Skip to main content
SpringerLink
Log in

Pre-operative and post-operative radiotherapy and rectal cancer

  • World Progress In Surgery
  • Published:
World Journal of Surgery Aims and scope Submit manuscript

Abstract

The appropriate role for additional radiotherapy in patients with resectable rectal cancer is not yet settled. Irradiation has been considered by surgeons and radiotherapists as superfluous since no effect on survival has been shown. However, numerous trials have demonstrated that perioperative radiotherapy decreases an often high local recurrence rate while others believe it has a definite place in routine management. Several surgeons have, on the contrary, claimed that a skilled surgeon compared to a less skilled surgeon, will get the same acceptably low local recurrence rates. Since we will probably never have a randomized trial comparing “good” and “bad” surgeons, this argument cannot be settled. A further obstacle arises in the difficulty of persuading surgeons to organize their routine work so that it is performed in an optimal way by those specializing in this field. The question also arises whether radiotherapy should be delivered pre-operatively, postoperatively or as a “sandwich” technique, i.e., both pre-operatively and postoperatively. According to radio-biological considerations and results from reported trials, the best effect on local tumor control has been achieved using pre-operative radiotherapy.

Résumé

La place de la radiothérapie adjuvante chez les patients ayant un cancer du rectum reste discutée. La radiothérapie est estimée “superflue” par certains chirurgiens et radiothérapeutes car aucun bénéfice n'a eté clairement démontré en ce qui concerne la survie. De nombreux essais cliniques ont indiqué, cependant, que la radiothérapie périopératoire diminuait le taux habituellement élevé des récldives locales, et certains estiment que la radiothérapie a toujours une place dans le schéma thérapeutique. D'autres, au contraire, croient que la quialité et l'expérience de l'opérateur influencent directement le taux de récidives, et équivalent l'efficacité de la radiothérapie. Puisqu'il est peu probable qu'on réalise une étude randomisée entre les “bons” et les “mauvais” chirurgiens, on ne peut régler cette querelle. Un autre obstacle incontournable semble être de persuader les chirurgiens d'organiser leur travail de façon à ce que cette chirurgie soit faite par des spécialistes. Le meilleur moment pour réaliser la radiothérapie (préopératoire, postopératoire, ou les deux) reste à déterminer. Selon les données radiobiologiques et les résultats des essais contrôlés, il semble que le meilleur contôle sur les récidives locales soit obtenu par la radiothérapie préopératoire.

Resumen

Aún no se ha defindo la indicación apropriada para radioterapia adicional en pacientes con cáncer rectal. La irradiación ha sido considerada como superflua por cirujanos y radioterapeutas, puesto que no se ha demostrado efecto sobre la sobrevida. Sin embargo, numerosos ensayos clínicos han demostrado que la radioterapia perioperatoria disminuye la que con frecuencia es una elevada tasa de recurrencía local, mientras ostros creen que tiene un lugar definido en el manejo rutinario. Por el contrario, varios cirujanos han planteado que un cirujano hábil comparado con uno menos hábil, logra las mismas aceptables tasas de recurrencia, alg que jamás se ha decidido, puesto que nunca habremos de realizar ensayos comparando “buenos” cirujanos con “malos” cirujanos. Un obstáculo adicional surge de la dificultad en cuanto a persuadir a los cirujanos de organizar su trabajo rutinario de tal manera que sea realizado en forma óptima por aquellos que se especializan en este campo. También ha surgido el interrogante sobre si la radioterapia debe ser administrada preoperatoriamente, postoperatoriamente o como técnica de “sandwich,” o sea tanto pre como postoperatoriamente. Según consideraciones radio-biológicas y los resultados de los ensayos clínicos, el mejor efecto sobre el control local del tumor ha sido logrado mediante el uso de radioterapia preoperatoria.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Fletcher, G.H.: Subclinical disease. Cancer53:1274, 1984

    PubMed  Google Scholar 

  2. Zagars, G.K., Schultheiss, T.E., Peters, L.J.: Inter-tumor heterogeneity and radiation dose-control curves. Radiother. Oncol.8:353, 1987

