1
|
Nazari R, Piozzi GN, Ghalehtaki R, Ahmadi-Tafti SM, Behboudi B, Mousavi Darzikolaee N, Aghili M, Gambacorta MA. Role of Oxaliplatin in the Neoadjuvant Concurrent Chemoradiotherapy in Locally Advanced Rectal Cancer: a Review of Evidence. Clin Med Insights Oncol 2024; 18:11795549241236409. [PMID: 38510317 PMCID: PMC10952988 DOI: 10.1177/11795549241236409] [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: 07/29/2023] [Accepted: 02/12/2024] [Indexed: 03/22/2024] Open
Abstract
The treatment of locally advanced rectal cancer (LARC) is a challenging situation for radiation oncologists and colorectal surgeons. Most current approaches recommend neoadjuvant fluorouracil or capecitabine-based chemoradiotherapy followed by surgery as a standard of care. Intensification of concurrent chemotherapy by adding oxaliplatin to fluorouracil or capecitabine backbone to get better outcomes is the matter that has remained unresolved. In this review, we searched Medline and Google Scholar databases and selected 28 prospective phase II and III clinical trials that addressed this question. We discussed the potential advantages and drawbacks of incorporating oxaliplatin into concurrent chemoradiation therapy. We tried to define whether adding oxaliplatin to concurrent chemoradiation with excellent performance and high-risk features benefits some subpopulations. The available literature suggests that by adding oxaliplatin there are some benefits in enhancing response to neoadjuvant chemoradiotherapy, however, without any translated improvements in long-term outcomes including overall and disease-free survival.
Collapse
Affiliation(s)
- Reza Nazari
- Department of Radiation Oncology, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Guglielmo Niccolò Piozzi
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Reza Ghalehtaki
- Department of Radiation Oncology, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
- Radiation Oncology Research Center, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Mohsen Ahmadi-Tafti
- Division of Colorectal Surgery, Department of Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran
| | - Behnam Behboudi
- Division of Colorectal Surgery, Department of Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran
| | - Nima Mousavi Darzikolaee
- Department of Radiation Oncology, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahdi Aghili
- Radiation Oncology Research Center, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Maria Antonietta Gambacorta
- UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| |
Collapse
|
2
|
Liao CK, Kuo YT, Chern YJ, Hsu YJ, Lin YC, Yu YL, Hsieh PS, Chiang JM, Yeh CY, You JF. Tegafur-Uracil/Leucovorin Plus Oxaliplatin (TEGAFOX) as Consolidation Regimen after Short-Course Radiotherapy Is Effective for Locally Advanced Rectal Cancer. J Clin Med 2022; 11:jcm11102920. [PMID: 35629045 PMCID: PMC9146085 DOI: 10.3390/jcm11102920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/26/2022] [Accepted: 05/20/2022] [Indexed: 11/25/2022] Open
Abstract
This study aimed to explore the safety and efficacy of neoadjuvant SCRT and tegafur−uracil/leucovorin plus oxaliplatin (TEGAFOX) for LARC in comparison to those of the modified 5-fluorouracil, leucovorin, and oxaliplatin (mFOLFOX-6) regimen. We retrospectively evaluated 15 and 22 patients with LARC who underwent SCRT, followed by consolidation chemotherapy with TEGAFOX and mFOLFOX-6 before surgery, respectively, between January 2015 and December 2019. The primary endpoint was the tumor response rate. The secondary endpoints were compliance, toxicity, complications, overall survival (OS), and disease-free survival (DFS). The dose reduction rate was lower in the TEGAFOX group (0 vs. 9.1% (n = 2)). No grade III-IV toxicities occurred in the TEGAFOX group. Two and four patients in the TEGAFOX and mFOLFOX-6 groups, respectively, achieved clinical complete responses. The pathologic complete response rate was lower in the TEGAFOX group (7.7% vs. 17.6%). Overall, 11 (73.3%) and 17 (81.0%) patients had a neoadjuvant rectal (NAR) score of <16 in the TEGAFOX and mFOLFOX-6 groups, respectively. All patients in this study received sphincter-preservation surgery. One patient in each group developed Clavien−Dindo grade III complications. There were no significant between-group differences in the 3-year OS (81.8% vs. 84.8%, p = 0.884) and 3-year DFS (72% vs. 71.6%, p = 0.824) rates. TEGAFOX, as consolidation chemotherapy after SCRT, achieves good tumor downstaging and patient compliance in LARC. The toxicity, complications, and surgical outcomes are similar to those of mFOLFOX-6. Thus, TEGAFOX can be considered a chemotherapy option for rectal cancer treatment.
