Neoadjuvant Therapy of Rectal Cancer: Pathologic Versus Clinical CR
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Transcript of Neoadjuvant Therapy of Rectal Cancer: Pathologic Versus Clinical CR
Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus Pathological Response
Mohamed Abdulla MDProf of Clinical OncologyCairo University
Member of Advisory Board Consultant and Speaker for Amgen Astellas AstraZeneca Hoffman la Roche Janssen
Cilag Merck Serono Novartis Pfizer The content of this presentation does not relate to any product
of a commercial interest
Speaker Disclosures
Principles
Surgery is the cornerstone in management
However
Local Recurrence Following Surgery Alone
Clinical Colorectal Cancer Vol 4 No 4 233-240 2004
Adjuvant Radiation Therapy
Clinical Colorectal Cancer Vol 4 No 4 233-240 2004
Local Recurrence Better Insight
Circumferential Margins
Number Local Recurrence
Rate
P
gt 2 mm 987 33 lt 00001
1 ndash 2 mm 100 85 002
lt 1 mm 227 131 008
Int J Radiation Oncology Biol Phys Vol 55 No 5 pp 1311ndash1320 2003
Total Mesorectal Excision (TME)
Removal of peri-rectal tissues involving lateral amp circumferential margins of mesorectal envelop
Dis Colon Rectum 2013 May56(5)535-50
Total Mesorectal Excision (TME)
Clinical Colorectal Cancer Vol 4 No 4 233-240 2004N Engl J Med 2001345638 ndash 646
Adjuvant Radiation Therapy
LR = 24
Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
GITSG NCCTG NSABP R-01
N Engl J Med 1986 3151294FJ Natl Cancer Inst 1988 8021 N Engl J Med 1991 324709
Adjuvant Fluoroupyremidine
X 2 monthsCRT ndash 6 Weeks
Adjuvant Fluoroupyremidine
X 2 months
Adjuvant Therapy = 6 months
Neoadjuvant Therapy The German Study A Shifting Concept
N Engl J Med 20043511731-40
German CAOAROAIO-94 11 Years Update
Sauer R et al JCO 2012301926-33
Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
10 - Year RTh + S S P
LR 5 11 lt 00001
OAS 48 49 086
CCSD 17 22 004
Lancet Oncol 2011 12 575ndash82
CCSD Cumulative Incidence of Cancer Specific Death
Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
Lancet Oncol 2011 12 575ndash82
OAS Benefit
Neoadjuvant TherapyShort versus Long Radiation Therapy Course
Polish Trial Trans-Tasman Radiation
Oncology Group
bull Local Recurrencebull DFSbull Distant Recurrencebull OASbull Severe Late
Toxicity
EQUIVALENT
J Clin Oncol 2012 303827Br J Surg 2006 931215
Distal Tumors LC gt SC
LR = 0 12
Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
Gastrointest Cancer Res 149-56 copy2007 by International Society of Gastrointestinal Oncology
Neoadjuvant TherapyThe Use of Capecitabine
The Cancer Journal bull Volume 13 Number 3 MayJune 2007
EQUIVALENT
Neoadjuvant TherapyAdding Oxaliplatin
Curr Opin Oncol 2012 24441ndash447
bull ++ Toxicity amp -- Compliancebull Did not improve
1 R0 RR2 pCR3 Sphincter Preservation
The PETACC-6 RCTltbr gt
Neoadjuvant TherapyAdding Oxaliplatin
ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no major differences between armsltbr gt
Neoadjuvant TherapyAdding Oxaliplatin
Neoadjuvant TherapyAdding EGFR Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyAdding VEGF Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyIndications
1 T3 ndash T4 Lesions The only definitive indication2 cT3N0 Should be treated (understaging)3 Depth of Extramural Invasion
ndash T3 lesions (gt5 mm) ++ LNs involvement Higher Cancer Specific Mortality (54 Versus 85)
ndash Selection of high risk T3 for treatmentndash Approved outside US
4 T1 ndash 2 lesions with Positive Nodes5 Low situated lesions6 Invasion of mesorectal fasciaBr J Cancer 2000 821131wwwuptodatecom (September 2015)
Neoadjuvant TherapyTreatment Outcome
Complete Response cCRpCR
bull 15 ndash 30bull Small amp Less
Advanced Lesions
bull 10 ndash 12 Weeks
bull Involution to flat scar
bull DRE amp Endoscopybull Imaging
bull Endorectal USbull PET-CTbull MRI
bull ypT0N0
BIASED
NOT ACCEPTED
Martin R et al Surg Oncol Clin N Am 23 (2014) 113ndash125
Neoadjuvant TherapyTreatment Outcome in Relation to Pathological Outcome German Study
Grade Regression Fibrosis0 No All cells are viable
1 Minor lt 25 fibrosis
2 Moderate 26 ndash 50nFibrosis
3 Good gt50
4 Total No Viable Cells
Neoadjuvant TherapyTumor Regression Grade
Grade 10 ndash year DM
P 10 ndash Year DFS
P
0 - 1 3960005
6300082 - 3 293 736
4 105 895
J Clin Oncol 321554-1562 copy 2014
Neoadjuvant TherapyImpact of Pathological CR
British Journal of Surgery 2012 99 918ndash928
Can we Avoid Surgery
Can we Avoid Surgery
Can we Avoid Surgery
JCO VOLUME 29 1113097 NUMBER 35 1113097 DECEMBER 10 2011
21 Patients pCR
Neoadjuvant CRTFor Stages II amp III Wait amp See
MRI Endoscopy amp Biopsy
Median Follow up =25 months
1 Patient LR Surgery
20 Pts Stages II amp III NAT pCR
Median Follow up =35 months
2 ndash Year DFS 91 2 ndash Year OAS 93
Neoadjuvant TherapyProblems with Current Practice
CRT 55 Weeks 6 wks TME
1 ndash 2 weeks 4-6 wks Adjuvant Cth
18 weeksbull Delayedbull Reducedbull Omitted
CRT TME Neodjuvant Chemoth
Neodjuvant Chemoth CRT TME
bull Total Neoadjuvant Therapy Paradigm
bull Better down-staging
bull Better pCR
bull Higher R0 Resection Rates
Adopted from Deborah Schragrsquos Presentation at 2015 ASCO Annual Meeting
Total Neoadjuvant ParadigmBrown University Study (CONTRE)
FOLFOX X 8 Courses CRT + Cape TME
Pathologic Grade
Total Number Stage II Stage III38 7 31
0 (Complete) 13 1 12
1 14 4 10
2 8 1 7
3 3 1 2
bull 35 Pts Completed Treatmentbull pCR = 33
Perez et al ASCO 2014 Abstract 3050
The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on DFS
The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on OAS
Slide 12
Near total neoadjuvant therapy
Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Trial Randomized Phase II ltbr gt
ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has better DFS not OS than 5FU after pre-op ChemoRT
Questions Total Neoadjuvant YesNoAdjuvant Cth YesNoLong versus Short Course
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
Member of Advisory Board Consultant and Speaker for Amgen Astellas AstraZeneca Hoffman la Roche Janssen
Cilag Merck Serono Novartis Pfizer The content of this presentation does not relate to any product
of a commercial interest
Speaker Disclosures
Principles
Surgery is the cornerstone in management
However
Local Recurrence Following Surgery Alone
Clinical Colorectal Cancer Vol 4 No 4 233-240 2004
Adjuvant Radiation Therapy
Clinical Colorectal Cancer Vol 4 No 4 233-240 2004
Local Recurrence Better Insight
Circumferential Margins
Number Local Recurrence
Rate
P
gt 2 mm 987 33 lt 00001
1 ndash 2 mm 100 85 002
lt 1 mm 227 131 008
Int J Radiation Oncology Biol Phys Vol 55 No 5 pp 1311ndash1320 2003
Total Mesorectal Excision (TME)
Removal of peri-rectal tissues involving lateral amp circumferential margins of mesorectal envelop
Dis Colon Rectum 2013 May56(5)535-50
Total Mesorectal Excision (TME)
Clinical Colorectal Cancer Vol 4 No 4 233-240 2004N Engl J Med 2001345638 ndash 646
Adjuvant Radiation Therapy
LR = 24
Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
GITSG NCCTG NSABP R-01
N Engl J Med 1986 3151294FJ Natl Cancer Inst 1988 8021 N Engl J Med 1991 324709
Adjuvant Fluoroupyremidine
X 2 monthsCRT ndash 6 Weeks
Adjuvant Fluoroupyremidine
X 2 months
Adjuvant Therapy = 6 months
Neoadjuvant Therapy The German Study A Shifting Concept
N Engl J Med 20043511731-40
German CAOAROAIO-94 11 Years Update
Sauer R et al JCO 2012301926-33
Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
10 - Year RTh + S S P
LR 5 11 lt 00001
OAS 48 49 086
CCSD 17 22 004
Lancet Oncol 2011 12 575ndash82
CCSD Cumulative Incidence of Cancer Specific Death
Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
Lancet Oncol 2011 12 575ndash82
OAS Benefit
Neoadjuvant TherapyShort versus Long Radiation Therapy Course
Polish Trial Trans-Tasman Radiation
Oncology Group
bull Local Recurrencebull DFSbull Distant Recurrencebull OASbull Severe Late
Toxicity
EQUIVALENT
J Clin Oncol 2012 303827Br J Surg 2006 931215
Distal Tumors LC gt SC
LR = 0 12
Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
Gastrointest Cancer Res 149-56 copy2007 by International Society of Gastrointestinal Oncology
Neoadjuvant TherapyThe Use of Capecitabine
The Cancer Journal bull Volume 13 Number 3 MayJune 2007
EQUIVALENT
Neoadjuvant TherapyAdding Oxaliplatin
Curr Opin Oncol 2012 24441ndash447
bull ++ Toxicity amp -- Compliancebull Did not improve
1 R0 RR2 pCR3 Sphincter Preservation
The PETACC-6 RCTltbr gt
Neoadjuvant TherapyAdding Oxaliplatin
ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no major differences between armsltbr gt
Neoadjuvant TherapyAdding Oxaliplatin
Neoadjuvant TherapyAdding EGFR Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyAdding VEGF Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyIndications
1 T3 ndash T4 Lesions The only definitive indication2 cT3N0 Should be treated (understaging)3 Depth of Extramural Invasion
ndash T3 lesions (gt5 mm) ++ LNs involvement Higher Cancer Specific Mortality (54 Versus 85)
ndash Selection of high risk T3 for treatmentndash Approved outside US
4 T1 ndash 2 lesions with Positive Nodes5 Low situated lesions6 Invasion of mesorectal fasciaBr J Cancer 2000 821131wwwuptodatecom (September 2015)
Neoadjuvant TherapyTreatment Outcome
Complete Response cCRpCR
bull 15 ndash 30bull Small amp Less
Advanced Lesions
bull 10 ndash 12 Weeks
bull Involution to flat scar
bull DRE amp Endoscopybull Imaging
bull Endorectal USbull PET-CTbull MRI
bull ypT0N0
BIASED
NOT ACCEPTED
Martin R et al Surg Oncol Clin N Am 23 (2014) 113ndash125
Neoadjuvant TherapyTreatment Outcome in Relation to Pathological Outcome German Study
Grade Regression Fibrosis0 No All cells are viable
1 Minor lt 25 fibrosis
2 Moderate 26 ndash 50nFibrosis
3 Good gt50
4 Total No Viable Cells
Neoadjuvant TherapyTumor Regression Grade
Grade 10 ndash year DM
P 10 ndash Year DFS
P
0 - 1 3960005
6300082 - 3 293 736
4 105 895
J Clin Oncol 321554-1562 copy 2014
Neoadjuvant TherapyImpact of Pathological CR
British Journal of Surgery 2012 99 918ndash928
Can we Avoid Surgery
Can we Avoid Surgery
Can we Avoid Surgery
JCO VOLUME 29 1113097 NUMBER 35 1113097 DECEMBER 10 2011
21 Patients pCR
Neoadjuvant CRTFor Stages II amp III Wait amp See
MRI Endoscopy amp Biopsy
Median Follow up =25 months
1 Patient LR Surgery
20 Pts Stages II amp III NAT pCR
Median Follow up =35 months
2 ndash Year DFS 91 2 ndash Year OAS 93
Neoadjuvant TherapyProblems with Current Practice
CRT 55 Weeks 6 wks TME
1 ndash 2 weeks 4-6 wks Adjuvant Cth
18 weeksbull Delayedbull Reducedbull Omitted
CRT TME Neodjuvant Chemoth
Neodjuvant Chemoth CRT TME
bull Total Neoadjuvant Therapy Paradigm
bull Better down-staging
bull Better pCR
bull Higher R0 Resection Rates
Adopted from Deborah Schragrsquos Presentation at 2015 ASCO Annual Meeting
Total Neoadjuvant ParadigmBrown University Study (CONTRE)
FOLFOX X 8 Courses CRT + Cape TME
Pathologic Grade
Total Number Stage II Stage III38 7 31
0 (Complete) 13 1 12
1 14 4 10
2 8 1 7
3 3 1 2
bull 35 Pts Completed Treatmentbull pCR = 33
Perez et al ASCO 2014 Abstract 3050
The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on DFS
The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on OAS
Slide 12
Near total neoadjuvant therapy
Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Trial Randomized Phase II ltbr gt
ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has better DFS not OS than 5FU after pre-op ChemoRT
Questions Total Neoadjuvant YesNoAdjuvant Cth YesNoLong versus Short Course
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
Principles
Surgery is the cornerstone in management
However
Local Recurrence Following Surgery Alone
Clinical Colorectal Cancer Vol 4 No 4 233-240 2004
Adjuvant Radiation Therapy
Clinical Colorectal Cancer Vol 4 No 4 233-240 2004
Local Recurrence Better Insight
Circumferential Margins
Number Local Recurrence
Rate
P
gt 2 mm 987 33 lt 00001
1 ndash 2 mm 100 85 002
lt 1 mm 227 131 008
Int J Radiation Oncology Biol Phys Vol 55 No 5 pp 1311ndash1320 2003
Total Mesorectal Excision (TME)
Removal of peri-rectal tissues involving lateral amp circumferential margins of mesorectal envelop
Dis Colon Rectum 2013 May56(5)535-50
Total Mesorectal Excision (TME)
Clinical Colorectal Cancer Vol 4 No 4 233-240 2004N Engl J Med 2001345638 ndash 646
Adjuvant Radiation Therapy
LR = 24
Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
GITSG NCCTG NSABP R-01
N Engl J Med 1986 3151294FJ Natl Cancer Inst 1988 8021 N Engl J Med 1991 324709
Adjuvant Fluoroupyremidine
X 2 monthsCRT ndash 6 Weeks
Adjuvant Fluoroupyremidine
X 2 months
Adjuvant Therapy = 6 months
Neoadjuvant Therapy The German Study A Shifting Concept
N Engl J Med 20043511731-40
German CAOAROAIO-94 11 Years Update
Sauer R et al JCO 2012301926-33
Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
10 - Year RTh + S S P
LR 5 11 lt 00001
OAS 48 49 086
CCSD 17 22 004
Lancet Oncol 2011 12 575ndash82
CCSD Cumulative Incidence of Cancer Specific Death
Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
Lancet Oncol 2011 12 575ndash82
OAS Benefit
Neoadjuvant TherapyShort versus Long Radiation Therapy Course
Polish Trial Trans-Tasman Radiation
Oncology Group
bull Local Recurrencebull DFSbull Distant Recurrencebull OASbull Severe Late
Toxicity
EQUIVALENT
J Clin Oncol 2012 303827Br J Surg 2006 931215
Distal Tumors LC gt SC
LR = 0 12
Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
Gastrointest Cancer Res 149-56 copy2007 by International Society of Gastrointestinal Oncology
Neoadjuvant TherapyThe Use of Capecitabine
The Cancer Journal bull Volume 13 Number 3 MayJune 2007
EQUIVALENT
Neoadjuvant TherapyAdding Oxaliplatin
Curr Opin Oncol 2012 24441ndash447
