A comparison of nonoperative vs. preoperative radiotherapy in rectal carcinoma. A 10-year randomized trial

Journey through the Decades: The Evolution in Treatment and Shared Decision Making for Locally Advanced Rectal Cancer

The management of locally advanced rectal cancer has undergone significant transformations over the decades and optimal treatment approaches continue to evolve. There have been numerous advances in surgery, chemotherapy, and radiation therapy from the first description of the abdominoperineal resection in 1908, timing of chemotherapy and radiation therapy in the late 20th and early 21st century, and most recently, the introduction of organ preservation or nonoperative management in 2004. Alongside these advancements, the concept of shared decision making in medicine has evolved, prompting a focus on patient-centered care. This evolution in practice has been fueled by a growing recognition of the importance of patient autonomy and the alignment of treatment options with patients' values and preferences. With the growing number of possible treatment options, variability in patient counseling exists, highlighting the need for a standardized approach to shared decision making in locally advanced rectal cancer. This narrative review will describe the evolution of treatment options of locally advanced rectal cancer as well as the concept of shared decision making and decision aids, and will introduce a decision aid for patients with locally advanced rectal cancer who have achieved a complete clinical response and are eligible for watch and wait.

Turnbull-Cutait pull-through coloanal anastomosis versus standard coloanal anastomosis plus diverting ileostomy for low anterior resection: a meta-analysis and systematic review

PURPOSE

Coloanal anastomosis with loop diverting ileostomy (CAA) is an option for low anterior resection of the rectum, and Turnbull-Cutait coloanal anastomosis (TCA) regained popularity in the effort to offer patients a reconstructive option. In this context, we aimed to compare both techniques.

METHODS

PubMed, Cochrane, and Scopus were searched for studies published until January 2024. Odds ratios (RRs) with 95% confidence intervals (CIs) were pooled with a random-effects model. Statistical significance was defined as p < 0.05. Heterogeneity was assessed using the Cochran Q test and I2 statistics, with p-values inferior to 0.10 and I2 >25% considered significant. Statistical analysis was conducted in RStudio version 4.1.2 (R Foundation for Statistical Computing). Registered number CRD42024509963.

RESULTS

One randomized controlled trial and nine observational studies were included, comprising 1,743 patients, of whom 899 (51.5%) were submitted to TCA and 844 (48.5%) to CAA. Most patients had rectal cancer (52.2%), followed by megacolon secondary to Chagas disease (32.5%). TCA was associated with increased colon ischemia (OR 3.54; 95% CI 1.13 to 11.14; p < 0.031; I2 = 0%). There were no differences in postoperative complications classified as Clavien-Dindo ≥ IIIb, anastomotic leak, pelvic abscess, intestinal obstruction, bleeding, permanent stoma, or anastomotic stricture. In subgroup analysis of patients with cancer, TCA was associated with a reduction in anastomotic leak (OR 0.55; 95% CI 0.31 to 0.97 p = 0.04; I2 = 34%).

CONCLUSION

TCA was associated with a decrease in anastomotic leak rate in subgroups analysis of patients with cancer.

A systematic review and network meta-analysis of randomised controlled trials comparing neoadjuvant treatment strategies for stage II and III rectal cancer

AIM

Multiple neoadjuvant therapy strategies have been used and compared for rectal cancer and there has been no true consensus as to the optimal neoadjuvant therapy regimen. The aim is to identify and compare the neoadjuvant therapies available for stage II and III rectal cancer.

DESIGN

A systematic literature review was performed, from inception to August 2022, of the following databases: MEDLINE, EMBASE, Science Citation Index Expanded, Cochrane Library. Only randomized controlled trials comparing neoadjuvant therapies for stage II and III rectal cancer were considered. Stata was used to draw network plots, and a Bayesian network meta-analysis was conducted through models utilizing the Markov Chain Monte Carlo method in WinBUGS.

RESULTS

A total of 58 articles were included based on 41 randomised controlled trials, reporting on 12,404 participants that underwent 15 neoadjuvant treatment regimens. No significant difference was identified between treatments for major or total postoperative complications, anastomotic leak rates, or sphincter-saving surgery. Straight to surgery (STS) ranked as best treatment for preoperative toxicity but ranked worst treatment for positive resection margins and complete response. STS had significantly increased positive resection margins compared to long-course chemoradiotherapy with short-wait (LCCRT-SW) or long-wait (LCCRT-LW) to surgery, or short-course radiotherapy with short-wait (SCRT-SW) or immediate surgery (SCRT-IS). LCCRT-SW or LCCRT-LW resulted in significantly increased complete response rates compared to STS. LCCRT-LW significantly improved 2-year overall survival compared to STS, SCRT-IS, SCRT-SW. Total neoadjuvant therapy regimes with short-course radiotherapy followed by consolidation chemotherapy (SCRT-CT-SW), induction chemotherapy followed by long-course chemoradiotherapy (CT-LCCRT-S), long-course chemoradiotherapy followed by consolidation chemotherapy (LCCRT-CT-S), significantly improved positive resection margins, complete response, and disease-free survival compared to STS. Chemotherapy with monoclonal antibodies followed by long-course chemoradiotherapy (CT+MAB-LCCRT+MAB-S) significantly improved complete response and positive resection margins compared to STS, and 2-year disease-free survival compared to STS, SCRT-IS, SCRT-SW, SCRT-CT-SW, LCCRT-SW, LCCRT-LW. CT+MAB-LCCRT+MAB-S ranked as best treatment for disease-free survival and overall survival.

CONCLUSIONS

Conventional neoadjuvant therapies with short-course radiation or long-course chemoradiotherapy have oncological benefits compared to no neoadjuvant therapy without increasing perioperative complication rates. Prolonged wait to surgery may improve oncological outcomes. Total neoadjuvant therapies provide additional benefits in terms of complete response, positive resection margins, and disease-free survival. Monoclonal antibody therapy may further improve oncological outcomes but currently is only applicable to a small subgroup of patients and requires further validation.

Neoadjuvant treatments for resectable rectal cancer: A network meta-analysis

Different neoadjuvant therapy regimens are available for rectal cancer, but the relative effects are controversial. The aim of the present network meta-analysis (NMA) was to estimate the relative efficacy and safety of neoadjuvant therapies for resectable rectal cancer. MEDLINE, EMBASE and Cochrane Central Registry of Controlled Trials were searched for publications dated from 1946 up to June 2018. The present study included randomized clinical trials that compared treatments for resected rectal cancer: Surgery alone, surgery preceded by neoadjuvant radiotherapy (RT), neoadjuvant chemotherapy (CT) or neoadjuvant chemoradiotherapy (CRT). Direct pairwise comparisons and NMA were conducted. A total of 23 randomized controlled trials were included in the present study. RT had an overall survival (OS) benefit when compared with surgery alone [HR (hazard ratio), 0.89; 95% confidence interval (CI), 0.82-0.97; quality of evidence, high]. All three neoadjuvant regimens were associated with lower local recurrence (LR) when compared with surgery alone [RT: odds ratio (OR), 0.44; 95% CI, 0.35-0.65; quality of evidence, high; CRT: OR, 0.34; 95% CI, 0.23-0.56; quality of evidence, low and CT: OR, 0.32; 95% CI, 0.11-1.00; quality of evidence, low]. There were no significant differences in OS and LR between CRT and RT (OS: OR, 1.10); 95% CI, 0.93-1.20; LR: OR, 0.81; 95% CI, 0.61-1.10). Ranking probabilities indicated that CRT was the best strategy for local control, with a surface under the cumulative ranking curve (SUCRA) of 78.78%. Patients treated with RT had improved disease-free survival compared with those treated with surgery alone (HR, 0.82; 95% CI, 0.64-1.00; quality of evidence, low). Neoadjuvant RT or CRT did not significantly improve distant metastases compared with surgery alone (RT: OR, 0.87; 95% CI, 0.69-1.10 and CRT: OR, 0.75; 95% CI, 0.47-1.10). CRT had an improved pathological complete response rate compared with RT (OR, 4.90; 95% CI, 21.80-17.00; quality of evidence, low). No significant difference for the risk of anastomotic leak between each treatment was observed in the NMA. In conclusion, RT decreased the LR and improved OS compared with surgery alone for resected rectal cancer. CRT was the best neoadjuvant therapy analyzed and CT was likely the second best for all outcomes based on SUCRA. However, these findings were limited by overall low quality of evidence.

