Preoperative Long Course Chemoirradiation in a Developing Country for Rectal Carcinoma: Kuala Lumpur Hospital Experience

Background: The use of preoperative chemoirradiation is the commonest treatment strategy employedin Malaysia for locally advanced rectal cancer. We need to determine the local control and survival rates forcomparison with established rates in the literature. Materials and
Methods: This retrospective study analyzedall newly diagnosed patients with rectal adenocarcinoma who underwent long course preoperative radiotherapy(RT) at the Department of Radiotherapy and Oncology, Kuala Lumpur Hospital (HKL) between 1st January2004 and 31st December 2010. The aim of the study was to determine the radiological response post radiotherapy,pathological response including circumferential resection margin (CRM) status, 3 years local control, 3 yearsoverall survival (OS) and 3 years disease free survival (DFS). Statistical analysis was performed using the SPSSsoftware. Kaplan-Meier and log rank analysis were used to determine survival outcomes.
Results: A total of 507patients with rectal cancer underwent RT at HKL. Sixty seven who underwent long course preoperative RT wereeligible for this study. The median age at diagnosis was 60 years old with a range of 26-78 years. The mediantumour location was 6 cm from the anal verge. Most patients had suspicion of mesorectum involvement (95.5%)while 28.4% of patients had enlarged pelvic nodes on staging CT scan. All patients underwent preoperativechemo-irradiation except for five who had preoperative RT alone. Only 38 patients underwent definitivesurgery (56.7%). Five patients were deemed to be inoperable radiologically and 3 patients were found to haveunresectable disease intraoperatively. The remaining 21 patients defaulted surgery (31.3%). The median timefrom completion of RT to surgery was 8 weeks (range 5.6 to 29.4 weeks). Fifteen patients (39.5%) had surgerymore than 8 weeks after completion of RT. Complete pathological response was noted in 4 patients (10.5%).The pathological CRM positive rate after RT was 18.4%. With a median follow-up of 38.8 months, the 3 yearlocal control rate was 67%. The 3 years rate for CRM positive (<2 mm), CRM clear (>2 mm) and pCR groupswere 0%, 88.1% and 100% respectively (p-value of 0.007). The 3 year OS and DFS were 57.3% and 44.8%respectively.
Conclusions: In conclusion, the approach of long course preoperative chemoirradiation for rectalcancer needs to be re-examined in our local setting. The high rate of local recurrence is worrying and is mainlydue to patient defaulting post-preoperative chemoirradiation or delayed definitive surgery.