Neoadjuvant-intensified treatment for rectal cancer:Time to change?

AIM:To investigate whether neoadjuvant-intensified radiochemotherapy improved overall and disease-free survival in patients with locally advanced rectal cancer.METHODS:Between January 2007 and December 2011,80 patients with histologically confirmed rectal adenocarcinoma were enrolled.Tumors were clinically classified as either T3 or T4 and by the N stage based on the presence or absence of positive regional lymph nodes.Patients received intensified combined modality treatment,consisting of neoadjuvant radiation therapy(50.4-54.0 Gy) and infusional chemotherapy(oxaliplatin 50 mg/m 2) on the first day of each week,plus five daily continuous infusions of fluorouracil(200 mg/m 2 per die) from the first day of radiation therapy until radiotherapy completion.Patients received five or six cycles of oxaliplatin based on performance status,clinical lymph node involvement,and potential risk of a non-sphincter-conserving surgical procedure.Surgery was planned 7 to 9 wk after the end of radiochemotherapy treatment;adjuvant chemotherapy treatment was left to the oncologist's discretion and was recommended in patients with positive lymph nodes.After treatment,all patients were monitored every three months for the first year and every six months for the subsequent years.RESULTS:Of the 80 patients enrolled,75 patients completed the programmed neoadjuvant radiochemotherapy treatment.All patients received the radiotherapy prescribed total dose;five patients suspended chemotherapy indefinitely because of chemotherapyrelated toxicity.At least five cycles of oxaliplatin were administered to 73 patients.Treatment was well tolerated with high compliance and a good level of toxicity.Most of the acute toxic effects observed were classified as grades 1-2.Proctitis grade 2 was the most common symptom(63.75%) and the earliest manifestation of acute toxicity.Acute toxicity grades 3-4 was reported in 30% of patients and grade 3 or 4 diarrhoea reported in just three patients(3.75%).Seventy-seven patients underwent surgery;low anterior resection was performed in 52 patients,Miles' surgery in 11 patients and total mesorectal excision in nine patients.Fifty patients showed tumor downsizing ≥ 50% pathological downstaging in 88.00% of tumors.Out of 75 patients surviving surgery,67 patients(89.33%) had some form of downstaging after preoperative treatment.A pathological complete response was achieved in 23.75% of patients and a nearly pathologic complete response(stage ypT1ypN0) in six patients.An involvement of the radial margin was never present.During surgery,intra-abdominal metastases were found in only one patient(1.25%).Initially,45 patients required an abdominoperineal resection due to a tumor distal margin ≤ 5 cm from the anal verge.Of these patients,only seven of them underwent Miles' surgery and sphincter preservation was guaranteed in 84.50% of patients in this subgroup.Fourteen patients received postoperative chemotherapy.In the full analysis of enrolled cohort,eight of the 80 patients died,with seven deaths related to rectal cancer and one to unrelated causes.Local recurrences were observed in seven patients(8.75%) and distant metastases in 17 cases(21.25%).The fiveyear rate of overall survival rate was 90.91%.Using a median follow-up time of 28.5 mo,the cumulative incidence of local recurrences was 8.75%,and the overall survival and disease-free survival rates were 90.00% and 70.00%,respectively.CONCLUSION:The results of this study suggest oxaliplatin chemotherapy has a beneficial effect on overall survival,likely due to an increase in local tumor control.

Neoadjuvant chemoradiotherapy for locally advanced rectal cancer:The debate continues

Rectal carcinoma represents the 30% of all colorectal cancers, with about 40000 new cases/years. In the past two decades, the management of rectal cancer has made important progress, highlighting the main role of a multimodality strategy approach, combining surgery, radiation therapy and chemotherapy. Nowadays, surgery remains the primary treatment and neoadjuvant chemoradiotherapy, based on fluoropyrimidine(5-FU) continuous infusion, is considered the standard in locally advanced rectal carcinoma. The aim is to reduce the incidence of local recurrence and to perform a conservative surgery. To improve these purposes different drugs combination have been tested in the neo-adjuvant setting. At American Society of Clinical Oncology 2014 an important abstract was presented focusing on the role of adding oxaliplatin to concomitant treatment, in patients with locally advanced rectal carcinoma. Rodel et al reported on the CAO/ARO/AIO-04 randomized phase Ⅲ trial that compared standard treatment with 5-FU and radiation therapy, to oxaliplatin plus 5-FU inassociation with radiation therapy. The addition of oxaliplatin to the neo-adjuvant treatment has been shown to improve disease-free survival from 71.2% to 75.9%(P = 0.03). This editorial was planned to clarify the optimal treatment in patients with locally advanced rectal cancer, considering the results from CAO/ARO/AIO-04 study.

