Journal of Radiation Oncology

, Volume 8, Issue 2, pp 217–224 | Cite as

Neoadjuvant chemotherapy and high-dose radiation using intensity-modulated radiotherapy followed by rectal sparing TEM for distal rectal cancer

  • Kinjal ParikhEmail author
  • Albert S DeNittis
  • Gerald Marks
  • Erik Zeger
  • David Cho
  • John Marks
Original Research



For distal rectal tumors, abdominoperineal resection may achieve local control but with significant morbidity. High-dose radiation can improve pathologic response and allow for full-thickness local excision (FTLE) with comparable outcomes and improved morbidity. We report 15 years of data on distal rectal cancer treated with chemotherapy, intensity-modulated radiotherapy (IMRT), and FTLE via transanal endoscopic microsurgery.

Methods and materials

Forty-four patients were treated for cT1–T3, N0, and M0 distal rectal cancer using IMRT at 5580 cGy with 5-FU chemotherapy, followed by FTLE. Local recurrence (LR), disease-free survival (DFS), and overall survival (OS) were reported.


Median follow-up was 51 months. Three patients (6.8%) had LR, all salvaged surgically. Mean DFS and OS are 8.56 and 9.10 years, respectively. DFS and OS were strongly associated with pathologic response to chemoradiotherapy (p = 0.043 and p = 0.023, respectively). Thirty-four patients (77%) are alive with no disease. Postoperative grade I–II complications noted in 17 patients and grade III complications in 2 patients. No patients required a diverting colostomy.


High-dose IMRT and chemotherapy followed by FTLE to treat distal rectal cancers are well tolerated and effective. FTLE may improve outcomes and minimize complications in appropriately selected patients. Randomized clinical trials are needed to compare it with standard surgery.


Transanal endoscopic microsurgery Intensity-modulated radiotherapy Distal rectal cancer Full-thickness local excision for rectal cancer Abdominoperineal resection for rectal cancer High-dose radiation for rectal cancer Rectal neoplasm 


Compliance with ethical standards


No funding was received for this study.

