Under-reporting of subjective symptoms and its prognostic value: a pooled analysis of 12 cancer clinical trials

BACKGROUND

Oncologists tend to under-report subjective symptoms during cancer treatment. This study describes the under-reporting rate of selected symptoms and explores its association with overall survival (OS). A secondary aim is to test the association of patient-reported symptoms with OS.

PATIENTS AND METHODS

This is a post hoc analysis on data pooled from 12 randomized trials, promoted by the National Cancer Institute of Naples (Italy), enrolling patients between 2002 and 2019, with published primary analyses. Occurrence and grade of six side-effects (anorexia, nausea, vomiting, constipation, diarrhea and fatigue) reported by physicians were compared with corresponding symptoms reported by patients in quality-of-life (QoL) questionnaires. Under-reporting was defined as the rate of cases reported grade 0 by the physician while grade ≥1 by the patient. Prognostic value was tested in a multivariable model stratified by trial, including age, sex and performance status as confounders. A landmark threshold was defined for OS analyses.

RESULTS

3792 patients with advanced lung, ovarian, pancreatic, breast or colorectal cancer were pooled; 2603 (68.6%) were eligible having at least one toxicity assessment and one QoL questionnaire, before the first planned disease restaging. Concordance between physicians' and patients' reporting was low with Cohen's k coefficients ranging from 0.03 (fatigue) to 0.33 (vomiting). Under-reporting ranged from 52.7% (nausea) to 80.5% (anorexia), and was not associated with OS. Patient-reported anorexia, vomiting and fatigue ('a little' or more) were significantly associated with shorter OS.

CONCLUSIONS

Under-reporting of treatment side-effects is frequent, but it does not affect OS. Patients' reported symptoms should be used for prognostic evaluation.

Establishment of patient-derived tumor organoids to functionally inform treatment decisions in metastatic colorectal cancer

BACKGROUND

Metastatic colorectal cancer (mCRC) patients tend to have modest benefits from molecularly driven therapeutics. Patient-derived tumor organoids (PDTOs) represent an unmatched model to elucidate tumor resistance to therapy, due to their high capacity to resemble tumor characteristics.

MATERIALS AND METHODS

We used viable tumor tissue from two cohorts of patients with mCRC, naïve or refractory to treatment, respectively, for generating PDTOs. The derived models were subjected to a 6-day drug screening assay (DSA) with a comprehensive pipeline of chemotherapy and targeted drugs against almost all the actionable mCRC molecular drivers. For the second cohort DSA data were matched with those from PDTO genotyping.

RESULTS

A total of 40 PDTOs included in the two cohorts were derived from mCRC primary tumors or metastases. The first cohort included 31 PDTOs derived from patients treated in front line. For this cohort, DSA results were matched with patient responses. Moreover, RAS/BRAF mutational status was matched with DSA cetuximab response. Ten out of 12 (83.3%) RAS wild-type PDTOs responded to cetuximab, while all the mutant PDTOs, 8 out of 8 (100%), were resistant. For the second cohort (chemorefractory patients), we used part of tumor tissue for genotyping. Four out of nine DSA/genotyping data resulted applicable in the clinic. Two RAS-mutant mCRC patients have been treated with FOLFOX-bevacizumab and mitomycin-capecitabine in third line, respectively, based on DSA results, obtaining disease control. One patient was treated with nivolumab-second mitochondrial-derived activator of caspases mimetic (phase I trial) due to high tumor mutational burden at genotyping, experiencing stable disease. In one case, the presence of BRCA2 mutation correlated with DSA sensitivity to olaparib; however, the patient could not receive the therapy.

CONCLUSIONS

Using CRC as a model, we have designed and validated a clinically applicable methodology to potentially inform clinical decisions with functional data. Undoubtedly, further larger analyses are needed to improve methodology success rates and propose suitable treatment strategies for mCRC patients.

