Randomized trial of postoperative adjuvant therapy in stage II and III rectal cancer to define the optimal sequence of chemotherapy and radiotherapy: a preliminary report

Quality of Surgical Outcome Reporting in Randomised Clinical Trials of Multimodal Rectal Cancer Treatment: A Systematic Review

INTRODUCTION

Randomised controlled trials (RCTs) continue to provide the best evidence for treatment options, but the quality of reporting in RCTs and the completeness rate of reporting of surgical outcomes and complication data vary widely. The aim of this study was to measure the quality of reporting of the surgical outcome and complication data in RCTs of rectal cancer treatment and whether this quality has changed over time.

METHODS

Eligible articles with the keywords ("rectal cancer" OR "rectal carcinoma") AND ("radiation" OR "radiotherapy") that were RCTs and published in the English, German, Polish, or Italian language were identified by reviewing all abstracts published from 1982 through 2022. Two authors independently screened and analysed all studies. The quality of the surgical outcome and complication data was assessed based on fourteen criteria, and the quality of RCTs was evaluated based on a modified Jadad scale. The primary outcome was the quality of reporting in RCTs and the completeness rate of reporting of surgical results and complication data.

RESULTS

A total of 340 articles reporting multimodal therapy outcomes for 143,576 rectal cancer patients were analysed. A total of 7 articles (2%) met all 14 reporting criteria, 13 met 13 criteria, 27 met from 11 to 12 criteria, 36 met from 9 to 10 criteria, 76 met from 7 to 8 criteria, and most articles met fewer than 7 criteria (mean 5.5 criteria). Commonly underreported criteria included complication severity (15% of articles), macroscopic integrity of mesorectal excision (17% of articles), length of stay (18% of articles), number of lymph nodes (21% of articles), distance between the tumour and circumferential resection margin (CRM) (26% of articles), surgical radicality according to the site of the primary tumour (R0 vs. R1 + R2) (29% of articles), and CRM status (38% of articles).

CONCLUSION

Inconsistent surgical outcome and complication data reporting in multimodal rectal cancer treatment RCTs is standard. Standardised reporting of clinical and oncological outcomes should be established to facilitate comparing studies and results of related research topics.

A Comprehensive Review of Randomized Clinical Trials Shaping the Landscape of Rectal Cancer Therapy

Colorectal carcinoma is the second leading cause of cancer-related deaths in the United States, with rectal cancer accounting for approximately one third of newly diagnosed cases. Surgery remains the cornerstone of curative therapy, with total mesorectal excision being the standard of care. Although minimally invasive procedures might be appropriate for a subset of patients with early-stage, superficial tumors, the standard of care for medically operable patients with nonmetastatic rectal cancer includes a comprehensive multimodality approach of neoadjuvant chemoradiotherapy, surgery with total mesorectal excision, and systemic chemotherapy. However, the morbidity and mortality related to both local and distant organ relapse have remained challenging. In the present review, we have discussed the trial-level evidence that has shaped the current clinical practice patterns in the treatment of curable, nonmetastatic rectal cancer. In addition, we have discussed the anticipated results of ongoing clinical trials and outlined pragmatic opportunities for future investigation to optimize the current status quo and, hopefully, provide prospective validation of novel approaches in the treatment of rectal cancer.

Oxaliplatin-Based Adjuvant Chemotherapy for Rectal Cancer After Preoperative Chemoradiotherapy (ADORE): Long-Term Results of a Randomized Controlled Trial

PURPOSE

We evaluated the role of oxaliplatin as adjuvant chemotherapy in patients with rectal cancer who received preoperative chemoradiotherapy (CRT) with fluoropyrimidine monotherapy and total mesorectal excision (TME).

METHODS

The ADORE trial (adjuvant oxaliplatin in rectal cancer) is a multicenter, randomized trial in patients with postoperative ypStage II (ypT3-4N0) or III (ypT_anyN1-2) rectal cancer after fluoropyrimidine-based preoperative CRT and TME. Patients were randomly assigned (1:1) to receive adjuvant chemotherapy either with FL (fluorouracil 380 mg/m² and leucovorin 20 mg/m²) or FOLFOX (oxaliplatin 85 mg/m², leucovorin 200 mg/m², and fluorouracil bolus 400 mg/m² on day 1, fluorouracil infusion 2,400 mg/m² for 46 hours). Stratification factors included ypStage and participating center. Primary end point was disease-free survival (DFS).

RESULTS

A total of 321 patients were enrolled between November 19, 2008, and June 12, 2012. Six-year DFS rates were 68.2% in the FOLFOX arm versus 56.8% in the FL arm, with a stratified hazard ratio of 0.63 (95% CI, 0.43 to 0.93; P = .018) by intention-to-treat analysis. In the subgroup analysis for DFS, FOLFOX was favorable versus FL in patients with ypStage III, ypN1b, ypN2, high-grade histology, minimally regressed tumor, and an absence of lymphovascular or perineural invasion. Six-year overall survival rate was 78.1% in the FOLFOX arm versus76.4% in the FL arm (hazard ratio, 0.73; 95% CI, 0.45 to 1.19; P = .21). In the subgroup analysis for OS, FOLFOX was favorable versus FL in patients with ypN2 and minimally regressed tumor.

CONCLUSION

Adjuvant FOLFOX improved DFS in patients with rectal cancer with ypStage II and III disease after preoperative CRT. Adjuvant FOLFOX may be considered on the basis of the postoperative pathologic stage in those who received preoperative CRT and TME.

Endoscopic ultrasound for rectal cancer staging: A population-based study of utilization, impact on treatment patterns, and survival

BACKGROUND AND AIM

Optimal rectal cancer (RC) outcomes depend on accurate locoregional staging. The study sought to describe the impact of endoscopic ultrasound (EUS) on RC treatment patterns and survival.

METHODS

Using the Surveillance, Epidemiology, and End Results-Medicare database, the study identified patients with RC between 2005 and 2007. The study excluded patients with stage IV disease, those not enrolled in Medicare parts A and B, those enrolled in managed care, and those staged with pelvic magnetic resonance imaging (because of low numbers). The study then compared outcomes between patients who received EUS and computed tomography of the abdomen and pelvis (CTAP) to those staged with CTAP alone after propensity score matching.

RESULTS

Between 2005 and 2007, we identified 3,408 nonmetastatic RC patients. Compared with patients staged with CTAP alone, those who received EUS and CTAP were younger (median age: 75 vs 76 years, P < 0.0001), more likely men (57.6% vs 48.7%, P < 0.0001), with a lower Charlson comorbidity index (P < 0.0001). Predictors of EUS included socioeconomic status (highest vs lowest) (odds ratio [OR] 1.87, 95% confidence interval [CI] 1.4-2.5), care by a gastroenterologist (OR 1.713, 95% CI 1.38-2.13), and care in a teaching hospital (OR 1.68, 95% CI 1.35-2.08). Receipt of neoadjuvant chemoradiation was higher in EUS-staged patients (50.3% vs 16.0%, P < 0.0001). EUS-staged patients had longer overall survival compared with those staged with CTAP alone (60 vs 57 months), but this was not statistically significant (P = 0.24).

CONCLUSION

Endoscopic ultrasound in RC staging is associated with higher utilization of neoadjuvant chemoradiation without a significant difference in overall survival.

Patients with pathological stage N2 rectal cancer treated with early adjuvant chemotherapy have a lower treatment failure rate

Background

In this era of oxaliplatin-based adjuvant therapy, the optimal sequence in which chemoradiotherapy should be administered for pathological stage N2 rectal cancer is unknown. The aim of this study was to investigate this sequence.

Methods

In the primary adjuvant concurrent chemoradiotherapy (A-CRT) group (n = 71), postoperative concurrent chemoradiotherapy was administered before adjuvant chemotherapy. In the primary adjuvant chemotherapy (A-CT) group (n = 43), postoperative concurrent chemoradiotherapy was administered during or after adjuvant chemotherapy. Postoperative radiotherapy comprised 45–50.4 Gy in 25–28 fractions. Concurrent chemotherapy comprised two cycles of oral capecitabine (1,600 mg/m²) on days 1–14 and 22–35. Patients receiving adjuvant chemotherapy with four or more cycles of XELOX (oxaliplatin plus capecitabine) or eight or more cycles of FOLFOX (fluorouracil, leucovorin, and oxaliplatin) were included.