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Gérard JP, Conroy T, Bonnetain F, Bouché O, Chapet O, Closon-Dejardin MT, Untereiner M, Leduc B, Francois É, Maurel J, Seitz JF (2006) Preoperative radiotherapy with or without concurrent fluorouracil and leucovorin in T3-4 rectal cancers: results of FFCD 9203. J Clin Oncol 24(28):4620–4625CrossRefGoogle Scholar
  2. 2.
    Hofheinz R, Wenz F, Post S, Matzdorff A, Laechelt S, Mueller L, Link H, Moehler M, Burkholder I, Hochhaus A (2009) Capecitabine (Cape) versus 5-fluorouracil (5-FU)-based (neo-) adjuvant chemoradiotherapy (CRT) for locally advanced rectal cancer (LARC): safety results of a randomized, phase III trial. J Clin Oncol 27(15S):4014Google Scholar
  3. 3.
    Pozo ME, Fang SH (2015) Watch and wait approach to rectal cancer: a review. World J Gastrointest Surg 7(11):306–312CrossRefGoogle Scholar
  4. 4.
    Guerrieri M, Gesuita R, Ghiselli R, Lezoche G, Budassi A, Baldarelli M (2014) Treatment of rectal cancer by transanal endoscopic microsurgery: experience with 425 patients. World J Gastroenterol: WJG 20(28):9556–9563CrossRefGoogle Scholar
  5. 5.
    Kunitake H, Abbas MA (2012) Transanal endoscopic microsurgery for rectal tumors: a review. Perm J 16(2):45–50CrossRefGoogle Scholar
  6. 6.
    Peeters KC, Marijnen CA, Nagtegaal ID, Kranenbarg EK, Putter H, Wiggers T, Rutten H, Pahlman L, Glimelius B, Leer JW, van de Velde CJ (2007) The TME trial after a median follow-up of 6 years: increased local control but no survival benefit in irradiated patients with resectable rectal carcinoma. Ann Surg 246(5):693–701CrossRefGoogle Scholar
  7. 7.
    Maggiori L, Panis Y (2012) Transanal endoscopic microsurgery (TEM) for T1 rectal cancer. Acta chirurgica Iugoslavica 59(2):87–90CrossRefGoogle Scholar
  8. 8.
    Veereman G, Vlayen J, Robays J, Fairon N, Stordeur S, Rolfo C, Bielen D, Bols A, Demetter P, D’hoore A, Haustermans K (2017) Systematic review and meta-analysis of local resection or transanal endoscopic microsurgery versus radical resection in stage i rectal cancer: a real standard? Crit Rev Oncol Hematol 114:43–52CrossRefGoogle Scholar
  9. 9.
    Lu JY, Lin GL, Qiu HZ, Xiao Y, Wu B, Zhou JL (2015) Comparison of transanal endoscopic microsurgery and total mesorectal excision in the treatment of T1 rectal cancer: a meta-analysis. PLoS One 10(10):e0141427CrossRefGoogle Scholar
  10. 10.
    Allaix ME, Arezzo A, Giraudo G, Morino M (2012) Transanal endoscopic microsurgery vs. laparoscopic total mesorectal excision for T2N0 rectal cancer. J Gastrointest Surg 16(12):2280–2287CrossRefGoogle Scholar
  11. 11.
    Bujko K, Richter P, Smith FM, Polkowski W, Szczepkowski M, Rutkowski A, Dziki A, Pietrzak L, Kołodziejczyk M, Kuśnierz J, Gach T (2013) Preoperative radiotherapy and local excision of rectal cancer with immediate radical re-operation for poor responders: a prospective multicentre study. Radiother Oncol 106(2):198–205CrossRefGoogle Scholar
  12. 12.
    Rödel C, Martus P, Papadoupolos T, Füzesi L, Klimpfinger M, Fietkau R, Liersch T, Hohenberger W, Raab R, Sauer R, Wittekind C (2005) Prognostic significance of tumor regression after preoperative chemoradiotherapy for rectal cancer. J Clin Oncol 23(34):8688–8696CrossRefGoogle Scholar
  13. 13.
    Park IJ, You YN, Agarwal A, Skibber JM, Rodriguez-Bigas MA, Eng C, Feig BW, Das P, Krishnan S, Crane CH, Hu CY (2012) Neoadjuvant treatment response as an early response indicator for patients with rectal cancer. J Clin Oncol 30(15):1770–1776CrossRefGoogle Scholar
  14. 14.
    Habr-Gama A, Gama-Rodrigues J, São Julião GP, Proscurshim I, Sabbagh C, Lynn PB, Perez RO (2014) Local recurrence after complete clinical response and watch and wait in rectal cancer after neoadjuvant chemoradiation: impact of salvage therapy on local disease control. Int J Radiat Oncol Biol Phys 88(4):822–828CrossRefGoogle Scholar
  15. 15.
    Wiltshire KL, Ward IG, Swallow C, Oza AM, Cummings B, Pond GR, Catton P, Kim J, Ringash J, Wong CS, Wong R (2006) Preoperative radiation with concurrent chemotherapy for resectable rectal cancer: effect of dose escalation on pathologic complete response, local recurrence-free survival, disease-free survival, and overall survival. Int J Radiat Oncol Biol Phys 64(3):709–716CrossRefGoogle Scholar
  16. 16.
