Planned Short-Course Radiation (scRT) is Superior to Upfront Concurrent Chemoradiation (CCRT) in Treating Metastatic Rectal Cancer

Neoadjuvant Pelvic Radiotherapy in the Management of Rectal Cancer with Synchronous Liver Metastases: Is It Worth It?

BACKGROUND

The use of neoadjuvant pelvic radiotherapy was a major advance in oncologic care for locally advanced rectal cancer in the twentieth century. The extrapolation of the care of locally advanced rectal cancer to the management of rectal cancer with treatable liver metastases is controversial. The aim of this review is to examine the available data on the role of pelvic radiotherapy and chemoradiation in the setting of treatable metastatic liver disease.

METHODS

A systematic search of MEDLINE was performed to report the landmark randomized controlled trials between 1993 and 2021.

RESULTS

Attaining liver clearance and total mesorectal excision with R0 margin remains the mainstay of cure. There is uncertainty regarding the sequencing of treatment. The literature lacks randomized clinical trials comparing the rectal first, liver first, interval strategy, and simultaneous surgical approaches. A multidisciplinary discussion regarding the utility of radiotherapy is emphasized to achieve the goals of treatment. Short-course radiotherapy has proved comparable disease-control outcomes to long-course chemoradiation with a significantly improved cost-performance. The implementation of short-course radiotherapy in the interval strategy and simultaneous surgical approach is promising. Neoadjuvant pelvic radiotherapy can be omitted in patients with metastatic rectal cancer if adequate margin clearance is achievable.

CONCLUSION

The use of radiotherapy in metastatic rectal cancer is popular but is based on limited data. Treatment should be tailored to the local extent of rectal cancer and priority of liver metastasis management. The optimal treatment strategy in patients with rectal cancer and synchronous liver metastatic disease needs to be studied in randomized trials.

Short-course radiotherapy in stage IV rectal cancer with resectable disease

INTRODUCTION

Stage IV rectal cancer with resectable disease presents challenging issues, as the radical treatment of the whole disease is difficult. Surgery and chemotherapy (CT) play an unquestionable role, but the contribution of pelvic radiotherapy (RT) is not very clear.

METHODS

In 2009, we established a prospective treatment protocol that included CT, short-course preoperative radiotherapy (SCRT) with surgery of the primary tumour and all metastatic locations.

RESULTS

Forty patients were included. Eight (20%) patients did not receive CT due to significant comorbidities. Radical surgery treatment was possible in 22 (55%) patients. The mean follow-up was 42.81 months (3.63-105.97). Overall survival at 24 and 36 months was 71.4% and 58.2%, respectively. There was good local control of the disease, as 97.2% of pelvic surgeries were R0 and there were no local recurrences.

CONCLUSION

In stage IV with resectable metastatic disease, the proposed therapeutic regimen seems very appropriate in well selected patients able to tolerate the treatment. We bet on the role of pelvic RT, due to the good local control of the disease in our series.