Preoperative chemoradiation versus radiation alone for stage II and III resectable rectal cancer
ABSTRACT Preoperative radiotherapy (RT) decreases local recurrence rate and improves survival in stage II and III rectal cancer patients. The combination of chemotherapy with RT has a sound radiobiological rationale, and phase II trials of combined chemoradiation (CRT) have shown promising activity in rectal cancer.
To compare preoperative RT with preoperative CRT in patients with resectable stage II and III rectal cancer.
We searched the Cochrane Central Register of Controlled Trials, Web of Science, Embase.com, and Pubmed from 1975 until june 2007. A manual search was performed of Ann Surg, Arch Surg, Cancer, J Clin Oncol, Int J Radiat Oncol Biol Phys and the proceedings of ASTRO, ECCO and ASCO from 1990 until june 2007.
Relevant studies randomized resectable stage II or III rectal cancer patients to at least one arm of preoperative RT alone or at least one arm of preoperative CRT.
Primary outcome parameters included overall survival (OS) at 5 years and local recurrence (LR) rate at 5 years. Secondary outcome parameters included disease free survival (DFS) at 5 years, metastasis rate, pathological complete response rate, clinical response rate, sphincter preservation rate, acute toxicity, postoperative mortality and morbidity, and anastomotic leak rate. Outcome parameters were summarized using the Odds Ratio (OR) and associated 95% confidence interval (CI) using the fixed effects model.
Four trials were identified and included in the meta-analysis. The addition of chemotherapy to preoperative RT significantly increased grade III and IV acute toxicity (OR 1.68-10, P = 0.002) while no differences were observed in postoperative morbidity or mortality. Compared to preoperative RT alone, preoperative CRT significantly increased the rate of complete pathological response (OR 2.52-5.27, P < 0.001) although this did not translate into a higher sphincter preservation rate (OR 0.92-1.31, P = 0.29). The incidence of local recurrence at five years was significantly lower in the CRT group compared to RT alone (OR 0.39-0.72, P < 0.001). No statistically significant differences were observed in DFS (OR 0.92-1.34, P = 0.27) or OS (OR 0.79-1.14, P = 0.58) at five years.
Compared to preoperative RT alone, preoperative CRT enhances pathological response and improves local control in resectable stage II and III rectal cancer, but does not benefit disease free or overall survival. The effects of preoperative CRT on functional outcome and quality of life are incompletely understood and should be addressed in future trials.
SourceAvailable from: Martina Mittlboeck[Show abstract] [Hide abstract]
ABSTRACT: Rectal cancer surgery in the older population remains a highly controversial topic. The present study was designed to assess whether older patients had an increased risk for postoperative complications after rectal resection for malignancies. Consecutive patients (n =627), who underwent rectal cancer resection at a single institution, were included in the study and analyzed retrospectively. Short-term complications were compared between patients >=80 years (n =55) and <80 years (n =572). Additionally, predictive factors for postoperative complications were analyzed. The older aged group showed a significantly higher rate of co-morbidities compared to controls, in terms of cardiovascular and pulmonary diseases (P =0.002, P =0.006). In older patients, a Hartmann's procedure and transanal endoscopic microsurgery (TEM) were performed most frequently (P <0.0001).The overall complication rate was 39% (n =244) (medical: n =59 (9%), surgical: n =185 (30%)), including 24 (44%) complications in the older aged group (medical: n =6 (11%), surgical: n =18 (33%)). Notably, the incidence of surgical and medical complications showed no significant difference between patients and controls (P =0.58, P =0.69).Neurological and cardiovascular disorders were associated with an increased risk for a eventful postoperative course in the older aged group (P =0.03, P =0.04). Rectal cancer resection can be performed safely in selected older patients. Age itself should not be considered as a risk factor for postoperative complications.World Journal of Surgical Oncology 11/2014; 12(1):355. DOI:10.1186/1477-7819-12-355 · 1.20 Impact Factor
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ABSTRACT: The routine application of neoadjuvant chemoradiotherapy for T3N0 rectal cancer remains controversial. The aim of this study was to use clinical, Magnetic resonance imaging, and pathological parameters to identify a subgroup of patients with low risk of local recurrence who might be precluded from neoadjuvant chemoradiotherapy. We retrospectively reviewed a prospectively maintained database of consecutive rectal cancer patients who underwent curative resection. 166 pathologic confirmed T3N0 rectal cancer patients with tumor located 5-12cm above the anal verge and preoperative circumferential resection margin>1mm were included in analysis. The primary outcomes measured were3- and 5-year local recurrence rates. Local recurrence was demonstrated during follow-up in 5 patients; the actuarial overall 3- and 5-year local recurrence rates were 2.5% and 3.4%, respectively. Inadequate sampling of lymph nodes (≤12) was associated with higher local recurrence (P = 0.03) in this group of patients. For upper and middle T3N0 rectal cancer with preoperative circumferential resection margin>1mm, local recurrence rate after total mesorectal excision is low and surgery alone may be enough for this group of patients.PLoS ONE 01/2015; 10(1):e0117141. DOI:10.1371/journal.pone.0117141 · 3.53 Impact Factor
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ABSTRACT: Rectal cancer accounts for a relevant part of colorectal cancer cases, with a mortality of 4-10/100000 per year. The development of locoregional recurrences and the occurrence of distant metastases both influences the prognosis of these patients. In the last two decades, new multimodality strategies have improved the prognosis of locally advanced rectal cancer with a significant reduction of local relapse and an increase in terms of overall survival. Radical surgery still remains the principal curative treatment and the introduction of total mesorectal excision has significantly achieved a reduction in terms of local recurrence rates. The employment of neoadjuvant treatment, delivered before surgery, also achieved an improved local control and an increased sphincter preservation rate in low-lying tumors, with an acceptable acute and late toxicity. This review describes the multidisciplinary management of rectal cancer, focusing on the effectiveness of neoadjuvant chemoradiotherapy and of post-operative adjuvant chemotherapy both in the standard combined modality treatment programs and in the ongoing research to improve these regimens.World Journal of Gastroenterology 12/2014; 20(46):17279-17287. DOI:10.3748/wjg.v20.i46.17279 · 2.43 Impact Factor