Preoperative radiotherapy and curative surgery for the management of localised rectal carcinoma

BACKGROUND

This is an update of the original review published in 2007.Carcinoma of the rectum is a common malignancy, especially in high income countries. Local recurrence may occur after surgery alone. Preoperative radiotherapy (PRT) has the potential to reduce the risk of local recurrence and improve outcomes in rectal cancer.

OBJECTIVES

To determine the effect of preoperative radiotherapy for people with localised resectable rectal cancer compared to surgery alone.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library; Issue 5, 2018) (4 June 2018), MEDLINE (Ovid) (1950 to 4 June 2018), and Embase (Ovid) (1974 to 4 June 2018). We also searched ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) for relevant ongoing trials (4 June 2018).

SELECTION CRITERIA

We included randomised controlled trials comparing PRT and surgery with surgery alone for people with localised advanced rectal cancer planned for radical surgery. We excluded trials that did not use contemporary radiotherapy techniques (with more than two fields to the pelvis).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the 'Risk of bias' domains for each included trial, and extracted data. For time-to-event data, we calculated the Peto odds ratio (Peto OR) and variances, and for dichotomous data we calculated risk ratios (RR) using the random-effects method. Potential sources of heterogeneity hypothesised a priori included study quality, staging, and the use of total mesorectal excision (TME) surgery.

MAIN RESULTS

We included four trials with a total of 4663 participants. All four trials reported short PRT courses, with three trials using 25 Gy in five fractions, and one trial using 20 Gy in four fractions. Only one study specifically required TME surgery for inclusion, whereas in another study 90% of participants received TME surgery.Preoperative radiotherapy probably reduces overall mortality at 4 to 12 years' follow-up (4 trials, 4663 participants; Peto OR 0.90, 95% CI 0.83 to 0.98; moderate-quality evidence). For every 1000 people who undergo surgery alone, 454 would die compared with 45 fewer (the true effect may lie between 77 fewer to 9 fewer) in the PRT group. There was some evidence from subgroup analyses that in trials using TME no or little effect of PRT on survival (P = 0.03 for the difference between subgroups).Preoperative radiotherapy may have little or no effect in reducing cause-specific mortality for rectal cancer (2 trials, 2145 participants; Peto OR 0.89, 95% CI 0.77 to 1.03; low-quality evidence).We found moderate-quality evidence that PRT reduces local recurrence (4 trials, 4663 participants; Peto OR 0.48, 95% CI 0.40 to 0.57). In absolute terms, 161 out of 1000 patients receiving surgery alone would experience local recurrence compared with 83 fewer with PRT. The results were consistent in TME and non-TME studies.There may be little or no difference in curative resection (4 trials, 4673 participants; RR 1.00, 95% CI 0.97 to 1.02; low-quality evidence) or in the need for sphincter-sparing surgery (3 trials, 4379 participants; RR 0.99, 95% CI 0.94 to 1.04; I² = 0%; low-quality evidence) between PRT and surgery alone.Low-quality evidence suggests that PRT may increase the risk of sepsis from 13% to 16% (2 trials, 2698 participants; RR 1.25, 95% CI 1.04 to 1.52) and surgical complications from 25% to 30% (2 trials, 2698 participants; RR 1.20, 95% CI 1.01 to 1.42) compared to surgery alone.Two trials evaluated quality of life using different scales. Both studies concluded that sexual dysfunction occurred more in the PRT group. Mixed results were found for faecal incontinence, and irradiated participants tended to resume work later than non-irradiated participants between 6 and 12 months, but this effect had attenuated after 18 months (low-quality evidence).

AUTHORS' CONCLUSIONS

We found moderate-quality evidence that PRT reduces overall mortality. Subgroup analysis did not confirm this effect in people undergoing TME surgery. We found consistent evidence that PRT reduces local recurrence. Risk of sepsis and postsurgical complications may be higher with PRT.The main limitation of the findings of the present review concerns their applicability. The included trials only assessed short-course radiotherapy and did not use chemotherapy, which is widely used in the contemporary management of rectal cancer disease. The differences between the trials regarding the criteria used to define rectal cancer, staging, radiotherapy delivered, the time between radiotherapy and surgery, and the use of adjuvant or postoperative therapy did not appear to influence the size of effect across the studies.Future trials should focus on identifying participants that are most likely to benefit from PRT especially in terms of improving local control, sphincter preservation, and overall survival while reducing acute and late toxicities (especially rectal and sexual function), as well as determining the effect of radiotherapy when chemotherapy is used and the optimal timing of surgery following radiotherapy.

Radiotherapy Combined with Other Treatments in Rectal Cancer

Since the first reports in the late 1950's, a large amount of data have been collected. The analysis of the main evidence from the major randomized trials will be analyzed in this paper according to preoperative, postoperative and chemoradiation approaches. Fifteen randomized preoperative trials were reported; they have been grouped according to the fractionation schedule. In the hypofractionation group (5 Gy for fraction), all five studies that delivered 3-5 doses in one week had a significant improvement in local control and one of them also showed improvement in survival. Operative mortality was higher in the radiotherapy arm if inadequate techniques had been applied. In 3 out of 8 studies with conventional fractionation there was a significant improvement in local control, but no impact in survival was detected. No studies with total dose lower than 34 Gy had an improvement in local control. None of the six randomized postoperative studies showed an improvement in local control or survival. In all trials the local control rate was uniform; ranging from 76% to 84%. Toxicity was higher in the radiotherapy arm. One preoperative and five postoperative randomized studies that used chemoradiation were analyzed. One postoperative chemoradiation study showed a significant improvement in survival in comparison to the surgery arm, and another showed the same advantage compared to the postoperative arm. Protracted infusional administration of 5FU concomitant to radiotherapy showed better survival than bolus administration. No advantages were shown in using MeCCNU or Levamisole in two studies. Toxicity was high and related to the dose and the modality of administration of the drugs in order to adequately treat the different stages of rectal cancer, patients must be carefully selected in order to prescribe the most effective and the least toxic treatment for the individual stage; organ preservation should be an essential goal for its impact on quality of life, and the cost estimates should be taken into account.