bull ++ Toxicity amp -- Compliancebull Did not improve
1 R0 RR2 pCR3 Sphincter Preservation
The PETACC-6 RCTltbr gt
Neoadjuvant TherapyAdding Oxaliplatin
ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no major differences between armsltbr gt
Neoadjuvant TherapyAdding Oxaliplatin
Neoadjuvant TherapyAdding EGFR Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyAdding VEGF Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyIndications
1 T3 ndash T4 Lesions The only definitive indication2 cT3N0 Should be treated (understaging)3 Depth of Extramural Invasion
ndash T3 lesions (gt5 mm) ++ LNs involvement Higher Cancer Specific Mortality (54 Versus 85)
ndash Selection of high risk T3 for treatmentndash Approved outside US
4 T1 ndash 2 lesions with Positive Nodes5 Low situated lesions6 Invasion of mesorectal fasciaBr J Cancer 2000 821131wwwuptodatecom (September 2015)
Neoadjuvant TherapyTreatment Outcome
Complete Response cCRpCR
bull 15 ndash 30bull Small amp Less
Advanced Lesions
bull 10 ndash 12 Weeks
bull Involution to flat scar
bull DRE amp Endoscopybull Imaging
bull Endorectal USbull PET-CTbull MRI
bull ypT0N0
BIASED
NOT ACCEPTED
Martin R et al Surg Oncol Clin N Am 23 (2014) 113ndash125
Neoadjuvant TherapyTreatment Outcome in Relation to Pathological Outcome German Study
Grade Regression Fibrosis0 No All cells are viable
1 Minor lt 25 fibrosis
2 Moderate 26 ndash 50nFibrosis
3 Good gt50
4 Total No Viable Cells
Neoadjuvant TherapyTumor Regression Grade
Grade 10 ndash year DM
P 10 ndash Year DFS
P
0 - 1 3960005
6300082 - 3 293 736
4 105 895
J Clin Oncol 321554-1562 copy 2014
Neoadjuvant TherapyImpact of Pathological CR
British Journal of Surgery 2012 99 918ndash928
Can we Avoid Surgery
Can we Avoid Surgery
Can we Avoid Surgery
JCO VOLUME 29 1113097 NUMBER 35 1113097 DECEMBER 10 2011
21 Patients pCR
Neoadjuvant CRTFor Stages II amp III Wait amp See
MRI Endoscopy amp Biopsy
Median Follow up =25 months
1 Patient LR Surgery
20 Pts Stages II amp III NAT pCR
Median Follow up =35 months
2 ndash Year DFS 91 2 ndash Year OAS 93
Neoadjuvant TherapyProblems with Current Practice
CRT 55 Weeks 6 wks TME
1 ndash 2 weeks 4-6 wks Adjuvant Cth
18 weeksbull Delayedbull Reducedbull Omitted
CRT TME Neodjuvant Chemoth
Neodjuvant Chemoth CRT TME
bull Total Neoadjuvant Therapy Paradigm
bull Better down-staging
bull Better pCR
bull Higher R0 Resection Rates
Adopted from Deborah Schragrsquos Presentation at 2015 ASCO Annual Meeting
Total Neoadjuvant ParadigmBrown University Study (CONTRE)
FOLFOX X 8 Courses CRT + Cape TME
Pathologic Grade
Total Number Stage II Stage III38 7 31
0 (Complete) 13 1 12
1 14 4 10
2 8 1 7
3 3 1 2
bull 35 Pts Completed Treatmentbull pCR = 33
Perez et al ASCO 2014 Abstract 3050
The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on DFS
The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on OAS
Slide 12
Near total neoadjuvant therapy
Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Trial Randomized Phase II ltbr gt
ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has better DFS not OS than 5FU after pre-op ChemoRT
Questions Total Neoadjuvant YesNoAdjuvant Cth YesNoLong versus Short Course
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
Local Recurrence Following Surgery Alone
Clinical Colorectal Cancer Vol 4 No 4 233-240 2004
Adjuvant Radiation Therapy
Clinical Colorectal Cancer Vol 4 No 4 233-240 2004
Local Recurrence Better Insight
Circumferential Margins
Number Local Recurrence
Rate
P
gt 2 mm 987 33 lt 00001
1 ndash 2 mm 100 85 002
lt 1 mm 227 131 008
Int J Radiation Oncology Biol Phys Vol 55 No 5 pp 1311ndash1320 2003
Total Mesorectal Excision (TME)
Removal of peri-rectal tissues involving lateral amp circumferential margins of mesorectal envelop
Dis Colon Rectum 2013 May56(5)535-50
Total Mesorectal Excision (TME)
Clinical Colorectal Cancer Vol 4 No 4 233-240 2004N Engl J Med 2001345638 ndash 646
Adjuvant Radiation Therapy
LR = 24
Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
GITSG NCCTG NSABP R-01
N Engl J Med 1986 3151294FJ Natl Cancer Inst 1988 8021 N Engl J Med 1991 324709
Adjuvant Fluoroupyremidine
X 2 monthsCRT ndash 6 Weeks
Adjuvant Fluoroupyremidine
X 2 months
Adjuvant Therapy = 6 months
Neoadjuvant Therapy The German Study A Shifting Concept
N Engl J Med 20043511731-40
German CAOAROAIO-94 11 Years Update
Sauer R et al JCO 2012301926-33
Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
10 - Year RTh + S S P
LR 5 11 lt 00001
OAS 48 49 086
CCSD 17 22 004
Lancet Oncol 2011 12 575ndash82
CCSD Cumulative Incidence of Cancer Specific Death
Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
Lancet Oncol 2011 12 575ndash82
OAS Benefit
Neoadjuvant TherapyShort versus Long Radiation Therapy Course
Polish Trial Trans-Tasman Radiation
Oncology Group
bull Local Recurrencebull DFSbull Distant Recurrencebull OASbull Severe Late
Toxicity
EQUIVALENT
J Clin Oncol 2012 303827Br J Surg 2006 931215
Distal Tumors LC gt SC
LR = 0 12
Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
Gastrointest Cancer Res 149-56 copy2007 by International Society of Gastrointestinal Oncology
Neoadjuvant TherapyThe Use of Capecitabine
The Cancer Journal bull Volume 13 Number 3 MayJune 2007
EQUIVALENT
Neoadjuvant TherapyAdding Oxaliplatin
Curr Opin Oncol 2012 24441ndash447
bull ++ Toxicity amp -- Compliancebull Did not improve
1 R0 RR2 pCR3 Sphincter Preservation
The PETACC-6 RCTltbr gt
Neoadjuvant TherapyAdding Oxaliplatin
ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no major differences between armsltbr gt
Neoadjuvant TherapyAdding Oxaliplatin
Neoadjuvant TherapyAdding EGFR Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyAdding VEGF Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyIndications
1 T3 ndash T4 Lesions The only definitive indication2 cT3N0 Should be treated (understaging)3 Depth of Extramural Invasion
ndash T3 lesions (gt5 mm) ++ LNs involvement Higher Cancer Specific Mortality (54 Versus 85)
ndash Selection of high risk T3 for treatmentndash Approved outside US
4 T1 ndash 2 lesions with Positive Nodes5 Low situated lesions6 Invasion of mesorectal fasciaBr J Cancer 2000 821131wwwuptodatecom (September 2015)
Neoadjuvant TherapyTreatment Outcome
Complete Response cCRpCR
bull 15 ndash 30bull Small amp Less
Advanced Lesions
bull 10 ndash 12 Weeks
bull Involution to flat scar
bull DRE amp Endoscopybull Imaging
bull Endorectal USbull PET-CTbull MRI
bull ypT0N0
BIASED
NOT ACCEPTED
Martin R et al Surg Oncol Clin N Am 23 (2014) 113ndash125
Neoadjuvant TherapyTreatment Outcome in Relation to Pathological Outcome German Study
Grade Regression Fibrosis0 No All cells are viable
1 Minor lt 25 fibrosis
2 Moderate 26 ndash 50nFibrosis
3 Good gt50
4 Total No Viable Cells
Neoadjuvant TherapyTumor Regression Grade
Grade 10 ndash year DM
P 10 ndash Year DFS
P
0 - 1 3960005
6300082 - 3 293 736
4 105 895
J Clin Oncol 321554-1562 copy 2014
Neoadjuvant TherapyImpact of Pathological CR
British Journal of Surgery 2012 99 918ndash928
Can we Avoid Surgery
Can we Avoid Surgery
Can we Avoid Surgery
JCO VOLUME 29 1113097 NUMBER 35 1113097 DECEMBER 10 2011
21 Patients pCR
Neoadjuvant CRTFor Stages II amp III Wait amp See
MRI Endoscopy amp Biopsy
Median Follow up =25 months
1 Patient LR Surgery
20 Pts Stages II amp III NAT pCR
Median Follow up =35 months
2 ndash Year DFS 91 2 ndash Year OAS 93
Neoadjuvant TherapyProblems with Current Practice
CRT 55 Weeks 6 wks TME
1 ndash 2 weeks 4-6 wks Adjuvant Cth
18 weeksbull Delayedbull Reducedbull Omitted
CRT TME Neodjuvant Chemoth
Neodjuvant Chemoth CRT TME
bull Total Neoadjuvant Therapy Paradigm
bull Better down-staging
bull Better pCR
bull Higher R0 Resection Rates
Adopted from Deborah Schragrsquos Presentation at 2015 ASCO Annual Meeting
Total Neoadjuvant ParadigmBrown University Study (CONTRE)
FOLFOX X 8 Courses CRT + Cape TME
Pathologic Grade
Total Number Stage II Stage III38 7 31
0 (Complete) 13 1 12
1 14 4 10
2 8 1 7
3 3 1 2
bull 35 Pts Completed Treatmentbull pCR = 33
Perez et al ASCO 2014 Abstract 3050
The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on DFS
The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on OAS
Slide 12
Near total neoadjuvant therapy
Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Trial Randomized Phase II ltbr gt
ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has better DFS not OS than 5FU after pre-op ChemoRT
Questions Total Neoadjuvant YesNoAdjuvant Cth YesNoLong versus Short Course
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
Adjuvant Radiation Therapy
Clinical Colorectal Cancer Vol 4 No 4 233-240 2004
Local Recurrence Better Insight
Circumferential Margins
Number Local Recurrence
Rate
P
gt 2 mm 987 33 lt 00001
1 ndash 2 mm 100 85 002
lt 1 mm 227 131 008
Int J Radiation Oncology Biol Phys Vol 55 No 5 pp 1311ndash1320 2003
Total Mesorectal Excision (TME)
Removal of peri-rectal tissues involving lateral amp circumferential margins of mesorectal envelop
Dis Colon Rectum 2013 May56(5)535-50
Total Mesorectal Excision (TME)
Clinical Colorectal Cancer Vol 4 No 4 233-240 2004N Engl J Med 2001345638 ndash 646
Adjuvant Radiation Therapy
LR = 24
Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
GITSG NCCTG NSABP R-01
N Engl J Med 1986 3151294FJ Natl Cancer Inst 1988 8021 N Engl J Med 1991 324709
Adjuvant Fluoroupyremidine
X 2 monthsCRT ndash 6 Weeks
Adjuvant Fluoroupyremidine
X 2 months
Adjuvant Therapy = 6 months
Neoadjuvant Therapy The German Study A Shifting Concept
N Engl J Med 20043511731-40
German CAOAROAIO-94 11 Years Update
Sauer R et al JCO 2012301926-33
Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
10 - Year RTh + S S P
LR 5 11 lt 00001
OAS 48 49 086
CCSD 17 22 004
Lancet Oncol 2011 12 575ndash82
CCSD Cumulative Incidence of Cancer Specific Death
Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
Lancet Oncol 2011 12 575ndash82
OAS Benefit
Neoadjuvant TherapyShort versus Long Radiation Therapy Course
Polish Trial Trans-Tasman Radiation
Oncology Group
bull Local Recurrencebull DFSbull Distant Recurrencebull OASbull Severe Late
Toxicity
EQUIVALENT
J Clin Oncol 2012 303827Br J Surg 2006 931215
Distal Tumors LC gt SC
LR = 0 12
Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
Gastrointest Cancer Res 149-56 copy2007 by International Society of Gastrointestinal Oncology
Neoadjuvant TherapyThe Use of Capecitabine
The Cancer Journal bull Volume 13 Number 3 MayJune 2007
EQUIVALENT
Neoadjuvant TherapyAdding Oxaliplatin
Curr Opin Oncol 2012 24441ndash447
bull ++ Toxicity amp -- Compliancebull Did not improve
1 R0 RR2 pCR3 Sphincter Preservation
The PETACC-6 RCTltbr gt
Neoadjuvant TherapyAdding Oxaliplatin
ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no major differences between armsltbr gt
Neoadjuvant TherapyAdding Oxaliplatin
Neoadjuvant TherapyAdding EGFR Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyAdding VEGF Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyIndications
1 T3 ndash T4 Lesions The only definitive indication2 cT3N0 Should be treated (understaging)3 Depth of Extramural Invasion
ndash T3 lesions (gt5 mm) ++ LNs involvement Higher Cancer Specific Mortality (54 Versus 85)
ndash Selection of high risk T3 for treatmentndash Approved outside US
4 T1 ndash 2 lesions with Positive Nodes5 Low situated lesions6 Invasion of mesorectal fasciaBr J Cancer 2000 821131wwwuptodatecom (September 2015)
Neoadjuvant TherapyTreatment Outcome
Complete Response cCRpCR
bull 15 ndash 30bull Small amp Less
Advanced Lesions
bull 10 ndash 12 Weeks
bull Involution to flat scar
bull DRE amp Endoscopybull Imaging
bull Endorectal USbull PET-CTbull MRI
bull ypT0N0
BIASED
NOT ACCEPTED
Martin R et al Surg Oncol Clin N Am 23 (2014) 113ndash125
Neoadjuvant TherapyTreatment Outcome in Relation to Pathological Outcome German Study
Grade Regression Fibrosis0 No All cells are viable
1 Minor lt 25 fibrosis
2 Moderate 26 ndash 50nFibrosis
3 Good gt50
4 Total No Viable Cells
Neoadjuvant TherapyTumor Regression Grade
Grade 10 ndash year DM
P 10 ndash Year DFS
P
0 - 1 3960005
6300082 - 3 293 736
4 105 895
J Clin Oncol 321554-1562 copy 2014
Neoadjuvant TherapyImpact of Pathological CR
British Journal of Surgery 2012 99 918ndash928
Can we Avoid Surgery
Can we Avoid Surgery
Can we Avoid Surgery
JCO VOLUME 29 1113097 NUMBER 35 1113097 DECEMBER 10 2011
21 Patients pCR
Neoadjuvant CRTFor Stages II amp III Wait amp See
MRI Endoscopy amp Biopsy
Median Follow up =25 months
1 Patient LR Surgery
20 Pts Stages II amp III NAT pCR
Median Follow up =35 months
2 ndash Year DFS 91 2 ndash Year OAS 93
Neoadjuvant TherapyProblems with Current Practice
CRT 55 Weeks 6 wks TME
1 ndash 2 weeks 4-6 wks Adjuvant Cth
18 weeksbull Delayedbull Reducedbull Omitted
CRT TME Neodjuvant Chemoth
Neodjuvant Chemoth CRT TME
bull Total Neoadjuvant Therapy Paradigm
bull Better down-staging
bull Better pCR
bull Higher R0 Resection Rates
Adopted from Deborah Schragrsquos Presentation at 2015 ASCO Annual Meeting
Total Neoadjuvant ParadigmBrown University Study (CONTRE)
FOLFOX X 8 Courses CRT + Cape TME
Pathologic Grade
Total Number Stage II Stage III38 7 31
0 (Complete) 13 1 12
1 14 4 10
2 8 1 7
3 3 1 2
bull 35 Pts Completed Treatmentbull pCR = 33
Perez et al ASCO 2014 Abstract 3050
The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on DFS
The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on OAS
Slide 12
Near total neoadjuvant therapy
Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Trial Randomized Phase II ltbr gt
ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has better DFS not OS than 5FU after pre-op ChemoRT
Questions Total Neoadjuvant YesNoAdjuvant Cth YesNoLong versus Short Course