Results

Between June 2005 and December 2013, data for 114 qualified rectal cancer patients were analyzed. The percentages of patients in whom treatment failed in the A-CRT and A-CT groups were 33.8% and 16.3%, respectively (p = 0.042). More patients had distant metastases in the A-CRT group than in the A-CT group (32.4% vs. 14.3%, p = 0.028). Multivariate analysis indicated that the sequence in which chemoradiotherapy was administered (A-CT vs. A-CRT) was an independent prognostic factor for both estimated disease-free survival [hazard ratio (HR) 0.345, 95% confidence interval (CI) 0.137–0.868, p = 0.024] and estimated distant metastasis-free survival (HR 0.366, 95% CI 0.143–0.938, p = 0.036).

Conclusions

In pathological stage N2 rectal cancer patients, administering adjuvant chemotherapy before chemoradiotherapy led to a lower rate of treatment failure, especially with respect to distant metastasis. Adjuvant chemotherapy prescribed as early as possible might benefit this cohort of patients in this era of oxaliplatin-based adjuvant therapy.

The multidisciplinary approach to the treatment of rectal cancer: 2015 update

The multidisciplinary approach to the management of rectal cancer continues to evolve with developments in surgery, radiation therapy as well as systemic chemotherapy. Refinement of surgical techniques to improve organ preservation, selective use of neoadjuvant (or adjuvant) therapies, improvements in staging modalities and emerging criteria for the selection of tailored therapies are some of the advancements made over the last three decades. In addition, neoadjuvant treatment alternatives, multimodality sequencing and adaptive therapies based on treatment response continue to be a subject of clinical investigation. The current article reviews the salient topics related to the multidisciplinary treatment of resectable rectal cancer.

Impact on Loco-regional Control of Radiochemotherapeutic Sequence and Time to Initiation of Adjuvant Treatment in Stage II/III Rectal Cancer Patients Treated with Postoperative Concurrent Radiochemotherapy

Purpose

This study was designed to evaluate the impact of radiochemotherapeutic sequence and time to initiation of adjuvant treatment on loco-regional control for resected stage II and III rectal cancer.

Materials and Methods

Treatment outcomes for rectal cancer patients from two hospitals with different sequencing strategies regarding adjuvant concurrent radiochemotherapy (CRCT) were compared retrospectively. Pelvic radiotherapy was administered concurrently on the first (early CRCT, n=180) or the third cycle of chemotherapy (late CRCT, n=180). During radiotherapy, two cycles of fluorouracil were provided to patients in both groups. In the early CRCT group, median six cycles of fluorouracil and leucovorin were prescribed during the post-CRCT period. In the late CRCT group, two cycles of fluorouracil were administered in the pre- and post-CRCT periods.

Results

No significant differences in the 5-year loco-regional recurrence-free survival (LRRFS) (92.5% vs. 95.6%, p=0.43) or overall survival and disease-free survival were observed between groups. Patients who began receiving adjuvant treatment later than five weeks after surgery had lower LRRFS than patients who received adjuvant treatment within five weeks following surgery (79% vs. 91%, p<0.01). The risk of loco-regional recurrence increased as the time to initiation of adjuvant treatment was delayed.

Conclusion

In the current study, treatment outcomes were not significantly influenced by the sequence of adjuvant treatment but by the delay of adjuvant treatment for more than five weeks. Timely administration of adjuvant treatment is deemed important in achieving loco-regional tumor control for stage II/III rectal cancer patients.

Comparison between preoperative and postoperative concurrent chemoradiotherapy for rectal cancer: an institutional analysis

PURPOSE

To evaluate the treatment outcomes of preoperative versus postoperative concurrent chemoradiotherapy (CRT) on locally advanced rectal cancer.

MATERIALS AND METHODS

Medical data of 114 patients with locally advanced rectal cancer treated with CRT preoperatively (54 patients) or postoperatively (60 patients) from June 2003 to April 2011 was analyzed retrospectively. 5-Fluorouracil (5-FU) or a precursor of 5-FU-based concurrent CRT (median, 50.4 Gy) and total mesorectal excision were conducted for all patients. The median follow-up duration was 43 months (range, 16 to 118 months). The primary end point was disease-free survival (DFS). The secondary end points were overall survival (OS), locoregional control, toxicity, and sphincter preservation rate.

RESULTS

The 5-year DFS rate was 72.1% and 48.6% for the preoperative and postoperative CRT group, respectively (p = 0.05, the univariate analysis; p = 0.10, the multivariate analysis). The 5-year OS rate was not significantly different between the groups (76.2% vs. 69.0%, p = 0.23). The 5-year locoregional control rate was 85.2% and 84.7% for the preoperative and postoperative CRT groups (p = 0.98). The sphincter preservation rate of low-lying tumor showed significant difference between both groups (58.1% vs. 25.0%, p = 0.02). Pathologic tumor and nodal down-classification occurred after the preoperative CRT (53.7% and 77.8%, both p < 0.001). Acute and chronic toxicities were not significantly different between both groups (p = 0.10 and p = 0.62, respectively).

CONCLUSION

The results confirm that preoperative CRT can be advantageous for improving down-classification rate and the sphincter preservation rate of low-lying tumor in rectal cancer.

ACR appropriateness criteria® resectable rectal cancer

The management of resectable rectal cancer continues to be guided by clinical trials and advances in technique. Although surgical advances including total mesorectal excision continue to decrease rates of local recurrence, the management of locally advanced disease (T3-T4 or N+) benefits from a multimodality approach including neoadjuvant concomitant chemotherapy and radiation. Circumferential resection margin, which can be determined preoperatively via MRI, is prognostic. Toxicity associated with radiation therapy is decreased by placing the patient in the prone position on a belly board, however for patients who cannot tolerate prone positioning, IMRT decreases the volume of normal tissue irradiated. The use of IMRT requires knowledge of the patterns of spreads and anatomy. Clinical trials demonstrate high variability in target delineation without specific guidance demonstrating the need for peer review and the use of a consensus atlas. Concomitant with radiation, fluorouracil based chemotherapy remains the standard, and although toxicity is decreased with continuous infusion fluorouracil, oral capecitabine is non-inferior to the continuous infusion regimen. Additional chemotherapeutic agents, including oxaliplatin, continue to be investigated, however currently should only be utilized on clinical trials as increased toxicity and no definitive benefit has been demonstrated in clinical trials. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every two years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Preoperative versus postoperative radiotherapy for rectal cancer in a decision analysis and outcome prediction model

PURPOSE

Reduction of local recurrences has been achieved by radiotherapy, but also by improved surgical technique (total mesorectal excision). Radiotherapy has adverse effects and cannot exceed local dose limits. Neoadjuvant radiotherapy may result in overtreatment. We aimed to define the minimum local benefit that would have to be postulated for radiotherapy in order to bring a benefit to the overall cohort. We hypothesized that saving radiotherapy as treatment for a subset of patients with high-risk tumors and local recurrences improves the outcome of the overall cohort. We sought to simulate preoperative versus postoperative radiotherapy in theoretical decision analysis model based on published recurrence rates, with overall survival being the primary end point.

METHODS

Computerized literature search for studies published between 1996 and 2011, supplemented by manual review of the retrieved reference lists.

RESULTS

Postoperative radiotherapy evolved as preferred strategy with cure rates of 65.6 % vs. 63.7 % for postoperative and neoadjuvant radiotherapy, respectively, and a decrease of radiation exposure to 42.9 % of the cohort. The system was sensitive to (1) the fraction of stage I cancers included in the cohort, (2) the difference between local recurrence rates (LRR) for neoadjuvant radiotherapy, adjuvant radiotherapy, or surgery-only approach, and (3) the compliance with the postoperative radiotherapy. If the surgery-only recurrence was set to the published 10 %, 13 %, and 27 %, respectively, adjuvant radiotherapy had to achieve LRR below the threshold values of 6.3 %, 8.5 %, and 18.3 % to reverse the impact of compliance.

