy in the management of gastrointestinal malignancies. Future Oncol 2011; 7:409-26. [PMID: 21417904 DOI: 10.2217/fon.11.7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Concurrent administration of chemotherapy and radiotherapy has been increasingly used in cancer treatment, leading to improvements in survival as well as quality of life. Currently, it is a feasible preference, often regarded as the standard therapeutic option, for many locally confined solid tumors, including anal, bladder, cervical, esophageal, gastric, head and neck, lung, pancreatic and rectal cancers. In patients with these tumors, combined modality therapy improves local tumor control and survival while, in some instances, obviating the need for surgical removal of the organ of origin. The scientific rationale for the use of chemoradiation derives from the preclinical and clinical observations of synergistic interactions between radiotherapy and chemotherapy. When chemotherapy and radiotherapy are administered together, the chemotherapeutic agents can sensitize the cancer cells to the effects of ionizing radiation, leading to increased tumor-killing effects within the radiotherapy field. This, in turn, can improve local control of the primary tumor and, in some cancers, render surgical resection unnecessary. In other cases, patients with tumors that were initially considered unresectable are able to undergo curative interventions after completing chemoradiation. The chemotherapy component can address any potential micrometastatic disease that, without therapy, leads to an increased risk of distant recurrence. A large body of evidence exists that supports the use of chemoradiotherapy in gastrointestinal cancers. In fact, one of the first tumor types in which the superior efficacy of chemoradiation was described was anal cancer. Since then, chemoradiotherapy has been explored in other gastrointestinal malignancies with superior outcomes when compared with either radiation or chemotherapy alone. This article aims to recapitulate the clinical evidence supporting the use of chemoradiotherapy in a variety of gastrointestinal tumor types.
Collapse
Affiliation(s)
- Autumn J McRee
- Department of Hematology/Oncology, University of North Carolina School of Medicine, NC, USA
| | | | | | | |
Collapse
|
45
|
|
46
|
Aschele C, Cionini L, Lonardi S, Pinto C, Cordio S, Rosati G, Artale S, Tagliagambe A, Ambrosini G, Rosetti P, Bonetti A, Negru ME, Tronconi MC, Luppi G, Silvano G, Corsi DC, Bochicchio AM, Chiaulon G, Gallo M, Boni L. Primary tumor response to preoperative chemoradiation with or without oxaliplatin in locally advanced rectal cancer: pathologic results of the STAR-01 randomized phase III trial. J Clin Oncol 2011; 29:2773-80. [PMID: 21606427 DOI: 10.1200/jco.2010.34.4911] [Citation(s) in RCA: 551] [Impact Index Per Article: 42.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To investigate oxaliplatin combined with fluorouracil-based chemoradiotherapy as preoperative treatment for locally advanced rectal cancer. PATIENTS AND METHODS Seven hundred forty-seven patients with resectable, locally advanced (cT3-4 and/or cN1-2) adenocarcinoma of the mid-low rectum were randomly assigned to receive pelvic radiation (50.4 Gy in 28 daily fractions) and concomitant infused fluorouracil (225 mg/m(2)/d) either alone (arm A, n = 379) or combined with oxaliplatin (60 mg/m(2) weekly × 6; arm B, n = 368). Overall survival is the primary end point. A protocol-planned analysis of response to preoperative treatment is reported here. RESULTS Grade 3 to 4 adverse events during preoperative treatment were more frequent with oxaliplatin plus fluorouracil and radiation than with radiation and fluorouracil alone (24% v 8% of treated patients; P < .001). In arm B, 83% of the patients treated with oxaliplatin had five or more weekly administrations. Ninety-one percent, compared with 97% in the control arm, received ≥ 45 Gy (P < .001). Ninety-six percent versus 95% of patients underwent surgery with similar rates of abdominoperineal resections (20% v 18%, arm A v arm B). The rate of pathologic complete responses was 16% in both arms (odds ratio = 0.98; 95% CI, 0.66 to 1.44; P = .904). Twenty-six percent versus 29% of patients had pathologically positive lymph nodes (arm A v arm B; P = .447), 46% versus 44% had tumor infiltration beyond the muscularis propria (P = .701), and 7% versus 4% had positive circumferential resection margins (P = .239). Intra-abdominal metastases were found at surgery in 2.9% versus 0.5% of patients (arm A v arm B; P = .014). CONCLUSION Adding oxaliplatin to fluorouracil-based preoperative chemoradiotherapy significantly increases toxicity without affecting primary tumor response. Longer follow-up is needed to assess the impact on efficacy end points.
