Diseases of the Colon & Rectum

, Volume 41, Issue 9, pp 1087–1096 | Cite as

Low rectal cancer

Impact of radiation and chemotherapy on surgical treatment
  • Angelita Habr-Gama
  • Pedro M. Santinho B. de Souza
  • Ulysses RibeiroJr.
  • Wladimir Nadalin
  • René Gansl
  • Afonso H. S. e SousaJr.
  • Fábio Guilherme Campos
  • Joaquim Gama-Rodrigues
Original Contributions


INTRODUCTION: The aim of this study was to evaluate the impact of combined radiotherapy and chemotherapy (leucovorin and 5-fluorouracil) on the treatment of potentially resectable low rectal cancer using the following end points: 1) toxicity of this combined modality regimen; 2) clinical and pathologic response rate and local control; 3) downstaging of the tumor and its influence on the number of sphincter-saving operations; 4) disease-free interval, patterns of relapse, and overall survival. METHODS: From 1991 to 1996, 118 patients with potentially resectable cases of histologically proven adenocarcinoma and no distant metastases were enrolled into this protocol. All patients were evaluated by clinical and proctologic examination, abdominal computed tomography, transrectal ultrasound, and chest radiography. Therapy consisted of 5,040 cGy (6 weeks) and concurrent leucovorin (20/mg/m2/day) with bolus doses of 5-fluorouracil administered intravenously at 425 mg/m2/day for three consecutive days on the first and last three days of radiation therapy. After two months, all patients underwent repeat evaluation and biopsy of any suspected residual lesions or scar tissue. RESULTS: Median follow-up was 36 months. Toxicity of chemotherapy regimen was minimum. Thirty-six patients (30.5 percent) were classified as being complete responders. In six of these patients, complete response was confirmed by the absence of tumor in the surgical specimens (3 abdominoperineal resections and 3 proctosigmoidectomies with coloanal anastomosis). In the remaining 30 patients, confirmation of a complete response was made by the absence of symptoms, negative findings on physical examination, and biopsy, transrectal ultrasound, and pelvic computed tomographic test results during follow-up. Eighty-two patients (69.4 percent) were considered incomplete responders. Residual lesions had already been identified during the first examination in 74 patients. In the other eight patients, residual tumor was only identified after 3 to 14 months. All patients underwent surgical treatment, except one patient who refused surgery. Eighty-seven patients underwent 90 surgical procedures: local excision, 9; coloanal anastomosis, 36; abdominoperineal resection, 4; Hartmann's procedure, 1. Isolated local recurrences occurred in five patients (4.3 percent) and combined local and distant failure in eight patients (6.7 percent). Ninety patients are alive and disease-free at a median follow-up of 36 months. CONCLUSIONS: Combined up-front chemoradiotherapy was associated with tolerable and acceptable side effects. A significant number of patients had complete disappearance of their tumors (30.5 percent) within a median follow-up of 36 months. This regimen spared 26.2 percent of patients from surgical treatment and allowed sphincter-saving management in 38.1 percent of patients who may have required abdominoperineal resection. Preliminary results of this trial suggests a reduction in the number of local recurrences and reinforces the concept that infiltrative low rectal cancer may be initially treated by chemoradiotherapy.

