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Radiotherapy in the Treatment of Resectable Rectal Adenocarcinoma

Mendenhall, William M. MD*; Zlotecki, Robert A. MD, PhD*; Snead, Felicia E. MD*; George, Thomas J. Jr MD; Marsh, Robert D. MD; Mendenhall, Charles M. MD; Rout, W Robert MD§

American Journal of Clinical Oncology: December 2009 - Volume 32 - Issue 6 - p 629-638
doi: 10.1097/COC.0b013e31817ff8e4
Review Article

Abstract: The goal of treatment is to cure whereas maintaining sphincter function and minimizing toxicity. Although the mainstay of the treatment is surgery, radiotherapy (RT) is used in a substantial proportion of patients depending on the location and extent of the tumor. The aim of this article is to discuss the role of RT in patients with resectable rectal adenocarcinoma. This article is a review of the pertinent literature.

Results show that patients with T1N0 exophytic, well to moderately differentiated, mobile tumors ≤3 cm in diameter may be treated with either transanal excision or endocavitary RT. The probability of cure with either approach is approximately 80% to 90% and depends on selection criteria. The advantages of endocavitary RT are that it is an outpatient procedure requiring, at most, local anesthesia and is suitable for elderly, infirm patients. The disadvantage is that few of these treatment units are available. Patients who experience a local-regional recurrence may be surgically salvaged.

Patients who undergo transanal excision and have unfavorable pathologic findings including equivocal or close margins, poor differentiation, invasion of the muscularis propria, and/or endothelial-lined space invasion have a high risk of local-regional recurrence after surgery alone. The addition of postoperative RT improves the likelihood of cure from 85% to 90%. Patients presenting with unfavorable tumors that are borderline resectable with a transanal excision may be downstaged with preoperative RT and rendered suitable for a wide local excision. The addition of concomitant chemotherapy probably enhances downstaging and may improve the likelihood of sphincter preservation.

Patients with T3 and/or N1 rectal cancers have a relatively high probability of local-regional recurrence after surgery alone. Preoperative RT and postoperative RT combined with adjuvant chemotherapy have been shown to significantly reduce the risk of local-regional recurrence and improve survival. Whether preoperative RT alone or combined with chemotherapy is more efficacious than postoperative chemoradiation remains unclear.

Endocavitary RT or transanal excision is suitable for patients with T1N0 cancers. Depending on tumor location and extent, adjuvant RT may improve the probability of local-regional control and survival for patients with locally advanced rectal adenocarcinomas.

From the *Department of Radiation Oncology and †Division of Hematology and Oncology, University of Florida College of Medicine, Gainesville, Florida; ‡Department of Radiation Oncology, Phoebe Putney Memorial Hospital, Albany, Georgia; §Department of Surgery, University of Florida College of Medicine, Gainesville, Florida; and ¶Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida.

Reprints: William M. Mendenhall, MD, Department of Radiation Oncology, University of Florida Health Science Center, P. O. Box 100385, Gainesville, FL 32610-0385. E-mail

© 2009 Lippincott Williams & Wilkins, Inc.