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Li A, Huang T, Zheng R, Chi P, Li Z, Wang X, Xu B. Preoperative chemoradiotherapy with capecitabine and triweekly oxaliplatin versus capecitabine monotherapy for locally advanced rectal cancer: a propensity-score matched study. BMC Cancer 2022; 22:789. [PMID: 35850711 PMCID: PMC9295262 DOI: 10.1186/s12885-022-09855-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 07/04/2022] [Indexed: 11/10/2022] Open
Abstract
Background Distant metastasis has been the main failure pattern for locoregionally advanced rectal cancer (LARC) patients, and intensified neoadjuvant chemotherapy has become a popular research topic. The present study aimed to compare the survival outcomes, acute toxicities and surgical complications in LARC patients who received preoperative chemoradiotherapy with triweekly oxaliplatin and capecitabine (triweekly XELOX) or capecitabine. Methods: Between 2007 and 2017, patients with clinically staged II-III rectal cancer who were treated with preoperative chemoradiotherapy using either triweekly XELOX (oxaliplatin 130 mg/m2 plus capecitabine 825 mg/m2) or capecitabine were included. Variables potentially influencing chemotherapy treatment selection were used to generate propensity scores (PS). The association between chemotherapy regimens and survival endpoints, including distant metastasis-free survival (DMFS), overall survival (OS) and disease-free survival (DFS), were evaluated and adjusted with PS. The acute toxicities and surgical complications were also compared. Results A total of 810 patients were included in the analysis; 277 (34.2%) patients received triweekly XELOX, and 533 (65.8%) received capecitabine. The pathological complete response (pCR) rates were 20.2 and 19.9% (P = 0.912) for the groups treated with triweekly XELOX and capecitabine, respectively. The 5-year DMFS, OS and DFS with triweekly XELOX versus capecitabine were 75.6% vs. 77.6% (P = 0.555), 79.2% vs. 83.3% (P = 0.101), and 69.9% vs. 73.7% (P = 0.283), respectively. Triweekly XELOX was not associated with an increased risk of severe toxicity during chemoradiotherapy, but it increased the risk of postoperative complications compared to capecitabine. After PS adjustment, the differences between the two groups remained insignificant in pCR rate, survival outcomes, and acute toxicities, and the difference in surgical complications disappeared. Conclusions Triweekly XELOX or capecitabine concurrent with neoadjuvant radiotherapy leads to similar long-term survival outcomes, acute toxicities and surgical complications in LARC patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-09855-z.
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Affiliation(s)
- Anchuan Li
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Xinquan Road 29, Fuzhou, 350001, China.,Department of Radiation Oncology, College of Clinical Medicine, Fujian Medical University, Fuzhou, 350001, China.,Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for Tumors, Fujian Medical University, Fuzhou, 350001, China.,Clinical Research Center for Radiology and Radiotherapy of Fujian Province (Digestive, Hematological and Breast Malignancies), Fuzhou, 350001, China
| | - Tingxuan Huang
- Department of Gastroenterology, Fujian Medical University Union Hospital, Xinquan Road 29, Fuzhou, 350001, China.,Fujian Medical University Cancer Center, Fujian Medical University, Fuzhou, 350001, China
| | - Rong Zheng
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Xinquan Road 29, Fuzhou, 350001, China.,Department of Radiation Oncology, College of Clinical Medicine, Fujian Medical University, Fuzhou, 350001, China.,Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for Tumors, Fujian Medical University, Fuzhou, 350001, China.,Clinical Research Center for Radiology and Radiotherapy of Fujian Province (Digestive, Hematological and Breast Malignancies), Fuzhou, 350001, China
| | - Pan Chi
- Department of Gastrointestinal Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, China
| | - Zhihua Li
- Department of Radiation Oncology, The Second Hospital of Zhangzhou, Zhangzhou, 363100, China
| | - Xiaozhong Wang
- Department of Gastroenterology, Fujian Medical University Union Hospital, Xinquan Road 29, Fuzhou, 350001, China. .,Fujian Medical University Cancer Center, Fujian Medical University, Fuzhou, 350001, China.
| | - Benhua Xu
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Xinquan Road 29, Fuzhou, 350001, China. .,Department of Radiation Oncology, College of Clinical Medicine, Fujian Medical University, Fuzhou, 350001, China. .,Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for Tumors, Fujian Medical University, Fuzhou, 350001, China. .,Clinical Research Center for Radiology and Radiotherapy of Fujian Province (Digestive, Hematological and Breast Malignancies), Fuzhou, 350001, China. .,Department of Medical Imagine Technology, College of Medical Technology and Engineering, Fujian Medical University, Fuzhou, 350001, China.
