Rödel C, Hohenberger W, Sauer R
Strahlentherapeutische Klinik und Poliklinik, Universität Erlangen-Nürnberg.
Strahlenther Onkol. 1998 Oct;174(10):497-504. doi: 10.1007/BF03038981.
The Consensus Conference of the German Cancer Society (CAO/AIO/ARO, 1.7.1998) has recently updated recommendations for patients with rectal cancer. Instead of a former reservation regarding the indication of adjuvant therapy for rectal cancer the actual version of the consensus particularly emphasizes the role of postoperative radiochemotherapy for stage-II/III tumors. This article reviews the most recent and ongoing trials of adjuvant and neoadjuvant therapy of rectal cancer.
To avoid local recurrence is the most important aspect in the primary treatment of rectal cancer. In some series, e.g. the results of the Surgical Department of the University of Erlangen, a significant correlation between local control and survival was noted. The final results of the Swedish Rectal Cancer Trial with 1168 randomized patients not only confirmed the potential of radiotherapy to reduce local recurrence rate, but also demonstrated a significant survival advantage for patients receiving short-course preoperative radiation therapy. Postoperative combination therapy is usual in the United States and in most European countries since the publication of two randomized trials of the Gastrointestinal Tumor Study Group (GITSG) and the North Central Cancer Treatment Group (NCCTG). The survival advantage resulting from an adjuvant radiotherapy with conventional doses and concurrent fluorouracil-based chemotherapy as compared to surgery alone was recently confirmed in a Norwegian trial. Protracted venous 5-fluorouracil infusion should further improve treatment results. Numerous phase-II studies have demonstrated the efficacy of preoperative radiochemotherapy with high rates of pathological response. Thus, neoadjuvant radiochemotherapy is recommended for patients with locally advanced tumor primarily not amenable to curative surgery. Prospective randomized trials are ongoing to clarify the role of preoperative versus postoperative combined treatment for patients with resectable rectal cancer.
Radiochemotherapy for rectal cancer is recommended as standard treatment outside clinical trials for stage II/III patients after curative treatment and for patients with T4-tumor prior to surgery. The optimal use of chemotherapy and the sequence of treatment modalities remains to be elucidated.
德国癌症协会共识会议（CAO/AIO/ARO，1998年7月1日）最近更新了直肠癌患者的治疗建议。与之前对直肠癌辅助治疗指征的保留态度不同，当前共识版本特别强调了术后放化疗在II/III期肿瘤治疗中的作用。本文回顾了直肠癌辅助治疗和新辅助治疗的最新及正在进行的试验。
避免局部复发是直肠癌初始治疗中最重要的方面。在一些系列研究中，例如埃尔朗根大学外科的研究结果，发现局部控制与生存率之间存在显著相关性。瑞典直肠癌试验对1168例随机患者的最终结果不仅证实了放疗降低局部复发率的潜力，还表明接受短程术前放疗的患者具有显著的生存优势。自胃肠道肿瘤研究组（GITSG）和北中部癌症治疗组（NCCTG）的两项随机试验发表以来，术后联合治疗在美国和大多数欧洲国家已成为常规治疗。最近在一项挪威试验中证实，与单纯手术相比，采用常规剂量辅助放疗并同时进行基于氟尿嘧啶的化疗可提高生存率。持续静脉输注5-氟尿嘧啶应能进一步改善治疗效果。大量II期研究已证明术前放化疗具有较高的病理缓解率，疗效显著。因此，对于局部晚期肿瘤且主要不宜进行根治性手术的患者，推荐新辅助放化疗。目前正在进行前瞻性随机试验，以明确术前与术后联合治疗对可切除直肠癌患者的作用。
对于II/III期患者，在根治性治疗后以及T4期肿瘤患者术前，推荐将直肠癌放化疗作为临床试验之外的标准治疗。化疗的最佳应用方式和治疗模式的顺序仍有待阐明。
