Volume 7, Issue 11, November – 2022 International Journal of Innovative Science and Research Technology

ISSN No:-2456-2165

The Comparison of Surgery and Chemo-Radio

Therapy in Locally Recurrent Colorectal Cancer
Dr. Muhammad Israr Khan Dr. Shumaila Ghazan
Consultant Surgeon, Department of General Surgery, Surgical Registrar DHQ Hospital Charsadda,
Hayatabad Medical Complex, Peshawar, Pakistan Pakistan

Dr. Maryam Munir (Corresponding Author) Dr. Muhib Ullah

Medical Officer, District Headquarter Hospital Specialist Registrar, Surgical “A” Ward,
Landikotal, Pakistan Hayatabad Medical Complex, Peshawar Pakistan

Abstract:- Introduction: Globally, over 2 million I. INTRODUCTION

colorectal cancer cases were diagnosed. It is the second
most common cause of cancer fatalities, causing 1 million Globally, over 2 million colorectal cancer cases were
deaths annually. The current study aimed to compare diagnosed. It is the second most common cause of cancer
surgery and chemoradiotherapy treatment outcomes in fatalities, causing 1 million deaths annually. However, there are
colorectal cancer recurrence. Method: The current study good screening approaches that potentially minimize illness
was conducted using a randomized clinical trial design. fatalities globally [1].
The study was carried out at Hayatabad Medical Complex,
Peshawar. A total of 74 patients previously treated for Asia has more than half of all colorectal cancer cases and
colorectal cancer, were selected. The patients who showed fatalities. China has more than 500,000 new cases and 280,000
recurrence, based on radiology results, were selected for fatalities every year. Japan has the second-most colorectal
the current study. Survival from the commencement of cancer fatalities per year, 60 000. International Agency for
chemoradiotherapy/surgery to death from any cause or Research on Cancer (IARC) projects that colorectal cancer will
censoring at the final follow-up was defined as overall grow by 56% between 2020 and 2040, reaching more than 3
survival (OS). OS were calculated using the Kaplan–Meier million new cases annually [2]. The illness is expected to cause
technique and compared with the log-rank test. All 1.6 million deaths globally by 2040, a 69% rise. Most growth
analyses were conducted using SPSS v25 and Jamovi. is projected in high-Human Development Index (HDI) nations.
Result: A total of 21 patient included in the final analysis. IARC researchers found that many variables enhance or reduce
The mean age in the surgery group was quite higher than colorectal cancer risk. Most of these variables increase or
the chemoradiotherapy group (p = 0.31). The male to decrease the risk of other cancers [3].
female ratio in each group was 12/4, 8/3 respectively. The
timer size was quite higher than the chemoradiotherapy In 2020, alcohol caused 165,000 new instances of
group (p = 0.20). Two patients were died in the colorectal cancer or 8% of all cases. Alcohol intake raises the
chemoradiotherapy group while one patient was died in risk of six additional cancers, including liver and breast cancer
surgery group. The survival rate of the surgery was quite [4]. Smoking causes lung cancer [5], while HPV causes
good as compared to the chemoradiotherapy group. In the cervical cancer [6]. Both variables lead to colorectal cancer.
chemoradiotherapy group the patients survived up to 30 Obesity raises colorectal cancer risk. Obesity caused 85 000
months, however, the patient treats with surgery showed instances of colon cancer and 25 000 cases of rectal cancer in
the longest survival. Conclusion: The current study 2012, or 23% of all colorectal cancer cases. Obesity raises the
compared the surgery and Chemo-radio therapy in locally risk of seven additional cancers. Weight reduction, exercise,
recurrent colorectal cancer. Two patients in the and diets rich in fish, fruits, and vegetables reduce colorectal
chemoradiotherapy group and one in the surgery group cancer risk [7]. Screening raises the likelihood of discovering
was died. Compared to those who had chemoradiation, colorectal cancer at an earlier, more controllable stage [8].
surgical patients had a much higher chance of survival. In
the chemoradiotherapy group, patients lived up to 30 Colorectal cancer treatment is broadly divided into two
months; nevertheless, the surgical group had the longest categories: local and systematic. Local therapies address the
survival rate. tumor without impacting other organs [9]. Colorectal surgeries
are the most common way to remove the tumor and surround
Keywords:- Colorectal Cancer, Recurrence, healthy tissues to resect the affected area. In addition to surgical
Chemoradiotherapy, Surgery. resection, the other options include laparoscopic surgeries,
colostomy, and radiofrequency ablation. Drugs may also be
used to treat colorectal cancer; they can be administered orally
or straight into circulation. These are systemic therapies
because they may reach almost all cancer cells in the body.
Chemotherapy for Colorectal Cancer, Targeted Therapy for
Colorectal Cancer, and Immunotherapy for Colorectal Cancer