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
Local Recurrence Better Insight
Circumferential Margins
Number Local Recurrence
Rate
P
gt 2 mm 987 33 lt 00001
1 ndash 2 mm 100 85 002
lt 1 mm 227 131 008
Int J Radiation Oncology Biol Phys Vol 55 No 5 pp 1311ndash1320 2003
Total Mesorectal Excision (TME)
Removal of peri-rectal tissues involving lateral amp circumferential margins of mesorectal envelop
Dis Colon Rectum 2013 May56(5)535-50
Total Mesorectal Excision (TME)
Clinical Colorectal Cancer Vol 4 No 4 233-240 2004N Engl J Med 2001345638 ndash 646
Adjuvant Radiation Therapy
LR = 24
Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
GITSG NCCTG NSABP R-01
N Engl J Med 1986 3151294FJ Natl Cancer Inst 1988 8021 N Engl J Med 1991 324709
Adjuvant Fluoroupyremidine
X 2 monthsCRT ndash 6 Weeks
Adjuvant Fluoroupyremidine
X 2 months
Adjuvant Therapy = 6 months
Neoadjuvant Therapy The German Study A Shifting Concept
N Engl J Med 20043511731-40
German CAOAROAIO-94 11 Years Update
Sauer R et al JCO 2012301926-33
Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
10 - Year RTh + S S P
LR 5 11 lt 00001
OAS 48 49 086
CCSD 17 22 004
Lancet Oncol 2011 12 575ndash82
CCSD Cumulative Incidence of Cancer Specific Death
Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
Lancet Oncol 2011 12 575ndash82
OAS Benefit
Neoadjuvant TherapyShort versus Long Radiation Therapy Course
Polish Trial Trans-Tasman Radiation
Oncology Group
bull Local Recurrencebull DFSbull Distant Recurrencebull OASbull Severe Late
Toxicity
EQUIVALENT
J Clin Oncol 2012 303827Br J Surg 2006 931215
Distal Tumors LC gt SC
LR = 0 12
Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
Gastrointest Cancer Res 149-56 copy2007 by International Society of Gastrointestinal Oncology
Neoadjuvant TherapyThe Use of Capecitabine
The Cancer Journal bull Volume 13 Number 3 MayJune 2007
EQUIVALENT
Neoadjuvant TherapyAdding Oxaliplatin
Curr Opin Oncol 2012 24441ndash447
bull ++ Toxicity amp -- Compliancebull Did not improve
1 R0 RR2 pCR3 Sphincter Preservation
The PETACC-6 RCTltbr gt
Neoadjuvant TherapyAdding Oxaliplatin
ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no major differences between armsltbr gt
Neoadjuvant TherapyAdding Oxaliplatin
Neoadjuvant TherapyAdding EGFR Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyAdding VEGF Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyIndications
1 T3 ndash T4 Lesions The only definitive indication2 cT3N0 Should be treated (understaging)3 Depth of Extramural Invasion
ndash T3 lesions (gt5 mm) ++ LNs involvement Higher Cancer Specific Mortality (54 Versus 85)
ndash Selection of high risk T3 for treatmentndash Approved outside US
4 T1 ndash 2 lesions with Positive Nodes5 Low situated lesions6 Invasion of mesorectal fasciaBr J Cancer 2000 821131wwwuptodatecom (September 2015)
Neoadjuvant TherapyTreatment Outcome
Complete Response cCRpCR
bull 15 ndash 30bull Small amp Less
Advanced Lesions
bull 10 ndash 12 Weeks
bull Involution to flat scar
bull DRE amp Endoscopybull Imaging
bull Endorectal USbull PET-CTbull MRI
bull ypT0N0
BIASED
NOT ACCEPTED
Martin R et al Surg Oncol Clin N Am 23 (2014) 113ndash125
Neoadjuvant TherapyTreatment Outcome in Relation to Pathological Outcome German Study
Grade Regression Fibrosis0 No All cells are viable
1 Minor lt 25 fibrosis
2 Moderate 26 ndash 50nFibrosis
3 Good gt50
4 Total No Viable Cells
Neoadjuvant TherapyTumor Regression Grade
Grade 10 ndash year DM
P 10 ndash Year DFS
P
0 - 1 3960005
6300082 - 3 293 736
4 105 895
J Clin Oncol 321554-1562 copy 2014
Neoadjuvant TherapyImpact of Pathological CR
British Journal of Surgery 2012 99 918ndash928
Can we Avoid Surgery
Can we Avoid Surgery
Can we Avoid Surgery
JCO VOLUME 29 1113097 NUMBER 35 1113097 DECEMBER 10 2011
21 Patients pCR
Neoadjuvant CRTFor Stages II amp III Wait amp See
MRI Endoscopy amp Biopsy
Median Follow up =25 months
1 Patient LR Surgery
20 Pts Stages II amp III NAT pCR
Median Follow up =35 months
2 ndash Year DFS 91 2 ndash Year OAS 93
Neoadjuvant TherapyProblems with Current Practice
CRT 55 Weeks 6 wks TME
1 ndash 2 weeks 4-6 wks Adjuvant Cth
18 weeksbull Delayedbull Reducedbull Omitted
CRT TME Neodjuvant Chemoth
Neodjuvant Chemoth CRT TME
bull Total Neoadjuvant Therapy Paradigm
bull Better down-staging
bull Better pCR
bull Higher R0 Resection Rates
Adopted from Deborah Schragrsquos Presentation at 2015 ASCO Annual Meeting
Total Neoadjuvant ParadigmBrown University Study (CONTRE)
FOLFOX X 8 Courses CRT + Cape TME
Pathologic Grade
Total Number Stage II Stage III38 7 31
0 (Complete) 13 1 12
1 14 4 10
2 8 1 7
3 3 1 2
bull 35 Pts Completed Treatmentbull pCR = 33
Perez et al ASCO 2014 Abstract 3050
The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on DFS
The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on OAS
Slide 12
Near total neoadjuvant therapy
Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Trial Randomized Phase II ltbr gt
ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has better DFS not OS than 5FU after pre-op ChemoRT
Questions Total Neoadjuvant YesNoAdjuvant Cth YesNoLong versus Short Course
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
Total Mesorectal Excision (TME)
Removal of peri-rectal tissues involving lateral amp circumferential margins of mesorectal envelop
Dis Colon Rectum 2013 May56(5)535-50
Total Mesorectal Excision (TME)
Clinical Colorectal Cancer Vol 4 No 4 233-240 2004N Engl J Med 2001345638 ndash 646
Adjuvant Radiation Therapy
LR = 24
Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
GITSG NCCTG NSABP R-01
N Engl J Med 1986 3151294FJ Natl Cancer Inst 1988 8021 N Engl J Med 1991 324709
Adjuvant Fluoroupyremidine
X 2 monthsCRT ndash 6 Weeks
Adjuvant Fluoroupyremidine
X 2 months
Adjuvant Therapy = 6 months
Neoadjuvant Therapy The German Study A Shifting Concept
N Engl J Med 20043511731-40
German CAOAROAIO-94 11 Years Update
Sauer R et al JCO 2012301926-33
Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
10 - Year RTh + S S P
LR 5 11 lt 00001
OAS 48 49 086
CCSD 17 22 004
Lancet Oncol 2011 12 575ndash82
CCSD Cumulative Incidence of Cancer Specific Death
Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
Lancet Oncol 2011 12 575ndash82
OAS Benefit
Neoadjuvant TherapyShort versus Long Radiation Therapy Course
Polish Trial Trans-Tasman Radiation
Oncology Group
bull Local Recurrencebull DFSbull Distant Recurrencebull OASbull Severe Late
Toxicity
EQUIVALENT
J Clin Oncol 2012 303827Br J Surg 2006 931215
Distal Tumors LC gt SC
LR = 0 12
Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
Gastrointest Cancer Res 149-56 copy2007 by International Society of Gastrointestinal Oncology
Neoadjuvant TherapyThe Use of Capecitabine
The Cancer Journal bull Volume 13 Number 3 MayJune 2007
EQUIVALENT
Neoadjuvant TherapyAdding Oxaliplatin
Curr Opin Oncol 2012 24441ndash447
bull ++ Toxicity amp -- Compliancebull Did not improve
1 R0 RR2 pCR3 Sphincter Preservation
The PETACC-6 RCTltbr gt
Neoadjuvant TherapyAdding Oxaliplatin
ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no major differences between armsltbr gt
Neoadjuvant TherapyAdding Oxaliplatin
Neoadjuvant TherapyAdding EGFR Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyAdding VEGF Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyIndications
1 T3 ndash T4 Lesions The only definitive indication2 cT3N0 Should be treated (understaging)3 Depth of Extramural Invasion
ndash T3 lesions (gt5 mm) ++ LNs involvement Higher Cancer Specific Mortality (54 Versus 85)
ndash Selection of high risk T3 for treatmentndash Approved outside US
4 T1 ndash 2 lesions with Positive Nodes5 Low situated lesions6 Invasion of mesorectal fasciaBr J Cancer 2000 821131wwwuptodatecom (September 2015)
Neoadjuvant TherapyTreatment Outcome
Complete Response cCRpCR
bull 15 ndash 30bull Small amp Less
Advanced Lesions
bull 10 ndash 12 Weeks
bull Involution to flat scar
bull DRE amp Endoscopybull Imaging
bull Endorectal USbull PET-CTbull MRI
bull ypT0N0
BIASED
NOT ACCEPTED
Martin R et al Surg Oncol Clin N Am 23 (2014) 113ndash125
Neoadjuvant TherapyTreatment Outcome in Relation to Pathological Outcome German Study
Grade Regression Fibrosis0 No All cells are viable
1 Minor lt 25 fibrosis
2 Moderate 26 ndash 50nFibrosis
3 Good gt50
4 Total No Viable Cells
Neoadjuvant TherapyTumor Regression Grade
Grade 10 ndash year DM
P 10 ndash Year DFS
P
0 - 1 3960005
6300082 - 3 293 736
4 105 895
J Clin Oncol 321554-1562 copy 2014
Neoadjuvant TherapyImpact of Pathological CR
British Journal of Surgery 2012 99 918ndash928
Can we Avoid Surgery
Can we Avoid Surgery
Can we Avoid Surgery
JCO VOLUME 29 1113097 NUMBER 35 1113097 DECEMBER 10 2011
21 Patients pCR
Neoadjuvant CRTFor Stages II amp III Wait amp See
MRI Endoscopy amp Biopsy
Median Follow up =25 months
1 Patient LR Surgery
20 Pts Stages II amp III NAT pCR
Median Follow up =35 months
2 ndash Year DFS 91 2 ndash Year OAS 93
Neoadjuvant TherapyProblems with Current Practice
CRT 55 Weeks 6 wks TME
1 ndash 2 weeks 4-6 wks Adjuvant Cth
18 weeksbull Delayedbull Reducedbull Omitted
CRT TME Neodjuvant Chemoth
Neodjuvant Chemoth CRT TME
bull Total Neoadjuvant Therapy Paradigm
bull Better down-staging
bull Better pCR
bull Higher R0 Resection Rates
Adopted from Deborah Schragrsquos Presentation at 2015 ASCO Annual Meeting
Total Neoadjuvant ParadigmBrown University Study (CONTRE)
FOLFOX X 8 Courses CRT + Cape TME
Pathologic Grade
Total Number Stage II Stage III38 7 31
0 (Complete) 13 1 12
1 14 4 10
2 8 1 7
3 3 1 2
bull 35 Pts Completed Treatmentbull pCR = 33
Perez et al ASCO 2014 Abstract 3050
The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on DFS
The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on OAS
Slide 12
Near total neoadjuvant therapy
Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Trial Randomized Phase II ltbr gt
ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has better DFS not OS than 5FU after pre-op ChemoRT
Questions Total Neoadjuvant YesNoAdjuvant Cth YesNoLong versus Short Course
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
Total Mesorectal Excision (TME)
Clinical Colorectal Cancer Vol 4 No 4 233-240 2004N Engl J Med 2001345638 ndash 646
Adjuvant Radiation Therapy
LR = 24
Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
GITSG NCCTG NSABP R-01
N Engl J Med 1986 3151294FJ Natl Cancer Inst 1988 8021 N Engl J Med 1991 324709
Adjuvant Fluoroupyremidine
X 2 monthsCRT ndash 6 Weeks
Adjuvant Fluoroupyremidine
X 2 months
Adjuvant Therapy = 6 months
Neoadjuvant Therapy The German Study A Shifting Concept
N Engl J Med 20043511731-40
German CAOAROAIO-94 11 Years Update
Sauer R et al JCO 2012301926-33
Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
10 - Year RTh + S S P
LR 5 11 lt 00001
OAS 48 49 086
CCSD 17 22 004
Lancet Oncol 2011 12 575ndash82
CCSD Cumulative Incidence of Cancer Specific Death
Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
Lancet Oncol 2011 12 575ndash82
OAS Benefit
Neoadjuvant TherapyShort versus Long Radiation Therapy Course
Polish Trial Trans-Tasman Radiation
Oncology Group
bull Local Recurrencebull DFSbull Distant Recurrencebull OASbull Severe Late
Toxicity
EQUIVALENT
J Clin Oncol 2012 303827Br J Surg 2006 931215
Distal Tumors LC gt SC
LR = 0 12
Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
Gastrointest Cancer Res 149-56 copy2007 by International Society of Gastrointestinal Oncology
Neoadjuvant TherapyThe Use of Capecitabine
The Cancer Journal bull Volume 13 Number 3 MayJune 2007
EQUIVALENT
Neoadjuvant TherapyAdding Oxaliplatin
Curr Opin Oncol 2012 24441ndash447
bull ++ Toxicity amp -- Compliancebull Did not improve
1 R0 RR2 pCR3 Sphincter Preservation
The PETACC-6 RCTltbr gt
Neoadjuvant TherapyAdding Oxaliplatin
ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no major differences between armsltbr gt
Neoadjuvant TherapyAdding Oxaliplatin
Neoadjuvant TherapyAdding EGFR Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyAdding VEGF Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyIndications
1 T3 ndash T4 Lesions The only definitive indication2 cT3N0 Should be treated (understaging)3 Depth of Extramural Invasion
ndash T3 lesions (gt5 mm) ++ LNs involvement Higher Cancer Specific Mortality (54 Versus 85)
ndash Selection of high risk T3 for treatmentndash Approved outside US
4 T1 ndash 2 lesions with Positive Nodes5 Low situated lesions6 Invasion of mesorectal fasciaBr J Cancer 2000 821131wwwuptodatecom (September 2015)
Neoadjuvant TherapyTreatment Outcome
Complete Response cCRpCR
bull 15 ndash 30bull Small amp Less
Advanced Lesions
bull 10 ndash 12 Weeks
bull Involution to flat scar
bull DRE amp Endoscopybull Imaging
bull Endorectal USbull PET-CTbull MRI
bull ypT0N0
BIASED
NOT ACCEPTED
Martin R et al Surg Oncol Clin N Am 23 (2014) 113ndash125
Neoadjuvant TherapyTreatment Outcome in Relation to Pathological Outcome German Study
Grade Regression Fibrosis0 No All cells are viable
1 Minor lt 25 fibrosis
2 Moderate 26 ndash 50nFibrosis
3 Good gt50
4 Total No Viable Cells
Neoadjuvant TherapyTumor Regression Grade
Grade 10 ndash year DM
P 10 ndash Year DFS
P
0 - 1 3960005
6300082 - 3 293 736
4 105 895
J Clin Oncol 321554-1562 copy 2014
Neoadjuvant TherapyImpact of Pathological CR
British Journal of Surgery 2012 99 918ndash928
Can we Avoid Surgery
Can we Avoid Surgery
Can we Avoid Surgery
JCO VOLUME 29 1113097 NUMBER 35 1113097 DECEMBER 10 2011
21 Patients pCR
Neoadjuvant CRTFor Stages II amp III Wait amp See
MRI Endoscopy amp Biopsy
Median Follow up =25 months
1 Patient LR Surgery
20 Pts Stages II amp III NAT pCR
Median Follow up =35 months
2 ndash Year DFS 91 2 ndash Year OAS 93
Neoadjuvant TherapyProblems with Current Practice
