Abstract
For many years, adjuvant postoperative chemotherapy and radiation has been the standard of care in the United States for patients with T3, T4, or node-positive rectal cancer. Preoperative chemoradiation has generally been reserved for situations in which a response to therapy would allow for sphincter-preserving surgery. Recent data support the use of chemoradiation in the preoperative setting, demonstrating improvements in tumor downstaging, treatment toxicity, rate of sphincter-preserving surgery, and pelvic recurrence.
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References and Recommended Reading
Jemal A, Murray T, Ward E, et al.: Cancer statistics, 2005. CA Cancer J Clin 2005, 55:10–30.
National Institutes of Health consensus conference: Adjuvant therapy for patients with colon and rectal cancer. JAMA 1990, 264:1444–1450.
Harnsberger JR, Vernava VM III, Longo WE: Radical abdominopelvic lymphadenopathy: historic perspective and current role in the surgical management of rectal cancer. Dis Colon Rectum 1994, 37:73–87.
Philips RK, Hittinger R, Blesovsky L, et al.: Local recurrence following ‘curative’ surgery for large bowel cancer. The overall picture. Br J Surg 1984, 71:12–16.
Kapiteijn E, Marijnen C, Colenbrader AC, et al.: Local recurrence in patients with rectal cancer diagnosed between 1988 and 1992: a population based study in the west-Netherlands. Eur J Surg Oncol 1998, 24:528–535.
Medical Research Council Rectal Cancer Working Party: Randomised trial of surgery alone versus surgery followed by radiotherapy for mobile cancer of the rectum. Lancet 1996, 348:1610–1614.
National Institutes of Health consensus conference: Adjuvant therapy of patients with colon and rectal cancer. JAMA 1990, 264:1444–1450.
Gastrointestinal Tumor Study Group: Prolongation of the disease-free interval in surgically treated rectal carcinoma. J Clin Oncol 1985, 312:1465–1472.
Krook JE, Moertel CG, Gunderson LL, et al.: Effective surgical adjuvant therapy for high-risk rectal carcinoma. N Engl J Med 1991, 342:709–715.
Fisher B, Wolmark N, Rockette H, et al.: Postoperative adjuvant chemotherapy or radiation therapy for rectal cancer: results from NSABP protocol R-01. J Natl Cancer Inst 1988, 80:21–29.
Wolmark N, Wieand S, Hyams DM, et al.: Randomized trial of postoperative adjuvant chemotherapy with or without radiation for carcinoma of the rectum: National Surgical Adjuvant Breast and Bowel Project Protocol R-02. J Natl Cancer Inst 2000, 92:388–396.
Tepper JE, O’Connell M, Niedzwiecki D, et al.: Adjuvant therapy in rectal cancer: analysis of stage, sex and local control-final report of Intergroup 0114. J Clin Oncol 2002, 20:1744–1750.
O’Connell MJ, Martenson JA, Wieand HS, et al.: Improving adjuvant therapy for rectal cancer by combining protracted venous infusion fluorouracil with radiation therapy after curative surgery. N Engl J Med 1994, 331:502–507. This randomized trial demonstrated an improvement in survival and a reduction in myelosuppression for continuous infusion 5FU versus bolus 5FU. There was no difference in the rate of local recurrence.
Smalley SR, Benedetti J, Williamson S, et al.: Intergroup 0144- phase III trial of 5-FU based chemotherapy regimens plus radiotherapy in postoperative adjuvant rectal cancer. Bolus 5-FU vs. prolonged venous infusion (PVI) before and after XRT + PVI vs. bolus 5-FU + leucovorin (LV) + Levamisole (LEV) before and after XRT + bolus 5-FU + LV. Proc ASCO 2003, 22:251.
Swedish Rectal Cancer Clinical Trial: Improved survival with preoperative radiotherapy in resectable rectal cancer. N Engl J Med 1997, 336:980–987.
