1
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van Geffen EGM, Langhout JMA, Hazen SJA, Sluckin TC, van Dieren S, Beets GL, Beets-Tan RGH, Borstlap WAA, Burger JWA, Horsthuis K, Intven MPW, Aalbers AGJ, Havenga K, Marinelli AWKS, Melenhorst J, Nederend J, Peulen HMU, Rutten HJT, Schreurs WH, Tuynman JB, Verhoef C, de Wilt JHW, Marijnen CAM, Tanis PJ, Kusters M, On Behalf Of The Dutch Snapshot Research Group. Evolution of clinical nature, treatment and survival of locally recurrent rectal cancer: Comparative analysis of two national cross-sectional cohorts. Eur J Cancer 2024; 202:114021. [PMID: 38520925 DOI: 10.1016/j.ejca.2024.114021] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 03/04/2024] [Accepted: 03/10/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND In the Netherlands, use of neoadjuvant radiotherapy for rectal cancer declined after guideline revision in 2014. This decline is thought to affect the clinical nature and treatability of locally recurrent rectal cancer (LRRC). Therefore, this study compared two national cross-sectional cohorts before and after the guideline revision with the aim to determine the changes in treatment and survival of LRRC patients over time. METHODS Patients who underwent resection of primary rectal cancer in 2011 (n = 2094) and 2016 (n = 2855) from two nationwide cohorts with a 4-year follow up were included. Main outcomes included time to LRRC, synchronous metastases at time of LRRC diagnosis, intention of treatment and 2-year overall survival after LRRC. RESULTS Use of neoadjuvant (chemo)radiotherapy for the primary tumour decreased from 88.5% to 60.0% from 2011 to 2016. The 3-year LRRC rate was not significantly different with 5.1% in 2011 (n = 114, median time to LRRC 16 months) and 6.3% in 2016 (n = 202, median time to LRRC 16 months). Synchronous metastasis rate did not significantly differ (27.2% vs 33.7%, p = 0.257). Treatment intent of the LRRC shifted towards more curative treatment (30.4% vs. 47.0%, p = 0.009). In the curatively treated group, two-year overall survival after LRRC diagnoses increased from 47.5% to 78.7% (p = 0.013). CONCLUSION Primary rectal cancer patients in 2016 were treated less often with neoadjuvant (chemo)radiotherapy, while LRRC rates remained similar. Those who developed LRRC were more often candidate for curative intent treatment compared to the 2011 cohort, and survival after curative intent treatment also improved substantially.
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Affiliation(s)
- E G M van Geffen
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Treatment and Quality of Life and Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - J M A Langhout
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - S J A Hazen
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Treatment and Quality of Life and Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - T C Sluckin
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Treatment and Quality of Life and Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - S van Dieren
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - G L Beets
- GROW School of Oncology and Developmental Biology, University of Maastricht, Maastricht, the Netherlands; Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - R G H Beets-Tan
- GROW School of Oncology and Developmental Biology, University of Maastricht, Maastricht, the Netherlands; Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands; Department of Radiology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - W A A Borstlap
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Treatment and Quality of Life and Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - J W A Burger
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - K Horsthuis
- Department of Radiology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - M P W Intven
- Department of Radiotherapy, Division Imaging and Oncology, University Medical Centre Utrecht, the Netherlands
| | - A G J Aalbers
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - K Havenga
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - A W K S Marinelli
- Department of Surgery, Haaglanden Medisch Centrum, Den Haag, the Netherlands
| | - J Melenhorst
- GROW School of Oncology and Developmental Biology, University of Maastricht, Maastricht, the Netherlands; Department of Surgery and Colorectal Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - J Nederend
- Department of Radiology, Catharina Hospital, Eindhoven, the Netherlands
| | - H M U Peulen
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - H J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - W H Schreurs
- Department of Surgery, Nothwest Clinics, Alkmaar, the Netherlands
| | - J B Tuynman
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Treatment and Quality of Life and Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - C Verhoef
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - J H W de Wilt
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - C A M Marijnen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands; Department of Radiation Oncology, Leiden University Medical Centre, Leiden, the Netherlands
| | - P J Tanis
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands; Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
| | - M Kusters
- Treatment and Quality of Life and Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, the Netherlands; Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands.
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2
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Piqeur F, Creemers DMJ, Banken E, Coolen L, Tanis PJ, Maas M, Roef M, Marijnen CAM, van Hellemond IEG, Nederend J, Rutten HJT, Peulen HMU, Burger JWA. Dutch national guidelines for locally recurrent rectal cancer. Cancer Treat Rev 2024; 127:102736. [PMID: 38696903 DOI: 10.1016/j.ctrv.2024.102736] [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] [Received: 11/27/2023] [Revised: 04/15/2024] [Accepted: 04/18/2024] [Indexed: 05/04/2024]
Abstract
Due to improvements in treatment for primary rectal cancer, the incidence of LRRC has decreased. However, 6-12% of patients will still develop a local recurrence. Treatment of patients with LRRC can be challenging, because of complex and heterogeneous disease presentation and scarce - often low-grade - data steering clinical decisions. Previous consensus guidelines have provided some direction regarding diagnosis and treatment, but no comprehensive guidelines encompassing all aspects of the clinical management of patients with LRRC are available to date. The treatment of LRRC requires a multidisciplinary approach and overarching expertise in all domains. This broad expertise is often limited to specific expert centres, with dedicated multidisciplinary teams treating LRRC. A comprehensive, narrative literature review was performed and used to develop the Dutch National Guideline for management of LRRC, in an attempt to guide decision making for clinicians, regarding the complete clinical pathway from diagnosis to surgery.
