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In Reply

Department of General Surgery, Medical University of Vienna, Vienna, Austria

Birgit Gruenberger

Department of Oncology, Rudolfstiftung Hospital, Vienna, Austria

We thank Dr Nasti and his colleagues for their interest in our study,¹ and welcome their ideas to improve outcome in patients with resectable liver metastases from colorectal cancer. They explain some concerns regarding the use of neoadjuvant chemotherapy in patients who may not benefit from this approach, and favor an alternative treatment schedule including positron emission tomography (PET) to identify responders after a single chemotherapy cycle.

The authors outline in their reply that patients with stable or progressive disease while receiving chemotherapy lack the potential of a surgical intervention. We would like to emphasize that achieving stable disease while receiving chemotherapy is still believed to be an attainment and improves outcome parameters in these patients. However, it is correct that the identification of progressive disease is important, but in contrast to the opinion of the authors, to our knowledge these patients will not benefit from a surgical intervention even if they can stil undergo resection, and should therefore undergo second-line chemotherapy instead.^2,3

The identification of predictors for response is an important issue and the use of a [18F]fluorodeoxyglucose-PET for an early evaluation is certainly one of the methods currently under investigation. It seems specifically interesting in patients receiving antiangiogenic drug–containing regimens because that a certain percentage of the liver metastases in these patients seem to respond to treatment without fulfilling the Response Evaluation Criteria in Solid Tumors criteria of response. This is demonstrated in a higher percentage of pathologic tumor necrosis,⁴ an increase in pathologic complete response rates,¹ a higher PET response compared with computed tomography response,⁵ and a decrease in contrast enhancement.⁶

To date, we have not recognized a different response pattern depending on tumor size, demonstrated in our article, where a significant tumor size reduction in a patient with a large metastasis is illustrated.

In summary, we support the necessity to identify responding patients during neoadjuvant treatment with early predictors and thereby increase the optimal sequence of chemotherapy and surgery.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Although all authors completed the disclosure declaration, the following authors or their immediate family members indicated a financial interest. No conflict exists for drugs or devices used in a study if they are not being evaluated as part of the investigation. For a detailed description of the disclosure categories, or for more information about ASCO's conflict of interest policy, please refer to the Author Disclosure Declaration and the Disclosures of Potential Conflicts of Interest section in Information for Contributors.

Employment or Leadership Position: None Consultant or Advisory Role: None Stock Ownership: None Honoraria: Thomas Gruenberger, Roche, Merck Serono Research Funding: Thomas Gruenberger, Roche, Merck Serono Expert Testimony: None Other Remuneration: None

REFERENCES

1. Gruenberger B, Tamandl D, Schueller J, et al: Bevacizumab, capecitabine, and oxaliplatin as neoadjuvant therapy for patients with potentially curable metastatic colorectal cancer. J Clin Oncol 26:1830-1835, 2008[Abstract/Free Full Text]

2. Gruenberger B, Scheithauer W, Punzengruber R, et al: Importance of response to neoadjuvant chemotherapy in potentially curable colorectal cancer liver metastases. BMC Cancer 8:120, 2008[CrossRef][Medline]

3. Adam R, Pascal G, Castaing D, et al: Tumor progression while on chemotherapy; a contraindication to liver resection for multiple colorectal metastases? Ann Surg 240:1052-1064, 2004[CrossRef][Medline]

4. Ribero D, Wang H, Donadon M, et al: Bevacizumab improves pathologic response and protects against hepatic injury in patients treated with oxaliplatin-based chemotherapy for colorectal liver metastases. Cancer 110:2761-2767, 2007[CrossRef][Medline]

5. Goshen E, Davidson T, Zwas S, et al: PET/CT in the evaluation of response to treatment of liver metastases from colorectal cancer with bevacizumab and irinotecan. Technol Cancer Res Treat 5:37-43, 2006[Medline]

6. Morgan B, Thomas AL, Drevs J, et al: Dynamic contrast-enhanced magnetic resonance imaging as a biomarker for the pharmacological response of PTK787/ZK 222584, an inhibitor of the vascular endothelial growth factor receptor tyrosine kinases, in patients with advanced colorectal cancer and liver metastases: results from two phase I studies. J Clin Oncol 21:3955-3964, 2003[Abstract/Free Full Text]

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This Article Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Gruenberger, T. Articles by Gruenberger, B. Search for Related Content PubMed Articles by Gruenberger, T. Articles by Gruenberger, B. Social Bookmarking                            What's this?