When Should Postoperative Radiochemotherapy Be Performed?
Postoperative radiochemotherapy is recommended for patients with resected stage II-III rectal cancer who did not receive preoperative therapy. In this setting, postoperative radiochemotherapy has been shown to improve local control compared to observation
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Jeffrey R. Olsen and Lisa A. Kachnic
30.1 Introduction For clinical stage II-III rectal cancer, preoperative radiochemotherapy (RCT) is generally preferred to postoperative treatment, due to results of the German CAO/ARO/AIO-94 trial, which demonstrated improvement in the 10-year cumulative incidence of local relapse (7.1% vs 10.1%, p = 0.048), reduced rate of surgical complications, and improved rate of sphincter preservation for those declared upfront to need an abdominal perineal resection [1]. Therefore, consideration of postoperative RCT typically occurs for patients with clinical stage I disease found to have occult pathologic stage II-III disease following extirpative resection. Available data demonstrates a significant benefit for adjuvant therapy compared to observation in this setting, although a relative paucity of data is available to refine indications for adjuvant RCT in the era of modern systemic therapy and total mesorectal excision (TME). This chapter will review data in support of adjuvant radiochemotherapy for rectal cancer, in the
J.R. Olsen, MD Departments of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA L.A. Kachnic, MD (*) Departments of Radiation Oncology, Boston Medical Center, Boston University School of Medicine, 830 Harrison Avenue, Boston, MA 02118, USA e-mail: [email protected]
context of recent advances in systemic therapy and surgical technique.
30.2 A djuvant Radiation for Stage II and III Rectal Cancer The efficacy of postoperative radiotherapy (RT) combined with 5-FU-based chemotherapy for stage II and III rectal cancer was initially established by a series of prospective, randomized North American clinical trials (the Gastrointestinal Tumor Study Group (GITSG) Protocol 7175, the Mayo/North Central Cancer Treatment Group Protocol (NCCTG) 79-47-51, and the National Surgical Adjuvant Breast and Bowel Project (NSABP) R-01) [2–4]. Results of these trials are summarized in Table 30.1. The GITSG protocol 7175 randomized 227 patients with resected Dukes’ B2 and C rectal cancer to undergo observation, postoperative RT alone, chemotherapy alone (methyl-CCNU plus 5-fluorouracil (5FU)), or postoperative RCT with concurrent 5FU and maintenance 5FU/methyl- CCNU. The study closed prematurely due to a significantly lower recurrence rate observed for adjuvant RCT compared to observation and improved in overall survival noted with extended follow-up [5]. The NCCTG 79-47-51 protocol randomized 204 patients with resected Dukes’ B2 and C rectal cancer to receive postoperative RT alone, or postoperative RCT with concurrent 5FU, in
© Springer-Verlag Berlin Heidelberg 2018 V. Valentini et al. (eds.), Multidisciplinary Management of Rectal Cancer, https://doi.org/10.1007/978-3-319-43217-5_30
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J.R. Olsen and L.A. Kachnic
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Table 30.1 Randomized trials of postoperative adjuvant radiotherapy with chemotherapy for rectal cancer Study GITSG [2, 5]
Treatment arms Surgery alone RT 5FU/MeCCNU RT + CT
NCCTG [3]
RT RT + 5FU/MeCCNU Surgery alone RT MOF
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