Neoadjuvant radiotherapy and radiochemotherapy for rectal cancer

Combined radiochemotherapy is the recommended standard postoperative therapy for patients with stage II and III rectal cancer in the USA and in Germany. During thelast decade, substantial progress has been made in treatment modalities: surgical management currently includes a broad spectrum of operative procedures ranging from radical operations such as abdominoperineal resections to innovative sphincter-preserving techniques. Specialized groups have reported excellent local control rates with total mesorectal excision (TME) alone without the addition of neoadjuvant or adjuvant treatment. New and improved radiation techniques using conformal radiotherapy as well as innovative chemotherapy schedules and combinations (capecitabine, oxaliplatin, irinotecan) of chemotherapy may have the potential to further increase the therapeutic benefit of (neo-)adjuvant treatment. Moreover, the basic issue of timing of radiotherapy-preoperative versus postoperative-within a multimodality regimen is currently being addressed in prospective trials. Evidently, the current monolithic approach established by studies conducted more than a decade ago, to either apply the same schedule of postoperative radiochemotherapy to all patients with UICC stage II and III rectal cancer or to give preoperative short-course radiation according to the Swedish concept for all patients with resectable rectal cancer irrespective of tumor stage and treatment goal (e.g., sphincter preservation), need to be questioned.