Preoperative radiation with concurrent 5-fluorouracil for locally advancedT4-primary rectal cancer

Purpose: In cT4-rectal carcinoma disease-free margins often cannot be obtai ned by primary surgery, and even if total en bloc resection is accomplished , local failure remains high with surgery alone. Herein we report on the cu rative resectability rate, acute toxicities, surgical complications, local control and 5-year survival rates achieved with a more aggressive multimoda lity regimen, including preoperative radiochemotherapy. Patients and Methods: Between 1/1990 and 12/1998, a total of 31 patients wi th cT4-rectal cancer were treated at our institution. All patients presente d with tumor contiguous or adherent to adjacent pelvic organs. Eight patien ts had synchronous distant metastases. A total radiation dose of 50.4 Gy wi th a small-volume boost of 5.4 to 9 Gy was delivered (single dose: 1.8 Gy). 5-FU was scheduled as a continuous infusion of 1000 mg/m(2) per 24 hours o n days 1 to 5 and 29 to 33. Six weeks after completion of radiochemotherapy , patients were reassessed for resectability. Results: After preoperative radiochemotherapy, 29/31 patients (94%) underwe nt surgery with curative intent. Resection of the pelvic tumor with negativ e margins was achieved in 26/31 patients (84%). 3 patients had microscopic residual pelvic disease. In 3/8 patients with distant spread at presentatio n a complete resection of metastases was finally accomplished. Toxicity of radiochemotherapy occurred mainly as diarrhea (NCI-CTC Grade 3: 23%), derma titis (Grade 3: 16%) and leucopenia (Grade 3: 10%). Surgical complications appeared as anastomotic leakage in 3, wound infection in 2, fistula, absces s and hemorrhage in 1 patient, respectively. With a median follow-up of 33 months, local failure after curative resection was observed in 4 patients ( 19%), 3 patients (14%) developed distant metastases. The 5-year overall sur vival rate for the entire group of 31 patients was 51%, following curative surgery 68%. Conclusion: A combination of high-dose preoperative radiochemotherapy follo wed by extended surgery can achieve clear resection margins in more than 80 % of patients with locally advanced cT4 rectal tumor. An encouraging trend evolves for this multimodality treatment to improve long-term local control and survival.