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Hall J, Wilson J, Shumway J, Yanagihara TK, Tepper J, Calvo B, Wang AZ, Pearlstein K, Wang K, Kim HJ. Outcomes of surgical resection and intraoperative electron radiotherapy for patients with para-aortic recurrences of gastrointestinal and gynecologic malignancies. Radiat Oncol 2023; 18:94. [PMID: 37268927 DOI: 10.1186/s13014-023-02289-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 05/25/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND Para-aortic lymph node (PALN) metastases from primary pelvic malignancies are often treated with resection, but recurrence is common. We report toxicity and oncologic outcomes for patients with PALN metastases from gastrointestinal and gynecologic malignancies treated with resection and intraoperative electron radiotherapy (IORT). METHODS We retrospectively identified patients with recurrent PALN metastases who underwent resection with IORT. All patients were included in the local recurrence (LR) and toxicity analyses. Only patients with primary colorectal tumors were included in the survival analysis. RESULTS There were 26 patients with a median follow up of 10.4 months. The rate of para-aortic local control (LC) was 77% (20/26 patients) and the rate of any cancer recurrence was 58% (15/26 patients). Median time from surgery and IORT to any recurrence was 7 months. The LR rate for those with positive/close margins was 58% (7/12 patients) versus 7% (1/14 patients) for those with negative margins (p = 0.009). 15% (4/26 patients) developed surgical wound and/or infectious complications, 8% (2/26 patients) developed lower extremity edema, 8% (2/26 patients) experienced diarrhea, and 19% (5/26 patients) developed an acute kidney injury. There were no reported nerve injuries, bowel perforations, or bowel obstructions. For patients with primary colorectal tumors (n = 19), the median survival (OS) was 23 months. CONCLUSIONS We report favorable LC and acceptable toxicity for patients receiving surgical resection and IORT for a population that has historically poor outcomes. Our data show disease control rates similar to literature comparisons for patients with strong risk factors for LR, such as positive/close margins.
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Affiliation(s)
- Jacob Hall
- Department of Radiation Oncology, University of North Carolina School of Medicine, 101 Manning Drive CB #7512, Chapel Hill, NC, 27514, USA.
| | - Jessica Wilson
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - John Shumway
- Department of Radiation Oncology, University of North Carolina School of Medicine, 101 Manning Drive CB #7512, Chapel Hill, NC, 27514, USA
| | - Ted K Yanagihara
- Department of Radiation Oncology, University of North Carolina School of Medicine, 101 Manning Drive CB #7512, Chapel Hill, NC, 27514, USA
| | - Joel Tepper
- Department of Radiation Oncology, University of North Carolina School of Medicine, 101 Manning Drive CB #7512, Chapel Hill, NC, 27514, USA
| | - Benjamin Calvo
- Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Andrew Z Wang
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kevin Pearlstein
- Department of Radiation Oncology, University of North Carolina School of Medicine, 101 Manning Drive CB #7512, Chapel Hill, NC, 27514, USA
| | - Kyle Wang
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, OH, USA
| | - Hong Jin Kim
- Division of Surgical Oncology, Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
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The use of intraoperative radiation therapy in the management of locally recurrent rectal cancer. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Calvo FA, Sole CV, Rutten HJ, Dries WJ, Lozano MA, Cambeiro M, Poortmans P, González-Bayón L. ESTRO/ACROP IORT recommendations for intraoperative radiation therapy in locally recurrent rectal cancer. Clin Transl Radiat Oncol 2020; 24:41-48. [PMID: 32613091 PMCID: PMC7320231 DOI: 10.1016/j.ctro.2020.06.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 06/14/2020] [Indexed: 12/28/2022] Open
Abstract
Multimodal strategies have been implemented for locally recurrent rectal cancer scheduled for complete surgical resection. Irradiation and systemic therapy have been added to improve the oncological outcome, as surgery alone was associated with a poor prognosis. Intraoperative irradiation (IORT) is a component of irradiation intensification. Long-term cancer control and a higher survival rate were consistently reported in patients who had IORT as a component of their multidisciplinary treatment. The experience reported by expert IORT groups is reviewed and recommendations to guide clinical practice are explained in detail.
