Desley van Zoggel

Induction chemotherapy in locally recurrent rectal cancer 21 CHAPTER 2 Introduction Despite better preoperative and surgical treatment of rectal cancer, the incidence of locally recurrent rectal cancer remains approximately 5–10 percent.1 Unlike primary rectal cancer, local recurrence is not confined to a well-defined surgical compartment, and multicompartment exenterative procedures are often required to achieve clear resection margins.2–4 Preoperative treatment is used to downsize the tumour and facilitate surgical resection. However, because most patients have received preoperative (chemo)radiotherapy for their primary rectal cancer, the possible modalities in recurrent disease are limited. Whether these patients can be reirradiated safely is still debated.5 Despite the fact that chemoradiation therapy (CRRT) cannot be considered standard therapy in the management of patientswith previously irradiated locally recurrent rectal cancer, it has beendemonstrated6–9 that reirradiationwitha limiteddoseof 30–39Gyandconcomitant chemotherapy can be applied safely and effectively in locally recurrent disease. Even after reirradiation, incomplete resection remains a problem in a significant number of patients. The most important positive prognostic factor for recurrent rectal cancer appears to be radical resection with clear margins (R0).4,10,11 Early development of metastatic disease is quite commonwhen local recurrence has occurred.12 Even after successful treatment of local recurrence, development of systemic disease remains the principal cause of death.13 This finding indicates the importance of administering systemic chemotherapy early in the treatment. The use of induction chemotherapy (ICT) as part of the preoperative management of patients with locally recurrent rectal cancer may offer several advantages. First, systemic treatment might improve resectability by a significant downsizing and downstaging effect, as shown in primary colorectal cancer.14,15 Second, ICT may lead to an increased rate of pathological complete response (pCR) and thus possibly better overall survival. Finally, it might prevent early metastatic disease or offer the best palliative treatment in the meantime, and prevent extensive surgical morbidity.