What Are the Present Recommendations for Short-Course Preoperative Radiotherapy (RT) and Delayed Surgery?

  • Bengt Glimelius


Short-course radiotherapy (RT) to 5 × 5 Gy with immediate surgery is an established treatment to lower local failure rates in many patients with primary rectal cancer. If surgery is delayed for 4–8 weeks, downstaging/downsizing is frequently seen and a pathological complete remission is seen in 10–15% of the patients. Previously non-resectable tumors have then frequently become resectable with long-term cure in a proportion of the patients. It has very low acute (and late) toxicity and is an alternative in elderly patients if comorbidity prevents chemoradiotherapy (CRT). It has been explored in randomized trials also in younger and fit patients and may become an alternative to short-course with immediate surgery and to CRT, both because of less acute toxicity and convenience with similar efficacy. The latter remains to be established.


Delayed surgery Downsizing Downstaging Rectal cancer Short-course radiotherapy 


  1. 1.
    Sebag-Montefiore D, Stephens RJ, Steele R, Monson J, Grieve R, Khanna S et al (2009) Preoperative radiotherapy versus selective postoperative chemoradiotherapy in patients with rectal cancer (MRC CR07 and NCIC-CTG C016): a multicentre, randomised trial. Lancet 373:811–820CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Glimelius B (2012) Multidisciplinary treatment of patients with rectal cancer: Development during the past decades and plans for the future. Ups J Med Sci 117:225–236CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Braendengen M, Tveit KM, Berglund A, Birkemeyer E, Frykholm G, Påhlman L et al (2008) A randomized phase III study (LARCS) comparing preoperative radiotherapy alone versus chemoradiotherapy in non-resectable rectal cancer. J Clin Oncol 26:3687–3694CrossRefPubMedGoogle Scholar
  4. 4.
    Widder J, Herbst F, Scheithauer W (2005) Preoperative sequential short-term radiotherapy plus chemotherapy can induce complete remission in T3 N2 rectal cancer. Acta Oncol 44:921–923CrossRefPubMedGoogle Scholar
  5. 5.
    Radu C, Berglund A, Påhlman L, Glimelius B (2008) Short course preoperative radiotherapy with delayed surgery in rectal cancer – a retrospective study. Radiother Oncol 87:343–349CrossRefPubMedGoogle Scholar
  6. 6.
    Hatfield P, Hingorani M, Radhakrishna G, Cooper R, Melcher A, Crellin A et al (2009) Short-course radiotherapy, with elective delay prior to surgery, in patients with unresectable rectal cancer who have poor performance status or significant co-morbidity. Radiother Oncol 92:210–214CrossRefPubMedGoogle Scholar
  7. 7.
    Pettersson D, Holm T, Iversen H, Blomqvist L, Glimelius B, Martling A (2012) Preoperative short-course radiotherapy with delayed surgery in primary rectal cancer. Br J Surg. 99:577–583CrossRefPubMedGoogle Scholar
  8. 8.
    Veenhof AA, Bloemena E, Engel AF, van der Peet DL, Meijer OW, Cuesta MA (2009) The relationship of histological tumor regression grade (TRG) and two different time intervals to surgery following radiation therapy for locally advanced rectal cancer. Int J Color Dis 24:1091–1096CrossRefGoogle Scholar
  9. 9.
    Faria S, Kopek N, Hijal T, Liberman S, Charlebois P, Stein B et al (2014) Phase II trial of short-course radiotherapy followed by delayed surgery for locoregionally advanced rectal cancer. Color Dis 16:O66–O70CrossRefGoogle Scholar
  10. 10.
    Pach R, Kulig J, Richter P, Gach T, Szura M, Kowalska T (2012) Randomized clinical trial on preoperative radiotherapy 25 Gy in rectal cancer--treatment results at 5-year follow-up. Langenbeck’s Arch Surg 397:801–807CrossRefGoogle Scholar
  11. 11.
    Latkauskas T, Pauzas H, Gineikiene I, Janciauskiene R, Juozaityte E, Saladzinskas Z et al (2012) Initial results of a randomized controlled trial comparing clinical and pathological downstaging of rectal cancer after preoperative short-course radiotherapy or long-term chemoradiotherapy, both with delayed surgery. Color Dis 14:294–298CrossRefGoogle Scholar
  12. 12.
    Tyc-Szczepaniak D, Wyrwicz L, Kepka L, Michalski W, Olszyna-Serementa M, Palucki J et al (2013) Palliative radiotherapy and chemotherapy instead of surgery in symptomatic rectal cancer with synchronous unresectable metastases: a phase II study. Ann Oncol 24:2829–2834CrossRefPubMedGoogle Scholar
  13. 13.
