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John AO, Singh A, Bala D, Joel A, Georgy JT, Jesudasan MR, Mittal R, Ram TS, Reddy JR, Murthy A, Chandramohan A, Eapen A, Masih D, Ramnath N, Dobrosotskaya I, Yadav B, Chacko RT. Total Neoadjuvant Therapy (TNT) with Full Dose Concurrent Chemotherapy in Locally Advanced Rectal Adenocarcinoma Including Signet Ring and Mucinous Cancers. J Gastrointest Cancer 2023:10.1007/s12029-023-00941-4. [PMID: 37479897 DOI: 10.1007/s12029-023-00941-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2023] [Indexed: 07/23/2023]
Abstract
PURPOSE Total neoadjuvant therapy (TNT) with pre-operative chemotherapy and chemoradiotherapy results in improved survival and is becoming the new standard of care in locally advanced rectal cancer (LARC). We describe our experience with TNT consisting of induction chemotherapy followed by chemoradiotherapy using full dose 5FU without oxaliplatin. METHODS Adults with biopsy-proven, newly diagnosed LARC with high-risk characteristics on pelvic MRI (T4a or T4b, extramural vascular invasion, N2, mesorectal fascia involvement, enlargement/tumor deposits on lateral lymph nodes) were included. The TNT protocol comprised of six biweekly courses of modified FOLFOX6 followed by pelvic RT with four concurrent cycles of biweekly 5-FU 2600 mg/m2 + LV 200 mg/m2 without oxaliplatin to complete 20 uninterrupted weeks of full dose 5FU. Surgery was planned 11-13 weeks after completing chemoradiotherapy. RESULTS Eighty-four LARC patients, including 26% with signet-ring cell carcinoma, with high-risk MRI characteristics were treated with the TNT protocol with a 96% completion rate. Significant (> grade 3) toxicities included neutropenia (23.8%), diarrhea (14.2%) anemia (10.7%), and two deaths. The median DFS at 2 years was 22.5 months with better survival noted for those who underwent surgery or had cCR (with NOM) compared to those who did not undergo surgery (due to progression, inadequate regression, or patient preference despite residual disease) -mDFS 27.7 months versus 11.4 months, p = < 0.0001 and mOS 29.2 months versus 15 months p = < 0.0001. CONCLUSION The hybrid TNT regimen was administered without significant dose delays or interruptions. Toxicity was manageable but with two treatment-related deaths. Ability to undergo surgery after TNT predicted for improved DFS and OS.
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Affiliation(s)
- Ajoy Oommen John
- Department of Medical Oncology, Christian Medical College, Vellore, Tamil, Nadu-632004, India
| | - Ashish Singh
- Department of Medical Oncology, Christian Medical College, Vellore, Tamil, Nadu-632004, India.
| | - Divya Bala
- Department of Medical Oncology, Christian Medical College, Vellore, Tamil, Nadu-632004, India
| | - Anjana Joel
- Department of Medical Oncology, Christian Medical College, Vellore, Tamil, Nadu-632004, India
| | - Josh Thomas Georgy
- Department of Medical Oncology, Christian Medical College, Vellore, Tamil, Nadu-632004, India
| | | | - Rohin Mittal
- Department of Colorectal Surgery, Christian Medical College, Vellore, India
| | - Thomas Samuel Ram
- Department of Radiation Oncology, Christian Medical College, Vellore, India
| | | | - Arvind Murthy
- Department of Radiation Oncology, Christian Medical College, Vellore, India
| | | | - Anu Eapen
- Department of Radiodiagnosis, Christian Medical College, Vellore, India
| | - Dipti Masih
- Department of Pathology, Christian Medical College, Vellore, India
| | - Nithya Ramnath
- Division of Medical Oncology, Ann Arbor Healthcare Systems, University of Michigan, Veterans Administration, Ann Arbor, USA
| | - Irina Dobrosotskaya
- Division of Medical Oncology, Ann Arbor Healthcare Systems, University of Michigan, Veterans Administration, Ann Arbor, USA
| | - Bijesh Yadav
- Department of Biostatistics, Christian Medical College, Vellore, India
| | - Raju Titus Chacko
- Department of Medical Oncology, Christian Medical College, Vellore, Tamil, Nadu-632004, India
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Bala D, Gowrisankar M, Babu S, Kumar KS, Ramachandran D. Study on Thermodynamic and Transport Properties of Binary Liquid Mixtures (N-Methylformamide with Aniline, N-Methylaniline, and N,N-Dimethylaniline) at Various Temperatures. Russ J Phys Chem 2022. [DOI: 10.1134/s0036024422040057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Jankowski M, Las-Jankowska M, Bala D, Wiczolek A, Trojakowska M, Smyk E, Wiśniewski D, Michal S, Hertmanowski W, Lewicka M, Kobylska J, Wojciechowska M, Tkaczynski K, Klag M, Zegarski W. 334. Does the number of lymph nodes detected in postoperative material in patients with rectum cancer have clinical importance? Eur J Surg Oncol 2016. [DOI: 10.1016/j.ejso.2016.06.230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Jankowski M, Las-Jankowska M, Bala D, Klag M, Zegarski W. 333. Local recurrence after neoadjuvant radiotherapy resectable locoregional advanced rectal cancer. Eur J Surg Oncol 2016. [DOI: 10.1016/j.ejso.2016.06.229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Jankowski M, Las-Jankowska M, Bala D, Wiczolek A, Tkaczynski K, Wiśniewski D, Zegarski W. 335. The importance of the location of the tumor in patients with resectable advanced cancer of the rectum. Eur J Surg Oncol 2016. [DOI: 10.1016/j.ejso.2016.06.231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Jankowski M, Las - Jankowska M, Bala D, Tkaczynski K, Tarczynski M, Wiczolek A, Zegarski W. 279. Treatment outcomes following extended resections due to advanced rectal cancer. Eur J Surg Oncol 2014. [DOI: 10.1016/j.ejso.2014.08.271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Abstract
Acute iron toxicity is usually seen in children with accidental ingestion of iron-containing syrups. However, the literature on acute iron toxicity with suicidal intent in adults is scant. We report, the first instance of two adults with fatal ingestion of a single drug overdose with iron tablets from India. Two young adults developed severe gastro-intestinal bleeding and fulminant hepatic failure 48 h after deliberate consumption of large doses of iron tablets. Serum iron levels measured 36 h after ingestion were normal presumably due to the redistribution of iron to the intracellular compartment. Despite aggressive supportive management in medical intensive care unit of a tertiary care hospital, the patients succumbed to the toxic doses of iron.
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