How do you currently manage the primary tumor in these patients.
If the rectal tumour itself is also resectable, I would go for resection of the primary lesion and the metastatis followed by
adjuvant therapy. This way the tumour would be debulked without undue delay before chemoirradiation. I wonder what would be gained in having neoadjuvant therapy first.
It is dependant from the special situation. If there is a small rectal cancer with only minimal invasion into the mesorectum or no invasion (- uT3a) primary resection of the rectum with/without simultaneous resection of the liver can be possible. In advanced rectal cancer primary chemoradiotherapy, but with not only 5-FU or capecitabine seems to be better. FolFox in combination with radiotherapy is possible and controls liver/lung metastases during the phase of radiotherapy. If you use only 5-FU or capecitabine you will have some progress of the metastatic disease. The rationle behind this concept is, that you will have better local control and you have the chance to treat the metastatic disease. In primary debulking of advanced rectal cancer the chance of locoregional control is less and some patients will experience local recurrence during teir lifetime, because we can better treat metastatic liver disease than local recurrences - even in 2013.
Thank you Dr. Becker. Achieving local control in patients with resectable distant disease is as important as in patients without metastases. If you look at the current survival plots there are subgroups of pts with metastases in whom 5-year disease-free survival exceeds 50%. So we should do all efforts to achieve local control in these patients too. And my interest on this subject comes from some our pts with liver metastases where we spent a lot of efforts to control the disease in the liver (PVE, two-step heaptectomy, hepatectomy+RFA etc.) and finally the disease recurred locally in the pelvis.
And if you do "big" liver surgery e. g. like right hemihepatectomy you will have problems because of portal hypertension if you aim at treating the local recurrence surgically.
But on the other hand knowing the longterm data from the Dutch rectal cancer study with less OAS after neoadjuvant short-course radiotherapy, we should reserve neoadjuvant treatmen tonly for those patients with an higher risk of local recurrence.
Dear Dr. Becker,
The problem with portal hypertension after major hepatectomy in noncirrhotic liver actually does not exist. And the pelvic recurrence unfortunately is rarely resectable, and usually requires sacral resection. Even in those situations the local control is questionable. On the other hand in all randomized trials of neoadjuvant RT/CRT for rectal cancer distant disease is exclusion criteria, so current practice to not irradiate patients with metastases (irrespective whether they are resectable or not) is presumptive and not evidence-based. That is why we insist to respect the same indications for neoadjuvant CRT in pts with resectable distant disease as in pts without metastases.
Dear Dr. Julianov,
The answer for this question is rather difficult, because too much scenario exists and it means that there is not an appropriate trial design can be set up.
I beleive that the most important is the work of a multidisciplinary team, because the treatment of a resectable distant metastases and the management of the local rectal malignant lesion is different.
There are basically four scenarios:
1st: liver met is small and resectable, rectal cancer is under T3. Probably the appropriate choice is the synchronous resection of liver and rectal malignancy.
2nd: liver met needs preop chemo, rectal cancer is under T3. I guess, the best choice is delivering preop chemo than synchronous resection
3rd: liver met is small and resectable and can be fit for local treatment, rectal cancer is T3 or over it (like N1 or T4). I would go for local procedures for liver met like RFA, and I would deliver state of the art chemoradiation for rectal cancer before operation of both
and the most difficult situation when liver met needs preop treatment and rectal cancer also needs preop chemoradiation. my current practice is out of evidence based outlined procedures: I used to start the preoperative chemoradiation for rectal cancer, the long course naturally, and biweekly I used to insert cycles od systemic chemo (usually FOLFOX4) for systemic control. After finishing the sandwich like chemoradiation therapy, patient can be almost promptly operated for the liver stuff, followed by the in-time ractal cancer surgery.
The response is Yes, the radiotherapy has to be used if the satging is T3/4 or/and N+
one important data: the Sweden short course radiotherapy is effective to decrease the local recurrence risk.
In practice for
- rectal cancer T3/4 or/and N+ CRM>1mm with an important liver involvement. The treatment of liver met is the priority and a preoperative 5X5gy is a good choice to avoid 3 months wihtout effective chemotherapy
- rectal cancer T3/4 or/and N+ CRM
In our institution, we will do neoadjuvant chemoradiation. However, we will deliver full dose chemotherapy for 6 months first for the consideration of controlling stage 4 disease. Normally, we see response in both primary site and metastatic sites. If no disease progression upon completion of chemotherapy, we will go on to have neoadjuvant chemoRT followed by definitive surgery on the primary site and metastatic sites. If the patient has disease progression during the period of receiving chemotherapy, we will deliver chemoradiation therapy for local control/palliation.
with metastatic disease, needs systemic chemotherapy. however while systemic chemotherapy may decrease primary size as well, however local raiotherapy may be add to local control.
at tata memorial after discussion in mdt, patients are offered short course raiotherapy with aplan to operate aftera gap of 8 weeks or more. along with this, we start 4 cycles of folfox or capeox and reasess after 4 cycles, this i feels offers systemic therapy as well as local therapy for rectal primary.
at tmh patients with t3n+ trial are being enrolled inn to IAEA trial where patients ae randomised to LCRT and surgery after 8 weeks vs. scrt and surgery after 8 weeks. interim analyis is expexted in the near future
a saklani
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