Adjuvant Therapy on Cancer of the Lower Rectum. Evaluation of the Effects of Preoperative Radiotherapy on the Prognosis of Patients with Cancer of the Lower Rectum

Jose Alfredo Reis Neto, Jose Alfredo Reis Junior, Odorino Kagohara, Joaquim Simões Neto, Sérgio O. Banci, Luciane H. Oliveira

Coloproctology, Clinica Reis Neto, Catholic University Campinas, Campinas, Brazil.
Surgery, Catholic University of Campinas, Campinas, Brazil.
Surgery, Clinica Reis Neto, Catholic University Campinas, Campinas, Brazil.

DOI: 10.4236/jct.2012.326117                

Abstract

Aims: The prognosis on treatment of the cancer of the rectum has not changed in the last fifty years. Survival rates of 50 to 55% seems immutable in several published series. The main cause for those results is the high incidence of recurrence, either local or widespread. Local recurrence is directly related to the number of undifferentiated cells and to the grade of wall invasion. Widespread recurrence depends specifically on the lymphatic and vascular spreading. So any kind of treatment that would diminish the number of undifferentiated cells and the size or the tumor wall penetration would certainly decrease the local recurrence rate, lengthening the interval free from cancer and, perhaps, modifying the long term survival rate. Between 1978 and 2009, a total of 538 patients with adenocarcinoma of the lower rectum (from the pectinate line to 10 cm above) were treated by preoperative radiotherapy. Methodology: The same protocol was used in all the patients – 400 cGy, 200 cGy/day, during 4 consecutive weeks (anterior and posterior pelvic fields) by means of a Linear Megavoltage Accelerator (25 MeV). Surgery was performed 2 months after completion of the radiotherapy. Results: Statistical analysis of the whole group showed that preoperative radiotherapy does decrease frequency of undifferentiated cells. Moreover, the incidence of local recurrence diminished after irradiation by 3.4%. Preoperative radiotherapy reduces tumor volume (ERUS) and wall invasion, as well as the mortality rate due to local recurrence (2.4%) and alters long-term survival rate (80.1%). Conclusion: Preoperative radiotherapy is really effective in reducing the number of undifferentiated cells and in diminishing the tumor volume and the carcinomatous infiltration of the rectal wall.

Keywords

Rectal Cancer; Cancer of the Lower Rectum; Irradiation; Preoperative Radiotherapy; Local Recurrence; Mortality; Survival

