Neoadjuvant chemotherapy followed by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for colorectal cancer:a feasibility and safety study

BACKGROUND: Standard treatment for colorectal peritoneal carcinomatosis typically involves cytoreductive surgery, hyperthermic intraperitoneal chemotherapy (HIPEC), and if possible, postoperative adjuvant chemotherapy. However, a substantial percentage of patients never receive adjuvant chemotherapy because of postoperative complications. Neoadjuvant chemotherapy could be beneficial in this setting, so we assessed its feasibility and safety when used before cytoreductive surgery and HIPEC. METHODS: In this non-randomized, single-center, observational feasibility study, patients were scheduled to receive six cycles of capecitabine and oxaliplatin before cytoreductive surgery and HIPEC. Computed tomography was performed after the third and sixth chemotherapy cycles to evaluate tumor response, and patients underwent cytoreductive surgery and HIPEC if there were no pulmonary and/or hepatic metastases. Postoperative complications, graded according to the Clavien-Dindo classification, were compared with those of a historic control group that received postoperative adjuvant chemotherapy. RESULTS: Of the 14 patients included in the study, 4 and 3 had to terminate neoadjuvant chemotherapy early because of toxicity and tumor progression, respectively. Cytoreductive surgery and HIPEC were performed in eight patients, and the timing and severity of complications were comparable to those of patients in the historic control group treated without neoadjuvant chemotherapy. CONCLUSION: Patients with peritoneal metastases due to colorectal carcinoma can be treated safely with neoadjuvant chemotherapy before definitive therapy with cytoreductive surgery and HIPEC. TRIAL REGISTRATION NUMBER: NTR 3905, registered on 20th march, 2013, http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=3905

LE DROIT NUCLÉAIRE CONFRONTÉ AU DROIT DE L’ENVIRONNEMENT : AUTONOMIE OU COMPLEMENTARITÉ ?

Doit-il nécessairement y avoir un combat dans les relations entre le droit de l’énergie nucléaire et le droit de l’environnement ? Dans plusieurs cercles, on peut très souvent avoir l’impression que la réticence persistante envers l’énergie nucléaire résulte d’un discrédit des règles gouvernant l’utilisation de ce type d’énergie. À ce propos, le souvenir de Tchernobyl – comme l’archétype d’une catastrophe environnementale ayant été gravé dans notre mémoire collective – n’aide certainement pas. Pourtant, cette perception est non seulement injuste, elle est aussi incorrecte au niveau factuel et conceptuel puisque l’intention même du droit national et international concernant l’énergie nucléaire, en tant que lex specialis, est de s’assurer que les diverses applications de cette énergie soient conduites de manière aussi sécuritaire que possible pour le public autant que pour l’environnement. En étudiant le droit de l’énergie nucléaire, on est naturellement porté à en faire la comparaison avec la sphère, certes jeune mais à croissance rapide, du droit environnemental. Ce faisant, l’on pourra se demander à quel point cette dernière est en lien ou puisse éventuellement englober la première, considérant que la finalité de ces deux branches est identique, jusqu’à un certain degré, et qu’elles possèdent beaucoup d’outils juridiques en commun issus. En effet, à travers de ce qui pourrait être qualifié de « pollinisation contrôlée », les deux branches du droit ont emprunté divers principes et concepts (traçabilité des matériaux, principe pollueur-payeur, etc.). Toutefois, un aspect sur lequel le droit de l’énergie nucléaire a encore quelques progrès à faire, tandis que le droit environnemental y excelle, est la promotion des valeurs de transparence et de participation du public aux activités pour lesquelles les prises de décisions ont longtemps été laissées dans les mains des « experts ». Cet aspect présente un important défi, tout spécialement à une époque où les industries et gouvernements parlent de renaissance nucléaire.Is there necessarily a fundamental antagonism in the relation between nuclear law and environmental law? One often has the impression that the persistent reticence towards nuclear energy in many circles results in undermining the credibility of the rules governing the use of this source of energy. The lasting memory of Chernobyl – as the archetypal environmental catastrophe – does not help of course. This perception is not only unfair – which is irrelevant – it is factually and conceptually wrong since the very purpose of the international and national nuclear law, as lex specialis, is to ensure that the many applications of nuclear energy are carried out in a manner which is safe for the public and the environment. When studying nuclear law, one is naturally inclined to compare it with the younger but quickly expanding sphere of environmental laws, and wonder to what extent the latter overlaps or may even eventually absorb the former, considering that the finality of both branches is, to a certain degree, identical and that they share many of the same legal tools. Indeed, through what might be qualified as “cross-fertilization process”, each branch has borrowed principles and concepts from the other (traceability of nuclear material, polluter pays principle, etc.). However, an area where nuclear law still has some ways to go, whereas environmental law excels, is in promoting values of transparency and public participation in activities where the decision-making process has long been left to the “experts”. This is an important challenge, especially at a time when industries and governments speak of nuclear renaissance