1. 종양혈액내과 R4 고원진 / pf. 김시영 Rectal cancer : state of the art in 2012 Curr Opin Oncol 2012, 24:441–447

2. Introduction Radiotherapy, chemotherapy, and surgical resection are the important elements of multimodal treatment for patients with locally advanced rectal cancer Preoperative 5-FU-based CRT has been shown to be the preferred treatment ; Compliance, toxicity, downstaging, and local control Preoperative CRT (radiotherapy with infusional 5-FU) + Total mesorectal excision (TME) surgery + Adjuvant chemotherapy with 5-FU for 4 months Has become a standard of care for stage II and III rectal cancer

3. Introduction Distant metastases are now the predominant mode of failure in rectal cancer None of the recently published randomized trials on combined modality treatment for rectal cancer has demonstrated a survival benefit This review will discuss the most recent developments of multimodal treatment for patients with locally advanced rectal cancer

4. Newer generation chemotherapeutics have been incorporated by trials of preoperative CRT Oral fluoropyrimidines, oxaliplatin, and irinotecan A recent randomized phase III trial in Germany confirmed noninferiority for the endpoint overall survival oral prodrug capecitabine during radiotherapy and adjuvant chemotherapy Early phase II trials adding oxaliplatin or irinotecan to 5-FU-CRT suggested higher pCR rates But, associated increase in acute toxicity INTEGRATING COMBINATION CHEMOTHERAPY

6. INDUCTION & ADJUVANT COMBINATION CHEMOTHERAPY J Clin Oncol 28:859-865

7. INTEGRATING TARGETED AGENTS The concurrent administration of EGFR inhibitors may interfere with the antitumor activity of CRT to target proliferating tumor cells Subgroups that may benefit from the addition of cetuximab No single marker or pattern of markers could be unambiguously identified to have predictive or prognostic value

8. INTEGRATING TARGETED AGENTS The EXPERT-C trial 96% 3y-OS) vs 91%

9. Preclinical data have suggested that proangiogenic factors, especially VEGF, may increase the resistance to radiotherapy VEGF expression has been linked to a worse prognosis VEGF-targeted therapy may lead to a ‘normalization’ of the tumor vasculature, thereby leading to greater tumor oxygenation and drug penetration INTEGRATING TARGETED AGENTS

11. NOVEL CLINICAL TRIAL DESIGN: DELAYED SURGERY Ann Surg. 2011 Jul;254(1):97-102.

12. NOVEL CLINICAL TRIAL DESIGN: MINIMAL SURGERY Ann Surg Oncol (2012) 19:384–391

13. NOVEL CLINICAL TRIAL DESIGN: OMITTED SURGERY J Clin Oncol. 2011 Dec 10;29(35):4633-40.

14. NOVEL CLINICAL TRIAL DESIGN: OMITTED RADIOTHERAPY Novel approaches address whether radiotherapy can be omitted in selected patients In a single-institution series of patients with stage II-III rectal cancer (T4 tumors excluded), Six cycles preoperative FOLFOX + bevacizumab (cycles 1–4 only) without the addition of radiotherapy in 30 patients All patients had a R0 resection and 25% had a pCR The U.S. Alliance cooperative group plans to validate this approach in a multicenter, randomized clinical trial

15. CONCLUSION Schedule of preoperative CRT to all patients with TNM stage II/III rectal cancer The inclusion of different multimodal treatment concepts, adapted to tumor stage, location, molecular profiles, response, and to the patient’s risk factors and preferences is upcoming These may include omission of radical surgery and omission of radiotherapy Further, treatment algorithms that need to be validated include induction chemotherapy protocols with or without targeted agents and CRT Thus, clinicopathological and molecular features as well as accurate imaging will take an integrative part in the multimodality treatment of rectal cancer