1. Do all patients with T2-3 mid-high rectal adenocarcinomas require RT as part of their neoadjuvant therapy? - Yes - 

Bruce Minsky

2. Colon vs. Rectal Cancer

3. Colon: Time to Recurrence
Sargent et al JCO 2007

4. CAO/ARO/AIO 94
Roedel et al JCO 2012

5. Preoperative Staging TRUS or MRI: T stage: 90% N stage: 60-70%
MRI + contrast*: T stage: 90%
N stage: 70-80% (↑ appx 10%)
*Gadofosveset (Lambregts, Ann Surg 2011)
*Iron oxide (Will et al, Lancet Oncol 2006)

6. Risk of LN+ by Distance High tumors have equivalent risk of LN+
Guillem pooled analysis
· 188 Pts with cT3N0 s/p preop CMT
· 6 international centers
Cm from AV # % ypN+
High tumors have equivalent risk of LN+
Guillem et al JCO 2008

7. cT3N0 @ 10 cm: CMT vs. LAR PREOP CMT - improved local control
- less toxicity
- but over treat 20% (pT1-2N0)
SURGERY
- avoid RT
- but if N+ (22% s/p preop CMT*)
then need postop CMT
- decreased local control
- higher toxicity
- poor function
Guillem et al JCO 2008

8. Distance from the AV Caveats: · All are subset analysis
· Include cT1-3 tumors
· Variable methods to measure distance
· 5 Gy x 5
· Dutch: flexible scope, < 15 cm, TME
· German: rigid scope, < 16 cm, TME
· SRCT: no details, variable surgery

9. Distance from the AV Surgery Preop RT Cm % 5-Yr LF % 5-Yr LF p Dutch
High
Mid <0.001
Low <
SRCT
High >
Mid <0.001
Low <

10. Distance from the AV Location # %10-Yr LF < 6 cm 166 11
German
Pre-op
Location # %10-Yr LF
< 6 cm
6- <12 cm
12-16 cm

11. Preop CMT – Selective RT
∙ 32 Pts, LAR eligible, uT2N1, uT3N0-1
FOXFOX/BEV x FOLFOX x 2 Surgery
∙ If preop POD salvage preop RT
∙ If pT4, N2, or margin+ post RT
∙ R0: 30/30
∙ pCR: 25%
∙ No preop RT, 2 postop RT
∙ 4 years: 0 LF, 84% DFS
* Alliance N1048 – 1000 pt trial
Schrag et al JCO 2014

12. Preop CMT – Selective RT
• 28 pts, Multicenter phase II
• MRI: T3 or > 2mm from mesorectal fascia (? LN)
• Mid rectal (> 5 cm from AV)
• 4 cycles Induction CAPOX-B
• None required preop CMT
• 15 % pCR, all R0
• 2 pts with pN2 needed postop CMT
• 50% Gr 3+ toxicity
Fernandez-Martos et al, ProcASCO 2012

14. ….Yes · Local recurrences in rectal cancer occur late
· LN+ is primary cause of LF
· 22% ypN+ even after preop CMT for cT3N0
· LN + is independent of distance from AV
·CT alone data are investigational and may have
higher toxicity