Consolidation chemotherapy during neoadjuvant chemoradiation (CRT) for distal rectal cancer leads to sustained decrease in tumor metabolism when compared to standard CRT regimen

Habr‐Gama, Angelita; Perez, Rodrigo Oliva; Julião, Guilherme P. São; Proscurshim, Igor; Fernández, Laura Melina; Figueiredo, Marleny Novaes; Gama-Rodrigues, Joaquim; Buchpiguel, Carlos Alberto

doi:10.1186/s13014-016-0598-6

Cited by 43 publications

(35 citation statements)

References 21 publications

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“…Like the TNT data detailed above, the regimen of CRT followed by ChT was well tolerated, with a reported 97% treatment completion rate . Furthermore, that group assessed tumor metabolic activity after treatment with CRT alone versus CRT followed by additional ChT . Through molecular imaging with radiolabeled glucose and positron emission tomography, investigators demonstrated that the addition of ChT during the “resting period” after CRT markedly decreased the probability of tumor regaining metabolic activity .…”

Section: Organ Preservationmentioning

confidence: 99%

“…57 Furthermore, that group assessed tumor metabolic activity after treatment with CRT alone versus CRT followed by additional ChT. 59 Through molecular imaging with radiolabeled glucose and positron emission tomography, investigators demonstrated that the addition of ChT during the "resting period" after CRT markedly decreased the probability of tumor regaining metabolic activity. 59 This finding, coupled with the improved cCR rates with additional ChT, supports the notion that NAC after CRT likely contributes at least in part to the improved pathologic outcomes observed by Garcia-Aguilar et al rather than just the temporal interval between CRT and surgery alone.…”

Section: Organ Preservationmentioning

confidence: 99%

“…59 Through molecular imaging with radiolabeled glucose and positron emission tomography, investigators demonstrated that the addition of ChT during the "resting period" after CRT markedly decreased the probability of tumor regaining metabolic activity. 59 This finding, coupled with the improved cCR rates with additional ChT, supports the notion that NAC after CRT likely contributes at least in part to the improved pathologic outcomes observed by Garcia-Aguilar et al rather than just the temporal interval between CRT and surgery alone. 28,58,59 Taken together, these efforts have validated the TNT approach of additional chemotherapy in the preoperative setting, resulting in a considerable increase in the proportion of patients who are eligible for organ preservation.…”

Section: Organ Preservationmentioning

confidence: 99%

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Total neoadjuvant therapy for rectal cancer: An emerging option

Ludmir

Palta

Willett

et al. 2017

Cancer

156

109

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The treatment of locally advanced rectal cancer (LARC) has benefited from improved surgical techniques and from the implementation of neoadjuvant chemoradiotherapy (CRT), which have markedly decreased the rates of local recurrence. However, distant metastatic disease remains the most significant cause of death for these patients. Although adjuvant chemotherapy (ChT) after neoadjuvant CRT and definitive surgery is commonly recommended, the value of adjuvant systemic therapy remains less clear. Trials evaluating adjuvant ChT for rectal cancer have been handicapped by poor compliance rates and inconsistent survival results. Shifting systemic therapy delivery to the neoadjuvant setting has the promise to improve compliance rates, reduce toxicity, and decrease distant relapse rates. Recently, multiple prospective trials have reported on the use of total neoadjuvant therapy (TNT) for patients with LARC, incorporating both ChT and CRT in the neoadjuvant setting. Here, the authors review the promising results from those trials. Because the studies have largely focused on pathologic outcomes (primarily pathologic complete response rates), ongoing phase 2 and 3 trials are now underway assessing the long-term disease-related outcomes with TNT. In addition to improving survival, TNT has the potential to increase the pool of patients with LARC who are eligible for organ preservation, which is also being evaluated. Cancer 2017;123:1497-1506. © 2017 American Cancer Society.

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Section: Organ Preservationmentioning

confidence: 99%

Section: Organ Preservationmentioning

confidence: 99%

Section: Organ Preservationmentioning

confidence: 99%

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Total neoadjuvant therapy for rectal cancer: An emerging option

Ludmir

Palta

Willett

et al. 2017

Cancer

156

109

View full text Add to dashboard Cite

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“…Comparison of the change in maximum standardized uptake value ( SUV max ) between extended and standard chemotherapy regimens from baseline to 12 weeks . The figure is published under the terms of the Creative Commons Attribution ( CC ‐ BY ) license.…”

Section: Metabolic Activity: Standard Vs Extended Crt Regimenmentioning

confidence: 99%

Session 4: Trying to augment response with chemotherapy: a triumph of hope over experience?

