Adjuvant therapy for rectal caner stage II and III after radical TME surgery without preoperative chemoradiotherapy - Observation, Standard De Gramont, FOLFOX ,FOLFIRI, CAPOX, FOLFOXIRI - is there strong evidence to support one over another regiment in term of overall survival (OS) . And what is your opinion ?
In stage II nothing is needed, but in stage III would be recommended any type of the suggested combinations.
Best regards
Rectal cancer has a worse prognosis than colon cancer many times. Even cT1 sm2 or worse will have high when compared to sm1. Besides many other high risk features, adjuvant therapy should be considered after chemoradiation or surgery (or both). Many chemo schemas are based on colon cancer, for which schemas with irinotecan are not indicated for strictly adjuvant regumens. For instance, whe have the Adore trial , with oxaliplatin added when bad response to chemo+rt is seen - Hong et al. Lancet 2014 Article Oxaliplatin, fluorouracil, and leucovorin versus fluorouraci...
.Other reviews may help:
Article Adjuvant chemotherapy for rectal cancer: Is it needed?
https://www.ncbi.nlm.nih.gov/m/pubmed/28593861/?i=11&from=rectal%20adjuvant&filters=Review
The choice of chemotherapy depend upon the timing of chemotherapy, i.e, neoadjuvant, adjuvant or concurrent setting. In the neoadjuvant setting, it is generally not preferred, although there are studies using CAPOX regimen for two-three cycles followed by surgery and adjuvant therapy as indicated. In the setting when neo-adjuvant CTRT is being administered, it is usually given as Capecitabine along with RT. In adjuvant setting, chemotherapy commonly used is CAPOX/XELOX (CHRONICLE Study) for 8 cycles(6 months), three-weekly or FOLFOX 12 cycles 2-weekly. Also, tried have been regimens like 5FU/LV (EORTC 22921, PROCTOR/SCRIPT, Italian Study). The ADORE study compared 5FU/LV vs FOLFOX, with no clear benefits. There was no clearcut evidence as to which one is a better chemotherapy regimen. There were no significant differences (in the p value, comparing different regimens), although the ADORE trial found a significant difference in DFS, there was no OS difference. So, the standard practice remains 6 months of CAPOX/XELOX or FOLFOX. Adjuvant chemo-radiation can be considered for cases which have been operated upfront. Also adding neo-adjuvant EGFR inhibition to the standard therapy has been tried with Gefitinib, Cetuximab, Panitumumab and also anti-VEGF agent Bevacizumab. However, none of them are established agents yet.
Adjuvant chemotherapy is indicated to the patient with stag III and Stage II( high risk group ) rectal cancer.
The best regiment from latest evidence is the FOLFOX or CAPOX
As Dr Lee mentioned adjuvant chemo rad is indicated.But does it matter if you administer after surgery ? because pts do come with bleeding and impending obstruction,Request to clarify
Taking into account the side effects of radiotherpay the best choice in these cases is give only adjuvant chemotherapy
Stade II no treatment
stade III ( = no metastasis) , consensus treatment is C12 FolFox as first line
nothing else
Neo-adjuvant Chemo-Radiation is indicated in almost all cases followed by Surgery followed by adjuvant chemo (If indicated). Indications for adjuvant chemotherapy in rectal cancer are T3,T4 or N+ disease in post-operative histopathology.
As far as the question of Dr.Reddy is concerned, in case of impending obstruction, a diversion colostomy can be done to relieve the obstruction, followed by chemo-radiation, surgery (Radical surgery - TME + LN dissection) +/- adjuvant chemotherapy.
please suggest literature review ,comparative results between preop versus post op operable rectal cancers please,txs
There are two landmark trials basically
(1) MRC CR07 (Sebag Montefiore et al. 2009) - it compares Pre-op short course Radiotherapy vs Post-op Chemo radiaotherapy.
(2) German Rectal Cancer Study (Sauer et al., 2004 NEJM) - IT COMPARES PRE-OP CHEMO-RADIOTHERAPY TO POST-OP CHEMO-RADIOTHERAPY. It showed increased sphincter conservation rates with pre-op treatment.
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