CRT 55 Weeks 6 wks TME
1 ndash 2 weeks 4-6 wks Adjuvant Cth
18 weeksbull Delayedbull Reducedbull Omitted
CRT TME Neodjuvant Chemoth
Neodjuvant Chemoth CRT TME
bull Total Neoadjuvant Therapy Paradigm
bull Better down-staging
bull Better pCR
bull Higher R0 Resection Rates
Adopted from Deborah Schragrsquos Presentation at 2015 ASCO Annual Meeting
Total Neoadjuvant ParadigmBrown University Study (CONTRE)
FOLFOX X 8 Courses CRT + Cape TME
Pathologic Grade
Total Number Stage II Stage III38 7 31
0 (Complete) 13 1 12
1 14 4 10
2 8 1 7
3 3 1 2
bull 35 Pts Completed Treatmentbull pCR = 33
Perez et al ASCO 2014 Abstract 3050
The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on DFS
The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on OAS
Slide 12
Near total neoadjuvant therapy
Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Trial Randomized Phase II ltbr gt
ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has better DFS not OS than 5FU after pre-op ChemoRT
Questions Total Neoadjuvant YesNoAdjuvant Cth YesNoLong versus Short Course
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
GITSG NCCTG NSABP R-01
N Engl J Med 1986 3151294FJ Natl Cancer Inst 1988 8021 N Engl J Med 1991 324709
Adjuvant Fluoroupyremidine
X 2 monthsCRT ndash 6 Weeks
Adjuvant Fluoroupyremidine
X 2 months
Adjuvant Therapy = 6 months
Neoadjuvant Therapy The German Study A Shifting Concept
N Engl J Med 20043511731-40
German CAOAROAIO-94 11 Years Update
Sauer R et al JCO 2012301926-33
Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
10 - Year RTh + S S P
LR 5 11 lt 00001
OAS 48 49 086
CCSD 17 22 004
Lancet Oncol 2011 12 575ndash82
CCSD Cumulative Incidence of Cancer Specific Death
Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
Lancet Oncol 2011 12 575ndash82
OAS Benefit
Neoadjuvant TherapyShort versus Long Radiation Therapy Course
Polish Trial Trans-Tasman Radiation
Oncology Group
bull Local Recurrencebull DFSbull Distant Recurrencebull OASbull Severe Late
Toxicity
EQUIVALENT
J Clin Oncol 2012 303827Br J Surg 2006 931215
Distal Tumors LC gt SC
LR = 0 12
Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
Gastrointest Cancer Res 149-56 copy2007 by International Society of Gastrointestinal Oncology
Neoadjuvant TherapyThe Use of Capecitabine
The Cancer Journal bull Volume 13 Number 3 MayJune 2007
EQUIVALENT
Neoadjuvant TherapyAdding Oxaliplatin
Curr Opin Oncol 2012 24441ndash447
bull ++ Toxicity amp -- Compliancebull Did not improve
1 R0 RR2 pCR3 Sphincter Preservation
The PETACC-6 RCTltbr gt
Neoadjuvant TherapyAdding Oxaliplatin
ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no major differences between armsltbr gt
Neoadjuvant TherapyAdding Oxaliplatin
Neoadjuvant TherapyAdding EGFR Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyAdding VEGF Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyIndications
1 T3 ndash T4 Lesions The only definitive indication2 cT3N0 Should be treated (understaging)3 Depth of Extramural Invasion
ndash T3 lesions (gt5 mm) ++ LNs involvement Higher Cancer Specific Mortality (54 Versus 85)
ndash Selection of high risk T3 for treatmentndash Approved outside US
4 T1 ndash 2 lesions with Positive Nodes5 Low situated lesions6 Invasion of mesorectal fasciaBr J Cancer 2000 821131wwwuptodatecom (September 2015)
Neoadjuvant TherapyTreatment Outcome
Complete Response cCRpCR
bull 15 ndash 30bull Small amp Less
Advanced Lesions
bull 10 ndash 12 Weeks
bull Involution to flat scar
bull DRE amp Endoscopybull Imaging
bull Endorectal USbull PET-CTbull MRI
bull ypT0N0
BIASED
NOT ACCEPTED
Martin R et al Surg Oncol Clin N Am 23 (2014) 113ndash125
Neoadjuvant TherapyTreatment Outcome in Relation to Pathological Outcome German Study
Grade Regression Fibrosis0 No All cells are viable
1 Minor lt 25 fibrosis
2 Moderate 26 ndash 50nFibrosis
3 Good gt50
4 Total No Viable Cells
Neoadjuvant TherapyTumor Regression Grade
Grade 10 ndash year DM
P 10 ndash Year DFS
P
0 - 1 3960005
6300082 - 3 293 736
4 105 895
J Clin Oncol 321554-1562 copy 2014
Neoadjuvant TherapyImpact of Pathological CR
British Journal of Surgery 2012 99 918ndash928
Can we Avoid Surgery
Can we Avoid Surgery
Can we Avoid Surgery
JCO VOLUME 29 1113097 NUMBER 35 1113097 DECEMBER 10 2011
21 Patients pCR
Neoadjuvant CRTFor Stages II amp III Wait amp See
MRI Endoscopy amp Biopsy
Median Follow up =25 months
1 Patient LR Surgery
20 Pts Stages II amp III NAT pCR
Median Follow up =35 months
2 ndash Year DFS 91 2 ndash Year OAS 93
Neoadjuvant TherapyProblems with Current Practice
CRT 55 Weeks 6 wks TME
1 ndash 2 weeks 4-6 wks Adjuvant Cth
18 weeksbull Delayedbull Reducedbull Omitted
CRT TME Neodjuvant Chemoth
Neodjuvant Chemoth CRT TME
bull Total Neoadjuvant Therapy Paradigm
bull Better down-staging
bull Better pCR
bull Higher R0 Resection Rates
Adopted from Deborah Schragrsquos Presentation at 2015 ASCO Annual Meeting
Total Neoadjuvant ParadigmBrown University Study (CONTRE)
FOLFOX X 8 Courses CRT + Cape TME
Pathologic Grade
Total Number Stage II Stage III38 7 31
0 (Complete) 13 1 12
1 14 4 10
2 8 1 7
3 3 1 2
bull 35 Pts Completed Treatmentbull pCR = 33
Perez et al ASCO 2014 Abstract 3050
The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on DFS
The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on OAS
Slide 12
Near total neoadjuvant therapy
Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Trial Randomized Phase II ltbr gt
ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has better DFS not OS than 5FU after pre-op ChemoRT
Questions Total Neoadjuvant YesNoAdjuvant Cth YesNoLong versus Short Course
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
Neoadjuvant Therapy The German Study A Shifting Concept
N Engl J Med 20043511731-40
German CAOAROAIO-94 11 Years Update
Sauer R et al JCO 2012301926-33
Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
10 - Year RTh + S S P
LR 5 11 lt 00001
OAS 48 49 086
CCSD 17 22 004
Lancet Oncol 2011 12 575ndash82
CCSD Cumulative Incidence of Cancer Specific Death
Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
Lancet Oncol 2011 12 575ndash82
OAS Benefit
Neoadjuvant TherapyShort versus Long Radiation Therapy Course
Polish Trial Trans-Tasman Radiation
Oncology Group
bull Local Recurrencebull DFSbull Distant Recurrencebull OASbull Severe Late
Toxicity
EQUIVALENT
J Clin Oncol 2012 303827Br J Surg 2006 931215
Distal Tumors LC gt SC
LR = 0 12
Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
Gastrointest Cancer Res 149-56 copy2007 by International Society of Gastrointestinal Oncology
Neoadjuvant TherapyThe Use of Capecitabine
The Cancer Journal bull Volume 13 Number 3 MayJune 2007
EQUIVALENT
Neoadjuvant TherapyAdding Oxaliplatin
Curr Opin Oncol 2012 24441ndash447
bull ++ Toxicity amp -- Compliancebull Did not improve
1 R0 RR2 pCR3 Sphincter Preservation
The PETACC-6 RCTltbr gt
Neoadjuvant TherapyAdding Oxaliplatin
ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no major differences between armsltbr gt
Neoadjuvant TherapyAdding Oxaliplatin
Neoadjuvant TherapyAdding EGFR Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyAdding VEGF Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyIndications
1 T3 ndash T4 Lesions The only definitive indication2 cT3N0 Should be treated (understaging)3 Depth of Extramural Invasion
ndash T3 lesions (gt5 mm) ++ LNs involvement Higher Cancer Specific Mortality (54 Versus 85)
ndash Selection of high risk T3 for treatmentndash Approved outside US
4 T1 ndash 2 lesions with Positive Nodes5 Low situated lesions6 Invasion of mesorectal fasciaBr J Cancer 2000 821131wwwuptodatecom (September 2015)
Neoadjuvant TherapyTreatment Outcome
Complete Response cCRpCR
bull 15 ndash 30bull Small amp Less
Advanced Lesions
bull 10 ndash 12 Weeks
bull Involution to flat scar
bull DRE amp Endoscopybull Imaging
bull Endorectal USbull PET-CTbull MRI
bull ypT0N0
BIASED
NOT ACCEPTED
Martin R et al Surg Oncol Clin N Am 23 (2014) 113ndash125
Neoadjuvant TherapyTreatment Outcome in Relation to Pathological Outcome German Study
Grade Regression Fibrosis0 No All cells are viable
1 Minor lt 25 fibrosis
2 Moderate 26 ndash 50nFibrosis
3 Good gt50
4 Total No Viable Cells
Neoadjuvant TherapyTumor Regression Grade
Grade 10 ndash year DM
P 10 ndash Year DFS
P
0 - 1 3960005
6300082 - 3 293 736
4 105 895
J Clin Oncol 321554-1562 copy 2014
Neoadjuvant TherapyImpact of Pathological CR
British Journal of Surgery 2012 99 918ndash928
Can we Avoid Surgery
Can we Avoid Surgery
Can we Avoid Surgery
JCO VOLUME 29 1113097 NUMBER 35 1113097 DECEMBER 10 2011
21 Patients pCR
Neoadjuvant CRTFor Stages II amp III Wait amp See
MRI Endoscopy amp Biopsy
Median Follow up =25 months
1 Patient LR Surgery
20 Pts Stages II amp III NAT pCR
Median Follow up =35 months
2 ndash Year DFS 91 2 ndash Year OAS 93
Neoadjuvant TherapyProblems with Current Practice
CRT 55 Weeks 6 wks TME
1 ndash 2 weeks 4-6 wks Adjuvant Cth
18 weeksbull Delayedbull Reducedbull Omitted
CRT TME Neodjuvant Chemoth
Neodjuvant Chemoth CRT TME
bull Total Neoadjuvant Therapy Paradigm
bull Better down-staging
bull Better pCR
bull Higher R0 Resection Rates
Adopted from Deborah Schragrsquos Presentation at 2015 ASCO Annual Meeting
Total Neoadjuvant ParadigmBrown University Study (CONTRE)
FOLFOX X 8 Courses CRT + Cape TME
Pathologic Grade
Total Number Stage II Stage III38 7 31
0 (Complete) 13 1 12
1 14 4 10
2 8 1 7
3 3 1 2
bull 35 Pts Completed Treatmentbull pCR = 33
Perez et al ASCO 2014 Abstract 3050
The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on DFS
The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on OAS
Slide 12
Near total neoadjuvant therapy
Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Trial Randomized Phase II ltbr gt
ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has better DFS not OS than 5FU after pre-op ChemoRT
Questions Total Neoadjuvant YesNoAdjuvant Cth YesNoLong versus Short Course
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
German CAOAROAIO-94 11 Years Update
Sauer R et al JCO 2012301926-33
Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
10 - Year RTh + S S P
LR 5 11 lt 00001
OAS 48 49 086
CCSD 17 22 004
Lancet Oncol 2011 12 575ndash82
CCSD Cumulative Incidence of Cancer Specific Death
Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
Lancet Oncol 2011 12 575ndash82
OAS Benefit
Neoadjuvant TherapyShort versus Long Radiation Therapy Course
Polish Trial Trans-Tasman Radiation
Oncology Group
bull Local Recurrencebull DFSbull Distant Recurrencebull OASbull Severe Late
Toxicity
EQUIVALENT
J Clin Oncol 2012 303827Br J Surg 2006 931215
Distal Tumors LC gt SC
LR = 0 12
Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
Gastrointest Cancer Res 149-56 copy2007 by International Society of Gastrointestinal Oncology
Neoadjuvant TherapyThe Use of Capecitabine
The Cancer Journal bull Volume 13 Number 3 MayJune 2007
EQUIVALENT
Neoadjuvant TherapyAdding Oxaliplatin
Curr Opin Oncol 2012 24441ndash447
bull ++ Toxicity amp -- Compliancebull Did not improve
1 R0 RR2 pCR3 Sphincter Preservation
The PETACC-6 RCTltbr gt
Neoadjuvant TherapyAdding Oxaliplatin
ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no major differences between armsltbr gt
Neoadjuvant TherapyAdding Oxaliplatin
Neoadjuvant TherapyAdding EGFR Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyAdding VEGF Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyIndications
1 T3 ndash T4 Lesions The only definitive indication2 cT3N0 Should be treated (understaging)3 Depth of Extramural Invasion
ndash T3 lesions (gt5 mm) ++ LNs involvement Higher Cancer Specific Mortality (54 Versus 85)
ndash Selection of high risk T3 for treatmentndash Approved outside US
4 T1 ndash 2 lesions with Positive Nodes5 Low situated lesions6 Invasion of mesorectal fasciaBr J Cancer 2000 821131wwwuptodatecom (September 2015)
Neoadjuvant TherapyTreatment Outcome
Complete Response cCRpCR
bull 15 ndash 30bull Small amp Less
Advanced Lesions
bull 10 ndash 12 Weeks
bull Involution to flat scar
bull DRE amp Endoscopybull Imaging
bull Endorectal USbull PET-CTbull MRI
bull ypT0N0
BIASED
NOT ACCEPTED
Martin R et al Surg Oncol Clin N Am 23 (2014) 113ndash125
Neoadjuvant TherapyTreatment Outcome in Relation to Pathological Outcome German Study
Grade Regression Fibrosis0 No All cells are viable
1 Minor lt 25 fibrosis
2 Moderate 26 ndash 50nFibrosis
3 Good gt50
4 Total No Viable Cells
Neoadjuvant TherapyTumor Regression Grade
Grade 10 ndash year DM
P 10 ndash Year DFS
P
0 - 1 3960005
6300082 - 3 293 736
4 105 895
J Clin Oncol 321554-1562 copy 2014
Neoadjuvant TherapyImpact of Pathological CR
British Journal of Surgery 2012 99 918ndash928
Can we Avoid Surgery
Can we Avoid Surgery
Can we Avoid Surgery
JCO VOLUME 29 1113097 NUMBER 35 1113097 DECEMBER 10 2011
21 Patients pCR
Neoadjuvant CRTFor Stages II amp III Wait amp See
MRI Endoscopy amp Biopsy
Median Follow up =25 months
1 Patient LR Surgery
20 Pts Stages II amp III NAT pCR
Median Follow up =35 months
2 ndash Year DFS 91 2 ndash Year OAS 93
Neoadjuvant TherapyProblems with Current Practice
CRT 55 Weeks 6 wks TME
1 ndash 2 weeks 4-6 wks Adjuvant Cth
18 weeksbull Delayedbull Reducedbull Omitted
CRT TME Neodjuvant Chemoth
Neodjuvant Chemoth CRT TME
bull Total Neoadjuvant Therapy Paradigm
bull Better down-staging
bull Better pCR
bull Higher R0 Resection Rates
Adopted from Deborah Schragrsquos Presentation at 2015 ASCO Annual Meeting
Total Neoadjuvant ParadigmBrown University Study (CONTRE)
FOLFOX X 8 Courses CRT + Cape TME
Pathologic Grade
Total Number Stage II Stage III38 7 31
0 (Complete) 13 1 12
1 14 4 10
2 8 1 7
3 3 1 2
bull 35 Pts Completed Treatmentbull pCR = 33
Perez et al ASCO 2014 Abstract 3050
