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Tailored Treatment Strategy for Locally Advanced Rectal Carcinoma Based on the Tumor Response to Induction Chemotherapy: Preliminary Results of the French Phase II Multicenter GRECCAR4 Trial

Rouanet, Philippe M.D., Ph.D.1; Rullier, Eric M.D., Ph.D.2; Lelong, Bernard M.D.3; Maingon, Philippe M.D., Ph.D.4; Tuech, Jean-Jacques M.D., Ph.D.5; Pezet, Denis M.D.6; Castan, Florence M.Sc.1; Nougaret, Stéphanie M.D., Ph.D.1and the GRECCAR Study Group

Diseases of the Colon & Rectum: July 2017 - Volume 60 - Issue 7 - p 653–663
doi: 10.1097/DCR.0000000000000849
Original Contributions: Colorectal/Anal Neoplasia
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BACKGROUND: Preoperative radiochemotherapy and total mesorectal excision are the standard-of-care for locally advanced rectal carcinoma, but some patients could be over- or undertreated.

OBJECTIVE: This study aimed to assess the feasibility of radiochemotherapy tailored based on the tumor response to induction chemotherapy (FOLFIRINOX) to obtain a minimum R0 resection rate of 90% in the 4 arms of the study.

DESIGN: This study is a multicenter randomized trial (NCT01333709).

SETTING: This study was conducted at 16 French cancer specialty centers.

PATIENTS: Two hundred six patients with locally advanced rectal carcinoma were enrolled between 2011 and 2014.

INTERVENTIONS: Good responders (≥75% tumor volume reduction) were randomly assigned to immediate surgery (arm A) or standard radiochemotherapy (Cap 50: 50 Gy irradiation and 1600 mg/m2 oral capecitabine daily) plus surgery (arm B). Poor responders were randomly assigned to Cap 50 (arm C) or intensive radiochemotherapy (Cap 60, 60 Gy irradiation, arm D) before surgery.

OUTCOME MEASURES: The primary end point was a R0 resection rate (circumferential resection margin >1 mm).

STATISTICAL CONSIDERATIONS: The experimental strategies were to be considered effective if at least 28 successes (R0 resection) among 31 patients in each arm of stratum I and 34 successes among 40 patients in each arm of stratum II were reported (Simon 2-stage design).

RESULTS: After induction treatment (good compliance), 194 patients were classified as good (n = 30, 15%) or poor (n = 164, 85%) responders who were included in arms A and B (16 and 14 patients) and arms C and D (113 and 51 patients). The trial was prematurely stopped because of low accrual in arms A and B and recruitment completion in arms C and D. Data from 133 randomly assigned patients were analyzed: 11, 19, 52, and 51 patients in arms A, B, C, and D. Good responders had smaller tumors than poor responders (23 cm3 vs 45 cm3; p < 0.001). The surgical procedure was similar among groups. The R0 resection rates [90% CI] were 100% [70–100], 100% [85–100], 83% [72–91], and 88% [77–95]. Among the first 40 patients, 34 successes were reported in arms C and D (85% R0 resection rate). The circumferential resection margin ≤1 rates were 0%, 0%, 12%, and 5% in arms A, B, C, and D. The rate of transformation from positive to negative circumferential resection margin was 93%.

LIMITATIONS: There was low accrual in arms A and B.

CONCLUSION: Tailoring preoperative radiochemotherapy based on the induction treatment response appears safe for poor responders and promising for good responders. Long-term clinical results are needed to confirm its efficacy. See Video Abstract at

Supplemental Digital Content is available in the text.

1 Institut régional du Cancer de Montpellier (ICM), Montpellier, France

2 Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France

3 Institut Paoli-Calmettes, Marseille, France

4 Centre Georges François Leclerc, Dijon, France

5 Centre Hospitalier Universitaire de Rouen, Rouen, France

6 Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML and PDF versions of this article on the journal’s Web site (

Funding/Support: This work was supported by the French National Cancer Institute (INCa). Grant INCa-DGOS_5506: PHRC-K 2012–112.

Financial Disclosure: None reported.

Presented at the meeting of the American Society of Colon and Rectal Surgeons, Los Angeles, CA, April 30 to May 4, 2016.

Correspondence: Philippe Rouanet, M.D., Ph.D., Institut régional du Cancer de Montpellier (ICM), 208 rue des Apothicaires, 34298 Montpellier, France. E-mail:

© 2017 The American Society of Colon and Rectal Surgeons