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LETTER TO EDITOR
Year : 2009  |  Volume : 46  |  Issue : 4  |  Page : 350-351
 

Complete clinical and pathological response to preoperative short course radiotherapy in T 2 rectal cancer


1 Department of Surgery, Leighton Hospital, Crewe, CW1 4QJ, United Kingdom
2 Department of Pathology, Leighton Hospital, Crewe, CW1 4QJ, United Kingdom

Date of Web Publication9-Sep-2009

Correspondence Address:
C R Selvasekar
Department of Surgery, Leighton Hospital, Crewe, CW1 4QJ
United Kingdom
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.55563

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How to cite this article:
Selvasekar C R, Obeidat S, Simcock P, Khan A U. Complete clinical and pathological response to preoperative short course radiotherapy in T 2 rectal cancer. Indian J Cancer 2009;46:350-1

How to cite this URL:
Selvasekar C R, Obeidat S, Simcock P, Khan A U. Complete clinical and pathological response to preoperative short course radiotherapy in T 2 rectal cancer. Indian J Cancer [serial online] 2009 [cited 2019 Dec 10];46:350-1. Available from: http://www.indianjcancer.com/text.asp?2009/46/4/350/55563


Sir,

Radical surgery including total mesorectal excision (TME) is the treatment of choice for localized rectal cancer. [1] Nevertheless, despite optimal surgery, local recurrence is around 20%, which is reduced to less than 5% with TME and neoadjuvant treatment. [2] Neoadjuvant short-course radiotherapy (SCRT) for rectal cancer is used to decrease local recurrence [2],[3] and improve an overall and disease-free survival. [3]

Recently, we had a 70-year-old male with rectal cancer treated with SCRT, where a complete clinical and pathological response was demonstrated. He was noted to have an ulceroproliferative tumor 4 cm from the anal verge [Figure 1]. A colonoscopy and biopsy confirmed moderately differentiated adenocarcinoma [Figure 2].

Magnetic resonance imaging (MRI) of the pelvis showed the lesion to be T 2 N 0 [Figure 3] with no evidence of metastasis. The patient underwent SCRT followed by abdominoperineal excision of the rectum and anus 19 days later.

Macroscopically, there was normal mucosa, and seven lymph nodes were identified. Histology showed features in-keeping with the previous radiotherapy, characterized by focal transmural fibrosis and a patchy transmural chronic inflammatory infiltrate. No residual neoplasia was identified and all lymph nodes showed simple reactive changes [Figure 4].

Surgery remains the mainstay treatment for rectal cancer, [1] although in Europe radiotherapy has been used in the neoadjuvant and adjuvant setting for a long time, to reduce local recurrence. [4] Short course radiotherapy (SCRT) including the Dutch Colorectal Cancer Group and the Swedish Rectal Cancer Trial demonstrated a reduced risk of local recurrence [2],[3] and concluded that preoperative SCRT might improve survival among patients with resectable rectal cancer. [3] In both these trials surgery was performed within a week of completing radiotherapy. A randomized controlled trial from Poland showed no difference in the local recurrence rate or survival and toxicity rate when comparing SCRT and CRT, which suggests an intensive radiotherapy protocol is achieved with SCRT. SCRT achieves similar results as those by the prolonged standard CRT. [5] In our patient there was a delay of 19 days before radical surgery was performed. This could have contributed to the complete pathological response.

There is reasonable literature on chemoradiation producing 15-30% complete pathological response [4] and this response may be increased with increased time delay between neoadjuvant treatment and surgery, [6] but this evidence is not conclusive. There is some evidence that the subgroup of patients who have favorable tumor regression grade and lymph node status may have a higher rate of complete response. [7] There is an American College of Surgeons Oncology Group (ACOSOG)-supported prospective trial in progress, using local excision following chemoradiation for ultrasound staged T 2 distal rectal cancer. [8] In a significant proportion of a high-risk patient's neoadjuvant treatment, either SCRT or CRT may result in a complete response, whereby, major rectal cancer surgery may be avoided or a local excision with minimal morbidity can be performed. To test this hypothesis, there is a need for a multi-arm randomized controlled trial of early rectal cancer, that is, < = T2 with no nodal disease on radiological staging, receiving SCRT or CRT with varying periods between radiotherapy and radical surgery, to define the optimal time period between radiotherapy regimes and surgery and to find the subgroup of patients where a major resection can be avoided.

 
  References Top

1.MacFarlane JK, Ryall RD, Heald RJ. Mesorectal excision for rectal cancer. Lancet 1993;341:457-60.  Back to cited text no. 1    
2.Kapiteijn E, Marijnen CA, Nagtegaal ID, Putter H, Steup WH, Wiggers T, et al . Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med 2001;345:638-46.  Back to cited text no. 2    
3.Improved survival with preoperative radiotherapy in resectable rectal cancer. Swedish Rectal Cancer Trial. N Engl J Med 1997;336:980-7.  Back to cited text no. 3    
4.Glynne-Jones R, Wallace M, Livingstone JI, Meyrick-Thomas J. Complete clinical response after preoperative chemoradiation in rectal cancer: is a "wait and see" policy justified? Dis Colon Rectum 2008;51:10-9.  Back to cited text no. 4    
5.Bujko K, Nowacki MP, Nasierowska-Guttmejer A, Michalski W, Bebenek M, Kryj M. Long-term results of a randomized trial comparing preoperative short-course radiotherapy with preoperative conventionally fractionated chemoradiation for rectal cancer. Br J Surg 2006;93:1215-23.  Back to cited text no. 5    
6.Tulchinsky H, Shmueli E, Figer A, Klausner JM, Rabau M. An interval >7 weeks between neoadjuvant therapy and surgery improves pathologic complete response and disease-free survival in patients with locally advanced rectal cancer. Ann Surg Oncol 2008;15:2661-7.  Back to cited text no. 6    
7.Lindebjerg J, Garm Spindler KL, Ploen J, Jakobsen AA. The Prognostic Value of Lymph Node Metastases and Tumor Regression Grade in Rectal Cancer Patients treated with Long-Course Preoperative Chemoradiotherapy. Colorectal Dis 2009;11:(3):264-9.  Back to cited text no. 7    
8.Ota DM, Nelson H; ACOSOG Group Co-Chairs.. Local excision of rectal cancer revisited: ACOSOG protocol Z6041. Ann Surg Oncol 2007;14:271.  Back to cited text no. 8    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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