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Kohrman NM, Wlodarczyk JR, Ding L, McAndrew NP, Algaze SD, Cologne KG, Lee SW, Koller SE. Rectal Cancer Survival for Residual Carcinoma In Situ Versus Pathologic Complete Response After Neoadjuvant Therapy. Dis Colon Rectum 2024; 67:920-928. [PMID: 38498775 DOI: 10.1097/dcr.0000000000003261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
BACKGROUND Pathologic complete response after neoadjuvant chemoradiotherapy for rectal cancer is associated with improved survival. It is unclear whether residual carcinoma in situ portends a similar outcome. OBJECTIVE To compare the survival of patients with locally advanced rectal cancer who received neoadjuvant therapy and achieved pathologic carcinoma in situ versus pathologic complete response. DESIGN Retrospective cohort study. SETTING National public database. PATIENTS A total of 4594 patients in the National Cancer Database from 2006 to 2016 with locally advanced rectal cancer who received neoadjuvant therapy, underwent surgery, and had node-negative ypTis or ypT0 on final pathology were included. Of these, 4321 patients (94.1%) had ypT0 and 273 (5.9%) had ypTis on final pathology. MAIN OUTCOME MEASURE Overall survival. RESULTS The median age was 60 years, and 1822 patients (39.7%) were women. On initial staging, 54.5% (n = 2503) had stage II disease and 45.5% (n = 2091) had stage III disease. The ypTis group had decreased overall survival compared to the ypT0 group (HR 1.42; 95% CI, 1.04-1.95; p = 0.028). Other factors associated with decreased overall survival were older age at diagnosis, increasing Charlson-Deyo score, and poorly differentiated tumor grade. Variables associated with improved survival were female sex, private insurance, and receipt of both neoadjuvant and adjuvant chemotherapy. For the total cohort, there was no difference in survival between clinical stage II and stage III. LIMITATIONS Standard therapy versus total neoadjuvant therapy could not be abstracted. Overall survival was defined as the time from surgery to death from any cause or last contact, allowing for some erroneously misclassified deaths. CONCLUSIONS ypTis is associated with worse overall survival than ypT0 for patients with locally advanced rectal cancer who receive neoadjuvant chemoradiotherapy followed by surgery. For this cohort, clinical stage was not a significant predictor of survival. Prospective trials comparing survival for these pathologic outcomes are needed. See Video Abstract . SUPERVIVENCIA DEL CNCER DE RECTO PARA EL CARCINOMA RESIDUAL IN SITU VS RESPUESTA PATOLGICA COMPLETA DESPUS DE LA TERAPIA NEOADYUVANTE ANTECEDENTESLa respuesta patológica completa después de la quimiorradioterapia neoadyuvante para el cáncer de recto se asocia con una mayor supervivencia. No está claro si el carcinoma residual in situ presagia un resultado similar.OBJETIVOComparar la supervivencia de pacientes con cáncer de recto localmente avanzado que recibieron terapia neoadyuvante y lograron un carcinoma patológico in situ versus una respuesta patológica completa.DISEÑOEstudio de cohorte retrospectivo.ESCENARIOBase de datos pública nacional.PACIENTESSe incluyeron 4,594 pacientes de la Base de Datos Nacional de Cáncer de 2006 a 2016 con cáncer de recto localmente avanzado que recibieron terapia neoadyuvante, fueron sometidos a cirugía y tuvieron ganglios negativos, ypTis o ypT0 en el reporte patológico final. 4.321 (94,1%) tuvieron ypT0 y 273 (5,9%) tuvieron ypTis en el reporte final.PRINCIPALES MEDIDAS DE RESULTADOSupervivencia general.RESULTADOSLa mediana de edad fue de 60 años. 1.822 pacientes (39,7%) fueron mujeres. El 54,5% (n = 2.503) tuvo la enfermedad en estadio II y el 45,5% (n = 2.091) tuvo la enfermedad en estadio III según la estadificación inicial. El grupo ypTis tuvo una supervivencia general reducida en comparación con el grupo ypT0 (HR 1,42, IC 95 % 1,04-1,95, p = 0,028). Otros factores asociados con una menor supervivencia general fueron una edad más avanzada al momento del diagnóstico, un aumento de la puntuación de Charlson-Deyo y un grado tumoral poco diferenciado. Las variables asociadas con una mejor supervivencia fueron el sexo femenino, el seguro privado y la recepción de quimioterapia neoadyuvante y adyuvante. Para la cohorte total, no hubo diferencias en la supervivencia entre el estadio clínico 2 y el estadio 3.LIMITACIONESNo se pudo resumir el tratamiento estándar versus el tratamiento neoadyuvante total. La supervivencia general se definió como el tiempo transcurrido desde la cirugía hasta la muerte por cualquier causa o último contacto, lo que permite algunas muertes erróneamente clasificadas.CONCLUSIONESypTis se asocia con una peor supervivencia general que ypT0 en pacientes con cáncer de recto localmente avanzado que reciben quimiorradioterapia neoadyuvante seguida de cirugía. Para esta cohorte, el estadio clínico no fue un predictor significativo de supervivencia. Se necesitan ensayos prospectivos que comparen la supervivencia de estos resultados patológicos. ( Traducción-Dr Osvaldo Gauto ).
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Affiliation(s)
- Nathan M Kohrman
- University of Southern California Keck School of Medicine, Los Angeles, California
| | - Jordan R Wlodarczyk
- Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Li Ding
- Department of Population and Public Health Sciences, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Nicholas P McAndrew
- Division of Hematology/Oncology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California
| | - Sandra D Algaze
- Division of Medical Oncology, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Kyle G Cologne
- Division of Colorectal Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Sang W Lee
- Division of Colorectal Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Sarah E Koller
- Division of Colorectal Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
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Yu Z, Hao Y, Huang Y, Ling L, Hu X, Qiao S. Radiotherapy in the preoperative neoadjuvant treatment of locally advanced rectal cancer. Front Oncol 2023; 13:1300535. [PMID: 38074690 PMCID: PMC10704030 DOI: 10.3389/fonc.2023.1300535] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 10/30/2023] [Indexed: 04/04/2024] Open
Abstract
Radiotherapy and chemotherapy are effective treatments for patients with locally advanced rectal cancer (LARC) and can significantly improve the likelihood of R0 resection. Radiotherapy can be used as a local treatment to reduce the size of the tumor, improve the success rate of surgery and reduce the residual cancer cells after surgery. Early chemotherapy can also downgrade the tumor and eliminate micrometastases throughout the body, reducing the risk of recurrence and metastasis. The advent of neoadjuvant concurrent radiotherapy (nCRT) and total neoadjuvant treatment (TNT) has brought substantial clinical benefits to patients with LARC. Even so, given increasing demand for organ preservation and quality of life and the disease becoming increasingly younger in its incidence profile, there is a need to further explore new neoadjuvant treatment options to further improve tumor remission rates and provide other opportunities for patients to choose watch-and-wait (W&W) strategies that avoid surgery. Targeted drugs and immunologic agents (ICIs) have shown good efficacy in patients with advanced rectal cancer but have not been commonly used in neoadjuvant therapy for patients with LARC. In this paper, we review several aspects of neoadjuvant therapy, including radiation therapy and chemotherapy drugs, immune drugs and targeted drugs used in combination with neoadjuvant therapy, with the aim of providing direction and thoughtful perspectives for LARC clinical treatment and research trials.