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Affiliation(s)
- Felipe A. Calvo
- Department of Oncology, Clínica Universidad de Navarra, Universidad de Navarra, Madrid, Spain
- School of Medicine, Complutense University, Madrid, Spain
- Institute for Sanitary Research, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Corresponding author at: Department of Oncology, Clínica Universidad de Navarra, Madrid, Spain.
| | - Claudio V. Sole
- Department of Radiation Oncology, Instituto de Radiomedicina, Santiago, Chile
- Institute for Sanitary Research, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Harm J. Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
- GROW: School of Oncology and Developmental Biology, University of Maastricht, Maastricht, the Netherlands
| | - Wim J. Dries
- Departments of Medical Physics and Radiotherapy, Catharina Hospital, Eindhoven, the Netherlands
| | - Miguel A. Lozano
- Department of Radiation Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Mauricio Cambeiro
- Department of Oncology, Clínica Universidad de Navarra, Universidad de Navarra, Madrid, Spain
| | - Philip Poortmans
- Department of Radiation Oncology, Institut Curie, Paris, France
- Paris Sciences & Lettres - PSL University, Paris, France
| | - Luis González-Bayón
- Institute for Sanitary Research, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Department of General Surgery, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Tam SY, Wu VWC. A Review on the Special Radiotherapy Techniques of Colorectal Cancer. Front Oncol 2019; 9:208. [PMID: 31001474 PMCID: PMC6454863 DOI: 10.3389/fonc.2019.00208] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 03/11/2019] [Indexed: 12/23/2022] Open
Abstract
Colorectal cancer is one of the commonest cancers worldwide. Radiotherapy has been established as an indispensable component of treatment. Although conventional radiotherapy provides good local control, radiotherapy treatment side-effects, local recurrence and distant metastasis remain to be the concerns. With the recent technological advancements, various special radiotherapy treatment options have been offered. This review article discusses the recently-developed special radiotherapy treatment modalities for various conditions of colorectal cancer ranging from early stage, locally advanced stage, recurrent, and metastatic diseases. The discussion focuses on the areas of feasibility, local control, and survival benefits of the treatment modalities. This review also provides accounts of the future direction in radiotherapy of colorectal cancer with emphasis on the coming era of personalized radiotherapy.
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Affiliation(s)
- Shing Yau Tam
- Department of Health Technology and Informatics, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Kowloon, Hong Kong
| | - Vincent W C Wu
- Department of Health Technology and Informatics, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Kowloon, Hong Kong
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Intraoperative Radiation Therapy for Locally Advanced or Locally Recurrent Rectal Cancer. CURRENT COLORECTAL CANCER REPORTS 2017. [DOI: 10.1007/s11888-017-0387-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Haddock MG. Intraoperative radiation therapy for colon and rectal cancers: a clinical review. Radiat Oncol 2017; 12:11. [PMID: 28077144 PMCID: PMC5225643 DOI: 10.1186/s13014-016-0752-1] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 12/21/2016] [Indexed: 01/06/2023] Open
Abstract
Although there have been significant advances in the adjuvant therapy of colorectal cancer, results for patients have historically been poor when complete resection is unlikely or not possible. Similarly, locally recurrent colorectal cancer patients often experience significant tumor related morbidity and disease control and long term survival have historically been poor with standard therapies. Intraoperative radiation therapy (IORT) has been proposed as a possible tool for dose escalation in patients with locally advanced colorectal cancer. For patients with locally advanced primary or recurrent colon cancer, the absence of prospective controlled trials limits the ability to draw definitive conclusions in completely resected patients. In subtotally resected patients, the available evidence is consistent with marked improvements in disease control and survival compared to historical controls. For patients with locally advanced primary or recurrent rectal cancer, a relatively large body of evidence suggests improved disease control and survival, especially in subtotally resected patients, with the addition of IORT to moderate dose external beam radiation (EBRT) and chemotherapy. The most important prognostic factor in nearly all series is the completeness of surgical resection. Many previously irradiated patients may be carefully re-treated with radiation and IORT in addition to chemotherapy resulting in long term survival in more than 25% of patients. Peripheral nerve is dose limiting for IORT and patients receiving 15 Gy or more are at higher risk. IORT is a useful tool when dose escalation beyond EBRT tolerance limits is required for acceptable local control in patients with locally advanced primary or recurrent colorectal cancer. Previously irradiated patients should not be excluded from treatment consideration.
