Postoperative Adjuvant Chemoradiotherapy for Rectal Cancer: Analysis of Acute and Chronic Toxicity

Postoperative Radiochemotherapy in Rectal Cancer Comparison of two Combination Schemes: Alternating versus Concomitant

Aims and background

To compare the results on disease control and toxicity of two different schedules of adjuvant combined treatment in advanced rectal cancer.

Methods

From January 1995 to September 1998, 127 patients with stage B2-C rectal cancer were treated with postoperative chemotherapy and radiotherapy with two different schemes: three cycles of 5-fluorouracil and leucovorin followed by pelvic radiotherapy and three weeks after radiation therapy was completed, another three cycles of chemotherapy were administered (alternating arm), or two cycles of 5-fluorouracil and leucovorin followed by concurrent radiochemotherapy and three weeks after ending another two cycles of 5-fluorouracil and leucovorin were administered (concomitant arm).

Results

Grade 3 acute toxicity was more frequent in the concomitant schedule group (33% vs 13%, P = 0.014). In the alternating schedule group, the acute adverse effects were observed after an average radiation dose of 28.4 Gy and in the concomitant schedule group after an average dose of 22.7 Gy (P = 0.012). In the arm of concomitant treatment, 37.8% of patients had to interrupt the irradiation for severe toxicity compared to 10.4% in the arm of alternating treatment (P = 0.001). There was no difference in the rate of late toxicity. The actuarial overall survival rates at 3 and 5 years were, respectively, 68.8% and 56.6% in the alternating arm and 75.5% and 61.8% in the concomitant arm (P = 0.4599). There were no differences between the two arms in the 5-year actuarial rates of overall recurrence (47% vs 51.3%, P= 0.722), local recurrence (34.6% vs 35.7%, P = 0.935) or distant recurrence (32.7% vs 31.8%, P = 0.983).

Conclusions

For patients with B2-C rectal cancer, postoperative treatment with an alternating scheme of chemoradiotherapy is as effective as a concomitant scheme in control of the disease. The concomitant scheme had a higher incidence, earlier appearance and higher severity of intestinal acute toxicity than the alternating scheme, with a lower completion rate of chemoradiotherapy but without any influence on late toxicity incidence.

Conservative therapies for hemorrhagic radiation proctitis: a review

Chronic radiation proctitis represents a challenging condition seen with increased frequency due to the common use of radiation for treatment of pelvic cancer. Hemorrhagic radiation proctitis represents the most feared complication of chronic radiation proctitis. There is no consensus for the management of this condition despite the great number of clinical approaches and techniques that have been employed. Rectal resection represents an available option although associated with high morbidity and risk of permanent colostomy. The effectiveness of nonoperative approaches remains far from desirable, and hemorrhagic recurrence represents a major drawback that leads to a need for consecutive therapeutic sessions and combination of techniques. We conducted a critical review of published reports regarding conservative management of hemorrhagic chronic radiation proctitis. Although prospective randomized trials about hemorrhagic radiation proctitis are still lacking, there is enough evidence to conclude that topical formalin therapy and an endoscopic approach delivering an argon plasma coagulation represent available options associated with elevated effectiveness for interruption of rectal bleeding in patients with chronic radiation proctitis.

Combined modality therapy of rectal cancers

Rectal cancer accounts for about 10% of new cancer cases each year. It strikes men and women at nearly the same rate, generally in the range of 50-80 years of age, with rising incidence with age. Despite simple screening procedures rectal cancer is often advanced when discovered. Current trends in the management of cancer have focused on organ preservation and improved quality of life without compromising the overall survival. During the last decade substantial progress has been made in treatment modalities: new and improved radiation techniques (conformal radiotherapy, altered fractionation, brachytherapy), chemotherapy (protracted infusion, use of radiosensitizers) and development of surgical procedures-enabling safer postoperative irradiation. In patients with advanced/unresectable disease aggressive combined chemoradiation can be added prior to surgery to downstage the tumour and increase the proportion treated with anal-rectal-sparing procedures. Preoperative chemoradiation therapy regimens are as safe and tolerable as the standard postoperative treatment. In this presentation indications for preoperative radiochemotherapy will be discussed in detail, together with treatment-related side effects, prognostic parameters, tumour response and outcome. Different irradiation settings and chemotherapy schedules are described. In patients with primary resectable disease (mainly Dukes C) several prospective randomised trials have shown less local recurrence with postoperative combined modality therapy.