The effects of hyperbaric oxygen therapy on experimental colon anastomosis after preoperative chemoradiotherapy

The aim of the present study was to investigate the effect of hyperbaric oxygen therapy (HBOT) on colon anastomosis after chemoradiotherapy (CRT). Sixty female Wistar-Albino rats were divided into 5 groups and underwent left colon resection and end-to-end anastomosis. CRT simulation was performed on 2 sham groups before the anastomosis, and 1 of these groups was administered additional postoperative HBOT. Two groups were administered CRT before the anastomosis, and 1 of them received additional postoperative HBOT. On postoperative day 5, all groups underwent relaparotomy; burst pressure was measured and samples were obtained for histopathologic and biochemical analysis. There was a significant weight loss in the CRT groups and postoperative HBOT had an improving effect. Significantly decreased burst pressure values increased up to the levels of the controls after HBOT. Hydroxyproline levels were elevated in all groups compared to the control group. Hydroxyproline levels decreased with HBOT after CRT. No significant difference was observed between the groups regarding fibrosis formation at the anastomosis site. However, regression was observed in fibrosis in the group receiving HBOT after CRT. Preoperative CRT affected anastomosis and wound healing unfavorably. These unfavorable effects were alleviated by postoperative HBOT. HBOT improved the mechanical and biochemical parameters of colon anastomosis in rats.

Neoadjuvant radiotherapy for rectal cancer: meta-analysis of randomized controlled trials

BACKGROUND

Although neoadjuvant radiotherapy may improve local control of rectal cancer, its clinical value requires further evaluation as a result of potential side effects and advances in surgical technique. A meta-analysis was performed to assess effectiveness and safety of neoadjuvant radiotherapy in the management of rectal cancer.

METHODS

The following databases were searched: the Cochrane Library, Biosis, Web of Science, Embase, ASCO Abstracts and WHO International Clinical Trials Registry Platform. Randomized controlled trials on the following comparisons were included: (1) neoadjuvant therapy versus surgery alone and (2) neoadjuvant chemoradiotherapy versus neoadjuvant radiotherapy.

RESULTS

We identified 17 and 5 relevant trials that enrolled 8,568 and 2,393 patients, respectively. Neoadjuvant radiotherapy improved local control (hazard ratio 0.59; 95 % confidence interval 0.48-0.72) compared to surgery alone even after total mesorectal excision, whereas its benefit in overall survival just failed to reach statistical significance (0.93; 0.85-1.00). However, it was associated with increased perioperative mortality (1.48; 1.08-2.03), in particular if a dose of 5 Gy per fraction was administered (1.85; 1.23-2.78). Chemoradiotherapy improved local control as opposed to radiotherapy (0.53; 0.39-0.72), with no impact on perioperative outcome and long-term survival.

CONCLUSIONS

Neoadjuvant radiotherapy improves local control in patients with rectal cancer, particularly when chemoradiotherapy is administered. The question if the use of more effective chemotherapy protocols improves overall survival warrants further investigation.

The impact of preoperative chemoradiotherapy on advanced low rectal cancer

BACKGROUND

Preoperative chemoradiotherapy (CCRT) followed by radical resection is an option for advanced low rectal cancer. This study was aimed to clarify the impact of CCRT on patients' outcome.

PATIENTS AND METHODS

One hundred thirty-six patients with rectal cancer (<10  cm from anal verge) were enrolled prospectively between July 2000 and December 2004. The preoperative clinical stage was T3, T4, or node-positive disease. Sixty-nine and 67 patients underwent surgery with and without preoperative CCRT, respectively. The regimen of pre-op CCRT was a radiation dosage of 45  Gy in 20 fractions and oral tegafur-uracil (UFUR) and leucovorin.

RESULTS

There was no statistical difference in the preserved anorectal function between two groups after 5 years of follow-up (62.3% vs. 47.8%; P = 0.125). The 5-year overall survival and disease-free survival (DFS) percentage were 88.4% and 76.8% for patients with preoperative CCRT, and 65.7% and 58.2% for patients without CCRT, respectively. Patients with preoperative CCRT had a higher overall survival rate and DFS (P = 0.001 and 0.015).

CONCLUSIONS

In patients with advanced low rectal cancer, preoperative CCRT followed by radical surgery significantly improved overall survival and DFS compared with surgery alone. The effect of sphincter preservation with preoperative CCRT is questionable.

Evaluation of biologic effective dose and schedule of fractionation for preoperative radiotherapy for rectal cancer: meta-analyses and meta-regression

PURPOSE

To evaluate whether the risk of local recurrence depends on the biologic effective dose (BED) or fractionation dose in patients with resectable rectal cancer undergoing preoperative radiotherapy (RT) compared with surgery alone.

METHODS AND MATERIALS

A meta-analysis of randomized controlled trials (RCTs) was performed. The MEDLINE, Embase, CancerLit, and Cochrane Library databases were systematically searched for evidence. To evaluate the dose-response relationship, we conducted a meta-regression analysis. Four subgroups were created: Group 1, RCTs with a BED >30 Gy(10) and a short RT schedule; Group 2, RCTs with BED >30 Gy(10) and a long RT schedule; Group 3, RCTs with BED ≤ 30 Gy(10) and a short RT schedule; and Group 4, RCTs with BED ≤ 30 Gy(10) and a long RT schedule.

RESULTS

Our review identified 21 RCTs, yielding 9,097 patients. The pooled results from these 21 randomized trials of preoperative RT showed a significant reduction in mortality for groups 1 (p = .004) and 2 (p = .03). For local recurrence, the results were also significant in groups 1 (p = .00001) and 2 (p = .00001).The only subgroup that showed a greater sphincter preservation (SP) rate than surgery was group 2 (p = .03). The dose-response curve was linear (p = .006), and RT decreased the risk of local recurrence by about 1.7% for each Gy(10) of BED.

CONCLUSION

Our data have shown that RT with a BED of >30 Gy(10) is more efficient in reducing local recurrence and mortality rates than a BED of ≤ 30 Gy(10), independent of the schedule of fractionation used. A long RT schedule with a BED of >30 Gy(10) should be recommended for sphincter preservation.

Randomized clinical trials in rectal and anal cancers

This article reviews randomized clinical trials (RCTs) published between April 2001 and November 2008 on the management of patients with rectal cancer. In total, the authors reviewed 78 RCTs on therapy for rectal cancer. Of these, five met the authors' criteria for level 1a evidence. The article discusses the major RCTs and relevant findings that have impacted clinical management most and includes most but not all RCTs on therapy for rectal cancer published during this period.

Preoperative radiotherapy is associated with worse functional results after coloanal anastomosis for rectal cancer

PURPOSE

This study was designed to evaluate functional outcome in patients treated with preoperative radiotherapy after low anterior resection and a coloanal anastomosis for low rectal cancer.

METHODS

Functional outcome data from patients enrolled in a prospective randomized trial comparing 3 reconstructive procedures were evaluated with respect to administration of preoperative radiotherapy. Incontinence was assessed with a questionnaire on bowel function including the Fecal Incontinence Severity Index; sexual function was assessed with the Sexual Health Inventory for Men and a gender-specific questionnaire for women. Quality of life was assessed with SF-36 scores.