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Affiliation(s)
- Michael G Haddock
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
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Intraoperative radiotherapy with low energy photons in recurrent colorectal cancer: a single centre retrospective study. Contemp Oncol (Pozn) 2016; 20:52-7. [PMID: 27095940 PMCID: PMC4829748 DOI: 10.5114/wo.2016.58500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 10/29/2015] [Indexed: 11/17/2022] Open
Abstract
AIM OF THE STUDY Intraoperative radiotherapy (IORT) may improve outcome of surgical treatment of recurrent colorectal cancer (CRC). The aim of this study is to determine the feasibility, safety and long-term results of surgical treatment of recurrent CRC with orthovolt IORT. MATERIAL AND METHODS Fifty-nine consecutive CRC patients with local recurrence (LR), undergoing surgery, were included in the retrospective analysis of prospectively collected data. The modified Wanebo classification was used to stage LR (Tr). Twenty-five (43%) patients received IORT using INTRABEAM(®) PRS 500. The complications were classified according to the Clavien-Dindo classification. RESULTS There were 32 males and 27 females, with a median age of 63 years. Multi-visceral resections were performed in 37 (63%) patients. Median hospitalization time after surgery with IORT was 7 days. One (1.7%) in-hospital postoperative death was reported. Grade 3/4 postoperative complications were found in 11 (19%) patients. Intraoperative radiotherapy had no effect on the postoperative hospitalization time, morbidity and mortality. Median survival after R0 resection was 32 months. Complete resection (R0), no synchronous liver metastases (M0), and no lateral and posterior pelvic wall involvement, were significant predictors of improved survival. Stage of LR was found to be an independent prognostic factor in the multivariate analysis (p = 0.03); Cox regression model). In patients with LR stage < Tr5, a 3-year overall survival (OS) rate was 52%. CONCLUSIONS Combination of surgical resection and orthovolt IORT is a safe and feasible procedure that does not increase the risk of postoperative complications or prolongs the hospital stay. Despite aggressive surgery supported by IORT, the advanced stage of LR is a limiting factor of long-term survival.
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Abstract
Adjuvant therapy with chemoradiation or short-course radiation in addition to improvements in surgical technique has led to improved outcomes for patients with locally advanced rectal cancer. Local recurrence rates of less than 10% and 5-year survival rate of 60% or higher is expected. However, for patients with very locally advanced primary or locally recurrent disease in whom surgical resection is likely to be associated with incomplete resection, survival and disease control rates are poor and standard doses of adjuvant radiation or chemoradiation are relatively ineffective. Dose-escalation approaches with intraoperative radiation (IORT) have been explored in both the primary and recurrent setting. Although high-level evidence is lacking, available data suggest improvements in local and distant control leading to improved survival with IORT approaches. This review summarizes the evidence for dose-escalation approaches with IORT for patients with very locally advanced and recurrent rectal cancer.