    PubMed  Google Scholar 

  3. Yaes, R.J.: Tumor heterogeneity, tumor size, and radioresistance. Int J. Radiat. Oncol. Biol. Phys.17:993, 1989

    PubMed  Google Scholar 

  4. Kumar, P.P., Good, R.R., Plantz, S.H., Hynes, P.R.: Technique of postoperative pelvic radiation in the management of rectal and rectosigmoid carcinoma. J. Natl. Med. Assoc.6:609, 1987

    Google Scholar 

  5. Kirk, J., Gray, W.M., Watson, E.R.: Cumulative radiation effect. Part I: Fractionated treatment regimes. Clin. Radiol.22:145, 1971

    PubMed  Google Scholar 

  6. Turesson, I.: Fractionation and dose rate in radiotherapy: An experimental and clinical study of cumulative radiation effect. Thesis, Gothenburg, 1978

  7. Ellis, F.: Dose, time and fractionation: A clinical hypothesis. Clin. Radiol.20:1, 1969

    PubMed  Google Scholar 

  8. Fowler, J.F.: The linear-quadratic formula and progress in fractionated radiotherapy. Br. J. Radiol.62:679, 1989

    PubMed  Google Scholar 

  9. Gilbertsen, V.A.: Adenocarcinoma of the rectum: Incidence and locations of recurrent tumor following present-day operations performed for cure. Ann. Surg.151:340, 1960

    Google Scholar 

  10. Gunderson, L., Sosin, H.: Areas of failure found at reoperation (second or symptomatic look) following “curative surgery” for adenocarcinoma of the rectum. Cancer34:1278, 1974

    PubMed  Google Scholar 

  11. Hermanek, P., Gall, F.P.: Der aborale Sicherheitsabstand bei der sphinctererhaltenden Rectumresektion. Chirurg52:25, 1981

    Google Scholar 

  12. Williams, N.S., Dixon, M.F., Johnston, D.: Reappraisal of the 5 centimetre rule of distal excision for carcinoma of the rectum: A study of distal intramural spread and of patients' survival. Br. J. Surg.70:150, 1983

    PubMed  Google Scholar 

  13. Heald, R.J., Ryall, R.D.H.: Recurrence and survival after total mesorectal excision for rectal cancer. Lancetii:1479, 1986

    Google Scholar 

  14. Grinell, R.: Results of ligation of inferior at the aorta in resections of carcinoma of the descending and sigmoid colon and rectum. Surg. Gynecol. Obstet.120:1031, 1965

    PubMed  Google Scholar 

  15. Pezim, M.E., Nicholls, R.J.: Survival after high or low ligation of the inferior mesenteric artery during curative surgery for rectal cancer. Ann. Surg.200:729, 1984

    PubMed  Google Scholar 

  16. von der Maase, H.: Experimental studies on interactions of radiation and cancer chemotherapeutic drugs in normal tissues and a solid tumour. Radiother. Oncol.7:47, 1986

    PubMed  Google Scholar 

  17. Wassif, S.B.: Ten years' experience with a multimodality treatment of advanced stages of rectal cancer. Cancer52:2017, 1983

    PubMed  Google Scholar 

  18. Berge, T., Ekelund, G., Meliner, C., Pihl, B., Wenckert, A.: Carcinoma of the colon and rectum in a defined population. Acta. Chir Scand. Suppl. 438, 1973

  19. Morson, B.C., Bussey, H.J.R.: Surgical pathology of rectal cancer in relation to adjuvant radiotherapy. Br. J. Radiol.40:161, 1967

    PubMed  Google Scholar 

  20. Påhlman, L., Glimelius, B.: Local recurrences after surgical treatment for rectal carcinoma. Acta. Chir Scand.150:331, 1984

    PubMed  Google Scholar 

  21. Phillips, R.K.S., Hittinger, R., Blesovsky, L., Fry, J.S., Fielding, L.P.: Local recurrence following “curative” surgery for large bowel cancer: I. The overall picture. Br. J. Surg.71:12, 1984

