Effective pelvic symptom control using initial chemoradiation without colostomy in metastatic rectal cancer

Purpose: To assess pelvic chemoradiotherapy (CXRT) without colostomy as a c omponent of the multidisciplinary management of patients presenting with me tastatic rectal cancer. Methods and Materials: Eighty patients with synchronous distant metastases from rectal cancer were treated with initial CXRT. Hypofractionated radioth erapy was administered usually with concurrent 5-FU (92%, 300 mg/m(2)/day, M-F). Three-held belly-hoard technique was used in 89%. Group 1 had CXRT al one (n = 55). Group 2 (n = 25) patients were selected for primary disease r esection, and sometimes HAI chemotherapy (n = 10) or hepatic resection (n = 5). Subsequently, 78% received systemic chemotherapy. Results: Symptoms from primary tumor resolved in 94%. Endoscopic complete c linical response rate was 36%. Two-year survival (11% vs. 46%,p < 0.0001) a nd symptomatic pelvic control (PC, 81% vs. 91%,p = 0.111) were higher in Gr oup 2, but colostomy-free rate (CFR) was lower (79% vs. 51% p = 0.02). CFR was 87% in Group I patients managed initially without fecal diversion (n = 50). Examining all patients using multivariate analysis, pelvic pain at pre sentation (p < 0.00001), BED (biologic equivalent dose at 2 Gy/fraction) < 35 Gy (p = 0.077), and poor differentiation (0.079) predicted worse PC. Poo r differentiation (p = 0.017) and selection for CXRT alone (p < 0.0001) pre dicted worse survival. There were 4 RTOG of Grade 3 or greater acute compli cations, 5 severe perioperative complications, and no significant late trea tment-related complications. Conclusions: Durable PC can be safely achieved without colostomy in most pa tients presenting with primary rectal cancer and synchronous systemic metas tases using hypofractionated pelvic chemoradiation. A BED greater than 35 G y is recommended. Selected patients appear to benefit from resection of pri mary disease. Higher doses should be investigated in patients with pelvic p ain. (C) 2001 Elsevier Science Inc.