CONCLUSIONS

Radiotherapy only improves cancer-specific survival of the cohort if there is a large difference in LRR with versus without it. Routine treatment may therefore be inferior to a tailored radiotherapy regimen.

The therapeutic and adverse effects of modified radiation fields for patients with rectal cancer

PURPOSE

To compare the therapeutic effect and complications of modified radiation fields (MRFs) with those of conventional pelvic radiation fields (CPRFs) for rectal cancer.

METHODS AND MATERIALS

From December 1996 to October 2009, a total of 160 patients with rectal carcinoma who received total mesorectal excision and postoperative radiotherapy were examined. Ninety-four patients were in the CPRFs group, and 66 were in the MRFs group. The dose was 50 Gy per 25 fractions in the initial plan.

RESULTS

The treatment volume and the volume of small bowel that received more than 15 Gy of the MRFs was smaller than that of the CPRFs (P < .001). The rates of local recurrence, overall survival, and disease-free survival were not statistically significant between the MRFs and CPRFs groups (P > .05). There was a statistical difference (P < .05) in the incidence of acute toxicity, which included serious complications in the lower digestive tract (grade ≥3). The completion rate for the initial radiotherapy plan was higher in the MRFs group than in the CPRFs group (P = .027).

CONCLUSIONS

Compared with CPRFs, MRFs manifested a lower incidence of complications and the same therapeutic effects. This finding will facilitate the clinical application of MRFs for patients with rectal cancer.

Adjuvant chemotherapy with or without pelvic radiotherapy after simultaneous surgical resection of rectal cancer with liver metastases: analysis of prognosis and patterns of recurrence

PURPOSE

To investigate the outcomes of adjuvant chemotherapy (CT) or chemoradiotherapy (CRT) after simultaneous surgical resection in rectal cancer patients with liver metastases (LM).

MATERIALS AND METHODS

One hundred and eight patients receiving total mesorectal excision for rectal cancer and surgical resection for LM were reviewed. Forty-eight patients received adjuvant CRT, and 60 were administered CT alone. Recurrence patterns and prognosis were analyzed. Disease-free survival (DFS) and overall survival (OS) rates were compared between the CRT and CT groups. The inverse probability of the treatment-weighted (IPTW) method based on the propensity score was used to adjust for selection bias between the two groups.

RESULTS

At a median follow-up period of 47.7 months, 77 (71.3%) patients had developed recurrences. The majority of recurrences (68.8%) occurred in distant organs. By contrast, the local recurrence rate was only 4.7%. Median DFS and OS were not significantly different between the CRT and CT groups. After applying the IPTW method, we observed no significant differences in terms of DFS (hazard ratio [HR], 1.347; 95% confidence interval [CI], 0.759-2.392; p = 0.309) and OS (HR, 1.413; CI, 0.752-2.653; p = 0.282). Multivariate analyses showed that unilobar distribution of LM and normal preoperative carcinoembryonic antigen level (<6 mg/mL) were significantly associated with longer DFS and OS.

CONCLUSIONS

The local recurrence rate after simultaneous resection of rectal cancer with LM was relatively low. DFS and OS rates were not different between the adjuvant CRT and CT groups. Adjuvant CRT may have a limited role in this setting. Further prospective randomized studies are required to evaluate optimal adjuvant treatment in these patients.

Rectal cancer radiotherapy: towards European consensus

BACKGROUND AND PURPOSE

During the first decade of the 21st century several important European randomized studies in rectal cancer have been published. In order to help shape clinical practice based on best scientific evidence, the International Conference on 'Multidisciplinary Rectal Cancer Treatment: Looking for an European Consensus' (EURECA-CC2) was organized. This article summarizes the consensus about imaging and radiotherapy of rectal cancer and gives an update until May 2010.

METHODS

Consensus was achieved using the Delphi method. Eight chapters were identified: epidemiology, diagnostics, pathology, surgery, radiotherapy and chemotherapy, treatment toxicity and quality of life, follow-up, and research questions. Each chapter was subdivided by topic, and a series of statements were developed. Each committee member commented and voted, sentence by sentence three times. Sentences which did not reach agreement after voting round # 2 were openly debated during the Conference in Perugia (Italy) December 2008. The Executive Committee scored percentage consensus based on three categories: "large consensus", "moderate consensus", "minimum consensus".

RESULTS

The total number of the voted sentences was 207. Of the 207, 86% achieved large consensus, 13% achieved moderate consensus, and only three (1%) resulted in minimum consensus. No statement was disagreed by more than 50% of members. All chapters were voted on by at least 75% of the members, and the majority was voted on by >85%. Considerable progress has been made in staging and treatment, including radiation treatment of rectal cancer.

CONCLUSIONS

This Consensus Conference represents an expertise opinion process that may help shape future programs, investigational protocols, and guidelines for staging and treatment of rectal cancer throughout Europe. In spite of substantial progress, many research challenges remain.

Randomized trial of postoperative adjuvant therapy in Stage II and III rectal cancer to define the optimal sequence of chemotherapy and radiotherapy: 10-year follow-up

PURPOSE

To determine the optimal sequence of postoperative adjuvant chemotherapy and radiotherapy in patients with Stage II or III rectal cancer.

METHODS AND MATERIALS

A total of 308 patients were randomized to early (n = 155) or late (n = 153) radiotherapy (RT). Treatment included eight cycles of chemotherapy, consisting of fluorouracil 375 mg/m(2)/day and leucovorin 20 mg/m(2)/day, at 4-week intervals, and pelvic radiotherapy of 45 Gy in 25 fractions. Radiotherapy started on Day 1 of the first chemotherapy cycle in the early RT arm and on Day 1 of the third chemotherapy cycle in the late RT arm.

RESULTS

At a median follow-up of 121 months for surviving patients, disease-free survival (DFS) at 10 years was not statistically significantly different between the early and late RT arms (71% vs. 63%; p = 0.162). A total of 36 patients (26.7%) in the early RT arm and 49 (35.3%) in the late RT arm experienced recurrence (p = 0.151). Overall survival did not differ significantly between the two treatment groups. However, in patients who underwent abdominoperineal resection, the DFS rate at 10 years was significantly greater in the early RT arm than in the late RT arm (63% vs. 40%; p = 0.043).

CONCLUSIONS

After the long-term follow-up duration, this study failed to show a statistically significant DFS advantage for early radiotherapy with concurrent chemotherapy after resection of Stage II and III rectal cancer. Our results, however, suggest that if neoadjuvant chemoradiation is not given before surgery, then early postoperative chemoradiation should be considered for patients requiring an abdominoperineal resection.

Impact of neoadjuvant treatment on total mesorectal excision for ultra-low rectal cancers

Background

This study reviewed the impact of pre-operative chemoradiotherapy or post-operative chemotherapy and/or radiotherapy on total mesorectal excision (TME) for ultralow rectal cancers that required either low anterior resection with peranal coloanal anastomosis or abdomino-perineal resection (APR). We examined surgical complications, local recurrence and survival.

Methods

Of the 1270 patients who underwent radical resection for rectal cancer from 1994 till 2007, 180 with tumors within 4 cm with either peranal coloanal anastomosis or APR were analyzed. Patients were compared in groups that had surgery only (Group A), pre-operative chemoradiotherapy (Group B), and post-operative therapy (Group C).

Results

There were 115 males and the mean age was 65.43 years (range 30-89). APR was performed in 134 patients while 46 had a sphincter-preserving resection with peranal coloanal anastomosis. The mean follow-up period was 52.98 months (range: 0.57 to 178.9). There were 69, 58 and 53 patients in Groups A, B, and C, respectively. Nine patients in Group B could go on to have sphincter-saving rectal resection. The overall peri-operative complication rate was 43.4% in Group A vs. 29.3% in Group B vs. 39.6% in Group C, respectively. The local recurrence rate was significantly lower in Group B (8.6.9% vs. 21.7% in Group A vs. 33.9% in Group C) p < 0.05. The 5-year cancer-specific survival rates for Group A was 49.3%, Group B was 69.9% and Group C was 38.8% (p = 0.14).