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	H. E. Bacon, “Cancer of the Colon, Rectum and Anal Canal,” J.B. Lippincott Co., Philadelphia, 1964.
[2]	I. Balslev, M. Pedersen, P. S. Tegljaerg, et al., “Postoperative Radiotherapy in Rectosigmoid Cancer Dukes B and C: Interim Report from a Randomized Multicentre Study,” British Journal of Cancer, Vol. 46, No. 4, 1982, pp. 551-556. doi:10.1038/bjc.1982.239
[3]	T. Buroker, N. Nigro, J. Correa, V. K. Vaitkevicius, M. Samson and B. Considine, “Combination Preoperative Radiation and Chemotherapy in Adenocarcinoma of the Rectum: Preliminary Report,” Diseases of the Colon & Rectum, Vol. 19, No. 8, 1976, pp. 660-663. doi:10.1007/BF02591003
[4]	A. M. Cohen, L. L. Gunderson and C. E. Welch, “Selective Use of Adjuvant Radiation Therapy in Resectable Colorectal Adenocarcinoma,” Diseases of the Colon & Rectum, Vol. 24, No. 4, 1981, pp. 247-251. doi:10.1007/BF02641869
[5]	B. J. Cummings, W. D. Rider, A. R. Harwood, T. J. Keane and G. M. Thomas, “Radical External Beam Radiation Therapy for Adenocarcinoma of the Rectum,” Diseases of the Colon & Rectum, Vol. 23, No. 1, 1983, pp. 30-36. doi:10.1007/BF02554676
[6]	B. J. Cummings, “Adjuvant Radiation Therapy for Rectal Adenocarcinoma,” Diseases of the Colon & Rectum, Vol. 27, No. 12, 1984, pp. 826-836. doi:10.1007/BF02553949
[7]	S. Drobni and F. Incze, “Surgery of Rectal Cancer,” Akademiai Kiado, Budapest, 1969.
[8]	G. H. Fletcher, “Textbook of Radiotherapy,” Lea & Febiger, Philadelphia, 1980, pp. 704-716.
[9]	A. H. Gama, P. M. S. B. Souza, U. Ribeiro Jr., F. Campos, A. H. S. Souza Jr., W. Nadalin, R. Gansi and J. G. Rodrigues, “Low Rectal Cancer: Impact of Pré-Operative Radiation and Chemotherapy on Surgical Treatment,” Hospital das Clínicas of the University of Sao Paulo Medical School Experience. In: J. A. Reis Neto, Ed., New Trends in Coloproctology, Revinter, 2000, pp. 423-429.
[10]	J. Gary-Bobo, H. Pujol, C. Solassol, J. L. Broquerie and M. Nguyen, “‘L’ Irradiation Pré-Operatoire du Cancer Rectal: Résultats à 4 ans de 116 Cas,” Bull Cancer, Vol. 66, No. 5, 1979, pp. 461-466.
[11]	B. Glimenius, S. Graffman, L. Pahlman, A. Rimsten and E. Wilander, “Preoperative Irradiation with High Dose Fractionation in Adenocarcinoma of the Rectum and Rectosigmoid,” Acta Radiologica, Vol. 21, No. 6, 1982, pp. 373-379. doi:10.3109/02841868209134315
[12]	J. C. Goligher, “Surgery of the Anus, Rectum and Colon,” 4th ed. London: Bailliere Tindall, 1980.
[13]	L. L. Gunderson, D. E. Dosoretz, S. E. Hedberg, et al., “Low Dose Preoperative Radiation Surgery and Elective Post-Operative Radiation Therapy for Resectable Rectum and Rectosigmoid Carcinoma,” Cancer, Vol. 52, No. 3, 1983, pp. 446-451. doi:10.1002/1097-0142(19830801)52:3<446::AID-CNCR2820520311>3.0.CO;2-H
[14]	C. M. Haskel, “Cancer Treatment,” WB Saunders, Philadelphia, 1980, 276-304.
[15]	G. A. Higgins, J. H. Conn, P. H. Jordan, E. W. Humphrey, B. Roswit and R. J. Keehn, “Preoperative Radiotherapy for Colorectal Cancer,” Annals of Surgery, Vol. 181, No. 5, 1975, pp. 624-631. doi:10.1097/00000658-197505000-00017
[16]	I. Kodner and R. J. Myerson, “Preoperative Radiation Therapy for Rectal Cancer,” In: J. A. Reis Neto, Ed., New Trends in Coloproctology, Revinter, 2000, pp. 385-399.
[17]	M. M. Kligerman, “Radiotherapy and Rectal Cancer,” Cancer, Vol. 39, Suppl. S2, 1977, pp. 986-990. doi:10.1002/1097-0142(197702)39:2+<896::AID-CNCR2820390728>3.0.CO;2-E
[18]	M. M. Kligerman, N. Urdaneta, A. Lnowlton, R. Vidone, P. V. Hartman and R. Vera, “Preoperative Irradiation of Rectosigmoid Carcinoma including Its Regional Lymph Nodes,” American Journalism Review, Vol. 114, No. 6, 1972, pp. 498-503.
[19]	B. C. Morson, “Factors Influencing the Prognosis of Early Cancer of the Rectum,” Proceedings of The Royal Society of Medicine, Vol. 59, No. 4, 1966, pp. 607-611.
[20]	I. P?hlman and B. Glimelius, “Pre or Postoperative Radiotherapy in Rectal and Rectosigmoid Carcinoma,” Annals of Surgery, Vol. 211, No. 2, 1990, pp. 187-195. doi:10.1097/00000658-199002000-00011