Cetuximab as third-line rechallenge plus either irinotecan or avelumab is an effective treatment in metastatic colorectal cancer patients with baseline plasma RAS/BRAF wild-type circulating tumor DNA: Individual patient data pooled analysis of CRICKET and CAVE trials

The rechallenge strategy is based on the concept that a subset of patients with RAS wild-type (WT) metastatic colorectal cancer (mCRC) could still benefit of epidermal growth factor receptor (EGFR) inhibition, after progression to an anti-EGFR based-therapy. We performed a pooled analysis of two-phase II prospective trials to determine the role of rechallenge in third-line mCRC patients with RAS/BRAF WT baseline circulating tumor DNA (ctDNA). Individual data of 33 and 13 patients from CAVE and CRICKET trials that received as third-line therapy cetuximab rechallenge were collected. Overall survival (OS), Progression-free survival (PFS), Overall response rate (ORR), Stable disease (SD) >6 months were calculated. Adverse events were reported. For the whole 46 patient population, median PFS (mPFS) was 3.9 months (95% Confidence Interval, CI 3.0-4.9) with median OS (mOS) of 16.9 months (95% CI 11.7-22.1). For CRICKET patients, mPFS was 3.9 months (95% CI 1.7-6.2); mOS was 13.1 months (95% CI 7.3-18.9) with OS rates at 12, 18, and 24 months of 62%, 23%, and 0%, respectively. For CAVE patients, mPFS was 4.1 months (95% CI 3.0-5.2); mOS was 18.6 months (95% CI 11.7-25.4) with OS rates at 12, 18, 24 months of 61%, 52%, 21%, respectively. Skin rash was more frequently reported in CAVE trial (87.9% vs. 30.8%; p = 0.001), whereas a increased incidence of hematological toxicities was observed in CRICKET trial (53.8%% vs. 12.1%; p = 0.003). Third-line cetuximab rechallenge in combination with either irinotecan or avelumab in RAS/BRAF WT ctDNA mCRC patients represents a promising therapy.

Regorafenib monotherapy as second-line treatment of patients with RAS-mutant advanced colorectal cancer (STREAM): an academic, multicenter, single-arm, two-stage, phase II study

BACKGROUND

Maintaining angiogenesis inhibition and switching the chemotherapy backbone represent the current second-line therapy in patients with RAS-mutant metastatic colorectal cancer (mCRC). Regorafenib, an oral multikinase inhibitor, prolonged overall survival (OS) in the chemorefractory setting.

MATERIALS AND METHODS

STREAM was an academic, multicenter, single-arm phase II trial, evaluating the activity of regorafenib in RAS-mutant mCRC, in terms of the rate of patients who were progression-free after 6 months from study entry (6mo-PF). Patients were pretreated with fluoropyrimidine, oxaliplatin, and bevacizumab. According to Simon's two-stage design, ≥18 patients 6mo-PF were needed in the overall population (N = 46). Secondary endpoints were safety, objective response rate (ORR), progression-free survival (PFS), and OS. Early metabolic response by [¹⁸F]2-fluoro-2-deoxy-D-glucose-positron emission tomography/computed tomography ([¹⁸F]-FDG PET/CT) scan was an exploratory endpoint. EudraCT Number: 2015-001105-13.

RESULTS

The number of patients 6mo-PF was 8/22 at the first stage and 14/46 in the overall population. The ORR was 10.9%, disease control rate was 54.6%, median (m)PFS was 3.6 months [95% confidence interval (CI) 1.9-6.7 months], mOS was 18.9 months (95% CI 10.3-35.3 months), and mPFS2 (from study entry to subsequent-line progression) was 13.3 months (95% CI 8.4-19.7 months). Long benefiter patients (>6mo-PF) significantly more often had a single metastatic site and lung-limited disease. No unexpected toxicity was reported. Grade ≥3 events occurred in 39.1% of patients, with hand-foot syndrome (13%), fatigue, and hyperbilirubinemia (6.5%) occurring mostly. Baseline metabolic assessment was associated with OS in the multivariate analysis, while early metabolic response was not associated with clinical outcomes.

CONCLUSIONS

The study did not meet its primary endpoint. However, regorafenib was well tolerated and did not preclude subsequent treatments. Patients with good prognostic features (single metastatic site and lung-limited disease) reported clinical benefit with regorafenib. The exploratory metabolic analysis suggests that baseline [¹⁸F]-FDG PET/CT might be useful to select patients with a favorable outcome. A chemotherapy-free interval with regorafenib was associated with durable disease control in a selected group of patients with favorable clinical characteristics.

Clinical efficacy of sequential treatments in KRASG12C-mutant metastatic colorectal cancer: findings from a real-life multicenter Italian study (CRC-KR GOIM)

Background

The presence of KRASG12C mutation in metastatic colorectal cancer (mCRC) correlates with poor outcome. Although different selective inhibitors are under clinical development, the optimal treatment remains uncertain. Thus, we conducted a retrospective analysis in a large cohort of patients with KRASG12C mCRC treated in 12 Italian oncology units.