Collapse
Affiliation(s)
- Chun-Kai Liao
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou, No. 5, Fuxing Street, Guishan District, Taoyuan 333423, Taiwan; (C.-K.L.); (Y.-T.K.); (Y.-J.C.); (Y.-J.H.); (Y.-C.L.); (P.-S.H.); (J.-M.C.); (C.-Y.Y.)
| | - Ya-Ting Kuo
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou, No. 5, Fuxing Street, Guishan District, Taoyuan 333423, Taiwan; (C.-K.L.); (Y.-T.K.); (Y.-J.C.); (Y.-J.H.); (Y.-C.L.); (P.-S.H.); (J.-M.C.); (C.-Y.Y.)
| | - Yih-Jong Chern
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou, No. 5, Fuxing Street, Guishan District, Taoyuan 333423, Taiwan; (C.-K.L.); (Y.-T.K.); (Y.-J.C.); (Y.-J.H.); (Y.-C.L.); (P.-S.H.); (J.-M.C.); (C.-Y.Y.)
| | - Yu-Jen Hsu
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou, No. 5, Fuxing Street, Guishan District, Taoyuan 333423, Taiwan; (C.-K.L.); (Y.-T.K.); (Y.-J.C.); (Y.-J.H.); (Y.-C.L.); (P.-S.H.); (J.-M.C.); (C.-Y.Y.)
| | - Yueh-Chen Lin
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou, No. 5, Fuxing Street, Guishan District, Taoyuan 333423, Taiwan; (C.-K.L.); (Y.-T.K.); (Y.-J.C.); (Y.-J.H.); (Y.-C.L.); (P.-S.H.); (J.-M.C.); (C.-Y.Y.)
| | - Yen-Lin Yu
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Keelung Branch, No. 222, Maijin Road, Anle District, Keelung City 204201, Taiwan;
| | - Pao-Shiu Hsieh
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou, No. 5, Fuxing Street, Guishan District, Taoyuan 333423, Taiwan; (C.-K.L.); (Y.-T.K.); (Y.-J.C.); (Y.-J.H.); (Y.-C.L.); (P.-S.H.); (J.-M.C.); (C.-Y.Y.)
- School of Medicine, Chang Gung University, No. 259, Wenhua 1st Road, Guishan District, Taoyuan 333323, Taiwan
| | - Jy-Ming Chiang
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou, No. 5, Fuxing Street, Guishan District, Taoyuan 333423, Taiwan; (C.-K.L.); (Y.-T.K.); (Y.-J.C.); (Y.-J.H.); (Y.-C.L.); (P.-S.H.); (J.-M.C.); (C.-Y.Y.)
- School of Medicine, Chang Gung University, No. 259, Wenhua 1st Road, Guishan District, Taoyuan 333323, Taiwan
| | - Chien-Yuh Yeh
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou, No. 5, Fuxing Street, Guishan District, Taoyuan 333423, Taiwan; (C.-K.L.); (Y.-T.K.); (Y.-J.C.); (Y.-J.H.); (Y.-C.L.); (P.-S.H.); (J.-M.C.); (C.-Y.Y.)
- School of Medicine, Chang Gung University, No. 259, Wenhua 1st Road, Guishan District, Taoyuan 333323, Taiwan
| | - Jeng-Fu You
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou, No. 5, Fuxing Street, Guishan District, Taoyuan 333423, Taiwan; (C.-K.L.); (Y.-T.K.); (Y.-J.C.); (Y.-J.H.); (Y.-C.L.); (P.-S.H.); (J.-M.C.); (C.-Y.Y.)
- School of Medicine, Chang Gung University, No. 259, Wenhua 1st Road, Guishan District, Taoyuan 333323, Taiwan
- Correspondence: ; Tel.: +886-975365617
| |
Collapse
|
3
|
Bananzadeh A, Hafezi AA, Nguyen N, Omidvari S, Mosalaei A, Ahmadloo N, Ansari M, Mohammadianpanah M. Efficacy and safety of sequential neoadjuvant chemotherapy and short-course radiation therapy followed by delayed surgery in locally advanced rectal cancer: a single-arm phase II clinical trial with subgroup analysis between the older and young patients. Radiat Oncol J 2022; 39:270-278. [PMID: 34986548 PMCID: PMC8743455 DOI: 10.3857/roj.2021.00654] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 07/22/2021] [Indexed: 12/18/2022] Open
Abstract
Purpose This study was performed to investigate the efficacy and safety of short-course radiation therapy (SCRT) and sequential chemotherapy followed by delayed surgery in locally advancer rectal cancer with subgroup analysis between the older and young patients. Materials and Methods In this single-arm phase II clinical trial, eligible patients with locally advanced rectal cancer (T3–4 and/or N1–2) were enrolled. All the patients received a median three sequential cycles of neoadjuvant CAPEOX (capecitabine + oxaliplatin) chemotherapy. A total dose of 25 Gy in five fractions during 1 week was prescribed to the gross tumor and regional lymph nodes. Surgery was performed about 8 weeks following radiotherapy. Pathologic complete response rate (pCR) and grade 3–4 toxicity were compared between older patients (≥65 years) and younger patients (<65 years). Results Ninety-six patients with locally advanced rectal cancer were enrolled. There were 32 older patients and 64 younger patients. Overall pCR was 20.8% for all the patients. Older patients achieved similar pCR rate (18.7% vs. 21.8; p = 0.795) compared to younger patients. There was no statistically significance in terms of the tumor and the node downstaging or treatment-related toxicity between older patients and younger ones; however, the rate of sphincter-saving surgery was significantly more frequent in younger patients (73% vs. 53%; p=0.047) compared to older ones. All treatment-related toxicities were manageable and tolerable among older patients. Conclusion Neoadjuvant SCRT and sequential chemotherapy followed by delayed surgery was safe and effective in older patients compared to young patients with locally advanced rectal cancer.
