International Journal of Radiation Oncology*Biology*Physics
Clinical InvestigationTumor downstaging and sphincter preservation with preoperative chemoradiation in locally advanced rectal cancer: the M. D. Anderson Cancer Center experience
Introduction
Preoperative radiation, administered alone or in combination with chemotherapy, has been used to cause tumor regression and allow complete resection of the rectal cancer with a sphincter saving procedure 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18. Other advantages for the use of preoperative radiation include a lower total dose of radiation, and easier displacement of the small bowel from the radiation field 19, 20, 21, 22, 23, 24, 25, 26, 27. No excess surgical complications have been reported as a result of preoperative radiation 4, 8, 22, 23, 28. A survival advantage, largely due to the decreased rates of local recurrence, has also been reported in the Swedish Rectal Cancer Trial 22, 23, 29, 30, 31, 32.
The significance of the level of downstaging after preoperative chemoradiation relative to the ability to perform a sphincter sparing procedure and the risk for local recurrence is still not completely described. Berger and colleagues (33) evaluated the residual tumor cell density after preoperative chemoradiation. Factors predictive for tumor downstaging included higher total radiation doses, tumor differentiation, preoperative tumor stage, and length of time between completion of radiation and surgery. No factor was found to be predictive of a complete pathologic response. In univariate analysis, the postoperative stage was statistically significant for survival. No assessment was performed that related the level of response with the type of surgical intervention performed or the rate of local control.
Our study evaluates the influence of the level of tumor downstaging on the ability to perform sphincter-sparing surgery after preoperative chemoradiation in locally advanced rectal cancer. Tumor location, pathologic characteristics, and rates of local control relative to the surgical procedure performed will be presented.
Section snippets
Materials and methods
Preoperative chemoradiotherapy was administered to 117 patients treated by a single surgeon (JS) from 1991–1995 with locally advanced rectal cancer. Locally advanced rectal cancer was defined as tumor extension through the bowel wall, based on clinical, endorectal ultrasound and/or radiographic evaluations, without associated distant metastases. Diagnostic studies performed at presentation included proctoscopy or colonoscopy, computed tomography (CT) of the abdomen and pelvis, chest x-ray, and
Results
The pretreatment stage distribution, as determined by endorectal ultrasound (u) in 102 patients, included uT2N0 in 2%, uT3N0 in 47%, uT3N1 in 49%, and uT4N0 in 2% of cases. Endorectal ultrasound was not performed in 13% of cases (15 patients) because of an obstructing tumor; 10 of these cases were staged clinically and radiographically as T3. Therefore, a total of 96% of cases (n = 108) were classified as having a stage T3 tumor. The 2 patients with uT2N0 disease were included because the
Discussion
Sphincter preservation is the primary goal of preoperative irradiation for locally advanced rectal cancer. The addition of chemotherapy during the course of preoperative radiation is advocated based on the high risk for disseminated disease and use of chemotherapy as a radiation sensitizer 4, 5, 8, 10, 14, 16, 38, 39, 40. Preoperative chemoradiation has been shown to reduce both the size and the proliferative activity of rectal tumors when compared to pretreatment levels 10, 41. Using
Acknowledgements
This work was supported in part by Grants P01 CA 06294, T32 CA 77050, P30 CA 16672 awarded by the National Cancer Institute, Department of Health and Human Services.
References (42)
- et al.
Radiotherapy in addition to radical surgery in rectal cancerevidence for a dose-response effect favoring preoperative treatment
Int J Radiat Oncol Biol Phys
(1997) - et al.
High-dose preoperative radiation therapy as the key to extending sphincter-preservation surgery for cancer of the distal rectum
Surg Oncol Clin North Am
(1992) - et al.
Preoperative irradiation for clinically resectable rectal adenocarcinoma
Semin Radiat Oncol
(1993) Preoperative radiation therapy followed by low anterior resection with coloanal anastomosis
Semin Radiat Oncol
(1998)- et al.
Sphincter preservation with preoperative radiation therapy and coloanal anastomosis
Int J Radiat Oncol Biol Phys
(1995) - et al.
Preoperative 5-FU, low-dose leucovorin, and radiation therapy for locally advanced and unresectable rectal cancer
Int J Radiat Oncol Biol Phys
(1997) - et al.
High dose preoperative radiation and the challenge of sphincter-preservation surgery for cancer of the distal 2 cm of the rectum
Int J Radiat Oncol Biol Phys
(1998) - et al.
Preoperative infusional chemoradiation therapy for Stage T3 Rectal cancer
Int J Radiat Oncol Biol Phys
(1995) - et al.
Sphincter preservation with preoperative radiation therapy (RT) and coloanal anastomosislong term follow-up
Int J Radiat Oncol Biol Phys
(1997) - et al.
Preoperative infusional chemoradiation and surgery with or without an electron beam intraoperative boost for advanced primary rectal cancer
Int J Radiat Oncol Biol Phys
(1995)
The lack of impact of pelvic irradition on small bowel mobilityimplications for radiotherapy treatment planning
Int J Radiat Oncol Biol Phys
The rationale to switch from postoperative hyperfractionated accelerated radiotherapy to preoperative hyperfractionated accelerated radiotherapy in rectal cancer
Int J Radiat Oncol Biol Phys
Efficacy of a belly board device with CT-simulation in reducing small bowel volume within pelvic irradiation fields
Int J Radiat Oncol Biol Phys
Preoperative radiotherapy in rectal carcinoma-aspects of acute adverse effects and radiation technique
Int J Radiat Oncol Biol Phys
The volume effect in radiation-related late small bowel complicationsResults of a clinical study of the EORTC Radiotherapy Cooperative Group in patients treated for rectal carcinoma
Radiother Oncol
Preoperative radiotherapy (RT) for rectal cancerpredictive factors of tumor downstaging and residual tumor cell density (RTCD): Prognostic implications
Int J Radiat Oncol Biol Phys
Radical and local excisional methods of sphincter-sparing surgery after high-dose radiation for cancer of the distal 3 cm of the rectum
Ann Surg Oncol
Organ and functional preservation in the management of anorectal cancers
Cancer Invest
Preliminary results of pre-operative 5-fluorouracil (5-FU), low dose leucovorin, and concurrent radiation therapy for resectable T3 rectal cancer
Dis Colon Rectum
Neoadjuvant chemoradiotherapy with sphincter sparing surgery for low lying rectal cancer
Proc ASCO
Conservative management of invasive rectal cancerAlternative to abdomino-perineal resection
Oncology
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