Department of Radiotherapy and Oncology, University of Frankfurt, Frankfurt, Germany.
Dig Dis. 2012;30 Suppl 2:102-8. doi: 10.1159/000342038. Epub 2012 Nov 23.
There are two general approaches to preoperative radiotherapy (RT) in rectal cancer: short-course (25 Gy in 5 fractions) radiation with immediate surgery and long-course 5-fluorouracil (5-FU)-based chemoradiotherapy (CRT; 50.4 Gy in 28 fractions) with surgery scheduled 6-8 weeks thereafter. While it is clear that downsizing and downstaging effects are more pronounced with long-course CRT and delayed surgery, a Polish randomized trial and, more recently, an Australian phase III trial demonstrated no significant differences in long-term oncologic outcomes and late toxicity rates between either preoperative concept. Ongoing studies currently address short-course preoperative RT with a longer interval to surgery (Stockholm III trial), and short-course RT with sequential combination chemotherapy in patients with synchronous distant metastasis. With respect to the long-course CRT approach, newer-generation chemotherapeutics as well as molecularly targeted agents have been tested within phase I-III studies, both as induction/adjuvant chemotherapy as well as during concomitant CRT. Evidently, the monolithic approaches to either apply the same schedule of preoperative 5-FU-based CRT to all patients with TNM stage II/III rectal cancer or to give preoperative short-course RT for all patients with resectable rectal cancer irrespective of tumor stage and location need to be questioned. The inclusion of different multimodal treatments into the surgical oncological concept, adapted to tumor location, stage, and individual patient risk factors and preferences is upcoming. Clearly, future developments will aim at identifying and selecting patients for ideal treatment alternatives.
术前放疗（RT）在直肠癌中有两种一般方法：短程（25Gy，5 次分割）放疗加立即手术和长程 5-氟尿嘧啶（5-FU）为基础的放化疗（CRT；50.4Gy，28 次分割），随后 6-8 周进行手术。虽然长程 CRT 和延迟手术的缩瘤和降期效果更为明显，但波兰随机试验以及最近的澳大利亚 III 期试验表明，两种术前方案在长期肿瘤学结果和晚期毒性发生率方面没有显著差异。目前正在进行的研究主要涉及手术间隔时间更长的短程术前 RT（斯德哥尔摩 III 期试验），以及伴有同步远处转移的患者中短程 RT 与序贯联合化疗。关于长程 CRT 方法，新一代化疗药物以及分子靶向药物已在 I-III 期研究中进行了测试，包括诱导/辅助化疗以及同期 CRT。显然，要么对所有 II/III 期 TNM 直肠癌患者应用相同的术前 5-FU 为基础的 CRT 方案，要么对所有可切除直肠癌患者应用术前短程 RT，而不考虑肿瘤分期和位置的单一方法都需要受到质疑。将不同的多模式治疗纳入手术肿瘤学概念中，根据肿瘤位置、分期和个体患者的风险因素和偏好进行调整即将到来。显然，未来的发展将旨在确定和选择理想治疗选择的患者。