RESULTS

Of 364 patients enrolled, 153 (42%) had no radiotherapy or chemotherapy, and 211 (58%) had preoperative radiotherapy; 186 (51%) had chemotherapy in addition to radiotherapy. Comparison of irradiated vs. nonirradiated patients showed no significant differences in postoperative morbidity (29.9% vs. 35.3%; P = 0.27). Two-year follow-up of 297 patients showed greater impairment of bowel function in irradiated patients (n = 170) vs. nonirradiated patients (n = 127): e.g., mean number of daily bowel movements at 12 months, 4.2 +/- 3.5 vs. 3.5 +/- 2.6, P = 0.032; urgency, 85% vs. 67%, P = 0.002). Antidiarrheal use was significantly higher in irradiated patients vs. nonirradiated patients at 4 (P = 0.043), 12 (P = 0.002), and 24 (P = 0.001) months. Sexual Health Inventory for Men scores indicated poorer function in irradiated patients at 24 months (P = 0.039). Preoperative radiotherapy had no deleterious effects on quality of life. Multivariate analyses showed that negative effects of preoperative radiotherapy on urgency at 4 months (P = 0.002) and antidiarrheal use at 24 months were independent of reconstruction technique, but a positive effect of reconstruction with a J-pouch was still observed in patients who received radiotherapy.

CONCLUSION

Preoperative radiotherapy does not increase overall morbidity but is associated with poorer functional outcome after low anterior resection with coloanal anastomosis. Preoperative radiotherapy and the J-pouch are nonconfounding predictors of functional outcome up to 24 months after surgery.

Influence of long-term radiotherapy on symptoms and signs of locally advanced primary rectal cancer of distant localisation

This study is a part of a clinical trial in preoperative radiotherapy of low rectal cancer, conducted as a prospective and partly retrospective clinical study. It was designed to estimate the influence of long-term radiotherapy on symptoms of locally advanced rectal cancer. We included 49 patients with T3/4 stage adenocarcinoma (diagnosis confirmed by clinical, pathological and CT examinations) of the lower two thirds of the rectum, who were treated with long-term radiotherapy (45 Gy in 20-25 fractions) and questioned for the presentation of symptoms before and after the treatment. The chief complaints of these patients were the presence of blood in stool, abdominal and pelvic pain, straining (tenesmus) and the alteration in bowel movement. We found a significant decrease in symptoms and signs of the illness after the radiotherapy as well as the improvement of the quality of life.

Adjuvant and neoadjuvant chemoradiation or radiotherapy in rectal cancer--a review focusing on open questions

BACKGROUND

The therapy of rectal cancer has been a matter of debate since decades, especially with regard to the benefits of neoadjuvant or adjuvant therapies. Principles of additional therapies have been established nearly two decades ago and are questioned nowadays on the basis of more recently modified operative techniques. Benefits and sequelae of therapies have to be balanced against each other, and it seems somewhat likely that a more differentiated strategy than simply stating that every patient with stage II and III rectal cancer needs chemoradiation or radiotherapy will, in long term, be recommended.

CONCLUSION

It should be kept in mind that results of centers of excellence and of phase-III studies with their positively selected patient populations are not representative for all the patients with rectal cancer and physicians treating them.

Câncer ano-reto-cólico: aspectos atuais II - câncer colorretal - fatores de riscos e prevenção

O câncer colorretal é curável e passível de prevenção. A chave para o alcance desses objetivos é relativamente simples e pode ser aplicada em escala populacional. Basta, para tanto, que sejamos capazes de conscientizar os médicos, independente da sua área especial de atuação, e proporcionar às pessoas o mais fácil alcance às informações médicas expressas em termos simples sobre a profilaxia e o diagnóstico precoce dessa neoplasia maligna, sobretudo, destacando os fatores protetores e os de riscos, principalmente os que são suscetíveis de ser modificados.

[Experience with only preoperative radiotherapy of non-metastatic rectal tumours]

INTRODUCTION

It is an accepted fact that the local recurrence rate can be decreased up to 50% for the metastatic rectum tumours irradiated only preoperatively.

MATERIALS AND METHODS

181 patients having rectum tumour were irradiated preoperatively with 36 or 40 Gy between 1990 and 2001. The classification was made according to the modified Astler-Coller pathological staging system. The radiation treatment was carried out with telecobalt unit or high energy photon of linear accelerator after computerized radiation treatment planning.

RESULTS

The most important characterizing factor for the efficiency of the preoperative irradiation is the local recurrence rate that was found to be 21.56% in our investigation. The survival rate was significantly influenced by the age of the patient and the applied dose.

CONCLUSION

Our statistical analysis was applied to investigate the efficiency of the only preoperatively irradiated patients. The results are in agreement with the reported contributions.

Pre-operative radiotherapy and curative surgery for the management of localized rectal carcinoma

BACKGROUND

Preoperative radiotherapy (PRT) has become part of standard practice offered to improve treatment outcomes in patients with rectal cancer.

OBJECTIVES

To determine if PRT improves outcome for patients with localized resectable rectal cancer and how it compared with other adjuvant or neoadjuvant strategies.

SEARCH STRATEGY

A computerized search was performed December 2006 on MEDLINE (from 1966 to December 2006) and the Cochrane Central Register of Controlled Trials (CENTRAL), conference proceedings, using MeSH and textwords where appropriate to identify randomized trials in PRT and rectal cancer. In addition, MetaRegister of Clinical Trials was searched for ongoing trials.

SELECTION CRITERIA

Randomized trials with a PRT arm versus surgery alone, or other neoadjuvant or adjuvant (NA/A) strategies, targeted patients with localized rectal cancer planned for radical surgery were included.

DATA COLLECTION AND ANALYSIS

Trials were selected, data extracted and quality assessed by 2 authors. Quality was assessed using a 14 point checklist. Summary statistics included Hazard ratios and variances (for the outcomes: overall (OA) mortality, cause specific (CS) mortality, any recurrence and local recurrences (LR)) and Odds Ratio (OR) for other outcomes. Potential sources of heterogeneity hypothesized a priori included study quality, biological effective dose (BED), radiotherapy RT technique, and total mesorectal excision (TME) surgery.

MAIN RESULTS

Nineteen trials compared PRT versus surgery alone. Overall (OA) mortality was marginally improved HR 0.93 [95% CI -0.87-1](absolute difference is 2% if the expected survival rate is 60%). Local recurrence (LR) was improved but the magnitude of benefit was heterogeneous across trials. Sensitivity analyses suggested greater benefits in patients treated with BED>30Gy(10) and multiple field RT techniques. There was significantly more pelvic or perineal wound infection, late rectal and sexual dysfunction. Nine trials compared PRT vs. other NA/A. Available evidence did not support an OA mortality or sphincter preserving benefit with the use of combined chemoradiotherapy (CRT) or selective postoperative RT. CRT provides incremental benefit for local control compared with PRT, which was independent of the timing of the CT. There was no significant difference in outcome for different intervals between RT and surgery (2 vs. 8 wk). Dose escalation with endocavitary boost showed significant effect on sphincter preservation.

AUTHORS' CONCLUSIONS

Optimal PRT improves LR, OA mortality, but no increase in sphincter sparing procedure. CRT further increases local control. If the objective is to increase the incidence of sphincter sparing surgery, endocavitary boost showed the most promise. Strategies with the potential to improve outcomes, especially OAS and sphincter sparing while reducing acute and late toxicities (rectal and sexual function) are needed to guide future strategy designs.