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Volume 7, Issue 11, November – 2022 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
may be administered depending on the kind of colorectal C. Statistical analysis
cancer [10, 11]. Multiple therapy methods may be utilized Survival from the commencement of
concurrently or sequentially depending on the cancer stage and chemoradiotherapy/surgery to death from any cause or
other parameters. Typically, stages 0, I, II, and III are surgically censoring at the final follow-up was defined as overall survival
treatable. However, many patients with stage III colorectal (OS). OS were calculated using the Kaplan–Meier technique
cancer, and some with stage II, have chemotherapy after and compared with the log-rank test. All analyses were
surgery to boost the likelihood of curing the illness. Before or conducted using SPSS v25 and Jamovi.
after surgery, individuals with stages II and III rectal cancer
will also get radiation treatment and chemotherapy. In most
cases, stage IV cancer cannot be cured, but it is treated to
control its progression and symptoms [12, 13]. The current
study aimed to compare surgery and chemoradiotherapy
treatment outcomes in colorectal cancer recurrence.

II. METHOD

A. Study design and patients

The current study was conducted using a randomized
clinical trial design. The study was carried out at Hayatabad
Medical Complex, Peshawar. A total of 74 patients previously
treated for colorectal cancer, were selected. The patients who
showed recurrence, based on radiology results, were selected
for the current study. Moreover, the patients that were not
eligible (stage IV) and were not willing to participate were
excluded from the current study. The selected patients were
randomly assigned to surgery (n =16) and chemoradiotherapy
(n = 11) groups and prospectively followed for three years. The
detail can be seen in Figure 1.

B. Chemoradiotherapy regimens
All patients received external beam radiation (50 to 60
Gy) with concurrent chemotherapy such as 5-FU continuous Fig 1. The detail of the patient selection and follow-up
infusion (ci), or S-1, weekly 5-FU ci plus oxaliplatin, modified
FOLFOX6 (mFOLFOX). 5-FU ci regimen was a continuous III. RESULTS
infusion of 2500 mg/week mg/m2 of 5-FU (7 days), repeated
every week. S-1 was administered orally at the dose of 80 A total of 21 patient included in the final analysis. The
mg/m2/day. Weekly 5-FU ci plus oxaliplatin regimen consisted mean age in the surgery group was quite higher than the
of intravenous infusion of 50 mg/m2 of oxaliplatin (2 h) on day chemoradiotherapy group (p = 0.31). The male to female ratio
1 and continuous infusion of 2,500 mg/week 5-FU (7 days), in each group was 12/4, 8/3 respectively. The timer size was
repeated every week. The mFOLFOX regimen consisted of quite higher than the chemoradiotherapy group ( p = 0.20). Two
intravenous infusion of 85 mg/m2 of oxaliplatin (2 h), 200 patients were died in the chemoradiotherapy group while one
mg/m2 l-leucovorin (2 hours), and 400 mg/m2 bolus 5-FU on patient was died in surgery group. The detail can be seen in
day 1, followed by a continuous infusion of 2,400 mg/m2 of 5- Table 1. The survival rate of the surgery was quite good as
FU (46 h), repeated every 2 weeks. Chemotherapy started from compared to the chemoradiotherapy group. In the
the first day and was repeated to the last day of radiotherapy in chemoradiotherapy group the patients survived up to 30
all patients, and subsequent chemotherapy regimens were months, however, the patient treats with surgery showed the
determined by each physician’s discretion according to the longest survival as shown in Figure 2.
efficacy and toxicities of CRT. Six patients continued to
receive chemotherapy until disease progression after the
completion of radiation therapy.

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Volume 7, Issue 11, November – 2022 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
Table 1. Patient characteristics and treatment outcome
Group
Surgery CRT P-value
Mean ± SD N (%) Mean ± SD N (%)
Age (years) 54 ± 14 49 ± 11 0.31
Gender Male 12 (60%) 8 (40)
0.89
Female 4 (57.1%) 3 (42.9)
Period of recurrence 32 ±8 29 ± 9 0.46
Tumor size 46.09 ± 5.28 42.81 ± 7.82 0.20
Patient Survived 15 (62.5) 9 (37.5)
status Death 0.33
1 (33.3) 2 (66.7)

Fig 1. Treatment of the surgery and CRT.