Conclusion

Pre-operative chemoradiation in low rectal cancer is not associated with a higher incidence of peri-operative complications and its benefits may include reduction local recurrence.

Sequential surgical resection of hepatic and pulmonary metastases from colorectal cancer

BACKGROUND

Resection of isolated hepatic or pulmonary metastases from colorectal cancer is widely accepted and associated with a 5-year survival rate of 25-40%. The value of aggressive surgical management in patients with both hepatic and pulmonary metastases still remains a controversial area.

MATERIALS AND METHODS

A retrospective review of 1,497 patients with colorectal carcinoma (CRC) was analysed. Of 73 patients identified with resection of CRC and, at some point in time, both liver and lung metastases, 17 patients underwent metastasectomy (resection group). The remaining 56 patients comprised the non-resection group. Primary tumour, hepatic and pulmonary metastases of all patients were surgically treated in our department of surgery, and the results are that of a single institution.

RESULTS

The resection group had a 3-year survival of 77%, a 5-year survival of 55% and a 10-year survival of 18%; median survival was 98 months. The longest overall survival was 136 months; six patients are still alive. In the resection group, overall survival was significantly higher than in the non-resection group (p < 0.01). Independent from the chronology of metastasectomy, 5-year survival was 55% with respect to the primary resection, 28% with respect to the first metastasectomy and 14% with respect to the second metastasectomy. A disease-free interval (>18 months), stage III (UICC) and age (<70 years) were found to be significant prognostic factors for overall survival.

CONCLUSION

Our report strongly supports aggressive surgical therapy in patients with both hepatic and pulmonary metastases from CRC. Overall survival for surgically treated selected patients with both hepatic and pulmonary metastases from CRC is comparable to hepatic or pulmonary metastasectomy. Simultaneous metastases tend to have a poorer outcome than metachronous metastases.

Multidisciplinary Rectal Cancer Management: 2nd European Rectal Cancer Consensus Conference (EURECA-CC2)

BACKGROUND AND PURPOSE

During the first decade of the 21st century a number of important European randomized studies were published. In order to help shape clinical practice based on best scientific evidence from the literature, the International Conference on 'Multidisciplinary Rectal Cancer Treatment: Looking for an European Consensus' (EURECA-CC2) was organized in Italy under the endorsement of European Society of Medical Oncology (ESMO), European Society of Surgical Oncology (ESSO), and European Society of Therapeutic Radiation Oncology (ESTRO).

METHODS

Consensus was achieved using the Delphi method. The document was available to all Committee members as a web-based document customized for the consensus process. Eight chapters were identified: epidemiology, diagnostics, pathology, surgery, radiotherapy and chemotherapy, treatment toxicity and quality of life, follow-up, and research questions. Each chapter was subdivided by a topic, and a series of statements were developed. Each member commented and voted, sentence by sentence thrice. Sentences upon which an agreement was not reached after voting round # 2 were openly debated during a Consensus Conference in Perugia (Italy) from 11 December to 13 December 2008. A hand-held televoting system collected the opinions of both the Committee members and the audience after each debate. The Executive Committee scored percentage consensus based on three categories: "large consensus", "moderate consensus", and "minimum consensus".

RESULTS

The total number of the voted sentences was 207. Of the 207, 86% achieved large consensus, 13% achieved moderate consensus, and only 3 (1%) resulted in minimum consensus. No statement was disagreed by more than 50% of the members. All chapters were voted on by at least 75% of the members, and the majority was voted on by >85%.

CONCLUSIONS

This Consensus Conference represents an expertise opinion process that may help shape future programs, investigational protocols, and guidelines for staging and treatment of rectal cancer throughout Europe.

Double blind randomized phase II study with radiation+5-fluorouracil+/-celecoxib for resectable rectal cancer

PURPOSE

To assess the feasibility and efficacy of the COX-2 inhibitor celecoxib in conjunction with preoperative chemoradiation for patients with locally advanced rectal cancer in a double blind randomized phase II study.

MATERIALS AND METHODS

Thirty-five patients of the initially planned 80 patients with locally advanced rectal cancer were treated with preoperative radiation (45 Gy; 1.8 Gy/fraction, 5 days/week) combined with 5-fluorouracil (continuous infusion, 225 mg/m(2)/day) and celecoxib (2 x 400 mg/day) or placebo. Pathological response and toxicity of study treatment were evaluated, as well as expression of COX-2 and Ki67 in tumor tissue and IL-6 in plasma as possible molecular correlates and predictors of response to treatment.

RESULTS

Patients treated with celecoxib tended to show a better response (61%) when compared to those treated with placebo (35%), although not significant (p=0.13). T-downstaging and N-downstaging were also slightly higher with celecoxib. Plasma IL-6 levels and intratumoral COX2 or Ki67 were altered by chemoradiation, but were not further altered by celecoxib treatment and therefore not useful for prediction of treatment benefit. Celecoxib therapy in conjunction with chemoradiation was not associated with additional toxicity and seemed to help mitigate therapy-related pain.

CONCLUSIONS

Addition of celecoxib to preoperative chemoradiation is feasible for patients with locally advanced rectal cancer. To study the individual effect of COX-2 inhibitors on pathological response phase III studies are required.

lymph node ratio as a prognostic factor in patients with stage III rectal cancer treated with total mesorectal excision followed by chemoradiotherapy

PURPOSE

To investigate the prognostic impact of lymph node ratio (LNR) on survival in the patients with Stage III rectal cancer.

METHODS AND MATERIALS

We retrospectively reviewed the data of 421 consecutive patients who underwent total mesorectal excision followed by chemoradiotherapy for rectal cancer from 1996 to 2006. The 232 patients with positive lymph nodes (LNs) were divided into four groups according to LNR quartiles: LNR <or=0.1 (n = 69), <or=0.2 (n = 49), <or=0.4 (n = 54), and >0.4 (n = 60). The association between LNR and survival was evaluated by the Kaplan-Meier method and multivariate analysis with covariates of prognostic significance in univariate analysis.

RESULTS

The median numbers of examined and positive LNs were 17 and 3, respectively, and the median LNR was 0.20 (range, 0.03-1). There was a strong correlation between the number of positive LNs and LNR (r = 0.724, p < 0.001). After a median follow-up of 53 months (range, 9-138 months), the actuarial overall survival and disease-free survival rates at 5 years were 69% and 56%, respectively. The 5-year survival rate decreased as LNR increased (<or=0.1, 89%; <or=0.2, 67%; <or=0.4, 64%; >0.4, 50%; p < 0.001). Lymph node ratio was also a significant prognostic factor on Cox regression analysis (<or=0.1, hazard ratio [HR] = 1; <or=0.2, HR = 1.3, p = 0.623; <or=0.4, HR = 2.4, p = 0.047; >0.4, HR = 3.7, p = 0.005). Lymph node ratio had a prognostic effect on overall survival in subgroups of patients with N1 (p = 0.032) and N2 (p = 0.034) tumors.

CONCLUSION

Lymph node ratio was the most significant predictor of survival in the patients with Stage III rectal cancer who had undergone postoperative chemoradiation.

Differences between clinical trial participants and patients in a population-based registry: the German Rectal Cancer Study vs. the Rostock Cancer Registry

PURPOSE

There are few data on whether the samples of randomized phase III studies are representative for cancer patients in general populations.

METHODS

We compared patient and disease characteristics of patients with stage II or III rectal cancer from the German Rectal Cancer Study (657 patients, 1995-2002) or the Rostock Cancer Registry (371 patients, 1997-2003). Differences between the Study and the Registry were analyzed for subgroups who received neoadjuvant chemoradiotherapy before resection or primary resection with or without postoperative chemoradiotherapy.