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Affiliation(s)
- Floor Piqeur
- Department of Radiation Oncology, Catharina Hospital, Michelangelolaan 2 5623EJ, Eindhoven, the Netherlands; Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121 1066 CX, Amsterdam, the Netherlands; Department of Radiation Oncology, Leiden University Medical Centre, Albinusdreef 2 2333ZA, Leiden, the Netherlands
| | - Davy M J Creemers
- GROW School of Oncology and Developmental Biology, University of Maastricht, Universiteitssingel 40 6229ER, Maastricht, the Netherlands; Department of Surgery, Catharina Hospital, Michelangelolaan 2 5623EJ, Eindhoven, the Netherlands
| | - Evi Banken
- GROW School of Oncology and Developmental Biology, University of Maastricht, Universiteitssingel 40 6229ER, Maastricht, the Netherlands; Department of Medical Oncology, Catharina Hospital, Michelangelolaan 2 5623 EJ, Eindhoven, the Netherlands
| | - Liën Coolen
- Department of Radiology, Catharina Hospital, Michelangelolaan 2 5623 EJ, Eindhoven, the Netherlands
| | - Pieter J Tanis
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus Medical Centre, Dr. Molewaterplein 40 3015 GD, Rotterdam, the Netherlands
| | - Monique Maas
- GROW School of Oncology and Developmental Biology, University of Maastricht, Universiteitssingel 40 6229ER, Maastricht, the Netherlands; Department of Radiology, The Netherlands Cancer Institute, Plesmanlaan 121 1066 CX, Amsterdam, the Netherlands
| | - Mark Roef
- Department of Nuclear Medicine, Catharina Hospital, Michelangelolaan 2 5623EJ, Eindhoven, the Netherlands
| | - Corrie A M Marijnen
- Department of Radiation Oncology, Leiden University Medical Centre, Albinusdreef 2 2333ZA, Leiden, the Netherlands
| | - Irene E G van Hellemond
- Department of Medical Oncology, Catharina Hospital, Michelangelolaan 2 5623 EJ, Eindhoven, the Netherlands
| | - Joost Nederend
- Department of Radiology, Catharina Hospital, Michelangelolaan 2 5623 EJ, Eindhoven, the Netherlands
| | - Harm J T Rutten
- GROW School of Oncology and Developmental Biology, University of Maastricht, Universiteitssingel 40 6229ER, Maastricht, the Netherlands; Department of Surgery, Catharina Hospital, Michelangelolaan 2 5623EJ, Eindhoven, the Netherlands
| | - Heike M U Peulen
- Department of Radiation Oncology, Catharina Hospital, Michelangelolaan 2 5623EJ, Eindhoven, the Netherlands
| | - Jacobus W A Burger
- Department of Surgery, Catharina Hospital, Michelangelolaan 2 5623EJ, Eindhoven, the Netherlands.
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3
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Nordkamp S, van Rees JM, van den Berg K, Mens DM, Creemers DMJ, Peulen HMU, Creemers GJ, Nieuwenhuijzen GAP, Tolenaar JL, Bloemen JG, Rothbarth J, Rutten HJT, Verhoef C, Burger JWA. Locally recurrent rectal cancer: oncological outcomes of neoadjuvant chemoradiotherapy with or without induction chemotherapy. Br J Surg 2023; 110:1637-1640. [PMID: 37406084 DOI: 10.1093/bjs/znad214] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/18/2023] [Accepted: 05/21/2023] [Indexed: 07/07/2023]
Affiliation(s)
- Stefi Nordkamp
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
| | - Jan M van Rees
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Kim van den Berg
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
- Department of Medical Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - David M Mens
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Davy M J Creemers
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Heike M U Peulen
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - Geert-Jan Creemers
- Department of Medical Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Jip L Tolenaar
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Johanne G Bloemen
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Joost Rothbarth
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Harm J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
| | - Cornelis Verhoef
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
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4
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Nordkamp S, Piqeur F, van den Berg K, Tolenaar JL, van Hellemond IEG, Creemers GJ, Roef M, van Lijnschoten G, Cnossen JS, Nieuwenhuijzen GAP, Bloemen JG, Coolen L, Nederend J, Peulen HMU, Rutten HJT, Burger JWA. Locally recurrent rectal cancer: Oncological outcomes for patients with a pathological complete response after neoadjuvant therapy. Br J Surg 2023:7181206. [PMID: 37243705 DOI: 10.1093/bjs/znad094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/11/2023] [Accepted: 03/21/2023] [Indexed: 05/29/2023]
Abstract
BACKGROUND For patients with locally recurrent rectal cancer, it is an ongoing pursuit to establish factors predicting or improving oncological outcomes. In locally advanced rectal cancer, a pCR appears to be associated with improved outcomes. The aim of this retrospective cohort study was to compare the oncological outcomes of patients with locally recurrent rectal cancer with and without a pCR. METHODS Patients who underwent neoadjuvant treatment and surgery for locally recurrent rectal cancer with curative intent between January 2004 and June 2020 at a tertiary referral hospital were analysed. Primary outcomes included overall survival, disease-free survival, metastasis-free survival, and local re-recurrence-free survival, stratified according to whether the patient had a pCR. RESULTS Of a total of 345 patients, 51 (14.8 per cent) had a pCR. Median follow-up was 36 (i.q.r. 16-60) months. The 3-year overall survival rate was 77 per cent for patients with a pCR and 51.1 per cent for those without (P < 0.001). The 3-year disease-free survival rate was 56 per cent for patients with a pCR and 26.1 per cent for those without (P < 0.001). The 3-year local re-recurrence-free survival rate was 82 and 44 per cent respectively (P < 0.001). Surgical procedures (for example soft tissue, sacrum, and urogenital organ resections) and postoperative complications were comparable between patients with and without a pCR. CONCLUSION This study showed that patients with a pCR have superior oncological outcomes to those without a pCR. It may therefore be safe to consider a watch-and-wait approach in highly selected patients, potentially improving quality of life by omitting extensive surgical procedures without compromising oncological outcomes.
