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![EVIDENCE BASED
MANAGEMENT OF RECTAL
MALIGNANCY
Dr. Kanhu Charan Patro
M.D,D.N.B (RADIATION ONCOLOGY)
[EX.SR - TATAMEMORIAL HOSPITAL]
Consultant- Radiation Oncology
MAHATMA GANDHI CANCER HOSPITAL
VISAKHAPATNAM
Email-drkcpatro@gmail.com
M-09160470564](https://image.slidesharecdn.com/rectumbam-210209014016/75/RECTUM-CANCER-MANAGEMENT-1-2048.jpg)
![Levels of evidence
Level I=large double blind RCTs, or, metaanalysis of
smaller RCTs , with clinically relevant outcomes
I a=evidence from meta-analysis of RCT
I b=evidence from at least 1 RCT
Level II=small RCTs, non-blinded RCTs
II a=evidence from one well designed non-RCT
II b=evidence from one well-designed quasi-
experimental study
Level III=observational [cohort ] studies , case-
control studies , non-RCTs
Level IV=opinion of expert committees, or
respected authorities
Level V=expert opinion 2](https://image.slidesharecdn.com/rectumbam-210209014016/75/RECTUM-CANCER-MANAGEMENT-2-2048.jpg)
![NNCTG/86-47-51 [bolus 5FU VS PI]
N=660
Improvement in RFS
(63% vs 53%
4yr OS (70% vs 60%)
Distant mets(31% vs
40%)
Improving Adjuvant Therapy for Rectal Cancer by Combining Protracted-
Infusion Fluorouracil with Radiation Therapy after Curative Surgery, O'Connell
; NEJM 1994
31](https://image.slidesharecdn.com/rectumbam-210209014016/75/RECTUM-CANCER-MANAGEMENT-31-2048.jpg)
![Resectable rectal cancer
algorithm
36
SURGERY
T1,T2-N0 >T1,T2-N0
OBSERVATION CT+RT
CT+RT[2 CYCLE CHEMORADIATION+CONCURRENT CHEMO2 CYCLE CHEMO]](https://image.slidesharecdn.com/rectumbam-210209014016/75/RECTUM-CANCER-MANAGEMENT-36-2048.jpg)
![Locally Advanced rectal cancer
algorithm
56
CT-RT
SURGERY
4 CYCLE CHEMO
6 WEEKS GAP
CT+RTRADIATION+CONCURRENT CHEMO]](https://image.slidesharecdn.com/rectumbam-210209014016/75/RECTUM-CANCER-MANAGEMENT-56-2048.jpg)
![The DOCK Group
DOCK
[dissemination of knowledge in oncology club]
landmark message
Doubts
case discussion
Any other related queries
TheDOCKgroup@yahoogroups.com
drkcpatro@gmail.com
73](https://image.slidesharecdn.com/rectumbam-210209014016/75/RECTUM-CANCER-MANAGEMENT-73-2048.jpg)
Uploaded byKanhu Charan
RECTUM CANCER MANAGEMENT
This document discusses evidence-based management of rectal malignancy. It provides an overview of preoperative staging for rectal cancer, TNM staging criteria, the importance of total mesorectal excision surgery, and the role of adjuvant radiation therapy and chemotherapy based on randomized controlled trials. For locally advanced rectal cancer, it reviews evidence that preoperative radiation therapy with chemotherapy provides benefits of downstaging and reduced local recurrence compared to postoperative treatment.
In this document
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Introduction to evidence-based management of rectal malignancy by Dr. Kanhu Charan Patro, with contact details.
Different levels of evidence categorized from Level I (RCTs) to Level V (expert opinion), crucial for assessing medical research quality.
Rectal cancer's incidence and risk factors; treatment is primarily surgical, with radiation therapy playing a critical supportive role.
Preoperative staging methods including clinical examinations and imaging techniques. Emphasis on PET scan's role in assessing disease.
Objectives of rectal cancer treatment focusing on tumor control and quality of life. Describes various surgical approaches including TME.
Importance of adjuvant therapy to reduce loco-regional recurrence after surgery, with radiation as a key component.
Summaries of major studies on postoperative radiation therapy's effects on local recurrence and overall survival in rectal cancer patients.Overview of chemotherapy agents and combinations used in conjunction with radiation therapy for effective treatment of rectal cancers.
Comparison of preoperative chemoradiotherapy versus postoperative, detailing outcomes in local control and recovery.