RESULTS

Study and Registry patients differed in age (median, 61.7 vs. 65.0 years, P < 0.001) and proportion of women (31.3 percent vs. 38.4 percent, P < 0.004). Significant age and gender differences were seen in primary resection but not in neoadjuvant subgroups. In neoadjuvant and in primary resection subgroups, Study participants were more likely than Registry patients to have tumor location in the lower third of the rectum, a higher rate of R0 resection, a greater number of lymph nodes assessed, and fewer T4 tumors. In the primary resection subgroups, Study participants were more likely to have received postoperative chemoradiotherapy. Multivariate analyses showed no effect of population type (Study vs. Registry) on disease-free or overall survival in neoadjuvant subgroups, but increased risk for Registry patients in primary resection subgroups.

CONCLUSIONS

Participants in clinical trials such as the German Rectal Cancer Study are not representative of all cancer patients of a general population. To enable wider extrapolation of results, future studies should include elderly and high-risk patients.

Brachytherapy and local excision for sphincter preservation in T1 and T2 rectal cancer

PURPOSE

To report long-term results of brachytherapy after local excision (LE) in the treatment of T1 and T2 rectal cancer at risk of recurrence due to residual subclinical disease.

METHODS AND MATERIALS

Between 1989 and 2007, 32 patients undergoing LE and brachytherapy were followed prospectively for a mean of 6.2 years. Estimates of local recurrence (LR), disease-specific survival (DSS), and overall survival (OS) were generated. Treatment-related toxicity and the effect of known prognostic factors were determined.

RESULTS

There were 8 LR (3 T1, 5 T2), of which 5 were salvaged surgically. Median time to the 8 LR was 14 months, and the 5-year rate of local control was 76%. Although there have been 9 deaths to date, only 5 were from disease. Five-year DSS and OS rates were 85% and 78%, respectively. There were 4 cases of Grade 2-3 radionecrosis and 1 case of mild stool incontinence. The sphincter was preserved in 27 of 32 patients.

CONCLUSION

Local excision and adjuvant brachytherapy for T1 and T2 rectal cancer is an appealing treatment alternative to immediate radical resection, particularly in the frail and elderly who are unable to undergo major surgery, as well as for patients wanting to avoid a permanent colostomy.

Molecular and clinico-pathological markers in rectal cancer: a tissue micro-array study

AIMS

The aims of the study were to study the effect of pre-operative treatment on the expression of tumour-related proteins and to correlate the expression of these proteins with response and survival of patients with advanced rectal cancer.

MATERIALS AND METHODS

Tissue micro-arrays from pre- and post-treatment biopsies of 99 patients with rectal cancer treated with pre-operative (chemo)radiotherapy were stained for epidermal growth factor receptor (EGFR), carbonic anhydrase IX, Ki67, vascular endothelial growth factor, cyclo-oxygenase 2 (COX-2) and cleaved cytokeratin 18 (c-CK18). Also, fibro-inflammatory alterations after treatment were evaluated.

RESULTS

Pre-operative (chemo)radiotherapy caused fibro-inflammatory changes, a downregulation of proliferation (Ki67) and EGFR and an upregulation of apoptosis (cleaved CK18). Patients with a good regression during pre-operative treatment showed less proliferating and apoptotic cells in the resection specimen. Multivariate analysis showed that T downstaging, fibro-inflammatory changes in the resection specimen and COX-2 expression in the biopsy correlated with overall survival.

CONCLUSIONS

Pre-operative treatment has an effect on proliferation, apoptosis, inflammation and EGFR expression. The classical clinical parameters as well as fibro-inflammatory changes and COX-2 expression seem most valuable as predictors for survival.

ACR Appropriateness Criteria on resectable rectal cancer: expert panel on radiation oncology--rectal/anal cancer

In what arguably may be the most pivotal recent trial in the area of resectable rectal cancer management, a randomized trial from Germany has established a regimen of preoperative chemoradiotherapy and surgery followed by additional cycles of chemotherapy alone as the standard of care for clinical stages T3 or T4, or for node-positive rectal cancer. Other clinical studies from the United States, Europe, and Asia have also influenced the treatment strategies of operable rectal cancer, as various approaches using preoperative or postoperative radiotherapy, with or without chemotherapy, have been examined. A summary of the major randomized clinical trials spanning the past several decades is provided.

Evidence and research in rectal cancer

The main evidences of epidemiology, diagnostic imaging, pathology, surgery, radiotherapy, chemotherapy and follow-up are reviewed to optimize the routine treatment of rectal cancer according to a multidisciplinary approach. This paper reports on the knowledge shared between different specialists involved in the design and management of the multidisciplinary ESTRO Teaching Course on Rectal Cancer. The scenario of ongoing research is also addressed. In this time of changing treatments, it clearly appears that a common standard for large heterogeneous patient groups have to be substituted by more individualised therapies based on clinical-pathological features and very soon on molecular and genetic markers. Only trained multidisciplinary teams can face this new challenge and tailor the treatments according to the best scientific evidence for each patient.

The role of radiation therapy for colorectal cancer

Radiation therapy (RT) has been used to treat cancers for more than a century. Recent randomized trials have helped clarify the treatment recommendations in the use of RT for colorectal cancers. This article reviews these trials to illustrate key concepts, places these trials in perspective, and provides direction for future research.

The multidisciplinary management of gastrointestinal cancer. Multimodal treatment of rectal cancer

Greater understanding of the natural history of rectal cancer, and the knowledge that a histologically involved circumferential margin due to inadequate lateral dissection confers a high risk of local recurrence have driven technical advances in surgical technique with meticulous surgical dissection along embryological planes. Significant improvements in local control and overall survival have been seen for patients with resectable rectal cancer. However, even high-quality surgery cannot always achieve a curative resection for locally advanced cancers that extend below the levators, having transgressed the mesorectal fascia. Magnetic resonance imaging is now accepted as a practical method of clinical staging, and can accurately predict pre-operatively the likelihood of achieving a clear circumferential margin. Technological advances in radiation planning and new effective cytotoxic drugs also give scope for dealing with unresectable rectal cancer, and the potential for controlling distant micrometastases. Hence, modern multimodal treatment of rectal cancer attempts to integrate surgery, radiotherapy and chemotherapy, and address the two distinct problems of local recurrence and metastatic disease. Multidisciplinary teams achieve the best results. This paper discusses the surgical management of rectal cancer, the pathology, the principles of imaging, and the lessons learnt from randomized trials of radiotherapy and chemoradiation.

Neoplastic mesorectal microfoci (MMF) following neoadjuvant chemoradiotherapy: clinical and prognostic implications

BACKGROUND

Neoplastic microfoci have frequently been found in the mesorectum, with poor outcome. In this study, incidence and clinical significance of mesorectal microfoci (MMF) were analyzed in patients operated on for rectal cancer following neoadjuvant chemoradiation.

METHODS

A case series of 68 patients with extraperitoneal rectal cancer treated with neoadjuvant chemoradiation and surgery (including total mesorectal excision) were investigated for presence of neoplastic MMF.

RESULTS

MMF were found in 26 cases (38.2%). Increasing incidence of microfoci was statistically related to pathologic involvement of the bowel wall (P = 0.0006), Mandard's tumor regression grading (P = 0.0006), and pathologic neoplastic mesorectal involvement (P < 0.00001). None of the nine patients with complete tumor disappearance displayed both microfoci and lymph node metastasis. Only one local recurrence developed in a patient with multiple MMF. One out of nine pT0 or TRG1 patients (11.1%) had distant metastases compared with 15 out of 59 pT1-4 or TRG2-5 (25.4%, P = 0.70).

CONCLUSIONS

A remarkable incidence of MMF was found following chemoradiation. However, when this therapy induced complete regression of primary tumor (pT0-TRG1), we found that node metastases and neoplastic MMF also disappeared. These features should be confirmed to assess the impact of these microfoci in treatment decision making in rectal cancers.

Analysis of Early Postoperative Morbidity Among Patients with Rectal Cancer Treated with and without Neoadjuvant Chemoradiotherapy

BACKGROUND

The impact of neoadjuvant treatment and their subsequent early complications in the treatment of rectal cancer has not been adequately assessed. The aim of this prospective study was to evaluate early postoperative morbidity and mortality among patients with rectal cancer treated with adjuvant radiotherapy and chemotherapy followed by surgery, compared with patients treated with surgery alone. We also identified independent risk factors associated with early major complications.