et al. 2018

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As part of an approach to improve tumour regression and increase the proportion of patients with complete clinical and radiological response, Dr Perez reviews the methods and evidence base for augmenting therapy and thus augmenting response rates preoperatively. Much of the data reviewed were in the context of patients undergoing a watch-and-wait approach for rectal cancer after initial treatment with chemoradiotherapy.There is much interest in tailoring management based on tumour response to chemoradiotherapy (CRT). At one end of the spectrum, patients who do not achieve a complete response might still need a radical operation; on the other hand, patients who achieve a complete clinical and radiological response may not need an operation at all.Achieving a complete response is a highly clinically relevant end-point. These patients are known to have an improved oncological outcome [1], so achieving a complete response in an increased proportion of patients has the potential to improve overall survival. Also, a more significant proportion of patients could avoid radical surgery; in itself, this has the potential to result in survival gains [2]. The standard regimenThe standard CRT regimen consists of 50.40 Gy over 6 weeks and two cycles of chemotherapy (concurrent leucovorin (20 mg/m 2 /day) with bolus doses of 5-fluorouracil administered intravenously at 425 mg/m 2 / day for three consecutive days) on the first and last 3 days of radiation therapy [3]. This approach achieved a complete response rate of 27.5% [3]. Professor HabrGama persuaded the radiation oncologist and medical oncologist at her institution to extend the CRT regimen because she believed a higher response rate was possible.

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“…Again, data about metabolic response from primary cancers have shown that reduction in SUV max may be treatment-and time-dependent [11,12]. Therefore, assessment at different intervals from RT completion may have significantly affected results.…”

mentioning

confidence: 99%

Tumour response to neoadjuvant chemoradiation within lateral pelvic nodes: another step towards precision surgery

Perez

Daneri²,

Vailati³

et al. 2018

Tech Coloproctol

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Lateral lymph-node dissection (LLND) in extraperitoneal rectal cancer has been neglected for a long time in western countries. In addition to being a technically challenging procedure, the high risk of perioperative blood loss and negative effects on urinary and sexual function have contributed to the lack of widespread implementation of LLND in clinical practice outside Japan and Korea [1,2]. Moreover, with the establishment of multimodal treatment in the management of locally advanced rectal cancer, it has been suggested that patients undergoing preoperative radiation with or without chemotherapy would not require LLND as radiation could potentially sterilize lateral pelvic nodes included in the radiation therapy field [3].Recently, LLND has attracted significant attention for several reasons. First, the results of a prospective randomized trial in Japan that failed to demonstrate non-inferiority of total mesorectal excision (TME) when compared to TME + LLND in patients with no preoperative evidence of lateral node metastases was quite disturbing [4]. No radiotherapy was used in this trial. The outcomes revealed a higher rate of local recurrence among patients undergoing TME alone. The same trial also demonstrated no differences in male sexual function after LLND when compared to TME alone [5]. Finally, despite the fact that LLND was associated with increased intraoperative bleeding, an elegant case-matched control study in Japan suggested that a minimally invasive approach could potentially solve this particular issue and minimal intraoperative bleeding was reported using the laparoscopic approach [6].As multimodality treatment of rectal cancer is now mainstreaming in Japan as well, a more selective approach to LLND has been the focus of recent publications. Specific Japanese and Korean centers are suggesting that only in the presence of positive lymph nodes at baseline, should patients undergo "selective" LLND after neoadjuvant chemoradiotherapy (nCRT) [7]. In fact, their own data suggest that nCRT is able to sterilize nearly 50% of lymph nodes. This means that only 50% of these patients would still harbor lateral node metastases after nCRT and would ultimately benefit from LLND. One patient out of two would not [7,8].In the present edition of Techniques in Coloproctology, Ishihara et al. are taking a step forward in the selective approach for LLND in rectal cancer. With the use of reassessment of tumor response using computed tomography/positron emission tomography (CT/PET) scanning they provide an interesting tool to predict the presence of residual lateral node metastases after nCRT. Using size and metabolic estimate [maximum standardized uptake value (SUV max )] cut-offs after nCRT, they were able to predict with high accuracy the presence of lateral node metastasis. This strategy allowed the authors to correctly identify patients that could benefit the most from LLND.However, prior to implementation of these results in clinical practice, rectal cancer surgeons should consider the following points: First...

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Consolidation chemotherapy during neoadjuvant chemoradiation (CRT) for distal rectal cancer leads to sustained decrease in tumor metabolism when compared to standard CRT regimen

Cited by 43 publications

References 21 publications

Total neoadjuvant therapy for rectal cancer: An emerging option

Total neoadjuvant therapy for rectal cancer: An emerging option

Session 4: Trying to augment response with chemotherapy: a triumph of hope over experience?

Tumour response to neoadjuvant chemoradiation within lateral pelvic nodes: another step towards precision surgery

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