Preoperative Chemoradiotherapy Allows for Local Control in Rectal Cancer – But Distant Metastases Remain an Unsolved Problem

Colorectal cancer represents a major health care problem because it is the second leading cause of cancer related deaths in Europe and the third cause in the U.S. (Jemal et al., 2007). Adenocarcinoma of the colon and the rectum is commonly referred to as a single disease, although rectal carcinoma is a distinct entity, with particular biologic and genetic features and clinical behavior. Whereas local recurrence is rare in colon cancer, it is a common event in rectal cancer. The particular anatomical location of the rectum within the narrow margins of the pelvis without a peritoneal cover renders local spread a common event with tumor deposits occurring in the perirectal fat as well as infiltration of the locoregional lymph nodes.

During the last 2 decades many landmark trials have added important information to the field and helped to improve the outcome of these patients. Surgery has remained the cornerstone in the multi-modal treatment of rectal cancer, and the progress has been particularly evident for the surgical procedure with the introduction of total mesorectal excision. The introduction of complementary treatments such as irradiation and chemotherapy allowed for an additional considerable reduction of local recurrence rates. The trimodality approach comprising surgery, radiotherapy, and chemotherapy has now become standard for locally advanced rectal cancer patients. However, the overall mortality for locally advanced rectal cancer patients remains unchanged with an incidence of ~ 40% at 5 years due to the occurrence of distant metastases representing a major unsolved problem (Bosset et al., 2006; Greene et al., 2004; Marijnen et al., 2005; Sauer et al., 2004).