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Affiliation(s)
| | | | | | | | - Xigang Hu
- Department of Radiation Oncology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
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Jácome AA, Peixoto RD, Gil MV, Ominelli J, Prolla G, Dienstmann R, Eng C. Biologics in rectal cancer. Expert Opin Biol Ther 2022; 22:1245-1257. [PMID: 35912589 DOI: 10.1080/14712598.2022.2108700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Despite the use of multimodality therapy, locally advanced rectal cancer (LARC) still presents high rates of disease recurrence. Fluoropyrimidine-based chemotherapy concurrently with radiation therapy (RT) remains the cornerstone of neoadjuvant therapy of LARC, and novel therapies are urgently needed in order to improve the clinical outcomes. AREAS COVERED We aim to summarize data from completed and ongoing clinical trials addressing the role of biological therapies, including monoclonal antibodies, immune checkpoint inhibitors (ICIs), antibody-drug conjugates, bispecific antibodies, and gene therapies in the systemic therapy of rectal cancer. EXPERT OPINION Deeper understanding of the molecular biology of colorectal cancer (CRC) has allowed meaningful advances in the systemic therapy of metastatic disease in the past few years. The larger applicability of biological therapy in CRC, including genome-guided targeted therapy, antiangiogenics, and immunotherapy, gives us optimism for the personalized management of rectal cancer. Microsatellite instability (MSI) tumors have demonstrated high sensitivity to ICIs, and preliminary findings in the neoadjuvant setting of rectal cancer are promising. To date, antiangiogenic and anti-EGFR therapies in LARC have not demonstrated the same benefit seen in metastatic disease. The outstanding results accomplished by biomarker-guided therapy in metastatic CRC will guide future developments of biological therapy in LARC.
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Affiliation(s)
- Alexandre A Jácome
- Department of Gastrointestinal Medical Oncology, Oncoclínicas, Belo Horizonte, Brazil
| | | | - Mariana V Gil
- Department of Gastrointestinal Medical Oncology, Oncoclínicas, Rio de Janeiro, Brazil
| | - Juliana Ominelli
- Department of Gastrointestinal Medical Oncology, Oncoclínicas, Rio de Janeiro, Brazil
| | - Gabriel Prolla
- Department of Gastrointestinal Medical Oncology, Oncoclínicas, Porto Alegre, Brazil
| | | | - Cathy Eng
- Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, USA
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A multicenter phase II trial of preoperative chemoradiotherapy with S-1 plus oxaliplatin and bevacizumab for locally advanced rectal cancer. Int J Clin Oncol 2021; 26:875-882. [PMID: 33486623 DOI: 10.1007/s10147-021-01868-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 01/01/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND We clarified the safety and efficacy of preoperative chemoradiotherapy for locally advanced rectal cancer using a multidrug regimen (S-1 + oxaliplatin + bevacizumab). METHODS This multicenter phase II trial involved 47 patients with locally advanced rectal cancer. All patients received S-1 orally (80 mg/m2/day on days 1-5, 8-12, 15-19, and 22-26) and infusions of oxaliplatin (50 mg/m2 on days 1, 8, 15, and 22) and bevacizumab (5 mg/kg on days 1 and 15). The total radiation dose was 40 Gy delivered in daily fractions of 2 Gy via the four-field technique. The primary endpoint was the pathological complete response rate. The secondary endpoints were safety (incidence of adverse events) and clinical response, relapse-free survival, overall survival, local recurrence, R0 resection, downstaging, and treatment completion rates. RESULTS All 47 patients received chemoradiotherapy, and 44 patients underwent curative resection. Two patients refused surgery and selected a watch-and-wait strategy. The pathological complete response rate was 18.2% in patients who underwent curative resection. The clinical response rate was 91.3% in 46 patients. Concerning hematotoxicity, there was one grade 4 adverse event (2.1%) and seven grade 3 events (14.9%). Diarrhea was the most frequent non-hematotoxic event, and the grade 3 event rate was 25.5%. CONCLUSIONS Although preoperative chemoradiotherapy for patients with locally advanced rectal cancer using the S-1 + oxaliplatin + bevacizumab regimen did not achieve the expected pathological complete response rate, this regimen led to an improved clinical response rate.
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Wu F, Zhou C, Wu B, Zhang X, Wang K, Wang J, Xiao L, Wang G. Adding Adjuvants to Fluoropyrimidine-based Neoadjuvant Chemoradiotherapy for Locally Advanced Rectal Cancer: An Option Worthy of Serious Consideration. J Cancer 2021; 12:417-427. [PMID: 33391438 PMCID: PMC7739002 DOI: 10.7150/jca.48337] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 10/29/2020] [Indexed: 12/28/2022] Open
Abstract
The application of fluoropyrimidine-based neoadjuvant chemoradiotherapy (Fu-nCRT) of locally advanced rectal cancer (LARC) has become a common therapeutic regimen. In order to improve the efficacy and enable more patients to benefit from this treatment, an accumulation of studies have been carried out on the auxiliary use of other drugs with Fu-nCRT. However, due to specific challenges and the potential opportunities that coexist in this field, a more reasonable approach to the mode of treatment remains to be explored. In this review, we have summarized the results of the studies on the combination of Fu-nCRT with cytotoxic drugs, anti-tumor angiogenesis, and anti-EGFR agents, as well as the status of the application of immune checkpoint inhibitors in the neoadjuvant therapy of LARC patients.
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Affiliation(s)
- Fengpeng Wu
- Department of Radiation Oncology, Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Chaoxi Zhou
- Department of Colorectal Surgery, Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Bingyuan Wu
- Department of Medical Imaging, Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Xiaoxiao Zhang
- Department of Radiation Oncology, Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Kanghua Wang
- Department of Radiation Oncology, Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Jun Wang
- Department of Radiation Oncology, Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Linlin Xiao
- Department of Radiation Oncology, Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Guiying Wang
- Department of Colorectal Surgery, Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
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Zhou Y, Guo Z, Wu Z, Shi J, Zhou C, Sun J, Hidasa I, Lu X, Lu C. The efficacy and safety of adding bevacizumab in neoadjuvant therapy for locally advanced rectal cancer patients: A systematic review and meta-analysis. Transl Oncol 2020; 14:100964. [PMID: 33248411 PMCID: PMC7704460 DOI: 10.1016/j.tranon.2020.100964] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 11/15/2020] [Accepted: 11/16/2020] [Indexed: 01/11/2023] Open
Abstract
Background Patients with locally advanced rectal cancer (LARC) are more likely to suffer local recurrence and distant metastases, contributing to worse prognoses. Considering the provided dramatic reduction of local recurrences, neoadjuvant CRT (nCRT) followed by curative resection with total mesorectal excision (TME) and adjuvant chemotherapy has been established as standard therapy for LARC patients. However, the efficacy of adding bevacizumab in neoadjuvant therapy, especially in induction therapy-containing nCRT for LARC patients remains uncertain. Materials PubMed, Embase, and Web of Science were searched to retrieve records on the application of bevacizumab in a neoadjuvant setting for LARC patients. The endpoints of interest were pCR and the rates of patients suffering Grade 3/4 bevacizumab-specific adverse events, namely bleeding, wound healing complications, and gastrointestinal perforation. Results 29 cohorts covering 1134 subjects were included in this systematic review. The pooled pCR rate for bevacizumab-relevant cohorts was 21% (95% confidence interval (95% CI), 17–25%; I2 = 61.8%), the pooled estimates of Grade 3/4 bleeding, Grade 3/4 wound healing complication, Grade 3/4 gastrointestinal perforation were 1% (95% CI, 0–3%; I2 = 0%), 2% (95% CI, 1–5%; I2 = 4.7%), and 2% (95% CI, 0–5%; I2 = 0%), respectively. Conclusion The addition of bevacizumab in the nCRT, especially in the TNT, for LARC patients provides promising efficacy and acceptable safety. However, the results should be interpreted cautiously due to the small amount of relevant data and need further confirmation by future studies.
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Affiliation(s)
- Yue Zhou
- Department of Medical Oncology, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang 110001, China
| | - Zhexu Guo
- Department of Surgical Oncology and General Surgery, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, China
| | - Zhonghua Wu
- Department of Surgical Oncology and General Surgery, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, China
| | - Jinxin Shi
- Department of Surgical Oncology and General Surgery, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, China
| | - Cen Zhou
- Department of Surgical Oncology and General Surgery, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, China
| | - Jie Sun
- Department of Surgical Oncology and General Surgery, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, China
| | - Iko Hidasa
- Department of Surgical Oncology and General Surgery, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, China
| | - Xuefei Lu
- Department of Pediatrics, People's Hospital of Yifeng County, 24 Chengnanmen Road, Yifeng County, Yichun 336300, China
| | - Chong Lu
- Department of Surgical Oncology and General Surgery, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, China.