    PubMed  Google Scholar 

  22. Horn, A., Halvorsen, J.F., Danl, O., Bond, W.H., Crowther, D., Deeley, T.J., Duthie, H.L., Dykes, P.W., Fielding, L.P., Flatman, G.E., Goligher, J.C., Hawley, P.R., Hughes, L.E., Joslin, C.A.F., Koreich, O.M., Morson, B.C., Oates, G.D., Peckham, M.J., Sandland, M.R., Schofield, P.F., Slack, W., Slaney, G., Smith, J.A.R., Stewart Scott, J., Whitehouse, J.M.A., Wrigley, P.F.M., York-Mason, A.: Preoperative radiotherapy in operable rectal cancer. Dis. Colon Rectum33:823, 1990

    PubMed  Google Scholar 

  23. Duncan, W., Smith, A.N., Freedman, L.S., Alderson, M.R., Arnott, S.J., Bleehen, N.M.: The evaluation of low dose preoperative x-ray therapy in the management of operable rectal cancer: Results of a randomly controlled trial. Br. J. Surg.71:21, 1984

    PubMed  Google Scholar 

  24. Higgins, G., Humphery, E., Dwight, R., Roswit, B., Lee, L., Keehn, R.: Preoperative radiation and surgery for cancer of the rectum: VASOG trial II. Cancer58:352, 1986

    PubMed  Google Scholar 

  25. Rider, W.D., Palmer, J.A., Mahoney, L.J., Robertson, C.T.: Preoperative irradiation in operable cancer of the rectum: Report of the Toronto trial. Can. J. Surg.20:335, 1977

    PubMed  Google Scholar 

  26. Roswit, B., Higgins, G., Keehn, R.: Preoperative irradiation for carcinoma of the rectum and rectosigmoid colon: Report of a National Veterans Administration randomized study. Cancer35:1597, 1975

    PubMed  Google Scholar 

  27. Stevens, K., Fletcher, W., Allen, C.: Anterior resection and primary anastomosis following high dose preoperative radiotherapy for adenocarcinoma of the rectosigmoid. Cancer41:2065, 1978

    PubMed  Google Scholar 

  28. Friedman, P., Garb, J.L., Park, W., Stark, A., DeConti, R., Chabot, R., Pace, O.: Survival following moderate-dose preoperative radiation therapy for carcinoma of the rectum. Cancer55:967, 1985

    PubMed  Google Scholar 

  29. Glimelius, B., Graffman, S., Påhlman, L., Rimsten, Å., Wilander, E.: Preoperative irradiation with high-dose fractionation in adenocarcinoma of the rectum and rectosigmoid. Acta Radiol. Oncol.21:373, 1982

    PubMed  Google Scholar 

  30. Mendenhall, W.M., Million, R.R., Bland, K.I., Pfaff, W.W., Copeland, E.M.: Preoperative radiation therapy for clinically resectable adenocarcinoma of the rectum. Ann. Surg.202:215, 1985

    PubMed  Google Scholar 

  31. Mohiuddin, M., Marks, G.J.: High dose preoperative radiation and sphincter preservation in the treatment of rectal cancer. Int. J. Radiat. Oncol. Biol. Phys.13:839, 1987

    PubMed  Google Scholar 

  32. Påhlman, L., Glimelius, B.: Pre- and postoperative radiotherapy in rectal carcinoma: Report from a randomized multicenter trial. Ann. Surg.211:187, 1990

    PubMed  Google Scholar 

  33. Romsdahl, M., Withers, R.: Radiotherapy combined with curative surgery. Arch. Surg.113:446, 1978

    PubMed  Google Scholar 

  34. Tepper, J.E., Cohen, A.M., Wood, W.C., Orlow, E.L., Hedberg, S.E.: Postoperative radiation therapy of rectal cancer. Int. J. Radiat. Oncol. Biol. Phys.13:5, 1987

    PubMed  Google Scholar 

  35. Shank, B., Enker, W., Santana, J., Morrissey, K., Daly, J., Quan, S., Knapper, W.: Local control with pre-operative radiotherapy alone versus “sandwich” radiotherapy for rectal carcinoma. Int. J. Radiat. Oncol. Biol. Phys.13:111, 1987