Diagnostic and therapy of locally advanced rectal cancer

The aim of the study was to check the results of the protocol with neoadjuvant chemoirradiation for the treatment of locally advanced rectal cancer. The value of preoperative methods for staging of rectal cancer was also studied. In the period 1st of June 2000 - 31st of December 2005, 116 patients were included into the study, all with histologically proven rectal cancer up to 12 cm from anal verge and all with T3/T4 No-2 M0 stage. Median follow up was 48 months. Operability rate was 90,1%, local recurrency 12%, and survival 78%, though only 66% without sign of local or distant recurrency.

Chemotherapy with preoperative radiotherapy in rectal cancer

BACKGROUND

Preoperative radiotherapy is recommended for selected patients with rectal cancer. We evaluated the addition of chemotherapy to preoperative radiotherapy and the use of postoperative chemotherapy in the treatment of rectal cancer.

METHODS

We randomly assigned patients with clinical stage T3 or T4 resectable rectal cancer to receive preoperative radiotherapy, preoperative chemoradiotherapy, preoperative radiotherapy and postoperative chemotherapy, or preoperative chemoradiotherapy and postoperative chemotherapy. Radiotherapy consisted of 45 Gy delivered over a period of 5 weeks. One course of chemotherapy consisted of 350 mg of fluorouracil per square meter of body-surface area per day and 20 mg of leucovorin per square meter per day, both given for 5 days. Two courses were combined with preoperative radiotherapy in the group receiving preoperative chemoradiotherapy and the group receiving preoperative chemoradiotherapy and postoperative chemotherapy; four courses were planned postoperatively in the group receiving preoperative radiotherapy and postoperative chemotherapy and the group receiving preoperative chemoradiotherapy and postoperative chemotherapy. The primary end point was overall survival.

RESULTS

We enrolled 1011 patients in the trial. There was no significant difference in overall survival between the groups that received chemotherapy preoperatively (P=0.84) and those that received it postoperatively (P=0.12). The combined 5-year overall survival rate for all four groups was 65.2%. The 5-year cumulative incidence rates for local recurrences were 8.7%, 9.6%, and 7.6% in the groups that received chemotherapy preoperatively, postoperatively, or both, respectively, and 17.1% in the group that did not receive chemotherapy (P=0.002). The rate of adherence to preoperative chemotherapy was 82.0%, and to postoperative chemotherapy was 42.9%.

CONCLUSIONS

In patients with rectal cancer who receive preoperative radiotherapy, adding fluorouracil-based chemotherapy preoperatively or postoperatively has no significant effect on survival. Chemotherapy, regardless of whether it is administered before or after surgery, confers a significant benefit with respect to local control. (ClinicalTrials.gov number, NCT00002523 [ClinicalTrials.gov].).

Does rectal cancer shrinkage induced by preoperative radio(chemo)therapy increase the likelihood of anterior resection? A systematic review of randomised trials

BACKGROUND AND PURPOSE

According to common conviction rectal tumour shrinkage after preoperative radio(chemo)therapy increases the likelihood of anterior resection (AR). In order to verify this belief, we performed a systematic review of randomised trials.

PATIENTS AND METHODS

We identified 10 randomised trials encompassing altogether 4596 patients in whom preoperative radio(chemo)therapy resulted in tumour shrinkage in the experimental arm as compared to the control arm.

RESULTS

Tumour shrinkage observed in the experimental groups did not result in a statistically significant higher ARs rate in any study when we performed an analysis of all the randomised cases. Subgroups of patients considered to be candidates for abdominoperineal resection before randomisation were identified in three trials. A statistically significantly higher rate of ARs was demonstrated in the experimental arm of the CAO/ARO/AIO 94 study. However, in that study, sphincter preservation was a secondary endpoint and some features of the trial may bias the estimation of the effect. The benefit of sphincter preservation was not confirmed by subgroup analyses performed in the Lyon R90-01 study and in the Polish study, which were originally designed to evaluate the sphincter preservation issue.

CONCLUSION

The body of evidence gathered from randomised trials does not support the concept of a beneficial effect of preoperative radiotherapy on the ARs rate.

How Safe is Adjuvant Chemotherapy and Radiotherapy for Rectal Cancer?

Over the last three decades, a series of clinical trials have led to the use of adjuvant pelvic radiotherapy and chemotherapy in high-risk (T3-4 or N1) rectal cancer. There is a need to improve patient selection in order to identify the group most at risk for recurrent disease. The toxicity of adjuvant therapy should be factored into this consideration. The optimal sequencing of adjuvant therapy before or after surgery, the use of short- or long-course radiotherapy, and the utility of concurrent chemotherapy is currently being examined in randomized controlled trials (RCTs). The aim of this report was to review the morbidity and mortality in all RCTs of adjuvant therapy for rectal cancer.

The use of preoperative radiotherapy in the management of patients with clinically resectable rectal cancer: a practice guideline

BACKGROUND

This systematic review with meta-analysis was designed to evaluate the literature and to develop recommendations regarding the use of preoperative radiotherapy in the management of patients with resectable rectal cancer.

METHODS

The MEDLINE, CANCERLIT and Cochrane Library databases, and abstracts published in the annual proceedings of the American Society of Clinical Oncology and the American Society for Therapeutic Radiology and Oncology were systematically searched for evidence. Relevant reports were reviewed by four members of the Gastrointestinal Cancer Disease Site Group and the references from these reports were searched for additional trials. External review by Ontario practitioners was obtained through a mailed survey. Final approval of the practice guideline report was obtained from the Practice Guidelines Coordinating Committee.

RESULTS

Two meta-analyses of preoperative radiotherapy versus surgery alone, nineteen trials that compared preoperative radiotherapy plus surgery to surgery alone, and five trials that compared preoperative radiotherapy to alternative treatments were obtained. Randomized trials demonstrate that preoperative radiotherapy followed by surgery is significantly more effective than surgery alone in preventing local recurrence in patients with resectable rectal cancer and it may also improve survival. A single trial, using surgery with total mesorectal excision, has shown similar benefits in local recurrence.

CONCLUSION

For adult patients with clinically resectable rectal cancer we conclude that: Preoperative radiotherapy is an acceptable alternative to the previous practice of postoperative radiotherapy for patients with stage II and III resectable rectal cancer. Both preoperative and postoperative radiotherapy decrease local recurrence but neither improves survival as much as postoperative radiotherapy combined with chemotherapy. Therefore, if preoperative radiotherapy is used, chemotherapy should be added postoperatively to at least patients with stage III disease.

[Indications for neoadjuvant therapy in rectal carcinoma]

Pre- and postoperative adjuvant treatments for locally advanced, operable (R0 resection) rectum carcinoma have led to improved results. In principle, according to the interdisciplinary consensus of the German Cancer Society, the recommended treatment for rectum carcinoma (T3/4; N0; M0; any T stage; N+; M0) is still postoperative adjuvant radiochemotherapy. In the meantime, however, based on the good results obtained from various clinical trials preoperative adjuvant treatment is favored internationally. Not only does this treatment scheme show a comparably better compliance of the patients but it also seems to be better tolerated. One treatment option for resectable T3 tumors immediately followed by surgery is the sole hypofractionated preoperative 3-4 field external beam radiotherapy. An additional benefit can be expected from protracted preoperative radiochemotherapy (single dose 2 Gy, total dose >40 Gy, chemotherapy based on 5-FU) followed by operation several weeks later. For T4 tumors with expected R1 or R2 resection, preoperative treatment is urgently recommended. A further aim in compliance with the surgical approach (R0 resection!) and multimodal treatment may be for individual cases the preservation of continence.

