The outcomes of induction chemotherapy, followed by neoadjuvant chemoradiotherapy and surgery, in locally advanced rectal cancer, single institute experience
DOI:
https://doi.org/10.56056/Keywords:
Neoadjuvant, Outcomes, Rectal cancerAbstract
Background & objectives: Total Neoadjuvant Therapy represents the gold standard for treating locally advanced rectal cancer. We conducted this study to investigate the therapeutic implications of induction chemotherapy followed by neoadjuvant chemoradiotherapy & surgery in locally advanced rectal cancer, in terms of response & toxicity.
Methods: Our retrospective study analyzed data from 40 rectal cancer cases who received treatment between 2018 & 2023 at Rizgary Medical Oncology Center in Hawler, Kurdistan Regional Governorate, Iraq. Patients received induction chemotherapy, and after 3-4 weeks, re-staging was done to exclude metastases. Subsequently, neoadjuvant chemo-radiotherapy was administered, followed by another evaluation 3-4 weeks later to exclude metastases and assess treatment response. Finally, a Total Mesorectal Excision was performed. The study looked at outcomes like downstaging, pathological Complete Response, surgical resection margins, Disease-Free Survival, and Overall Survival, as well as side effects related to the treatment.
Results: Patients' ages ranged from 28 to 81 years old, with an average age of 50.5. After receiving the treatment, there was a 50% reduction in tumor size, and 12.5% of our patients achieved pathological Complete Response. While 75% of the cases showed free surgical margins, which was significantly associated with tumor relapse (p-value = 0.009). The 3-year Disease Free Survival was 50% and the 3-year Overall Survival was 90%, with a median follow-up of 23.5 months. Treatment-related toxicities varied from 2% to 12%, mostly in grades 2 and 3, and were appropriately managed.
Conclusions: Induction chemotherapy followed by neoadjuvant chemoradiotherapy, and surgery might be a good & safe way to treat locally advanced rectal cancer.
Downloads
References
1. Bray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2024;74(3):229‐263. doi:10.3322/caac.21834/
2. Ionescu VA, Gheorghe G, Bacalbasa N, Chiotoroiu AL, Diaconu C. Colorectal Cancer: From Risk Factors to Oncogenesis. Medicina (Kaunas). 2023;59(9):1646. doi:10.3390/medicina59091646/
3. Rodríguez-Luna MR, Guarneros-Zárate JE, Tueme-Izaguirre J. Total Mesorectal Excision, an erroneous anatomical term for the gold standard in rectal cancer treatment. Int J Surg. 2015;23(Pt A):97-100. doi: 10.1016/j.ijsu.2015.09.047/
4. Dahlberg M, Glimelius B, Påhlman L. Improved survival and reduction in local failure rates after preoperative radiotherapy: evidence for the generalizability of the results of Swedish Rectal Cancer Trial. Ann Surg. 1999;229(4):493-497. doi:10.1097/00000658-199904000-00007/
5. Sauer R, Becker H, Hohenberger W, Rödel C, Wittekind C, Fietkau R, et al. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med. 2004;351(17):1731-1740. doi:10.1056/NEJMoa040694/
6. Daprà V, Airoldi M, Bartolini M, Fazio R, Mondello G, Tronconi MC, et al. Total Neoadjuvant Treatment for Locally Advanced Rectal Cancer Patients: Where Do We Stand. Int J Mol Sci. 2023;24(15):12159. doi:10.3390/ijms241512159/
7. Benson AB, Venook AP, Al-Hawary MM, Arain MA, Chen YJ, Ciombor KK, et al. NCCN Guidelines Insights: Rectal Cancer, Version 6.2020. J Natl Compr Canc Netw. 2020;18(7):806-815. doi:10.6004/jnccn.2020.0032/
8. Sauer R, Liersch T, Merkel S, Fietkau R, Hohenberger W, Hess C, et al. Preoperative versus postoperative chemoradiotherapy for locally advanced rectal cancer: results of the German CAO/ARO/AIO-94 randomized phase III trial after a median follow-up of 11 years. J Clin Oncol. 2012;30(16):1926-1933. doi:10.1200/JCO.2011.40.1836/
9. National Comprehensive Cancer Network Guidelines. Rectal Cancer, Version 2. 2024. https://www.nccn.org/
10. Liu S, Jiang T, Xiao L, Yang S, Liu Q, Gao Y, et al. Total Neoadjuvant Therapy (TNT) versus Standard Neoadjuvant Chemoradiotherapy for Locally Advanced Rectal Cancer: A Systematic Review and Meta-Analysis. Oncologist. 2021;26(9): e1555-e1566. doi:10.1002/onco.13824/
