Hesketh P J, Bulger K N
Department of Medicine, Boston University School of Medicine, Massachusetts.
Adv Intern Med. 1991;36:219-47.
After nearly three decades of consistently disappointing adjuvant therapy trials in resectable colorectal cancer, recently emerging results offer some basis for cautious optimism. Adjuvant fluorouracil-containing regimens appear to confer a modest treatment benefit in completely resected colonic adenocarcinomas. The two most promising chemotherapy approaches at present appear to be the fluorouracil-levamisole and fluorouracil-leucovorin regimens. The optimal schedule and dose of these agents remains to be determined. Portal vein chemotherapy infusion studies have yielded promising but inconclusive results to date. As data from completed or ongoing large group studies become available, the role of this modality will be better clarified. In rectal cancer, adjuvant radiotherapy alone has a modest but consistent ability to reduce local recurrence without demonstrating any survival advantage. The optimal dose and sequencing of radiotherapy remains poorly defined. Two completed cooperative group studies strongly suggest that the optimal use of radiotherapy is in combination with chemotherapy. The independent role of chemotherapy in rectal cancer remains unclear. There is suggestive evidence that adjuvant chemotherapy is more effective with rectal cancer than with primaries arising proximal to the peritoneal reflection. Despite the large number of unresolved questions that remain, the following interim treatment recommendations can be made: 1. Patients with Dukes' B and C rectal and colonic adenocarcinomas should be entered into an appropriate adjuvant clinical trial when feasible. 2. Outside the setting of a protocol, there is a sound rationale to treat Dukes' B and C rectal cancer with combination chemotherapy and postoperative radiotherapy. The chemotherapy could consist of fluorouracil either alone or combined with leucovorin. 3. In more proximal colonic tumors (above the pelvic peritoneal reflection), recently described improvements in survival for patients with Dukes' B disease suggests that adjuvant therapy should be withheld in this group when not participating in a clinical study. Patients with Dukes' C tumors should receive fluorouracil-levamisole.
在可切除结肠癌的辅助治疗试验近三十年一直令人失望之后，最近出现的结果为谨慎乐观提供了一些依据。含氟尿嘧啶的辅助治疗方案似乎在完全切除的结肠腺癌中带来适度的治疗益处。目前最有前景的两种化疗方法似乎是氟尿嘧啶-左旋咪唑和氟尿嘧啶-亚叶酸方案。这些药物的最佳给药方案和剂量仍有待确定。门静脉化疗灌注研究迄今已产生了有前景但尚无定论的结果。随着已完成或正在进行的大型研究的数据可用，这种治疗方式的作用将得到更好的阐明。在直肠癌中，单纯辅助放疗在降低局部复发方面有适度但持续的能力，但未显示出任何生存优势。放疗的最佳剂量和顺序仍不清楚。两项已完成的协作组研究强烈表明，放疗的最佳使用方式是与化疗联合。化疗在直肠癌中的独立作用仍不清楚。有证据表明，辅助化疗对直肠癌比对腹膜反折近端的原发性肿瘤更有效。尽管仍有大量未解决的问题，但可提出以下临时治疗建议：1. 可行时，Dukes B期和C期的直肠和结肠腺癌患者应参加适当的辅助临床试验。2. 在没有临床试验方案的情况下，有充分的理由用联合化疗和术后放疗治疗Dukes B期和C期直肠癌。化疗可单独使用氟尿嘧啶或与亚叶酸联合使用。3. 在更近端的结肠肿瘤（盆腔腹膜反折以上）中，最近描述的Dukes B期疾病患者生存率的提高表明，不参加临床研究时，该组患者应不进行辅助治疗。Dukes C期肿瘤患者应接受氟尿嘧啶-左旋咪唑治疗。