Collapse
Affiliation(s)
- Alimohammad Bananzadeh
- Colorectal Research Center, Department of Colorectal Surgery, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ali Akbar Hafezi
- Department of Radiation Oncology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - NamPhong Nguyen
- Department of Radiation Oncology, Howard University Hospital, Washington, DC, USA
| | - Shapour Omidvari
- Breast Diseases Research Center, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ahmad Mosalaei
- Breast Diseases Research Center, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Niloofar Ahmadloo
- Breast Diseases Research Center, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mansour Ansari
- Breast Diseases Research Center, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Mohammadianpanah
- Colorectal Research Center, Department of Colorectal Surgery, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| |
Collapse
|
4
|
Patel A, Spychalski P, Corrao G, Jereczek-Fossa BA, Glynne-Jones R, Garcia-Aguilar J, Kobiela J. Neoadjuvant short-course radiotherapy with consolidation chemotherapy for locally advanced rectal cancer: a systematic review and meta-analysis. Acta Oncol 2021; 60:1308-1316. [PMID: 34308767 PMCID: PMC8448977 DOI: 10.1080/0284186x.2021.1953137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 07/03/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Short-course radiotherapy with consolidation chemotherapy (SCRT-CCT) has emerged as a promising alternative to the long course chemoradiotherapy (LCRT) regimen in locally advanced rectal cancer management. The systematic review and meta-analysis is aimed at summarizing current evidence on SCRT-CCT and comparing it to LCRT. MATERIAL AND METHODS Electronic databases of MEDLINE, Web of Science, and Cochrane library were searched using a predefined search strategy returning 3314 articles. This review included 11 studies (6 randomized trials and 5 non-randomized studies) on SCRT-CCT regimen based on seven different cohorts. Weighted arithmetic means and forest plots were generated to determine summary estimates. RESULTS The probability of achieving pathological complete response (pCR) was higher with SCRT-CCT compared to LCRT (risk ratio [RR] = 1.75, 95% confidence interval [CI]: 1.41-2.19). No statistically significant difference in 3-year overall survival (OS) was observed between the two groups (RR= 1.06, 95% CI: 0.98-1.14). The weighted arithmetic mean of 3-year OS and pCR was 83.6% versus 80.9%, and 24.5% versus 13.6% for SCRT-CCT and LCRT, respectively. R0 resection and T-downstaging rates ranged from 69.2-100% to 47-75% for SCRT-CCT, and 71-92.3% and 41-75% for LCRT, respectively. The regimens had similar compliance, postoperative, and late toxicity, however, acute toxicity rates varied primarily due to differences in treatment protocols. CONCLUSIONS This review highlights the ability of SCRT-CCT to produce improved tumor response with comparable OS, R0 resection, and T-downstaging at the cost of increased acute toxicity. However, heterogeneity in treatment protocols across studies makes it difficult to provide definitive conclusions regarding the regimen. Several ongoing trials are expected to provide further evidence confirming the findings of RAPIDO trial and detail appropriate SCRT-CCT protocols to improve oncological outcomes, minimize toxicity, and determine its effectiveness as the standard-of-care for locally advanced rectal cancer patients.
