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Management of locally advanced rectal cancer has long been addressed by a multimodal approach incorporating radiotherapy, chemotherapy and surgery. The optimal sequencing of such modalities have been subject to many studies. The current standard for management of LARC has long been established to be the use of neoadjuvant concurrent chemoradiation followed by surgery and adjuvant flouropyrimidine based chemotherapy.
However after the aggressive treatment with chemoradiotherapy and surgery many patients aren’t able to complete their full course of adjuvant therapy. The introduction of the Total Neoadjuvant Therapy aimed at administrating the full course of systemic treatment in the neoadjuvant setting aiming at initial down staging of the primary tumor, less toxicity profile and early treatment of micro metastatic disease.
Patients demonstrated high compliance to induction chemotherapy CapeOx (97%) which is a high rate, especially when compared with previous studies’ findings regarding the ability to complete the full course of systemic chemotherapy in the adjuvant setting.
Grade 3 or more toxicity was encountered in 19.9% after induction CapeOx includind diarrhea and vomiting and in 10.3% during CCRTH being diarrhea and cystitis.Regarding radiological response, the objective response rate after induction chemotherapy was 55.9% and further increased to 75.9% after the CCRTH. With symptomatic improvement in more than half of the patients (65.7%) after the induction chemotherapy.
Patients older than 50 years and those with clinically T3 tumors had better radiological responses compared to other subgroups. And the result was statistically significant.
Several studies with different designs addressed the protocol of induction chemotherapy with pathological complete response rate ranging from 20 to 33% with acceptable toxicity.
The current study demonstrated a similar pathological complete response rate to previous studies which is 20% in patients who underwent surgery.
Seventy five percent of the patients who underwent surgery achieved pathological downstaging in T or N stage or both. Other than one patient with positive CRM the rest had clear margins.
To sum, the use of induction chemotherapy with Capecitabine and Oxaliplatin before CCRTH in locally advanced rectal cancer patients has a comparable complete pathological response rate and accepted toxicity profile.