Discussion on various chemotherapy agents, treatment regimens, and their effectiveness for metastatic colorectal cancer.
Survival statistics indicating improved outcomes with combined chemotherapy regimens, establishing treatment standards.Final remarks on the effectiveness of FOLFOX regimen as a standard therapy for advanced colorectal cancer.
Introduction of DOCK group for sharing knowledge and resolving queries in oncology.
Closing notes with appreciation for attendance and support.
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- 1. EVIDENCE BASED MANAGEMENT OFRECTAL MALIGNANCY Dr. Kanhu Charan Patro M.D,D.N.B (RADIATION ONCOLOGY) [EX.SR - TATAMEMORIAL HOSPITAL] Consultant- Radiation Oncology MAHATMA GANDHI CANCER HOSPITAL VISAKHAPATNAM [email protected] M-09160470564
- 2. Levels of evidence Level I=large double blind RCTs, or, metaanalysis of smaller RCTs , with clinically relevant outcomes I a=evidence from meta-analysis of RCT I b=evidence from at least 1 RCT Level II=small RCTs, non-blinded RCTs II a=evidence from one well designed non-RCT II b=evidence from one well-designed quasi- experimental study Level III=observational [cohort ] studies , case- control studies , non-RCTs Level IV=opinion of expert committees, or respected authorities Level V=expert opinion 2
- 3.
- 4.
- 5. Rectal Cancer Introduction Togetherwith colon, it is third commonest cancer in USA In India, it is not common but incidence is rising More frequent in population which consumes high fat- low fiber diet Affects both the sexes equally 5
- 6.
- 7.
- 8. Introduction ..contd.. Surgeryis the mainstay of treatment Narrow confines of the pelvis limits the adequacy of resected margins Proximity of the anal sphincter- poor quality of life RT plays an important role for the above two reasons 8
- 9. Preoperative staging Clinical examination ERUS CT scan MRI T2 sen Spe T3 sen ERUS 94 86 90 CT 79 MR 94 69 82 For local invasion, endoluminal US was most accurate Poor sensitivity 67% specificity 77% Lymph node detection 9
- 10. TNM Staging T1localised disease T2 T3 T4 Locally N1 Advanced N2 Metastatic disease Stage IIA T3, N0, M0 Stage IIB T4, N0, M0 Stage IIIA T1, N1, M0 T2, N1, M0 Stage IIIB T3, N1, M0 T4, N1, M0 Stage IIIC N2, M0 Stage IV M1 10
- 11. Likelihood ofLN involvement pT1 – 5.6% pT2 – 10% pT3 – 36.7% pT4 – 77.7% 11
- 12. PET scan Metabolic imaging Role in Detection of regional and metastatic disease* changed Rx in 17% altered preop staging in 40% Assessment of tumor response to therapy 12
- 13. aims local control long-term survival preservation of anal sphincter bladder sexual function maintenance or improvement in QOL. 13
- 14. Mainstay treatment- Surgery AR LAR APR TOTAL MESORECTAL EXCISION MINIMUM OF 12 NODE DISSECTION TEMPORARY/PERMANENT COLOSTOMY 14
- 15. Non TME Surgery Bluntintramesorectal dissection Rectosacral fascia traction Disruption of NVB Dissection onto front of rectum Nodal or occult micrometastatic disease frequently left in situ 15
- 16.
- 17. TME surgery- Principle- enbloc removal of tumor within envelope of endopelvic fascia Plane between visceral and parietal pelvic fascia Entire mesorectm remains within the fascia Lateral dissection separates mesorectum from NVB 12-15 perirectal and pelvic LNs Complete removal of vascular suppy, lymphatics, lymph nodes. 17
- 18. 1.Heald : Lancet1986 Retrospective Local recurrence 32-35% with conventional surgery 4-9% with TME Increase in overall survival by 30% 2.Prospective Dutch colorectal cancer group LR 9% c/w 16% 18
- 19. Incidence and predominantlocation on recurrences after TME IJROBP 2006 Roels S 5 subsites were noted as predominant risk of recurrences 1) Mesorectal 2) Posterior pelvic/ Presacral space (22%) 3) Lateral pelvic wall (6%) 4) Inferior pelvic especially if tumor <6cm from anal verge (11%) 5) Anterior pelvic (5%) 6) Anastamotic recurrences (10-21%) 19
- 20.