11. Zhao Y, Zhu J, Yang B, Gao Q, Xu Y, Wei X, et al. Retrospective study of total neoadjuvant therapy for locally advanced rectal cancer. Future Oncol. 2022;18(6):691-700. doi:10.2217/fon-2021-0644/
12. Fan A, Zhao B, Vu P, Abbadessa B, Lopez N, Eisenstein S, et al. Increased Pathologic Downstaging with Induction versus Consolidation Chemotherapy in Patients with Locally Advanced Rectal Cancer Treated with Total Neoadjuvant Therapy-A National Cancer Database Analysis. J Clin Med. 2024;13(3):781. doi:10.3390/jcm13030781/
13. Marcellinaro R, Spoletini D, Grieco M, Avella P, Cappuccio M, Troiano R, et al. Colorectal Cancer: Current Updates and Future Perspectives. J Clin Med. 2023;13(1):40. doi:10.3390/jcm13010040/
14. Ibrahem S, Ahmed H, Zangana S. Trends in colorectal cancer in Iraq over two decades: incidence, mortality, topography and morphology. Ann Saudi Med. 2022;42(4):252-261. doi:10.5144/0256-4947.2022.252/
15. Siegel RL, Wagle NS, Cercek A, Smith RA, Jemal A. Colorectal cancer statistics, 2023. CA Cancer J Clin. 2023;73(3):233-254. doi:10.3322/caac.21772/
16. Glynne-Jones R, Wyrwicz L, Tiret E, Brown G, Rödel C, Cervantes A, et al. Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2018;29(Suppl 4): iv263. doi:10.1093/annonc/mdy161/
17. Baek JH, Baek DW, Kang BW, Kim HJ, Park SY, Park JS, et al. Prognostic Impact of the Neoadjuvant Rectal Score as Compared with the Tumor Regression Grade and Yield Pathologic TNM Stage in Patients with Locally Advanced Rectal Cancer After Neoadjuvant Chemoradiotherapy. In Vivo. 2020;34(4):1993-1999. doi:10.21873/invivo.11997/
18. Zhang JW, Cai Y, Xie XY, Hu HB, Ling JY, Wu ZH, et al. Nomogram for predicting pathological complete response and tumor downstaging in patients with locally advanced rectal cancer on the basis of a randomized clinical trial. Gastroenterol Rep (Oxf). 2020;8(3):234-241. doi:10.1093/gastro/goz073/
19. Gérard JP, Conroy T, Bonnetain F, Bouché O, Chapet O, Closon-Dejardin MT, et al. Preoperative radiotherapy with or without concurrent fluorouracil and leucovorin in T3-4 rectal cancers: results of FFCD 9203. J Clin Oncol. 2006;24(28):4620-4625. doi:10.1200/JCO.2006.06.7629/
20. Bosset JF, Collette L, Calais G, Mineur L, Maingon P, Radosevic-Jelic L, et al. Chemotherapy with preoperative radiotherapy in rectal. N Engl J Med. 2006 Sep 14;355(11):1114-23. doi:10.1056/NEJMoa060829/
21. Jin J, Tang Y, Liu S, Zhu Y, Wang W, Li G, et al. Short-term radiotherapy plus chemotherapy versus long-term chemoradiotherapy in locally advanced rectal cancer (STELLAR): A planned interim analysis. Ann. Oncol. 2018 Oct 1;29: viii167. doi:10.1093/annonc/mdy281.043/
22. Fernandez-Martos C, Garcia-Albeniz X, Pericay C, Maurel J, Aparicio J, Montagut C, et al. Chemoradiation, surgery and adjuvant chemotherapy versus induction chemotherapy followed by chemoradiation and surgery: long-term results of the Spanish GCR-3 phase II randomized trial. Ann Oncol. 2015;26(8):1722-1728. doi:10.1093/annonc/mdv223/
23. Bujko K, Polish Colorectal Study Group. Neoadjuvant chemoradiation for fixed cT3 or cT4 rectal cancer: Results of a Polish II multicentre phase III study. J. Clin. Oncol. 2016; 34(4): 489-489. doi.org/10.1200/jco.2016.34.4_suppl.489/
24. Roh MS, Colangelo LH, O'Connell MJ, Yothers G, Deutsch M, Allegra CJ, et al. Preoperative multimodality therapy improves disease-free survival in patients with carcinoma of the rectum: NSABP R-03. J Clin Oncol. 2009;27(31):5124-5130. doi:10.1200/JCO.2009.22.0467/
25. Weiser MR, Zhang Z, Schrag D. Locally advanced rectal cancer: time for precision therapeutics. ASCO Publications. 2015 Jan 1;35(1): e192-6.doi.org/10.14694/EdBook_AM.2015.35. e192/
Downloads
Published
Issue
Section
License
Copyright (c) 2026 Mohammed Akram Abas, Jangi Shawkat Muhialdin, Ahmed Sami Kamal
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
The copyright on any article published in AMJ (The Scientific Journal of Kurdistan Higher Council of Medical Specialties )is retained by the author(s) in agreement with the Creative Commons Attribution Non-Commercial ShareAlike License (CC BY-NC-SA 4.0)