Key words

Low rectal cancer Chemotherapy Radiotherapy Sphincter-saving Recurrence Survival Downstaging 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Aleman BM, Bartelink H, Gunderson LL. The current role of radiotherapy in colorectal cancer. Eur J Cancer 1995;31A:1333–9.Google Scholar
  2. 2.
    O'Connell MJ. A phase III trial of 5-fluorouracil and leucovorin in the treatment of advanced colorectal cancer: a Mayo Clinic/North Central Cancer Treatment Group Study. Cancer 1989;63:1026–30.PubMedGoogle Scholar
  3. 3.
    Cohen AM. Adjuvant therapy in rectal cancer. Hepatogastroenterology 1992;39:215–21.PubMedGoogle Scholar
  4. 4.
    Chari RS, Tyler DS, Anscher MS,et al. Preoperative radiation and chemotherapy in the treatment of adenocarcinoma of the rectum. Ann Surg 1995;221:778–87.Google Scholar
  5. 5.
    Påhlman L & Glimelius B. The value of adjuvant radio-(chemo)therapy for rectal cancer. Eur J Cancer 1995;31A:1347–50.Google Scholar
  6. 6.
    Boulis-Wassif S, Gérard A, Loygue J, Camelot D, Buyse M, Suez N. Final results of a randomized trial on the treatment of rectal cancer with preoperative radiotherapy alone or in combination with 5-fluorouracil, followed by radical surgery: Trial of the European Organization on Research and Treatment of Gastrointestinal Cancer Cooperative Group. Cancer 1984;53:1811–8.PubMedGoogle Scholar
  7. 7.
    Rider WD, Palmer JA, Mahoney LJ, Robertson CT. Preoperative irradiation in operable cancer of the rectum: report of the Toronto Trial. Can J Surg 1977;20:335–8.PubMedGoogle Scholar
  8. 8.
    Cohen AM, Minsky BD. A phase I trial of preoperative radiation proctectomy and endo-anal reconstruction. Arch Surg 1990;125:247–51.PubMedGoogle Scholar
  9. 9.
    Minsky BD, Kemeny N, Cohen AM,et al. Preoperative high-dose leucoverin/5-fluorouracil and radiation therapy for unresectable rectal cancer. Cancer 1991;67:2859–66.PubMedGoogle Scholar
  10. 10.
    Minsky BD, Cohen AM, Kemeny N,et al. Enhancement of radiation-induced downstaging of rectal cancer by fuorouracil and high-dose leucoverin chemotherapy. J Clin Oncol 1992;10:79–84.PubMedGoogle Scholar
  11. 11.
    Byfield JE, Frankel SS, Sharp SS, Hornback CL, Callipari FB. Phase I and pharmacological study of 72 hour infused and hyperfractionated cyclical radiation. Int J Radiat Oncol Biol Phys 1985;11:791–800.PubMedGoogle Scholar
  12. 12.
    Haghbin M, Sischy B, Hinson J. Combined modality therapy in poor prognostic rectal adenocarcinoma. Radiother Oncol 1988;13:75–81.CrossRefPubMedGoogle Scholar
  13. 13.
    Nadalin W, Habr-Gama A. O papel da radioterapia no câncer retal. Oncologia Atual 1994;4:124–33.Google Scholar
  14. 14.
    Mohiuddin M, Dobelbower RR, Turalba C, Kramer S, Marks G. A selective sandwich technique of adjuvant radiotherapy in the treatment of rectal cancer: a preliminary experience. Dis Colon Rectum 1979;22:1–4.PubMedGoogle Scholar
  15. 15.
    Winchester DP, Cox JD. Standards for breast-conservation treatment. Cancer J Clin 1992;42:135–63.Google Scholar
  16. 16.
    Meterissian S, Skibber J, Rich T,et al. Patterns of residual disease after preoperative chemoradiation in ultrasound T3 rectal carcinoma. Ann Surg Oncol 1994;1:111–6.PubMedGoogle Scholar
  17. 17.
    Neville R, Fielding LP, Amendola C. Local tumor recurrence after curative resection for rectal cancer: a ten-hospital review. Dis Colon Rectum 1987;30:12–7.PubMedGoogle Scholar
  18. 18.
    Rich T, Gunderson LL, Lew R, Galdibini JJ, Cohen AM, Donaldson G. Patterns of recurrence of rectal cancer after potentially curative surgery. Cancer 1983;52:1317–29.PubMedGoogle Scholar
  19. 19.
    Gastrointestinal Tumor Study Group. Survival after postoperative combination treatment of rectal carcinoma. N Engl J Med 1986;315:1294–5.Google Scholar
  20. 20.
    Cummings BJ. Radiation therapy for colorectal cancer. Surg Clin North Am 1993;73:167–81.PubMedGoogle Scholar
  21. 21.
    Kodner IJ, Shemesh EI, Fry RD,et al. Preoperative irradiation for rectal cancer: improved local control and long-term survival. Ann Surg 1989;209:194–9.PubMedGoogle Scholar
  22. 22.
    Reis Neto JA, Quilici FA, Reis JA Jr. A comparison of nonoperativeversus preoperative radiotherapy in rectal carcinoma: a 10-year randomized trial. Dis Colon Rectum 1989;32:702–10.PubMedGoogle Scholar
  23. 23.
    Enker WE, Paty PB, Minsky BD, Cohen AM. Restorative or preservative operations in the treatment of rectal cancer. Surg Oncol Clin North Am 1992;1:57–69.Google Scholar
  24. 24.
    Marks G, Mohiuddin M, Masoni L, Montori A. High-dose preoperative radiation therapy as the key to extending sphincter-preservation surgery for cancer of the distal rectum. Surg Oncol Clin North Am 1992;1:71–86.Google Scholar
  25. 25.
    Minsky BD. Rectal Cancer: the preoperative combined modality approach. Gastrointest Cancer 1994;2:254–60.Google Scholar
  26. 26.
    Poon MA, O'Connell MJ, Moertel CG,et al. Biochemical modulation of fluorouracil: evidence of significant improvement of survival and quality of life in patients with advanced colorectal cancer. J Clin Oncol 1989;7:1407–18.PubMedGoogle Scholar
  27. 27.
    Rotman M, Aziz H. Concomitant continuous infusion chemotherapy and radiation. Cancer 1990;65:823–35.PubMedGoogle Scholar
  28. 28.
    NIH Consensus Conference. Adjuvant therapy for patient with colon and rectal cancer. JAMA 1990;264:1444–50.Google Scholar
  29. 29.
    Erlichman C, Fine S, Wong A, Elhakim T. A randomized trial of 5-FU and folinic acid in patients with metastatic colorectal carcinoma. J Clin Oncol 1988;6:469–75.PubMedGoogle Scholar
  30. 30.
    Napoleon B, Pujol B, Berger F, Valette PJ, Gerard JP, Souquet JC. Accuracy of endosonography in the staging of rectal cancer treated by radiotherapy. Br J Surg 1991;78:785–8.PubMedGoogle Scholar
  31. 31.
    Habr-Gama A. Cirurgia radical do câncer do reto com conservação do sistema esfincteriano. Prensa Med Argent 1980;67:698–703.Google Scholar
  32. 32.
    Letschert JG, Lebesque JV, de Boer RW, Hart AA, Bartelink H. Dose-volume correlation in radiation related late small bowel complications: a clinical study. Radiother Oncol 1990;18:307–20.CrossRefPubMedGoogle Scholar

Copyright information

© American Society of Colon and Rectal Surgeons 1998

Authors and Affiliations

  • Angelita Habr-Gama
    • 1
  • Pedro M. Santinho B. de Souza
    • 1
  • Ulysses RibeiroJr.
    • 1
  • Wladimir Nadalin
    • 1
  • René Gansl
    • 1
  • Afonso H. S. e SousaJr.
    • 1
  • Fábio Guilherme Campos
    • 1
  • Joaquim Gama-Rodrigues
    • 1
  1. 1.From the Colorectal Unit of the Department of Gastroenterology and the Department of RadiotherapyUniversity of São PauloSão PauloBrazil

Personalised recommendations