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9
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Terezakis S, Morikawa L, Wu A, Zhang Z, Shi W, Weiser MR, Paty PB, Guillem J, Temple L, Nash GM, Zelefsky MJ, Goodman KA. Long-Term Survival After High-Dose-Rate Brachytherapy for Locally Advanced or Recurrent Colorectal Adenocarcinoma. Ann Surg Oncol 2015; 22:2168-78. [PMID: 25631062 DOI: 10.1245/s10434-014-4271-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND We evaluated outcomes of intraoperative radiotherapy delivered with focal high-dose-rate (HDR) brachytherapy [intraoperative radiotherapy (IORT)] in the management of locally recurrent (LR) and locally advanced (LA) primary T4 colorectal carcinoma (CRC). LR CRC or LA primary disease is a clinical challenge due to the difficulty in obtaining negative margins after radical surgery and the high risk of subsequent recurrence. Few data exist on long-term outcomes of patients treated with surgery and HDR-IORT for LR or LA primary CRC. METHODS Three hundred CRC patients underwent HDR-IORT to the pelvis with gross surgical resection during November 1992-December 2007. Median follow-up for surviving patients was 53 (range 5-216) months. Eighty-eight patients (29 %) were treated for LA primary and 212 (71 %) LR disease. HDR-IORT was delivered using an iridium-192 remote afterloader and a Harrison-Anderson-Mick applicator. Median IORT dose was 1,500 (range 1,000-2,000) cGy. RESULTS Five-year overall survival probability was 49 %. Positive margin status was associated with inferior overall survival and disease-free survival. Competing-risks analysis for time to local failure and distant metastases identified a 5-year cumulative incidence of local failure and distant metastases of 33 and 47 %, respectively. Five-year cumulative incidence of local failure was 22 % for the LA group and 38 % in the LR group. Five-year probability of disease-free survival was 48 and 31 % for LA and LR patients, respectively, and 5-year probability of overall survival was 56 and 45 % for LA and LR patients, respectively. CONCLUSIONS HDR-IORT combined with resection results in encouraging local control rates with acceptable toxicity for patients with locally aggressive CRC.
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Affiliation(s)
- Stephanie Terezakis
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Wiig JN, Giercksky KE, Tveit KM. Intraoperative radiotherapy for locally advanced or locally recurrent rectal cancer: Does it work at all? Acta Oncol 2014; 53:865-76. [PMID: 24678823 DOI: 10.3109/0284186x.2014.895037] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Intraoperative radiotherapy (IORT) has been given for primary and locally recurrent rectal cancer for 30 years. Still, its effect is not clear. MATERIAL AND METHODS PubMed and EMBASE search for papers after 1989 on surgical treatment and external beam radiotherapy (EBRT) for primary advanced and locally recurrent rectal cancer, with and without IORT. From each center the most recent paper was generally selected. Survival and local recurrence at five years was tabulated for the total groups and separate R-stages. Also, the technique for IORT, use of EBRT and chemotherapy as well as surgical approach was registered. RESULTS In primary cancer 18 papers from 14 centers were tabulated, including one randomized and five internally comparing studies, as well as seven studies without IORT. In locally recurrent cancer 18 papers from 13 centers were tabulated, including four internally comparing studies and also five without IORT. Overall survival (OS) and local recurrence rate (LRR) were higher for primary cancer compared to recurrent cancer. Patients with R0 resections had better outcome than patients with R1 or R2 resections. For primary cancer OS and LR rate of the total groups and R0 stages was not influenced by IORT. An effect on R1/R2 stages cannot be excluded. The only randomized study (primary cancer) did not show any effect of IORT. CONCLUSION IORT does not convincingly improve OS and LR rate for primary and locally recurrent rectal cancer. If there is an effect of IORT, it is small and cannot be shown outside randomized studies analyzing the separate R stages.
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Affiliation(s)
- Johan N Wiig
- Department of Gastroenterological Surgery, The Norwegian Radium Hospital, Oslo University Hospital , Oslo , Norway
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Seo YS, Kim MS, Yoo HJ, Jang WI. Stereotactic body radiotherapy for oligo-recurrence within the nodal area from colorectal cancer. World J Gastroenterol 2014; 20:2005-2013. [PMID: 24587675 PMCID: PMC3934470 DOI: 10.3748/wjg.v20.i8.2005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 09/25/2013] [Accepted: 01/08/2014] [Indexed: 02/06/2023] Open
Abstract
Recurrence of colorectal cancer (CRC) often presents as solitary metastases, oligometastases or oligo-recurrence. Surgical resection became the preferred treatment for patients with CRC lung and hepatic metastases. However, surgical treatment for oligo-recurrence within nodal area is not a widely accepted treatment due to due to their relative rarity and high postoperative morbidity. Stereotactic body radiotherapy (SBRT) is one of the emerging radiation treatment techniques in which a high radiation dose can be delivered to the tumor. High-dose SBRT can ablate the tumor with an efficacy similar to that achieved with surgery, especially for small tumors. However, there have been very few studies on SBRT for oligo-recurrence within nodal area, although several studies have evaluated the role of SBRT in the treatment of liver and lung metastases from CRC. This article reviews the current clinical status of and treatment methods for oligo-recurrence within nodal area from CRC, with particular emphasis on SBRT.