The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on DFS
The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on OAS
Slide 12
Near total neoadjuvant therapy
Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Trial Randomized Phase II ltbr gt
ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has better DFS not OS than 5FU after pre-op ChemoRT
Questions Total Neoadjuvant YesNoAdjuvant Cth YesNoLong versus Short Course
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
10 - Year RTh + S S P
LR 5 11 lt 00001
OAS 48 49 086
CCSD 17 22 004
Lancet Oncol 2011 12 575ndash82
CCSD Cumulative Incidence of Cancer Specific Death
Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
Lancet Oncol 2011 12 575ndash82
OAS Benefit
Neoadjuvant TherapyShort versus Long Radiation Therapy Course
Polish Trial Trans-Tasman Radiation
Oncology Group
bull Local Recurrencebull DFSbull Distant Recurrencebull OASbull Severe Late
Toxicity
EQUIVALENT
J Clin Oncol 2012 303827Br J Surg 2006 931215
Distal Tumors LC gt SC
LR = 0 12
Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
Gastrointest Cancer Res 149-56 copy2007 by International Society of Gastrointestinal Oncology
Neoadjuvant TherapyThe Use of Capecitabine
The Cancer Journal bull Volume 13 Number 3 MayJune 2007
EQUIVALENT
Neoadjuvant TherapyAdding Oxaliplatin
Curr Opin Oncol 2012 24441ndash447
bull ++ Toxicity amp -- Compliancebull Did not improve
1 R0 RR2 pCR3 Sphincter Preservation
The PETACC-6 RCTltbr gt
Neoadjuvant TherapyAdding Oxaliplatin
ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no major differences between armsltbr gt
Neoadjuvant TherapyAdding Oxaliplatin
Neoadjuvant TherapyAdding EGFR Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyAdding VEGF Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyIndications
1 T3 ndash T4 Lesions The only definitive indication2 cT3N0 Should be treated (understaging)3 Depth of Extramural Invasion
ndash T3 lesions (gt5 mm) ++ LNs involvement Higher Cancer Specific Mortality (54 Versus 85)
ndash Selection of high risk T3 for treatmentndash Approved outside US
4 T1 ndash 2 lesions with Positive Nodes5 Low situated lesions6 Invasion of mesorectal fasciaBr J Cancer 2000 821131wwwuptodatecom (September 2015)
Neoadjuvant TherapyTreatment Outcome
Complete Response cCRpCR
bull 15 ndash 30bull Small amp Less
Advanced Lesions
bull 10 ndash 12 Weeks
bull Involution to flat scar
bull DRE amp Endoscopybull Imaging
bull Endorectal USbull PET-CTbull MRI
bull ypT0N0
BIASED
NOT ACCEPTED
Martin R et al Surg Oncol Clin N Am 23 (2014) 113ndash125
Neoadjuvant TherapyTreatment Outcome in Relation to Pathological Outcome German Study
Grade Regression Fibrosis0 No All cells are viable
1 Minor lt 25 fibrosis
2 Moderate 26 ndash 50nFibrosis
3 Good gt50
4 Total No Viable Cells
Neoadjuvant TherapyTumor Regression Grade
Grade 10 ndash year DM
P 10 ndash Year DFS
P
0 - 1 3960005
6300082 - 3 293 736
4 105 895
J Clin Oncol 321554-1562 copy 2014
Neoadjuvant TherapyImpact of Pathological CR
British Journal of Surgery 2012 99 918ndash928
Can we Avoid Surgery
Can we Avoid Surgery
Can we Avoid Surgery
JCO VOLUME 29 1113097 NUMBER 35 1113097 DECEMBER 10 2011
21 Patients pCR
Neoadjuvant CRTFor Stages II amp III Wait amp See
MRI Endoscopy amp Biopsy
Median Follow up =25 months
1 Patient LR Surgery
20 Pts Stages II amp III NAT pCR
Median Follow up =35 months
2 ndash Year DFS 91 2 ndash Year OAS 93
Neoadjuvant TherapyProblems with Current Practice
CRT 55 Weeks 6 wks TME
1 ndash 2 weeks 4-6 wks Adjuvant Cth
18 weeksbull Delayedbull Reducedbull Omitted
CRT TME Neodjuvant Chemoth
Neodjuvant Chemoth CRT TME
bull Total Neoadjuvant Therapy Paradigm
bull Better down-staging
bull Better pCR
bull Higher R0 Resection Rates
Adopted from Deborah Schragrsquos Presentation at 2015 ASCO Annual Meeting
Total Neoadjuvant ParadigmBrown University Study (CONTRE)
FOLFOX X 8 Courses CRT + Cape TME
Pathologic Grade
Total Number Stage II Stage III38 7 31
0 (Complete) 13 1 12
1 14 4 10
2 8 1 7
3 3 1 2
bull 35 Pts Completed Treatmentbull pCR = 33
Perez et al ASCO 2014 Abstract 3050
The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on DFS
The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on OAS
Slide 12
Near total neoadjuvant therapy
Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Trial Randomized Phase II ltbr gt
ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has better DFS not OS than 5FU after pre-op ChemoRT
Questions Total Neoadjuvant YesNoAdjuvant Cth YesNoLong versus Short Course
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
Lancet Oncol 2011 12 575ndash82
OAS Benefit
Neoadjuvant TherapyShort versus Long Radiation Therapy Course
Polish Trial Trans-Tasman Radiation
Oncology Group
bull Local Recurrencebull DFSbull Distant Recurrencebull OASbull Severe Late
Toxicity
EQUIVALENT
J Clin Oncol 2012 303827Br J Surg 2006 931215
Distal Tumors LC gt SC
LR = 0 12
Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
Gastrointest Cancer Res 149-56 copy2007 by International Society of Gastrointestinal Oncology
Neoadjuvant TherapyThe Use of Capecitabine
The Cancer Journal bull Volume 13 Number 3 MayJune 2007
EQUIVALENT
Neoadjuvant TherapyAdding Oxaliplatin
Curr Opin Oncol 2012 24441ndash447
bull ++ Toxicity amp -- Compliancebull Did not improve
1 R0 RR2 pCR3 Sphincter Preservation
The PETACC-6 RCTltbr gt
Neoadjuvant TherapyAdding Oxaliplatin
ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no major differences between armsltbr gt
Neoadjuvant TherapyAdding Oxaliplatin
Neoadjuvant TherapyAdding EGFR Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyAdding VEGF Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyIndications
1 T3 ndash T4 Lesions The only definitive indication2 cT3N0 Should be treated (understaging)3 Depth of Extramural Invasion
ndash T3 lesions (gt5 mm) ++ LNs involvement Higher Cancer Specific Mortality (54 Versus 85)
ndash Selection of high risk T3 for treatmentndash Approved outside US
4 T1 ndash 2 lesions with Positive Nodes5 Low situated lesions6 Invasion of mesorectal fasciaBr J Cancer 2000 821131wwwuptodatecom (September 2015)
Neoadjuvant TherapyTreatment Outcome
Complete Response cCRpCR
bull 15 ndash 30bull Small amp Less
Advanced Lesions
bull 10 ndash 12 Weeks
bull Involution to flat scar
bull DRE amp Endoscopybull Imaging
bull Endorectal USbull PET-CTbull MRI
bull ypT0N0
BIASED
NOT ACCEPTED
Martin R et al Surg Oncol Clin N Am 23 (2014) 113ndash125
Neoadjuvant TherapyTreatment Outcome in Relation to Pathological Outcome German Study
Grade Regression Fibrosis0 No All cells are viable
1 Minor lt 25 fibrosis
2 Moderate 26 ndash 50nFibrosis
3 Good gt50
4 Total No Viable Cells
Neoadjuvant TherapyTumor Regression Grade
Grade 10 ndash year DM
P 10 ndash Year DFS
P
0 - 1 3960005
6300082 - 3 293 736
4 105 895
J Clin Oncol 321554-1562 copy 2014
Neoadjuvant TherapyImpact of Pathological CR
British Journal of Surgery 2012 99 918ndash928
Can we Avoid Surgery
Can we Avoid Surgery
Can we Avoid Surgery
JCO VOLUME 29 1113097 NUMBER 35 1113097 DECEMBER 10 2011
21 Patients pCR
Neoadjuvant CRTFor Stages II amp III Wait amp See
MRI Endoscopy amp Biopsy
Median Follow up =25 months
1 Patient LR Surgery
20 Pts Stages II amp III NAT pCR
Median Follow up =35 months
2 ndash Year DFS 91 2 ndash Year OAS 93
Neoadjuvant TherapyProblems with Current Practice
CRT 55 Weeks 6 wks TME
1 ndash 2 weeks 4-6 wks Adjuvant Cth
18 weeksbull Delayedbull Reducedbull Omitted
CRT TME Neodjuvant Chemoth
Neodjuvant Chemoth CRT TME
bull Total Neoadjuvant Therapy Paradigm
bull Better down-staging
bull Better pCR
bull Higher R0 Resection Rates
Adopted from Deborah Schragrsquos Presentation at 2015 ASCO Annual Meeting
Total Neoadjuvant ParadigmBrown University Study (CONTRE)
FOLFOX X 8 Courses CRT + Cape TME
Pathologic Grade
Total Number Stage II Stage III38 7 31
0 (Complete) 13 1 12
1 14 4 10
2 8 1 7
3 3 1 2
bull 35 Pts Completed Treatmentbull pCR = 33
Perez et al ASCO 2014 Abstract 3050
The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on DFS
The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on OAS
Slide 12
Near total neoadjuvant therapy
Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Trial Randomized Phase II ltbr gt
ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has better DFS not OS than 5FU after pre-op ChemoRT
Questions Total Neoadjuvant YesNoAdjuvant Cth YesNoLong versus Short Course
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
Neoadjuvant TherapyShort versus Long Radiation Therapy Course
Polish Trial Trans-Tasman Radiation
Oncology Group
bull Local Recurrencebull DFSbull Distant Recurrencebull OASbull Severe Late
Toxicity
EQUIVALENT
J Clin Oncol 2012 303827Br J Surg 2006 931215
Distal Tumors LC gt SC
LR = 0 12
Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
Gastrointest Cancer Res 149-56 copy2007 by International Society of Gastrointestinal Oncology
Neoadjuvant TherapyThe Use of Capecitabine
The Cancer Journal bull Volume 13 Number 3 MayJune 2007
EQUIVALENT
Neoadjuvant TherapyAdding Oxaliplatin
Curr Opin Oncol 2012 24441ndash447
bull ++ Toxicity amp -- Compliancebull Did not improve
1 R0 RR2 pCR3 Sphincter Preservation
The PETACC-6 RCTltbr gt
Neoadjuvant TherapyAdding Oxaliplatin
ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no major differences between armsltbr gt
Neoadjuvant TherapyAdding Oxaliplatin
Neoadjuvant TherapyAdding EGFR Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyAdding VEGF Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyIndications
1 T3 ndash T4 Lesions The only definitive indication2 cT3N0 Should be treated (understaging)3 Depth of Extramural Invasion
ndash T3 lesions (gt5 mm) ++ LNs involvement Higher Cancer Specific Mortality (54 Versus 85)
ndash Selection of high risk T3 for treatmentndash Approved outside US
4 T1 ndash 2 lesions with Positive Nodes5 Low situated lesions6 Invasion of mesorectal fasciaBr J Cancer 2000 821131wwwuptodatecom (September 2015)
Neoadjuvant TherapyTreatment Outcome
Complete Response cCRpCR
bull 15 ndash 30bull Small amp Less
Advanced Lesions
bull 10 ndash 12 Weeks
bull Involution to flat scar
bull DRE amp Endoscopybull Imaging
bull Endorectal USbull PET-CTbull MRI
bull ypT0N0
BIASED
NOT ACCEPTED
Martin R et al Surg Oncol Clin N Am 23 (2014) 113ndash125
Neoadjuvant TherapyTreatment Outcome in Relation to Pathological Outcome German Study
Grade Regression Fibrosis0 No All cells are viable
1 Minor lt 25 fibrosis
2 Moderate 26 ndash 50nFibrosis
3 Good gt50
4 Total No Viable Cells
Neoadjuvant TherapyTumor Regression Grade
Grade 10 ndash year DM
P 10 ndash Year DFS
P
0 - 1 3960005
6300082 - 3 293 736
4 105 895
J Clin Oncol 321554-1562 copy 2014
Neoadjuvant TherapyImpact of Pathological CR
British Journal of Surgery 2012 99 918ndash928
Can we Avoid Surgery
Can we Avoid Surgery
Can we Avoid Surgery
JCO VOLUME 29 1113097 NUMBER 35 1113097 DECEMBER 10 2011
21 Patients pCR
Neoadjuvant CRTFor Stages II amp III Wait amp See
MRI Endoscopy amp Biopsy
Median Follow up =25 months
1 Patient LR Surgery
20 Pts Stages II amp III NAT pCR
Median Follow up =35 months
2 ndash Year DFS 91 2 ndash Year OAS 93
Neoadjuvant TherapyProblems with Current Practice
CRT 55 Weeks 6 wks TME
1 ndash 2 weeks 4-6 wks Adjuvant Cth
18 weeksbull Delayedbull Reducedbull Omitted
CRT TME Neodjuvant Chemoth
Neodjuvant Chemoth CRT TME
bull Total Neoadjuvant Therapy Paradigm
bull Better down-staging
bull Better pCR
bull Higher R0 Resection Rates
Adopted from Deborah Schragrsquos Presentation at 2015 ASCO Annual Meeting
Total Neoadjuvant ParadigmBrown University Study (CONTRE)
FOLFOX X 8 Courses CRT + Cape TME
Pathologic Grade
Total Number Stage II Stage III38 7 31
0 (Complete) 13 1 12
1 14 4 10
2 8 1 7
3 3 1 2
bull 35 Pts Completed Treatmentbull pCR = 33
Perez et al ASCO 2014 Abstract 3050
The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on DFS
The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on OAS
Slide 12
Near total neoadjuvant therapy
Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Trial Randomized Phase II ltbr gt
ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has better DFS not OS than 5FU after pre-op ChemoRT
Questions Total Neoadjuvant YesNoAdjuvant Cth YesNoLong versus Short Course
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
Gastrointest Cancer Res 149-56 copy2007 by International Society of Gastrointestinal Oncology
Neoadjuvant TherapyThe Use of Capecitabine
The Cancer Journal bull Volume 13 Number 3 MayJune 2007
EQUIVALENT
Neoadjuvant TherapyAdding Oxaliplatin
Curr Opin Oncol 2012 24441ndash447
bull ++ Toxicity amp -- Compliancebull Did not improve
1 R0 RR2 pCR3 Sphincter Preservation
The PETACC-6 RCTltbr gt
Neoadjuvant TherapyAdding Oxaliplatin
ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no major differences between armsltbr gt
Neoadjuvant TherapyAdding Oxaliplatin
Neoadjuvant TherapyAdding EGFR Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyAdding VEGF Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyIndications
1 T3 ndash T4 Lesions The only definitive indication2 cT3N0 Should be treated (understaging)3 Depth of Extramural Invasion
ndash T3 lesions (gt5 mm) ++ LNs involvement Higher Cancer Specific Mortality (54 Versus 85)
ndash Selection of high risk T3 for treatmentndash Approved outside US
4 T1 ndash 2 lesions with Positive Nodes5 Low situated lesions6 Invasion of mesorectal fasciaBr J Cancer 2000 821131wwwuptodatecom (September 2015)
Neoadjuvant TherapyTreatment Outcome
Complete Response cCRpCR
bull 15 ndash 30bull Small amp Less
Advanced Lesions
bull 10 ndash 12 Weeks
bull Involution to flat scar