Nelson H, Petrelli N, Carlin A, et al.: Guidelines 2000 for colon and rectal cancer surgery. J Natl Cancer Inst 2001, 93:583–596. These are the most recent guidelines for optimizing surgical outcome as proposed by the NCI.
Kapiteijn E, Marijnen CAM, Nagtegaal ID, et al.: Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med 2001, 345:638–646. This randomized clinical trial demonstrated a very low local recurrence rate when a TME is performed. Despite the low recurrence rate in the control group, patients receiving short-course radiation therapy 1 week prior to surgery experienced a significantly lower rate of local recurrence, but no improvement on survival was demonstrated.
van den Brink M, Stiggelbout AM, van den Hout WB, et al.: Clinical nature and prognosis of locally recurrent rectal cancer after total mesorectal excision with or without preoperative radiotherapy. J Clin Oncol 2004, 22:3958–3964.
Marijnen CAM, Kapiteijn E, van de Velde HM, et al.: Acute Side effects and complications after short-term preoperative radiotherapy combined with total mesorectal excision in primary rectal cancer: report of a multicenter randomized trial. J Clin Oncol 2002, 20:817–825.
Marijnen CAM, Nagtegaal ID, Kranenbarg EK, et al.: No downstaging after short-term preoperative radiotherapy in rectal cancer patients. J Clin Oncol 2001, 19:1976–1984.
Francois Y, Nemoz CJ, Baulieux J, et al.: Influence of the interval between preoperative radiation therapy and surgery on downstaging and on the rate of sphincter-sparing surgery for rectal cancer: the Lyon R90-01 randomized trial. J Clin Oncol 1999, 17:2396–2402.
Gerard JP, Chapet O, Nemoz C, et al.: Preoperative concurrent chemoradiotherapy in locally advanced rectal cancer with high-dose radiation and oxaliplatin-containing regimen: the Lyon R0-04 phase II trial. J Clin Oncol 2003, 21:1119–1124.
Colorectal Cancer Collaborative Group: Adjuvant therapy for rectal cancer: a systematic overview of 8507 patients from 22 randomised trials. Lancet 2001, 358:1291–1304.
Minsky BD, Cohen AM, Kemeny N, et al.: Enhancement of radiation-induced downstaging of rectal cancer by 5FU and high-dose leucovorin chemotherapy. J Clin Oncol 1992, 10:79–84.
Rich TA, Skipper JM, Ajani JA, et al.: Preoperative infusional chemoirradiation for stage T3 rectal cancer. Int J Radiat Oncol Biol Phys 1995, 32:1025–1029.
Wagman R, Minsky BD, Cohen AM, et al.: Sphincter prevention with preoperative radiation therapy and coloanal anastomosis. Int J Radiat Oncol Biol Phys 1998, 42:51–57.
Bosset JF, Magnin V, Maingon P, et al.: Preoperative radiochemotherapy in rectal cancer: long-term results of a phase II trial. Int J Radiat Oncol Biol Phys 2000, 46:323–327.
Bossett J-F, Calais G, Mineur L, et al.: Does the addition of chemotherapy to preoperative radiotherapy increase the pathologic response in patients with resected rectal cancer: report of the 22921 EORTC phase III trial. Proc ASCO 2004, 23:247.
Bosset JF, Calais G, Mineur et al.: Preoperative radiation in rectal cancer: effect and timing of additional chemotherapy, 5-year results of the EORTC 2291 trial. Proc ASCO 2005, 23:247s.
Bosset JF, Calais G, Daban A, et al.: Preoperative chemoradiotherapy versus preoperative radiotherapy in rectal cancer patients: assessment of acute toxicity and treatment compliance. Report of the 22921 randomised trial conducted by the EORTC radiotherapy group. Eur J Cancer 2004, 40:219–224.
Conroy T, Bonnetain O, Chapet O, et al.: Preoperative radiotherapy (RT) + 5FU/folinic acid (FA) in T3, T4 rectal cancer: preliminary results of the FFCD 9203 randomized trial. Proc ASCO 2004, 23:277.
