Optimising Treatment for Resectable Rectal Cancer
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Drugs & Aging 2001; 18 (2): 79-85 1170-229X/01/0002-0079/$22.00/0 © Adis International Limited. All rights reserved.
Optimising Treatment for Resectable Rectal Cancer Is Preoperative Therapy Beneficial? Samuel Y. K. Ngan Peter MacCallum Cancer Institute, Melbourne, Victoria, Australia
Abstract
Preoperative radiotherapy is becoming the standard of care for resectable locally advanced adenocarcinoma of the rectum. Its practice is no longer limited to a few specialised cancer centres. Adjuvant preoperative radiotherapy can reduce the risk of local recurrence by 50% compared with surgery alone and it has a moderate effect in improving survival. Treatment-related toxicity is superior to that after postoperative radiotherapy. Early results of preoperative radiotherapy with concurrent chemotherapy are promising, with a low toxicity profile and a high pathological response rate. Advances in technology, endorectal ultrasound and magnetic resonance imaging enable selection of appropriate patients for preoperative radiotherapy.
There is little argument that preoperative radiotherapy with concurrent chemotherapy (chemoradiation) should be considered the standard therapy for clinically unresectable or recurrent rectal cancers.[1-3] Attention is now focused on the use of preoperative radiotherapy as a standard of care for resectable locally advanced rectal cancer. Although preoperative radiotherapy has been used for over 30 years, it is the randomised controlled trials of postoperative adjuvant therapy that have established combined therapy, with surgery, radiotherapy and chemotherapy, as the standard management for high risk rectal cancer. Studies performed in the early 1970s demonstrated that it is not the extent of distal resection margins that determines local recurrence.[4] The risk of local recurrence depends on depth of tumour penetration into the perirectal tissue and radial surgical clearance.[5-7] It also depends on the completeness of removal of meso-rectum, which contains the lymphatic drainage.[8] Specifically, the risk group for recurrence includes patients with T3
tumour (tumour invades through muscularis propria into perirectal tissues) or positive locoregional lymph nodes (Dukes B2 and C). This group of locally advanced rectal cancers is the subject of a number of adjuvant postoperative randomised controlled trials. The Gastrointestinal Tumour Study Group demonstrated the benefit of postoperative radiotherapy and chemotherapy over surgery alone, in terms of local control and overall survival rates.[9] The benefit of combined therapy was confirmed by the North Central Cancer Treatment Group (NCCTG) trial.[10] Refinement of the treatment with protracted infusion fluorouracil further improved the survival benefit.[11] Based on this evidence, the US National Institutes of Health recommended that postoperative chemotherapy and radiotherapy should form part of the treatment for patients with stage T3 tumour or lymph node-positive rectal cancer.[12] Most clinicians are satisfied with the magnitude of the benefit f
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