Journal of clinical oncology : official journal of the American Society of Clinical Oncology 2004-05-15
Impact of T and N stage and treatment on survival and relapse in adjuvant rectal cancer: a pooled analysis.
Abstract
Purpose
To determine survival and relapse rates by T and N stage and treatment method in five randomized phase III North American rectal adjuvant studies.
Patients and methods
Data were pooled from 3,791 eligible patients enrolled onto North Central Cancer Treatment Group (NCCTG) 79-47-51, NCCTG 86-47-51, US Gastrointestinal Intergroup 0114, National Surgical Adjuvant Breast and Bowel Project (NSABP) R01, and NSABP R02. Surgery alone (S) was the treatment arm in 179 patients. The remaining patients received adjuvant treatment as follows: irradiation (RT) alone (n = 281), RT + fluorouracil (FU) +/- semustine bolus chemotherapy (CT; n = 779), RT + protracted venous infusion CT (n = 325), RT + FU +/- leucovorin or levamisole bolus CT (n = 1,695), or CT alone (n = 532). Five-year follow-up was available in 94% of surviving patients, and 8-year follow-up, in 62%.
Results
Overall (OS) and disease-free survival were dependent on TN stage, NT stage, and treatment method. Even among N2 patients, T substage influenced 5-year OS (T1-2, 67%; T3, 44%; T4, 37%; P <.001). Three risk groups of patients were defined: (1) intermediate (T1-2/N1, T3/N0), (2) moderately high (T1-2/N2, T3/N1, T4/N0), and (3) high (T3/N2, T4/N1, T4/N2). For intermediate-risk patients, those receiving S plus CT had 5-year OS rates of 85% (T1-2/N1) and 84% (T3/N0), which was similar to results with S plus RT plus CT (T1-2/N1, 78% to 83%; T3/N0, 74% to 80%). For moderately high-risk lesions, 5-year OS ranged from 43% to 70% with S plus CT, and 44% to 80% with S plus RT plus CT. For high-risk lesions, 5-year OS ranged from 25% to 45% with S plus CT, and 29% to 57% with S plus RT plus CT.
Conclusion
Different treatment strategies may be indicated for intermediate-risk versus moderately high- or high-risk patients based on differential survival rates and rates of relapse. Use of trimodality treatment for all patients with intermediate-risk lesions may be excessive, since S plus CT resulted in 5-year OS of approximately 85%; however, 5-year disease-free survival rates with S plus CT were 78% (T1-2/N1) and 69%(T3/N0), indicating room for improvement.
Related Questions
Would you recommend additional post-operative chemoradiation for a T2N1 proximal rectal cancer having received adjuvant capecitabine/oxaliplatin?
Pathologic T2N1 after high-quality R0 TME, in an otherwise favorable pelvic risk patient (per pre-op staging MRI) with upper rectal cancer, would not be sufficient for me to recommend post-op CRT as I don’t think there would be a clinically significant benefit that would warrant the known acute and ...
Would you offer adjuvant chemotherapy or radiation to a resected MSS T3N0 high-rectal lesion with low anterior resection without pre-op therapy?
For patients with T3N0 upper rectal cancer with no significant risk factors (R0, CRM clear, no EMVI) who undergo high quality TME surgery as suggested by an intact TME pathologic specimen, the 5-year risk of pelvic recurrence without the delivery of adjuvant radiotherapy is < 5%. I do not recommend ...
Would you ever omit adjuvant radiation for a patient with rectal cancer originally staged cT1N0, but found to be pT1N1 after surgery?
Certainly a topic that comes up not uncommonly in tumor boards. The gold standard comparing pre to post operative chemoradiation remains the German colorectal trial, and showed increase in acute diarrhea from 12% to 18% and long term GI sx from 9% to 15%, strictures from 4% to 12%. Although there is...
What adjuvant therapy would you offer for rectosigmoid junction adenocarcinoma after initial LAR?
The ideal treatment of rectosigmoid cancers is often nebulous, as depending on their presentation, they can be approached like rectal cancer or colon cancer.Given that this patient had initial surgery, I would approach this patient as a higher risk stage 2 colon cancer, based on the perforation as w...
When giving total neoadjuvant therapy for rectal cancer, do you sequence radiation and chemotherapy differently depending on the tumor distance from the anal verge?
With all of the emerging data in rectal cancer and, particularly, if considering non-operative management, I think it is crucial to discuss these patients as part of a multidisciplinary team now more than ever. Prior to starting any therapy, we try to ensure that all of our newly diagnosed rectal ca...
Is tumor deposit (N1c) alone an indication for adjuvant chemoRT for rectal cancer that did not receive neoadjuvant therapy?
Some patients such as this were undoubtedly included in the early rectal cancer trials [GITSG and Mayo North Central (NCCTG)] that established the role of post-operative chemoradiation for stage II and III rectal cancer. However, accrual numbers were too small for stratification of TN subsets and it...
Can total neoadjuvant therapy be considered an option equivalent to standard of care treatment for patients with T3N0 or T3N1 rectal adenocarcinoma?
NCCN says that it is a standard of care for this group of patients (excluding early T3N0 without threatened mesorectal fascia). Theoretically, TNT should be better tolerated, allow patients to complete all of the chemotherapy, able to improve organ preservation rates, and improve oncologic outcomes....
What is the appropriate treatment for a low lying rectal cancer in the setting of prior definitive prostate IMRT?
As is true for most complicated clinical situations, there is not any absolute answer to this question.First, it does allow me to remind everyone that prostate radiation therapy increases the incidence of subsequent rectal cancer- probably about 2 fold. This shouldn't surprise anyone, but it is some...