Preoperative chemoradiation for rectal cancer: kudos and a caution.

man rectal cancer trial (CAO/ ARO/AIO-94) now made public, we have a prospective randomized study that has confirmed what those treating rectal cancer have long suspected: preoperative chemoradiation provides a significant advantage over postoperative therapy in terms of pelvic control and sphincter preservation. Full-course radiation therapy with 5-fluorouracil-based chemotherapy, similar to that employed in the German trial, provides clinical complete response (clinical CR) rates of 19%– 38% and pathologic CR rates of 8%– 30% (Table 1). Such therapy, as distinct from the short-course preoperative radiotherapy that came into wide use after the Swedish rectal cancer trial, can provide for significant downstaging of bulky and nonresectable rectal cancers. With fullcourse therapy, 60%–90% of clinically nonresectable tumours can be made resectable. The apparent success of preoperative chemoradiation has led some to ask whether surgery is necessary after a CR. For example, Rossi and colleagues reported on a prospective trial of 16 patients with low infiltrative rectal cancers who were treated with preoperative chemoradiation. The 6 patients who achieved clinical CR were followed without surgery by monthly proctoscopy. After 34 months of follow-up only 1 patient remained free of disease; the other 5 developed a local recurrence after periods of 1–10 months. The authors concluded that surgery was necessary in view of the temporary nature of most clinical CRs. Nakagawa and associates provided data from a series of 104 patients with midor low-rectal adenocarcinomas who were treated with full-course chemoradiation. The 10 patients who sustained clinical CR (confirmed by proctoscopic biopsy) were followed by clinical and proctoscopic examinations every 3 months. Of these patients, 8 (80%) developed recurrent cancer within a median follow-up period of 6 months, of whom 4 were salvaged by surgical intervention. Only 2 patients sustained CRs and remained disease-free at 37.5 and 58 months. These authors likewise concluded that patients with CRs should not go without prompt surgery. Interestingly, a similar study led Habr-Gama and coworkers to a very different conclusion. They reported on 38 patients with low rectal cancers who sustained an initial clinical CR (confirmed by physical exam, biopsy, transrectal ultrasound and pelvic CT) with preoperative chemoradiation without immediate surgery. Of these patients, 8 (21%) required resection for recurrent disease within 3–14 months of chemoradiation. Nonetheless, 30 patients remained disease-free after a median follow-up of 36 months. These authors concluded that it was acceptable to delay surgical management of patients with CRs. They further suggested that salvage surgery could be done at the time of local recurrence without detriment to the patients. Habr-Gama and colleagues’ study raises a number of issues, such as the accuracy of clinical staging. This par-