Does Chemo-Radiation Therapy Influence Outcomes in Unresectable Locally Advanced State IV Rectal Cancer?

Joaquin J. Estrada, Vivek Chaudhry, Jose R. Cintron, Leela M. Prasad, Herand Abcarian

Division of Colon and Rectal Surgery, John H. Stroger Jr. Hospital of Cook County, Chicago, USA.

DOI: 10.4236/ss.2012.310093                

Abstract

Introduction: The median survival for patients with stage IV rectal cancer is approximately 20 months. Therapy should focus not only on improving survival but also on quality of life. The aim of our study was to determine if chemoradiation (C-RT) would improve palliation for metastatic unresectable locally advanced disease compared to patients receiving palliative chemotherapy alone (C) for stage IV cancer. Methods: Retrospective review of a prospectively maintained database at a single institution was carried out under IRB approval. From January 2004 to December 2008, 43 patients presenting with unresectable stage IV rectal cancer were identified with a median follow-up of 12 months. Patients with evidence of locally advanced disease or bulky disease received infusional 5-FU ± bevacizumab and 3D conformed mega voltage photon therapy (5400 cGy). Patients without evidence of bulky disease received either FOLFOX or FOLFIRI ± bevacizumab. Data on demographics, investigations, treatment, complications, metastasis, number of blood transfusions, days of hospitalization, and surgical intervention were analyzed using SPSS statistical software. p < 0.05 was considered statistically significant. Results: There were 25 and 18 patients in the C and C-RT groups respectively. There was no difference in mean age, sex or overall survival. Three patient (12%) in the C group developed hydronephrosis compared to 8 patients (44%) in the C-RT group (p < 0.05). Six patients (24%) developed bowel obstructions requiring an ostomy in the C group compared to 9 patient (50%) in the C-RT group (p = 0.07). In the C arm, 80% of patients required multiple hospitalizations for symptoms consistent with progression of disease compared to 61% of patients in the C-RT arm (p < 0.01). Conclusion: Chemoradiation in patients with locally advanced unresectable stage IV cancer has not been extensively investigated. At our institution, patients treated with C-RT for bulky stage IV rectal cancer required fewer hospitalizations when compared to those treated with chemotherapy alone.

Keywords

Chemo-Radiation; Cancer

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	American Cancer Society, “Colorectal Cancer Facts & Figures 2011-2013,” American Cancer Society, Atlanta, 2011.
[2]	S. M. Ronnekleiv-Kelly and G. D. Kennedy, “Management of Stage IV Rectal Cancer: Palliative Options,” World Journal of Gastroenterology, Vol. 17, No. 7, 2011, pp. 835-847. doi:10.3748/wjg.v17.i7.835
[3]	A. Jemal, R. Siegel, E. Ward, Y. Hao, J. Xu and M. J. Thun, “Cancer Statistics, 2009,” CA: A Cancer Journal for Clinicians, Vol. 59, No. 4, 2009, pp. 225-249. doi:10.3322/caac.20006
[4]	R. Stangl, A. Altendorf-Hofmann, R. M. Charnley and J. Scheele, “Factors Influencing the Natural History of Colorectal Liver Metastases,” Lancet, Vol. 343, No. 8910, 1994, pp. 1405-1410. doi:10.1016/S0140-6736(94)92529-1
[5]	R. J. Heald and R. D. H. Ryall, “Recurrence and Survival after Total Mesorectal Excision for Rectal Cancer,” Lancet, Vol. 327, No. 8496, 1986, pp. 1479-1482. doi:10.1016/S0140-6736(86)91510-2
[6]	J. K. MacFarlane, R. D. H. Ryall and R. J. Heald, “Mesorectal Excision for Rectal Cancer,” Lancet, Vol. 341, No. 8843, 1993, pp. 457-460. doi:10.1016/0140-6736(93)90207-W
[7]	Swedish Rectal Cancer Trial, “Improved Survival with Preoperative Radiotherapy in Resectable Rectal Cancer,” The New England Journal of Medicine, Vol. 336, No. 14, 1997, pp. 980-987. doi:10.1056/NEJM199704033361402
[8]	C. Camma, M. Giunta, F. Fiorica, et al., “Preoperative Radiotherapy for Resectable Rectal Cancer: A Meta-Analysis,” Journal of American Medical Association, Vol. 284, No. 8, 2000, pp. 1008-1015. doi:10.1001/jama.284.8.1008
[9]	A. DeGramont, J. F. Bosset, C. Milan, P. Rougier, O. Bouché, P. L. Etienne, F. Morvan, C. Louvet, T. Guillot, E. Francois and L. Bedenne, “Randomized Trial Comparing Monthly Low-Dose Leucovorin and Fluorouracil Bolus with Bimonthly High-Dose Leucovorin and Fluorouracil Bolus Plus Continuous Infusion for Advanced Colorectal Cancer: A French Intergroup Study,” Journal of Clinical Oncology, Vol. 15, No. 2, 1997, pp. 808-815.
[10]	T. Kramer, R. Share, K. Kiel, et al., “Intraoperative Radiation Therapy of Colorectal Cancer,” In: M. Abe, Ed., Intraoperative Radiation Therapy, Pergamon Press, New York, 1991, pp. 308-310.
[11]	I. D. Nagtegaal, C. A. Marijnen, E. K. Kranenbarg, et al., “Circumferential Margin Involvement Is Still an Important Predictor of Local Recurrence in Rectal Carcinoma: Not One Millimeter But Two Millimeters Is the Limit,” American Journal of Surgical Pathology, Vol. 26, No. 3, 2002, pp. 350-357. doi:10.1097/00000478-200203000-00009
[12]	A. Wibe, P. R. Rendedal, E. Svensson, et al., “Prognostic Significance of the Circumferential Resection Margin Following Total Mesorectal Excision for Rectal Cancer,” British Journal of Surgery, Vol. 89, No. 3, 2002, pp. 327-334. doi:10.1046/j.0007-1323.2001.02024.x
[13]	J. F. Bosset, L. Collette, G. Calais, et al., “Chemotherapy with Preoperative Radiotherapy in Rectal Cancer,” The New England Journal of Medicine, Vol. 355, No. 11, 2006, pp. 1114-1123. doi:10.1056/NEJMoa060829
[14]	R. K. Wong, V. Tandan, S. De Silva, A. Figueredo, “Pre-Operative Radiotherapy and Curative Surgery for the Management of Localized Rectal Carcinoma,” Cochrane Database Systematic Reviews, Vol. 2, No. 2, 2007, p. CD 002102.
[15]	C. G. Willett and L. L. Gunderson, “Palliative Treatment of Rectal Cancer: Is Radiotherapy Alone a Good Option?” Journal of Gastrointestinal Surgery, Vol. 8, No. 3, 2004, pp. 277-279. doi:10.1016/j.gassur.2003.11.015
[16]	S. H. Bae, W. Park, D. H. Choi, H. Nam, W. K. Kang, Y. S. Park, J. O. Park, H. K. Chun, W. Y. Lee, S. H. Yun and H. C. Kim, “Palliative Radiotherapy in Patients with a Symptomatic Pelvic Mass of Metastatic Colorectal Cancer,” Radiation Oncology, Vol. 6, No. 52, 2011, pp. 1-8. doi:10.1186/1748-717X-6-52
[17]	A. Suppiah, J. E. Hartley and J. R. Monson, “Advances in Radiotherapy in Operable Rectal Cancer,” Digestive Surgery, Vol. 26, No. 3, 2009, pp. 187-199. doi:10.1159/000219931