Complete remission and increased leak rate. Where is the balance in the complex treatment of rectal cancer?

Background: Neoadjuvant chemoradiation seems to become standard treatment for rectal cancer. Selection criteria varies from centre to centre, but confirmation of stage III disease results in preoperative treatment in most of them. Downstaging and higher resecability rate together with higher rate of sphincter preserving operations have been described. In some cases the complete remission rate is as high as 30%, however there is an associated rise in anastomotic leak rate.

Material and methods:. All patients admitted with rectal cancer underwent preoperative staging, including clinical assessment, and abdominal CT. In most of the cases endo rectal ultrasound was used as well. T3–4 tumor size and/or lymph node positivity determined the need for preoperative neoadjuvant chemoradiation. They received 50 to 54 Gy in fractions for 5 weeks and Carboplatin, 5FU, Ca folinat chemotherapy on the first and the fifth week of the treatment. After six weeks they underwent surgical intervention.

Results: 213 patients were admitted to our unit with the diagnosis of rectal cancer from 1. Oct. 1998 to 30. Jun. 2003. Male: female ratio 2 to 1. 73 (34.3%) of those have had preoperative chemoradiation. Need for diverting ileostomy was 72% in the chmeoradiation group and 24% in the rest. Anastomotic leak rate was 19% in the chemoradiation group and 9% in the rest. Downstaging was confirmed in 44 out of 73 (60%). 9 out of 44 (20.4%) responders showed complete remission. This represents 12.3% (9 out of 73) of all preoperatively treated patients.

Conclusions: Preoperative chemoradiation resulted in downstaging which made possible a higher rate of rectal resections. However it also induced a higher rate of anastomotic leak, which was subclinical in most of the cases due to the diverting ileostomy.