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Disseminated rectal cancer – the disease, which caused an unique treatment strategy

V.A.Aliev, Y.A. Barsukov.

Nowadays, as we can see, the indications for surgical treatment for patients with operable distance metastases are expended. In case with inoperable metastases the percent of surgical treatment go down. However, there is no well-defined treatment strategy for metastatic rectal cancer.

The frequency of local recurrence after surgical treatment in case with metastatic regional lymph nodes invasion (without distance metastases) is still so high (up to 35%) in 2-3 year after surgery. The introduction of preoperative radiotherapy along or combination with new scheme of chemotherapy with good surgical technique made it possible to achieve a good therapeutic pathomorphism, to reduce the frequency of local recurrence rate (up to 1-5%) and metastases.

For patients with disseminated rectal cancer, the combination of radiotherapy with brand-new scheme of chemotherapy can increase the tumor size and reduce the dissemination of tumor cells, which could extend the indications for sphincter-preserving operation. The addition of chemotherapy over a period of 2-3 months allows consolidate the effect after treatment, or in case with tumor progression – to base the cancellation of surgical treatment.

We designed a new original treatment scheme of neoadjuvant treatment for patients with disseminated rectal cancer [Patent for invention № 2453345 (RU) 20.06.2012].  The reason for the choice the type of a preoperative chemoradiotherapy scheme was the primary tumor dustribution. By the 2012-year 75 patients included in the study, all of theme underwent 3 courses of preoperative chemotherapy in combination of oxaliplatin with fluorouracil. The first course of chemotherapy was simultaneously combined with radiotherapy. 41 (54,7%) patients (T2-3NxM1) underwent 3 courses of chemotherapy in FOLFOX-6 regimen with simultaneous radiotherapy (5 Gy x 5 days up to 25 Gy) with two radiosensitizing drugs (local SHF hypothermia and polymeric composition with metronidazole 10 мг/м2). 34 (45,3%) patients (T4NxM1) underwent 3 courses of chemotherapy in XELOX regimen with radiotherapy (4 Gy - 3 times in a week during 21 days up to cumulative dose 36-40 Gy) with two radiosensitizing drugs.

Sphincter-preserving operations performed in 38 (63,3%) patients. R0-resection underwent 27(45%) patients, 15(55,5%) of them were performed simultaneously. After surgical treatment we also provide 6 courses of chemotherapy for consolidation effect. The severe drug toxicity, which would have to cancel treatment, wasn’t admitted. In 3 patients (4%) was reduced the dose of chemotherapy, in 12 patients (16%) the radio modifiers are not applied. We decide that in stage T4NxM1b for patient without complications from the primary tumor it acceptable to use only chemoradiotherapy (without surgery). After combined treatment were admitted the certain increase of 1 - year overall survival from 60 to 79% in comparison with those group of patients who firstly underwent primary tumor removal.

The brand-new treatment scheme of neoadjuvant chemoradiotherapy have an acceptable toxicity profile, could extended the indications for sphincter-preserving surgery and justify R0 resection for patients with good tumor response.

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