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Roeder F, Meldolesi E, Gerum S, Valentini V, Rödel C. Recent advances in (chemo-)radiation therapy for rectal cancer: a comprehensive review. Radiat Oncol 2020; 15:262. [PMID: 33172475 PMCID: PMC7656724 DOI: 10.1186/s13014-020-01695-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 10/21/2020] [Indexed: 12/18/2022] Open
Abstract
The role of radiation therapy in the treatment of (colo)-rectal cancer has changed dramatically over the past decades. Introduced with the aim of reducing the high rates of local recurrences after conventional surgery, major developments in imaging, surgical technique, systemic therapy and radiation delivery have now created a much more complex environment leading to a more personalized approach. Functional aspects including reduction of acute or late treatment-related side effects, sphincter or even organ-preservation and the unsolved problem of still high distant failure rates have become more important while local recurrence rates can be kept low in the vast majority of patients. This review summarizes the actual role of radiation therapy in different subgroups of patients with rectal cancer, including the current standard approach in different subgroups as well as recent developments focusing on neoadjuvant treatment intensification and/or non-operative treatment approaches aiming at organ-preservation.
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Affiliation(s)
- F Roeder
- Department of Radiotherapy and Radiation Oncology, Paracelsus Medical University, Landeskrankenhaus, Müllner Hautpstrasse 48, 5020, Salzburg, Austria.
| | - E Meldolesi
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, UOC Radioterapia Oncologica, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Roma, Italy
| | - S Gerum
- Department of Radiotherapy and Radiation Oncology, Paracelsus Medical University, Landeskrankenhaus, Müllner Hautpstrasse 48, 5020, Salzburg, Austria
| | - V Valentini
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, UOC Radioterapia Oncologica, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Roma, Italy
| | - C Rödel
- Department of Radiotherapy, University of Frankfurt, Frankfurt, Germany
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Yoon SM, Lee P, Raldow A. The Evolving Landscape of Neoadjuvant Radiation Therapy for Locally Advanced Rectal Cancer. CURRENT COLORECTAL CANCER REPORTS 2020. [DOI: 10.1007/s11888-020-00451-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Lee SH. How to Achieve a Higher Pathologic Complete Response in Patients With Locally Advanced Rectal Cancer Who Receive Preoperative Chemoradiation Therapy. Ann Coloproctol 2019; 35:3-8. [PMID: 30879278 PMCID: PMC6425243 DOI: 10.3393/ac.2019.02.17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 02/17/2019] [Indexed: 12/20/2022] Open
Abstract
The current standard of care for treating patients with locally advanced rectal cancer includes preoperative chemoradiation therapy (PCRT) followed by a total mesorectal excision and postoperative adjuvant chemotherapy. A subset of these patients has achieved a pathologic complete response (pCR) and they have shown improved disease-free and overall survival compared to non-pCR patients. Thus, many efforts have been made to achieve a higher pCR through PCRT. In this review, results from various ongoing and recently completed clinical trials that are being or have been conducted with an aim to improve tumor response by modifying therapy will be discussed.
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Affiliation(s)
- Suk-Hwan Lee
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Seoul, Korea
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10
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Arcangeli S, Jereczek-Fossa BA, Alongi F, Aristei C, Becherini C, Belgioia L, Buglione M, Caravatta L, D'Angelillo RM, Filippi AR, Fiore M, Genovesi D, Greco C, Livi L, Magrini SM, Marvaso G, Mazzola R, Meattini I, Merlotti A, Palumbo I, Pergolizzi S, Ramella S, Ricardi U, Russi E, Trovò M, Sindoni A, Valentini V, Corvò R. Combination of novel systemic agents and radiotherapy for solid tumors - part I: An AIRO (Italian association of radiotherapy and clinical oncology) overview focused on treatment efficacy. Crit Rev Oncol Hematol 2018; 134:87-103. [PMID: 30658886 DOI: 10.1016/j.critrevonc.2018.11.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 11/13/2018] [Accepted: 11/20/2018] [Indexed: 02/07/2023] Open
Abstract
Over the past century, technologic advances have promoted the evolution of radiation therapy into a precise treatment modality allowing for the maximal administration of dose to tumors while sparing normal tissues. In parallel with this technological maturation, the rapid expansion in understanding the basic biology and heterogeneity of cancer has led to the development of several compounds that target specific pathways. Many of them are in advanced steps of clinical development for combination treatments with radiotherapy, and can be incorporated into radiation oncology practice for a personalized approach to maximize the therapeutic gain. This review describes the rationale for combining novel agents with radiation, and provides an overview of the current landscape focused on treatment efficacy.
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Affiliation(s)
- Stefano Arcangeli
- Department of Radiation Oncology, Policlinico S. Gerardo and University of Milan "Bicocca", Milan, Italy.
| | | | - Filippo Alongi
- Department of Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, Negrar-Verona, and University of Brescia, Brescia, Italy
| | - Cynthia Aristei
- Radiation Oncology Section, Department of Surgical and Biomedical Science, University of Perugia, Perugia General Hospital, Perugia, Italy
| | - Carlotta Becherini
- Radiotherapy Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Firenze, Italy
| | - Liliana Belgioia
- Department of Radiation Oncology, Ospedale Policlinico San Martino and University of Genoa, Genoa, Italy
| | - Michela Buglione
- Department of Radiation Oncology, University and Spedali Civili Hospital, Brescia, Italy
| | - Luciana Caravatta
- Department of Radiation Oncology, SS. Annunziata Hospital, G. D'Annunzio University of Chieti, Chieti, Italy
| | | | | | - Michele Fiore
- Radiotherapy Unit, Campus Bio-Medico University, Rome, Italy
| | - Domenico Genovesi
- Department of Radiation Oncology, SS. Annunziata Hospital, G. D'Annunzio University of Chieti, Chieti, Italy
| | - Carlo Greco
- Radiotherapy Unit, Campus Bio-Medico University, Rome, Italy
| | - Lorenzo Livi
- Radiotherapy Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Firenze, Italy
| | - Stefano Maria Magrini
- Department of Radiation Oncology, University and Spedali Civili Hospital, Brescia, Italy
| | - Giulia Marvaso
- Deparment of Radiation Oncology of IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Rosario Mazzola
- Department of Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, Negrar-Verona, and University of Brescia, Brescia, Italy
| | - Icro Meattini
- Radiotherapy Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Firenze, Italy
| | - Anna Merlotti
- Department of Radiation Oncology, S. Croce and Carle Teaching Hospital, Cuneo, Italy
| | - Isabella Palumbo
- Radiation Oncology Section, Department of Surgical and Biomedical Science, University of Perugia, Perugia General Hospital, Perugia, Italy
| | - Stefano Pergolizzi
- Department of Biomedical Sciences and Morphological and Functional Images, University of Messina, Italy
| | - Sara Ramella
- Radiotherapy Unit, Campus Bio-Medico University, Rome, Italy
| | | | - Elvio Russi
- Department of Radiation Oncology, S. Croce and Carle Teaching Hospital, Cuneo, Italy
| | - Marco Trovò
- Department of Radiation Oncology, Azienda Sanitaria Universitaria Integrata of Udine, Udine, Italy
| | - Alessandro Sindoni
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Vincenzo Valentini
- Gemelli Advanced Radiation Therapy Center, Fondazione Policlinico Universitario "A. Gemelli", Catholic University of Sacred Heart, Rome, Italy
| | - Renzo Corvò
- Department of Radiation Oncology, Ospedale Policlinico San Martino and University of Genoa, Genoa, Italy
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Arcangeli S, Jereczek-Fossa BA, Alongi F, Aristei C, Becherini C, Belgioia L, Buglione M, Caravatta L, D'Angelillo RM, Filippi AR, Fiore M, Genovesi D, Greco C, Livi L, Magrini SM, Marvaso G, Mazzola R, Meattini I, Merlotti A, Palumbo I, Pergolizzi S, Ramella S, Ricardi U, Russi E, Trovò M, Sindoni A, Valentini V, Corvò R. Combination of novel systemic agents and radiotherapy for solid tumors - Part II: An AIRO (Italian association of radiotherapy and clinical oncology) overview focused on treatment toxicity. Crit Rev Oncol Hematol 2018; 134:104-119. [PMID: 30658887 DOI: 10.1016/j.critrevonc.2018.11.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 11/13/2018] [Accepted: 11/20/2018] [Indexed: 12/31/2022] Open
Abstract
Clinical development and use of novel systemic agents in combination with radiotherapy (RT) is at nowadays most advanced in the field of treatment of solid tumors. Although for many of these substances preclinical studies provide sufficient evidences on their principal capability to enhance radiation effects, the majority of them have not been investigated in even phase I clinical trials for safety in the context of RT. In clinical practice, unexpected acute and late side effects may emerge especially in combination with RT. As a matter of fact, despite combined modality treatment holds potential for enhancing the therapeutic ratio, some concerns are raised from the lack of high-quality clinical data to guide the care of patients who are treated with novel compounds in conjunction with RT. The aim of this review is to provide, from a radio-oncological point of view, an overview of the most advanced combined treatment concepts for solid tumors focusing on treatment toxicity.