- 21. Prognosis/Local Failure Tstage Nodal involvement CRM – Quirke et al Lancet 1986 : 86% with CRM +ve developed LRR c/w 3% with CRM –ve CRM of at least 2 to 5 mm results in a much lower rate of local failures than with lesser margins Location of the tumor in the rectum (tumors located low in the rectum have a higher incidence of local failure) Experience and ability of the surgeon Local-regional failure rates of less than 5% after TME without the use of any adjuvant therapy 21
- 22. Stage 5 year,no adjuvant XRT T1 10% T2 15-35% T3 20-45% T4 >50% N+ 40-65% More than half of there recurrances are local Survival inversely related to recurrance With surgery alone, 5 yr survival T1,T2 - 80% T3, N+ < 25% Hence, Need for adjuvant treatment for high risk patients Generally – need for adj Rx if risk of LR >20% 22
- 23. Rationale of AdjuvantTherapy After surgery 20-50% patients develop loco-regional recurrence (LRR) Stage I : 5-15% Stage II : 20-30% Stage III : 20-50% Hence Adjuvant treat. is aimed to reduce the LRR and improve survival 23
- 24. Radiation Therapy asAdjuvant Therapy Preoperative RT (Neoadjuvant) Postoperative RT (Adjuvant) Combined with Chemotherapy 24
- 25. Addition of radiotherapy Adjuvant Disadvantage 1) increased small bowel toxicity 2) Potentially radioresistant hypoxic bed 3) May require a long time for healing for wound before RT 4) If APR, large portal to include perineal scar 25
- 26. NSABP R01 1977-86 N=555 3 arms- Post op Chemo improved DFS Post op RT reduced LR not OS Postoperative Radiation and Postoperative Systemic Chemotherapy in the Management of Resectable Rectal Carcinoma 26
- 27. NSABP R 02 1987-92 Post op CT +/- RT N=694 PORT reduced LR (8% vs 13%) not OS or DFS Compare Adjuvant MOF With and Without Radiation, to Adjuvant LV+5FU With and Without Radiation, in Patients with Dukes' B and C Carcinoma of the Rectum Post op RT did not improve OS BUT improved Local control 27
- 28. GITSG GI-7175 1975-80 N=227 Adjuvant postop RT and CT in Rectal cancer: a review of the GITSG : RO 1988 5yr Rec LR 10yr OS Surgery alone 55% 25% 27% Sx – CTRT (40-44 Gy + 5FU) 33% 10% 54% 28
- 29. NIH consensus 1990 Adjuvant CTRT in stage II and III rectal Ca Standard of care Which type of chemo? 29
- 30. 5 FU Leucovorin Levamisole Metastatic disease where 5-FU and leucovorin improved response rate Most regimens have used FU traditionally NEW- Oxaliplatin , Irinotecal, Oral 5FU 30
- 31. NNCTG/86-47-51 [bolus 5FUVS PI] N=660 Improvement in RFS (63% vs 53% 4yr OS (70% vs 60%) Distant mets(31% vs 40%) Improving Adjuvant Therapy for Rectal Cancer by Combining Protracted- Infusion Fluorouracil with Radiation Therapy after Curative Surgery, O'Connell ; NEJM 1994 31
- 32. Infusional 5-FUis superior to bolus 5-FU and is considered to be a standard adjuvant therapy 32
- 33. INT 114 1990-92 n=1695 In pT3, pT4, pN+ 2# chemo – CTRT – 2# chemo 4 arms 5FU vs 5FU+Levamisole vs FU+LV vs 5FU+LV+levamisole RT = 45Gy/25# to pelvis – 5.4Gy boost ; 3 or 4 fields RESULT = no diff in DFS or OS High rates of failure in T3,T4 Adjuvant Therapy in Rectal Cancer: Analysis of Stage, Sex, and Local Control—Final Report of Intergroup 0114- J.E. Tepper 33
- 34. Tumors locatedhigh in the rectum T1-2N or T3N0 disease, Tumors where the surgeon has been formally trained to perform a TME and there is confirmation that this has been performed, HPR- surgical margins by the method of Quirke et al and where at least 12-14 nodes have been identified in the pathology specimen to confirm N0 status Intergroup 0114 : JE Tepper Favourable Subset of patients 34
- 35. Favourable Subset ofpatients Prognostic factors in stage T3N0 rectal cancer: do all patients require postoperative pelvic irradiation and chemotherapy Willett CG (MGH) high risk factors- 1) perirectal invasion>2mm 2) LVI 3) Poorly dfferentiated 10 yr LC – 95 vs 87% 10 yr RFS – 71 vs 55% T3N0 rectal cancer: results following sharp mesorectal excision and no adjuvant therapy Merchant NB (MSKCC) LAR or APR with sharp TME results in LRF <10% histopath factor of significance = LVE 35
- 36. Resectable rectal cancer algorithm 36 SURGERY T1,T2-N0>T1,T2-N0 OBSERVATION CT+RT CT+RT[2 CYCLE CHEMORADIATION+CONCURRENT CHEMO2 CYCLE CHEMO]
- 37.