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Affiliation(s)
- Stefi Nordkamp
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
- Faculty of Health, Medicine and Life Sciences, GROW School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
| | - Floor Piqeur
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, the Netherlands
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Kim van den Berg
- Department of Medical Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - Jip L Tolenaar
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Geert-Jan Creemers
- Department of Medical Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - Mark Roef
- Department of Nuclear Medicine, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Jeltsje S Cnossen
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Johanne G Bloemen
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Liën Coolen
- Department of Radiology, Catharina Hospital, Eindhoven, the Netherlands
| | - Joost Nederend
- Department of Radiology, Catharina Hospital, Eindhoven, the Netherlands
| | - Heike M U Peulen
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - Harm J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
- Faculty of Health, Medicine and Life Sciences, GROW School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
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5
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Piqeur F, Hupkens BJP, Nordkamp S, Witte MG, Meijnen P, Ceha HM, Berbee M, Dieters M, Heyman S, Valdman A, Nilsson MP, Nederend J, Rutten HJT, Burger JWA, Marijnen CAM, Peulen HMU. Development of a consensus-based delineation guideline for locally recurrent rectal cancer. Radiother Oncol 2022; 177:214-221. [PMID: 36410547 DOI: 10.1016/j.radonc.2022.11.008] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 11/08/2022] [Accepted: 11/13/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND PURPOSE Neoadjuvant chemoradiotherapy (nCRT) is used in locally recurrent rectal cancer (LRRC) to increase chances of a radical surgical resection. Delineation in LRRC is hampered by complex disease presentation and limited clinical exposure. Within the PelvEx II trial, evaluating the benefit of chemotherapy preceding nCRT for LRRC, a delineation guideline was developed by an expert LRRC team. MATERIALS AND METHODS Eight radiation oncologists, from Dutch and Swedish expert centres, participated in two meetings, delineating GTV and CTV in six cases. Regions at-risk for re-recurrence or irradical resection were identified by eleven expert surgeons and one expert radiologist. Target volumes were evaluated multidisciplinary. Inter-observer variation was analysed. RESULTS Inter-observer variation in delineation of LRRC appeared large. Multidisciplinary evaluation per case is beneficial in determining target volumes. The following consensus regarding target volumes was reached. GTV should encompass all tumour, including extension into OAR if applicable. If the tumour is in fibrosis, GTV should encompass the entire fibrotic area. Only if tumour can clearly be distinguished from fibrosis, GTV may be reduced, as long as the entire fibrotic area is covered by the CTV. CTV is GTV with a 1 cm margin and should encompass all at-risk regions for irradical resection or re-recurrence. CTV should not be adjusted towards other organs. Multifocal recurrences should be encompassed in one CTV. Elective nodal delineation is only advised in radiotherapy-naïve patients. CONCLUSION This study provides a first consensus-based delineation guideline for LRRC. Analyses of re-recurrences is needed to understand disease behaviour and to optimize delineation guidelines accordingly.
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Affiliation(s)
- Floor Piqeur
- Department of Radiation Oncology, Catharina Hospital, Michelangelolaan 2, 5623EJ Eindhoven, the Netherlands; Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands; Department of Radiation Oncology, Leiden University Medical Centre, Albinusdreef 2, 2333ZA Leiden, the Netherlands
| | - Britt J P Hupkens
- Department of Radiation Oncology, Catharina Hospital, Michelangelolaan 2, 5623EJ Eindhoven, the Netherlands; Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Doctor Tanslaan 12, 6229ET Maastricht, the Netherlands
| | - Stefi Nordkamp
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623EJ Eindhoven, the Netherlands
| | - Marnix G Witte
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands
| | - Philip Meijnen
- Department of Radiation Oncology, Amsterdam University Medical Centre, De Boelelaan 1118, 1081HZ Amsterdam, the Netherlands
| | - Heleen M Ceha
- Department of Radiation Oncology, Haaglanden Medical Centre, Burg. Banninglaan 1, 2262AK Leidschendam, the Netherlands
| | - Maaike Berbee
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Doctor Tanslaan 12, 6229ET Maastricht, the Netherlands
| | - Margriet Dieters
- Department of Radiation Oncology, University Medical Centre Groningen, Hanzeplein 1, 9713GZ Groningen, the Netherlands
| | - Sofia Heyman
- Department of Oncology, Institute of Clinical Sciencs, Sahlgrenska Academy at University of Gothenburg, Bla straket 5, 412 45 Götenborg, Sweden
| | - Alexander Valdman
- Department of Radiation Oncology, Karolinska University Hospital, Anna Steckséns gata 41, 171 64 Stockholm, Sweden
| | - Martin P Nilsson
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lasarettsgatan 23, 221 85 Lund, Sweden
| | - Joost Nederend
- Department of Radiology, Catharina Hospital, Michelangelolaan 2, 5623 EJ Eindhoven, the Netherlands
| | - Harm J T Rutten
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623EJ Eindhoven, the Netherlands; GROW School of Oncology and Developmental Biology, University of Maastricht, Universiteitssingel 40, 6229ER Maastricht, the Netherlands
| | - Jacobus W A Burger
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623EJ Eindhoven, the Netherlands
| | - Corrie A M Marijnen
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands; Department of Radiation Oncology, Leiden University Medical Centre, Albinusdreef 2, 2333ZA Leiden, the Netherlands
| | - Heike M U Peulen
- Department of Radiation Oncology, Catharina Hospital, Michelangelolaan 2, 5623EJ Eindhoven, the Netherlands.