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Ryan ÉJ, O'Sullivan DP, Kelly ME, Syed AZ, Neary PC, O'Connell PR, Kavanagh DO, Winter DC, O'Riordan JM. Meta-analysis of the effect of extending the interval after long-course chemoradiotherapy before surgery in locally advanced rectal cancer. Br J Surg 2019; 106:1298-1310. [PMID: 31216064 DOI: 10.1002/bjs.11220] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 03/27/2019] [Accepted: 04/01/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND The current standard of care in locally advanced rectal cancer (LARC) is neoadjuvant long-course chemoradiotherapy (nCRT) followed by total mesorectal excision (TME). Surgery is conventionally performed approximately 6-8 weeks after nCRT. This study aimed to determine the effect on outcomes of extending this interval. METHODS A systematic search was performed for studies reporting oncological results that compared the classical interval (less than 8 weeks) from the end of nCRT to TME with a minimum 8-week interval in patients with LARC. The primary endpoint was the rate of pathological complete response (pCR). Secondary endpoints were recurrence-free survival, local recurrence and distant metastasis rates, R0 resection rates, completeness of TME, margin positivity, sphincter preservation, stoma formation, anastomotic leak and other complications. A meta-analysis was performed using the Mantel-Haenszel method. RESULTS Twenty-six publications, including four RCTs, with 25 445 patients were identified. A minimum 8-week interval was associated with increased odds of pCR (odds ratio (OR) 1·41, 95 per cent c.i. 1·30 to 1·52; P < 0·001) and tumour downstaging (OR 1·18, 1·05 to 1·32; P = 0·004). R0 resection rates, TME completeness, lymph node yield, sphincter preservation, stoma formation and complication rates were similar between the two groups. The increased rate of pCR translated to reduced distant metastasis (OR 0·71, 0·54 to 0·93; P = 0·01) and overall recurrence (OR 0·76, 0·58 to 0·98; P = 0·04), but not local recurrence (OR 0·83, 0·49 to 1·42; P = 0·50). CONCLUSION A minimum 8-week interval from the end of nCRT to TME increases pCR and downstaging rates, and improves recurrence-free survival without compromising surgical morbidity.
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Affiliation(s)
- É J Ryan
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
| | - D P O'Sullivan
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
| | - M E Kelly
- Surgical Professorial Unit, St Vincent's University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
| | - A Z Syed
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
| | - P C Neary
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland.,School of Medicine, Trinity College Dublin, University of Dublin, Dublin, Ireland
| | - P R O'Connell
- Surgical Professorial Unit, St Vincent's University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
| | - D O Kavanagh
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland.,School of Medicine, Trinity College Dublin, University of Dublin, Dublin, Ireland
| | - D C Winter
- Surgical Professorial Unit, St Vincent's University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
| | - J M O'Riordan
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland.,School of Medicine, Trinity College Dublin, University of Dublin, Dublin, Ireland
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Abstract
Purpose of Review Pathological complete response is seen in approximately one fifth of rectal cancer patients following neoadjuvant chemoradiation. Since these patients have excellent oncological outcomes, there has been a rapidly growing interest in organ preservation for those who develop a clinical complete response. We review the watch-and-wait strategy and focus on all aspects of this hot topic, including who should be considered for this approach, how should we identify treatment response and what are the expected outcomes. Recent Findings The major challenges in interpreting the data on watch-and-wait are the significant heterogeneity of patients selected for this approach and of methods employed to identify them. The evidence available comes mostly from retrospective cohort studies, but has shown good oncological outcomes, including the rate of successful salvage surgery, locoregional control and overall survival. Summary There is currently not enough and not robust enough evidence to support watch-and-wait as a standard approach, outside a clinical trial, for patients achieving clinical complete response following neoadjuvant chemoradiation. Furthermore, there is a lack of data on long-term outcomes. However, the results we have so far are promising, and there is therefore an urgent need for randomised control studies such as the TRIGGER trial to confirm the safety of this strategy.
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