- 38.
- 39. Pre op treatment Rationale/ advantage 1. downstaging 2. decreased tumor seeding 3. decreased acute toxicity 4. more oxic cells – improved radiosensitivity 5. enhanced sphincter preservation Downside Overtreatment of T1, T2 disease 39
- 40.
- 41. Uppasala(Sweden) N= 471 preoperative irradiation at comparable, or even lower dosage levels, is more efficient in reducing the local recurrence rate than postoperative irradiation higher dosages are necessary to kill micrometastases in surgically disturbed tissue than in nondisturbed tissue RT technique Pre- or postoperative radiotherapy in rectal and rectosigmoid carcinoma: report from a randomized multicenter trial.- Påhlman L: Ann Surg 1990 Pre-op Post-op LR 12% 21% 41
- 42. Meta-analysis – benefitof preop RT Camma et al , JAMA 2000 14 RCTs Overall survival benefit + Colorectal Cancer Collaboratice Group, Lancet 2001 14 RCTs Reduced LR , not OS 42
- 43. Swedish Rectal CancerTrial N=1168 Surgery alone (notTME) 25Gy/5# - Surgery 21% benefit in OS (95%CI 8-34%) IMPROVED SURVIVAL WITH PREOPERATIVE RADIOTHERAPY IN RESECTABLE RECTAL CANCER - -NEJM 1997 LR-27 OS-58 11 48 10% absolute OS advtg 43
- 44. BUT Excessive acuteand late toxicity ( 5Gy per fraction) Slower recovery of bowel function More bowel incontinence Higher incidence of sexual dysfunction Poorer quality of life Short interval for downstaging Interval before surgery- Downstaging max after 10 days (Graf et al, RO 1997) Increase chance of downstaging if interval > 2 weeks ( LYON 90.01 , JCO 1999) No downstaging at 7 days (Dutch CKVO , JCO 2001) NO CONSENSUS YET 44
- 45. Need for preopRT with TME? Dutch CKVO 95-04 N=1861 pts 25 Gy – Sx vs Sx alone 2 yr local recurrence 2% vs 8% No benefit in OS/Sph preserv 45
- 46. Swedish council oftechnology assessment in health care 2003 systematic review of radiation therapy trials 25 351 patients Preoperative RT at BED>30 Gy decreases the relative risk of a local failure by 50-70% Postop RT decreases the risk by 30-40% at doses that generally are higher strong evidence that preop RT is more effective than postoperative. moderate evidence that preoperative radiotherapy significantly decreases the local failure rate (from 8% to 2% after 2 years) also with TME. strong evidence that preoperative radiotherapy improves survival (~ 10%) 46
- 47. Chemotherapy in preopsetting 47
- 48. Chemotherapy With RT– enhance radiosensitivity Adjuvant – eradicate micro mets 48
- 49. EORTC 22921 Patients withT3 or resectable T4 M0 rectal cancer (N = 1011) Preoperative RT-CT 45 Gy total with Leucovorin (20 mg/m2/day) plus Fluorouracil (350 mg/m2/day) in 5-day courses on Weeks 1, 5 (n = 506) Preoperative RT 45 Gy total (n = 505) Surgery* 3-10 wks after preoperative treatments Week 5 *Anterior resection or abdominoperineal resection. Week 1 -Chemotherapy with Preoperative Radiotherapy in Rectal Cancer –Bosset NEJM 2006 49
