Desley van Zoggel

Improved outcomes for responders to induction chemotherapy 49 CHAPTER 3 Although patients with a pCR have excellent oncological outcomes, patients with a good response (Mandard 2–3) also showed improved outcomes. There have been no previous reports about the prognostic value of response on neoadjuvant treatment in patients with locally recurrent rectal cancer. There have been several studies assessing the prognostic value of tumour regression in patients with LARC. Most studies showed that the extent of response was a significant independent prognostic factor for longterm oncological outcomes, which supports the findings in our study.31–35 Together with the observation that there is a significant linear relation between the degree of response and the R0 resection rate, this underlines the necessity of adequate neoadjuvant treatment in patients with LRRC. Potential bias caused by whether or not patients received neoadjuvant treatment for the primary tumour was investigated by chi-square (data not shown) and showed no correlation, suggesting that induction chemotherapy is sufficient for tumour downstaging regardless of prior treatment. Future research to establish whether a correlation exists between radiological and pathologic response could help to identify patients in whom a different treatment approached may be justified. The R0 resection rate in this study was 63 percent, which is consistent compared with the findings in the literature after treatment with neoadjuvant chemoradiotherapy alone. However, in this study 21 percent of the included patients were considered irresectable at primary staging. For patients with synchronous metastases the story seems different. LRRC patients with synchronous metastases clearly have a more aggressive biological behaviour of their tumour, which is characterized by rapid progression and decreased disease-free survival. For these patients, a different approach and different counselling may be indicated. This study is limited by its retrospective character. Many patients underwent their preoperative treatment in the referring hospitals and therefore data on toxicity of treatment are not complete. Besides, drop-out rates during neoadjuvant treatment were not available as progressive disease under induction chemotherapymay have occurred and thesepatientshaveneverbeenreferredback for surgery.Nevertheless, theavailable data on toxicity implicates that treatment waswell tolerated. Furthermore, neoadjuvant treatment regimen combining induction chemotherapy with chemoradiotherapy resulted inmajor postoperativemorbidity in 32 percent of the patients. This percentage is comparable to the literature, suggesting that the addition of induction chemotherapy does not lead tomore postoperative complications when comparing it with the current standard treatment of neoadjuvant chemoradiotherapy.4,36