Effective pelvic symptom control using initial chemoradiation without colostomy in metastatic rectal cancer

• Published in: International journal of radiation oncology, biology, physics Vol. 49; no. 1; pp. 107 - 116
• Main Authors: Crane, Christopher H, Janjan, Nora A, Abbruzzese, James L, Curley, Steve, Vauthey, Jean-Nicolas, Sawaf, Hassan B, Dubrow, Ronelle, Allen, Pamela, Ellis, Lee M, Hoff, Paulo, Wolff, Robert A, Lenzi, Renato, Brown, Thomas D, Lynch, Patrick, Cleary, Karen, Rich, Tyvin A, Skibber, John
• Format: Journal Article
• Language: English
• Published: New York, NY Elsevier Inc 2001; Elsevier
• Subjects: Adult; Aged; Aged, 80 and over; Analysis of Variance; Antimetabolites, Antineoplastic - therapeutic use; Biological and medical sciences; Cohort Studies; Colostomy; Combined Modality Therapy; Disease Progression; Diseases of the digestive system; Female; Fluorouracil - therapeutic use; Follow-Up Studies; Gastroenterology. Liver. Pancreas. Abdomen; Gastrointestinal Hemorrhage - drug therapy; Gastrointestinal Hemorrhage - etiology; Gastrointestinal Hemorrhage - radiotherapy; Humans; Infusions, Intravenous; Intestinal Obstruction - drug therapy; Intestinal Obstruction - etiology; Intestinal Obstruction - radiotherapy; Liver Neoplasms - drug therapy; Liver Neoplasms - radiotherapy; Liver Neoplasms - secondary; Male; Medical sciences; Metastatic; Middle Aged; Neoplasm Staging; Palliative; Pelvic Neoplasms - drug therapy; Pelvic Neoplasms - radiotherapy; Pelvic Neoplasms - secondary; Radiotherapy; Radiotherapy Dosage; Radiotherapy. Instrumental treatment. Physiotherapy. Reeducation. Rehabilitation, orthophony, crenotherapy. Diet therapy and various other treatments (general aspects); Rectal cancer; Rectal Neoplasms - drug therapy; Rectal Neoplasms - pathology; Rectal Neoplasms - radiotherapy; Stomach. Duodenum. Small intestine. Colon. Rectum. Anus; Survival Analysis; Treatment Outcome; Tumors; Metastatic; Colostomy; Rectal cancer; Radiotherapy; Palliative; Human; Evaluation; Rectal disease; Treatment efficiency; Case control study; Metastasis; Malignant tumor; Chemoradiotherapy; Fractionated dose; Radiation dose; Rectum; Digestive diseases; Intestinal disease; Treatment planning
• ISSN: 0360-3016; 1879-355X
• DOI: 10.1016/S0360-3016(00)00777-X

Purpose: To assess pelvic chemoradiotherapy (CXRT) without colostomy as a component of the multidisciplinary management of patients presenting with metastatic rectal cancer. Methods and Materials: Eighty patients with synchronous distant metastases from rectal cancer were treated with initial CXRT. Hypofractionated radiotherapy was administered usually with concurrent 5-FU (92%, 300 mg/m 2/day, M–F). Three-field belly-board technique was used in 89%. Group 1 had CXRT alone ( n = 55). Group 2 ( n = 25) patients were selected for primary disease resection, and sometimes HAI chemotherapy ( n = 10) or hepatic resection ( n = 5). Subsequently, 78% received systemic chemotherapy. Results: Symptoms from primary tumor resolved in 94%. Endoscopic complete clinical response rate was 36%. Two-year survival (11% vs. 46%, p < 0.0001) and symptomatic pelvic control (PC, 81% vs. 91%, p = 0.111) were higher in Group 2, but colostomy-free rate (CFR) was lower (79% vs. 51% p = 0.02). CFR was 87% in Group 1 patients managed initially without fecal diversion ( n = 50). Examining all patients using multivariate analysis, pelvic pain at presentation ( p < 0.00001), BED (biologic equivalent dose at 2 Gy/fraction) < 35 Gy ( p = 0.077), and poor differentiation (0.079) predicted worse PC. Poor differentiation ( p = 0.017) and selection for CXRT alone ( p < 0.0001) predicted worse survival. There were 4 RTOG of Grade 3 or greater acute complications, 5 severe perioperative complications, and no significant late treatment-related complications. Conclusions: Durable PC can be safely achieved without colostomy in most patients presenting with primary rectal cancer and synchronous systemic metastases using hypofractionated pelvic chemoradiation. A BED greater than 35 Gy is recommended. Selected patients appear to benefit from resection of primary disease. Higher doses should be investigated in patients with pelvic pain.