Long-course oxaliplatin-based preoperative chemoradiation versus 5 × 5 Gy and consolidation chemotherapy for cT4 or fixed cT3 rectal cancer: results of a randomized phase III study

BACKGROUND

Improvements in local control are required when using preoperative chemoradiation for cT4 or advanced cT3 rectal cancer. There is therefore a need to explore more effective schedules.

PATIENTS AND METHODS

Patients with fixed cT3 or cT4 cancer were randomized either to 5 × 5 Gy and three cycles of FOLFOX4 (group A) or to 50.4 Gy in 28 fractions combined with two 5-day cycles of bolus 5-Fu 325 mg/m(2)/day and leucovorin 20 mg/m(2)/day during the first and fifth week of irradiation along with five infusions of oxaliplatin 50 mg/m(2) once weekly (group B). The protocol was amended in 2012 to allow oxaliplatin to be then foregone in both groups.

RESULTS

Of 541 entered patients, 515 were eligible for analysis; 261 in group A and 254 in group B. Preoperative treatment acute toxicity was lower in group A than group B, P = 0.006; any toxicity being, respectively, 75% versus 83%, grade III-IV 23% versus 21% and toxic deaths 1% versus 3%. R0 resection rates (primary end point) and pathological complete response rates in groups A and B were, respectively, 77% versus 71%, P = 0.07, and 16% versus 12%, P = 0.17. The median follow-up was 35 months. At 3 years, the rates of overall survival and disease-free survival in groups A and B were, respectively, 73% versus 65%, P = 0.046, and 53% versus 52%, P = 0.85, together with the cumulative incidence of local failure and distant metastases being, respectively, 22% versus 21%, P = 0.82, and 30% versus 27%, P = 0.26. Postoperative and late complications rates in group A and group B were, respectively, 29% versus 25%, P = 0.18, and 20% versus 22%, P = 0.54.

CONCLUSIONS

No differences were observed in local efficacy between 5 × 5 Gy with consolidation chemotherapy and long-course chemoradiation. Nevertheless, an improved overall survival and lower acute toxicity favours the 5 × 5 Gy schedule with consolidation chemotherapy.

CLINICAL TRIAL NUMBER

The trial is registered as ClinicalTrials.gov number NCT00833131.

[Relation between the vectorcardiogram and mean pulmonary arterial pressure in pulmonary pathology]

Mean pulmonary artery pressure (PAP) is considered to be a valuable indicator of the severity of disease in patients with chronic lung damage. Its measurement requires minicatheterisation, an invasive technique associated with some morbidity. This study was undertaken to establish a relationship between PAP and vectorcardiography (VCG) in 76 patients with chronic lung disease. The patients were divided into three groups: Group I, PAP less than 19 mmHg; Group II, PAP between 19 and 30 mmHg; Group III, PAP greater than 30 mmHg. The patients presented with an obstructive pulmonary syndrome in 67,1% of cases, and an emphysematous syndrome in 32,9% of cases. The ECG tracing was suggestive of chronic cor pulmonale in 20 patients. The three VCG planes were analysed. The direction and amplitude of the 0,01 sec, 0,02 sec, 0,04 sec, 0,06 sec and maximum vector over each QRS loop were measured; the direction of rotation of the QRS loop and, in the horizontal plane, the duration of the terminal forces were also determined. Treatment of the angular data by Down's centre of gravity method allowed definition of the preferential direction of the vectors and of an index of precision. The statistical significance of the results was checked by the usual methods (chi-square, F test). The results confirmed the importance of the right posterior quadrant of the horizontal plane in assessing the degree of electrical overload and for evaluating the repercussions on the pulmonary circulation. In this plane, all angular positions of the 0,06 sec vector beyond -125 degrees corresponded in 9 out of 10 cases to higher than normal PAP (greater than 19 mmHg). A voltage of over 0,80 MV was always associated with higher than normal PAP. The predictive value of this method was 92%, with a specificity of 88% and a sensitivity of 39%. The VCG was also more sensitive than the ECG in assessing PAP of 19 to 30 mmHg; 25,6% of patients had deviation of the 0,06 sec vector of beyond -125 degrees in the horizontal plane whilst only 6,3% of cases had ECG criteria of chronic cor pulmonale. This study shows that simple and reliable non-invasive VCG criteria may be used to assess mean pulmonary artery pressure.