Collapse
Affiliation(s)
- Carlo Aschele
- Istituto Nazionale per la Ricerca sul Cancro, Genova, Italy.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
47
|
Wolff HA, Conradi LC, Schirmer M, Beissbarth T, Sprenger T, Rave-Fränk M, Hennies S, Hess CF, Becker H, Christiansen H, Liersch T. Gender-specific acute organ toxicity during intensified preoperative radiochemotherapy for rectal cancer. Oncologist 2011; 16:621-31. [PMID: 21558132 DOI: 10.1634/theoncologist.2010-0414] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Patients with locally advanced rectal cancer (cUICC stages II/III) are typically treated with preoperative 5-fluorouracil-based (5-FU-based) radiochemotherapy (RCT). However, trials are currently being conducted to improve the complete remission rates and the systemic control by combining 5-FU with oxaliplatin. The primary objective was to identify the subgroups of rectal cancer patients who were at risk for high-grade toxicity. All 196 patients who were included in the present study were treated with 50.4 Gy and chemotherapy that included either 5-FU (n = 115) or 5-FU+oxaliplatin (n = 81). The preoperative RCT was followed by a total mesorectal excision and adjuvant chemotherapy. Acute toxicity was monitored weekly and a toxicity grade ≥3 (Common Toxicity Criteria) for a skin reaction, cystitis, proctitis, or enteritis was defined as high-grade acute organ toxicity. After RCT with 5-FU+oxaliplatin, complete tumor remission was achieved in 13.6% of the patients and in 11.3% after RCT with 5-FU alone. Complete irradiation dosages of 50.4 Gy were given to 99% (5-FU) and 95% (5-FU+oxaliplatin) of the patients. Concomitant chemotherapy was fully administered in 95% of the patients treated with 5-FU compared with the 84% of patients treated with 5-FU+oxaliplatin. A significantly higher proportion of acute organ toxicity was found in the patients who were treated with 5-FU+oxaliplatin compared with those who were treated with 5-FU. Additionally, women with a low body mass index were at the highest risk for acute organ toxicity. These results suggest that there are basic clinical parameters, such as gender and body mass index, that may be potential markers for generating individual risk profiles of RCT-induced toxicity.
Collapse
Affiliation(s)
- Hendrik A Wolff
- Department of Radiotherapy and Radiooncology, University Medical Center Göttingen, Robert-Koch-Strasse 40, 37075 Göttingen, Germany.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
48
|
Preoperative intensified radiochemotherapy for rectal cancer: experience of a single institution. Int J Colorectal Dis 2011; 26:153-64. [PMID: 21107849 DOI: 10.1007/s00384-010-1064-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/04/2010] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim of our study was to evaluate the feasibility and the effectiveness of an intensified neoadjuvant protocol with the addition of weekly oxaliplatin in the preoperative strategy of rectal cancer treatment. PATIENTS AND METHODS Patients with locally advanced rectal cancer received continous infusion 5-Fluorouracil (5-FU) 200 mg/m(2)/day in combination with weekly oxaliplatin at a dose of 50 mg/m(2). Doses of radiotherapy were 45 Gy to the whole pelvis plus 5.4-9 Gy to the tumour mass. The primary end-points of the study were evaluation of toxicity, compliance with radiotherapy and chemotherapy, downstaging, pathological complete response (pCR) and the rate of sphincter preservation for distal cancers. Secondary end-points were relapse-free and overall survival. RESULTS From November 2006 to June 2009, 51 patients were enrolled into the study. Compliance with chemotherapy was 80%. The incidence of G3 diarrhoea and proctitis were 17.6% and 21.5%, respectively. Surgery was performed in 48 patients with 100% R0 resection. 76.4% of low-lying tumours underwent conservative treatment. Seventy-nine percent of patients were downstaged: T and N downstaging were observed in 71% and 75% of patients, respectively. A pCR was obtained in 11 (22.9%) patients. CONCLUSIONS Intensification of neoadjuvant treatment for rectal cancer with the addition of weekly oxaliplatin is feasible, with remarkable rates of downstaging and pathological complete response. Data on sphincter preservation for distal cancers were excellent. Phase III trials with a longer follow-up will establish whether this good outcome in terms of surrogate end-points will translate into better rates of disease-free and overall survival.
Collapse
|
49
|
Kao PS, Chang SC, Wang LW, Lee RC, Liang WY, Lin TC, Chen WS, Jiang JK, Yang SH, Wang HS, Lin JK. The impact of preoperative chemoradiotherapy on advanced low rectal cancer. J Surg Oncol 2011; 102:771-7. [PMID: 20872811 DOI: 10.1002/jso.21711] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Preoperative chemoradiotherapy (CCRT) followed by radical resection is an option for advanced low rectal cancer. This study was aimed to clarify the impact of CCRT on patients' outcome. PATIENTS AND METHODS One hundred thirty-six patients with rectal cancer (<10 cm from anal verge) were enrolled prospectively between July 2000 and December 2004. The preoperative clinical stage was T3, T4, or node-positive disease. Sixty-nine and 67 patients underwent surgery with and without preoperative CCRT, respectively. The regimen of pre-op CCRT was a radiation dosage of 45 Gy in 20 fractions and oral tegafur-uracil (UFUR) and leucovorin. RESULTS There was no statistical difference in the preserved anorectal function between two groups after 5 years of follow-up (62.3% vs. 47.8%; P = 0.125). The 5-year overall survival and disease-free survival (DFS) percentage were 88.4% and 76.8% for patients with preoperative CCRT, and 65.7% and 58.2% for patients without CCRT, respectively. Patients with preoperative CCRT had a higher overall survival rate and DFS (P = 0.001 and 0.015). CONCLUSIONS In patients with advanced low rectal cancer, preoperative CCRT followed by radical surgery significantly improved overall survival and DFS compared with surgery alone. The effect of sphincter preservation with preoperative CCRT is questionable.
Collapse
Affiliation(s)
- Ping-Sheng Kao
- Division of Colon & Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, National Yang-Ming University, Taipei, Taiwan
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
50
|
Gerard JP, Francois E, Freyer G, Milano G, Aschele C. Rectal Cancer: Rectal Preservation Is an Important End Point. J Clin Oncol 2010. [DOI: 10.1200/jco.2010.30.2059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | | | - Carlo Aschele
- Istituto Nazionale per la Ricerca sul Cancro, Genoa, Italy
| |
Collapse
|