rectal cancer : other therapies

Question 1

Aim of neo/adjuvant therapies

Answer 1

-for Operable disease – reduces local relapse rates
- for when (CRM) is involved/threatened – improved rates of R0 resection and local control
-for Inoperable disease (baseline) – improved rates of R0 resection, local control, and cancer-specific survival

Question 2

Total Neoadjuvant Therapy (TNT) before surgery

Answer 2

-FOLFOX—>LCCRT (5FU) or SCRT
-LCCRT (5FU)—>FOLFOX(12-16 weeks)
-SCRT—>FOLFOX (12-16 weeks)

Question 3

Why can’t chemo be given concurrently with SCRT

Answer 3

unsuitable for patients with inflammatory bowel disease and/or history of bowel obstruction

Question 4

Why use RT?

Answer 4

Reduce the risk of local recurrence
◦ Involvement of the circumferential margin
◦ Lymph node status
◦ Extramural venous invasion

Question 5

why use Neoadjuvant RT

Answer 5

◦ Induce tumour response prior to Sx
◦ Better definition of the target
◦ less small bowel toxicity as bowel adhesions more common after Sx

Question 6

Stage I: T1 or 2 N0 M0
Primary tx:

Answer 6

-Local excision
-APR or sphincter sparing

Question 7

Stage I: T1 or 2 N0 M0

Answer 7

-pT1-2 N0 with no high risk factors=Observation
-T1-2 with high risk factors=CRT

Question 8

High Risk Features:

Answer 8

*+ve margin
*LVI
*Poorly diff
*Invasion into the lower ⅓ of submucosa

Question 9

Locally advanced disease=

Answer 9

T3-4, node-negative (N0) or
node positive disease without distant metastasis (T any;N1-2M0)

Question 10

Standard treatment for patients for CRM Clear: Greater than 1-2mm from MRF

NEOADJUVANT

Answer 10

LCCRT( infusional 5-FuP)
Or
SCRT

Question 11

Standard treatment for patients for CRM Clear: Greater than 1-2mm from MRF

PRIMARY TREATMENT

Answer 11

a)Transabdominal resection
Or
b)Resection contraindicated

Question 12

Standard treatment for patients for CRM Clear: Greater than 1-2mm from MRF

Adjuvant treatment

Answer 12

IF:
a)folfox then surveillance
B) systemic therapy

Question 13

Standard treatment for patients for CRM Less than 1mm from MRF
additional therapies

Answer 13

Consolidation:
Chemotherapy for 12-16 weeks (after LCCRT OR SCRT)

induction: same but before

Question 14

Rationale for TNT

Answer 14

Significant improvement in:
*Overall pathologic complete response rate
* Disease-free survival
* Distant metastasis-free survival
*Overall survival

Question 15

LCCRT vs SCRT in terms of down-staging

Answer 15

-LCCRT is preferred for locally advanced tumours as ‘downstaging’ needed to ↓ chance of a +CRM or
↑ sphincter preservation

-The lesser ‘downstaging’ effect of SCRT may now be
better overcome with a longer delay to surgery or pre-operative/induction chemotherapy (i.e. TNT approach)

Question 16

LCCRT vs SCRT
pt2
its preferred to administer CRT in the pre-operative setting because

Answer 16

improvement in locoregional control,
sphincter preservation,
reduced acute and late toxicity

Question 17

Rationale for pre- or post-op concurrent chemo:

Answer 17

Ø Increases radiosensitivity
Ø Systemic control of disease
Ø Increased pCR and sphincter preservation

Question 18

Oligometastatic Disease M1 Resectable disease CLEAR CRM

Answer 18

Chemo —>RT (25/5#) or C (5FU )/Pelvic RT—> Resection, if possible

Question 19

Oligometastatic Disease M1 Resectable disease INVOLVED CRM

Answer 19

-Chemo (FOLFOX) then C (5FU) /RT (50.4/28#)
-RT (25/5#) or C (5FU )/Pelvic RT then Chemo (FOLFOX)

Question 20

Oligometastatic Disease M1 Unresectable disease

Answer 20

Chemo then if resectable RT (25/5#) or C (5FU )/Pelvic RT THEN RESECT
Chemo then if unresectable then Systematic Tx

Question 21

Unresectable?

Answer 21

-Tumour involving or extending beyond MRF
-Tumour within 1-2mm of MRF
-Involving nodes beyond MRF
-Invasion of pelvic organs