bull DRE amp Endoscopybull Imaging
bull Endorectal USbull PET-CTbull MRI
bull ypT0N0
BIASED
NOT ACCEPTED
Martin R et al Surg Oncol Clin N Am 23 (2014) 113ndash125
Neoadjuvant TherapyTreatment Outcome in Relation to Pathological Outcome German Study
Grade Regression Fibrosis0 No All cells are viable
1 Minor lt 25 fibrosis
2 Moderate 26 ndash 50nFibrosis
3 Good gt50
4 Total No Viable Cells
Neoadjuvant TherapyTumor Regression Grade
Grade 10 ndash year DM
P 10 ndash Year DFS
P
0 - 1 3960005
6300082 - 3 293 736
4 105 895
J Clin Oncol 321554-1562 copy 2014
Neoadjuvant TherapyImpact of Pathological CR
British Journal of Surgery 2012 99 918ndash928
Can we Avoid Surgery
Can we Avoid Surgery
Can we Avoid Surgery
JCO VOLUME 29 1113097 NUMBER 35 1113097 DECEMBER 10 2011
21 Patients pCR
Neoadjuvant CRTFor Stages II amp III Wait amp See
MRI Endoscopy amp Biopsy
Median Follow up =25 months
1 Patient LR Surgery
20 Pts Stages II amp III NAT pCR
Median Follow up =35 months
2 ndash Year DFS 91 2 ndash Year OAS 93
Neoadjuvant TherapyProblems with Current Practice
CRT 55 Weeks 6 wks TME
1 ndash 2 weeks 4-6 wks Adjuvant Cth
18 weeksbull Delayedbull Reducedbull Omitted
CRT TME Neodjuvant Chemoth
Neodjuvant Chemoth CRT TME
bull Total Neoadjuvant Therapy Paradigm
bull Better down-staging
bull Better pCR
bull Higher R0 Resection Rates
Adopted from Deborah Schragrsquos Presentation at 2015 ASCO Annual Meeting
Total Neoadjuvant ParadigmBrown University Study (CONTRE)
FOLFOX X 8 Courses CRT + Cape TME
Pathologic Grade
Total Number Stage II Stage III38 7 31
0 (Complete) 13 1 12
1 14 4 10
2 8 1 7
3 3 1 2
bull 35 Pts Completed Treatmentbull pCR = 33
Perez et al ASCO 2014 Abstract 3050
The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on DFS
The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on OAS
Slide 12
Near total neoadjuvant therapy
Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Trial Randomized Phase II ltbr gt
ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has better DFS not OS than 5FU after pre-op ChemoRT
Questions Total Neoadjuvant YesNoAdjuvant Cth YesNoLong versus Short Course
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
Neoadjuvant TherapyThe Use of Capecitabine
The Cancer Journal bull Volume 13 Number 3 MayJune 2007
EQUIVALENT
Neoadjuvant TherapyAdding Oxaliplatin
Curr Opin Oncol 2012 24441ndash447
bull ++ Toxicity amp -- Compliancebull Did not improve
1 R0 RR2 pCR3 Sphincter Preservation
The PETACC-6 RCTltbr gt
Neoadjuvant TherapyAdding Oxaliplatin
ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no major differences between armsltbr gt
Neoadjuvant TherapyAdding Oxaliplatin
Neoadjuvant TherapyAdding EGFR Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyAdding VEGF Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyIndications
1 T3 ndash T4 Lesions The only definitive indication2 cT3N0 Should be treated (understaging)3 Depth of Extramural Invasion
ndash T3 lesions (gt5 mm) ++ LNs involvement Higher Cancer Specific Mortality (54 Versus 85)
ndash Selection of high risk T3 for treatmentndash Approved outside US
4 T1 ndash 2 lesions with Positive Nodes5 Low situated lesions6 Invasion of mesorectal fasciaBr J Cancer 2000 821131wwwuptodatecom (September 2015)
Neoadjuvant TherapyTreatment Outcome
Complete Response cCRpCR
bull 15 ndash 30bull Small amp Less
Advanced Lesions
bull 10 ndash 12 Weeks
bull Involution to flat scar
bull DRE amp Endoscopybull Imaging
bull Endorectal USbull PET-CTbull MRI
bull ypT0N0
BIASED
NOT ACCEPTED
Martin R et al Surg Oncol Clin N Am 23 (2014) 113ndash125
Neoadjuvant TherapyTreatment Outcome in Relation to Pathological Outcome German Study
Grade Regression Fibrosis0 No All cells are viable
1 Minor lt 25 fibrosis
2 Moderate 26 ndash 50nFibrosis
3 Good gt50
4 Total No Viable Cells
Neoadjuvant TherapyTumor Regression Grade
Grade 10 ndash year DM
P 10 ndash Year DFS
P
0 - 1 3960005
6300082 - 3 293 736
4 105 895
J Clin Oncol 321554-1562 copy 2014
Neoadjuvant TherapyImpact of Pathological CR
British Journal of Surgery 2012 99 918ndash928
Can we Avoid Surgery
Can we Avoid Surgery
Can we Avoid Surgery
JCO VOLUME 29 1113097 NUMBER 35 1113097 DECEMBER 10 2011
21 Patients pCR
Neoadjuvant CRTFor Stages II amp III Wait amp See
MRI Endoscopy amp Biopsy
Median Follow up =25 months
1 Patient LR Surgery
20 Pts Stages II amp III NAT pCR
Median Follow up =35 months
2 ndash Year DFS 91 2 ndash Year OAS 93
Neoadjuvant TherapyProblems with Current Practice
CRT 55 Weeks 6 wks TME
1 ndash 2 weeks 4-6 wks Adjuvant Cth
18 weeksbull Delayedbull Reducedbull Omitted
CRT TME Neodjuvant Chemoth
Neodjuvant Chemoth CRT TME
bull Total Neoadjuvant Therapy Paradigm
bull Better down-staging
bull Better pCR
bull Higher R0 Resection Rates
Adopted from Deborah Schragrsquos Presentation at 2015 ASCO Annual Meeting
Total Neoadjuvant ParadigmBrown University Study (CONTRE)
FOLFOX X 8 Courses CRT + Cape TME
Pathologic Grade
Total Number Stage II Stage III38 7 31
0 (Complete) 13 1 12
1 14 4 10
2 8 1 7
3 3 1 2
bull 35 Pts Completed Treatmentbull pCR = 33
Perez et al ASCO 2014 Abstract 3050
The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on DFS
The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on OAS
Slide 12
Near total neoadjuvant therapy
Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Trial Randomized Phase II ltbr gt
ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has better DFS not OS than 5FU after pre-op ChemoRT
Questions Total Neoadjuvant YesNoAdjuvant Cth YesNoLong versus Short Course
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
Neoadjuvant TherapyAdding Oxaliplatin
Curr Opin Oncol 2012 24441ndash447
bull ++ Toxicity amp -- Compliancebull Did not improve
1 R0 RR2 pCR3 Sphincter Preservation
The PETACC-6 RCTltbr gt
Neoadjuvant TherapyAdding Oxaliplatin
ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no major differences between armsltbr gt
Neoadjuvant TherapyAdding Oxaliplatin
Neoadjuvant TherapyAdding EGFR Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyAdding VEGF Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyIndications
1 T3 ndash T4 Lesions The only definitive indication2 cT3N0 Should be treated (understaging)3 Depth of Extramural Invasion
ndash T3 lesions (gt5 mm) ++ LNs involvement Higher Cancer Specific Mortality (54 Versus 85)
ndash Selection of high risk T3 for treatmentndash Approved outside US
4 T1 ndash 2 lesions with Positive Nodes5 Low situated lesions6 Invasion of mesorectal fasciaBr J Cancer 2000 821131wwwuptodatecom (September 2015)
Neoadjuvant TherapyTreatment Outcome
Complete Response cCRpCR
bull 15 ndash 30bull Small amp Less
Advanced Lesions
bull 10 ndash 12 Weeks
bull Involution to flat scar
bull DRE amp Endoscopybull Imaging
bull Endorectal USbull PET-CTbull MRI
bull ypT0N0
BIASED
NOT ACCEPTED
Martin R et al Surg Oncol Clin N Am 23 (2014) 113ndash125
Neoadjuvant TherapyTreatment Outcome in Relation to Pathological Outcome German Study
Grade Regression Fibrosis0 No All cells are viable
1 Minor lt 25 fibrosis
2 Moderate 26 ndash 50nFibrosis
3 Good gt50
4 Total No Viable Cells
Neoadjuvant TherapyTumor Regression Grade
Grade 10 ndash year DM
P 10 ndash Year DFS
P
0 - 1 3960005
6300082 - 3 293 736
4 105 895
J Clin Oncol 321554-1562 copy 2014
Neoadjuvant TherapyImpact of Pathological CR
British Journal of Surgery 2012 99 918ndash928
Can we Avoid Surgery
Can we Avoid Surgery
Can we Avoid Surgery
JCO VOLUME 29 1113097 NUMBER 35 1113097 DECEMBER 10 2011
21 Patients pCR
Neoadjuvant CRTFor Stages II amp III Wait amp See
MRI Endoscopy amp Biopsy
Median Follow up =25 months
1 Patient LR Surgery
20 Pts Stages II amp III NAT pCR
Median Follow up =35 months
2 ndash Year DFS 91 2 ndash Year OAS 93
Neoadjuvant TherapyProblems with Current Practice
CRT 55 Weeks 6 wks TME
1 ndash 2 weeks 4-6 wks Adjuvant Cth
18 weeksbull Delayedbull Reducedbull Omitted
CRT TME Neodjuvant Chemoth
Neodjuvant Chemoth CRT TME
bull Total Neoadjuvant Therapy Paradigm
bull Better down-staging
bull Better pCR
bull Higher R0 Resection Rates
Adopted from Deborah Schragrsquos Presentation at 2015 ASCO Annual Meeting
Total Neoadjuvant ParadigmBrown University Study (CONTRE)
FOLFOX X 8 Courses CRT + Cape TME
Pathologic Grade
Total Number Stage II Stage III38 7 31
0 (Complete) 13 1 12
1 14 4 10
2 8 1 7
3 3 1 2
bull 35 Pts Completed Treatmentbull pCR = 33
Perez et al ASCO 2014 Abstract 3050
The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on DFS
The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on OAS
Slide 12
Near total neoadjuvant therapy
Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Trial Randomized Phase II ltbr gt
ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has better DFS not OS than 5FU after pre-op ChemoRT
Questions Total Neoadjuvant YesNoAdjuvant Cth YesNoLong versus Short Course
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
The PETACC-6 RCTltbr gt
Neoadjuvant TherapyAdding Oxaliplatin
ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no major differences between armsltbr gt
Neoadjuvant TherapyAdding Oxaliplatin
Neoadjuvant TherapyAdding EGFR Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyAdding VEGF Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyIndications
1 T3 ndash T4 Lesions The only definitive indication2 cT3N0 Should be treated (understaging)3 Depth of Extramural Invasion
ndash T3 lesions (gt5 mm) ++ LNs involvement Higher Cancer Specific Mortality (54 Versus 85)
ndash Selection of high risk T3 for treatmentndash Approved outside US
4 T1 ndash 2 lesions with Positive Nodes5 Low situated lesions6 Invasion of mesorectal fasciaBr J Cancer 2000 821131wwwuptodatecom (September 2015)
Neoadjuvant TherapyTreatment Outcome
Complete Response cCRpCR
bull 15 ndash 30bull Small amp Less
Advanced Lesions
bull 10 ndash 12 Weeks
bull Involution to flat scar
bull DRE amp Endoscopybull Imaging
bull Endorectal USbull PET-CTbull MRI
bull ypT0N0
BIASED
NOT ACCEPTED
Martin R et al Surg Oncol Clin N Am 23 (2014) 113ndash125
Neoadjuvant TherapyTreatment Outcome in Relation to Pathological Outcome German Study
Grade Regression Fibrosis0 No All cells are viable
1 Minor lt 25 fibrosis
2 Moderate 26 ndash 50nFibrosis
3 Good gt50
4 Total No Viable Cells
Neoadjuvant TherapyTumor Regression Grade
Grade 10 ndash year DM
P 10 ndash Year DFS
P
0 - 1 3960005
6300082 - 3 293 736
4 105 895
J Clin Oncol 321554-1562 copy 2014
Neoadjuvant TherapyImpact of Pathological CR
British Journal of Surgery 2012 99 918ndash928
Can we Avoid Surgery
Can we Avoid Surgery
Can we Avoid Surgery
JCO VOLUME 29 1113097 NUMBER 35 1113097 DECEMBER 10 2011
21 Patients pCR
Neoadjuvant CRTFor Stages II amp III Wait amp See
MRI Endoscopy amp Biopsy
Median Follow up =25 months
1 Patient LR Surgery
20 Pts Stages II amp III NAT pCR
Median Follow up =35 months
2 ndash Year DFS 91 2 ndash Year OAS 93
Neoadjuvant TherapyProblems with Current Practice
CRT 55 Weeks 6 wks TME
1 ndash 2 weeks 4-6 wks Adjuvant Cth
18 weeksbull Delayedbull Reducedbull Omitted
CRT TME Neodjuvant Chemoth
Neodjuvant Chemoth CRT TME
bull Total Neoadjuvant Therapy Paradigm
bull Better down-staging
bull Better pCR
bull Higher R0 Resection Rates
Adopted from Deborah Schragrsquos Presentation at 2015 ASCO Annual Meeting
Total Neoadjuvant ParadigmBrown University Study (CONTRE)
FOLFOX X 8 Courses CRT + Cape TME
Pathologic Grade
Total Number Stage II Stage III38 7 31
0 (Complete) 13 1 12
1 14 4 10
2 8 1 7
3 3 1 2
bull 35 Pts Completed Treatmentbull pCR = 33
Perez et al ASCO 2014 Abstract 3050
The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on DFS
The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on OAS
Slide 12
Near total neoadjuvant therapy
Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Trial Randomized Phase II ltbr gt
ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has better DFS not OS than 5FU after pre-op ChemoRT
Questions Total Neoadjuvant YesNoAdjuvant Cth YesNoLong versus Short Course
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no major differences between armsltbr gt
Neoadjuvant TherapyAdding Oxaliplatin
Neoadjuvant TherapyAdding EGFR Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyAdding VEGF Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyIndications
1 T3 ndash T4 Lesions The only definitive indication2 cT3N0 Should be treated (understaging)3 Depth of Extramural Invasion
ndash T3 lesions (gt5 mm) ++ LNs involvement Higher Cancer Specific Mortality (54 Versus 85)
ndash Selection of high risk T3 for treatmentndash Approved outside US
4 T1 ndash 2 lesions with Positive Nodes5 Low situated lesions6 Invasion of mesorectal fasciaBr J Cancer 2000 821131wwwuptodatecom (September 2015)
Neoadjuvant TherapyTreatment Outcome
Complete Response cCRpCR
bull 15 ndash 30bull Small amp Less
Advanced Lesions
bull 10 ndash 12 Weeks
bull Involution to flat scar
bull DRE amp Endoscopybull Imaging
bull Endorectal USbull PET-CTbull MRI
bull ypT0N0
BIASED
NOT ACCEPTED
Martin R et al Surg Oncol Clin N Am 23 (2014) 113ndash125
Neoadjuvant TherapyTreatment Outcome in Relation to Pathological Outcome German Study
Grade Regression Fibrosis0 No All cells are viable
1 Minor lt 25 fibrosis
2 Moderate 26 ndash 50nFibrosis
3 Good gt50
4 Total No Viable Cells
Neoadjuvant TherapyTumor Regression Grade
Grade 10 ndash year DM
P 10 ndash Year DFS
P
0 - 1 3960005
6300082 - 3 293 736
4 105 895
J Clin Oncol 321554-1562 copy 2014
Neoadjuvant TherapyImpact of Pathological CR
British Journal of Surgery 2012 99 918ndash928
Can we Avoid Surgery
Can we Avoid Surgery
Can we Avoid Surgery
JCO VOLUME 29 1113097 NUMBER 35 1113097 DECEMBER 10 2011
21 Patients pCR
Neoadjuvant CRTFor Stages II amp III Wait amp See