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6
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van den Berg K, Schaap DP, Voogt ELK, Buffart TE, Verheul HMW, de Groot JWB, Verhoef C, Melenhorst J, Roodhart JML, de Wilt JHW, van Westreenen HL, Aalbers AGJ, van 't Veer M, Marijnen CAM, Vincent J, Simkens LHJ, Peters NAJB, Berbée M, Werter IM, Snaebjornsson P, Peulen HMU, van Lijnschoten IG, Roef MJ, Nieuwenhuijzen GAP, Bloemen JG, Willems JMWE, Creemers GJM, Nederend J, Rutten HJT, Burger JWA. Neoadjuvant FOLFOXIRI prior to chemoradiotherapy for high-risk ("ugly") locally advanced rectal cancer: study protocol of a single-arm, multicentre, open-label, phase II trial (MEND-IT). BMC Cancer 2022; 22:957. [PMID: 36068495 PMCID: PMC9446695 DOI: 10.1186/s12885-022-09947-w] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 07/29/2022] [Indexed: 11/14/2022] Open
Abstract
Background The presence of mesorectal fascia (MRF) invasion, grade 4 extramural venous invasion (EMVI), tumour deposits (TD) or extensive or bilateral extramesorectal (lateral) lymph nodes (LLN) on MRI has been suggested to identify patients with indisputable, extensive locally advanced rectal cancer (LARC), at high risk of treatment failure. The aim of this study is to evaluate whether or not intensified chemotherapy prior to neoadjuvant chemoradiotherapy improves the complete response (CR) rate in these patients. Methods This multicentre, single-arm, open-label, phase II trial will include 128 patients with non-metastatic high-risk LARC (hr-LARC), fit for triplet chemotherapy. To ensure a study population with indisputable, unfavourable prognostic characteristics, hr-LARC is defined as LARC with on baseline MRI at least one of the following characteristics; MRF invasion, EMVI grade 4, enlarged bilateral or extensive LLN at high risk of an incomplete resection, or TD. Exclusion criteria are the presence of a homozygous DPD deficiency, distant metastases, any chemotherapy within the past 6 months, previous radiotherapy within the pelvic area precluding standard chemoradiotherapy, and any contraindication for the planned treatment. All patients will be planned for six two-weekly cycles of FOLFOXIRI (5-fluorouracil, leucovorin, oxaliplatin and irinotecan) prior to chemoradiotherapy (25 × 2 Gy or 28 × 1.8 Gy with concomitant capecitabine). A resection will be performed following radiological confirmation of resectable disease after the completion of chemoradiotherapy. A watch and wait strategy is allowed in case of a clinical complete response. The primary endpoint is the CR rate, described as a pathological CR or a sustained clinical CR one year after chemoradiotherapy. The main secondary objectives are long-term oncological outcomes, radiological and pathological response, the number of resections with clear margins, treatment-related toxicity, perioperative complications, health-related costs, and quality of life. Discussion This trial protocol describes the MEND-IT study. The MEND-IT study aims to evaluate the CR rate after intensified chemotherapy prior to concomitant chemoradiotherapy in a homogeneous group of patients with locally advanced rectal cancer and indisputably unfavourable characteristics, defined as hr-LARC, in order to improve their prognosis. Trial registration Clinicaltrials.gov: NCT04838496, registered on 02–04-2021 Netherlands Trial Register: NL9790. Protocol version Version 3 dd 11–4-2022.
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Affiliation(s)
- K van den Berg
- Department of Medical Oncology, Catharina Hospital, Eindhoven, the Netherlands.,Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - D P Schaap
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - E L K Voogt
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - T E Buffart
- Department of Gastrointestinal Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands.,Department of Medical Oncology, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - H M W Verheul
- Department of Medical Oncology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - J W B de Groot
- Department of Medical Oncology, Isala Oncology Centre, Zwolle, the Netherlands
| | - C Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - J Melenhorst
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - J M L Roodhart
- Department of Medical Oncology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - J H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | | | - A G J Aalbers
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - M van 't Veer
- Department of Research and Education, Catharina Hospital, Eindhoven, the Netherlands
| | - C A M Marijnen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands.,Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - J Vincent
- Department of Medical Oncology, Elkerliek Hospital, Helmond, the Netherlands
| | - L H J Simkens
- Department of Medical Oncology, Maxima Medical Centre, Veldhoven, the Netherlands
| | - N A J B Peters
- Department of Medical Oncology, St. Jans Hospital, Weert, the Netherlands
| | - M Berbée
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - I M Werter
- Department of Medical Oncology, Rijnstate Hospital, Arnhem, the Netherlands
| | - P Snaebjornsson
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - H M U Peulen
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - I G van Lijnschoten
- Department of Pathology, PAMM Laboratory for Pathology and Medical Microbiology, Eindhoven, the Netherlands
| | - M J Roef
- Department of Nuclear Medicine, Catharina Hospital, Eindhoven, the Netherlands
| | | | - J G Bloemen
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - J M W E Willems
- Department of Medical Oncology, Anna Hospital, Geldrop, the Netherlands
| | - G J M Creemers
- Department of Medical Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - J Nederend
- Department of Radiology, Catharina Hospital, Eindhoven, the Netherlands
| | - H J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands.,GROW School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
| | - J W A Burger
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands.