Current evidence does not support routine adjuvant radiotherapy for rectal cancer

BACKGROUND

There is widespread support in the published literature for routine adjuvant radiotherapy for rectal cancer.

METHODS

In the present paper, the current evidence regarding adjuvant radiotherapy is reviewed, particularly the most recent studies of preoperative radiotherapy (usually including patients with Stage I, II and III disease) and postoperative radiotherapy (usually for Stage II and III disease), and meta-analyses. Two questions in particular are addressed: Does radiotherapy improve survival when surgeons are able to achieve low local recurrence rates with surgery alone? Does radiotherapy improve patients' quality of life?

RESULTS

Radiotherapy has only been demonstrated to significantly improve survival in one individual study and one recent meta-analysis. The local recurrence rates in the no-radiotherapy arm of these studies were 27% and 21-36.5%, respectively. In more recent studies, with lower local recurrence rates reflecting modern surgical standards, no survival advantage has been found. It is currently unknown whether radiotherapy improves patients' quality of life. Studies have demonstrated that radiotherapy has acute and long-term detrimental effects on quality of life. While local recurrence can be very debilitating, it can also be asymptomatic, and the overall effect of the local recurrence statistics found in adjuvant therapy studies on quality of life has not been systematically investigated. The most recent studies demonstrate that 17-20 patients need to undergo adjuvant radiotherapy to prevent one local recurrence.

CONCLUSION

Current evidence does not support the widespread advocacy for routine adjuvant radiotherapy as used in the treatment arms of recent trials.

The role of preoperative and postoperative radiotherapy in rectal cancer

Radiotherapy has an important role to play when used in addition to surgery in primary and recurrent rectal cancer. In primary resectable rectal cancer, a large number of randomized trials have shown that preoperative radiotherapy can slightly improve survival and can decrease local recurrence rates by more than half. Postoperative radiotherapy may also decrease the risk of local failure although with less efficacy. A preoperative schedule of 5 Gy/day for 5 out of 7 days is a convenient and low-toxic treatment, provided it is not given with 2 beams to large volumes, and it appears to be at least as effective as postoperative radiochemotherapy, generally meaning 6 months of therapy with 5 weeks of radiation. The schedule of 5 Gy/day for 5 days also reduces local recurrences with total mesorectal excision. It is unlikely that preoperative radiochemotherapy will substantially increase the chances of a sphincter-preserving procedure in a low-lying rectal cancer and that the long-term function will be adequate even if this is believed by many. In primary nonresectable or locally recurrent rectal cancer, preoperative radiotherapy may downsize or downstage the tumor so that it can be resected. Scientific support that radiochemotherapy is more efficient than radiotherapy alone in this situation is weak.

Importance of tumor regression assessment in predicting the outcome in patients with locally advanced rectal carcinoma who are treated with preoperative radiotherapy

BACKGROUND

Locally advanced rectal carcinoma has a poor prognosis. However, since the introduction of preoperative radiotherapy, the outcome of patients with rectal carcinoma has been reported to have improved. Nevertheless, to the authors' knowledge few data are available regarding the histopathologic response to radiotherapy as assessed on surgical specimens as a potential predictive factor for outcome.

METHODS

To estimate the effect of radiotherapy on rectal carcinoma, the authors retrospectively reviewed the surgical specimens of 102 patients with T3-4, N0 or > or = N1 rectal carcinoma and 1 patient with T2 but N1 rectal carcinoma. All patients were treated preoperatively with a hyperfractionated accelerated radiotherapy schedule in a prospective protocol (Trial 93-01). Using a standardized approach, tumor regression was graded using a system that varies from Grade 1 (tumor regression Grade [TRG] 1) when complete tumor regression is observed to Grade 5 (TRG5) when no tumor regression is observed.

RESULTS

Radiotherapy resulted in tumor downstaging in 43% of the patients. There were 2 pT1 tumors (2%), 21 pT2 tumors (20%), 66 pT3 tumors (64%), and 14 pT4 tumors (14%) after treatment. Regional lymph nodes were involved in 55 patients (53%). None of the patients demonstrated a complete tumor regression after radiotherapy, but in 79% of the specimens a partial tumor regression was observed (TRG1: 0%; TRG2: 20%; TRG3: 39%; TRG4: 20%; and TRG5: 21%). The median actuarial overall survival (OS) and disease-free survival (DFS) were 52 months. Actuarial local recurrence rates at 2 years and 5 years were 6.4% and 7.6%, respectively. Univariate analysis showed the actuarial DFS to be significantly lower in patients with lymph node metastases (P = 0.0004) and advanced pT stages (pT3-4) (P = 0.03). A favorable outcome for OS, DFS, and local control was observed in patients with TRG2-4 (i.e., responders) compared with patients with TRG5 (i.e., nonresponders), but also in patients with low residual tumor cell density (TRG2, 3, and 4). On multivariate analysis, TRG remained an independent prognostic indicator for local tumor control.

CONCLUSIONS

Tumor regression as well as residual tumor cell density were found to be predictive factors of survival in rectal carcinoma patients after preoperative radiotherapy. Even after preoperative radiotherapy, the pathologic stage of the surgical specimen remained a prognostic factor. The use of a standardized approach for pathologic evaluation must be implemented to allow comparison between the results of various treatment approaches.

Rectal cancer in Victoria in 1994: patterns of reported management

BACKGROUND

A retrospective survey of medical practitioners was conducted to describe the management of patients newly diagnosed with rectal cancer in 1994, prior to the publication of best practice guidelines.

METHODS

A sample of 908 patients with rectal cancer diagnosed between 1 January and 31 December 1994 was identified from the Victorian Cancer Registry. Questionnaires were then sent to the treating doctor(s) for completion. The topics covered by the questionnaires included: reported management by method of diagnosis; staging investigations; and treatment by surgery, chemotherapy and radiotherapy.

RESULTS

Seven hundred and twenty-six (80%) of 908 eligible patients were surveyed. Surgery was the primary treatment in 681 (93.8%) with curative intent in 483 (70.9%) of these cases. One- third (163; 33.7%) of curative cases were pathologically staged as Dukes' C. Almost all patients (96%) were symptomatic, and three-quarters were referred by general practitioners to 166 surgeons. One-third (221; 32.5%) underwent liver computed tomography or ultrasound, and only three cases had transrectal ultrasound. Restorative anterior resection was the most common surgical procedure (431; 63.3%) with 160 (23.5%) and 34 (5.0%) patients being managed with abdominoperineal resections and local excision, respectively. Chemotherapy and radiotherapy were administered as part of the initial management to 216 (31.7%) and 171 (25.1%) patients, respectively. In five of the 171 cases, radiotherapy was given preoperatively.

CONCLUSIONS

There was considerable variation in preoperative assessment. Staging was less complete than expected by today's standards. The diversity of surgical techniques observed may reflect both the lack of clinical trials and disparity in surgical training and experience. Referral to stomal therapists, and medical and radiation oncologists was lower than would now be expected, as was the use and timing of adjuvant therapies. These findings will be useful as a baseline for comparison with subsequent surveys conducted since the introduction of evidence-based guidelines.