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Affiliation(s)
- Stefano Arcangeli
- Department of Radiation Oncology, Policlinico S. Gerardo and University of Milan "Bicocca", Milan, Italy.
| | | | - Filippo Alongi
- Department of Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, Negrar-Verona, University of Brescia, Brescia, Italy
| | - Cynthia Aristei
- Radiation Oncology Section, Department of Surgical and Biomedical Science, University of Perugia, Perugia General Hospital, Perugia, Italy
| | - Carlotta Becherini
- Radiotherapy Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Firenze, Italy
| | - Liliana Belgioia
- Department of Radiation Oncology, Ospedale Policlinico San Martino and University of Genoa, Genoa, Italy
| | - Michela Buglione
- Department of Radiation Oncology, University and Spedali Civili Hospital, Brescia, Italy
| | - Luciana Caravatta
- Department of Radiation Oncology, SS. Annunziata Hospital, G. D'Annunzio University of Chieti, Chieti, Italy
| | | | | | - Michele Fiore
- Radiotherapy Unit, Campus Bio-Medico University, Rome, Italy
| | - Domenico Genovesi
- Department of Radiation Oncology, SS. Annunziata Hospital, G. D'Annunzio University of Chieti, Chieti, Italy
| | - Carlo Greco
- Radiotherapy Unit, Campus Bio-Medico University, Rome, Italy
| | - Lorenzo Livi
- Radiotherapy Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Firenze, Italy
| | - Stefano Maria Magrini
- Department of Radiation Oncology, University and Spedali Civili Hospital, Brescia, Italy
| | - Giulia Marvaso
- Deparment of Radiation Oncology of IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Rosario Mazzola
- Department of Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, Negrar-Verona, University of Brescia, Brescia, Italy
| | - Icro Meattini
- Radiotherapy Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Firenze, Italy
| | - Anna Merlotti
- Department of Radiation Oncology, S. Croce and Carle Teaching Hospital, Cuneo, Italy
| | - Isabella Palumbo
- Radiation Oncology Section, Department of Surgical and Biomedical Science, University of Perugia, Perugia General Hospital, Perugia, Italy
| | - Stefano Pergolizzi
- Department of Biomedical Sciences and Morphological and Functional Images, University of Messina, Italy
| | - Sara Ramella
- Radiotherapy Unit, Campus Bio-Medico University, Rome, Italy
| | | | - Elvio Russi
- Department of Radiation Oncology, S. Croce and Carle Teaching Hospital, Cuneo, Italy
| | - Marco Trovò
- Department of Radiation Oncology, Azienda Sanitaria Universitaria Integrata of Udine, Udine, Italy
| | - Alessandro Sindoni
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Vincenzo Valentini
- Gemelli Advanced Radiation Therapy Center, Fondazione Policlinico Universitario "A. Gemelli", Catholic University of Sacred Heart, Rome, Italy
| | - Renzo Corvò
- Department of Radiation Oncology, Ospedale Policlinico San Martino and University of Genoa, Genoa, Italy
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12
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Beppu N, Yanagi H, Tomita N. A review of preoperative chemoradiotherapy for lower rectal cancer. JOURNAL OF THE ANUS RECTUM AND COLON 2018; 1:65-73. [PMID: 31583303 PMCID: PMC6768672 DOI: 10.23922/jarc.2017-013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 04/06/2017] [Indexed: 12/22/2022]
Abstract
In Western countries, rectal cancer has been treated by chemoradiotherapy (CRT) for several decades now, and good local control has been reported. However, Japanese guidelines did not strongly recommend CRT, because CRT is only useful for achieving local control and imbues no survival benefit. For this reason, CRT was rarely used to treat rectal cancer in Japan. However, in the 2000s, several studies involving CRT began to be reported from Western countries, such as “correlation between pathological complete response and survival,” “induction chemotherapy followed by CRT,” and “watch-and-wait policies.” These studies were directly correlated with survival of and benefits to the patients. Given these findings, Japanese institutions have recently begun to introduce CRT for rectal cancer. Therefore, in the present study, we reviewed several topics regarding CRT for rectal cancer.
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Affiliation(s)
- Naohito Beppu
- Department of Surgery, Meiwa Hospital Nishinomiya, Hyogo, Japan
| | - Hidenori Yanagi
- Department of Surgery, Meiwa Hospital Nishinomiya, Hyogo, Japan
| | - Naohiro Tomita
- Division of Lower Gastrointestinal Surgery, Department of Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
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13
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Zhong X, Wu Z, Gao P, Shi J, Sun J, Guo Z, Wang Z, Song Y. The efficacy of adding targeted agents to neoadjuvant therapy for locally advanced rectal cancer patients: a meta-analysis. Cancer Med 2018; 7:565-582. [PMID: 29464874 PMCID: PMC5852374 DOI: 10.1002/cam4.1298] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 11/22/2017] [Accepted: 11/26/2017] [Indexed: 12/19/2022] Open
Abstract
Patients with locally advanced rectal cancer (LARC) are at tremendous risk of metastatic diseases. To improve the prognoses of LARC patients, the efficacy of adding targeted agents to neoadjuvant therapy has been investigated by many researchers but remains controversial. A literature search of relevant databases was conducted through December 2016, 804 studies were identified and 32 investigations were ultimately included. A total of 1196 patients from 31 cohorts of 29 studies were eligible for quantitative synthesis in this single‐arm setting meta‐analysis. As pathologic complete response (pCR) shows promise as a prognosis indicator, we focused on pCR rates to evaluate whether adding targeted agents to neoadjuvant therapies improves the outcome of LARC patients. In our study, we revealed pooled estimates of pCR of 27% (95%CI, 21–34%) and 14% (95%CI, 9–21%) for bevacizumab‐relevant cohorts and cetuximab‐relevant cohorts, respectively. The safety of adding targeted agents to neoadjuvant therapy was also evaluated by pooling the data of Grade 3/4 toxicity. In conclusion, our study revealed that adding bevacizumab to the neoadjuvant therapy regimens provides appreciable pCR for LARC patients. Meanwhile, the efficacy of cetuximab remains inconclusive, RCTs with larger scale and better study design that stress more on mutational status are needed.
