Twenty patients with primary or recurrent unresectable rectal cancer limited to the pelvis were entered on a Phase I trial of preoperative pelvic radiation therapy (RT) (5040 cGy) and two cycles of combined high-dose leucovorin (LV) and 5fluorouracil (S-FU), followed by surgery and ten cycles of postoperative LV/S-FU (sequential). Maximum tolerated doses (MTD) were determined for preoperative combined LV/S-FU and RT and for postoperative sequential LV/S-FU. 5-FU was escalated 50 mg/rnz while the LV remained constant at 200 mg/mz. The initial doses of 5-FU were combined LVIS-FU and RT (200 mg/m2) and sequential LV/5-FU (325 mg/mz). The median follow-up time was 1 4 months. The resectability rate was 89%, and the pathologic complete response rate was 21%. The MTD for combined LV/5-FU and RT was 300 mg/m2; therefore, the recommended dose of 5-FU is 250 mg/mz. The recommended dose of 5-FU for sequential LV/S-FU is 375 mg/mz. The doselimiting toxicities in this trial were diarrhea, tenesmus, increased bowel movements, dysuria, and myelosuppression. For the six patients who received 5-FU at the recommended dose level, the median low counts were leukocyte count, 3.7/pl (range, 2.4 to 4.9/pl); hemoglobin, 9.0 g/dl (range, 8.2 to 11.9 g/dl); and platelet count (XlOOO), 146/p1 (range, 89 to 182/pl). The incidence rate of any Grade 3 toxicity was 17% (diarrhea and frequent bowel movements). The recommended doses of 5-FU used in this protocol were well tolerated. Because there was a long delay before optimal doses of 5-FU could be delivered, the authors do not recommend that high-dose LV be used in conjunction with combined 5-FU and RT with the treatment regimen as currently designed. However, because the resectability and complete response rates were higher than those previously reported for preoperative RT alone, the authors are encouraged by the combined technique approach. New trials are currently being undertaken to determine if the use of a low-dose LV regimen is more tolerable. Cancer 672859-2866,1991.
N PATIENTS WITH resectable rectal cancer, results of randomized trials show a significant survival advantage of chemotherapy alone' or radiation therapy (RT) plus ~hemotherapy*-~ compared with surgery alone. It is more difficult to obtain these results in patients with unresect-The standard approach to patients with unresectable I