The role of neoadjuvant radiotherapy for locally-advanced rectal cancer with resectable synchronous metastasis

Abstract

Background: Although neoadjuvant radiotherapy is typically administered for locally-advanced rectal cancer to reduce local recurrence (LR), its role for patients who present with synchronous resectable liver and/or lung metastasis is not well defined. The aim of this study was to evaluate the role of neoadjuvant radiotherapy for patients with stage IV rectal cancer undergoing curative-intent surgery. Methods: This study is a retrospective review of a prospectively maintained surgical registry of all consecutive adult patients who underwent curative-intent resection at Mayo Clinic in Rochester, MN, from January 1990 until December 2014 with a median follow-up time of 43 (IQR 16-67) months. Eligible patients had locally-advanced rectal cancer (T3, T4 and/or nodal involvement) with synchronous resectable liver and/or lung metastasis. Exclusion criteria were as follows: patients with primary tumor stage of T1N0 or T2N0, patients with metastasis to organs other than the liver or lung, patients who had palliative resection, patients who had non-surgical treatment of synchronous metastasis (e.g., radiofrequency ablation), patients who received postoperative radiotherapy, or absence of research authorization. Ninety three patients were included of which 47 received neoadjuvant radiotherapy and 46 did not. All patients received neoadjuvant chemotherapy +/− radiotherapy followed by curative-intent surgery with metastasectomy performed either simultaneously with resection of the primary tumor or as a planned staged resection. The primary outcomes of this study are LR, distant metastasis, overall and disease-specific survival (DSS).Results: LR was observed in 12 patients (26%) who did not receive radiotherapy, while no LR developed in those who received neoadjuvant radiotherapy, P<0.001. Univariate analysis showed that neither age, sex, ASA class, BMI, tumor location, procedure performed, or neoadjuvant chemotherapy were associated with subsequent LR. The 5-year overall survival (OS) rates were: 43.3% (95% CI: 30.1, 62.3) for no radiotherapy vs. 58.3% (95% CI: 43.4, 78.2) with radiotherapy.Conclusions: Neoadjuvant radiotherapy should be considered in patients with locally-advanced stage IV rectal cancer. These data add to the evidence supporting neoadjuvant radiotherapy in the setting of resectable metastatic disease.

Survival Benefit of Preoperative Versus Postoperative Radiotherapy in Metastatic Rectal Cancer Treated With Definitive Surgical Resection of Primary Tumor: A Population Based, Propensity Score-Matched Study

“…They found that preoperative radiotherapy improved local control of metastatic rectal cancer while postoperative radiotherapy did not. Similarly, Fossum et al 12 also observed a decreased local recurrence rate for patients who received neoadjuvant radiotherapy compared with those who did not receive radiotherapy. In this study, local recurrence was observed in 26% patients who did not receive radiotherapy, while no local recurrence developed in those who received neoadjuvant radiotherapy.…”

A Concise Review of Pelvic Radiation Therapy (RT) for Rectal Cancer with Synchronous Liver Metastases

“…Several studies investigating the omission of RT in the setting of nonmetastatic or metastatic disease consistently reported inferior outcomes, substantiating the utility of RT in multimodality management of rectal cancer [88–91]. Moreover, in the setting of metastatic rectal cancer, improved primary tumor control by use of local therapy has been associated with improved prognosis and survival as well [92, 93].…”

“…In the study by Fossum et al including 93 patients, LR was not observed in patients receiving neoadjuvant RT, and omission of neoadjuvant RT was associated with development of subsequent LR [91].…”

Management of Colorectal Cancer Patients During The COVID-19 Pandemic: Triage and Treatment

“…At present, clinical trials have proved that both FOLFOX regimen and CapeOX regimen have good e cacy in the treatment of locally advanced colon cancer [22,31] . And NCR can improve local control, anus retention rate and is associated with reduced toxicity compared to the postoperative chemoradiotherapy, despite the similar overall survival [24][25][26][27][28][29] .…”

“…The application of radiotherapy in rectal cancer is more bene cial than in colon cancer. A large number of existing studies have shown that preoperative neoadjuvant chemoradiotherapy (NCR) for cT3-4 rectal cancer has signi cant bene ts in reducing the local recurrence rate comparing to postoperative chemoradiotherapy, despite no signi cant difference in overall survival [24][25][26][27][28][29] . Additionally, preoperative neoadjuvant chemoradiotherapy can reduce tumor size, increase the tumor resection rate and anus retention rate with very slight side effect [30] .…”