Patients and methods

Patients with unresectable mCRC harboring KRASG12C mutation receiving a first-line chemotherapy doublet or triplet between 2011 and 2021 were included in the study. Evaluation of overall response rate (ORR), progression-free survival (PFS) and overall survival (OS) analysis was carried out.

Results

A total of 256/6952 (3.7%) patients with mCRC displayed KRASG12C mutation; of these, 111 met the inclusion criteria. The ORR of first-line therapy was 38.7% (43/111). Median PFS (mPFS) was 9 months [95% confidence interval (CI) 7.5-10.5 months]. After progression, only 62% and 36% of the patients are fit to receive second or third lines of treatment, with limited clinical benefit. Median OS (mOS) was 21 months (95% CI 17.4-24.6 months). In patients receiving first-line triplet chemotherapy, ORR was 56.3% (9/16), mPFS was 13 months (95% CI 10.3-15.7 months) and mOS was 32 months (95% CI 7.7-56.3 months). For irinotecan-based doublets, ORR was 34.5 (10/29), mPFS was 9 months (95% CI 6.4-11.6 months) and mOS was 22 months (95% CI 16.0-28.0 months). With oxaliplatin-based doublets ORR was 36.4% (24/62), mPFS was 7 months (95% CI 4.6-9.4 months) and mOS was 18 months (95% CI, 13.6-22.4 months).

Conclusion

Patients with KRASG12C-mutant mCRC had a disappointing response to standard treatments. Within the limitations of a retrospective study, these results suggest that first-line chemotherapy intensification with FOLFOXIRI is a valid option in fit patients.

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KRASG12C mutation is rare and occurs in 3.7% of the study population.

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The presence of KRASG12C mutation is correlated with an aggressive disease, with reduced response to chemotherapy.

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Only 62% and 36% of patients with KRASG12C-mutant mCRC are fit to receive second or third lines of treatment, respectively.

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The use of chemotherapy triplets is associated with improved outcomes compared with chemotherapy doublets.

Current status on response to treatment in locally advanced rectal cancer: what the radiologist should know

The assessment of tumor response, after neoadjuvant radiochemotherapy (nCRT), allows stratifying the patient in order to consider the proper therapeutical management. Histopathology analysis of the surgical specimen is considered the gold standard to assess tumour response and the definition of a complete cancer response is related to the clinical and endoscopic features, by direct evaluation of the rectal wall. However, imaging studies, especially Magnetic Resonance Imaging (MRI) have provided additional parameters, as the evaluation of nodal or mesorectal status. MRI provides a radiological tumour regression grade (mrTRG) that is correlated with the pathologic tumor regression grade (pTRG). Functional MRI parameters have additional impending in early prediction of the efficacy of therapy and can be valuable in drug development processes. Some of functional methodologies are already part of clinical practice: diffusion-weighted MRI (DW-MRI) and perfusion imaging (dynamic contrast enhanced MRI [DCE-MRI]). Other technologies, such as radiomics with MRI are still in the experimental phase. An adequate radiological report describing the restaging of rectal cancer after nCRT should be a "structured report" to improve communication in a multidisciplinary team.

Germinal BRCA1-2 pathogenic variants (gBRCA1-2pv) and pancreatic cancer: epidemiology of an Italian patient cohort

OBJECTIVE

Germline BRCA1-2 pathogenic variants (gBRCApv) increase the risk of pancreatic cancer and predict for response to platinating agents and poly(ADP-ribose) polymerase inhibitors. Data on worldwide gBRCApv incidence among pancreatic ductal adenocarcinoma (PDAC) patients are sparse and describe a remarkable geographic heterogeneity. The aim of this study is to analyze the epidemiology of gBRCApv in Italian patients.

MATERIALS AND METHODS

Patients of any age with pancreatic adenocarcinoma, screened within 3 months from diagnosis for gBRCApv in Italian oncologic centers systematically performing tests without any selection. For the purposes of our analysis, breast, ovarian, pancreas, and prostate cancer in a patient's family history was considered as potentially BRCA-associated. Patients or disease characteristics were examined using the χ2 test or Fisher's exact test for qualitative variables and the Student's t-test or Mann-Whitney test for continuous variables, as appropriate.