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Affiliation(s)
- Xi Zhong
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang, 110001, China
| | - Zhonghua Wu
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang, 110001, China
| | - Peng Gao
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang, 110001, China
| | - Jinxin Shi
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang, 110001, China
| | - Jingxu Sun
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang, 110001, China
| | - Zhexu Guo
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang, 110001, China
| | - Zhenning Wang
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang, 110001, China
| | - Yongxi Song
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang, 110001, China
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14
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Teo MTW, McParland L, Appelt AL, Sebag-Montefiore D. Phase 2 Neoadjuvant Treatment Intensification Trials in Rectal Cancer: A Systematic Review. Int J Radiat Oncol Biol Phys 2017; 100:146-158. [PMID: 29254769 DOI: 10.1016/j.ijrobp.2017.09.042] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 08/23/2017] [Accepted: 09/21/2017] [Indexed: 12/12/2022]
Abstract
PURPOSE Multiple phase 2 trials of neoadjuvant treatment intensification in locally advanced rectal cancer have reported promising efficacy signals, but these have not translated into improved cancer outcomes in phase 3 trials. Improvements in phase 2 trial design are needed to reduce these false-positive signals. This systematic review evaluated the design of phase 2 trials of neoadjuvant long-course radiation or chemoradiation therapy treatment intensification in locally advanced rectal cancer. METHODS AND MATERIALS The PubMed, EMBASE, MEDLINE, and Cochrane Library databases were searched for published phase 2 trials of neoadjuvant treatment intensification from 2004 to 2016. Trial clinical design and outcomes were assessed, with statistical design and compliance rated using a previously published system. Multivariable meta-regression analysis of pathologic complete response (pCR) was conducted. RESULTS We identified 92 eligible trials. Patients with American Joint Committee on Cancer stage II and III equivalent disease were eligible in 87 trials (94.6%). In 43 trials (46.7%), local staging on magnetic resonance imaging was mandated. Only 12 trials (13.0%) were randomized, with 8 having a standard-treatment control arm. Just 51 trials (55.4%) described their statistical design, with 21 trials (22.8%) failing to report their sample size derivation. Most trials (n=84, 91.3%) defined a primary endpoint, but 15 different primary endpoints were used. All trials reported pCR rates. Only 38 trials (41.3%) adequately reported trial statistical design and compliance. Meta-analysis revealed a pooled pCR rate of 17.5% (95% confidence interval, 15.7%-19.4%) across treatment arms of neoadjuvant long-course radiation or chemoradiation therapy treatment intensification and substantial heterogeneity among the reported effect sizes (I2 = 55.3%, P<.001). Multivariable meta-regression analysis suggested increased pCR rates with higher radiation therapy doses (adjusted P=.025). CONCLUSIONS Improvement in the design of future phase 2 rectal cancer trials is urgently required. A significant increase in randomized trials is essential to overcome selection bias and determine novel schedules suitable for phase 3 testing. This systematic review provides key recommendations to guide future treatment intensification trial design in rectal cancer.
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Affiliation(s)
- Mark T W Teo
- Radiotherapy Research Group, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK; Leeds Cancer Centre, St James University Hospital, Leeds, UK
| | - Lucy McParland
- Radiotherapy Research Group, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK; Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Ane L Appelt
- Radiotherapy Research Group, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK; Leeds Cancer Centre, St James University Hospital, Leeds, UK
| | - David Sebag-Montefiore
- Radiotherapy Research Group, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK; Leeds Cancer Centre, St James University Hospital, Leeds, UK.
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15
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Benevento I, De Felice F, Musio D, Tombolini V. The Addition of Target Therapy to Neoadjuvant Chemoradiotherapy in Locally Advanced Rectal Cancer: A Review. Chemotherapy 2017; 62:314-322. [PMID: 28595169 DOI: 10.1159/000476056] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 04/25/2017] [Indexed: 12/18/2022]
Abstract
Currently, neoadjuvant fluoropyrimidine-based chemoradiotherapy (CRT) is standard practice in the management of locally advanced rectal cancer (LARC). In the last decade there has been a lively interest in the improvement of clinical outcomes by modifying this standard regimen by the addition of further agents. We review combinations of targeted therapies and conventional CRT currently under investigation in LARC patients.
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Affiliation(s)
- Ilaria Benevento
- Department of Radiotherapy, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
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16
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Hamming LC, Slotman BJ, Verheul HMW, Thijssen VL. The clinical application of angiostatic therapy in combination with radiotherapy: past, present, future. Angiogenesis 2017; 20:217-232. [PMID: 28364160 PMCID: PMC5437175 DOI: 10.1007/s10456-017-9546-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 03/14/2017] [Indexed: 12/14/2022]
Abstract
Although monotherapy with angiostatic drugs is still far from effective, there is abundant evidence that angiostatic therapy can improve the efficacy of conventional treatments like radiotherapy. This has instigated numerous efforts to optimize and clinically implement the combination of angiostatic drugs with radiation treatment. The results from past and present clinical trials that explored this combination therapy indeed show encouraging results. However, current findings also show that the combination has variable efficacy and is associated with increased toxicity. This indicates that combining radiotherapy with angiostatic drugs not only holds opportunities but also provides several challenges. In the current review, we provide an update of the most recent insights from clinical trials that evaluated the combination of angiostatic drugs with radiation treatment. In addition, we discuss the outstanding questions for future studies in order to improve the clinical benefit of combining angiostatic therapy with radiation therapy.
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Affiliation(s)
- Lisanne C Hamming
- Department of Medical Oncology, VU University Medical Centre, De Boelelaan 1118, 1081 HV, Amsterdam, The Netherlands
| | - Ben J Slotman
- Department of Radiation Oncology, VU University Medical Centre, De Boelelaan 1118, 1081 HV, Amsterdam, The Netherlands
| | - Henk M W Verheul
- Department of Medical Oncology, VU University Medical Centre, De Boelelaan 1118, 1081 HV, Amsterdam, The Netherlands
| | - Victor L Thijssen
- Department of Radiation Oncology, VU University Medical Centre, De Boelelaan 1118, 1081 HV, Amsterdam, The Netherlands.
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17
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Lee KH, Kim JS, Kim JY. Long-term oncologic outcomes of neoadjuvant concurrent chemoradiotherapy with capecitabine and radical surgery in locally advanced rectal cancer: 10-year experiences at a single institution. Ann Surg Treat Res 2016; 91:178-186. [PMID: 27757395 PMCID: PMC5064228 DOI: 10.4174/astr.2016.91.4.178] [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: 07/05/2016] [Revised: 08/22/2016] [Accepted: 09/05/2016] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Oral capecitabine has demonstrated to be safe and efficient as neoadjuvant concurrent chemoradiotherapy (NCRT) for locally advanced rectal cancers. The aim of this study was to evaluate the long-term oncologic outcomes of NCRT with capecitabine and radical surgery. METHODS From January 2000 to June 2010, 238 patients were treated at our center for locally advanced rectal cancers using conventional NCRT with capecitabine and radical surgery. Univariate and multivariate analyses were used to evaluate the factors associated with oncologic outcomes with log rank and Cox regression tests. RESULTS The incidence of grade >3 capecitabine-related toxicity was found to be 4.6%. A pathologic complete response was observed in 14.7% of patients. The 5-year overall and 5-year disease-free survival rate, local and systemic recurrence rate were 82.8%, 75.1%, 4.8%, and 20.3%. Abdominoperineal resection and node-positive disease were independent prognostic factors of 5-year overall survival, 5-year disease-free survival, and systemic recurrence. CONCLUSION NCRT with capecitabine and radical surgery showed favorable long-term oncologic outcomes with benefits of acceptable toxicity and convenience. We suggest that capecitabine can be one of the favorable therapeutic options for NCRT in rectal cancer.
