Bachet J-B, Rougier P, de Gramont A, André T
Faculté de Médecine PIFO, UFR Paris Ile-de-France-Ouest, Université de Versailles-Saint-Quentin-en-Yvelines, 9 Boulevard d'Alembert, Bâtiment François-Rabelais, 78280 Guyancourt, France.
Bull Cancer. 2010 Jan;97(1):107-22. doi: 10.1684/bdc.2009.1010.
Adenocarcinoma of the rectum represents about a third of cases of colorectal cancer, with an annual incidence of 12,000 cases in France. On the contrary of colon cancer, the benefice of adjuvant chemotherapy in rectal cancer has not been definitively proved, more because this question was assessed in few recent studies than because negative results. Preoperative radiochemotherapy is now the reference treatment for mid and lower rectal cancers, and allow to increase the local control without improvement of progression free survival and overall survival. The data of the "historical studies" of adjuvant treatment in rectal cancer published before 1990, of the meta-analysis of adjuvant trials in rectal cancer and of the QUASAR study suggest that adjuvant chemotherapy with fluoropyrimidines (intravenous or oral), in absence of pre-operative treatment, decrease the risk of metastatic relapse after curative surgery for a rectal cancer of stage II or III. This benefice seems similar to the one observed in colon cancer. In the EORTC radiotherapy group trial 22921, an adjuvant chemotherapy with 5-fluorouracil and low dose of leucovorin was not associated with a significantly improvement of overall survival but, despite the fact that only 42.9% of patients received all planed cycles, the progression free survival was increased (not significantly) in groups receiving adjuvant chemotherapy. The French recommendations are to discuss the indication of adjuvant chemotherapy by fluoropyrimidines in cases of stage III rectal cancer on histopathologic reports and no chemotherapy in case of stade II. Despite the fact that none study have assessed a combination of fluoropyrimidines and oxaliplatin in adjuvant setting in rectal cancer, like in colon cancer, the Folfox4, modified Folfox6 or Xelox regimens are valid options in stage III (experts opinion). In cases of pathologic complete remission or in absence of involved nodes, the benefice of adjuvant chemotherapy is not assessed. In all cases, the decision of adjuvant chemotherapy has to be taken during a multidisciplinary meeting. The interest of a combination of fluoropyrimidine and oxaliplatin is assessed in currently adjuvant trials (PETTAC-6 and CAO/ARO/AIO-04), and future trials will assess the interest of neoadjuvant chemotherapy.
直肠癌约占结直肠癌病例的三分之一，在法国每年有12,000例发病。与结肠癌相反，直肠癌辅助化疗的益处尚未得到明确证实，更多是因为近期相关研究较少，而非结果为阴性。术前放化疗目前是中低位直肠癌的标准治疗方法，可提高局部控制率，但对无进展生存期和总生存期并无改善。1990年前发表的直肠癌辅助治疗“历史研究”数据、直肠癌辅助试验的荟萃分析以及QUASAR研究表明，对于II期或III期直肠癌，在未进行术前治疗的情况下，使用氟嘧啶（静脉或口服）进行辅助化疗可降低根治性手术后发生转移复发的风险。这种益处似乎与结肠癌中观察到的相似。在欧洲癌症研究与治疗组织（EORTC）放疗组试验22921中，5-氟尿嘧啶与低剂量亚叶酸钙的辅助化疗未显著改善总生存期，尽管只有42.9%的患者接受了所有计划疗程，但接受辅助化疗的组中无进展生存期有所增加（未达显著水平）。法国的建议是，根据组织病理学报告，对III期直肠癌病例讨论氟嘧啶辅助化疗的适应证，II期则不进行化疗。尽管尚无研究评估氟嘧啶与奥沙利铂联合用于直肠癌辅助治疗的情况，如同结肠癌那样，但Folfox4、改良Folfox6或Xelox方案在III期是有效的选择（专家意见）。对于病理完全缓解或无淋巴结受累的情况，不评估辅助化疗的益处。在所有情况下，辅助化疗的决策都应在多学科会议上做出。目前的辅助试验（PETTAC-6和CAO/ARO/AIO-04）正在评估氟嘧啶与奥沙利铂联合使用的益处，未来的试验将评估新辅助化疗的益处。