Collapse
Affiliation(s)
- Agastya Patel
- Department of General Surgery, Endocrine and Transplant Surgery, Medical University of Gdansk, Poland
| | - Piotr Spychalski
- Department of General Surgery, Endocrine and Transplant Surgery, Medical University of Gdansk, Poland
| | - Giulia Corrao
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
- Division of Radiotherapy, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Barbara A. Jereczek-Fossa
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
- Division of Radiotherapy, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Robert Glynne-Jones
- Department of Radiation Oncology, Mount Vernon Cancer Centre, Northwood, United Kingdom Department of Radiation Oncology, Mount Vernon Cancer Centre, Northwood, United Kingdom
| | - Julio Garcia-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Jarek Kobiela
- Department of General Surgery, Endocrine and Transplant Surgery, Medical University of Gdansk, Poland
| |
Collapse
|
5
|
Wilson K, Flood M, Narasimhan V, Pham T, Warrier S, Ramsay R, Michael M, Heriot A. Complete pathological response in rectal cancer utilising novel treatment strategies for neo-adjuvant therapy: A systematic review. Eur J Surg Oncol 2021; 47:1862-1874. [PMID: 33814240 DOI: 10.1016/j.ejso.2021.03.245] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/07/2021] [Accepted: 03/17/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Locally advanced rectal cancer is routinely treated with neo-adjuvant long course chemoradiotherapy or short course radiotherapy, followed by total mesorectal excision. Not all patients respond to this treatment and there has been an emergence of novel treatment strategies designed to improve outcomes for these patients. This systematic review aims to assess the current novel neo-adjuvant treatment strategies being utilised in the treatment of patients with rectal cancer and how these impact pathological complete response (pCR) rates. METHODS A systematic review of the literature was performed to evaluate pathological response in patients with rectal cancer receiving novel neo-adjuvant therapy. EMBASE and Medline electronic databases were searched for relevant articles. Articles published between January 2008 and February 2019 were retrieved. Included studies underwent critical appraisal and complete pathological response rates were recorded. RESULTS Of the initial 1074 articles identified, 217 articles fulfilled the inclusion criteria, of these 60 articles (4359 patients) were included. Neo-adjuvant therapy delivered included novel long course chemoradiation therapy, neoadjuvant chemotherapy alone, addition of a biological agent, total neo-adjuvant therapy, novel short course radiation therapy and studies utilising biomarkers to select patients for therapy. Complete pathological response rates ranged from 0 to 60%. CONCLUSION A validated novel neo-adjuvant therapy that significantly increases pCR rates in patients with rectal cancer has not been identified.
Collapse
Affiliation(s)
- K Wilson
- Peter MacCallum Cancer Centre, Department of Surgical Oncology, Australia; Differentiation and Transcription Laboratory, Sir Peter MacCallum Cancer Centre, Australia; Sir Peter MacCallum Dept. of Oncology, University of Melbourne, Australia.
| | - M Flood
- Peter MacCallum Cancer Centre, Department of Surgical Oncology, Australia; Differentiation and Transcription Laboratory, Sir Peter MacCallum Cancer Centre, Australia; Sir Peter MacCallum Dept. of Oncology, University of Melbourne, Australia
| | - V Narasimhan
- Peter MacCallum Cancer Centre, Department of Surgical Oncology, Australia; Differentiation and Transcription Laboratory, Sir Peter MacCallum Cancer Centre, Australia; Sir Peter MacCallum Dept. of Oncology, University of Melbourne, Australia
| | - T Pham
- Peter MacCallum Cancer Centre, Department of Surgical Oncology, Australia; Differentiation and Transcription Laboratory, Sir Peter MacCallum Cancer Centre, Australia; Sir Peter MacCallum Dept. of Oncology, University of Melbourne, Australia
| | - S Warrier
- Peter MacCallum Cancer Centre, Department of Surgical Oncology, Australia
| | - R Ramsay
- Peter MacCallum Cancer Centre, Department of Surgical Oncology, Australia; Differentiation and Transcription Laboratory, Sir Peter MacCallum Cancer Centre, Australia
| | - M Michael
- Peter MacCallum Cancer Centre, Department of Medical Oncology, Australia; Sir Peter MacCallum Dept. of Oncology, University of Melbourne, Australia
| | - A Heriot
- Peter MacCallum Cancer Centre, Department of Surgical Oncology, Australia; Sir Peter MacCallum Dept. of Oncology, University of Melbourne, Australia
| |
Collapse
|
6
|
Aghili M, Ghalehtaki R, Mousavi Darzikolaee N, Jafari F, Moshtaghian M. Radiotherapy and COVID-19: Practical recommendations from iran. Radiother Oncol 2020; 149:70-71. [PMID: 32387545 PMCID: PMC7204685 DOI: 10.1016/j.radonc.2020.04.051] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 04/23/2020] [Accepted: 04/26/2020] [Indexed: 01/09/2023]
Affiliation(s)
- Mahdi Aghili
- Radiation Oncology Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran.
| | - Reza Ghalehtaki
- Radiation Oncology Research Center, Cancer Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Department of Radiation Oncology, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Nima Mousavi Darzikolaee
- Radiation Oncology Research Center, Cancer Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Department of Radiation Oncology, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Jafari
- Radiation Oncology Research Center, Cancer Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Department of Radiation Oncology, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahsa Moshtaghian
- Radiation Oncology Research Center, Cancer Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Department of Radiation Oncology, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
7
|
Socha J, Kairevice L, Kępka L, Michalski W, Spałek M, Paciorek K, Bujko K. Should Short-Course Neoadjuvant Radiation Therapy Be Applied for Low-Lying Rectal Cancer? A Systematic Review and Meta-Analysis of the Randomized Trials. Int J Radiat Oncol Biol Phys 2020; 108:1257-1264. [PMID: 32634546 DOI: 10.1016/j.ijrobp.2020.06.077] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/16/2020] [Accepted: 06/28/2020] [Indexed: 01/17/2023]
Abstract
PURPOSE National Comprehensive Cancer Network guidelines recommend either long-course chemoradiation (LC) or short-course radiation (SC, 5 × 5 Gy) for rectal cancer before total mesorectal excision. However, they do not recommend SC for low-lying tumors. As early toxicity of SC is lower than that of LC, and postoperative complications as well as late toxicity are similar, the probable reason is a notion that for low-lying tumors LC may be more effective than SC in assuring local control. METHODS AND MATERIALS A systematic review and meta-analysis of the randomized trials comparing SC with LC was performed to test the hypothesis that for low-lying tumors, LC is superior to SC in reducing the risk of local failure. RESULTS The systematic search identified 4 trials including, in total, 421 patients with tumors <5 cm from the anal verge; 221 were randomized to SC and 200 to LC. The meta-analysis showed that the difference in local failure rate between SC and LC was insignificant; the pooled odds ratio was 0.87, 95% confidence interval 0.53 to 1.44, P = .59. Heterogeneity between trials was insignificant; I2 = 0.0%, P = .47. CONCLUSIONS Our meta-analysis does not support the notion that LC given before total mesorectal excision is superior to SC in reducing the risk of local failure in low-lying tumors.
