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Infusional chemoradiation for operable rectal cancer: post-, pre-, or nonoperative management?

The use of adjuvant irradiation combined with systemic chemotherapy, or "chemoradiation," in the management of patients with operable rectal cancer has enabled more conservative surgery to be performed. Chemoradiation has been employed in both postoperative and preoperative settings, and also has been used as sole therapy in selected patients. Of the various schedules of postoperative chemoradiation evaluated to date, a protracted infusion of fluorouracil (5-FU) combined with irradiation appears to maximize control of both local and distant micrometastatic disease. Preoperative infusional chemoradiation is highly effective in patients with advanced rectal cancer. Data also suggest that it may be possible to treat selected patients with low-lying rectal cancers with radical chemoradiation alone, thus obviating the need for a permanent colostomy. Future studies of preoperative and nonoperative infusional chemoradiation are warranted.