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Goo MJ, Park JK, Hong IH, Kim AY, Lee EM, Lee EJ, Hwang M, Jeong KS. Increased susceptibility of radiation-induced intestinal apoptosis in SMP30 KO mice. Int J Mol Sci 2013; 14:11084-95. [PMID: 23708106 PMCID: PMC3709720 DOI: 10.3390/ijms140611084] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Revised: 05/08/2013] [Accepted: 05/15/2013] [Indexed: 11/16/2022] Open
Abstract
Recently, senescence marker protein-30 (SMP30) knockout (KO) mice have been reported to be susceptible to apoptosis, however, the role of SMP30 has not been characterized in the small intestine. The aim of the present study is to investigate the role of SMP30 in the process of spontaneous and γ-radiation-induced apoptosis in mouse small intestine. Eight-week-old male wild-type (WT) mice and SMP30 KO mice were examined after exposure to 0, 1, 3, 5, and 9 Gy of γ-radiation. Apoptosis in the crypts of the small intestine increased in the 0 to 5 Gy radiated SMP30 KO and WT mice. Radiation-induced apoptosis and the BAX/Bcl-2 ratio in the SMP30 KO mice were significantly increased in comparison to each identically treated group of WT mice (p < 0.05). The levels of spontaneous apoptosis in both WT and KO mice were similar (p > 0.05), indicating that increased apoptosis of crypt cells of SMP30 KO by irradiation can be associated with SMP30 depletion. These results suggested that SMP30 might be involved in overriding the apoptotic homeostatic mechanism in response to DNA damage.
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Affiliation(s)
- Moon-Jung Goo
- Department of Pathology, College of Veterinary Medicine, Kyungpook National University, Daegu 702-701, Korea; E-Mails: (M.-J.G.); (J.-K.P.); (I.-H.H.); (A.-Y.K.); (E.-M.L.); (E.-J.L.); (M.H.)
| | - Jin-Kyu Park
- Department of Pathology, College of Veterinary Medicine, Kyungpook National University, Daegu 702-701, Korea; E-Mails: (M.-J.G.); (J.-K.P.); (I.-H.H.); (A.-Y.K.); (E.-M.L.); (E.-J.L.); (M.H.)
| | - Il-Hwa Hong
- Department of Pathology, College of Veterinary Medicine, Kyungpook National University, Daegu 702-701, Korea; E-Mails: (M.-J.G.); (J.-K.P.); (I.-H.H.); (A.-Y.K.); (E.-M.L.); (E.-J.L.); (M.H.)
| | - Ah-Young Kim
- Department of Pathology, College of Veterinary Medicine, Kyungpook National University, Daegu 702-701, Korea; E-Mails: (M.-J.G.); (J.-K.P.); (I.-H.H.); (A.-Y.K.); (E.-M.L.); (E.-J.L.); (M.H.)
- Stem Cell Therapeutic Research Institute, Kyungpook National University, Daegu 702-701, Korea
| | - Eun-Mi Lee
- Department of Pathology, College of Veterinary Medicine, Kyungpook National University, Daegu 702-701, Korea; E-Mails: (M.-J.G.); (J.-K.P.); (I.-H.H.); (A.-Y.K.); (E.-M.L.); (E.-J.L.); (M.H.)