- 50. Results- Preop CTRT waswell tolerated c/w postop CTRT (<50% complaince) Chemoradiotherapy resulted in downsizing and down- staging of tumors Decrease in local recurrence with chemotherapy 8.6% vs 17% No difference in OS with chemotherapy Increase rate of pCR with preop CTRT 14% vs 5% with RT alone -Chemotherapy with Preoperative Radiotherapy in Rectal Cancer –Bosset NEJM 2006 50
- 51. So, if RTis given, then 5FU based chemotherapy given concurrently with RT prior to or following surgery gives significant advantage in local control 51
- 52. FFCD 9203 N=762 RT +/- CT Sx CT 5-year incidence of LR was lower with CTRT 8% v 16% pCR more frequent with CTRT 12% VS 4% No difference in sphincter preservation 52% VS 53% 5yr OS / DFS similar 67% Grade 3 or 4 acute toxicity was more frequent with CTRT 15% VS 3% Compliance 93% in preop CTRT , 70% in post op CT Preoperative Radiotherapy With or Without Concurrent Fluorouracil and Leucovorin in T3-4 Rectal Cancers: Results of FFCD 9203 Gérard : JCO 2006 52
- 53. Pre op vsPost op CTRT German rectal cancer group Sauer R, et al. N Engl J Med, 2004;351:1731-1740. Arm A* (n = 415) Arm B† (n = 384) Locally advanced rectal cancer, T3, T4, or node positive (N = 823) *Arm A: Preoperative chemoradiotherapy: 28 fractions (180 cGy/day, 5 x/wk) radiotherapy plus 5- fluorouracil (5-FU) as 120-hr continuous infusion (1000 mg/m2/day) in Wks 1 and 5 of RT Postoperative chemotherapy: bolus 5-FU (500 mg/m2 5 x/wk) every 4 wks for 4 cycles †Arm B: Chemotherapy: bolus 5-FU (500 mg/m2/day) for 5 days, every 4 wks for 4 cycles Follow-up every 3 mos for 2 yrs, then every 6 mos for 3 yrs Surgery Wk 12 Preoperative chemoradiotherapy (6 wks) Wk 0 Postoperative chemotherapy Wk 16 Wk 0 Surgery Wk 16 Postoperative + 540 cGy boost chemotherapy 53
- 54. Results- Survival comparablebetween groups 5yr OS 76% in preop group vs 74% in postop group (P = .80) 5yr DFS 68% in preop group vs 65% in postop group (P = .32) Preoperative treatment improved local control 5-year local recurrence incidence 6% in preop vs 15% in postop group (P = .006) Distant recurrence similar between groups Sphincter preservation rates in patients with abdominoperineal resection before randomization Higher with preoperative chemoradiotherapy (39% vs 20% P = .004) Toxicity was less with the pre op group Acute 27% vs 49% Chronic 14% vs 24% Sauer R, et al. N Engl J Med, 2004;351:1731-1740. 54
- 55. Schedule of RT– polish study whether preop conventionally fractionated CTRT offers an advantage in sphincter preservation in comparison with preop short-term RT resectable T3-4 rectal carcinoma without sphincters' infiltration preop 25Gy/5#/1wk TME performed within 7 days or CTRT to 50.4Gy/28# concomitantly with two courses of bolus 5FU-LV followed by TME after 4-6 weeks. N=316 pCR : CTRT 15% SCRT 1% Sph Pre 58% 61% <1 mm CRM 13% SCRT vs 4% in CTRT No difference in LR, OS, DFS 55
- 56. Locally Advanced rectalcancer algorithm 56 CT-RT SURGERY 4 CYCLE CHEMO 6 WEEKS GAP CT+RTRADIATION+CONCURRENT CHEMO]
- 57.