Collapse
Affiliation(s)
- Joanna Socha
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland; Department of Radiotherapy, Regional Oncology Centre, Czestochowa, Poland.
| | - Laura Kairevice
- Department of Oncology and Hematology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Lucyna Kępka
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland
| | - Wojciech Michalski
- Bioinformatics and Biostatistics Unit, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Mateusz Spałek
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Karol Paciorek
- Department of Radiotherapy I, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Krzysztof Bujko
- Department of Radiotherapy I, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| |
Collapse
|
8
|
Ciseł B, Pietrzak L, Michalski W, Wyrwicz L, Rutkowski A, Kosakowska E, Cencelewicz A, Spałek M, Polkowski W, Jankiewicz M, Styliński R, Bębenek M, Kapturkiewicz B, Maciejczyk A, Sadowski J, Zygulska J, Zegarski W, Jankowski M, Las-Jankowska M, Toczko Z, Żelazowska-Omiotek U, Kępka L, Socha J, Wasilewska-Tesluk E, Markiewicz W, Kładny J, Majewski A, Kapuściński W, Suwiński R, Bujko K. Long-course preoperative chemoradiation versus 5 × 5 Gy and consolidation chemotherapy for clinical T4 and fixed clinical T3 rectal cancer: long-term results of the randomized Polish II study. Ann Oncol 2020; 30:1298-1303. [PMID: 31192355 DOI: 10.1093/annonc/mdz186] [Citation(s) in RCA: 126] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND This trial evaluated whether preoperative short-course radiotherapy and consolidation chemotherapy (CCT) were superior to chemoradiation in rectal cancers with clinical (c)T4 or fixed cT3. Previously, we reported early results showing no differences in the radical surgery rate (primary end point). In the short-course/CCT group, we observed lower acute toxicity of preoperative treatment and better overall survival (OS). We updated results to determine whether the benefit in OS was sustained and to evaluate late complications. PATIENTS AND METHODS Patients with cT4 or fixed cT3 rectal cancer were randomized either to preoperative 5 × 5 Gy and three cycles of FOLFOX4 or to chemoradiation (50.4 Gy with bolus 5-Fu, leucovorin and oxaliplatin). RESULTS Patients (N = 515) were eligible for analysis, 261 in the short-course/CCT group and 254 in the chemoradiation group. The median follow-up was 7.0 years. The difference in OS was insignificant [hazard ratio (HR) 0.90; 95% confidence interval (CI) 0.70-1.15; P = 0.38). However, the difference in early OS favouring short-course/CCT previously reported was observed again, being 9% at 3 years (95% CI 0.5% to 17%). This difference disappeared later; at 8 years OS was 49% in both groups. There was no difference in disease-free survival (HR 0.95; 95% CI 0.75-1.19; P = 0.65) at 8 years 43% versus 41% in the short-course/CCT group versus the chemoradiation group, respectively. The corresponding values for cumulative incidences of local failure and distant metastases did not differ and were HR = 1.08, 95% CI 0.70-1.23, P = 0.60, 35% versus 32% and HR = 1.10, 95% CI 0.68-1.23, P = 0.54, 36% versus 34%, respectively. The rate of late complications was similar (P = 0.66), grade 3+ being 11% versus 9% in the short-course/CCT group versus the chemoradiation group, respectively. CONCLUSION The superiority of preoperative short-course/CCT over chemoradiation was not demonstrated. CLINICAL TRIAL NUMBER The trial is registered as ClinicalTrials.gov number NCT00833131.