METHODS

Between 1995 and 2004, 273 consecutive patients underwent treatment for rectal cancer. A total of 170 patients (group A) received preoperative radiotherapy with a total of 45-50.4 Gy (180 cGy per day) and 5-fluorouracil-based chemotherapy, followed by surgery; 103 patients (group B) were treated with surgery alone. Dependent variables related to patients, treatment, radiotherapy, and tumor were analyzed.

RESULTS

Both groups were similar with regard to age, sex, body mass index, American Society of Anesthesiologists (ASA) score, and tumor location but not for ileostomy (27% in group A vs. 6.8% in group B). The number of complications was similar in both groups (43.1% in group A vs. 44.6% in group B). No differences in wound infection (8.2% vs. 7.8%), intra-abdominal abscess (4.7% vs. 4.9%), anastomotic dehiscence (4.2% vs. 3.8%), postoperative hemorrhage (3.5% vs. 3.9%), urinary complications (6.5% vs. 4.9%), paralytic ileus (8.9% vs. 9.7%), or general complications (7.1% vs. 9.6%) were found. The global mortality in the first 30 days after surgery was .7%. An ASA score of III-IV and surgery duration longer than 3 hours were identified as independent prognostic factors for early complications.

CONCLUSIONS

Preoperative chemoradiation in patients with rectal cancer treated with surgery is not associated with a higher incidence of early postoperative complications. The patient's preoperative clinical condition and lengthy surgery time are prognostic factors for early complications.

Neoplastic mesorectal microfoci (MMF) following neoadjuvant chemoradiotherapy: clinical and prognostic implications

BACKGROUND

Neoplastic microfoci have frequently been found in the mesorectum, with poor outcome. In this study, incidence and clinical significance of mesorectal microfoci (MMF) were analyzed in patients operated upon for rectal cancer following neoadjuvant chemoradiation.

METHODS

A case series of 68 patients with extraperitoneal rectal cancer, treated with neoadjuvant chemoradiation and surgery (including total mesorectal excision), was investigated for the presence of neoplastic MMF.

RESULTS

Mesorectal microfoci were found in 26 cases (38.2%). Increasing incidence of microfoci was statistically related to pathologic involvement of bowel wall (P = 0.0006), Mandard's tumor regression grading (P = 0.0006) and pathologic neoplastic mesorectal involvement (P < 0.00001). None of the nine patients with complete tumor disappearance displayed both microfoci and lymph node metastasis. Only one local recurrence developed in a patient with multiple MMF. Out of 9 pT0 or TRG1 patients, 1 (11.1%) had distant metastases, compared to 15 out of 59 pT1-4 or TRG2-5 (25.4%, P = 0.70).

CONCLUSIONS

A remarkable incidence of MMF was found following chemoradiation. However, when this therapy induces complete regression of primary tumor (pT0-TRG1), node metastases and neoplastic MMF could also disappear, as shown in our cases. These features should be confirmed because they could significantly impact the treatment decision-making of rectal cancers.

Radiation therapy and combined modality treatment of gastrointestinal carcinomas

BACKGROUND

Ionizing radiation (IR) is a potent agent in enhancing tumor control of locally advanced cancer and has been shown to improve disease-free and overall survival in several entities. However, the role of radiotherapy (RT) in the treatment of gastrointestinal tumors remains controversial because of the marked radiation sensitivity of neighboring organs frequently compromising application of high doses of ionizing radiation.

METHODS

The Medline and the Cochrane Library from 1980 until 2005 were searched using subject heading (MeSH) terms including "esophageal neoplasm", "gastric neoplasm", "pancreatic neoplasm" and "rectal neoplasm", in combination with the subheadings "radiotherapy", "chemotherapy". The term, "randomized controlled trial", was used to identify randomized trials. The proceedings of the annual meeting of the American Society for Therapeutic Radiology and Oncology from 1999 to 2004 and the annual meeting of the American Society of Clinical Oncology from 1999 until 2005 were searched. Ongoing trials were identified through the Physician Data Query database (www.cancer.gov/search/clinical_trials).

RESULTS

RT in combination with surgery enhances tumor control of locally advanced cancer disease and has been shown to improve disease-free and overall survival in rectal cancer. In esophageal adenocarcinoma, survival was prolonged with pre-operative chemo-radiation in a meta-analysis. In gastric cancer, post-operative chemo-radiation can be considered after limited lymphadenectomy. Evidence for improving survival remains to be shown for pancreatic cancer and hepatobiliary carcinoma. In colon cancer, post-operative chemotherapy has proven to prolong survival. The impact of RT seems to be most prominent in the pre-operative setting in patients treated with curative intent.

CONCLUSIONS

Pre-operative RT or pre-operative chemo-radiation may be considered in individual cases, but should not be used routinely for gastro-intestinal carcinoma, except for rectal carcinoma. In many studies, pre-operative radiotherapy/chemo-radiation yielded promising results and merits validation in large controlled trials.

Anemia and long-term outcome in adjuvant and neoadjuvant radiochemotherapy of stage II and III rectal adenocarcinoma: The Freiburg experience (1989-2002)

AIM: To evaluate the long-term outcome of standard 5-FU based adjuvant or neoadjuvant radiochemotherapy and to identify the predictive factors, especially anemia before and after radiotherapy as well as hemoglobin increase or decrease during radiotherapy.

METHODS: Two hundred and eighty-six patients with Union International Contre Cancer (UICC) stage II and III rectal adenocarcinomas, who underwent resection by conventional surgical techniques (low anterior or abdominoperineal resection), received either postoperative (n = 233) or preoperative (n = 53) radiochemotherapy from January 1989 until July 2002. Overall survival (OAS), cancer-specific survival (CSS), disease-free survival (DFS), local-relapse-free (LRS) and distant-relapse-free survival (DRS) were evaluated using Kaplan-Meier, Log-rank test and Cox’s proportional hazards as statistical methods. Multivariate analysis was used to identify prognostic factors. Median follow-up time was 8 years.

RESULTS: Anemia before radiochemotherapy was an independent prognostic factor for improved DFS (risk ratio 0.76, P = 0.04) as well as stage, grading, R status (free radial margins), type of surgery, carcinoembryonic antigen (CEA) levels, and gender. The univariate analysis revealed that anemia was associated with impaired LRS (better local control) but with improved DFS. In contrast, hemoglobin decrease during radiotherapy was an independent risk factor for DFS (risk ratio 1.97, P = 0.04). During radiotherapy, only 30.8% of R0-resected patients suffered from hemoglobin decrease compared to 55.6% if R1/2 resection was performed (P = 0.04). The 5-year OAS, CSS, DFS, LRS and DRS were 47.0%, 60.0%, 41.4%, 67.2%, and 84.3%, respectively. Significant differences between preoperative and postoperative radiochemotherapy were not found.

CONCLUSION: Anemia before radiochemotherapy and hemoglobin decrease during radiotherapy have no predictive value for the outcome of rectal cancer. Stage, grading, R status (free radial margins), type of surgery, CEA levels, and gender have predictive value for the outcome of rectal cancer.

Neoadjuvant chemotherapy prior to preoperative chemoradiation or radiation in rectal cancer: should we be more cautious?

