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Journal of Gastrointestinal Cancer

, Volume 46, Issue 3, pp 219–236 | Cite as

Review of Neoadjuvant Chemotherapy Alone in Locally Advanced Rectal Cancer

  • Omer Jalil
  • Leica Claydon
  • Tan Arulampalam
Review Article

Abstract

Background

Currently, the standard management of locally advanced rectal cancer (LARC) is neoadjuvant chemoradiotherapy followed by resection. Despite the significant improvement in local recurrence, survival benefits are not gained due to distant failure and radiotherapy-associated toxicity. Compliance to adjuvant chemotherapy after preoperative chemoradiotherapy is also poor. Neoadjuvant chemotherapy alone followed by surgery may be an alternative. The objective of this review is to determine the efficacy of neoadjuvant chemotherapy alone in operable LARC.

Materials and Methods

Electronic databases searched (from database inception–December 2013) were Medline, PubMed, Embase, Scopus, Cochrane library, and the Clinical Trials Register. Specific journals were also hand searched. The selection criteria were studies published in English investigating stage II–III non-metastatic rectal cancer patients treated with neoadjuvant chemotherapy (oral, intravenous or rectal route) followed by curative resection. The primary outcome measure was tumour response. Secondary outcome measures included acute toxicity, operative morbidity, R0 resection, local recurrence, overall survival (OS) and disease-free survival (DFS).

Results

One randomised phase III trial, six single-arm phase II trials and one retrospective case series study were eligible for inclusion. Six studies administered fluoropyrimidine-based multiple agent regimens and two studies administered fluorouracil-based monotherapy. The studies with multiple agents and stronger chemotherapy regimens (intravenous and/or oral) followed by delayed surgery showed better tumour response rates. The overall objective response rate was good and ranged from 62.5 to 93.7 %. Pathological complete response ranged from 3.8 to 33.3 %. The R0 resection and compliance rates were also high ranging from 90 to 100 % and 72 to 100 %, respectively. Grade 3–4 toxicities ranged from 2.3 to 39 %. Four- to 5-year OS and DFS ranged from 67.2 to 91 % and 60.5 to 84 %, respectively.

Conclusion

This review demonstrates that neoadjuvant chemotherapy could be affectively administered in LARC and could provide a good alternative to chemoradiotherapy in moderate-risk rectal cancers without compromising short- and long-term outcomes.

Keywords

Rectal neoplasm Preoperative period Preoperative care neoadjuvant therapy Combined modality therapy Drug therapy 

Abbreviations

APR

Abdominoperineal resection

CAPOX

Oxaliplatin and capecitabine

CIV

Continuous intravenous infusion

cPR

Complete pathological response

CRC

Colorectal cancer

CRM

Circumferential resection margin

CRT

Chemoradiotherapy

DFS

Disease-free survival

5-FU

5-Fluorouracil

FLOFOX

Oxaliplatin, fluorouracil (5-FU) and folinic acid

IFL

Irinotecan, 5-fluorouracil and leucovorin

ITT

Intention to treat

IV

Intravenous

LAR

Low anterior resection

MRI

Magnetic resonance imaging

OS

Overall survival

PRISMA

Preferred reporting items for systematic reviews and meta-analyses

RCT

Randomised controlled trial

RECISTs

Response evaluation criteria in solid tumours

TPE

Total pelvic exenteration

XELOX

Oxaliplatin and capacitabine

Notes

Conflict of Interest

All the authors declare no conflict of interests.

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Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  1. 1.Department of General and Colorectal SurgeryColchester Hospital UniversityColchesterUK
  2. 2.Gloucestershire Royal HospitalGloucesterUK
  3. 3.Anglia Ruskin UniversityChelmsfordUK

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