Collapse
Affiliation(s)
- B Ciseł
- Department of Surgical Oncology, Medical University of Lublin, Lublin
| | | | | | | | - A Rutkowski
- Gastroenterological Oncology, M. Skłodowska-Curie Memorial Cancer Centre, Warsaw
| | - E Kosakowska
- Gastroenterological Oncology, M. Skłodowska-Curie Memorial Cancer Centre, Warsaw
| | - A Cencelewicz
- Gastroenterological Oncology, M. Skłodowska-Curie Memorial Cancer Centre, Warsaw
| | | | - W Polkowski
- Department of Surgical Oncology, Medical University of Lublin, Lublin
| | - M Jankiewicz
- Department of Surgical Oncology, Medical University of Lublin, Lublin; Department of Radiotherapy, St. John's Cancer Center, Lublin
| | - R Styliński
- 1st Department of General Surgery, Transplantology and Nutritional Therapy Medical University of Lublin
| | | | | | - A Maciejczyk
- Radiotherapy, Silesian Oncological Centre, Wrocław
| | - J Sadowski
- Department of Radiotherapy, Regional Oncological Centre, Kielce
| | - J Zygulska
- Department of Radiotherapy, Beskid Centre of Oncology, Bielsko-Biala
| | | | | | - M Las-Jankowska
- Clinical Oncology, Collegium Medicum Nicolaus Copernicus University and Oncology Centre, Bydgoszcz
| | - Z Toczko
- Department of Surgery, Regional Hospital, Elblag
| | | | - L Kępka
- Department of Radiotherapy, Military Institute of Medicine, Warsaw
| | - J Socha
- Department of Radiotherapy, Military Institute of Medicine, Warsaw; Department of Radiotherapy, Regional Oncology Center, Czestochowa
| | - E Wasilewska-Tesluk
- Radiotherapy Department, Public Health Care Facility of the Ministry of the Interior and Warmian-Masurian Oncology Centre, Olsztyn; Department of Oncology, University of Warmia and Mazury, Olsztyn
| | - W Markiewicz
- Department of Surgery, Regional Cancer Centre, Białystok
| | - J Kładny
- Department of General Surgery and Surgical Oncology First Clinical Hospital of Pomeranian Medical University, Szczecin
| | - A Majewski
- Department of Surgery, Regional Hospital, Wałbrzych
| | - W Kapuściński
- Department of Radiotherapy, Regional Cancer Centre, Copernicus Memorial Hospital of Łódź, Łódź
| | - R Suwiński
- Department of Radiotherapy, M. Skłodowska-Curie Memorial Cancer Centre, Gliwice, Poland
| | - K Bujko
- II Department of Radiotherapy.
| | | |
Collapse
|
9
|
Aghili M, Khalili N, Khalili N, Babaei M, Farhan F, Haddad P, Salarvand S, Keshvari A, Fazeli MS, Mohammadi N, Ghalehtaki R. Short-course versus long-course neoadjuvant chemoradiotherapy in patients with rectal cancer: preliminary results of a randomized controlled trial. Radiat Oncol J 2020; 38:119-128. [PMID: 33012155 PMCID: PMC7533412 DOI: 10.3857/roj.2020.00115] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 05/12/2020] [Indexed: 12/22/2022] Open
Abstract
Purpose Colorectal cancer is becoming an increasing concern in the middle-aged population of Iran. This study aimed to compare the preliminary results of short-course and long-course neoadjuvant chemoradiotherapy treatment for rectal cancer patients. Materials and Methods In this clinical trial we recruited patients with rectal adenocarcinoma located from 5 cm to 15 cm above the anal verge. Patients in group I (short-course) received three-dimensional conformational radiotherapy with a dose of 25 Gy/5 fractions in 1 week plus concurrent XELOX regimen (capecitabine 625 mg/m2 from day 1–5 twice daily and oxaliplatin 50 mg/m2 on day 1 once daily). Patients in group II (long-course) received a total dose of 50–50.4 Gy/25–28 fractions for 5 to 5.5 weeks plus capecitabine 825 mg/m2 twice daily. Both groups underwent consolidation chemotherapy followed by delayed surgery at least 8 weeks after radiotherapy completion. The pathological response was assessed with tumor regression grade. Results In this preliminary report on complications and pathological response, 66 patients were randomized into two study groups. Mean duration of radiotherapy in groups I and II was 5 ± 1 days (range, 5 to 8 days) and 38 ± 6 days (range, 30 to 58 days). The median follow-up was 18 months. Pathological complete response was achieved in 32.3% and 23.1% of patients in the short-course and long-course groups, respectively (p = 0.558). Overall, acute grade 3 or higher treatment-related toxicities occurred in 24.2% and 22.2% of patients in group I and II, respectively (p = 0.551). No acute grade 4 or 5 adverse events were observed in either group except one grade 4 hematologic toxicity that was seen in group II. Within one month of surgery, no significant difference was seen regarding grade ≥3 postoperative complications (p = 0.333). Conclusion For patients with rectal cancer located at least 5 cm above the anal verge, short-course radiotherapy with concurrent and consolidation chemotherapy and delayed surgery is not different in terms of acute toxicity, postoperative morbidity, complete resection, and pathological response compared to long-course chemoradiotherapy.