- 58. The main stayof metastatic colorectal cancer is multi agent chemotherapy 58
- 59. CHEMOTHERAPEUTIC AGENTS FOR COLORECTAL CANCER 5FU LEVAMISOLE LEUCOVORIN ORAL 5FU AGENTS IRNOTECAN OXALIPLATIN 59
- 60. WHAT IS STANDARD Based on INT 0089 trial 5FU+LV for 7-8 month is standard treatment for stage III colorectal cancer .then it is being used since 1996 Neither INT-0089 nor NSABP trial showed that levamisole with 5FU+LV is better than 5FU+LV 60
- 61. WHAT IS STANDARD PROTOCOLFOR 5FU ADMINISRTATION VARIOUS REGIMENS USED FOR 5FU+LV ARE DEGARMONT NCCTG LOKICH ROSWELLPARK MAYO CLINIC 61
- 62. ROSWELL PARK REGIMEN 5FU----500mg/m2/WKX6WK LV-----500mg/m2/WKX6WK REAPT AT EVERY 8WK FOR 6 CYCLES 62
- 63. MAYO CLINIC REGIMEN 5FU----425mg/m2/dX5d LV-----20mg/m2/dX5d REAPT AT EVERY 4WK FOR 6 CYCLES 63
- 64. What should bethe standard method of 5FU administration Lokich et.al compared 6 metaanalysis of 5FU adminisration RESULTS Cont. inf increased response rate Cont. inf. Has modest survival benefit Protracted inf. Associated with greater hand food syndrome Protracted inf. Associated with lesser incidence of Gr—3,4 neutropenia. Protracted inf. Associated with considerable inconvenience & disruption of daily activities . 64
- 65. What should befollowed Infusion regimens to be favored in Europe for their safety and improved efficacy profile. in U.S.A bolus regimens followed for ease administration Conclusion– clinicians should choose a regimen best suited to their patient 65
- 66. CAPECITABINE It is aorally absorbed flouro pyrimidine not activated in gut and absorbed as such and converted to 5fu by 3 step enzymatic cascade. The last enzyme that converts this to 5fu is thimidine phosphorylase is significantly more active in tumor tissue. 66
- 67. TRIALS ON CAPECITABINE Hoffet.al.(2ooo) RR OS(M) TDP(M) MAYO CLINC REG. 17% 12.8 4.7 CAPECITABINE 26% 12.9 4.6 THE SAFETY PROFILE OF CAPECITABINE WAS BETTER IN ALL RESPECT TO 5FU+LV BUT HAND FOOT SYNDROME IS MORE IN CAPECITABINE ARM. CONCLUSION--- CAPECITABINE IS SUPERIOR RR TO 5FU/LV 67
- 68. COMBINATION CHEMOTHERAPIES FULFOX 1,2,3,4,6 FULFIRI IFL bFL OXIRI IROX FULFOX ALTERNATING WITH FULFIRI 68
- 69. STUDY PT REGRR(%) M,PFS(M) M,OS(M) SALTZ et. al. 226 5FU/LV 21 4.3 12.6 EJM(2000) 231 IFL 39 7 14.8 226 IR 18 4.2 12 DOULLIER 198 5FU/LV 22 4.4 14.1 et. al.(2OOO) 188 FOLFIRI 35 6.7 17.4 DEGRAMONT 210 5FU/LV 22.3 6.2 14.7 et. al.(2OOO) 188 FOLFOX4 5O.7 9 16.2 GIACHETTI 100 5FU/LV 16 6.1 19.9 et. al.(2OOO) 188 FOLFOX6 53 8.7 19.4 GOLDBERG et. al. 264 IFL 29 6.9 14.1 JCO(2004) 267 FOLFOX 38 8.8 18.6 264 OXIRI 29 NA NA 69
- 70. SURVIVAL NOW IT ISCLEAR THAT WITH ALL SUPPORTIVE CARE MEDIAN SURVIVAL IN ADVANCED COLORECTAL CANCER IS 9 MONTH,WITH 5FU LV IT IS 12 MONTH BUT WHEN 5FU/LV COMBINED WITH IRINOTECAN OR OXALIPLATIN THEN MEDIAN SURVIVAL IS 14 TO19 MONTH. 70
- 71. CONCLUSION AFTER GOLDBERG TRIALTHE PUBLISHED STATEMENT IN JCO JAN 2004 TELLS THAT FOLFOX REGIMEN IS ACTIVE AND COMPARITEVELY SAFE . SO IT SHOULD BE CONSIDERED AS A STANDARD THERAPY FOR ADVANCED COLORECTAL CANCER 71
- 72. ALTERNATE FOLFOX with FOLFIRI BASED ON GOLDIE COLDMNN HYPOTHESIS RECHIA et.al(2004) CONDUCTED A PHASE II TRIAL THAT COMPRISING FOLFOX ALTERNATING WITH FOLFIRI SHOWED THAT RR IS 69%, DISEASE STABILISATION IN 11% OF CASES. IN ALL TOTAL 8O% GOT BENEFIT. 72
- 73. The DOCK Group DOCK [dissemination of knowledge in oncology club] landmark message Doubts case discussion Any other related queries [email protected] [email protected] 73
- 74. ? ? ?? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ?? 74
- 75.