Role of radiation therapy in the treatment of resectable rectal adenocarcinoma

The purpose of this study is to review the role of radiation therapy in the treatment of resectable rectal adenocarcinoma. Selection criteria, treatment techniques, and results are discussed.

Intraoperative presacral electron boost following preoperative chemoradiation in T3-4Nx rectal cancer: initial local effects and clinical outcome analysis

BACKGROUND AND PURPOSE

To analyze early results of a single institution experience using adjuvant intraoperative electron radiation therapy (IOERT) presacral boost in locally advanced rectal cancer following preoperative chemoradiation.

MATERIALS AND METHODS

In a 63 month period (March 1995-June 2000), 100 consecutive T(3-4)N(x) rectal cancer patients were treated with preoperative chemoradiation (45-50 Gy plus oral Tegafur or 5-Fluorouracil continuous intravenous infusion), radical surgery and IOERT presacral boost (mean dose, 12.5 Gy; range, 10-15 Gy). Adjuvant chemotherapy (5-FU-leucovorin: 4-6 cycles) was given to 52 patients. The median age was 63 years, and 39 patients were >or=70 years old (65 males). Clinical staging was performed with computed tomography (94%) and/or endorectal ultrasound (71%) categorizing 90 cT(3), 10 cT(4), 20 cN(x), and 36 cN(+). Abdomino-perineal resection was performed in 41 cases.

RESULTS

The IOERT cancellation rate was 6%. With a median follow-up of 23 months in IOERT treated patients, three developed pelvic recurrence: one anastomotic and one in the posterior vaginal wall (simultaneously with distant metastatic disease); and one presacral (in-field IOERT) as the only site of initial failure. Distant metastasis has been observed in 14 patients (exceptionally in pT(0-1) downstaged patients: 1/20; 5%). Overall treatment tolerances, including neoadjuvant and surgical segments, were acceptable. The actuarial 4-year estimations of local control, disease-free and overall survival are 94, 75 and 65%, respectively.

CONCLUSIONS

IOERT electron boost to the presacral region is feasible to integrate systematically in the intensive combined treatment of locally advanced rectal cancer, including neoadjuvant chemoradiation segment. Topography of pelvic recurrences identified 2/3 relapses located in non-IOERT boosted anatomic intrapelvic sites: posterior vaginal wall and anastomotic suture. Presacral recurrence in locally advanced rectal cancer seems to be of low incidence, in a non-subspecialized academic surgical practice coordinated with a multidisciplinary oncology evaluation context, if an IOERT boost is included as a component of treatment together with preoperative chemoradiation.

Randomized clinical trials in rectal and anal cancer

Treatment of rectal cancer has changed dramatically over the past two decades. Radical surgery alone for resectable rectal cancer has been replaced by combined modality therapy. Interest in optimizing sphincter preservation and quality of life motivated surgeons to seek less radical surgery without compromising oncologic principles.

Pathologic downstaging of T3-4Nx rectal cancer after chemoradiation: 5-fluorouracil vs. Tegafur

PURPOSE

To describe downstaging effects in locally advanced rectal cancer induced by 2 fluopirimidine radiosensitizing agents given through different routes in conjunction with preoperative radiotherapy.

METHODS AND MATERIALS

From March 1995 to December 1999, two consecutive groups of patients with cT3-4Nx rectal cancer (94% CT scan, 71% endorectal ultrasound) were treated with either (1) 45-50 Gy (1.8 Gy/day, 25 fractions) and 5-fluorouracil (5-FU) (500-1,000 mg/m2 by 24-h continuous i.v. infusion on Days 1-4 and 21-25) or (2) oral Tegafur (1,200 mg/day on Days 1-35, including weekends). Surgery was performed 4 to 6 weeks after the completion of chemoradiation.

RESULTS

The total T downstaging rate was 46% in the 5-FU group and 53% in the Tegafur group. Subcategories were downstaged by the sensitizing agents (5-FU vs. Tegafur) as follows: pT0-1, 14% vs. 23%; pT2, 32% vs. 32%; pT3, 49% vs. 37%; pT4, 5% vs. 7%; and N(0), 74% vs. 86%. Analysis of residual malignant disease in the specimen discriminated mic/mac subgroups (mic: <20% of microscopic cancer residue), with evident superior downstaging effects in the Tegafur-treated group: pTmic 23% vs. 58% (p = 0.002).

CONCLUSIONS

When administered concurrent with pelvic irradiation, oral Tegafur induced downstaging rates in both T and N categories superior to those induced by intermediate doses of 5-FU by continuous i.v. infusion. In this pilot experience, oral Tegafur reproduced the characteristics of downstaging described previously when full doses of 5-FU have been combined with radiotherapy.

Adjuvant radiotherapy for rectal cancer: a systematic overview of 8,507 patients from 22 randomised trials

BACKGROUND

At least 28 randomised, controlled trials have compared outcomes of surgery for rectal cancer combined with preoperative or postoperative radiotherapy with those of surgery alone. We have done a collaborative meta-analysis of these results to give a more balanced view of the total evidence and to increase statistical precision.

METHODS

We centrally checked and analysed individual patient data from 22 randomised comparisons between preoperative (6,350 patients in 14 trials) or postoperative (2157 in eight trials) radiotherapy and no radiotherapy for rectal cancer.

FINDINGS

Overall survival was only marginally better in patients who were allocated to radiotherapy than in those allocated to surgery alone (62% vs 63% died; p=0.06). Rates of apparently curative resection were not improved by preoperative radiotherapy (85% radiotherapy vs 86% control). Yearly risk of local recurrence was 46% (SE 6) lower in those who had preoperative radiotherapy than in those who had surgery alone (p=0.00001), and 37% (10) lower in those who had postoperative treatment than those who had surgery alone (p=0.002). Fewer patients who had preoperative radiotherapy died from rectal cancer than did those who had surgery alone (45% vs 50%, respectively, p=0.0003), but early (</=1 year after treatment) deaths from other causes increased (8% vs 4% died, p<0.0001).

INTERPRETATION

Preoperative radiotherapy (at biologically effective doses >/=30 Gy) reduces risk of local recurrence and death from rectal cancer. If safety can be improved without compromising effectiveness, then overall survival would be moderately improved by use of preoperative radiotherapy, especially for young, high risk patients. Postoperative radiotherapy also reduces local recurrence, but short preoperative radiation schedules seem to be at least as effective as longer schedules.

Optimising treatment for resectable rectal cancer: is preoperative therapy beneficial?

Preoperative radiotherapy is becoming the standard of care for resectable locally advanced adenocarcinoma of the rectum. Its practice is no longer limited to a few specialised cancer centres. Adjuvant preoperative radiotherapy can reduce the risk of local recurrence by 50% compared with surgery alone and it has a moderate effect in improving survival. Treatment-related toxicity is superior to that after postoperative radiotherapy. Early results of preoperative radiotherapy with concurrent chemotherapy are promising, with a low toxicity profile and a high pathological response rate. Advances in technology, endorectal ultrasound and magnetic resonance imaging enable selection of appropriate patients for preoperative radiotherapy.