Collapse
Affiliation(s)
- Mahdi Aghili
- Radiation Oncology Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Nastaran Khalili
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Neda Khalili
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Babaei
- Radiation Oncology Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Farshid Farhan
- Radiation Oncology Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Peiman Haddad
- Radiation Oncology Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Samaneh Salarvand
- Department of Anatomical and Clinical Pathology, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Keshvari
- Colorectal Research Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Sadegh Fazeli
- Colorectal Research Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Negin Mohammadi
- Radiation Oncology Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Ghalehtaki
- Radiation Oncology Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
10
|
Total Neoadjuvant Therapy in Rectal Cancer: A Systematic Review and Meta-analysis of Treatment Outcomes. Ann Surg 2020; 271:440-448. [PMID: 31318794 DOI: 10.1097/sla.0000000000003471] [Citation(s) in RCA: 187] [Impact Index Per Article: 46.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The addition of induction chemotherapy to concomitant neoadjuvant chemoradiation in locally advanced rectal cancer could increase pathological downstaging and act on occult micrometastatic disease, leading ultimately to a better outcome. A systematic review was carried out of the existing literature on the treatment outcomes of total neoadjuvant therapy (TNT) on locally advanced rectal cancer. TNT was defined as chemotherapy using cycles of induction and/or consolidation in conjunction with standard chemoradiotherapy prior to surgery. METHODS A systematic search of PubMed, Embase, and the Cochrane Library was performed according to the PRISMA statement up until January 2019. The primary endpoints were complete pathologic response (pCR), disease-free survival, and overall survival rates. RESULTS A total of 28 studies (3 retrospective and 25 prospective for a total of 3579 patients) were included in the final analysis (n = 2688 treated with TNT and n = 891 with neoadjuvant chemoradiotherapy therapy). The pooled pCR rate was 22.4% (95% CI 19.4%-25.7%) in all patients treated with TNT (n = 27 studies with data available). In n = 10 comparative studies with data available, TNT was found to increase the odds of pCR by 39% (1.40, 95% CI 1.08-1.81, P = 0.01). CONCLUSIONS The addition of induction or consolidation chemotherapy to standard neoadjuvant chemoradiotherapy results in a higher pCR rate. Given that the comparative analysis was derived from few randomized publications, large confirmatory trials should be carried out before a strong recommendation is made in favor of TNT.
Collapse
|
11
|
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]
|
12
|
Kane C, Glynne-Jones R. Should we favour the use of 5 × 5 preoperative radiation in rectal cancer. Cancer Treat Rev 2019; 81:101908. [DOI: 10.1016/j.ctrv.2019.101908] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 10/03/2019] [Indexed: 12/20/2022]
|
13
|
Phase 1 Study of Neoadjuvant Short-Course Radiation Therapy Concurrent With Infusional 5-Fluorouracil for the Treatment of Locally Advanced Rectal Cancer. Adv Radiat Oncol 2019; 4:605-612. [PMID: 31673654 PMCID: PMC6817539 DOI: 10.1016/j.adro.2019.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 04/19/2019] [Accepted: 04/24/2019] [Indexed: 01/19/2023] Open
Abstract
Purpose To assess the safety and feasibility of neoadjuvant short-course radiation therapy (RT) concurrent with continuous infusion 5-fluorouracil (5-FU) for the treatment of locally advanced rectal cancer. Methods and Materials Patients with cT3-4 or N + rectal adenocarcinoma based on ultrasound or magnetic resonance imaging were prospectively enrolled in this study. Study treatment consisted of continuous infusion 5-FU combined with short-course RT (5 Gy x 5 fractions) followed by 4 cycles of mFOLFOX, total mesorectal excision (TME), and 6 cycles of adjuvant mFOLFOX. To mitigate the potential added toxicity from concurrent 5-FU, intensity modulated RT was used. Using the continual reassessment method, the dose of 5-FU was escalated from 100 to a maximum-tolerated dose of 200 mg/m2/d. Results Fourteen patients were accrued. All patients completed continuous infusion 5-FU and short-course RT and the 5-FU dose was safely escalated to 200 mg/m2/d with no dose-limiting toxicity. Thirteen patients received the neoadjuvant mFOLFOX, and only 1 patient went straight to surgery after chemoradiation. Clinical response was 21% complete, 63% partial, 14% stable disease, and no patients had progression. Three patients with cCR had negative biopsies and did not have TME. Pathologic response was 64% partial response and 14% stable disease. No patients had pathologic progression. The most common grade 3 and 4 toxicities were cytopenias. The most common grade 1 and 2 toxicities were cytopenia, fatigue, diarrhea, and nausea. Conclusions Our findings suggest that concurrent chemotherapy with neoadjuvant short-course RT is feasible and can be safely given with concurrent continuous infusion 5-FU. This works adds to the growing evidence that short-course RT is not only equivalent to long-course RT, but also may provide additional benefits, such as allowing for a transition to full dose systemic therapy in the neoadjuvant setting, selective organ preservation in complete responders, and providing a more convenient and cost-effective way of delivering pelvic RT.