MRI Endoscopy amp Biopsy
Median Follow up =25 months
1 Patient LR Surgery
20 Pts Stages II amp III NAT pCR
Median Follow up =35 months
2 ndash Year DFS 91 2 ndash Year OAS 93
Neoadjuvant TherapyProblems with Current Practice
CRT 55 Weeks 6 wks TME
1 ndash 2 weeks 4-6 wks Adjuvant Cth
18 weeksbull Delayedbull Reducedbull Omitted
CRT TME Neodjuvant Chemoth
Neodjuvant Chemoth CRT TME
bull Total Neoadjuvant Therapy Paradigm
bull Better down-staging
bull Better pCR
bull Higher R0 Resection Rates
Adopted from Deborah Schragrsquos Presentation at 2015 ASCO Annual Meeting
Total Neoadjuvant ParadigmBrown University Study (CONTRE)
FOLFOX X 8 Courses CRT + Cape TME
Pathologic Grade
Total Number Stage II Stage III38 7 31
0 (Complete) 13 1 12
1 14 4 10
2 8 1 7
3 3 1 2
bull 35 Pts Completed Treatmentbull pCR = 33
Perez et al ASCO 2014 Abstract 3050
The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on DFS
The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on OAS
Slide 12
Near total neoadjuvant therapy
Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Trial Randomized Phase II ltbr gt
ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has better DFS not OS than 5FU after pre-op ChemoRT
Questions Total Neoadjuvant YesNoAdjuvant Cth YesNoLong versus Short Course
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
Neoadjuvant TherapyAdding EGFR Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyAdding VEGF Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyIndications
1 T3 ndash T4 Lesions The only definitive indication2 cT3N0 Should be treated (understaging)3 Depth of Extramural Invasion
ndash T3 lesions (gt5 mm) ++ LNs involvement Higher Cancer Specific Mortality (54 Versus 85)
ndash Selection of high risk T3 for treatmentndash Approved outside US
4 T1 ndash 2 lesions with Positive Nodes5 Low situated lesions6 Invasion of mesorectal fasciaBr J Cancer 2000 821131wwwuptodatecom (September 2015)
Neoadjuvant TherapyTreatment Outcome
Complete Response cCRpCR
bull 15 ndash 30bull Small amp Less
Advanced Lesions
bull 10 ndash 12 Weeks
bull Involution to flat scar
bull DRE amp Endoscopybull Imaging
bull Endorectal USbull PET-CTbull MRI
bull ypT0N0
BIASED
NOT ACCEPTED
Martin R et al Surg Oncol Clin N Am 23 (2014) 113ndash125
Neoadjuvant TherapyTreatment Outcome in Relation to Pathological Outcome German Study
Grade Regression Fibrosis0 No All cells are viable
1 Minor lt 25 fibrosis
2 Moderate 26 ndash 50nFibrosis
3 Good gt50
4 Total No Viable Cells
Neoadjuvant TherapyTumor Regression Grade
Grade 10 ndash year DM
P 10 ndash Year DFS
P
0 - 1 3960005
6300082 - 3 293 736
4 105 895
J Clin Oncol 321554-1562 copy 2014
Neoadjuvant TherapyImpact of Pathological CR
British Journal of Surgery 2012 99 918ndash928
Can we Avoid Surgery
Can we Avoid Surgery
Can we Avoid Surgery
JCO VOLUME 29 1113097 NUMBER 35 1113097 DECEMBER 10 2011
21 Patients pCR
Neoadjuvant CRTFor Stages II amp III Wait amp See
MRI Endoscopy amp Biopsy
Median Follow up =25 months
1 Patient LR Surgery
20 Pts Stages II amp III NAT pCR
Median Follow up =35 months
2 ndash Year DFS 91 2 ndash Year OAS 93
Neoadjuvant TherapyProblems with Current Practice
CRT 55 Weeks 6 wks TME
1 ndash 2 weeks 4-6 wks Adjuvant Cth
18 weeksbull Delayedbull Reducedbull Omitted
CRT TME Neodjuvant Chemoth
Neodjuvant Chemoth CRT TME
bull Total Neoadjuvant Therapy Paradigm
bull Better down-staging
bull Better pCR
bull Higher R0 Resection Rates
Adopted from Deborah Schragrsquos Presentation at 2015 ASCO Annual Meeting
Total Neoadjuvant ParadigmBrown University Study (CONTRE)
FOLFOX X 8 Courses CRT + Cape TME
Pathologic Grade
Total Number Stage II Stage III38 7 31
0 (Complete) 13 1 12
1 14 4 10
2 8 1 7
3 3 1 2
bull 35 Pts Completed Treatmentbull pCR = 33
Perez et al ASCO 2014 Abstract 3050
The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on DFS
The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on OAS
Slide 12
Near total neoadjuvant therapy
Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Trial Randomized Phase II ltbr gt
ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has better DFS not OS than 5FU after pre-op ChemoRT
Questions Total Neoadjuvant YesNoAdjuvant Cth YesNoLong versus Short Course
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
Neoadjuvant TherapyAdding VEGF Inhibition
Curr Opin Oncol 2012 24441ndash447
Neoadjuvant TherapyIndications
1 T3 ndash T4 Lesions The only definitive indication2 cT3N0 Should be treated (understaging)3 Depth of Extramural Invasion
ndash T3 lesions (gt5 mm) ++ LNs involvement Higher Cancer Specific Mortality (54 Versus 85)
ndash Selection of high risk T3 for treatmentndash Approved outside US
4 T1 ndash 2 lesions with Positive Nodes5 Low situated lesions6 Invasion of mesorectal fasciaBr J Cancer 2000 821131wwwuptodatecom (September 2015)
Neoadjuvant TherapyTreatment Outcome
Complete Response cCRpCR
bull 15 ndash 30bull Small amp Less
Advanced Lesions
bull 10 ndash 12 Weeks
bull Involution to flat scar
bull DRE amp Endoscopybull Imaging
bull Endorectal USbull PET-CTbull MRI
bull ypT0N0
BIASED
NOT ACCEPTED
Martin R et al Surg Oncol Clin N Am 23 (2014) 113ndash125
Neoadjuvant TherapyTreatment Outcome in Relation to Pathological Outcome German Study
Grade Regression Fibrosis0 No All cells are viable
1 Minor lt 25 fibrosis
2 Moderate 26 ndash 50nFibrosis
3 Good gt50
4 Total No Viable Cells
Neoadjuvant TherapyTumor Regression Grade
Grade 10 ndash year DM
P 10 ndash Year DFS
P
0 - 1 3960005
6300082 - 3 293 736
4 105 895
J Clin Oncol 321554-1562 copy 2014
Neoadjuvant TherapyImpact of Pathological CR
British Journal of Surgery 2012 99 918ndash928
Can we Avoid Surgery
Can we Avoid Surgery
Can we Avoid Surgery
JCO VOLUME 29 1113097 NUMBER 35 1113097 DECEMBER 10 2011
21 Patients pCR
Neoadjuvant CRTFor Stages II amp III Wait amp See
MRI Endoscopy amp Biopsy
Median Follow up =25 months
1 Patient LR Surgery
20 Pts Stages II amp III NAT pCR
Median Follow up =35 months
2 ndash Year DFS 91 2 ndash Year OAS 93
Neoadjuvant TherapyProblems with Current Practice
CRT 55 Weeks 6 wks TME
1 ndash 2 weeks 4-6 wks Adjuvant Cth
18 weeksbull Delayedbull Reducedbull Omitted
CRT TME Neodjuvant Chemoth
Neodjuvant Chemoth CRT TME
bull Total Neoadjuvant Therapy Paradigm
bull Better down-staging
bull Better pCR
bull Higher R0 Resection Rates
Adopted from Deborah Schragrsquos Presentation at 2015 ASCO Annual Meeting
Total Neoadjuvant ParadigmBrown University Study (CONTRE)
FOLFOX X 8 Courses CRT + Cape TME
Pathologic Grade
Total Number Stage II Stage III38 7 31
0 (Complete) 13 1 12
1 14 4 10
2 8 1 7
3 3 1 2
bull 35 Pts Completed Treatmentbull pCR = 33
Perez et al ASCO 2014 Abstract 3050
The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on DFS
The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on OAS
Slide 12
Near total neoadjuvant therapy
Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Trial Randomized Phase II ltbr gt
ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has better DFS not OS than 5FU after pre-op ChemoRT
Questions Total Neoadjuvant YesNoAdjuvant Cth YesNoLong versus Short Course
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
Neoadjuvant TherapyIndications
1 T3 ndash T4 Lesions The only definitive indication2 cT3N0 Should be treated (understaging)3 Depth of Extramural Invasion
ndash T3 lesions (gt5 mm) ++ LNs involvement Higher Cancer Specific Mortality (54 Versus 85)
ndash Selection of high risk T3 for treatmentndash Approved outside US
4 T1 ndash 2 lesions with Positive Nodes5 Low situated lesions6 Invasion of mesorectal fasciaBr J Cancer 2000 821131wwwuptodatecom (September 2015)
Neoadjuvant TherapyTreatment Outcome
Complete Response cCRpCR
bull 15 ndash 30bull Small amp Less
Advanced Lesions
bull 10 ndash 12 Weeks
bull Involution to flat scar
bull DRE amp Endoscopybull Imaging
bull Endorectal USbull PET-CTbull MRI
bull ypT0N0
BIASED
NOT ACCEPTED
Martin R et al Surg Oncol Clin N Am 23 (2014) 113ndash125
Neoadjuvant TherapyTreatment Outcome in Relation to Pathological Outcome German Study
Grade Regression Fibrosis0 No All cells are viable
1 Minor lt 25 fibrosis
2 Moderate 26 ndash 50nFibrosis
3 Good gt50
4 Total No Viable Cells
Neoadjuvant TherapyTumor Regression Grade
Grade 10 ndash year DM
P 10 ndash Year DFS
P
0 - 1 3960005
6300082 - 3 293 736
4 105 895
J Clin Oncol 321554-1562 copy 2014
Neoadjuvant TherapyImpact of Pathological CR
British Journal of Surgery 2012 99 918ndash928
Can we Avoid Surgery
Can we Avoid Surgery
Can we Avoid Surgery
JCO VOLUME 29 1113097 NUMBER 35 1113097 DECEMBER 10 2011
21 Patients pCR
Neoadjuvant CRTFor Stages II amp III Wait amp See
MRI Endoscopy amp Biopsy
Median Follow up =25 months
1 Patient LR Surgery
20 Pts Stages II amp III NAT pCR
Median Follow up =35 months
2 ndash Year DFS 91 2 ndash Year OAS 93
Neoadjuvant TherapyProblems with Current Practice
CRT 55 Weeks 6 wks TME
1 ndash 2 weeks 4-6 wks Adjuvant Cth
18 weeksbull Delayedbull Reducedbull Omitted
CRT TME Neodjuvant Chemoth
Neodjuvant Chemoth CRT TME
bull Total Neoadjuvant Therapy Paradigm
bull Better down-staging
bull Better pCR
bull Higher R0 Resection Rates
Adopted from Deborah Schragrsquos Presentation at 2015 ASCO Annual Meeting
Total Neoadjuvant ParadigmBrown University Study (CONTRE)
FOLFOX X 8 Courses CRT + Cape TME
Pathologic Grade
Total Number Stage II Stage III38 7 31
0 (Complete) 13 1 12
1 14 4 10
2 8 1 7
3 3 1 2
bull 35 Pts Completed Treatmentbull pCR = 33
Perez et al ASCO 2014 Abstract 3050
The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on DFS
The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on OAS
Slide 12
Near total neoadjuvant therapy
Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Trial Randomized Phase II ltbr gt
ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has better DFS not OS than 5FU after pre-op ChemoRT
Questions Total Neoadjuvant YesNoAdjuvant Cth YesNoLong versus Short Course
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
Neoadjuvant TherapyTreatment Outcome
Complete Response cCRpCR
bull 15 ndash 30bull Small amp Less
Advanced Lesions
bull 10 ndash 12 Weeks
bull Involution to flat scar
bull DRE amp Endoscopybull Imaging
bull Endorectal USbull PET-CTbull MRI
bull ypT0N0
BIASED
NOT ACCEPTED
Martin R et al Surg Oncol Clin N Am 23 (2014) 113ndash125
Neoadjuvant TherapyTreatment Outcome in Relation to Pathological Outcome German Study
Grade Regression Fibrosis0 No All cells are viable
1 Minor lt 25 fibrosis
2 Moderate 26 ndash 50nFibrosis
3 Good gt50
4 Total No Viable Cells
Neoadjuvant TherapyTumor Regression Grade
Grade 10 ndash year DM
P 10 ndash Year DFS
P
0 - 1 3960005
6300082 - 3 293 736
4 105 895
J Clin Oncol 321554-1562 copy 2014
Neoadjuvant TherapyImpact of Pathological CR
British Journal of Surgery 2012 99 918ndash928
Can we Avoid Surgery
Can we Avoid Surgery
Can we Avoid Surgery
JCO VOLUME 29 1113097 NUMBER 35 1113097 DECEMBER 10 2011
21 Patients pCR
Neoadjuvant CRTFor Stages II amp III Wait amp See
MRI Endoscopy amp Biopsy
Median Follow up =25 months
1 Patient LR Surgery
20 Pts Stages II amp III NAT pCR
Median Follow up =35 months
2 ndash Year DFS 91 2 ndash Year OAS 93
Neoadjuvant TherapyProblems with Current Practice
CRT 55 Weeks 6 wks TME
1 ndash 2 weeks 4-6 wks Adjuvant Cth
18 weeksbull Delayedbull Reducedbull Omitted
CRT TME Neodjuvant Chemoth
Neodjuvant Chemoth CRT TME
bull Total Neoadjuvant Therapy Paradigm
bull Better down-staging
bull Better pCR
bull Higher R0 Resection Rates
Adopted from Deborah Schragrsquos Presentation at 2015 ASCO Annual Meeting
Total Neoadjuvant ParadigmBrown University Study (CONTRE)
FOLFOX X 8 Courses CRT + Cape TME
Pathologic Grade
Total Number Stage II Stage III38 7 31
0 (Complete) 13 1 12
1 14 4 10
2 8 1 7
3 3 1 2
bull 35 Pts Completed Treatmentbull pCR = 33
Perez et al ASCO 2014 Abstract 3050
The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on DFS
The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on OAS
Slide 12
Near total neoadjuvant therapy
Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Trial Randomized Phase II ltbr gt
ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has better DFS not OS than 5FU after pre-op ChemoRT
Questions Total Neoadjuvant YesNoAdjuvant Cth YesNoLong versus Short Course
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
Neoadjuvant TherapyTreatment Outcome in Relation to Pathological Outcome German Study
Grade Regression Fibrosis0 No All cells are viable
1 Minor lt 25 fibrosis
2 Moderate 26 ndash 50nFibrosis
3 Good gt50
4 Total No Viable Cells
Neoadjuvant TherapyTumor Regression Grade
Grade 10 ndash year DM
P 10 ndash Year DFS
P
0 - 1 3960005
6300082 - 3 293 736
4 105 895
J Clin Oncol 321554-1562 copy 2014
Neoadjuvant TherapyImpact of Pathological CR
British Journal of Surgery 2012 99 918ndash928
Can we Avoid Surgery
Can we Avoid Surgery
Can we Avoid Surgery
JCO VOLUME 29 1113097 NUMBER 35 1113097 DECEMBER 10 2011
21 Patients pCR
Neoadjuvant CRTFor Stages II amp III Wait amp See
MRI Endoscopy amp Biopsy
Median Follow up =25 months
1 Patient LR Surgery
20 Pts Stages II amp III NAT pCR
Median Follow up =35 months
2 ndash Year DFS 91 2 ndash Year OAS 93
Neoadjuvant TherapyProblems with Current Practice
CRT 55 Weeks 6 wks TME
1 ndash 2 weeks 4-6 wks Adjuvant Cth
18 weeksbull Delayedbull Reducedbull Omitted
CRT TME Neodjuvant Chemoth
Neodjuvant Chemoth CRT TME
bull Total Neoadjuvant Therapy Paradigm
bull Better down-staging
bull Better pCR
bull Higher R0 Resection Rates
Adopted from Deborah Schragrsquos Presentation at 2015 ASCO Annual Meeting
Total Neoadjuvant ParadigmBrown University Study (CONTRE)
FOLFOX X 8 Courses CRT + Cape TME
Pathologic Grade
