Journal of Gastrointestinal Surgery

, Volume 16, Issue 10, pp 1888–1896 | Cite as

Concurrent Chemoradiotherapy Followed by Metastasectomy Converts to Survival Benefit in Stage IV Rectum Cancer

  • Jen-Kou Lin
  • Lin-Kun Lee
  • Wei-Shone Chen
  • Tzu-Chen Lin
  • Jeng-Kai Jiang
  • Shung-Haur Yang
  • Huann-Sheng Wang
  • Shih-Ching Chang
  • Yuan-Tzu Lan
  • Chun-Chi Lin
  • Chueh-Chuan Yen
  • Jin-Hwang Liu
  • Cheng-Hwai Tzeng
  • Hao-Wei Teng
Original Article

Abstract

Background

To investigate the impact of concurrent chemoradiotherapy (CCRT) on stage IV rectum cancer.

Methods

Between 2000 and 2011, 297 consecutive patients diagnosed with stage IV rectum cancer (synchronous metastasis) were enrolled. Cox proportional hazard analyses were used for prognostic factors determination, and the Kaplan–Meier method was used for survival analyses. Propensity scores with the one-to-one nearest-neighbor matching model were used to select matched patients for validation studies.

Results

In total, 63 patients received CCRT and 234 did not. The patients in the CCRT group were younger, had more low-lying lesions, and had more T4 lesions, lung metastases, metastasectomies, and oxaliplatin-based upfront chemotherapy. Before propensity-score matching, a younger age (HR = 0.662, P = 0.016), lower carcinoembryonic antigen (CEA) level (≤20 ng/ml) (HR = 0.531, P = 0.001), no metastasectomy (HR = 3.214, P < 0.001), and no CCRT (HR = 1.844, P = 0.019) were independent prognostic factors after controlling for other confounding factors. After matching, only CEA and metastasectomy, but not CCRT, were independent prognostic factors. The survival benefit of CCRT was restricted to patients who undergo subsequent metastasectomy.

Conclusions

Upfront CCRT only provided a survival benefit in patients with stage IV rectum cancer who undergo subsequent metastasectomy.