Collapse
|
14
|
A Concise Review of Pelvic Radiation Therapy (RT) for Rectal Cancer with Synchronous Liver Metastases. Int J Surg Oncol 2019; 2019:5239042. [PMID: 31139467 PMCID: PMC6500597 DOI: 10.1155/2019/5239042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 04/03/2019] [Indexed: 02/01/2023] Open
Abstract
Background and Objective Colorectal cancer is a major health concern as a very common cancer and a leading cause of cancer-related mortality worldwide. The liver is a very common site of metastatic spread for colorectal cancers, and, while nearly half of the patients develop metastases during the course of their disease, synchronous liver metastases are detected in 15% to 25% of cases. There is no standardized treatment in this setting and no consensus exists on optimal sequencing of multimodality management for rectal cancer with synchronous liver metastases. Methods Herein, we review the use of pelvic radiation therapy (RT) as part of potentially curative or palliative management of rectal cancer with synchronous liver metastases. Results There is accumulating evidence on the utility of pelvic RT for facilitating subsequent surgery, improving local tumor control, and achieving palliation of symptoms in patients with stage IV rectal cancer. Introduction of superior imaging capabilities and contemporary RT approaches such as Intensity Modulated Radiation Therapy (IMRT) and Image Guided Radiation Therapy (IGRT) offer improved precision and toxicity profile of radiation delivery in the modern era. Conclusion Even in the setting of stage IV rectal cancer with synchronous liver metastases, there may be potential for extended survival and cure by aggressive management of primary tumor and metastases in selected patients. Despite lack of consensus on sequencing of treatment modalities, pelvic RT may serve as a critical component of multidisciplinary management. Resectability of primary rectal tumor and liver metastases, patient preferences, comorbidities, symptomatology, and logistical issues should be thoroughly considered in decision making for optimal management of patients.
Collapse
|
15
|
Zhang MX, Li XB, Guan BJ, Guan GX, Lin XY, Wu XD, Chi P, Xu BH. Dose escalation of preoperative short-course radiotherapy followed by neoadjuvant chemotherapy in locally advanced rectal cancer: protocol for an open-label, single-centre, phase I clinical trial. BMJ Open 2019; 9:e025944. [PMID: 30904869 PMCID: PMC6475145 DOI: 10.1136/bmjopen-2018-025944] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Preoperative radiotherapy followed by total mesorectal excision with adjuvant chemotherapy has been recommended as the preferred treatment method for locally advanced rectal cancer (LARC). Similar rates of local control, survival and toxicity were observed in preoperative long-course chemoradiotherapy (LCRT) (45-50.4 Gy in 25-28 fractions) and in short-course radiotherapy (SCRT) with 25 Gy over five fractions. Both regimens lower the local recurrence rates compared with that of surgery followed by postoperative radiotherapy. With the simplicity and lower cost of SCRT, a growing number of patients have been receiving SCRT as preoperative radiotherapy. However, the currently established SCRT (25 Gy over five fractions) followed immediately by surgery resulted in poor downstaging and sphincter preservation rate. The pathological complete response (pCR) rate is also markedly lower with SCRT than with LCRT (0.7%vs16%). Several studies recommended SCRT with delayed surgery for more than 4 weeks with expectation of improved pathological outcomes and fewer postoperative complications. While a number of clinical trials demonstrated a persistently better overall local control with SCRT than with LCRT, overall survival advantage has not been observed. Since survival is mainly depended on distant metastases, efforts should be made towards more effective pathological response and systemic treatment. Given the apparent advantages of SCRT, we aimed to establish a dose escalation of SCRT and sequential modified FOLFOX6 (mFOLFOX6) as preoperative therapy for LARC with objectives of achieving an optimal balance of safety, cost effectiveness and clinical outcome, and to support further investigation of this regimen in a phase II/III setting. METHODS In this phase I study, three dose levels (6Gy×5F, 7Gy×5F, 8Gy×5F to gross tumour volume, while keeping the rest of irradiated volume at 5Gy×5) of SCRT followed by four cycles of mFOLFOX6 chemotherapy as neoadjuvant therapy will be tested by using the traditional 3+3 design. The pCR rate, R0 resection rate, sphincter preservation rate and treatment related toxicity will be assessed. ETHICS AND DISSEMINATION The study protocol was approved by the Ethics Committee of Fujian Medical University Union Hospital (No. 2017YF020-02) and all participants provided written informed consent. Results from our study will be disseminated in international peer-reviewed journals. All study procedures were developed in order to assure data protection and confidentiality. TRIAL REGISTRATION NUMBER NCT03466424; Pre-results.
Collapse
Affiliation(s)
- Meng-xia Zhang
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Xiao-bo Li
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Collogy of medical technology and engineering, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Bing-jie Guan
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Guo-xian Guan
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Xiao-yan Lin
- Department of Medical Oncology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Xiao-dong Wu
- Department of Radiation Oncology, Cancer Hospital of Fudan University, Shanghai, China
- Department of biomedical engineering, Innovative Cancer Institute, Miami, Florida, USA
| | - Pan Chi
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Ben-hua Xu
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- School of Clinical Medicine, Fujian Medical University, Fuzhou, Fujian, China
| |
Collapse
|