title: Combined modality therapy of rectal cancer: decreased acute toxicity with the preoperative approach.
abstract: OBJECTIVE
  We compared the combined radiation therapy (RT) plus chemotherapy segments of two separate parallel phase I trials to determine if combined pelvic RT, fluorouracil (5-FU), and high-dose leucovorin (LV) had less acute toxicity when delivered preoperatively versus postoperatively in patients with rectal cancer.
  
  
  METHODS
  Patients with unresectable disease received preoperative RT plus LV and 5-FU followed by surgery and postoperative LV and 5-FU. Patients with resectable disease received identical doses, techniques, and schedules of RT and LV and 5-FU except all therapy was delivered postoperatively. On day 1, patients received LV and 5-FU times one cycle. RT began on day 8. A second cycle of LV and 5-FU was given concurrently with the fourth week of RT.
  
  
  RESULTS
  Although more patients (75% v 32%; P = .02) received the higher dose level of 5-FU (250 mg/m2), significantly fewer experienced acute grade 3 to 4 toxicity with preoperative versus postoperative therapy (13% v 48%; P = .045). There was no grade 3 to 4 myelosuppression in either group. The two grade 3 toxicities in the preoperative group were gastrointestinal. The grade 3 toxicities in the postoperative group included seven gastrointestinal and two genitourinary; four patients had a grade 4 toxicity.
  
  
  CONCLUSIONS
  Given the high incidence of grade 3 to 4 toxicity also reported in the postoperative combined modality adjuvant randomized trials, future adjuvant trials should explore the preoperative approach.
authors.affiliation: Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY 10021.
authors.forename: B D
authors.initials: BD
authors.lastname: Minsky
authors.forename: A M
authors.initials: AM
authors.lastname: Cohen
authors.forename: N
authors.initials: N
authors.lastname: Kemeny
authors.forename: W E
authors.initials: WE
authors.lastname: Enker
authors.forename: D P
authors.initials: DP
authors.lastname: Kelsen
authors.forename: B
authors.initials: B
authors.lastname: Reichman
authors.forename: L
authors.initials: L
authors.lastname: Saltz
authors.forename: E R
authors.initials: ER
authors.lastname: Sigurdson
authors.forename: J
authors.initials: J
authors.lastname: Frankel
mesh_terms: D000328:Adult; D000368:Aged; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000009:adverse effects* / Q000627:therapeutic use; D003131:Combined Modality Therapy; D004334:Drug Administration Schedule; D004341:Drug Evaluation; D005260:Female; D005472:Fluorouracil / Q000008:administration & dosage; D006801:Humans; D002955:Leucovorin / Q000008:administration & dosage; D008297:Male; D008875:Middle Aged; D011878:Radiotherapy / Q000009:adverse effects; D011879:Radiotherapy Dosage; D012004:Rectal Neoplasms / Q000188:drug therapy* / Q000532:radiotherapy* / Q000601:surgery
chemical_list: D002955:Leucovorin; D005472:Fluorouracil