Preoperative chemoradiation in fixed distal rectal cancer: Dose time factors for pathological complete response

Purpose: Preoperative chemoradiation is being utilized extensively in the t reatment of rectal cancer. However, a variety of dose time factors in both delivery of chemotherapy and irradiation remain to be established. This stu dy was undertaken to examine the impact of dose time factors on pathologica l complete response (pCR) rates following preoperative chemoradiation for f ixed rectal cancer. Methods and Materials: Thirty-three patients with fixed rectal cancers were treated with combined 5-fluorouracil (5-FU) chemotherapy and pelvic radiat ion. Twenty-one patients received bolus 5-FU during the first 3-5 days of r adiation and repeated on days 28-33 of their radiation treatment. Twelve pa tients were treated with continuous infusion (CI) 5-FU, 225 mg/m(2) for the duration of the pelvic radiation. Fifteen patients received a planned tota l radiation dose of 45 to 50 Gy and 18 patients received a dose of 55 to 60 Gy. Surgical resection was then carried out 6-8 weeks after completion of treatment. Results: Diarrhea was the most frequent acute toxicity. Grade 3 diarrhea wa s observed in 6 patients requiring treatment interruption and was not relat ed to the chemotherapy regimen. There was no Grade 4 or 5 toxicity. pCR was observed in 2 of 21 (10%) patients treated with bolus 5-FU as compared to 8 of 12 (67%) for patients treated with CI (p = 0.002). pCR were observed i n 8 of 18 (44%) patients receiving radiation dose greater than or equal to 5500 cGy as compared to 2 of 15 (13%) patients treated to a dose less than or equal to 5000 cGy (p = 0.05). In the high-dose radiation (greater than o r equal to 5500 cGy) group, a significant difference in pCR rate was observ ed in patients treated with CI, 8 of 12 (67%) (p 0.017) as compared with bo lus 5-FU (0 of 6). There was no significant difference in operative morbidi ty or in wound healing between patients treated with bolus 5-FU or CI or wi thin the groups treated with low or high doses of radiation. Three patients have developed local recurrence at 14 and 24 months, two in the low-dose g roup treated with bolus 5-FU and one patient in the CVI group. The overall 5-year survival for the whole group is 71%. Conclusion: Dose intensity of 5-FU and dose of radiation correlate signific antly with the likelihood of achieving a pCR. Continuous infusion 5-FU (CI) and a preoperative radiation dose of 5500 cGy or higher can achieve pCR ra tes of similar to 50%, even in fixed cancers of the rectum. (C) 2000 Elsevi er Science Inc.