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Neoadjuvant Pelvic Radiotherapy in the Management of Rectal Cancer with Synchronous Liver Metastases: Is It Worth It?

  • Review Article
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Background

The use of neoadjuvant pelvic radiotherapy was a major advance in oncologic care for locally advanced rectal cancer in the twentieth century. The extrapolation of the care of locally advanced rectal cancer to the management of rectal cancer with treatable liver metastases is controversial. The aim of this review is to examine the available data on the role of pelvic radiotherapy and chemoradiation in the setting of treatable metastatic liver disease.

Methods

A systematic search of MEDLINE was performed to report the landmark randomized controlled trials between 1993 and 2021.

Results

Attaining liver clearance and total mesorectal excision with R0 margin remains the mainstay of cure. There is uncertainty regarding the sequencing of treatment. The literature lacks randomized clinical trials comparing the rectal first, liver first, interval strategy, and simultaneous surgical approaches. A multidisciplinary discussion regarding the utility of radiotherapy is emphasized to achieve the goals of treatment. Short-course radiotherapy has proved comparable disease-control outcomes to long-course chemoradiation with a significantly improved cost-performance. The implementation of short-course radiotherapy in the interval strategy and simultaneous surgical approach is promising. Neoadjuvant pelvic radiotherapy can be omitted in patients with metastatic rectal cancer if adequate margin clearance is achievable.

Conclusion

The use of radiotherapy in metastatic rectal cancer is popular but is based on limited data. Treatment should be tailored to the local extent of rectal cancer and priority of liver metastasis management. The optimal treatment strategy in patients with rectal cancer and synchronous liver metastatic disease needs to be studied in randomized trials.

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Abbreviations

CRC:

Colorectal cancer

RC:

Rectal cancer

CRLM:

Colorectal liver metastasis

RLM:

Rectal cancer liver metastasis

mRC:

Metastatic rectal cancer

OS:

Overall survival

OR:

Odds ratio

CRM:

Circumferential resection margin

DFS:

Disease-free survival

HR:

Hazard ratio

TME:

Total mesorectal excision

SC-RT:

Neoadjuvant short-course radiotherapy

NACR:

Neoadjuvant chemoradiation

pCR:

Pathologic complete response

LC-CRT:

Long-course chemoradiation

TNT:

Total neoadjuvant therapy

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Authors and Affiliations

  1. Methodist Richardson Medical Center, 2805 E. President George Bush Highway, Richardson, TX, USA

    Maitham A. Moslim & D. Rohan Jeyarajah

  2. Swedish Medical Center, Seattle, WA, USA

    Amir L. Bastawrous

  3. TCU/UNTHSC School of Medicine, Fort Worth, TX, USA

    D. Rohan Jeyarajah

Authors
  1. Maitham A. Moslim
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  2. Amir L. Bastawrous
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  3. D. Rohan Jeyarajah
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Contributions

Conception and design: Maitham Moslim and D. Rohan Jeyarajah. Collection and assembly of data: Maitham Moslim, Amir Bastawrous and D. Rohan Jeyarajah. Data analysis and interpretation: Maitham Moslim, Amir Bastawrous and D. Rohan Jeyarajah. Manuscript writing: Maitham Moslim, Amir Bastawrous and D. Rohan Jeyarajah. Final approval of manuscript: Maitham Moslim, Amir Bastawrous and D. Rohan Jeyarajah.

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Correspondence to D. Rohan Jeyarajah.

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Conflict of Interest

Dr. Jeyarajah serves as a consultant for SIRTEX, Ethicon and Angiodynamics. Dr. Bastawrous serves as a consultant for Intuitive Surgical and Medtronic and is an investor in Twistle. Dr. Moslim has no conflict of interest.

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Moslim, M.A., Bastawrous, A.L. & Jeyarajah, D.R. Neoadjuvant Pelvic Radiotherapy in the Management of Rectal Cancer with Synchronous Liver Metastases: Is It Worth It?. J Gastrointest Surg 25, 2411–2422 (2021). https://doi.org/10.1007/s11605-021-05042-w

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