Gerard JP, Bonnetain F, Conroy T, et al.: Preoperative radiotherapy +/- 5 FU/folinic acid in T3-4 rectal cancers: results of the FFCD 9203 randomized trial. Proc ASCO 2005, 23:247s.
Bujko K, Nowacki MP, Nasierowska-Guttmejer A, et al.: Sphincter preservation following preoperative radiotherapy for rectal cancer: report of a randomized trial comparing short-term radiotherapy vs. conventionally fractionated radiochemotherapy. Radiother Oncol 2004, 72:15–24.
Hyams DM, Mamounas EP, Petrelli N, et al.: A clinical trial to evaluate the worth of preoperative multimodality therapy in patients with operable carcinoma of the rectum. A progress report of the National Surgical Adjuvant Breast and Bowel Project protocol R-03. Dis Colon Rectum 1997, 40:131–139.
Roh MS, Colangelo L, Wieand S, et al.: Response to preoperative multimodality therapy predicts survival in patients with carcinoma of the rectum. Proc ASCO 2004, 23:247.
Sauer R, Becker H, Hohenberger W, et al.: Preoperative versus postoperative chemoradiation for rectal cancer. N Engl J Med 2004, 351:1731–1740. This is the only completed randomized clinical trial of preoperative versus postoperative chemoradiation and demonstrated the superiority of preoperative therapy in regard to local recurrence, functional outcome, ability to perform a sphincter-preserving surgery, and toxicity. There was no significant difference in overall survival.
Hoff PM, Ansari R, Batist G, et al.: Comparison of oral capecitabine versus intravenous fluorouracil plus leucovorin as first-line treatment in 605 patients with metastatic colorectal cancer: results of a randomized phase III study. J Clin Oncol 2001, 19:2282–2292.
Van Cutsem E, Twelves C, Cassidy J, et al.: Oral capecitabine compared with intravenous fluorouracil plus leucovorin in patients with metastatic colorectal cancer: results of a large phase III study. J Clin Oncol 2001, 19:4097–4106.
Cassidy J, Scheithauer W, McKendrick J, et al.: Capecitabine versus bolus 5-FU/leucovorin as adjuvant therapy for colon cancer (the X-ACT study): efficacy results of a phase III trial. Proc ASCO 2004, 22:14s.
Dunst J, Reese T, Debus J, et al.: Phase II study of preoperative chemoradiation with capecitabine in rectal cancer. Proc ASCO 2004, 23:260.
DePaoli A, Chiara S, Luppi G, et al.: A phase II study of capecitabine and pre-operative radiation therapy in respectable, locally advanced rectal cancer. Proc ASCO 2004, 22:255.
Dupuis O, Vie B, Lledo G, et al.: Capecitabine chemoradiation in the preoperative treatment of patients with rectal adenocarcinomas: a phase II GERCOR trial. Proc ASCO 2004, 22:255.
Kim JS, Kim JS, Cho MJ, et al.: Preoperative chemoradiation using oral capecitabine in locally advanced rectal cancer. Int J Radiat Oncol Biol Phys 2002, 54:403–408.
Mitchell EP, Anne P, Fry R, et al.: Combined modality therapy of locally advanced or recurrent adenocarcinoma of the rectum: report of a phase I/II trial of chemotherapy with CPT-11, 5-FU and concomitant irradiation. Proc ASCO 2001, 20:131a.
Willet CG, Boucher Y, di Tomaso E, et al.: Direct evidence that the VEGF specific antibody bevacizumab has antivascular effects in human rectal cancer. Nat Med 2004, 110:145–147.
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Blaszkowsky, L.S. Chemoradiation for localized rectal cancer: Neoadjuvant versus adjuvant approaches. Curr colorectal cancer rep 1, 51–57 (2005). https://doi.org/10.1007/s11888-005-0016-1
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DOI: https://doi.org/10.1007/s11888-005-0016-1