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Affiliation(s)
- Kyung Ha Lee
- Department of Surgery, Chungnam National University Hospital, Daejeon, Korea
| | - Jin Soo Kim
- Department of Surgery, Chungnam National University Hospital, Daejeon, Korea
| | - Ji Yeon Kim
- Department of Surgery, Chungnam National University Hospital, Daejeon, Korea
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18
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Avallone A, Pecori B, Bianco F, Aloj L, Tatangelo F, Romano C, Granata V, Marone P, Leone A, Botti G, Petrillo A, Caracò C, Iaffaioli VR, Muto P, Romano G, Comella P, Budillon A, Delrio P. Critical role of bevacizumab scheduling in combination with pre-surgical chemo-radiotherapy in MRI-defined high-risk locally advanced rectal cancer: Results of the BRANCH trial. Oncotarget 2016; 6:30394-407. [PMID: 26320185 PMCID: PMC4745808 DOI: 10.18632/oncotarget.4724] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Accepted: 07/17/2015] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND We have previously shown that an intensified preoperative regimen including oxaliplatin plus raltitrexed and 5-fluorouracil/folinic acid (OXATOM/FUFA) during preoperative pelvic radiotherapy produced promising results in locally advanced rectal cancer (LARC). Preclinical evidence suggests that the scheduling of bevacizumab may be crucial to optimize its combination with chemo-radiotherapy. PATIENTS AND METHODS This non-randomized, non-comparative, phase II study was conducted in MRI-defined high-risk LARC. Patients received three biweekly cycles of OXATOM/FUFA during RT. Bevacizumab was given 2 weeks before the start of chemo-radiotherapy, and on the same day of chemotherapy for 3 cycles (concomitant-schedule A) or 4 days prior to the first and second cycle of chemotherapy (sequential-schedule B). Primary end point was pathological complete tumor regression (TRG1) rate. RESULTS The accrual for the concomitant-schedule was early terminated because the number of TRG1 (2 out of 16 patients) was statistically inconsistent with the hypothesis of activity (30%) to be tested. Conversely, the endpoint was reached with the sequential-schedule and the final TRG1 rate among 46 enrolled patients was 50% (95% CI 35%-65%). Neutropenia was the most common grade ≥ 3 toxicity with both schedules, but it was less pronounced with the sequential than concomitant-schedule (30% vs. 44%). Postoperative complications occurred in 8/15 (53%) and 13/46 (28%) patients in schedule A and B, respectively. At 5 year follow-up the probability of PFS and OS was 80% (95%CI, 66%-89%) and 85% (95%CI, 69%-93%), respectively, for the sequential-schedule. CONCLUSIONS These results highlights the relevance of bevacizumab scheduling to optimize its combination with preoperative chemo-radiotherapy in the management of LARC.
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Affiliation(s)
- Antonio Avallone
- Gastrointestinal Medical Oncology Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" - IRCCS, 80131, Napoli, Italy
| | - Biagio Pecori
- Radiotherapy Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" - IRCCS, 80131, Napoli, Italy
| | - Franco Bianco
- Gastrointestinal Surgery, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" - IRCCS, 80131, Napoli, Italy
| | - Luigi Aloj
- Nuclear Medicine Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" - IRCCS, 80131, Napoli, Italy
| | - Fabiana Tatangelo
- Pathology Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" - IRCCS, 80131, Napoli, Italy
| | - Carmela Romano
- Gastrointestinal Medical Oncology Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" - IRCCS, 80131, Napoli, Italy
| | - Vincenza Granata
- Radiology Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" - IRCCS, 80131, Napoli, Italy
| | - Pietro Marone
- Endoscopy Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" - IRCCS, 80131, Napoli, Italy
| | - Alessandra Leone
- Experimental Pharmacology Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" - IRCCS, 80131, Napoli, Italy
| | - Gerardo Botti
- Pathology Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" - IRCCS, 80131, Napoli, Italy
| | - Antonella Petrillo
- Radiology Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" - IRCCS, 80131, Napoli, Italy
| | - Corradina Caracò
- Nuclear Medicine Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" - IRCCS, 80131, Napoli, Italy
| | - Vincenzo R Iaffaioli
- Gastrointestinal Medical Oncology Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" - IRCCS, 80131, Napoli, Italy
| | - Paolo Muto
- Radiotherapy Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" - IRCCS, 80131, Napoli, Italy
| | - Giovanni Romano
- Gastrointestinal Surgery, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" - IRCCS, 80131, Napoli, Italy
| | - Pasquale Comella
- Gastrointestinal Medical Oncology Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" - IRCCS, 80131, Napoli, Italy
| | - Alfredo Budillon
- Experimental Pharmacology Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" - IRCCS, 80131, Napoli, Italy
| | - Paolo Delrio
- Colorectal Surgery Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" - IRCCS, 80131, Napoli, Italy
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Baumann R, Depping R, Delaperriere M, Dunst J. Targeting hypoxia to overcome radiation resistance in head & neck cancers: real challenge or clinical fairytale? Expert Rev Anticancer Ther 2016; 16:751-8. [PMID: 27253509 DOI: 10.1080/14737140.2016.1192467] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Tumor hypoxia is a major cause for failure of therapy in patients with inoperable head and neck cancers. AREAS COVERED Various anti-hypoxic treatment strategies (e.g. hyperbaric oxygenation, hypoxic cell sensitizers) have been tested in clinical trials in head and neck cancer over the past 30 years and have shown modest improvements in combination with radiotherapy in meta-analyses. Anemia worsens tumor hypoxia, but anemia correction had no significant effect. New approaches (e.g. anti-HIF-directed molecular therapies) have just entered early clinical studies and data are lacking. Expert commentary: A new attractive and promising approach derives from recent advances in imaging and radiotherapy delivery. Progress in imaging of hypoxia (e.g. by positron emission tomography) can select patients for specific therapies and may, in particular, facilitate anti-hypoxia-directed radiotherapy which has become feasible with advanced radiotherapy techniques (IMRT with 'dose-painting'). The combination of both methods may offer a powerful tool for effective targeting of hypoxia in the near future.
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Affiliation(s)
- René Baumann
- a Department of Radiation Oncology , Christian-Albrechts-University Kiel , Kiel , Germany
| | - Reinhard Depping
- b Institute of Physiology , University of Luebeck , Luebeck , Germany
| | - Marc Delaperriere
- a Department of Radiation Oncology , Christian-Albrechts-University Kiel , Kiel , Germany
| | - Juergen Dunst
- a Department of Radiation Oncology , Christian-Albrechts-University Kiel , Kiel , Germany
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20
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Abstract
Preoperative radiotherapy has an accepted role in reducing the risk of local recurrence in locally advanced resectable rectal cancer, particularly when the circumferential resection margin is breached or threatened, according to magnetic resonance imaging. Fluoropyrimidine-based chemoradiation can obtain a significant down-sizing response and a curative resection can then be achieved. Approximately, 20% of the patients can also obtain a pathological complete response, which is associated with less local recurrences and increased survival. Patients who achieve a sustained complete clinical response may also avoid radical surgery. In unresectable or borderline resectable tumors, around 20% of the patients still fail to achieve a sufficient down-staging response with the current chemoradiation schedules. Hence, investigators have aspired to increase pathological complete response rates, aiming to improve curative resection rates, enhance survival, and potentially avoid mutilating surgery. However, adding additional cytotoxic or biological agents have not produced dramatic improvements in outcome and often led to excess surgical morbidity and higher levels of acute toxicity, which effects on compliance and in the global efficacy of chemoradiation.
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Affiliation(s)
- Rob Glynne-Jones
- Mount Vernon Centre for Cancer Treatment, Northwood, Middlesex, UK.