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Voogt ELK, Schaap DP, van den Berg K, Nieuwenhuijzen GAP, Bloemen JG, Creemers GJ, Willems J, Cnossen JS, Peulen HMU, Nederend J, van Lijnschoten G, Burger JWA, Rutten HJT. Reply to: Use of induction chemotherapy in locally advanced rectal cancers to increase the response rates: Is it actually helping? Eur J Surg Oncol 2021; 47:2473-2474. [PMID: 34210580 DOI: 10.1016/j.ejso.2021.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 06/18/2021] [Indexed: 10/21/2022] Open
Affiliation(s)
- E L K Voogt
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands.
| | - D P Schaap
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - K van den Berg
- Department of Medical Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | | | - J G Bloemen
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - G J Creemers
- Department of Medical Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - J Willems
- Department of Medical Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - J S Cnossen
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - H M U Peulen
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - J Nederend
- Department of Radiology, Catharina Hospital, Eindhoven, the Netherlands
| | - G van Lijnschoten
- Pathology Department, PAMM Laboratory for Pathology and Medical Microbiology, Eindhoven, the Netherlands
| | - J W A Burger
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - H J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands; GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands
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8
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Voogt ELK, Schaap DP, van den Berg K, Nieuwenhuijzen GAP, Bloemen JG, Creemers GJ, Willems J, Cnossen JS, Peulen HMU, Nederend J, van Lijnschoten G, Burger JWA, Rutten HJT. Improved response rate in patients with prognostically poor locally advanced rectal cancer after treatment with induction chemotherapy and chemoradiotherapy when compared with chemoradiotherapy alone: A matched case-control study. Eur J Surg Oncol 2021; 47:2429-2435. [PMID: 34030921 DOI: 10.1016/j.ejso.2021.05.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/16/2021] [Accepted: 05/07/2021] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION The addition of induction chemotherapy (ICT) to neoadjuvant chemoradiotherapy (CRT) has the potential to improve outcomes in patients with locally advanced rectal cancer (LARC). However, patient selection is essential to prevent overtreatment. This study compared the complete response (CR) rate after treatment with and without ICT of LARC patients with prognostically poor characteristics. METHODS All LARC patients who were treated with neoadjuvant CRT, whether or not preceded by ICT, and who underwent surgery or were considered for a wait-and-see strategy between January 2016 and March 2020 in the Catharina Hospital Eindhoven, were retrospectively selected. LARC was defined as any T4 tumour, or a T2/T3 tumour with extramural venous invasion and/or tumour deposits and/or N2 lymph node status, and/or mesorectal fascia involvement (T3 tumours only). Case-control matching was performed based on the aforementioned characteristics. RESULTS Of 242 patients, 178 (74%) received CRT (CRT-group) and 64 patients (26%) received ICT followed by CRT (ICT-group). In the ICT-group, 3 patients (5%) did not receive the minimum of three cycles. In addition, in this selected cohort, compliance with radiotherapy was 100% in the ICT-group and 97% in the CRT-group. The CR rate was 30% in the ICT-group and 15% in the CRT-group (p = 0.011). After case-control matching, the CR rate was 28% and 9%, respectively (p = 0.013). CONCLUSION Treatment including ICT seemed well tolerated and resulted in a high CR rate. Hence, this treatment strategy may facilitate organ preservation and improve survival in LARC patients with prognostically poor characteristics.
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Affiliation(s)
- E L K Voogt
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands.
| | - D P Schaap
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - K van den Berg
- Department of Medical Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | | | - J G Bloemen
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - G J Creemers
- Department of Medical Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - J Willems
- Department of Medical Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - J S Cnossen
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - H M U Peulen
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - J Nederend
- Department of Radiology, Catharina Hospital, Eindhoven, the Netherlands
| | - G van Lijnschoten
- Department of Pathology, PAMM Laboratory for Pathology and Medical Microbiology, Eindhoven, the Netherlands
| | - J W A Burger
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - H J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands; GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands
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Voogt ELK, Nordkamp S, Nieuwenhuijzen GAP, Creemers GJ, Peulen HMU, Rutten HJT, Burger JWA. Curative treatment of locally recurrent rectal cancer: is induction chemotherapy warranted? Br J Surg 2021; 108:e213-e214. [PMID: 33709100 DOI: 10.1093/bjs/znab065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 01/29/2021] [Indexed: 11/15/2022]
Affiliation(s)
- E L K Voogt
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - S Nordkamp
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | | | - G J Creemers
- Department of Medical Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - H M U Peulen
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - H J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands.,GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands
| | - J W A Burger
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
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10
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de Haan R, van den Heuvel MM, van Diessen J, Peulen HMU, van Werkhoven E, de Langen AJ, Lalezari F, Pluim D, Verwijs-Janssen M, Vens C, Schellens JHM, Steeghs N, Verheij M, van Triest B. Phase I and Pharmacologic Study of Olaparib in Combination with High-dose Radiotherapy with and without Concurrent Cisplatin for Non-Small Cell Lung Cancer. Clin Cancer Res 2021; 27:1256-1266. [PMID: 33262140 DOI: 10.1158/1078-0432.ccr-20-2551] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 10/26/2020] [Accepted: 11/23/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE To identify an MTD of olaparib, a PARP inhibitor, in combination with loco-regional radiotherapy with/without cisplatin for the treatment of non-small cell lung cancer (NSCLC). PATIENTS AND METHODS Olaparib dose was escalated in two groups: radiotherapy (66 Gy/24 fractions in 2.75 Gy/fraction) with and without daily cisplatin (6 mg/m2), using time-to-event continual reassessment method with a 1-year dose-limiting toxicity (DLT) period. The highest dose level with a DLT probability <15% was defined as MTD. Poly ADP-ribose (PAR) inhibition and radiation-induced PAR-ribosylation (PARylation) were determined in peripheral blood mononuclear cells. RESULTS Twenty-eight patients with loco-regional or oligometastatic disease (39%) were treated: 11 at olaparib 25 mg twice daily and 17 at 25 mg once daily. The lowest dose level with cisplatin was above the MTD due to hematologic and late esophageal DLT. The MTD without cisplatin was olaparib 25 mg once daily. At a latency of 1-2.8 years, severe pulmonary adverse events (AE) were observed in 5 patients across all dose levels, resulting in 18% grade 5 pulmonary AEs. Exploratory analyses indicate an association with the radiation dose to the lungs. At the MTD, olaparib reduced PAR levels by more than 95% and abolished radiation-induced PARylation. Median follow-up of survivors was 4.1 years. Two-year loco-regional control was 84%, median overall survival in patients with locally advanced NSCLC was 28 months. CONCLUSIONS Combined mildly hypofractionated radiotherapy and low-dose daily cisplatin and olaparib was not tolerable due to esophageal and hematologic toxicity. Severe pulmonary toxicity was observed as well, even without cisplatin. More conformal radiotherapy schedules with improved pulmonary and esophageal sparing should be explored.