    Myint AS (2014 Jun) Novel radiation techniques for rectal cancer. J Gastrointest Oncol 5(3):212–217Google Scholar
  17. 17.
    Gunther JR, Chadha AS, Shin US, Park IJ, Kattepogu KV, Grant JD, Weksberg DC, Eng C, Kopetz SE, Das P, Delclos ME (2017) Preoperative radiation dose escalation for rectal cancer using a concomitant boost strategy improves tumor downstaging without increasing toxicity: a matched-pair analysis. Adv Radiat OncolGoogle Scholar
  18. 18.
    Verseveld M, De Graaf EJ, Verhoef C, van Meerten E, Punt CJ, de Hingh IH, Nagtegaal ID, Nuyttens JJ, Marijnen CA, de Wilt JH (2015) Chemoradiation therapy for rectal cancer in the distal rectum followed by organ-sparing transanal endoscopic microsurgery (CARTS study). Br J Surg 102(7):853–860CrossRefGoogle Scholar
  19. 19.
    Issa N, Murninkas A, Schmilovitz-Weiss H, Agbarya A, Powsner E (2015) Transanal endoscopic microsurgery after neoadjuvant chemoradiotherapy for rectal cancer. J Laparoendosc Adv Surg Tech 25(8):617–624CrossRefGoogle Scholar
  20. 20.
    Mohiuddin M, Paulus R, Mitchell E, Hanna N, Yuen A, Nichols R, Yalavarthi S, Hayostek C, Willett C (2013) Neoadjuvant chemoradiation for distal rectal cancer: 5-year updated results of a randomized phase 2 study of neoadjuvant combined modality chemoradiation for distal rectal cancer. Int J Radiat Oncol Biol Phys 86(3):523–528CrossRefGoogle Scholar
  21. 21.
    Samuelian JM, Callister MD, Ashman JB, Young-Fadok TM, Borad MJ, Gunderson LL (2012) Reduced acute bowel toxicity in patients treated with intensity-modulated radiotherapy for rectal cancer. Int J Radiat Oncol Biol Phys 82(5):1981–1987CrossRefGoogle Scholar
  22. 22.
    Wang JF, Li H, Xiong H, Huang H, Zou YM (2016) Influence of position and radiation technique on organs at risk in radiotherapy of rectal cancer. J Huazhong Univ Sci Technolog Med Sci 36(5):741–746CrossRefGoogle Scholar
  23. 23.
    Zhao J, Hu W, Cai G, Wang J, Xie J, Peng J, Zhang Z (2016) Dosimetric comparisons of VMAT, IMRT and 3DCRT for locally advanced rectal cancer with simultaneous integrated boost. Oncotarget 7(5):6345–6351Google Scholar
  24. 24.
    Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213CrossRefGoogle Scholar
  25. 25.
    Bosset JF, Calais G, Mineur L, Maingon P, Radosevic-Jelic L, Daban A, Bardet E, Beny A, Briffaux A, Collette L (2005) Enhanced tumorocidal effect of chemotherapy with preoperative radiotherapy for rectal cancer: preliminary results—EORTC 22921. J Clin Oncol 23(24):5620–5627CrossRefGoogle Scholar
  26. 26.
    Winde G, Nottberg H, Keller R, Schmid KW, Bünte H (1996) Surgical cure for early rectal carcinomas (T1). Dis Colon Rectum 39(9):969–976CrossRefGoogle Scholar
  27. 27.
    Lee W, Lee D, Choi S, Chun H (2003) Transanal endoscopic microsurgery and radical surgery for T1 and T2 rectal cancer. Surg Endosc 17(8):1283–1287CrossRefGoogle Scholar
  28. 28.
    Sengupta S, Tjandra JJ (2001) Local excision of rectal cancer. Dis Colon Rectum 44(9):1345–1361CrossRefGoogle Scholar
  29. 29.
    Wong SJ, Winter K, Meropol NJ, Anne R, Kachnic LA, Rashid A, Watson JC, Mitchell EP, Pollock J, Lee RJ, Willett CG (2008) RTOG 0247: a randomized phase II study of neoadjuvant capecitabine and irinotecan versus capecitabine and oxaliplatin with concurrent radiation therapy for locally advanced rectal cancer. J Clin Oncol 26(15_suppl):4021CrossRefGoogle Scholar
  30. 30.
    Guerrero Urbano MT, Henrys AJ, Adams EJ, Norman AR, Bedford JL, Harrington KJ, Nutting CM, Dearnaley DP, Tait DM (2006) Intensity-modulated radiotherapy in patients with locally advanced rectal cancer reduces volume of bowel treated to high dose levels. Int J Radiat Oncol Biol Phys 65(3):907–916CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Kinjal Parikh
    • 1
    Email author
  • Albert S DeNittis
    • 2
    • 3
  • Gerald Marks
    • 4
  • Erik Zeger
    • 1
  • David Cho
    • 3
  • John Marks
    • 4
  1. 1.Department of Hematology OncologyLankenau Medical Center and the Lankenau Institute for Medical ResearchWynnewoodUSA
  2. 2.Department of Radiation OncologyLankenau Medical Center and the Lankenau Institute for Medical ResearchWynnewoodUSA
  3. 3.Department of Radiation OncologyCape Regional Medical CenterCape May Court HouseUSA
  4. 4.Department of Colorectal SurgeryLankenau Medical Center and the Lankenau Institute for Medical ResearchWynnewoodUSA

Personalised recommendations