- Stem Cell Therapeutic Research Institute, Kyungpook National University, Daegu 702-701, Korea
| | - Eun-Joo Lee
- Department of Pathology, College of Veterinary Medicine, Kyungpook National University, Daegu 702-701, Korea; E-Mails: (M.-J.G.); (J.-K.P.); (I.-H.H.); (A.-Y.K.); (E.-M.L.); (E.-J.L.); (M.H.)
- Stem Cell Therapeutic Research Institute, Kyungpook National University, Daegu 702-701, Korea
| | - Meeyul Hwang
- Department of Pathology, College of Veterinary Medicine, Kyungpook National University, Daegu 702-701, Korea; E-Mails: (M.-J.G.); (J.-K.P.); (I.-H.H.); (A.-Y.K.); (E.-M.L.); (E.-J.L.); (M.H.)
- Stem Cell Therapeutic Research Institute, Kyungpook National University, Daegu 702-701, Korea
| | - Kyu-Shik Jeong
- Department of Pathology, College of Veterinary Medicine, Kyungpook National University, Daegu 702-701, Korea; E-Mails: (M.-J.G.); (J.-K.P.); (I.-H.H.); (A.-Y.K.); (E.-M.L.); (E.-J.L.); (M.H.)
- Stem Cell Therapeutic Research Institute, Kyungpook National University, Daegu 702-701, Korea
- Author to whom correspondence should be addressed; E-Mail: ; Tel.: +82-53-950-5975; Fax: +82-53-950-5955
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Tanis PJ, Doeksen A, van Lanschot JJB. Intentionally curative treatment of locally recurrent rectal cancer: a systematic review. Can J Surg 2013; 56:135-44. [PMID: 23517634 DOI: 10.1503/cjs.025911] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND There is a lack of outcome data beyond local recurrence rates after primary treatment in rectal cancer, despite more information being necessary for clinical decision-making. We sought to determine patient selection, therapeutic modalities and outcomes of locally recurrent rectal cancer treated with curative intent. METHODS We searched MEDLINE (1990-2010) using the medical subject headings "rectal neoplasms" and "neoplasm recurrence, local." Selection of cohort studies was based on the primary intention of treatment and availability of at least 1 outcome variable. RESULTS We included 55 cohort studies comprising 3767 patients; 8 studies provided data on the rate of intentionally curative treatment from an unselected consecutive cohort of patients (481 of 1188 patients; 40%). Patients were symptomatic with pain in 50% (796 of 1607) of cases. Overall, 3088 of 3767 patients underwent resection. The R0 resection rate was 56% (1484 of 2637 patients). The rate of external beam radiotherapy was 100% in 9 studies, 0% in 5 studies, and ranged from 12% to 97% in 37 studies. Overall postoperative mortality was 2.2% (57 of 2515 patients). Five-year survival was at least 25%, with an upper limit of 41% in 11 of 18 studies including at least 50 resections. We found a significant increase in reported survival rates over time (r2 = 0.214, p = 0.007). CONCLUSION More uniformity in treatment protocols and reporting on outcomes for locally recurrent rectal cancer is warranted. The observed improvement of reported survival rates in time is probably related to better patient selection and optimized multimodality treatment in specialized centres.