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Affiliation(s)
- Rosemarie de Haan
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Michel M van den Heuvel
- Department of Thoracic Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Judi van Diessen
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Heike M U Peulen
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Erik van Werkhoven
- Department of Biometrics, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Adrianus J de Langen
- Department of Thoracic Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Ferry Lalezari
- Department of Radiology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Dick Pluim
- Division of Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Manon Verwijs-Janssen
- Division of Cell Biology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Conchita Vens
- Division of Cell Biology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | | | - Neeltje Steeghs
- Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Marcel Verheij
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Baukelien van Triest
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands.
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11
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Voogt ELK, van Rees JM, Hagemans JAW, Rothbarth J, Nieuwenhuijzen GAP, Cnossen JS, Peulen HMU, Dries WJF, Nuyttens J, Kolkman-Deurloo IK, Verhoef C, Rutten HJT, Burger JWA. Intraoperative Electron Beam Radiation Therapy (IOERT) Versus High-Dose-Rate Intraoperative Brachytherapy (HDR-IORT) in Patients With an R1 Resection for Locally Advanced or Locally Recurrent Rectal Cancer. Int J Radiat Oncol Biol Phys 2021; 110:1032-1043. [PMID: 33567303 DOI: 10.1016/j.ijrobp.2021.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 12/18/2020] [Accepted: 02/02/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE Intraoperative radiation therapy (IORT), delivered by intraoperative electron beam radiation therapy (IOERT) or high-dose-rate intraoperative brachytherapy (HDR-IORT), may reduce the local recurrence rate in patients with locally advanced and locally recurrent rectal cancer (LARC and LRRC, respectively). The aim of this study was to compare the oncological outcomes between both IORT modalities in patients with LARC or LRRC who underwent a microscopic irradical (R1) resection. METHODS All consecutive patients who received IORT because of an R1 resection of LARC or LRRC between 2000 and 2016 in two tertiary referral centers were included. In LARC, a resection margin of ≤2 mm was considered R1. A resection margin of 0 mm was considered R1 in LRRC. RESULTS In total, 215 patients with LARC were included, of whom 151 (70%) received IOERT and 64 (30%) received HDR-IORT; in addition, 158 patients with LRRC were included, of whom 112 (71%) received IOERT and 46 (29%) received HDR-IORT. After multivariable analyses, the overall survival was not significantly different between the two IORT modalities. The local recurrence-free survival was significantly longer in patients treated with HDR-IORT, both in LARC (hazard ratio [HR], 0.496; 95% CI, 0.253-0.973; P = .041) and LRRC (HR, 0.567; 95% CI, 0.349-0.920; P = .021). In patients with LARC, major postoperative complications were similar for both IORT modalities (IOERT, 30%; HDR-IORT, 27%), whereas in patients with LRRC, the incidence of major postoperative complications was higher after HDR-IORT (IOERT, 26%; HDR-IORT, 46%). CONCLUSIONS This study showed a significantly better local recurrence-free survival in favor of HDR-IORT in patients with an R1 resection for LARC or LRRC. Optimization of the IOERT technique seems warranted.
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Affiliation(s)
- Eva L K Voogt
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands.
| | - Jan M van Rees
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Jan A W Hagemans
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Joost Rothbarth
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | | | - Jeltsje S Cnossen
- Department of Radiation Oncology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Heike M U Peulen
- Department of Radiation Oncology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Wim J F Dries
- Department of Radiation Oncology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Joost Nuyttens
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | | | - Cornelis Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Harm J T Rutten
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands; GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Jacobus W A Burger
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands; Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
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12
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Theelen WSME, Chen D, Verma V, Hobbs BP, Peulen HMU, Aerts JGJV, Bahce I, Niemeijer ALN, Chang JY, de Groot PM, Nguyen QN, Comeaux NI, Simon GR, Skoulidis F, Lin SH, He K, Patel R, Heymach J, Baas P, Welsh JW. Pembrolizumab with or without radiotherapy for metastatic non-small-cell lung cancer: a pooled analysis of two randomised trials. Lancet Respir Med 2020; 9:467-475. [PMID: 33096027 DOI: 10.1016/s2213-2600(20)30391-x] [Citation(s) in RCA: 226] [Impact Index Per Article: 56.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/21/2020] [Accepted: 08/10/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Radiotherapy might augment systemic antitumoral responses to immunotherapy. In the PEMBRO-RT (phase 2) and MDACC (phase 1/2) trials, patients with metastatic non-small-cell lung cancer were randomly allocated immunotherapy (pembrolizumab) with or without radiotherapy. When the trials were analysed individually, a potential benefit was noted in the combination treatment arm. However, owing to the small sample size of each trial, differences in response rates and outcomes were not statistically significant but remained clinically notable. We therefore did a pooled analysis to infer whether radiotherapy improves responses to immunotherapy in patients with metastatic non-small-cell lung cancer. METHODS Inclusion criteria for the PEMBRO-RT and MDACC trials were patients (aged ≥18 years) with metastatic non-small-cell lung cancer and at least one unirradiated lesion to monitor for out-of-field response. In the PEMBRO-RT trial, patients had previously received chemotherapy, whereas in the MDACC trial, patients could be either previously treated or newly diagnosed. Patients in both trials were immunotherapy-naive. In the PEMBRO-RT trial, patients were randomly