• Pathological complete response rate [ Designated as safety issue: No ]
  

• Toxicity [ Designated as safety issue: Yes ]
  

OBJECTIVES:

Primary

• Evaluate the pathological complete response rate in patients with T3 or T4 rectal cancer treated with neoadjuvant bevacizumab in combination with radiotherapy, capecitabine, and oxaliplatin followed by surgical resection and adjuvant bevacizumab in combination with fluorouracil, leucovorin calcium, and oxaliplatin.

Secondary

• Evaluate the resection rate for T3 and T4 rectal cancers.
• Evaluate the expected versus actual type of resection (abdominoperineal resection [APR] vs low anterior resection [LAR] vs LAR/coloanal anastomosis) performed on these patients.
• Determine, preliminarily, survival and patterns of recurrence in patients treated with this regimen.
• Determine the toxicity and tolerability of this preoperative and postoperative regimen.

OUTLINE: This is a multicenter study. Patients are stratified according to primary tumor size (T3 vs T4).

• Preoperative chemoradiotherapy: Patients undergo radiotherapy once daily 5 days a week and receive oral capecitabine twice daily 5 days a week for 5½ weeks. Patients also receive oxaliplatin IV over 2 hours on days 1, 8, 15, 22, and 29 and bevacizumab IV over 30-90 minutes on days 1, 15, and 29 during radiotherapy.
• Surgery: Approximately 6-8 weeks after completion of chemoradiotherapy, patients undergo surgical resection. Patients whose tumors are not completely resected or who have metastatic disease discontinue protocol therapy.
• Postoperative chemotherapy: Approximately 4-8 weeks after surgery, patients receive oxaliplatin IV over 2 hours, leucovorin calcium IV over 2 hours, and bevacizumab IV over 30-90 minutes on day 1. Patients also receive fluorouracil (5-FU) IV continuously over 46 hours beginning on day 1. Treatment repeats every 2 weeks for 9 courses in the absence of disease progression or unacceptable toxicity. Patients then receive up to 3 additional courses of leucovorin calcium, 5-FU, and bevacizumab.

After completion of study treatment, patients are followed periodically for 10 years.

PROJECTED ACCRUAL: A total of 58 patients will be accrued for this study.

DISEASE CHARACTERISTICS:

• Histologically confirmed adenocarcinoma of the rectum

  • Locally advanced disease

• Must have primary T3 or T4 tumor

  • Transmural penetration of tumor through the muscularis propria by CT scan plus endorectal ultrasound or MRI

    • An endorectal coil or pelvic MRI is allowed
  • Distal border of the tumor must be at or below the peritoneal reflection, defined as within 12 cm of the anal verge by proctoscopic examination

  • Tumors that are clinically fixed, clinical stage T4, N0-2, M0 are eligible if it is believed that the tumors are potentially resectable after chemoradiotherapy, based on the following:

    • Clinically fixed tumors on rectal examination with tumor adherent to the pelvic sidewall or sacrum

      • Sciatica attributed to sacral root invasion with CT scan/MRI evidence of the lack of clear tissue plane will be considered evidence of fixation
    • Hydronephrosis on CT scan or intravenous pyelogram or ureteric or bladder invasion as documented by cystoscopy and cytology or biopsy, or invasion into the prostate
    • Vaginal or uterine involvement

• Nonmetastatic disease

  • No evidence of tumor outside of the pelvis
  • No liver metastases
  • No peritoneal seeding
  • No metastatic inguinal lymphadenopathy

• Resectable disease, defined as completely resectable disease with negative margins based on routine examination of the non-anesthetized patient

  • A surgeon must prospectively define the tumor as either initially resectable or potentially resectable after preoperative chemoradiotherapy
  • A surgical evaluation must confirm patient's ability to tolerate the proposed surgical procedure
• Carcinoembryonic antigen must be determined prior to initiation of therapy

PATIENT CHARACTERISTICS:

• ECOG performance status 0-1
• Absolute neutrophil count ≥ 1,500/mm³
• Platelet count ≥ 100,000/mm³
• Creatinine clearance ≥ 50 mL/min
• Creatinine ≤ 1.5 times upper limit of normal (ULN)
• Bilirubin ≤ 1.5 times ULN
• Alkaline phosphatase < 2 times ULN
• SGOT < 2 times ULN

• Urine protein:creatinine ratio < 1

  • Patients with a urine protein:creatinine ratio of ≥ 1 must demonstrate < 1 gm of protein by 24-hour urine collection

• INR ≤ 1.5 unless patient is on full-dose anticoagulants and the following criteria is met:

  • In range INR (usually between 2 and 3)
  • On a stable dose of warfarin or on a stable dose of low molecular weight heparin
  • Must not have active bleeding or a pathological condition that is associated with a high risk of bleeding
• Caloric intake > 1,500 kilocalories/day
• Albumin > 2 gm/dL
• No known dihydropyrimidine dehydrogenase deficiency
• Not pregnant or nursing
• Negative pregnancy test
• Fertile patients must use effective contraception during and for 6 months after discontinuing bevacizumab
• No clinical evidence of high-grade (lumen diameter < 1 cm) large bowel obstruction, unless diverting colostomy has been performed
• No active inflammatory bowel disease
• No history of cerebrovascular accident/transient ischemic attack
• No myocardial infarction or unstable angina within the past 12 months
• No peripheral neuropathy > grade 1
• No clinically significant peripheral vascular disease
• Patients with a history of hypertension must have a blood pressure of < 150/90 mm Hg and be on a stable regimen of antihypertensive therapy
• No New York Heart Association class II-IV congestive heart failure
• No evidence of bleeding diathesis/coagulopathy
• No serious nonhealing wound or bone fracture
• No abdominal fistula, gastrointestinal perforation, or intra-abdominal abscess within the past 28 days
• No significant traumatic injury within the past 28 days
• No other malignancy within the past 5 years except nonmelanoma skin cancer or carcinoma in situ of the cervix
• No known allergy to study drugs
• No other serious medical illness or disease that might limit the patient's ability to receive protocol therapy

PRIOR CONCURRENT THERAPY:

• At least 28 days since prior major surgical procedure or open biopsy
• At least 7 days since prior core biopsy
• No prior chemotherapy for rectal cancer
• No prior pelvic irradiation
• No prior intra-operative radiotherapy (IORT) or brachytherapy treatment to the pelvis
• No concurrent intensity-modulated radiotherapy
• No concurrent full-dose anticoagulants