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Affiliation(s)
- Pieter J Tanis
- The Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
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Mirnezami R, Chang GJ, Das P, Chandrakumaran K, Tekkis P, Darzi A, Mirnezami AH. Intraoperative radiotherapy in colorectal cancer: systematic review and meta-analysis of techniques, long-term outcomes, and complications. Surg Oncol 2013; 22:22-35. [PMID: 23270946 PMCID: PMC4663079 DOI: 10.1016/j.suronc.2012.11.001] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Revised: 11/03/2012] [Accepted: 11/10/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND The precise contribution of IORT to the management of locally advanced and recurrent colorectal cancer (CRC) remains uncertain. We performed a systematic review and meta-analysis to assess the value of IORT in this setting. METHODS Studies published between 1965 and 2011 that reported outcomes after IORT for advanced or recurrent CRC were identified by an electronic literature search. Studies were assessed for methodological quality and design, and evaluated for technique of IORT delivery, oncological outcomes, and complications following IORT. Outcomes were analysed with fixed-effect and random-effect model meta-analyses and heterogeneity and publication bias examined. RESULTS 29 studies comprising 14 prospective and 15 retrospective studies met the inclusion criteria and were assessed, yielding a total of 3003 patients. The indication for IORT was locally advanced disease in 1792 patients and locally recurrent disease in 1211 patients. Despite heterogeneity in methodology and reporting practice, IORT is principally applied for the treatment of close or positive margins. When comparative studies were evaluated, a significant effect favouring improved local control (OR 0.22; 95% CI = 0.05-0.86; p = 0.03), disease free survival (HR 0.51; 95% CI = 0.31-0.85; p = 0.009), and overall survival (HR 0.33; 95% CI = 0.2-0.54; p = 0.001) was noted with no increase in total (OR 1.13; 95% CI = 0.77-1.65; p = 0.57), urologic (OR 1.35; 95% CI = 0.84-2.82; p = 0.47), or anastomotic complications (OR 0.94; 95% CI = 0.42-2.1; p = 0.98). Increased wound complications were noted after IORT (OR 1.86; 95% CI = 1.03-3.38; p = 0.049). CONCLUSIONS Despite methodological weaknesses in the studies evaluated, our results suggest that IORT may improve oncological outcomes in advanced and recurrent CRC.
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Affiliation(s)
- Reza Mirnezami
- Section of Biosurgery & Surgical Technology, Department of Surgery & Cancer, Imperial College London, 10th Floor QEQM Building, St Mary's Hospital, London W2 1NY, UK
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Roeder F, Goetz JM, Habl G, Bischof M, Krempien R, Buechler MW, Hensley FW, Huber PE, Weitz J, Debus J. Intraoperative Electron Radiation Therapy (IOERT) in the management of locally recurrent rectal cancer. BMC Cancer 2012; 12:592. [PMID: 23231663 PMCID: PMC3557137 DOI: 10.1186/1471-2407-12-592] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Accepted: 12/03/2012] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND To evaluate disease control, overall survival and prognostic factors in patients with locally recurrent rectal cancer after IOERT-containing multimodal therapy. METHODS Between 1991 and 2006, 97 patients with locally recurrent rectal cancer have been treated with surgery and IOERT. IOERT was preceded or followed by external beam radiation therapy (EBRT) in 54 previously untreated patients (median dose 41.4 Gy) usually combined with 5-Fluouracil-based chemotherapy (89%). IOERT was delivered via cylindric cones with doses of 10-20 Gy. Adjuvant CHT was given only in a minority of patients (34%). Median follow-up was 51 months. RESULTS Margin status was R0 in 37%, R1 in 33% and R2 in 30% of the patients. Neoadjuvant EBRT resulted in significantly increased rates of free margins (52% vs. 24%). Median overall survival was 39 months. Estimated 5-year rates for central control (inside the IOERT area), local control (inside the pelvis), distant control and overall survival were 54%, 41%, 40% and 30%. Resection margin was the strongest prognostic factor for overall survival (3-year OS of 80% (R0), 37% (R1), 35% (R2)) and LC (3-year LC 82% (R0), 41% (R1), 18% (R2)) in the multivariate model. OS was further significantly affected by clinical stage at first diagnosis and achievement of local control after treatment in the univariate model. Distant failures were found in 46 patients, predominantly in the lung. 90-day postoperative mortality was 3.1%. CONCLUSION Long term OS and LC can be achieved in a substantial proportion of patients with recurrent rectal cancer using a multimodality IOERT-containing approach, especially in case of clear margins. LC and OS remain limited in patients with incomplete resection. Preoperative re-irradiation and adjuvant chemotherapy may be considered to improve outcome.
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Affiliation(s)
- Falk Roeder
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, Heidelberg, 69120, Germany.
