Bruce D. Minsky, MD | Authors

MRI-Based Treatment Decision Making for Rectal Cancer

August 15, 2014

There are a number of clinicopathologic variables that predict outcome in rectal cancer. In the era of postoperative chemoradiation treatment, these were more easily identified and were used to help select patients for adjuvant therapy.

Have the Changes in Treatment of Rectal Cancer Made a Significant Difference to Our Patients?

December 15, 2011

Treatment for patients with locally advanced, resectable rectal cancer has clearly evolved, with significant refinements in preoperative assessment, surgical technique, and use of preoperative chemoradiation.

Controversies in Preoperative Chemoradiation for Rectal Cancer

May 01, 2009

Since the early 1990s, postoperative adjuvant chemoradiotherapy was widely viewed as the main approach to treat patients with stage II and III rectal cancer. Over the past few years, significant efforts have shifted towards developing neoadjuvant approaches, which combine chemotherapy with radiotherapy prior to surgical resection.

Multidisciplinary Management of Resectable Rectal Cancer

November 16, 2008

Prior to the publication of the German CAO/ARO/AIO 94 trial, the conventional adjuvant approach for patients with clinically resectable, ultrasonographically diagnosed T3 (uT3) and/or node-positive rectal cancer was initial surgery and, if pathologically confirmed T3 (pT3) and/or node-positive, postoperative combined chemotherapy plus radiation. The German trial confirmed that compared to postoperative therapy, the preoperative approach was associated with significantly lower local recurrence rates, less acute and chronic toxicity, and an increased incidence of sphincter preservation.

Key Developments in Rectal Cancer Treatment

August 01, 2007

Epidermal growth factor receptor (EGFR) and vascular endothelial growth factor (VEGF) are often overexpressed in colorectal cancer and are associated with inferior outcomes. Based on successful randomized phase III trials, anti-EGFR and anti-VEGF therapeutics have entered clinical practice. Cetuximab (Erbitux), an EGFR-specific antibody, is currently approved in the United States in combination with irinotecan (Camptosar) for patients with metastatic colorectal cancer refractory to irinotecan or as a single agent for patients unable to tolerate irinotecan-based therapy. In retrospective analyses, patients with EGFR-expressing rectal cancer undergoing neoadjuvant radiation therapy had a significantly inferior disease-free survival and lower rates of achieving pathologic complete response. Based on the positive data in metastatic colorectal cancer and synergy with radiation therapy seen in preclinical models, there is a strong rationale to combine cetuximab with neoadjuvant radiation therapy and chemotherapy in rectal cancer. Bevacizumab (Avastin), a VEGF-specific antibody, was the first antiangiogenic agent to be approved in the United States for use in combination with standard chemotherapy in the first- and second-line of treatment in metastatic colorectal cancer. VEGF-targeted therapy may lead to indirect killing of cancer cells by damaging tumor blood vessels, and may increase the radiosensitivity of tumor-associated endothelial cells. VEGF blockade can also "normalize" tumor vasculature, thereby leading to greater tumor oxygenation and drug penetration. This review will address completed and ongoing trials that have established and continue to clarify the effects of these agents in rectal cancer.

Primary Combined-Modality Therapy for Esophageal Cancer

April 30, 2006

Based on positive results from the Radiation Therapy Oncology Group (RTOG) 85-01 trial, the conventional nonsurgical treatment of esophageal carcinoma is combined-modality therapy. Dose intensification of the RTOG 85-01 regimen, examined in the Intergroup (INT)-0123/RTOG 94-05 trial, did not improve local control or survival. Areas of clinical investigation include the development of combined-modality therapy regimens with newer systemic agents, the use of 18F-fluorodeoxyglucose positron-emission tomography to assist in the development of innovative radiation treatment planning techniques, and the identification of prognostic molecular markers. The addition of surgery following primary combined-modality therapy apparently does not improve survival, but this finding is controversial.

Commentary (Minsky): Radiation Therapy for Resectable Colon Cancer

February 02, 2006

Colon cancer is a major public health problem. The primary treatment is resection. For patients with early-stage disease, surgery results in excellent survival rates. In contrast, patients with locally advanced tumors arising in "anatomically immobile" segments of large bowel have a less satisfactory outcome, in part secondary to compromised surgical clearance. Patterns-of-failure analyses suggest that for tumors that invade adjacent organs, exhibit perforation or fistula, or are subtotally resected, local failure rates exceed 30%. Multiple single-institution retrospective studies have shown improved local control and possibly survival with the addition of external irradiation and/or intraoperative radiation. In contrast, a recent Intergroup trial failed to show any benefit by the addition of adjuvant radiation therapy combined with chemotherapy. Interpretation of this trial's results is handicapped by low patient accrual. With the advent of novel and more effective systemic therapies for metastatic colon cancer, current and future clinical research will address the efficacy of these agents in the adjuvant setting. Adjuvant radiation therapy should be considered in patients with colon cancer at high risk for local failure.

Combined-Modality Therapy of Rectal Cancer With Irinotecan- Based Regimens

December 04, 2004

There are two conventional treatments for clinically resectable rectalcancer. The first is surgery followed by postoperative combinedmodalitytherapy if the tumor is T3 and/or N1/2. The second, if thetumor is ultrasound T3 or clinical T4, is preoperative combined-modalitytherapy followed by surgery and postoperative chemotherapy. Thereare a number of new chemotherapeutic agents that have been developedfor the treatment of colorectal cancer. Phase I/II trials are examiningthe use of new chemotherapeutic agents in combination with pelvicradiation therapy, most commonly in the preoperative setting. Thereis considerable interest in integrating irinotecan (Camptosar) into preoperativecombined-modality therapy regimens for rectal cancer. Basedon these trials, the recommended regimen for patients who receiveirinotecan-based combined-modality therapy is continuous infusionfluorouracil (5-FU), irinotecan, and pelvic radiation. New trials examiningpreoperative combined-modality therapy regimens substitutingcapecitabine (Xeloda) for continuous infusion 5-FU are in progress.