RESULTS

Between June 2015 and May 2020, 939 patients were tested by 14 Italian centers; 492 (52%) males, median age 62 years (range 28-87), 569 (61%) metastatic, 273 (29%) with a family history of potentially BRCA-associated cancers. gBRCA1-2pv were found in 76 patients (8.1%; 9.1% in metastatic; 6.4% in non-metastatic). The gBRCA2/gBRCA1 ratio was 5.4 : 1. Patients with gBRCApv were younger compared with wild-type (59 versus 62 years, P = 0.01). The gBRCApv rate was 17.1% among patients <40 years old, 10.4% among patients 41-50 years old, 9.2% among patients 51-60 years old, 6.7% among patients aged 61-70 years, and 6.2% among patients >70 years old (none out of 94 patients >73 years old). gBRCApv frequency in 845 patients <74 years old was 9%. Patients with/without a family history of potentially BRCA-associated tumors had 14%/6% mutations.

CONCLUSION

Based on our findings of a gBRCApv incidence higher than expected in a real-life series of Italian patients with incident PDAC, we recommend screening all PDAC patients <74 years old, regardless of family history and stage, due to the therapeutic implications and cancer risk prevention in patients' relatives.

Liver radiologic findings of chemotherapy-induced toxicity in liver colorectal metastases patients

There are a number of chemotherapy-effects that should be assessed with liver imaging since they have an influence on surgical morbidity. Chemotherapy-related complications, steatosis, chemotherapy-associated steatohepatitis (CASH), and SOS might impair the hepatic parenchyma, thus reducing the functionality and influencing the outcome following resection. The main role of a radiologist is to provide an accurate diagnosis of the lesion. With constant advances in medicine, a radiologist's role should extend beyond just reporting the data of tumor, providing additional information that may greatly improve patient care. Radiologists should assess both chemotherapy effects on the hepatic metastasis itself, as well as chemo-induced focal and diffuse modifications of non-tumor hepatic parenchyma, since it is important to avoid impaired hepatic function after hepatic resection.

Vorinostat synergises with capecitabine through upregulation of thymidine phosphorylase

Background:

Potentiation of anticancer activity of capecitabine is required to improve its therapeutic index. In colorectal cancer (CRC) cells, we evaluated whether the histone deacetylase-inhibitor vorinostat may induce synergistic antitumour effects in combination with capecitabine by modulating the expression of thymidine phosphorylase (TP), a key enzyme in the conversion of capecitabine to 5-florouracil (5-FU), and thymidylate synthase (TS), the target of 5-FU.

Methods:

Expression of TP and TS was measured by real-time PCR, western blotting and immunohistochemistry. Knockdown of TP was performed by specific small interfering RNA. Antitumour activity of vorinostat was assessed in vitro in combination with the capecitabine active metabolite deoxy-5-fluorouridine (5′-DFUR) according to the Chou and Talay method and by evaluating apoptosis as well as in xenografts-bearing nude mice in combination with capecitabine.

Results:

Vorinostat induced both in vitro and in vivo upregulation of TP as well as downregulation of TS in cancer cells, but not in ex vivo treated peripheral blood lymphocytes. Combined treatment with vorinostat and 5′-DFUR resulted in a synergistic antiproliferative effect and increased apoptotic cell death in vitro. This latter effect was impaired in cells where TP was knocked. In vivo, vorinostat plus capecitabine potently inhibited tumour growth, increased apoptosis and prolonged survival compared with control or single-agent treatments.

Conclusions:

Overall, this study suggests that the combination of vorinostat and capecitabine is an innovative antitumour strategy and warrants further clinical evaluation for the treatment of CRC.

Evaluation of two different schedules of bevacizumab (BEV) with oxaliplatin (OXA), raltitrexed (TOM), levo-folinic acid (LFA), and 5-fluorouracil (5-FU) during preoperative (preop) pelvic RT in high-risk locally advanced rectal cancer (HR-LARC) patients (pts)