assigned (1:1) and stratified by smoking status (<10 vs ≥10 pack-years). In the MDACC trial, patients were entered into one of two cohorts based on radiotherapy schedule feasibility and randomly assigned (1:1). Because of the nature of the intervention in the combination treatment arm, blinding to radiotherapy was not feasible in either trial. Pembrolizumab was administered intravenously (200 mg every 3 weeks) with or without radiotherapy in both trials. In the PEMBRO-RT trial, the first dose of pembrolizumab was given sequentially less than 1 week after the last dose of radiotherapy (24 Gy in three fractions), whereas in the MDACC trial, pembrolizumab was given concurrently with the first dose of radiotherapy (50 Gy in four fractions or 45 Gy in 15 fractions). Only unirradiated lesions were measured for response. The endpoints for this pooled analysis were best out-of-field (abscopal) response rate (ARR), best abscopal disease control rate (ACR), ARR at 12 weeks, ACR at 12 weeks, progression-free survival, and overall survival. The intention-to-treat populations from both trials were included in analyses. The PEMBRO-RT trial (NCT02492568) and the MDACC trial (NCT02444741) are registered with ClinicalTrials.gov. FINDINGS Overall, 148 patients were included in the pooled analysis, 76 of whom had been assigned pembrolizumab and 72 who had been assigned pembrolizumab plus radiotherapy. Median follow-up for all patients was 33 months (IQR 32·4-33·6). 124 (84%) of 148 patients had non-squamous histological features and 111 (75%) had previously received chemotherapy. Baseline variables did not differ between treatment groups, including PD-L1 status and metastatic disease volume. The most frequently irradiated sites were lung metastases (28 of 72 [39%]), intrathoracic lymph nodes (15 of 72 [21%]), and lung primary disease (12 of 72 [17%]). Best ARR was 19·7% (15 of 76) with pembrolizumab versus 41·7% (30 of 72) with pembrolizumab plus radiotherapy (odds ratio [OR] 2·96, 95% CI 1·42-6·20; p=0·0039), and best ACR was 43·4% (33 of 76) with pembrolizumab versus 65·3% (47 of 72) with pembrolizumab plus radiotherapy (2·51, 1·28-4·91; p=0·0071). Median progression-free survival was 4·4 months (IQR 2·9-5·9) with pembrolizumab alone versus 9·0 months (6·8-11·2) with pembrolizumab plus radiotherapy (hazard ratio [HR] 0·67, 95% CI 0·45-0·99; p=0·045), and median overall survival was 8·7 months (6·4-11·0) with pembrolizumab versus 19·2 months (14·6-23·8) with pembrolizumab plus radiotherapy (0·67, 0·54-0·84; p=0·0004). No new safety concerns were noted in the pooled analysis. INTERPRETATION Adding radiotherapy to pembrolizumab immunotherapy significantly increased responses and outcomes in patients with metastatic non-small-cell lung cancer. These results warrant validation in a randomised phase 3 trial. FUNDING Merck Sharp & Dohme.
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Affiliation(s)
| | - Dawei Chen
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China.
| | - Vivek Verma
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Brian P Hobbs
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Heike M U Peulen
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands; Department of Radiation Oncology, Catharina Hospital, Eindhoven, Netherlands
| | | | - Idris Bahce
- Department of Pulmonology, VU Medical Center, Amsterdam, Netherlands
| | | | - Joe Y Chang
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Patricia M de Groot
- Department of Diagnostic Radiology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Quynh-Nhu Nguyen
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Nathan I Comeaux
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - George R Simon
- Department of Thoracic/Head & Neck Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Ferdinandos Skoulidis
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Steven H Lin
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Kewen He
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Roshal Patel
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - John Heymach
- Department of Thoracic/Head & Neck Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Paul Baas
- Department of Thoracic Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - James W Welsh
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA.
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13
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Voogt ELK, van Zoggel DMGI, Kusters M, Nieuwenhuijzen GAP, Bloemen JG, Peulen HMU, Creemers GJM, van Lijnschoten G, Nederend J, Roef MJ, Burger JWA, Rutten HJT. Improved Outcomes for Responders After Treatment with Induction Chemotherapy and Chemo(re)irradiation for Locally Recurrent Rectal Cancer. Ann Surg Oncol 2020; 27:3503-3513. [PMID: 32193717 DOI: 10.1245/s10434-020-08362-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Despite improvements in the multimodality treatment for patients with locally recurrent rectal cancer (LRRC), oncological outcomes remain poor. This study evaluated the effect of induction chemotherapy and subsequent chemo(re)irradiation on the pathologic response and the rate of resections with clear margins (R0 resection) in relation to long-term oncological outcomes. METHODS All consecutive patients with LRRC treated in the Catharina Hospital Eindhoven who underwent a resection after treatment with induction chemotherapy and subsequent chemo(re)irradiation between January 2010 and December 2018 were retrospectively reviewed. Induction chemotherapy consisted of CAPOX/FOLFOX. Endpoints were pathologic response, resection margin and overall survival (OS), disease free survival (DFS), local recurrence free survival (LRFS), and metastasis free survival (MFS). RESULTS A pathologic complete response was observed in 22 patients (17%), a "good" response (Mandard 2-3) in 74 patients (56%), and a "poor" response (Mandard 4-5) in 36 patients (27%). An R0 resection was obtained in 83 patients (63%). The degree of pathologic response was linearly correlated with the R0 resection rate (p = 0.026). In patients without synchronous metastases, pathologic response was an independent predictor for LRFS, MFS, and DFS (p = 0.004, p = 0.003, and p = 0.024, respectively), whereas R0 resection was an independent predictor for LRFS and OS (p = 0.020 and p = 0.028, respectively). CONCLUSIONS Induction chemotherapy in addition to neoadjuvant chemo(re)irradiation is a promising treatment strategy for patients with LRRC with high pathologic response rates that translate into improved oncological outcomes, especially when an R0 resection has been achieved.