[21]	I. Pahlman and B. Glimelius, “The Value of Adjuvant Radiotherapy for Rectal Cancer,” European Journal of Cancer, Vol. 31A, No. 7-8, 1995, pp. 1347-1350. doi:10.1016/0959-8049(95)91268-H
[22]	J. Papillon, “New Prospects in the Conservative Treatment of Rectal Cancer (Abstr),” Diseases of the Colon & Rectum, Vol. 27, No. 11, 1984, pp. 566-567. doi:10.1007/BF02554589
[23]	J. Papillon, “Rectal and Anal Cancer,” Springer-Verlag, Berlin, 1980, pp. 24-32.
[24]	J. A. Reis Neto, F. A. Quilici and F. Cordeiro, “Radioterapia Pré-Operatória em Cancer do Reto,” XXIX Cong Bras Proctologia, Belo Horizonte, 1979.
[25]	J. A. Reis Neto, F. A. Quilici and F. Cordeiro, “Radioterapia + Cirurgia: Novos Conceitos em Cancer do Reto,” XXX Cong Bras Proctologia, Rio de Janeiro, 1980.
[26]	J. A. Reis Neto, F. A. Quilici and F. Cordeiro, “Pre-Operative Radiotherapy for Cancer of the Rectum. Colorectal Mass Screening & Management,” 4th International Symposium Prevention and Detect of Cancer, London, 1980.
[27]	J. A. Reis Neto, F. A. Quilici, F. Cordeiro and J. A. Reis, “Radiotherapy and Survival-Rate,” XIVth Biennial Congress ISUCRS, Crete, 1992.
[28]	J. A. Reis Neto, F. A. Quilici and J. A. Reis Junior, “A Comparison of Nonoperative vs. Preoperative radiotherapy in Rectal Carcinoma. A 10-Year Randomized Trial,” Diseases of the Colon & Rectum, Vol. 32, No. 8, 1989, pp. 702-710. doi:10.1007/BF02555778
[29]	J. A. Reis Neto, F. A. Quilici, F. Cordeiro, S. Ciquini, J. A. Reis Jr., O. Kagohara and J. Simoes Neto, “Long-Term Results of Preoperative Radiotherapy for Cancer of the Lower Rectum,” In: J. A. Reis Neto, Ed., New Trends in Coloproctology, Revinter, 2000, pp. 401-410.
[30]	B. Roswit, G. A. Higgins and R. J. Keehn, “Preoperative Irradiation for Carcinoma of the Rectum and Rectosigmoid Colon: Report of a National Veterans Administration Randomized Study,” Cancer, Vol. 35, No. 6, 1975, pp. 1597-1602. doi:10.1002/1097-0142(197506)35:6<1597::AID-CNCR2820350618>3.0.CO;2-S
[31]	L. Sofo, C. Ratto, G. B. Doglietto, V. Valentini, et al., “Intraoperative Radiation Therapy in Integrated Treatment of Rectal Cancers: Results of Phase II Study,” Diseases of the Colon & Rectum, Vol. 39, No. 12, 1996, pp. 1396-1403. doi:10.1007/BF02054528
[32]	M. W. Stearn Jr., M. R. Deddish and S. H. Quan, “Preoperative Roentgen Therapy for Cancer of the Rectum,” Surgery Gynecology & Obstetrics, Vol. 109, 1959, pp. 225-229.
[33]	M. W. Stearn Jr., “Pre- or Post-Operative Radiation in Resectable Tumors,” In: K. Welwaart, L. H. Blumgart and J. Breuning, Eds., Colorectal Cancer, Leiden University Press, The Hague, 1980, pp. 153-159. doi:10.1007/978-94-009-9158-3_18
[34]	K. R. Stevens, C. V. Allen and W. S. Fletcher, “Peroperative Radiotherapy for Adenocarcinoma of the Rectosigmoid,” Cancer, Vol. 37, No. 6, 1976, pp. 2866-2868. doi:10.1002/1097-0142(197606)37:6<2866::AID-CNCR2820370644>3.0.CO;2-M
[35]	Swedish Rectal Cancer Trial, “Improved Survival with Preoperation Radiotherapy in Respectable Rectal Cancers,” New England Journal Medicine, Vol. 336, No. 3, 1997, pp. 423-430.
[36]	B. J. Walz and J. W. Fleshman Jr., “Adjunctive Use of Radiation Therapy in Rectal Adenocarcinoma,” In: I. J. Kodner, R. D. Fry and J. P. Roe, Eds., Colon, Rectal and Anal Surgery, Current Techniques and Controversies, CV Mosby Co., Saint Louis, 1985, pp. 204-217.
[37]	S. B. Wassif, B. L. Langenhorst and W. C. Hop, “The Contribution of Preoperative Radiotherapy in the Management of Borderline Operability Rectal Cancer,” In: S. E. Salmon and S. E. Jones, Eds., Adjuvant Therapy of Cancer, Grune & Stratton, New York, 1979, pp. 612-621.
[38]	S. B. Wassif, “The Role of Preoperative Adjuvant Therapy in the Management of Borderline Operability Rectal Cancer,” Clinical Radiology, Vol. 33, No. 3, 1982, pp. 353-358. doi:10.1016/S0009-9260(82)80289-4
[39]	R. Zucali, G. Gardani and F. Volterrani, “Adjuvant Post-Operative Radiotherapy in Locally Advanced Rectal and Rectosigmoidal Cancer,” Tumori, Vol. 31, No. 4, 1980, pp. 592-600.