    PubMed  Google Scholar 

  36. Gunderson, L., Dosoretz, D.E., Hedberg, S.E., Blitzer, P.H., Rodkey, G., Hoskin, B., Shipley, W.U., Cohen, A.C.: Low-dose preoperative irradiation, surgery, and elective postoperative radiation therapy for resectable rectum and rectosigmoid carcinoma. Cancer52:446, 1983

    PubMed  Google Scholar 

  37. Mohuiddin, M., Kramer, S., Marks, G., Dobelbower, R.R.: Combined pre- and postoperative radiation for carcinoma of the rectum. Int. J. Radiat. Oncol. Biol. Phys.8:133, 1982

    PubMed  Google Scholar 

  38. Gérard, A., Buyse, M., Nordlinger, B., Loygue, J., Pène, F., Kempf, P., Bosset, J-F., Gignoux, M., Arnaud, J-P., Desaive, C., Duez, N.: Preoperative radiotherapy as adjuvant treatment in rectal cancer. Ann. Surg.208:606, 1988

    PubMed  Google Scholar 

  39. Jones, D.J., Zaloudik, J., James, R.D., Haboubi, N., Moore, M., Schofield, P.F.: Predicting local recurrence of carcinoma of the rectum after preoperative radiotherapy and surgery. Br. J. Surg.76:1172, 1989

    PubMed  Google Scholar 

  40. MRC Trial Office: Personal communication

  41. Stockholm Rectal Cancer Study Group (Cedermark, B.).: The Stockholm trial: A randomized study on short-term preoperative radiotherapy in rectal carcinoma. 4th Congress of the European Society of Surgical Oncology in Paris, Abstract, 1988

  42. Balslev, I., Pedersen, M., Teglbjaerg, P.S., Hanberg-Soerensen, F., Bone, J., Jacobsen, N.O., Overgaard, J., Sell, A., Bertelsen, K., Hage, E., Fenger, C., Kronborg, O., Hansen, L., Hoestrup, H., Noergaard-Pedersen, B.: Postoperative radiotherapy in Dukes' B and C carcinoma of the rectum and rectosigmoid: A randomized multicenter study. Cancer58:22, 1986

    PubMed  Google Scholar 

  43. Fisher, B., Wolmark, N., Rockette, H., Redmond, C., Deutsch, M., Wickerham, D.L., Fisher, E.R., Caplan, R., Jones, J., Lerner, H., Gordon, P., Feldman, M., Cruz, A., Legault-Poisson, S., Wexler, M., Lawrence, W., Robidoux, A.: Postoperative adjuvant chemotherapy or radiation therapy for rectal cancer: Results from NSABP Protocol R-01. J. Natl. Cancer Inst.80:21, 1988

    PubMed  Google Scholar 

  44. GITSG: Prolongation of the disease-free interval in surgically treated rectal carcinoma. New Engl. J. Med.312:1464, 1985

    Google Scholar 

  45. NCCTG: Effective surgical adjuvant therapy for high-risk rectal cancer. New Engl. J. Med.324:709, 1991

    Google Scholar 

  46. Boyse, M., Zeleniuch-Jacquotte, A., Chalmers, T.C.: Adjuvant therapy of colorectal cancer: Why we still don't know. J.A.M.A.259:3571, 1988

    PubMed  Google Scholar 

  47. NIH Consensus Conference: Adjuvant therapy for patients with colon and rectal cancer. J.A.M.A.264:114, 1990

    Google Scholar 

  48. Swedish Rectal Cancer Trial: Preoperative irradiation vs surgery alone in resectable rectal carcinoma: First report from a nation wide Swedish multicenter trial. (personal communication)

  49. UK Coordinating Committee on Cancer Research (UKCCR), Cancer Research Campaign: AXIS-protocol (Adjuvant X-ray and 5-FU Infusion Study), 1989

  50. Påhlman, L., Glimelius, B., Graffman, S.: Pre- versus postoperative radiotherapy in rectal carcinoma: An interim report from a randomized multicentre trial. Br. J. Surg.72:961, 1985

    PubMed  Google Scholar 

  51. Stockholm Rectal Cancer Study Group: Short-term preoperative radiotherapy for adenocarcinoma of the rectum. Am. J. Clin. Oncol.10:369, 1987