Neoadjuvant chemotherapy (NACT) is a term originally used to describe the administration of chemotherapy preoperatively before surgery. The original rationale for administering NACT or so-called induction chemotherapy to shrink or downstage a locally advanced tumour, and thereby facilitate more effective local treatment with surgery or radiotherapy, has been extended with the introduction of more effective combinations of chemotherapy to include reducing the risks of metastatic disease. It seems logical that survival could be lengthened, or organ preservation rates increased in resectable tumours by NACT. In rectal cancer NACT is being increasingly used in locally advanced and nonmetastatic unresectable tumours. Randomised studies in advanced colorectal cancer show high response rates to combination cytotoxic therapy. This evidence of efficacy coupled with the introduction of novel molecular targeted therapies (such as Bevacizumab and Cetuximab), and long waiting times for radiotherapy have rekindled an interest in delivering NACT in locally advanced rectal cancer. In contrast, this enthusiasm is currently waning in other sites such as head and neck and nasopharynx cancer where traditionally NACT has been used. So, is NACT in rectal cancer a real advance or just history repeating itself? In this review, we aimed to explore the advantages and disadvantages of the separate approaches of neoadjuvant, concurrent and consolidation chemotherapy in locally advanced rectal cancer, drawing on theoretical principles, preclinical studies and clinical experience both in rectal cancer and other disease sites. Neoadjuvant chemotherapy may improve outcome in terms of disease-free or overall survival in selected groups in some disease sites, but this strategy has not been shown to be associated with better outcomes than postoperative adjuvant chemotherapy. In particular, there is insufficient data in rectal cancer. The evidence for benefit is strongest when NACT is administered before surgical resection. In contrast, the data in favour of NACT before radiation or chemoradiation (CRT) is inconclusive, despite the suggestion that response to induction chemotherapy can predict response to subsequent radiotherapy. The observation that spectacular responses to chemotherapy before radical radiotherapy did not result in improved survival, was noted 25 years ago. However, multiple trials in head and neck cancer, nasopharyngeal cancer, non-small-cell lung cancer, small-cell lung cancer and cervical cancer do not support the routine use of NACT either as an alternative, or as additional benefit to CRT. The addition of NACT does not appear to enhance local control over concurrent CRT or radiotherapy alone. Neoadjuvant chemotherapy before CRT or radiation should be used with caution, and only in the context of clinical trials. The evidence base suggests that concurrent CRT with early positioning of radiotherapy appears the best option for patients with locally advanced rectal cancer and in all disease sites where radiation is the primary local therapy.

Chemo-radiotherapy versus radiotherapy alone in the pre-operative treatment of resectable rectal cancer

AIM

To determine the differences in downstaging, local control (LC), disease free survival (DFS) and overall survival (OS) between combined pre-operative chemoradiation and pre-operative radiotherapy alone in the treatment of resectable rectal cancer.

METHODS

One hundred and ten patients who underwent pre-operative radiotherapy or chemo-radiotherapy were reviewed. Fifty-seven patients were treated with radiotherapy (30 Gy/3 Gy) alone and 53 patients with chemo-radiotherapy (bolus 5FU+45 Gy/1.8 Gy). The median interval between the end of neo-adjuvant treatment and surgery was 28 and 46 days for the patients treated with radiotherapy alone and chemo-radiotherapy.

RESULTS

The groups were homogeneously distributed for all characteristics except for cN-stage with more clinically node positive patients in the combined modality treatment group (47 vs 73%). A significant downstaging for tumour and/or lymph node status was observed in both groups. More ypT0-x-is were observed after chemoradiation than after radiotherapy alone (26 vs 7%; p=0.02). The local control rate at 3 years was 94% for both groups. DFS after radiation and chemoradiation was comparable with a 3-year DFS of 83 and 88%, respectively.

CONCLUSION

Both pre-operative schemes have similar outcomes concerning DFS, OS and LC. Tumour downstaging is associated with improved survival.

Preoperative concurrent radiotherapy with capecitabine before total mesorectal excision in locally advanced rectal cancer

PURPOSE

Capecitabine is an attractive radiosensitizer which can be tumor specific. This study was undertaken to evaluate the toxicity and efficacy of oral capecitabine when used with preoperative radiation therapy.

METHODS AND MATERIALS

We conducted a prospective Phase II trial to assess the pathologic response, sphincter preservation effect, and acute toxicity of preoperative chemoradiation (CRT) in locally advanced (uT3-4/N +) but resectable adenocarcinoma of the lower two-thirds of the rectum. The radiation dose was 50 Gy over 5 weeks (46 Gy to whole pelvis + 4 Gy boost), and capecitabine was administered daily at a dose of 1650 mg/m(2) during the entire course of radiation therapy. Surgery was performed with standardized total mesorectal excision 4 to 6 weeks after completion of CRT and followed by four cycles of capecitabine (2500 mg/m(2)/day for 14 days).

RESULTS

Ninety-five patients were entered into this study; their median age was 55 (range, 31-75 years). Ninety (95%) patients completed preoperative CRT as planned, and complete resection was achieved in 92 of 94 resected cases (98%). Downstaging rate was 71% (56/79) on endorectal ultrasonography, and it was 76% (71/94) on pathology finding. No tumor cell was observed in the specimens of 11 patients (12%). Among the 54 whose tumor was located within 5 cm from the anal verge, 40 patients (74%) underwent sphincter-preserving procedures. Elevation of the distal tumor margin from the anal verge by preoperative CRT was 0.8 +/- 1.3 cm. Grade 3 toxicities were rare (diarrhea in 3% and neutropenia in 1%).

CONCLUSION

Preoperative CRT using capecitabine achieved encouraging rates of tumor downstaging and sphincter preservation with a low toxicity profile.

The multidisciplinary rectal cancer treatment: Main convergences, controversial aspects and investigational areas which support the need for an European Consensus

BACKGROUND AND PURPOSE

During the past decades staging and treatment of rectal cancer are used different in Europe and in North America. To promote a process to integrate the daily practice with the best evidence of the literature an International Conference was organized in Italy. Agreement between Experts, Centres, and specialists who participated in the Conference are reported.

METHODS

Five aspects were analyzed and a questionnaire was tailored for this purpose. The questionnaire had 159 questions. During the Conference, at the beginning of each Session, the moderators showed the answers from the Experts and the Centres, and, at the end of the session, the audience voted in all controversial issues. Agreements were scored at three levels: minimum, if it was between 51 and 74% of votes for each group; moderate, between 75 and 94%; large, more than 94%.

RESULTS

The main results are: staging: endoanal ultrasound was considered as mandatory in T staging, in the evaluation of sphincter infiltration, and in the restaging of T after chemoradiotherapy (chRT). Magnetic Resonance Imaging is mandatory in the evaluation of mesorectal fascia infiltration. Endoscopy had a moderate agreement for the definition of tumour location, and the barium enema as optional. Digital rectal examination is complementary for staging and PET-CT investigational for T, N and yT staging. Preoperative radiotherapy: for T4 stage chRT was always the preferred treatment, often with moderate agreement, for any tumour location and N status. For T3, chRT received the same agreement except for high location and N0-N1. For T2 stage, N2 and positive nodes outside the mesorectum, chRT received minimum agreement for low and middle tumours; for high tumours only positive nodes outside the mesorectum was agreed upon. Preoperative radiotherapy, negative specimen and sphincter preservation: chRT was agreed by many for all T stages and N presentations of lower third tumours, except for T1-2 N0-N1. Postoperative treatments: the selection for these treatments often received moderate agreement according to the infiltration of surrounding organs, positive nodal status and circumferential radial margins. Therapy of metastatic disease: an agreement was found for FOLFOX as first-line therapy and for FOLFIRI as second-line, although comparative studies show similar activity of FOLFOX and FOLFIRI regimens.

CONCLUSIONS

This process represents an expertise opinion process that may contribute to increased scientific debate and to promote the development of 'guidelines', 'clinical recommendations' and ultimately a Consensus on the evolving approach to rectal cancer treatment.

Radiotherapy and concurrent radiochemotherapy for rectal cancer

Adjuvant radiotherapy with or without chemotherapy has been used widely in an attempt to improve outcome in rectal cancer. For locally advanced disease, postoperative radiochemotherapy significantly improved both local control and overall survival when compared with surgery alone or surgery plus irradiation. This prompted a National Cancer Institute Consensus Conference in the United States in 1990 to recommend postoperative radiochemotherapy for patients with TNM stage II and III rectal cancer as standard treatment. In Europe, several randomized studies tested preoperative radiotherapy in comparison to surgery alone and showed lower local failure rates. A recent meta-analysis concluded that the combination of preoperative radiotherapy and surgery, as compared with surgery alone, significantly improves local control and overall survival. These results are, however, challenged by more recent reports of extraordinarily low local failure rates following improved surgical techniques, including total mesorectal excision. Evidently, the current monolithic approaches to either apply the same schedule of postoperative radiochemotherapy to all patients with stage II/III rectal cancer or to give preoperative intensive short-course radiation according to the Swedish concept for all patients with resectable rectal cancer irrespective of tumor stage and treatment goal (e.g. sphincter preservation), need to be questioned.

