Preoperative chemoradiation in locally advanced rectal cancer: A single center experience
Authors: L. Oliveira, A. Rolo, C. Carvalho, I. Faustino, C. Alpoim, C. Calçada, A. Costa, G. Fonseca, J. Conde, A. Teixeira, C. Fardilha, P. Costa, C. Coutinho
Journal: Annals of Oncology (2018)

Introduction: Preoperative chemoradiation (CRT) is the standard treatment for locally advanced rectal cancer (LARC). The aim of this study was to evaluate the efficacy and tolerability of neoadjuvant CRT in the treatment of LARC in Hospital de Guimarães. Methods: A retrospective review was conducted between June 2012 and December 2017 for patients with stage II and III rectal cancer treated with neoadjuvant CRT. All patients performed a long course of radiotherapy with concurrent chemotherapy (87% with 5-fluorouracil 225mg/m2 for 24 hours 7 days/week and 13% with capecitabine 825 mg/m2 twice daily 5 days/week). All patients were treated with 3D conformal radiotherapy using multiple fields (>4) and mixed photon energies. The most common treatment schedule (96,8%) was 50-50,4 Gy (2-1,8 Gy/fraction), 5 fractions per week. Results: There were 92 patients identified, the median age was 61 years (26-83 years) and 64,1% were males. Rectal cancer location was low (up to 5cm) in 30,4%, middle (>5 to 10 cm) in 43,5% and high (>10 to 15 cm) in 26,1% of cases. The main symptom present at diagnosis in 50% of patients was rectal bleeding and improved with neoadjuvant treatment in 89,1% of cases. Treatment was well tolerated, 40,2% of patients experienced acute grade 1 or 2 toxicities [National Cancer Institute's Common Terminology Criteria for Adverse Events (NCI-CTCAE) v4.03]. Acute grade 3 toxicity (NCI-CTCAE v4.03) was found in 3,2% of patients: tenesmus, diarrhea and mucositis. The median time to surgery after neoadjuvant CRT was 8 weeks. After complete CRT, 95,7% of patients underwent surgical resection: 71,6% anterior resections and 28,4% abdominal-perineal amputation. The remaining 4,3% of patients did not undergo surgical resection due to early metastatic progression or unresectable disease. R0 resection was achieved in 95,4% of cases. Tumour downstage after CRT was observed in most patients (76,1%), with 14,1% cases showing a pathological complete response. Considering tumour location, the rate of downstage was 73,9%, 78,9% and 87,5% for low, middle and high rectum, respectively. Anal sphincter preservation was not possible in 29,5% of patients (22,7% with low and 6,8% with middle rectal cancer). Among the 28 tumours located up to 5 cm from the anal verge, 21,4% were resected with a sphincter preservation. Most of the patients (94,3%) received fluoropyrimidine-based adjuvant chemotherapy. Concerning the patients that totalize surgical resection, 11,3% experienced recurrence in a median time of 14 months following surgery (4 – 32 months): 7,9% with distant disease recurrence and 3,4% developed both local and distant disease recurrence. Most of the patients (84,1%) are free of disease. Conclusion: CRT for LARC in neoadjuvant setting it´s a treatment modality with excellent outcomes concerning tolerability and pathologic response. In this sample, we achieved high pathologic responses rates specially in high rectum tumours (pathologic response rate 87,5%) with a low toxicity profile (acute grade 3 toxicity rate: 3,2%). Our results are similar to the data published in the literature. In addition, CRT allowed sphincter sparing surgery in 21,4% of patients whose tumours were located up to 5 cm from the anal verge.