    Google Scholar 

  52. Bubrik, M.P., Rolfmeyers, E.S., Schauer, R.M., Feeney, D.A., Johnston, G.R., Strom, R.L., Hitchcock, C.R.: Effects of high-dose and low-dose preoperative irradiation on low anterior anastomosis in dogs. Dis. Colon Rectum25:406, 1982

    PubMed  Google Scholar 

  53. Degges, R.D., Cannon, D.J., Lang, N.P.: The effects of preoperative radiation on healing of rat colonic anastomosis. Dis. Colon Rectum26:598, 1983

    PubMed  Google Scholar 

  54. Schauer, R.M., Bubrick, M.P., Feeney, D.A., Johnston, G.R., Rolfmeyer, E.S., Strom, R.L., Hitchcock, C.R.: Effects of low-dose preoperative irradiation on low anterior anastomosis in dogs. Dis. Colon Rectum25:401, 1982

    PubMed  Google Scholar 

  55. Porter, N.H., Nicholls, R.J.: Pre-operative radiotherapy in operable rectal cancer: Interim report of a trial carried out by the Rectal Cancer Group. Br. J. Surg.72:62, 1985

    Google Scholar 

  56. Gallagher, M.J., Brereton, H.D., Rostock, R.A., Zero, J.M., Zekoski, D.A., Poyss, L.F., Richter, M.P., Kligerman, M.M.: A prospective study of treatment techniques to minimize the volume of pelvic small bowel with reduction of acute and late effects associated with pelvic irradiation. Int. J. Radiat. Oncol. Biol. Phys.12:1565, 1986

    PubMed  Google Scholar 

  57. Gunderson, L.L., Russell, A.H., Llewellyn, H.J., Doppke, K.P., Tepper, J.E.: Treatment planning for colorectal cancer: Radiation and surgical techniques and value of small-bowel films. Int. J. Radiat. Oncol. Biol. Phys.11:1379, 1985

    PubMed  Google Scholar 

  58. Feldman, M.I., Kavanah, M.T., Devereux, D.F., Choe, S.: New surgical method to prevent pelvic radiation enteropathy. Am. J. Clin. Oncol.11:25, 1988

    PubMed  Google Scholar 

  59. Hoskin, B., Gunderson, L., Dosoretz, D., Rich, T., Galdabini, J., Donaldson, G., Cohen, A.: Adjuvant postoperative radiotherapy in carcinoma of the rectum and rectosigmoid. Cancer55:61, 1985

    PubMed  Google Scholar 

  60. Frykholm, G., Glimelius, B., Påhlman, L.: Additional radiotherapy in the treatment of adenocarcinoma of the rectum: Late secondary effects. Dis. Colon Rectum (submitted)

  61. Bjerkeset, T., Dahl, O.: Irradiation and surgery for primarily inoperable rectal adenocarcinoma. Dis. Colon Rectum23:298, 1980

    PubMed  Google Scholar 

  62. Durdey, P., Williams, N.S.: The effect of malignant and inflammatory fixation of rectal carcinoma on prognosis after rectal excision. Br. J. Surg.71:787, 1984

    PubMed  Google Scholar 

  63. Fortier, G.A., Krochak, R.J., Kim, J.A., Constable, W.C.: Dose response to preoperative irradiation in rectal cancer: Implications for local control and complications associated with sphincter sparing surgery and abdominoperineal resection. Int. J. Radiat. Oncol. Biol. Phys.12:1559, 1986

    PubMed  Google Scholar 

  64. Dosoretz, D.E., Gunderson, L.L., Hedberg, S., Hoskins, B., Blitzer, P.H., Shipley, W., Cohen, A.: Preoperative irradiation for unresectable rectal and rectosigmoid carcinomas. Cancer52:814, 1989

    Google Scholar 

  65. Frykholm, G., Påhlman, L., Glimelius, B.: Preoperative irradiation with and without chemotherapy (MFL) in the treatment of primarily non-resectable adenocarcinoma of the rectum: Results from two consecutive studies. Eur. J. Cancer Clin. Oncol.25:1535, 1989

    PubMed  Google Scholar 

  66. Overgaard, M., Overgaard, J., Sell, A.: Dose-response relationship for radiation therapy of recurrent, residual, and primarily inoperable colorectal cancer. Radicther. Oncol.1:217, 1984