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21
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Jeong JH, Hong YS, Park Y, Kim J, Kim JE, Kim KP, Kim SY, Park JH, Kim JH, Park IJ, Lim SB, Yu CS, Kim JC, Kim TW. Phase 1 Study of Preoperative Chemoradiation Therapy With Temozolomide and Capecitabine in Patients With Locally Advanced Rectal Cancer. Int J Radiat Oncol Biol Phys 2016; 96:289-295. [PMID: 27473815 DOI: 10.1016/j.ijrobp.2016.05.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 05/05/2016] [Accepted: 05/10/2016] [Indexed: 12/21/2022]
Abstract
PURPOSE Preoperative chemoradiation therapy (CRT) with capecitabine is a standard treatment strategy in patients with locally advanced rectal cancer (LARC). Temozolomide improves the survival of patients with glioblastoma with hypermethylated O(6)-methylguanine DNA methyltransferase (MGMT); MGMT hypermethylation is one of the colorectal carcinogenesis pathways. We aimed to determine the dose-limiting toxicity (DLT) and recommended dose (RD) of temolozomide in combination with capecitabine-based preoperative CRT for LARC. METHODS AND MATERIALS Radiation therapy was delivered with 45 Gy/25 daily fractions with coned-down boost of 5.4 Gy/3 fractions. Concurrent chemotherapy comprised fixed and escalated doses of capecitabine and temozolomide, respectively. The MGMT hypermethylation was evaluated in pretreatment tumor samples. This trial is registered with ClinicalTrials.gov with the number NCT01781403. RESULTS Twenty-two patients with LARC of cT3-4N0 or cTanyN1-2 were accrued. Dose level 3 was chosen as the RD because DLT was noticeably absent in 10 patients treated up to dose level 3. An additional 12 patients were recruited in this group. Grade III adverse events were noted, and pathologic complete response (pCR) was observed in 7 patients (31.8%); MGMT hypermethylation was detected in 16. The pCR rate was 37.5% and 16.7% in the hypermethylated and unmethylated MGMT groups, respectively (P=.616). CONCLUSIONS There was a tendency toward higher pCR rates in patients with hypermethylated MGMT. Future randomized studies are therefore warranted.
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Affiliation(s)
- Jae Ho Jeong
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong Sang Hong
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yangsoon Park
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jihun Kim
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Eun Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyu-Pyo Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sun Young Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin-Hong Park
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong Hoon Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In Ja Park
- Department of Colorectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seok-Byung Lim
- Department of Colorectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang Sik Yu
- Department of Colorectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Cheon Kim
- Department of Colorectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae Won Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Greenhalgh T, Dearman C, Sharma R. Combination of Novel Agents with Radiotherapy to Treat Rectal Cancer. Clin Oncol (R Coll Radiol) 2016; 28:116-139. [DOI: 10.1016/j.clon.2015.11.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Revised: 10/25/2015] [Accepted: 10/26/2015] [Indexed: 02/07/2023]
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23
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Mallick S, Benson R, Haresh K, Rath G. Neoadjuvant treatment intensification or adjuvant chemotherapy for locally advanced carcinoma rectum: The optimum treatment approach remains unresolved. J Egypt Natl Canc Inst 2015; 27:179-85. [DOI: 10.1016/j.jnci.2015.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Revised: 05/13/2015] [Accepted: 05/14/2015] [Indexed: 10/23/2022] Open
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Combining bevacizumab and chemoradiation in rectal cancer. Translational results of the AXEBeam trial. Br J Cancer 2015; 112:1314-25. [PMID: 25867261 PMCID: PMC4402460 DOI: 10.1038/bjc.2015.93] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 12/04/2014] [Accepted: 02/12/2015] [Indexed: 02/06/2023] Open
Abstract
Background: This study characterises molecular effect of bevacizumab, and explores the relation of molecular and genetic markers with response to bevacizumab combined with chemoradiotherapy (CRT). Methods: From a subset of 59 patients of 84 rectal cancer patients included in a phase II study combining bevacizumab with CRT, tumour and blood samples were collected before and during treatment, offering the possibility to evaluate changes induced by one dose of bevacizumab. We performed cDNA microarrays, stains for CD31/CD34 combined with α-SMA and CA-IX, as well as enzyme-linked immunosorbent assay (ELISA) for circulating angiogenic proteins. Markers were related with the pathological response of patients. Results: One dose of bevacizumab changed the expression of 14 genes and led to a significant decrease in microvessel density and in the proportion of pericyte-covered blood vessels, and a small but nonsignificant increase in hypoxia. Alterations in angiogenic processes after bevacizumab delivery were only detected in responding tumours. Lower PDGFA expression and PDGF-BB levels, less pericyte-covered blood vessels and higher CA-IX expression were found after bevacizumab treatment only in patients with pathological complete response. Conclusions: We could not support the ‘normalization hypothesis' and suggest a role for PDGFA, PDGF-BB, CA-IX and α-SMA. Validation in larger patient groups is needed.
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Wu B, Li T, Cai J, Xu Y, Zhao G. Cost-effectiveness analysis of adjuvant chemotherapies in patients presenting with gastric cancer after D2 gastrectomy. BMC Cancer 2014; 14:984. [PMID: 25526802 PMCID: PMC4301844 DOI: 10.1186/1471-2407-14-984] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 12/10/2014] [Indexed: 12/26/2022] Open
Abstract
Background To analyze and compare the economic outcomes of adjuvant chemotherapy with capecitabine plus oxaliplatin (referred to as the XELOX strategy) and of S-1 (the S-1 strategy) for gastric cancer patients after D2 gastrectomy. Methods A Markov model was developed to simulate the lifetime disease course associated with stage II or III gastric cancer after D2 gastrectomy. The lifetime quality-adjusted life years (QALYs), associated costs, and incremental cost-effectiveness ratios (ICERs) were estimated. The clinical data were derived from the results of pilot studies. Direct costs were estimated from the perspective of the Chinese healthcare system, and the utility data were measured from end-point observations of Chinese patients. Sensitivity analyses were used to explore the impact of uncertainty on the model’s outcomes. Results The combined adjuvant chemotherapy strategy with XELOX yielded the greatest increase in QALYs over the course of the disease (8.1 QALYs compared with 7.8 QALYs for the S-1 strategy and 6.2 for surgery alone). The incremental cost per QALY gained using the XELOX strategy was significantly lower than that for the S-1 strategy ($3,502 vs. $6,837, respectively). The results were sensitive to the costs of oxaliplatin and the hazard ratio of relapse-free survival. Conclusion The observations reported herein suggest that adjuvant therapy with capecitabine plus oxaliplatin is a highly cost-effective strategy and more favorable treatment option than the S-1 strategy in patients with stage II or III gastric cancer who have undergone D2 gastrectomy.
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Affiliation(s)
| | | | | | | | - Gang Zhao
- Department of General Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
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Borg C, André T, Mantion G, Boudghène F, Mornex F, Maingon P, Adenis A, Azria D, Piutti M, Morsli O, Bosset J. Pathological response and safety of two neoadjuvant strategies with bevacizumab in MRI-defined locally advanced T3 resectable rectal cancer: a randomized, noncomparative phase II study. Ann Oncol 2014; 25:2205-2210. [DOI: 10.1093/annonc/mdu377] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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A clinical study of metastasized rectal cancer treatment: assessing a multimodal approach. Med Oncol 2014; 31:839. [PMID: 24477647 PMCID: PMC3933738 DOI: 10.1007/s12032-014-0839-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 01/09/2014] [Indexed: 12/21/2022]
Abstract
Metastasized rectal cancer has long been considered incurable. During recent years, the treatment of rectal cancer patients has been improved, and nowadays, a subgroup of patients might even be cured. The aim of this study was to investigate the optimal timing of treatment in a multimodal therapy schedule in order to see whether the addition of bevacizumab (Avastin) to conventional chemotherapy was effective. The study included 39 patients with metastatic rectal cancer between 2009 and 2011, and three were excluded due to the lack of metastases or lack of follow-up information. The remaining 36 patients were divided into groups by treatment intention. The group with curative intention received mainly oxaliplatin (Eloxatin) in combination with capecitabine (Xeloda) with or without bevacizumab (Avastin) for 2 months followed by preoperative radiotherapy (RT) and surgery. Palliative patients had very different treatments depending on their needs of palliation. The median survival time for patients with curative intention was 31 months and for the palliative patients 12 months. Four of the patients (11 %) with curative intention were considered cured at the end of follow-up. The response to chemotherapy after 2-month treatment is a good prognostic sign for which patients can be cured. Long-lasting palliation can be obtained with this treatment schedule. The main side effects were gastrointestinal events, including bowel perforation, neuropathy, thrombo-embolic disease and reduced general condition. All side effects are known, and the treatment is considered tolerable. We conclude that a good treatment schedule would be oxaliplatin (Eloxatin) in combination with capecitabine (Xeloda) with or without bevacizumab (Avastin) for 2 months, followed by preoperative RT and surgery.