    van Dijk TH, Tamas K, Beukema JC, Beets GL, Gelderblom AJ, de Jong KP et al (2013) Evaluation of short-course radiotherapy followed by neoadjuvant bevacizumab, capecitabine, and oxaliplatin and subsequent radical surgical treatment in primary stage IV rectal cancer. Ann Oncol 24:1762–1769CrossRefPubMedGoogle Scholar
  14. 14.
    Nilsson PJ, van Etten B, Hospers GAP, Påhlman L, van de Velde CJH, Beets-Tan RGH et al (2013) Short-course radiotherapy followed by neo-adjuvant chemotherapy in locally advanced rectal cancer – the RAPIDO trial. BMC Cancer 13:279CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Pettersson D, Cedermark B, Holm T, Radu C, Pahlman L, Glimelius B et al (2010) Interim analysis of the Stockholm III trial of preoperative radiotherapy regimens for rectal cancer. Br J Surg. 97:580–587CrossRefPubMedGoogle Scholar
  16. 16.
    Pettersson D, Glimelius B, Iversen H, Johansson H, Holm T, Martling A (2013) Impaired postoperative leucocyte counts after preoperative radiotherapy for rectal cancer in the Stockholm III Trial. Br J Surg. 100:969–975CrossRefPubMedGoogle Scholar
  17. 17.
    Pettersson D, Lorinc E, Holm T, Iversen H, Cedermark B, Glimelius B et al (2015) Tumour regression in the randomized Stockholm III Trial of radiotherapy regimens for rectal cancer. Br J Surg 102:972–978CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Bujko K, Nowacki MP, Nasierowska-Guttmejer A, Michalski W, Bebenek M, Kryj M et al (2006) Long-term results of a randomised trial comparing preoperative short-course radiotherapy vs preoperative conventionally fractionated chemoradiation for rectal cancer. Br J Surg. 93:1215–1223CrossRefPubMedGoogle Scholar
  19. 19.
    Ngan SY, Burmeister B, Fisher RJ, Solomon M, Goldstein D, Joseph D et al (2012) Randomized trial of short-course radiotherapy versus long-course chemoradiation comparing rates of local recurrence in patients with t3 rectal cancer: trans-tasman radiation oncology group trial 01.04. J Clin Oncol 30:3827–3833CrossRefPubMedGoogle Scholar
  20. 20.
    Zhou ZR, Liu SX, Zhang TS, Chen LX, Xia J, Hu ZD et al (2014) Short-course preoperative radiotherapy with immediate surgery versus long-course chemoradiation with delayed surgery in the treatment of rectal cancer: a systematic review and meta-analysis. Surg Oncol 23:211–221CrossRefPubMedGoogle Scholar
  21. 21.
    Loos M, Quentmeier P, Schuster T, Nitsche U, Gertler R, Keerl A et al (2013) Effect of preoperative radio(chemo)therapy on long-term functional outcome in rectal cancer patients: a systematic review and meta-analysis. Ann Surg Oncol 20:1816–1828CrossRefPubMedGoogle Scholar
  22. 22.
    Guckenberger M, Saur G, Wehner D, Thalheimer A, Kim M, Germer CT et al (2013) Long-term quality-of-life after neoadjuvant short-course radiotherapy and long-course radiochemotherapy for locally advanced rectal cancer. Radiother Oncol 108:326–330CrossRefPubMedGoogle Scholar
  23. 23.
    Valentini V, Aristei C, Glimelius B, Minsky BD, Beets-Tan R, Borras JM et al (2009) Multidisciplinary rectal cancer management. Radiother Oncol 92:148–163CrossRefPubMedGoogle Scholar
  24. 24.
    Schmoll HJ, Van Cutsem E, Stein A, Valentini V, Glimelius B, Haustermans K et al (2012) ESMO Consensus Guidelines for management of patients with colon and rectal cancer. a personalized approach to clinical decision making. Ann Oncol 23:2479–2516CrossRefPubMedGoogle Scholar
  25. 25.
    Glimelius B, Tiret E, Cervantes A, Arnold D, Group EGW (2013) Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 24(Suppl 6):vi81–vi88CrossRefPubMedGoogle Scholar
  26. 26.
    Valentini V, Glimelius B, Haustermans K, Marijnen CA, Rodel C, Gambacorta MA et al (2014) EURECCA consensus conference highlights about rectal cancer clinical management: the radiation oncologist’s expert review. Radiother Oncol 110:195–198CrossRefPubMedGoogle Scholar
  27. 27.
    Glimelius B (2014) Optimal time intervals between pre-operative radiotherapy or chemoradiotherapy and surgery in rectal cancer? Front Oncol 4:50CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Veenhof AA, Kropman RH, Engel AF, Craanen ME, Meijer S, Meijer OW et al (2007) Preoperative radiation therapy for locally advanced rectal cancer: a comparison between two different time intervals to surgery. Int J Color Dis 22:507–513CrossRefGoogle Scholar

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© Springer-Verlag Berlin Heidelberg 2018

Authors and Affiliations

  1. 1.Department of Immunology, Genetics and PathologyUppsala University, Uppsala University HospitalUppsalaSweden

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