Keywords

Colorectal cancer Metastases Propensity score model Radiation 

References

  1. 1.
    Naishadham D, Lansdorp-Vogelaar I, Siegel R, Cokkinides V, et al.: State disparities in colorectal cancer mortality patterns in the United States. Cancer Epidemiol Biomarkers Prev 2011;20:1296-1302.PubMedCrossRefGoogle Scholar
  2. 2.
    Cunningham D, Humblet Y, Siena S, Khayat D, et al.: Cetuximab monotherapy and cetuximab plus irinotecan in irinotecan-refractory metastatic colorectal cancer. N Engl J Med 2004;351:337-345.PubMedCrossRefGoogle Scholar
  3. 3.
    Falcone A, Ricci S, Brunetti I, Pfanner E, et al.: Phase III trial of infusional fluorouracil, leucovorin, oxaliplatin, and irinotecan (FOLFOXIRI) compared with infusional fluorouracil, leucovorin, and irinotecan (FOLFIRI) as first-line treatment for metastatic colorectal cancer: the Gruppo Oncologico Nord Ovest. J Clin Oncol 2007;25:1670-1676.PubMedCrossRefGoogle Scholar
  4. 4.
    Montagnani F, Chiriatti A, Turrisi G, Francini G, et al.: A systematic review of FOLFOXIRI chemotherapy for the first-line treatment of metastatic colorectal cancer: improved efficacy at the cost of increased toxicity. Colorectal Dis 2011;13:846-852.PubMedCrossRefGoogle Scholar
  5. 5.
    Saltz LB, Clarke S, Diaz-Rubio E, Scheithauer W, et al.: Bevacizumab in combination with oxaliplatin-based chemotherapy as first-line therapy in metastatic colorectal cancer: a randomized phase III study. J Clin Oncol 2008;26:2013-2019.PubMedCrossRefGoogle Scholar
  6. 6.
    Souglakos J, Androulakis N, Syrigos K, Polyzos A, et al.: FOLFOXIRI (folinic acid, 5-fluorouracil, oxaliplatin and irinotecan) vs FOLFIRI (folinic acid, 5-fluorouracil and irinotecan) as first-line treatment in metastatic colorectal cancer (MCC): a multicentre randomised phase III trial from the Hellenic Oncology Research Group (HORG). Br J Cancer 2006;94:798-805.PubMedCrossRefGoogle Scholar
  7. 7.
    Sauer R, Becker H, Hohenberger W, Rodel C, et al.: Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 2004;351:1731-1740.PubMedCrossRefGoogle Scholar
  8. 8.
    Minsky BD: Counterpoint: long-course chemoradiation is preferable in the neoadjuvant treatment of rectal cancer. Semin Radiat Oncol 2011;21:228-233.PubMedCrossRefGoogle Scholar
  9. 9.
    Kapiteijn E, Marijnen CA, Nagtegaal ID, Putter H, et al.: Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med 2001;345:638-646.PubMedCrossRefGoogle Scholar
  10. 10.
    Madoff RD: Chemoradiotherapy for rectal cancer—when, why, and how? N Engl J Med 2004;351:1790-1792.PubMedCrossRefGoogle Scholar
  11. 11.
    D'Agostino RB, Jr.: Propensity score methods for bias reduction in the comparison of a treatment to a non-randomized control group. Stat Med 1998;17:2265-2281.PubMedCrossRefGoogle Scholar
  12. 12.
    Hong TS, Ritter MA, Tome WA, Harari PM: Intensity-modulated radiation therapy: emerging cancer treatment technology. Br J Cancer 2005;92:1819-1824.PubMedCrossRefGoogle Scholar
  13. 13.
    Meyer J, Czito B, Yin FF, Willett C: Advanced radiation therapy technologies in the treatment of rectal and anal cancer: intensity-modulated photon therapy and proton therapy. Clin Colorectal Cancer 2007;6:348-356.PubMedCrossRefGoogle Scholar
  14. 14.
    Bosset JF, Collette L, Calais G, Mineur L, et al.: Chemotherapy with preoperative radiotherapy in rectal cancer. N Engl J Med 2006;355:1114-1123.PubMedCrossRefGoogle Scholar
  15. 15.
    Sebag-Montefiore D: Developments in the use of chemoradiotherapy in rectal cancer. Colorectal Dis 2006;8 Suppl 3:14-17.PubMedCrossRefGoogle Scholar
  16. 16.
    Gerard JP, Conroy T, Bonnetain F, Bouche O, et al.: Preoperative radiotherapy with or without concurrent fluorouracil and leucovorin in T3-4 rectal cancers: results of FFCD 9203. J Clin Oncol 2006;24:4620-4625.PubMedCrossRefGoogle Scholar
  17. 17.
    Radu C, Berglund A, Pahlman L, Glimelius B: Short-course preoperative radiotherapy with delayed surgery in rectal cancer—a retrospective study. Radiother Oncol 2008;87:343-349.PubMedCrossRefGoogle Scholar
  18. 18.
    Bosset JF, Calais G, Mineur L, Maingon P, et al.: Enhanced tumorocidal effect of chemotherapy with preoperative radiotherapy for rectal cancer: preliminary results—EORTC 22921. J Clin Oncol 2005;23:5620-5627.PubMedCrossRefGoogle Scholar
  19. 19.
    Choti MA, Sitzmann JV, Tiburi MF, Sumetchotimetha W, et al.: Trends in long-term survival following liver resection for hepatic colorectal metastases. Ann Surg 2002;235:759-766.PubMedCrossRefGoogle Scholar
  20. 20.
    Pawlik TM, Scoggins CR, Zorzi D, Abdalla EK, et al.: Effect of surgical margin status on survival and site of recurrence after hepatic resection for colorectal metastases. Ann Surg 2005;241:715-722, discussion 722-714.PubMedCrossRefGoogle Scholar
  21. 21.
    Bartlett DL, Berlin J, Lauwers GY, Messersmith WA, et al.: Chemotherapy and regional therapy of hepatic colorectal metastases: expert consensus statement. Ann Surg Oncol 2006;13:1284-1292.PubMedCrossRefGoogle Scholar
  22. 22.
    Shin SJ, Yoon HI, Kim NK, Lee KY, et al.: Upfront systemic chemotherapy and preoperative short-course radiotherapy with delayed surgery for locally advanced rectal cancer with distant metastases. Radiat Oncol 2011;6:99.PubMedCrossRefGoogle Scholar
  23. 23.
    Fernandez-Martos C, Pericay C, Aparicio J, Salud A, et al.: Phase II, randomized study of concomitant chemoradiotherapy followed by surgery and adjuvant capecitabine plus oxaliplatin (CAPOX) compared with induction CAPOX followed by concomitant chemoradiotherapy and surgery in magnetic resonance imaging-defined, locally advanced rectal cancer: Grupo cancer de recto 3 study. J Clin Oncol 2010;28:859-865.PubMedCrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2012

Authors and Affiliations

  • Jen-Kou Lin
    • 3
    • 4
  • Lin-Kun Lee
    • 1
    • 3
  • Wei-Shone Chen
    • 3
    • 4
  • Tzu-Chen Lin
    • 3
    • 4
  • Jeng-Kai Jiang
    • 3
    • 4
  • Shung-Haur Yang
    • 3
    • 4
  • Huann-Sheng Wang
    • 3
    • 4
  • Shih-Ching Chang
    • 3
    • 4
  • Yuan-Tzu Lan
    • 3
    • 4
  • Chun-Chi Lin
    • 3
    • 4
  • Chueh-Chuan Yen
    • 1
    • 3
  • Jin-Hwang Liu
    • 1
    • 3
  • Cheng-Hwai Tzeng
    • 1
    • 3
  • Hao-Wei Teng
    • 1
    • 2
    • 3
  1. 1.Division of Hematology and Oncology, Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan
  2. 2.Institute of Clinical MedicineNational Yang-Ming UniversityTaipeiTaiwan
  3. 3.School of MedicineNational Yang-Ming UniversityTaipeiTaiwan
  4. 4.Division of Colon and Rectum Surgery, Department of SurgeryTaipei Veterans General Hospital and National Yang-Ming UniversityTaipeiTaiwan

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