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PAN-EX: a pooled analysis of two trials of neoadjuvant chemotherapy followed by chemoradiotherapy in MRI-defined, locally advanced rectal cancer
Royal Marsden NHS Fdn Trust, Dept Med, London, England.;Royal Marsden NHS Fdn Trust, Dept Med, Sutton, Surrey, England..
Royal Marsden NHS Fdn Trust, Dept Radiol, London, England.;Royal Marsden NHS Fdn Trust, Dept Radiol, Sutton, Surrey, England..
Royal Marsden NHS Fdn Trust, Dept Med, London, England.;Royal Marsden NHS Fdn Trust, Dept Med, Sutton, Surrey, England..
Royal Marsden NHS Fdn Trust, Dept Histopathol, London, England.;Royal Marsden NHS Fdn Trust, Dept Histopathol, Sutton, Surrey, England..
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2016 (English)In: Annals of Oncology, ISSN 0923-7534, E-ISSN 1569-8041, Vol. 27, no 8, p. 1557-1565Article in journal (Refereed) Published
Abstract [en]

This analysis confirms that administering neoadjuvant chemotherapy (NACT) before chemoradiotherapy (CRT) could be a potential option for high-risk, locally advanced rectal cancer. In this setting, MRI tumour regression grade is an independent prognostic factor and, when assessed after NACT, may predict the probability and magnitude of incremental benefit from sequential CRT.EXPERT and EXPERT-C were phase II clinical trials of neoadjuvant chemotherapy (NACT) followed by chemoradiotherapy (CRT) in high-risk, locally advanced rectal cancer (LARC). We pooled individual patient data from these trials. The primary objective was overall survival (OS) in the intention-to-treat (ITT) population. Prognostic factors were also analysed. A total of 269 patients were included. Of these, 91.1% completed NACT, 88.1% completed CRT and 240 (89.2%) underwent curative surgery (R0/R1). After a median follow-up of 71.9 months, 5-year progression-free survival (PFS) and OS were 66.4% and 73.3%, respectively. In the group of R0/R1 resection patients, 5-year relapse-free survival (RFS) and OS were 71.6% and 77.2%, respectively, with local recurrence occurring in 5.5% and distant metastases in 20.6% of cases. Significant prognostic factors after multivariate analyses included age, tumour grade and MRI extramural venous invasion (mrEMVI) at baseline, MRI tumour regression grade (mrTRG) after CRT, ypT stage after surgery and adherence to study treatment. mrTRG after NACT was associated with PFS (P = 0.002) and OS (P = 0.018) and appeared to stratify patients based on the incremental benefit from sequential CRT. Among the outcome measures considered, in the subgroup of R0/R1 resection patients, ypT and ypStage had the highest predictive accuracy for RFS (concordance index: 0.6238 and 0.6252, respectively) and OS (concordance index: 0.6094 and 0.6132, respectively). Administering NACT before CRT could be a potential strategy for high-risk LARC. In this setting, mrTRG after CRT is an independent prognostic factor, while mrTRG after NACT should be tested as a parameter for treatment selection in trials of NACT +/- CRT. ypT stage may be a valuable surrogate end point for future phase II trials investigating intensified neoadjuvant treatments in similar patient populations.

Place, publisher, year, edition, pages
2016. Vol. 27, no 8, p. 1557-1565
Keyword [en]
locally advanced rectal cancer, neoadjuvant chemotherapy, chemoradiotherapy, MR tumour regression grade, pooled analysis
National Category
Cancer and Oncology
Identifiers
URN: urn:nbn:se:uu:diva-308950DOI: 10.1093/annonc/mdw215ISI: 000383182800025PubMedID: 27217542OAI: oai:DiVA.org:uu-308950DiVA: diva2:1052819
Available from: 2016-12-07 Created: 2016-12-01 Last updated: 2017-11-29Bibliographically approved

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