Effective pelvic symptom control using initial chemoradiation without colostomy in metastatic rectal cancer.
OBJECTIVE
To assess pelvic chemoradiotherapy (CXRT) without colostomy as a component of the multidisciplinary management of patients presenting with metastatic rectal cancer.


METHODS
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.
Crane
C H
CH
Department of Radiation, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA
Janjan
N A
NA
Abbruzzese
J L
JL
Curley
S
S
Vauthey
J
J
Sawaf
H B
HB
Dubrow
R
R
Allen
P
P
Ellis
L M
LM
Hoff
P
P
Wolff
R A
RA
Lenzi
R
R
Brown
T D
TD
Lynch
P
P
Cleary
K
K
Rich
T A
TA
Skibber
J
J
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000704:Analysis of Variance; D000964:Antimetabolites, Antineoplastic / Q000627:therapeutic use*; D015331:Cohort Studies; D003125:Colostomy; D003131:Combined Modality Therapy; D018450:Disease Progression; D005260:Female; D005472:Fluorouracil / Q000627:therapeutic use*; D005500:Follow-Up Studies; D006471:Gastrointestinal Hemorrhage / Q000188:drug therapy / Q000209:etiology / Q000532:radiotherapy; D006801:Humans; D007262:Infusions, Intravenous; D007415:Intestinal Obstruction / Q000188:drug therapy / Q000209:etiology / Q000532:radiotherapy; D008113:Liver Neoplasms / Q000188:drug therapy* / Q000532:radiotherapy* / Q000556:secondary; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D010386:Pelvic Neoplasms / Q000188:drug therapy* / Q000532:radiotherapy* / Q000556:secondary; D011879:Radiotherapy Dosage; D012004:Rectal Neoplasms / Q000188:drug therapy* / Q000473:pathology / Q000532:radiotherapy*; D016019:Survival Analysis; D016896:Treatment Outcome
D000964:Antimetabolites, Antineoplastic; D005472:Fluorouracil