IV. DISCUSSION Reportedly, the combination of 5-FU radiotherapy (RT)

improves survival for locally unresectable rectal cancer over
The current study compared the surgery and Chemo-radio radiotherapy alone [17]. It has been observed that observed that
therapy in locally recurrent colorectal cancer. Two patients in Chemoradiotherapy (CRT) (continuous infusion of 5-FU+RT)
the chemoradiotherapy group and one in the surgery group was was more effective than radiotherapy alone in 30 patients with
died. Compared to those who had chemoradiation, surgical locally recurrent rectal cancer. In addition, it has been showed
patients had a much higher chance of survival. In the increase in the median OS of patients treated with CRT over
chemoradiotherapy group, patients lived up to 30 months; RT alone (median survival time 9.3 months). In addition, CRT
nevertheless, the surgical group had the longest survival rate. was successful in relieving pain, and 5-FU-based regimens
were found to be effective and safe. Compared to their findings
Regarding the treatment approach for local rectal cancer on CRT, our results demonstrated similar survival effects of
recurrence, there is no unanimity. Only 20-40% of patients with CRT. The median OS was not attained in our investigation, and
recurrent rectal cancer are suitable for curative resection (R0) survival in our group was superior to that of the CRT group in
resection, despite the fact that radical resection is the treatment Ito's trial. This disparity in effectiveness between the Ito
of choice with a high cure rate [14]. It has been observed that research and our present data may be attributable to variations
there was no significant difference in long-term survival in chemotherapy regimens and radiation treatment.
between R2 resection and non-surgical treatments for patients
who are ineligible [15]. Consequently, if R0 cannot be done, Since the introduction of oxaliplatin into clinical practice,
surgical resection is not anticipated to provide a greater colorectal cancer chemotherapy has achieved significant
advantage. Radiation therapy and systemic chemotherapy advances. Chemotherapy using oxaliplatin and 5-FU, such as
alone or in combination should be considered at this point in the FOLFOX regimen, is more successful and has become the
the treatment of patients [16]. In contrast, in the current study, standard treatment for colorectal cancer in its later stages [18,
the survival was quite good in surgery group compared to the 19]. In addition, preoperative CRT with an oxaliplatin-
chemoradiotherapy. containing regimen demonstrated a high success rate with
acceptable toxicity in patients with locally advanced rectal
cancer. Hu et al. evaluated CRT [FOLFOX4+three-
dimensional conformal radiation (3-DCRT)] and RT based on

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Volume 7, Issue 11, November – 2022 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
prior research on CRT that included oxaliplatin-containing [11]. Hashiguchi, Y., et al., Japanese Society for Cancer of the
regimens for rectal cancer recurrence. The CRT group had a Colon and Rectum (JSCCR) guidelines 2019 for the
much better 2-year survival rate and a significantly greater treatment of colorectal cancer. International journal of
response rate (56% vs 40%) [20]. You et al. also evaluated the clinical oncology, 2020. 25(1): p. 1-42.
efficacy of concurrent CRT with oxaliplatin [12]. Piawah, S. and A.P. Venook, Targeted therapy for
(oxaliplatin+pelvic irradiation) in 96 patients with locally colorectal cancer metastases: A review of current
recurrent rectal cancer and reported a CR rate of 14% and a PR methods of molecularly targeted therapy and the use of
rate of 61%. (24). Cai et al. reported a CR rate of 5.6% after tumor biomarkers in the treatment of metastatic
CRT with capecitabine and irinotecan and intensity modulated colorectal cancer. Cancer, 2019. 125(23): p. 4139-4147.
radiation treatment (IMRT) (45 Gy), which was related with a [13]. Brouwer, N.P., et al., An overview of 25 years of
3-year survival rate of 36.5%; the 3-year local progression-free incidence, treatment and outcome of colorectal cancer
survival rate was 33.9% after a median follow-up of 31 months. patients. International journal of cancer, 2018. 143(11):
As for side effects, the incidence of grade 4 leukopenia was p. 2758-2766.
4.8%, grade 3 diarrhoea was 22.5%, and the toxicity was within [14]. Bhangu, A., et al., Comparison of long‐term survival
the allowable limit [21]. outcome of operative vs nonoperative management of
recurrent rectal cancer. Colorectal Disease, 2013. 15(2):
This study has several limitations. First, we only p. 156-163.
evaluated a small number of patients. Second, many of the [15]. Pacelli, F., et al., Locally recurrent rectal cancer:
patients were censored cases, which may have led to prognostic factors and long-term outcomes of
overestimation of the OS results. multimodal therapy. Annals of Surgical Oncology, 2010.
17(1): p. 152-162.
V. CONCLUSION [16]. Tanis, P.J., A. Doeksen, and J.J.B. van Lanschot,
Intentionally curative treatment of locally recurrent rectal
The current study compared the surgery and Chemo-radio cancer: a systematic review. Canadian journal of
therapy in locally recurrent colorectal cancer. Two patients in Surgery, 2013. 56(2): p. 135.
the chemoradiotherapy group and one in the surgery group was [17]. Moertel, C., et al., Combined 5-fluorouracil and
died. Compared to those who had chemoradiation, surgical supervoltage radiation therapy of locally unresectable
patients had a much higher chance of survival. In the gastrointestinal cancer. The Lancet, 1969. 294(7626): p.
chemoradiotherapy group, patients lived up to 30 months; 865-867.
nevertheless, the surgical group had the longest survival rate. [18]. de Gramont, A.d., et al., Leucovorin and fluorouracil
with or without oxaliplatin as first-line treatment in
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