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Dellas K, Buller J, Görtz GJ, Richter M, Höhler T, Arnold D, Keck T, Dunst J, Zühlke H. Analysis of bevacizumab-based preoperative radiochemotherapy in patients with locally advanced rectal cancer on surgery-associated spectrum of complications. Ann Surg Oncol 2013; 21:1352-60. [PMID: 24306667 DOI: 10.1245/s10434-013-3412-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Indexed: 01/16/2023]
Abstract
BACKGROUND Preoperative radiochemotherapy (RCT) is a standard of care for patients with locally advanced rectal cancer (LARC; stages II and III). Results of our phase II study (BevXelOx-RT) have shown that this regimen is feasible but without a significant improvement of pathological complete response. Whether preoperatively administered bevacizumab, due to its specific toxicity profile, leads to increased rates of surgical complications is currently a subject for debate. This analysis focusses on the surgery-associated spectrum of complications. METHODS Data from 62 patients with rectal cancer (uT3-4; N0/1, M0) of the phase II trial were analyzed. Patients received radiotherapy (50.4/1.8 Gy fractions), simultaneous bevacizumab 5 mg/kg (d1, d15, d29), and capecitabine 825 mg/m(2) twice daily (d1-14, d22-35), oxaliplatin 50 mg/m(2) (d1, d8, d22, d29). Four to six weeks after RCT, surgical resection was performed. RESULTS Overall, 69/69 patients underwent surgery, and 66 (95.7 %) patients had R0 resection. Surgery was mainly conducted (in 66 %) by highly experienced surgeons (>20 resections of rectal cancer/year) with differences between the institutions due to the operative procedures but without effects on the rate of R0 resection or complications. The average duration of surgery was 239 min (±10). Frequency of multivisceral resections (11 %), intraoperative (8 %) and postoperative (43 %) complications were all in the expected range. In particular, we did not observe an increased rate of postoperative bleedings (3 %). The postoperative mortality rate was 0 %. CONCLUSIONS Quantity and the kind of surgery-associated spectrum of complications followed by a preoperative bevacizumab-containing RCT regimen in patients with LARC were in line with comparable trials of bevacizumab-based approaches.
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Affiliation(s)
- Kathrin Dellas
- Department of Radiooncology Kiel/Luebeck, University of Kiel, Kiel, Germany,
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Valentini V, Glimelius B, Haustermans K, Marijnen CAM, Rödel C, Gambacorta MA, Boelens PG, Aristei C, van de Velde CJH. EURECCA consensus conference highlights about rectal cancer clinical management: the radiation oncologist's expert review. Radiother Oncol 2013; 110:195-8. [PMID: 24286634 DOI: 10.1016/j.radonc.2013.10.024] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 10/20/2013] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE Although rectal and colon cancer management has progressed greatly in the last few decades clinical outcomes still need to be optimized. Furthermore, consensus is required on several issues as some of the main international guidelines provide different recommendations. The European Registration of Cancer Care (EURECCA) drew up documents to standardize management and care in Europe and aid in decision-making. MATERIAL AND METHODS In the present section the panel of experts reviews and discusses data from the literature on rectal cancer, focusing on recommendations for selecting between short-course radiotherapy (SCRT) and long-course radio-chemotherapy (LCRTCT) as preoperative treatment as well as on the controversies about adjuvant treatment in patients who had received a pre-operative treatment. RESULTS The starting-point of the present EURECCA document is that adding SCRT or LCRTCT to TME improved loco-regional control but did not increase overall survival in any single trial which, in any case, had improved with the introduction of total mesorectal excision (TME) into clinical practice. Moderate consensus was achieved for cT3 anyNM0 disease. In this frame, agreement was reached on either SCRT followed by immediate surgery or LCRTCT with delayed surgery for mesorectal fascia (MRF) negative tumors at presentation. LCRTCT was recommended for tumor shrinkage in MRF+ at presentations but if patients were not candidates for chemotherapy, SCRT with delayed surgery is an option/alternative. LCRTCT was recommended for cT4 anycNM0. SCRT offers the advantages of less acute toxicity and lower costs, and LCRTCT tumor shrinkage and down-staging, with 13-36% pathological complete response (pCR) rates. To improve the efficacy of preoperative treatment both SCRT and LCRTCT have been, or are being, associated with diverse schedules of chemotherapy and even new targeted therapies but without any definitive evidence of benefit. Nowadays, standard treatment is fluoropyrimidine alone since alternative agents and regimens have not been shown to be more active, only more toxic. CONCLUSIONS The EURECCA panel summarized available evidence in an attempt to reduce variance in rectal cancer management. This is expected to benefit patients. Results from ongoing randomized trials will help clarify some of the issues that are still under debate.
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Affiliation(s)
- Vincenzo Valentini
- Department of Radiation Oncology, Cattedra di Radioterapia, Università Cattolica S. Cuore, Rome, Italy
| | - Bengt Glimelius
- Department of Radiology, Oncology and Radiation Science, Uppsala University, Sweden
| | - Karin Haustermans
- Department of Radiation Oncology, University Hospitals Leuven Campus Gasthuisberg, Belgium
| | - Corrie A M Marijnen
- Department of Clinical Oncology, Leiden University Medical Center, The Netherlands
| | - Claus Rödel
- Radiation Oncology, University Hospital of Frankfurt, Germany
| | | | - Petra G Boelens
- Department of Surgery, Leiden University Medical Center, The Netherlands
| | - Cynthia Aristei
- Radiation Oncology Section, Department of Surgery, Radiology and Dentistry, University of Perugia, Italy
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Glynne-Jones R, Hadaki M, Harrison M. The status of targeted agents in the setting of neoadjuvant radiation therapy in locally advanced rectal cancers. J Gastrointest Oncol 2013; 4:264-84. [PMID: 23997939 DOI: 10.3978/j.issn.2078-6891.2013.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 05/21/2013] [Indexed: 12/18/2022] Open
Abstract
Radiotherapy has a longstanding and well-defined role in the treatment of resectable rectal cancer to reduce the historically high risk of local recurrence. In more advanced borderline or unresectable cases, where the circumferential resection margin (CRM) is breached or threatened according to magnetic resonance imaging (MRI), despite optimized local multimodality treatment and the gains achieved by modern high quality total mesorectal excision (TME), at least half the patients fail to achieve sufficient downstaging with current schedules. Many do not achieve an R0 resection. In less locally advanced cases, even if local control is achieved, this confers only a small impact on distant metastases and a significant proportion of patients (30-40%) still subsequently develop metastatic disease. In fact, distant metastases have now become the predominant cause of failure in rectal cancer. Therefore, increasing the intensity and efficacy of chemotherapy and chemoradiotherapy by integrating additional cytotoxics and biologically targetted agents seems an appealing strategy to explore-with the aim of enhancing curative resection rates and improving distant control and survival. However, to date, we lack validated biomarkers for these biological agents apart from wild-type KRAS. For cetuximab, the appearance of an acneiform rash is associated with response, but low levels of magnesium appear more controversial. There are no molecular biomarkers for bevacizumab. Although some less invasive clinical markers have been proposed for bevacizumab, such as circulating endothelial cells (CECS), circulating levels of VEGF and the development of overt hypertension, these biomarkers have not been validated and are observed to emerge only after a trial of the agent. We also lack a simple method of ongoing monitoring of 'on target' effects of these biological agents, which could determine and pre-empt the development of resistance, prior to radiological and clinical assessessments or even molecular imaging. These shortcomings probably explain our current relative lack of success in the arena of combining these agents with chemoradiation.
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