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Background: OXA, RTX, 5FU, and LFA during preop pelvic RT produced a high rate of complete (TRG1) or subtotal (TRG2) tumor regression in HR-LARC. BEV might enhance response to chemoradiotherapy (CH-RT), but scheduling of BEV could be critical. Therefore, we added BEV to CH-RT in two different schedules to evaluate their feasibility and activity. According to the Simon's two-stage design, assuming a hypothesis of a 50% TRG1 (α=0.05, β=0.20), at least 6/16 TRG1 should be obtained to continue pts accrual in every schedule. Methods: Inclusion criteria were: cT4, cN+, cT3(<5 cm from the anal verge and/or +ve CRM), resectable M1. Pts received 3 biweekly courses(c) of OXA (100 mg/m2)/TOM (2.5 mg/m2) on day 1, and 5FU (800 mg/m2)/LFA(250 mg/m2) on day 2 during pelvic RT (45 Gy). BEV (5 mg/kg) was given biweekly from day -14 for 4 c in schedule A, and from day -4 for 2 c in schedule B. Toxicity was graded with NCI-CTCv3. Changes of circulating endothelial cells (CECs)assessed by flow cytometry in 17 (7 A; 10 B) pts, and glucose metabolism evaluated by FDG-PET in 27 (15 A; 12 B) pts after 1st c of CT were used as surrogate markers of tumor response. The Mann-Whitney test assessed the differences in CECs and FDG-PET related to schedules. TME was planned 8 wks after CH- RT. Results: Until now, 28 pts (16 A; 12 B) were treated: M/F=19/9; median age 57 (range, 43–74) yrs. All but one pt (A) completed the planned CH-RT. Grade 3/4 neutropenia was the most common toxicity with schedule A (7 pts, 44%), while it never occurred with schedule B. No treatment-related or postop death occurred. CECs were more decreased by schedule B than by schedule A (median, -78% vs -29%, p< 0.05). Glucose metabolism was also more reduced by schedule B (median, -78% vs -50%, p < 0.05). All but one pt (refusal) of schedule A, and 7 pts of schedule B proceeded to TME. With schedule A, 2 pts obtained a TRG1, 8 pts a TRG2, 3 pts a TRG3 and 2 pts a TRG4. With schedule B, 4 pts obtained a TRG1 and 3 pts a TRG2. Conclusions: These data suggest the relevance of BEV scheduling during preop CT-RT to optimize safety and efficacy of the combination treatment. Updated results on the whole study population will be presented.

No significant financial relationships to disclose.

Metronomic irinotecan and standard FOLFIRI regimen as first-line chemotherapy in metastatic colorectal cancer (MCRC). Final results of phase II study

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Background: Angiogenesis is necessary to sustain the growth of both the primary tumour and the development of metastases in colorectal cancer. Before the clinical use of bevacizumab, metronomic chemotherapy was the only mean to block the growth of tumor microvessel. CPT-11 showed, in preclinical model, to have antiangiogenetic properties using low doses and weekly administration. We carried out this study in order to evaluate the activity and toxicity of mixed metronomic and standard FOLFIRI regimen in MCRC. Methods: From 10/03 to 9/05 we treated 46 pts (24M 22F), median age 66 years (range 41–79), ECOG PS 0–2 with this schedule: CPT- 11 10 mg/mq days 1, 7, 10 and CPT-11 150 mg/mq day 2, l-Folinic Acid 100 mg/mq days 2 and 3, 5-FU 400 mg/mq bolus days 2 and 3 and 5- FU 600 mg/mq 44 hours c.i. days 2 and 3 every two weeks for a maximum of 12 cycles. Results: All pts have been evaluable activity and toxicity. We obtained 9 CR (20%), 12 PR (26%) with an ORR of 46% (CI 95%: ±13%) and 17 SD. After a median follow-up of 24 months we registered a median TTP of 10 months and a median OS of 22 months. As regard toxicity, the chemotherapy has been well tolerated; no toxic deaths occurred and no therapy ended for toxicity. 6 pts had 25% dose reduction (standard schedule) for diarrhea G4 after the first cycle. The main toxicities recorded on a total of 440 cycles (cy) delivered were: diarrhea G4 1.7% and G3 2.3% of the cy. Neutropenia G3 5.8% and vomiting G3 0.5% of the cy. Anemia G2 was recorded in 14 pts. All pts suffered from partial alopecia and half of the pts from mild oral mucositis. Conclusions: This mixed schedule seems to be active and well tolerated, ORR, TTP and OS are similar to Hurwitz results (NEJM 2004; 350: 2335–42) but with less adverse events. The combination of this schedule with bevacizumab deserves further studies.

No significant financial relationships to disclose.

High rate of TRG1–2 and prolonged RFS with OXA/TOM and FU/LFA during preoperative pelvic RT in patients with poor prognosis locally advanced rectal cancer (LARC)

