Selective use of preoperative radiotherapy in the treatment of cancer in the lower two thirds of the rectum

Purpose. The authors review the result of the selection of patients with a low rectal cancer for pre-operative radiotherapy. Methods. The selection wa s based on the findings of digital examination eventually combined with sur gical staging consisting of bimanual palpation during a staging laparotomy or "trial" operation. This selection was used to divide the patients into t hree groups: one where local radicality could be expected from primary surg ery (group 1), one with deeply infiltrating but mobile tumours requiring 10 x 3 Gy pre-operative radiotherapy (group 2) and one with fixed or borderli ne resectable tumours requiring protracted pre-operative radiotherapy with 55-59 Gy (group 3). One hundred and one patients were eligible for this stu dy. A resection aiming for pelvic radicality was carried out in 94 patients : primary resection in 38 (group 1), surgery subsequent to 10 x 3 Gy pre-op erative radiotherapy in 20 (group 2) and 55-59 Gy in 36 (group 3). Results. The calculated risk of local recurrence at 5 years was 15% (95% C.I. 4-27) for group 1, 8% (95% C.I. 0-20) for group 2 and 30% (95% C.I. 16-44) for g roup 3. The calculated 5 years survival for the 3 groups was respectively 6 0%, 49% and 39%. Conclusion. The overlap in local recurrence rate between t he three groups suggests a substantial downgrading by this approach of sele ctive use of preoperative e radiotherapy in the patients with the most adva nced tumour. Notwithstanding recent improvements of imaging techniques ther e still is a place for the staging laparotomy in the selection of the treat ment strategy for advanced rectal cancers.