Total Number Stage II Stage III38 7 31
0 (Complete) 13 1 12
1 14 4 10
2 8 1 7
3 3 1 2
bull 35 Pts Completed Treatmentbull pCR = 33
Perez et al ASCO 2014 Abstract 3050
The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on DFS
The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on OAS
Slide 12
Near total neoadjuvant therapy
Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Trial Randomized Phase II ltbr gt
ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has better DFS not OS than 5FU after pre-op ChemoRT
Questions Total Neoadjuvant YesNoAdjuvant Cth YesNoLong versus Short Course
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
Grade Regression Fibrosis0 No All cells are viable
1 Minor lt 25 fibrosis
2 Moderate 26 ndash 50nFibrosis
3 Good gt50
4 Total No Viable Cells
Neoadjuvant TherapyTumor Regression Grade
Grade 10 ndash year DM
P 10 ndash Year DFS
P
0 - 1 3960005
6300082 - 3 293 736
4 105 895
J Clin Oncol 321554-1562 copy 2014
Neoadjuvant TherapyImpact of Pathological CR
British Journal of Surgery 2012 99 918ndash928
Can we Avoid Surgery
Can we Avoid Surgery
Can we Avoid Surgery
JCO VOLUME 29 1113097 NUMBER 35 1113097 DECEMBER 10 2011
21 Patients pCR
Neoadjuvant CRTFor Stages II amp III Wait amp See
MRI Endoscopy amp Biopsy
Median Follow up =25 months
1 Patient LR Surgery
20 Pts Stages II amp III NAT pCR
Median Follow up =35 months
2 ndash Year DFS 91 2 ndash Year OAS 93
Neoadjuvant TherapyProblems with Current Practice
CRT 55 Weeks 6 wks TME
1 ndash 2 weeks 4-6 wks Adjuvant Cth
18 weeksbull Delayedbull Reducedbull Omitted
CRT TME Neodjuvant Chemoth
Neodjuvant Chemoth CRT TME
bull Total Neoadjuvant Therapy Paradigm
bull Better down-staging
bull Better pCR
bull Higher R0 Resection Rates
Adopted from Deborah Schragrsquos Presentation at 2015 ASCO Annual Meeting
Total Neoadjuvant ParadigmBrown University Study (CONTRE)
FOLFOX X 8 Courses CRT + Cape TME
Pathologic Grade
Total Number Stage II Stage III38 7 31
0 (Complete) 13 1 12
1 14 4 10
2 8 1 7
3 3 1 2
bull 35 Pts Completed Treatmentbull pCR = 33
Perez et al ASCO 2014 Abstract 3050
The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on DFS
The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on OAS
Slide 12
Near total neoadjuvant therapy
Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Trial Randomized Phase II ltbr gt
ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has better DFS not OS than 5FU after pre-op ChemoRT
Questions Total Neoadjuvant YesNoAdjuvant Cth YesNoLong versus Short Course
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
Neoadjuvant TherapyImpact of Pathological CR
British Journal of Surgery 2012 99 918ndash928
Can we Avoid Surgery
Can we Avoid Surgery
Can we Avoid Surgery
JCO VOLUME 29 1113097 NUMBER 35 1113097 DECEMBER 10 2011
21 Patients pCR
Neoadjuvant CRTFor Stages II amp III Wait amp See
MRI Endoscopy amp Biopsy
Median Follow up =25 months
1 Patient LR Surgery
20 Pts Stages II amp III NAT pCR
Median Follow up =35 months
2 ndash Year DFS 91 2 ndash Year OAS 93
Neoadjuvant TherapyProblems with Current Practice
CRT 55 Weeks 6 wks TME
1 ndash 2 weeks 4-6 wks Adjuvant Cth
18 weeksbull Delayedbull Reducedbull Omitted
CRT TME Neodjuvant Chemoth
Neodjuvant Chemoth CRT TME
bull Total Neoadjuvant Therapy Paradigm
bull Better down-staging
bull Better pCR
bull Higher R0 Resection Rates
Adopted from Deborah Schragrsquos Presentation at 2015 ASCO Annual Meeting
Total Neoadjuvant ParadigmBrown University Study (CONTRE)
FOLFOX X 8 Courses CRT + Cape TME
Pathologic Grade
Total Number Stage II Stage III38 7 31
0 (Complete) 13 1 12
1 14 4 10
2 8 1 7
3 3 1 2
bull 35 Pts Completed Treatmentbull pCR = 33
Perez et al ASCO 2014 Abstract 3050
The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on DFS
The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on OAS
Slide 12
Near total neoadjuvant therapy
Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Trial Randomized Phase II ltbr gt
ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has better DFS not OS than 5FU after pre-op ChemoRT
Questions Total Neoadjuvant YesNoAdjuvant Cth YesNoLong versus Short Course
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
Can we Avoid Surgery
Can we Avoid Surgery
JCO VOLUME 29 1113097 NUMBER 35 1113097 DECEMBER 10 2011
21 Patients pCR
Neoadjuvant CRTFor Stages II amp III Wait amp See
MRI Endoscopy amp Biopsy
Median Follow up =25 months
1 Patient LR Surgery
20 Pts Stages II amp III NAT pCR
Median Follow up =35 months
2 ndash Year DFS 91 2 ndash Year OAS 93
Neoadjuvant TherapyProblems with Current Practice
CRT 55 Weeks 6 wks TME
1 ndash 2 weeks 4-6 wks Adjuvant Cth
18 weeksbull Delayedbull Reducedbull Omitted
CRT TME Neodjuvant Chemoth
Neodjuvant Chemoth CRT TME
bull Total Neoadjuvant Therapy Paradigm
bull Better down-staging
bull Better pCR
bull Higher R0 Resection Rates
Adopted from Deborah Schragrsquos Presentation at 2015 ASCO Annual Meeting
Total Neoadjuvant ParadigmBrown University Study (CONTRE)
FOLFOX X 8 Courses CRT + Cape TME
Pathologic Grade
Total Number Stage II Stage III38 7 31
0 (Complete) 13 1 12
1 14 4 10
2 8 1 7
3 3 1 2
bull 35 Pts Completed Treatmentbull pCR = 33
Perez et al ASCO 2014 Abstract 3050
The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on DFS
The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on OAS
Slide 12
Near total neoadjuvant therapy
Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Trial Randomized Phase II ltbr gt
ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has better DFS not OS than 5FU after pre-op ChemoRT
Questions Total Neoadjuvant YesNoAdjuvant Cth YesNoLong versus Short Course
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
Can we Avoid Surgery
JCO VOLUME 29 1113097 NUMBER 35 1113097 DECEMBER 10 2011
21 Patients pCR
Neoadjuvant CRTFor Stages II amp III Wait amp See
MRI Endoscopy amp Biopsy
Median Follow up =25 months
1 Patient LR Surgery
20 Pts Stages II amp III NAT pCR
Median Follow up =35 months
2 ndash Year DFS 91 2 ndash Year OAS 93
Neoadjuvant TherapyProblems with Current Practice
CRT 55 Weeks 6 wks TME
1 ndash 2 weeks 4-6 wks Adjuvant Cth
18 weeksbull Delayedbull Reducedbull Omitted
CRT TME Neodjuvant Chemoth
Neodjuvant Chemoth CRT TME
bull Total Neoadjuvant Therapy Paradigm
bull Better down-staging
bull Better pCR
bull Higher R0 Resection Rates
Adopted from Deborah Schragrsquos Presentation at 2015 ASCO Annual Meeting
Total Neoadjuvant ParadigmBrown University Study (CONTRE)
FOLFOX X 8 Courses CRT + Cape TME
Pathologic Grade
Total Number Stage II Stage III38 7 31
0 (Complete) 13 1 12
1 14 4 10
2 8 1 7
3 3 1 2
bull 35 Pts Completed Treatmentbull pCR = 33
Perez et al ASCO 2014 Abstract 3050
The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on DFS
The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on OAS
Slide 12
Near total neoadjuvant therapy
Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Trial Randomized Phase II ltbr gt
ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has better DFS not OS than 5FU after pre-op ChemoRT
Questions Total Neoadjuvant YesNoAdjuvant Cth YesNoLong versus Short Course
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
Neoadjuvant TherapyProblems with Current Practice
CRT 55 Weeks 6 wks TME
1 ndash 2 weeks 4-6 wks Adjuvant Cth
18 weeksbull Delayedbull Reducedbull Omitted
CRT TME Neodjuvant Chemoth
Neodjuvant Chemoth CRT TME
bull Total Neoadjuvant Therapy Paradigm
bull Better down-staging
bull Better pCR
bull Higher R0 Resection Rates
Adopted from Deborah Schragrsquos Presentation at 2015 ASCO Annual Meeting
Total Neoadjuvant ParadigmBrown University Study (CONTRE)
FOLFOX X 8 Courses CRT + Cape TME
Pathologic Grade
Total Number Stage II Stage III38 7 31
0 (Complete) 13 1 12
1 14 4 10
2 8 1 7
3 3 1 2
bull 35 Pts Completed Treatmentbull pCR = 33
Perez et al ASCO 2014 Abstract 3050
The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on DFS
The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on OAS
Slide 12
Near total neoadjuvant therapy
Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Trial Randomized Phase II ltbr gt
ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has better DFS not OS than 5FU after pre-op ChemoRT
Questions Total Neoadjuvant YesNoAdjuvant Cth YesNoLong versus Short Course
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
Total Neoadjuvant ParadigmBrown University Study (CONTRE)
FOLFOX X 8 Courses CRT + Cape TME
Pathologic Grade
Total Number Stage II Stage III38 7 31
0 (Complete) 13 1 12
1 14 4 10
2 8 1 7
3 3 1 2
bull 35 Pts Completed Treatmentbull pCR = 33
Perez et al ASCO 2014 Abstract 3050
The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on DFS
The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on OAS
Slide 12
Near total neoadjuvant therapy
Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Trial Randomized Phase II ltbr gt
ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has better DFS not OS than 5FU after pre-op ChemoRT
Questions Total Neoadjuvant YesNoAdjuvant Cth YesNoLong versus Short Course
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on DFS
The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on OAS
Slide 12
Near total neoadjuvant therapy
Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Trial Randomized Phase II ltbr gt
ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has better DFS not OS than 5FU after pre-op ChemoRT
Questions Total Neoadjuvant YesNoAdjuvant Cth YesNoLong versus Short Course
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatment Benefit
Impact of Adjuvant Therapy on OAS
Slide 12
Near total neoadjuvant therapy
Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Trial Randomized Phase II ltbr gt
ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has better DFS not OS than 5FU after pre-op ChemoRT
Questions Total Neoadjuvant YesNoAdjuvant Cth YesNoLong versus Short Course
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
Slide 12
Near total neoadjuvant therapy
Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Trial Randomized Phase II ltbr gt
ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has better DFS not OS than 5FU after pre-op ChemoRT
Questions Total Neoadjuvant YesNoAdjuvant Cth YesNoLong versus Short Course
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
Near total neoadjuvant therapy
Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Trial Randomized Phase II ltbr gt
ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has better DFS not OS than 5FU after pre-op ChemoRT
Questions Total Neoadjuvant YesNoAdjuvant Cth YesNoLong versus Short Course
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Trial Randomized Phase II ltbr gt
ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has better DFS not OS than 5FU after pre-op ChemoRT
Questions Total Neoadjuvant YesNoAdjuvant Cth YesNoLong versus Short Course
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has better DFS not OS than 5FU after pre-op ChemoRT
Questions Total Neoadjuvant YesNoAdjuvant Cth YesNoLong versus Short Course
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
Questions Total Neoadjuvant YesNoAdjuvant Cth YesNoLong versus Short Course
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr gt
Can we Omit Radiation From NAT
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal Cancer
Can we Omit Radiation From NAT
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
What to do today
Clinical Trial whenever possible Careful assessment Chemosensitization by 5-FU or Capecitabine is enough Upfront chemotherapy is appealing Total amp Near Total
NAT should be encourgaed pCR TME IS THE STANDARD SURGICAL APPROACH
(STAGES II amp III) Postoperative chemotherapy should be discussed and
considered for high risk patients DFS
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-
Thank You
- Neoadjuvant Therapy in Rectal Cancer Complete Clinical versus
- Speaker Disclosures
- Principles
- Local Recurrence Following Surgery Alone
- Adjuvant Radiation Therapy
- Local Recurrence Better Insight
- Total Mesorectal Excision (TME)
- Total Mesorectal Excision (TME) (2)
- Adjuvant Chemoradiation in Stages II amp III Rectal Cancer
- Neoadjuvant Therapy The German Study A Shifting Concept
- German CAOAROAIO-94 11 Years Update
- Neoadjuvant Therapy TME Trial ldquoShort Courserdquo 10 Years FU
- Neoadjuvant Therapy TME Trial 10-Year Subset Analysis
- Neoadjuvant Therapy Short versus Long Radiation Therapy Course
- Radiation + Chemotherapy are MANDATORY in Neoadjuvant Therapy
- Neoadjuvant Therapy The Use of Capecitabine
- Neoadjuvant Therapy Adding Oxaliplatin
- The PETACC-6 RCTltbr gt
- ltbr gtPETACC-6 ltbr gtEarly analysis at 31 months shows no majo
- Neoadjuvant Therapy Adding EGFR Inhibition
- Neoadjuvant Therapy Adding VEGF Inhibition
- Neoadjuvant Therapy Indications
- Neoadjuvant Therapy Treatment Outcome
- Neoadjuvant Therapy Treatment Outcome in Relation to Pathologi
- Neoadjuvant Therapy Tumor Regression Grade
- Neoadjuvant Therapy Impact of Pathological CR
- Can we Avoid Surgery
- Can we Avoid Surgery (2)
- Neoadjuvant Therapy Problems with Current Practice
- Total Neoadjuvant Paradigm Brown University Study (CONTRE)
- The Cochrane Review Metanalysis Demonstrates DFS Adjuvant Treat
- The Cochrane Review Metanalysis Demonstrates OS Adjuvant Treatm
- Slide 34
- Near total neoadjuvant therapy
- Postop Adjuvant 5FU or FOLFOX for Rectal Cancer The ADORE Tria
- ltbr gtGerman CAOAROAIO-04 Studyltbr gtAdjuvant FOLFOX has bet
- Slide 38
- PROSPECT N1048 is ongoingltbr gtSelective Use of Pelvic XRTltbr
- MSKCC 07-021 Phase II Trial of Selective Radiation for Rectal
- What to do today
- Slide 43
-