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Background: We have previously reported that 3 cycles of Oxaliplatin (OXA), Raltitrexed (TOM) and 5-Fluorouracile (FU) + levo-folinic acid (LFA) during pelvic RT had an acceptable toxicity and produced a complete (TRG1, 42%) or subtotal (TRG2, 29%) pathologic tumor regression in 71% of 31 pts with poor prognosis LARC (Avallone et al, Br J Cancer 2006). Here we report an expanded experience on such treatment. Methods: We enrolled 62 eligible pts (M, 33; F, 29), with median age of 58 (27–79) yrs, and adenocarcinoma of the extraperitoneal rectum, with at least one of the following characteristics: cT4 (N pts), cN+ (N), cT3N0 with tumor location = 5 cm from the anal verge and/or CRM +ve (assessed by MRI) (N). Pts received 3 biweekly courses of OXA 100 mg/sqm + TOM 2.5 mg/sqm on day 1, and LFA 250 mg/sqm + FU 900 mg/sqm (31 pts) or 800 mg/sqm (31 pts) on day 2, and concomitant pelvic RT (1.8 Gy/day, total dose 45 Gy). TME was planned 8 weeks after the end of treatment. Pathologic response was evaluated by tumor regression grading (TRG) according to Mandard’s modified classification. Pts with cT4, pN+ and pCRM +ve received also 4 months of weekly FU/FA. Results: All pts received full dose of RT, and 98% of the planned CT cycles. Neutropenia was the most common grade = 3 toxicity (40%), while grade 3 diarrhea was seen in 19% of pts with FU 900 mg/sqm, and in only 6% of pts with FU 800 mg/sqm. All but 2 pts had a TME with R0 resection, and no treatment-related or perioperative death occurred. Median number of sampled lymph nodes was 36 (range, 10–80). 28 (45%) pts obtained a TRG1, and 17 (27%) pts a TRG2. Activity of the treatment was similar in all risk groups, regardless of FU dosage. 1 pt suffered a local recurrence (after 9 months), and 3 pts had distant metastases (after 22, 33, and 47 months). After a median follow-up of 34 (range 6–54) months, all pts are alive, and the estimated 34-month RFS was 95%. All pts achieving a TRG1, and all but one with TRG2 (pCRM +ve), were recurrence-free. Conclusions: These data confirm the feasibility and activity of the whole treatment. A slight reduction of FU dosage appeared to improve the safety of this combination. Currently, we are now evaluating the addition of bevacizumab 5 mg/kg every 2 weeks before and during this concurrent treatment.

No significant financial relationships to disclose.

Biweekly oxaliplatin, raltitrexed, 5-fluorouracil and folinic acid combination chemotherapy during preoperative radiation therapy for locally advanced rectal cancer: a phase I-II study

Oxaliplatin (OXA), raltitrexed (RTX), 5-fluorouracil (FU) and folinic acid (FA) have shown activity in metastatic colorectal cancer, radioenhancing effect and synergism when combined. We evaluated a chemotherapy (CT) combination of OXA, RTX and FU/FA during preoperative radiotherapy (RT) in locally advanced rectal cancer (LARC) patients. Fifty-one patients with LARC at high risk of recurrence (T4, N+ or T3N0 ⩽5 cm from anal verge and/or circumferential resection margin ⩽5 mm) received three biweekly courses of CT during pelvic RT (45 Gy). Surgery was planned 8 weeks after CT-RT. Recommended doses (RDs) determined during phase I were utilised in the subsequent phase II trial, where the rate of tumour regression grade (TRG) 1 or 2 was the main end point. No toxic deaths occurred, and severe toxicity was easily managed. In phase II, RDs delivered in 31 patients were OXA 100 mg m⁻² and RTX 2.5 mg m⁻² on day 1, and FU 900 mg m⁻² and LFA 250 mg m⁻² on day 2. Main severe toxicities by patients were grade 4 neutropenia (23%) and grade 3 diarrhoea (19%). In 71% (95% confidence limits, 52–86%) of patients, TRG1 (13) or TRG2 (9) was obtained. All patients are alive and recurrence-free after a median follow-up of 29 months. Combination of OXA, RTX and FU/FA with pelvic RT has an acceptable toxicity and a high clinical activity in LARC and should be studied further in patients at high risk of recurrence.

Combined multistep approach in a locally advanced rectal cancer with sacral invasion: case report

Composite pelvic resection with sacrectomy may provide good local control in case of locally advanced rectal cancer infiltrating the sacral bone. A combined multidisciplinary approach including chemotherapy and radiotherapy is here presented for a case of rectal tumor invading the sacrum.

Multidisciplinary approach to locally advanced rectal cancer: results of a single institution trial

Locally advanced rectal cancer carries out a dismail prognosis despite optimal surgery in terms of local and distant relapses. Neoadjuvant chemoradiation offers good results with tumor downstaging and downsizing and leads to more radical surgery with conservative intent. Selection of patients and an intensive chemotherapy may improve long term results. Our experience with a combined polichemotherapy and radiotherapy for low advanced rectal cancer is presented.