title: Neoadjuvant treatment intensification or adjuvant chemotherapy for locally advanced carcinoma rectum: The optimum treatment approach remains unresolved.
abstract: BACKGROUND
  Rectal carcinoma [RC] is often managed with preoperative radiotherapy or radio-chemotherapy followed by total mesorectal excision (TME). Efforts are being made to improve outcome by intensifying the preoperative treatment. However, the optimum therapy remains unclear. There is ongoing controversy regarding the optimum radiation dose, chemotherapy regimen and schedule. In addition there exists growing disagreement regarding the role of adjuvant chemotherapy after neoadjuvant radiation or chemoradiation.
  
  
  METHODS
  We reviewed the recent land mark trials to find a road map in the management of locally advanced rectal carcinoma.
  
  
  RESULTS
  Preoperative short course radiotherapy has long been proven to improve local disease control. The initial trials with long course chemoradiotherapy, comparing short course radiotherapy have shown to increase local control and pathological complete response rates. Since then treatment intensification of this neoadjuvant schedule has been tried by many researchers. But initial results of these treatment intensification trials, show no significant benefit and are associated with increased toxicity. There is an unmet need to stratify patients depending on risk to assign them to long course chemoradiotherapy or short course radiotherapy. Current evidence does not support the use of adjuvant chemotherapy in patients who were treated with preoperative (chemo)radiotherapy.
  
  
  CONCLUSIONS
  Preoperative radiotherapy appears to improve disease control with favorable toxicity profile and there is very little to choose between long course chemoradiotherapy and short course radiotherapy. However, long course chemoradiotherapy may be beneficial for patients with high risk features like positive circumferential resection margin [CRM] and extramural spread of >5mm. There is no role for adjuvant chemotherapy in patients who were treated preoperative (chemo)radiotherapy.
authors.affiliation: Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India. Electronic address: drsupriyamallick@gmail.com.
authors.forename: Supriya
authors.initials: S
authors.lastname: Mallick
authors.affiliation: Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Rony
authors.initials: R
authors.lastname: Benson
authors.affiliation: Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: K P
authors.initials: KP
authors.lastname: Haresh
authors.affiliation: Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: G K
authors.initials: GK
authors.lastname: Rath
mesh_terms: D000230:Adenocarcinoma / Q000188:drug therapy* / Q000401:mortality / Q000473:pathology* / Q000628:therapy; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D017024:Chemotherapy, Adjuvant; D002986:Clinical Trials as Topic; D003131:Combined Modality Therapy; D019468:Disease Management; D006801:Humans; D020360:Neoadjuvant Therapy; D009367:Neoplasm Staging; D012004:Rectal Neoplasms / Q000188:drug therapy* / Q000401:mortality / Q000473:pathology* / Q000628:therapy; D016896:Treatment Outcome
keywords: Adjuvant chemotherapy; Chemo-radiotherapy; Locally advanced; Long course radiotherapy; Preoperative; Rectal carcinoma; Short course radiotherapy