Chemoradiation as definitive treatment for primary squamous cell cancer of the rectum

In this report,we present a case of advanced squamous cell cancer located in the rectum of a 78-year-old woman treated with chemoradiation with curative intent.The patient showed a complete clinical response to chemoradiation;multiple biopsies were performed at the site of the previous mass 5 mo after the end of treatment and histological examination showed no residual tumour in the specimens.Surgical intervention was avoided and the patient was free of disease 12 mo after the diagnosis of cancer.Primary chemoradiation should be considered as the treatment of choice for this rare malignancy.

An unusual case of fatty liver in a patient with desmoid tumor

A desmoid tumor,also known as aggressive fibromatosis,is a rare benign neoplasm that arises from fascial or musculoaponeurotic tissues.It can occur in any anatomical location,most commonly the abdominal wall,shoulder girdle and retroperitoneum.The typical clinical presentation is a painless mass with a slow and progressive invasion of contiguous structures.It is associated with a high local recurrence rate after resection.Many issues regarding the optimal treatment of desmoid tumors remain controversial.Aggressive surgical resection with a wide margin(2-3 cm) remains the gold standard treatment with regard to preserving quality of life.Radiotherapy alone has been shown to be effective for the control of unresectable or recurrent lesions.Desmoid tumors tend to be locally infiltrative,therefore,the fields must be generous to prevent marginal recurrence.The radiation dose appropriate for treating desmoid tumors remains controversial.We present a 25-year-old Caucasian man with local recurrence of a desmoid tumor after repeated surgical resection,treated with radiotherapy.The patient achieved complete tumor regression at 4 mo after radiotherapy,and he is clinically free of disease at 12 mo after the end of treatment,with an acceptable quality of life.The patient developed short bowel syndrome as a complication of second surgical resection.Consequently,radiotherapy might have worsened an already present malabsorption and so led to steatohepatitis.

Unusual presentation of metastatic adenocarcinoma of the lung

On September 2013, a 62-year-old man with metastatic adenocarcinoma of the lung complained tenderness and pain of the first terminal phalange of his right hand. The biopsy confirmed metastatic adenocarcinoma of the lung to the finger. A single 8-Gy fraction of palliative radiotherapy was delivered to the patient's right hand. The patient received magnetic resonance-guided focused ultrasound surgery treatment to the phalange because he showed few improvement of clinical symptoms and persistence of moderate pain after radiotherapy. After magnetic resonance-guided focused ultrasound surgery, the clinical symptoms improved significantly. No serious adverse effects were reported and the patient compliance was very high. Our patient showed improvement of clinical symptoms after combined treatment. The patient remains in good health conditions.

Solitary rib metastasis of nasopharyngeal carcinoma

We report a case of a 49-year-old man who developed solitary rib metastasis of nasopharyngeal cancer. Patient had been treated for primary carcinoma with radiation therapy and concomitant chemotherapy. The bone metastasis presented as bulky, solid, painful mass in the posterior arch of 10th rib, within nine months the end of treatment. Biopsy of the solitary lesion presented the same histological characteristics as those of primary lesion. Although there are reported in literature series of nasopharyngeal cancer metastasizing to bone, we did not find previously pubfished report of a nasopharyngeal carcinoma metastasizing only to a rib.

An Analysis of the Global and Partial Voice Handicap Index in Patients with Early Glottic Carcinoma Treated with High Level of Irradiation

Background: This is a retrospective study on a group of patients with early glottic carcinoma, treated with curative radiotherapy. The aim of the study is to assess voice quality after treatment. We also evaluated local recurrence, overall survival, disease free survival and toxicity. Material and Methods: We examined a total of 36 patients, out of which 27 were smokers: 10 females/5 smokers;26 males/22 smokers. The sample was observed from January 2007 to July 2012 (average follow-up period: 33.5 months, range 12 - 76). Diagnosis of early glottic carcinoma was eight during the two-year period 2007/2008, nine during 2009/2010, eleven during year 2011 and eight during year 2012. All patients suffering from early glottic carcinoma, histopathologically confirmed, were classified as follows: 24 patients T1a, 3 patients T1b, 6 patients T2 and 3 patients had a carcinoma in situ. They were treated only with conventional radiotherapy. After the treatment (total dose 70 Gy), patients were asked to fill out the Voice Handicap Index (VHI) questionnaire, composed of 30 questions that covered physical, emotional and functional areas. Results: The global VHI was evidenced with good voice quality (62% of patients: VHI < 30;34% of patients: VHI 31 - 60). Vocal disability was mild in over 70% of patients within the physical area and over 80% within the emotional area. We observed two local recurrences, one occurred five years after the end of radiation therapy and one six months after. In terms of toxicity, we observed that acute reactions, such as dysphonia, dysphagia and erythema, were relatively limited. Conclusions: The VHI index suggests that radiotherapy produces acceptable functional results, with limited repercussion on life quality. In line with literature, our data confirmed good cure rates and larynx preservation (94.4%).