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Affiliation(s)
- E L K Voogt
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands.
| | | | - M Kusters
- Department of Surgery, Amsterdam University Medical Centres, Location VUmc, Amsterdam, The Netherlands
| | | | - J G Bloemen
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - H M U Peulen
- Department of Radiotherapy, Catharina Hospital, Eindhoven, The Netherlands
| | - G J M Creemers
- Department of Medical Oncology, Catharina Hospital, Eindhoven, The Netherlands
| | - G van Lijnschoten
- Pathology Department, PAMM Laboratory for Pathology and Medical Microbiology, Eindhoven, The Netherlands
| | - J Nederend
- Department of Radiology, Catharina Hospital, Eindhoven, The Netherlands
| | - M J Roef
- Department of Nuclear Medicine, Catharina Hospital, Eindhoven, The Netherlands
| | - J W A Burger
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - H J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands.,GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
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14
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Theelen WSME, Peulen HMU, Lalezari F, van der Noort V, de Vries JF, Aerts JGJV, Dumoulin DW, Bahce I, Niemeijer ALN, de Langen AJ, Monkhorst K, Baas P. Effect of Pembrolizumab After Stereotactic Body Radiotherapy vs Pembrolizumab Alone on Tumor Response in Patients With Advanced Non-Small Cell Lung Cancer: Results of the PEMBRO-RT Phase 2 Randomized Clinical Trial. JAMA Oncol 2019; 5:1276-1282. [PMID: 31294749 DOI: 10.1001/jamaoncol.2019.1478] [Citation(s) in RCA: 567] [Impact Index Per Article: 113.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance Many patients with advanced non-small cell lung cancer (NSCLC) receiving immunotherapy show primary resistance. High-dose radiotherapy can lead to increased tumor antigen release, improved antigen presentation, and T-cell infiltration. This radiotherapy may enhance the effects of checkpoint inhibition. Objective To assess whether stereotactic body radiotherapy on a single tumor site preceding pembrolizumab treatment enhances tumor response in patients with metastatic NSCLC. Design, Setting, and Participants Multicenter, randomized phase 2 study (PEMBRO-RT) of 92 patients with advanced NSCLC enrolled between July 1, 2015, and March 31, 2018, regardless of programmed death-ligand 1 (PD-L1) status. Data analysis was of the intention-to-treat population. Interventions Pembrolizumab (200 mg/kg every 3 weeks) either alone (control arm) or after radiotherapy (3 doses of 8 Gy) (experimental arm) to a single tumor site until confirmed radiographic progression, unacceptable toxic effects, investigator decision, patient withdrawal of consent, or a maximum of 24 months. Main Outcomes and Measures Improvement in overall response rate (ORR) at 12 weeks from 20% in the control arm to 50% in the experimental arm with P < .10. Results Of the 92 patients enrolled, 76 were randomized to the control arm (n = 40) or the experimental arm (n = 36). Of those, the median age was 62 years (range, 35-78 years), and 44 (58%) were men. The ORR at 12 weeks was 18% in the control arm vs 36% in the experimental arm (P = .07). Median progression-free survival was 1.9 months (95% CI, 1.7-6.9 months) vs 6.6 months (95% CI, 4.0-14.6 months) (hazard ratio, 0.71; 95% CI, 0.42-1.18; P = .19), and median overall survival was 7.6 months (95% CI, 6.0-13.9 months) vs 15.9 months (95% CI, 7.1 months to not reached) (hazard ratio, 0.66; 95% CI, 0.37-1.18; P = .16). Subgroup analyses showed the largest benefit from the addition of radiotherapy in patients with PD-L1-negative tumors. No increase in treatment-related toxic effects was observed in the experimental arm. Conclusions and Relevance Stereotactic body radiotherapy prior to pembrolizumab was well tolerated. Although a doubling of ORR was observed, the results did not meet the study's prespecified end point criteria for meaningful clinical benefit. Positive results were largely influenced by the PD-L1-negative subgroup, which had significantly improved progression-free survival and overall survival. These results suggest that a larger trial is necessary to determine whether radiotherapy may activate noninflamed NSCLC toward a more inflamed tumor microenvironment. Trial Registration ClinicalTrials.gov identifier: NCT02492568.
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Affiliation(s)
| | - Heike M U Peulen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam.,Department of Radiation Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - Ferry Lalezari
- Department of Radiology, Netherlands Cancer Institute, Amsterdam
| | | | | | - Joachim G J V Aerts
- Department of Pulmonology, Erasmus Medical Center, Rotterdam, Amsterdam, the Netherlands
| | - Daphne W Dumoulin
- Department of Pulmonology, Erasmus Medical Center, Rotterdam, Amsterdam, the Netherlands
| | - Idris Bahce
- Department of Pulmonology, VU Medical Center, Amsterdam, the Netherlands
| | | | | | - Kim Monkhorst
- Department of Pathology, Netherlands Cancer Institute, Amsterdam
| | - Paul Baas
- Department of Thoracic Oncology, Netherlands Cancer Institute, Amsterdam
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Vanfleteren LEGW, Peulen HMU, Creytens DHKV, Smulders NM, Utama I, de Ruysscher DKM, Velde GPMT. Complete metabolic remission of an irresectable mediastinal solitary fibrous tumour with concurrent chemoradiation. Thorax 2009; 64:822-3. [DOI: 10.1136/thx.2008.109561] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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