Adjuvant therapy for resectable rectal adenocarcinoma

The mainstay of treatment for rectal cancer over the past 100 years has been surgical resection. However, for the majority of rectal cancers treated conventionally by resection alone, locoregional recurrence is the major mode of failure. Over the past several decades, significant progress has been made in developing effective adjuvant regimens. In the United States, postoperative chemoradiation is standard treatment for T3 or node-positive patients. However, preoperative radiation with or without chemotherapy decreases local recurrence, increases sphincter preservation, and may improve survival. The purpose of this article is to review the role of adjuvant therapy in resectable rectal cancers and to update the status of ongoing randomized trials.

Usefulness of endorectal ultrasound after preoperative radiotherapy in rectal cancer: comparison between sonographic and histopathologic changes

PURPOSE

Our aim was to assess the advantages of endorectal ultrasound after preoperative radiotherapy in rectal cancer, its reliability in tumoral staging, and its capacity to identify completely sterilized lesions.

METHODS

From 1994 to 1997, 29 patients with rectal cancer were systematically subjected to endorectal ultrasound before and after preoperative radiotherapy. Each patient was administered 30 to 50 Gy, followed by surgery six to eight weeks after completion of radiotherapy. Endorectal ultrasound was performed using a biplanar (linear and sectorial) endorectal probe. The morphologic, quantitative, and echo-pattern changes of the irradiated tumor were examined. Results of ultrasound findings before and after radiotherapy and a histologic examination of the surgical specimens were compared. Histopathologic studies were used to evaluate macromicroscopical radiation-induced changes, case by case. A comparison between tumoral shrinkage and fibrotic replacement was made using the semiquantitative Dworak's method.

RESULTS

Morphologically and quantitatively, postradiation endorectal ultrasound showed the reappearance of anatomic cleavage planes, a considerable shrinkage of the tumor, and in low rectal tumors, an increase in the distance from the anorectal ring in more than 50 percent of the cases. These data had a direct influence on surgical treatment. Histologic examination showed that, in 28 out of 29 cases, fibrosis was the most dominant component of the irradiated lesions, varying by more than 50 to 100 percent of the lesion (four cases pTO). A comparison of postradiation endorectal ultrasound with histopathology revealed that fibrosis became the morphologic basis of ultrasound images; therefore, after radiotherapy, what endorectal ultrasound staged was no longer the tumor but the extent of fibrosis in the rectal wall. A histopathologic examination showed that the residual tumor, when present, was always within the fibrosis, never outside or separate from it. Postradiation endorectal ultrasound showed echo-pattern changes. Some of the changes (more echogenic and nonhomogeneous lesions) were histologically related to the persistence of the tumor to a considerable degree; other changes (reappearance of parietal layers) were related to complete sterilization of lesions in two of three cases.

CONCLUSIONS

From the morphologic and quantitative point of view, postradiation endorectal ultrasound provides oncologists and surgeons useful information to assess treatment effectiveness and plan the surgical approach. From the tumor staging point of view, our report presents a completely new concept: that six to eight weeks after radiotherapy, endorectal ultrasound no longer stages the tumor, but rather the fibrosis that takes its place. However, postradiation endorectal ultrasound is a valid tool, because the extent of fibrosis in the rectal wall is a direct indication of the depth of residual cancer. A residual tumor, when present, is always inside the fibrosis. Finally, however, as regards the capacity of endorectal ultrasound to exclude or indicate complete sterilization of the lesion, the actual significance of the echo-pattern changes we observed needs to be assessed further by studies on a large number of cases.

Improved outcome following preoperative radiochemotherapy: 40.5 Gy accelerated hyperfractionation and 5-fluorouracil suppositories for patients with carcinoma of the lower rectum

The aim of this study was to determine the long-term effects of administering preoperative radiochemotherapy to patients with carcinoma of the lower rectum. The outcomes of 29 patients who underwent curative surgery for carcinoma of the lower rectum after receiving radiochemotherapy in the form of 40.5 Gy accelerated hyperfractionation and a total dose of 3 400 mg 5-fluorouracil given as suppositories, with or without hyperthermia, and 48 patients who underwent surgery alone, were retrospectively compared. The tumors in all the patients were histologically diagnosed as stage T3. The cumulative 5-year survival rate and 5-year local recurrence-free rate of the patients treated with radiochemotherapy plus surgery were significantly better than those of the patients treated by surgery alone, the respective values being 80.5% vs 59.8% (P = 0.0325) and 95.7% vs 61.4% (P = 0.0041). Dehiscence of the perineal wound, anastomotic leakage, and postoperative ileus occurred at similar frequencies in both groups; however, perineal wound healing after abdominoperineal resection was delayed in the patients treated with radiochemotherapy plus surgery at 42.7 days vs 25.4 days (P = 0. 0062). In conclusion, although the wound healing was delayed, preoperative radiochemotherapy is considered to be beneficial for patients with carcinoma of the lower rectum.

Preoperative chemoradiation with cisplatin and 5-fluorouracil for extraperitoneal T3 rectal cancer: acute toxicity, tumor response, sphincter preservation

PURPOSE

To evaluate the impact of preoperative external radiation therapy intensified by systemic chemotherapy including bolus cisplatin (c-DDP) and 4-day infusional 5-fluorouracil (PLAFUR-4) on tumor response and sphincter preservation in patients with extraperitoneal T3 rectal cancer with acceptable toxicity, and to compare the results to our previous experience with bolus mitomycin c (MMC) and 4-day infusion 5-FU (FUMIR).

METHODS AND MATERIALS

Between October 1995 and March 1998, 40 consecutive patients with resectable extraperitoneal adenocarcinoma of the rectum were treated with preoperative chemoradiation: slow infusion i.v. c-DDP, 60 mg/m2, day 1 and 29 plus 24-h continuous infusion i.v. 5-fluorouracil (5-FU) 1000 mg/m2, days 1-4 and 29-32, and concurrent external beam radiotherapy (45 Gy whole pelvis followed by 5.4 Gy boost). All but 3 patients had T3 disease. Surgery was performed 6-8 weeks after the end of chemoradiation.

RESULTS

No patient had Grade 4 acute toxicity. Grade 3 hematological toxicity was observed only in 2 (5%) patients. No patient had major gastrointestinal, skin, or urological acute toxicity. All patients had radical surgery. There was no perioperative mortality; perioperative morbidity rate was 12%. Overall, 23% (9 of 40) of patients had a complete pathological response and 10% (4 of 40) of patients had rare isolated residual cancer cells (Tmic). Comparing the stage at the diagnostic workup with the pathological stage, tumor downstaging was observed in 27 (68%) patients; nodal status downstaging was detected in 24 (60%) patients. Thirty-four (85%) patients had a sphincter-saving surgical procedure. In 4 of 10 (40%) patients who were definitive candidates for an abdominoperineal resection (APR), the sphincter was preserved, as it was in 13 of 13 (100%) probable candidates. Lengthening of the distance between the anorectal ring and the lower pole of the tumor > or =20 mm was observed in 9 (23%) patients. None of the patients had soilage after the sphincter-saving procedure. In our previous experience with FUMIR the complete pathological response was 9%, the sphincter-saving surgical procedure was performed in 66% cases, and the Grade 3+ toxicity was observed in 13% of patients.

CONCLUSIONS

The addition of c-DDP to 5-FU (PLAFUR-4) in a neoadjuvant radiochemotherapy schedule improved the pathological response rate in comparison with our previous experience. Toxicity was low indeed, thus we commenced another study adding one more day of 5-FU infusion (PLAFUR-5) to further improve our results.