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cT3N0 rectal cancer: potential overtreatment with preoperative chemoradiotherapy is warranted

Cited 159 time in Web of Science Cited 174 time in Scopus
Authors
Guillem, Jose G.; Diaz-Gonzalez, Juan A.; Minsky, Bruce D.; Valentini, Vincenzo; Jeong, Seung-Yong; Rodriguez-Bigas, Miguel A.; Coco, Claudio; Leon, Rebecca; Hernandez-Lizoain, Jose L.; Aristu, Jose J.; Riedel, Elyn R.; Nitti, Donato; Wong, W. Douglas; Pucciarelli, Salvatore
Issue Date
2008-01-19
Publisher
American Society of Clinical Oncology
Citation
J Clin Oncol. 2008 ;26(3):368-73.
Keywords
Adenocarcinoma/*drug therapy/pathology/*radiotherapyAdultAgedAged, 80 and overAntineoplastic Combined Chemotherapy Protocols/therapeutic useCarboplatin/administration & dosageCisplatin/administration & dosageCombined Modality TherapyEndosonographyFemaleFluorouracil/administration & dosageGamma RaysHumansLeucovorin/administration & dosageLymph Nodes/pathologyMagnetic Resonance ImagingMaleMiddle AgedNeoplasm StagingPreoperative CareRectal Neoplasms/*drug therapy/pathology/*radiotherapy
Abstract
PURPOSE: Although combined-modality therapy (CMT) is the preferred treatment for T3 and/or lymph node (LN)-positive rectal cancer, the German rectal cancer study published in 2004 demonstrated that 18% of patients deemed suitable for preoperative CMT by endorectal ultrasound (ERUS) may be overstaged. Because data also suggest that LN-negative rectal cancer after total mesorectal excision may not require radiotherapy, it is reasonable to consider omitting radiotherapy for the cT3N0 subset. We therefore determined the accuracy of pre-CMT ERUS or magnetic resonance imaging (MRI) staging, to explore the validity of a nonpreoperative CMT approach for cT3N0 disease. PATIENTS AND METHODS: One hundred eighty-eight ERUS-/MRI-staged T3N0 rectal cancer patients received preoperative CMT (fluorouracil based and 45-50.4 Gy) followed by radical resection. Rates of pathologic complete response (pCR) and mesorectal LN involvement were determined. RESULTS: Tumors were located a median of 5 cm from the anal verge. Sphincter-preserving surgery was performed in 143 patients (76%). Overall pCR was 20%, and 41 patients (22%) had pathologically positive mesorectal LNs. The incidence of positive LNs significantly increased with T stage: ypT0, 3%; ypT1, 7%; ypT2, 20%; ypT3-4, 36% (P = .001). CONCLUSION: The accuracy of preoperative ERUS/MRI for staging mid to distal cT3N0 rectal cancer is limited because 22% of patients have undetected mesorectal LN involvement despite CMT. Therefore, ERUS-/MRI-staged T3N0 rectal cancer patients should continue to receive preoperative CMT. Although 18% may be overstaged and therefore overtreated, our data suggest that an even larger number would be understaged and require postoperative CMT, which is associated with significantly inferior local control, higher toxicity, and worse functional outcome.
ISSN
1527-7755 (Electronic)
0732-183X (Print)
Language
English
URI
http://hdl.handle.net/10371/62653
DOI
https://doi.org/10.1200/JCO.2007.13.5434
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College of Medicine/School of Medicine (의과대학/대학원)Surgery (외과학전공)Journal Papers (저널논문_외과학전공)
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