A phase I-II study of weekly oxaliplatin, 5-fluorouracil continuous infusion and preoperative radiotherapy in locally advanced rectal cancer

BACKGROUND

Oxaliplatin (OXA) significantly enhanced the antitumour activity of 5-fluorouracil (FUra) in patients with advanced colorectal cancer and displayed radiosensitising properties in preclinical studies. This study was thus performed to test the feasibility, identify the recommended doses (RDs) and explore preliminarily the clinical activity of weekly OXA and infused FUra combined with preoperative pelvic radiotherapy.

PATIENTS AND METHODS

Forty-six patients with recurrent or locally advanced (cT3-4 and/or N+) adenocarcinomas of the mid-low rectum were treated with escalating doses of OXA (25, 35, 45, 60 mg/m2, weekly for 6 weeks) and FUra (200-225 mg/m2/day, 6-week infusion) concurrent to preoperative pelvic radiotherapy (50.4 Gy/28 fractions). The RDs for the phase II part of the study were immediately below the level resulting in dose-limiting toxicities in more than one third of the patients, or corresponded to the last planned dose level.

RESULTS

In the escalation phase, dose-limiting toxicities only occurred in one patient at the fourth level and one of six patients treated at the last planned dose level (grade III diarrhoea). OXA 60 mg/m2 and FUra 225 mg/m2/day are therefore the RDs for the regimen. Among 25 patients globally treated at these doses (phase II part), the incidence of grade III diarrhoea was 16% with no grade IV toxicity. Neurotoxicity did not exceed grade II (12%). All patients completed radiotherapy and were operated on as scheduled. Twenty-one of 25 patients had the tumour down-staged after chemoradiation with seven (28%) pathological complete responses and 12 (48%) residual tumours limited to ypT1-2N0.

CONCLUSIONS

Weekly OXA, at doses potentially active systemically, can be combined with full-dose, infused FUra and radiotherapy. Given the low toxicity and promising activity, this regimen is being compared to standard FUra-based pelvic chemoradiation in a randomised study.

Aktuelle Behandlungsstrategien beim Rektumkarzinom

In the last ten years, considerable progress has been achieved in the treatment of rectal cancer. According to improved interdisciplinary staging, rectal carcinomas can be treated based on a stage-dependent concept: "low-risk" pT1 (G1/G2) carcinomas can be cured by local full wall excision, while "high-risk" pT1 (G3/G4) and pT2 carcinomas require transabdominal resection. In contrast, locally advanced rectal cancers in cUICC-II/-III stages (T3/T4 or N(+)) should receive long-term, 5-FU-based, neoadjuvant chemoradiotherapy according to the excellent results of the CAO/AIO/ARO-94 trial of the German Rectal Cancer Study Group. High-quality resection must be based on radical oncologic principles such as "no-touch" technique, radicular dissection of vessels, and total mesorectal excision. Multimodal treatment is completed with adjuvant 5-FU-based chemotherapy. This therapeutic approach led to a reduction in the 5-year local recurrence rate to 6% and disease-free survival of approximately 68% in advanced rectal cancer (overall survival: 76%).

Prospective phase II study of preoperative chemoradiation with capecitabine in locally advanced rectal cancer

PURPOSE

Capecitabine is an attractive oral chemotherapeutic agent that has a radiosensitizing effect and tumor-selectivity. This study was performed to evaluate the efficacy and toxicity of preoperative chemoradiation therapy, when used with oral capecitabine, for locally advanced rectal cancer.

MATERIALS AND METHODS

A prospective phase II trial of preoperative chemoradiation for locally advanced adenocarcinomas of the lower two-thirds of the rectum was conducted. A radiation dose of 50 Gy over five weeks and a daily dose of 1650 mg/m(2) capecitabine in two portions was administered during the entire course of radiation therapy. Surgery was performed with standardized total mesorectal excision four to six weeks after completion of the chemoradiation.

RESULTS

Between January 2002 and September 2003, 61 patients were enrolled onto this prospective phase II trial. The pretreatment clinical stages were T3 in 64% (n=39), T4 in 36% (n=22) and N1-2 in 82% (n=50) of these patients. Fifty-six (92%) patients completed the chemoradiation as initially planned and a complete resection performed in 58 (95%). Down-staging was observed in 45 patients (74%) and a pathologic complete response in 6 (10%). Among the 37 patients with tumors located within 5 cm from the anal verge on colonoscopy, 27 (73%) underwent a sphincter-preserving procedure. No grade 3 and 4 proctitis or hematological toxicities were observed.

CONCLUSION

Preoperative chemoradiation therapy with capecitabine achieved encouraging rates of tumor downstaging and sphincter preservation, with a low toxicity profile. This combined modality can be regarded as a safe and effective treatment for locally advanced rectal cancer.

Combined-Modality Therapy of Rectal Cancer with Oxaliplatin-Based Regimens

There are 2 conventional treatments for clinically resectable rectal cancer. First is surgery and, if the tumor is stage T3 and/or N1/2, this is followed by postoperative combined modality therapy. The second is preoperative combined modality therapy followed by surgery and postoperative combined modality therapy if the tumor is stage uT3/4 and/or node-positive. There are a number of new chemotherapeutic agents that have been developed for the treatment of patients with colorectal cancer. Phase I/II trials examining the use of these new chemotherapeutic agents in combination with pelvic radiation therapy, most commonly in the preoperative setting are in progress and suggest higher complete response rates. There is considerable interest in integrating oxaliplatin into preoperative combined modality therapy regimens for rectal cancer. Based on results from phase I/II trials, the recommended regimen for patients who receive oxaliplatin-based combined modality therapy is continuous infusion 5-fluorouracil or capecitabine with pelvic radiation.

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.

Outcome of rectal and sigmoid carcinoma patients receiving adjuvant chemoradiotherapy in Marmara University Hospital

Adjuvant chemoradiotherapy is the standard treatment in resected stage II/III rectosigmoid carcinoma. We report a retrospective analysis of 33 patients who received adjuvant chemoradiotherapy. Patients received 5-fluorouracil (375mg/m2/day x 5days) and calcium leucovorin (20mg/m2/day x 5days), q4weeks, two courses before and two courses after radiotherapy. The 5-fluorouracil dose was reduced to 225mg/m2/day given continuously as protracted short-term infusion on the first and last 3 days during radiotherapy. Radiotherapy was started at 7th week and 45-50.4 Gy was given to pelvic region. Median age was 63 years. Median follow-up was 38 months starting from the operation date. Four-year local and distant control rates were 78% and 69%, respectively. Four-year disease-free survival and overall survival were 60% and 62%, respectively. Protracted short-term infusion of 5-fluorouracil during pelvic irradiation is a safe treatment modality. Further studies are needed to improve the local control of high-risk rectal and sigmoid carcinomas.

[Principles of postoperative therapy in rectal carcinoma]

In stage II (T3-4N0) and III (TxN1-2) rectal cancer, adjuvant radiochemotherapy improves overall survival and decreases the rate of local failure compared to only surgical therapy and is regarded as standard for patients with carcinoma of the lower and intermediate rectum. (Preoperative) radiotherapy also decreases the local failure rate following total mesorectal excision. Postoperative radiotherapy has no proven influence on distant metastasis rates or on overall survival. In adjuvant therapy, continuous infusion of 5-flourouracil compared to bolus application increases long-term survival. However, additional administration of leucovorin or levamisole results in increased toxicity and not improved survival. Results of randomized trials of adjuvant therapy with new drugs such as capecitabine, UFT, irinotecan, or oxaliplatin are not yet available. These drugs should not be used outside clinical trials. Elderly patients benefit from adjuvant therapy to the same extent as younger patients and should receive adjuvant radiochemotherapy, if no contraindication exists.