Although it is now considered a standard treatment to irradiate an advanced mid or low rectal tumor before surgical total mesorectal excision (TME), the optimal time interval between radiation therapy and surgery remains controversial.
Between 1995 and 2005, patients undergoing preoperative radiation therapy and TME for locally advanced mid and low rectal tumors treated in the VU Medical Center or the Zaans Medical Center were entered into this study. All patients received identical radiation treatment in the VU Medical Center and were subsequently operated on within 2 weeks in the Zaans Medical Center (SI group) and after 6-8 weeks in the VU Medical Center (LI group). Preoperative tumor staging, operative data, postoperative complications, pathology results, and follow-up were compared.
The SI group (N=57) underwent surgery after a median delay of 4 days and the LI group (N=51) after 45 days. Operative data and short-term morbidity were comparable for both groups. However, significantly higher numbers of complete remissions (12 vs 0%), tumor downstaging (55 vs 26%), and less lymph-node metastases (22 vs 44%) were found in the LI group. No significant differences were found regarding local control or long-term survival after a median follow-up of 34 months.
Several advantages, such as complete remissions and downstaging in the LI group, do not appear to have expression in a better survival or less local recurrences after a median follow-up of 34 months. Although larger (randomized) studies will be needed for definite conclusions, this may indicate that patients can be operated on within 2 weeks after radiation therapy.
"Nevertheless, many surgeons were concerned that further delays would increase difficulty with the operation, including fibrosis and may result in increased surgical morbidity [1,4,12,18,19]. For these reasons, some surgeons suggest operation as early as possible, if there is no oncological benefit derived by the difference in time interval between completion of CRT and surgery [2,20-22]. Moore et al.  observed more frequent anastomotic complications (0% vs. 7%, P = 0.05) among patients undergoing surgery more than 44 days after chemoradiation. Withers and Haustermans  reported that a longer interval after RT may increase the risk of emergence of subclinical tumors, which can grow more rapidly than the primary tumor, and change the risk of developing distant metastases. "
[Show abstract][Hide abstract] ABSTRACT: The optimal time between neoadjuvant chemoradiotherapy (CRT) and surgery for rectal cancer has been debated. This study evaluated the influence of this interval on oncological outcomes.
We compared postoperative complications, pathological downstaging, disease recurrence, and survival in patients with locally advanced rectal cancer who underwent surgical resection <8 weeks (group A, n = 105) to those who had surgery ≥8 weeks (group B, n = 48) after neoadjuvant CRT.
Of 153 patients, 117 (76.5%) were male and 36 (23.5%) were female. Mean age was 57.8 years (range, 28 to 79 years). There was no difference in the rate of sphincter preserving surgery between the two groups (group A, 82.7% vs. group B, 77.6%; P = 0.509). The longer interval group had decreased postoperative complications, although statistical significance was not reached (group A, 28.8% vs. group B, 14.3%; P = 0.068). A total of 111 (group A, 75 [71.4%] and group B, 36 [75%]) patients were downstaged and 26 (group A, 17 [16.2%] and group B, 9 [18%]) achieved pathological complete response (pCR). There was no significant difference in the pCR rate (P = 0.817). The longer interval group experienced significant improvement in the nodal (N) downstaging rate (group A, 46.7% vs. group B, 66.7%; P = 0.024). The local recurrence (P = 0.279), distant recurrence (P = 0.427), disease-free survival (P = 0.967), and overall survival (P = 0.825) rates were not significantly different.
It is worth delaying surgical resection for 8 weeks or more after completion of CRT as it is safe and is associated with higher nodal downstaging rates.
Journal of the Korean Surgical Society 06/2013; 84(6):338-45. DOI:10.4174/jkss.2013.84.6.338 · 0.73 Impact Factor
"However, the increase in fibrosis did not significantly increase the technical difficulty of the operation (P = 0.2220) and did not increase the risk of postoperative complications . Several previous studies also reported that increasing the interval between the completion of CRT and surgery did not appear to increase postoperative morbidity [2,4-6,8-12]. "
[Show abstract][Hide abstract] ABSTRACT: The standard treatment for patients with locally advanced rectal cancer is preoperative chemoradiotherapy followed by total mesorectal excision. This approach is supported by randomized trials, but there are still many unanswered questions about the multimodal management of rectal cancer. In surgical terms, these include the optimal time interval between completion of chemoradiotherapy and surgery; adequate distal resection margin and circumferential radial margin; sphincter preservation; laparoscopic surgery; and conservative management, including a 'wait and see' policy and local excision. This review considers these controversial issues in preoperative chemoradiotherapy.
Journal of the Korean Surgical Society 01/2013; 84(1):1-8. DOI:10.4174/jkss.2013.84.1.1 · 0.73 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To evaluate the clinical factors that influence pathological and clinical outcomes after preoperative concurrent chemoradiotherapy in patients with rectal cancer.
Between 1999 and 2004, 121 patients with cT3-4 or node-positive rectal cancer received preoperative chemoradiotherapy and surgery. Preoperative radiation therapy with 45 Gy was delivered. Fluorouracil-based chemotherapy was administered to most of the patients.
Pathological complete remission was 14.3% after preoperative chemoradiotherapy. More than 60% tumor circumferential extent was an independent adverse factor for complete remission (P = 0.011, HR 4.643, 95% CI 1.415-15.231). Local recurrence developed in 9.9% of the cases. Serum CEA level > 5 ng/ml (P = 0.057, HR 3.022, 95% CI 0.967-9.441) and > 60% circumferential extent of tumor (P = 0.064, HR 4.232, 95% CI 0.918-19.531) were marginal adverse factors for local recurrence. Five-year disease-free survival and overall survival were 72.2% and 86.6%, respectively. Disease-free survival was poor for patients with the lymph nodes > or = 1 cm in diameter (P = 0.028), cN2 stage disease (P = 0.047) and > 60% circumferential extent of tumor (P = 0.058). Multivariate analysis for disease-free survival showed that the lymph node size > or = 1 cm was an adverse factor (P = 0.019, HR 2.380, 95% CI 1.115-4.906). Patients with > 60% circumferential extent of tumor and cN2 stage had a more unfavorable survival than the other patients (disease-free survival, P = 0.018; overall survival, P = 0.015). Patients with > 60% circumferential extent of tumor and/or lymph node > or = 1 cm also had an unfavorable survival (disease-free survival, P = 0.016; overall survival, P = 0.049).
In rectal cancer, circumferential extent of tumor and clinical lymph node status were important factors for preoperative chemoradiotherapy and surgery. A further prospective study is needed to confirm and expand these findings.
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