    Google Scholar 

  67. Påhlman, L., Glimelius, B., Ginman, C., Graffman, S., Adalsteinsson, B.: Preoperative irradiation of primary non-resectable adenocarcinoma of the rectum and rectosigmoid. Acta Radiol. Oncol.24:35, 1985

    PubMed  Google Scholar 

  68. Nicholls, R.J., York Mason, A., Morson, B.C., Dixon, A.K., Kelsey Fry, I.: The clinical staging of rectal cancer. Br. J. Surg.69:404, 1982

    PubMed  Google Scholar 

  69. Byfield, J., Calabro-Jones, P., Klisak, I., Kulhanian, F.: Pharmacologic requirements for obtaining sensitization of human tumour cells in vitro to combined 5-Fluorouracil or Ftorafur and X-rays. Int. J. Radiat. Oncol. Biol. Phys.8:1923, 1982

    PubMed  Google Scholar 

  70. Overgaard, M., Besthelsen, K., Dahlmark, M., Gadeberg, C.G., van der Maase, H., Overgaard, J., Sell, A.: A randomized trial of radiotherapy alone or combined with 5-FU in the treatment of locally advanced colorectal carcinoma. ECCO 5, meeting abstract, 0626, 1989

  71. Danjoux, C.E., Gelber, R.D., Catton, G.E., Klaassen, D.J.: Combination chemoradiotherapy for residual, recurrent or inoperable carcinoma of the rectum: E.C.O.G. study (EST 3276). Int. J. Radiat. Oncol. Biol. Phys.11:765, 1985

    PubMed  Google Scholar 

  72. Rominger, C.J., Gelber, R.D., Gunderson, L.L., Conner, N.: Radiation therapy alone or in combination with chemotherapy in the treatment of residual or inoperable carcinoma of the rectum and rectosigmoid or pelvic recurrence following colorectal surgery: Radiation Therapy Oncology Group study (76–16). Am. J. Clin. Oncol.8:118, 1985

    PubMed  Google Scholar 

  73. Gunderson, L.L., Martin, J.K., Beart, R.W., Nagorney, D.M., Fieck, J.M., Wieand, H.S., Martinez, A., O'Connell, M.J., Martenson, J.A., McIlrath, D.C.: Intraoperative and external beam irradiation for locally advanced colorectal cancer. Ann. Surg.207:52, 1988

    PubMed  Google Scholar 

  74. Sichy, B.: Intraoperative electron beam radiation therapy with particular reference to the treatment of rectal carcinomas: Primary and recurrent. Dis. Colon Rectum29:714, 1986

    PubMed  Google Scholar 

  75. Beynon, J., Mortensen, N.J., Mc. C., Foy, D.M.A., Channer, J.L., Virjee, J., Goddard, P.: Preoperative assessment of local invasion in rectal cancer: Digital examination, endoluminal sonography or computed tomography? Br. J. Surg.73:1015, 1986

    PubMed  Google Scholar 

  76. Hildebrandt, U., Fiefel, G.: Pre-operative staging of rectal cancer by intrarectal ultrasound. Dis. Colon Rectum28:42, 1985

    PubMed  Google Scholar 

  77. Frykholm, G., Hemmingsson, A., Nyman, R., Påhlman, L., Glimelius, B.: Magnetic resonance imaging in the assessment of locally non-resectable adenocarcinoma of the rectum. Acta Radiol. (in press)

Download references

Author information

Authors and Affiliations

  1. Departments of Surgery and Oncology, University of Uppsala, Akademiska sjukhuset, Uppsala, Sweden

    Lars Påhlman M.D., Ph.D. & Bengt Glimelius M.D., Ph.D.

Authors
  1. Lars Påhlman M.D., Ph.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Bengt Glimelius M.D., Ph.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

Rights and permissions

Reprints and permissions

About this article

Cite this article

Påhlman, L., Glimelius, B. Pre-operative and post-operative radiotherapy and rectal cancer. World J. Surg. 16, 858–865 (1992). https://doi.org/10.1007/BF02066982

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF02066982

Keywords

Search

Navigation