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16
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Sun DS, Zhang JD, Li L, Dai Y, Yu JM, Shao ZY. Accelerated hyperfractionation field-involved re-irradiation combined with concurrent capecitabine chemotherapy for locally recurrent and irresectable rectal cancer. Br J Radiol 2011; 85:259-64. [PMID: 21385917 DOI: 10.1259/bjr/28173562] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES To evaluate the efficacy and treatment-related toxicity of accelerated hyperfractionation field-involved re-irradiation combined with concurrent capecitabine chemotherapy for locally recurrent and irresectable rectal cancer (LRIRC). METHODS 72 patients with LRIRC who underwent the treatment were studied. Three-dimensional conformal accelerated hyperfractionation radiotherapy (3D-CAHRT) was performed and the dose was delivered with a schedule of 1.2 Gy twice daily, with an interval of at least 6 h between fractions, 5 days a week. Concurrent capecitabine chemotherapy was administered twice daily. After 36 Gy in 30 fractions over 3 weeks, patients were evaluated to define the resectability of the disease. If resection was not feasible irradiation was resumed until the total dose administered to the tumour reached 51.6-56.4 Gy. RESULTS Two patients temporarily interrupted concurrent chemoradiation because of Grade IV diarrhoea. The remaining 70 patients completed the planned concurrent chemoradiation. In all patients, the complete response rate was 8.3% and the partial response rate was 51.4%. The overall response rate was 59.7% and clinical benefit rate was 93.1%. Symptomatic responses proved to be obvious and tumour resection was performed in 18 patients. The overall median survival time and median progression-free survival time were 32 and 17 months, respectively. 3 year overall survival and progression-free survival were 45.12% and 31.19%, respectively. Severely acute toxicities included Grade III-IV diarrhoea and granulocytopenia with 9.7% and 8.3% incidence respectively. Small bowel obstruction was severely late toxicity, and the incidence was 1.4%. CONCLUSION Three-dimensional conformal accelerated hyperfractionation field-involved re-irradiation combined with concurrent capecitabine chemotherapy might be an effective and well-tolerated regimen for patients with LRIRC.
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Affiliation(s)
- D-S Sun
- Department of Oncology, the Second Hospital of Shandong University, Jinan, Shandong Province, China
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17
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Haddock MG, Miller RC, Nelson H, Pemberton JH, Dozois EJ, Alberts SR, Gunderson LL. Combined modality therapy including intraoperative electron irradiation for locally recurrent colorectal cancer. Int J Radiat Oncol Biol Phys 2010; 79:143-50. [PMID: 20395067 DOI: 10.1016/j.ijrobp.2009.10.046] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2009] [Revised: 10/26/2009] [Accepted: 10/29/2009] [Indexed: 12/12/2022]
Abstract
PURPOSE To evaluate survival, relapse patterns, and prognostic factors in patients with colorectal cancer relapse treated with curative-intent therapy, including intraoperative electron radiation therapy (IOERT). METHODS AND MATERIALS From April 1981 through January 2008, 607 patients with recurrent colorectal cancer received IOERT as a component of treatment. IOERT was preceded or followed by external radiation (median dose, 45.5 Gy) in 583 patients (96%). Resection was classified as R0 in 227 (37%), R1 in 224 (37%), and R2 in 156 (26%). The median IOERT dose was 15 Gy (range, 7.5-30 Gy). RESULTS Median overall survival was 36 months. Five- and 10-year survival rates were 30% and 16%, respectively. Survival estimates at 5 years were 46%, 27%, and 16% for R0, R1, and R2 resection, respectively. Multivariate analysis revealed that R0 resection, no prior chemotherapy, and more recent treatment (in the second half of the series) were associated with improved survival. The 3-year cumulative incidence of central, local, and distant relapse was 12%, 23%, and 49%, respectively. Central and local relapse were more common in previously irradiated patients and in those with subtotal resection. Toxicity Grade 3 or higher partially attributable to IOERT was observed in 66 patients (11%). Neuropathy was observed in 94 patients (15%) and was more common with IOERT doses exceeding 12.5 Gy. CONCLUSIONS Long-term survival and disease control was achievable in patients with locally recurrent colorectal cancer. Continued evaluation of curative-intent, combined-modality therapy that includes IOERT is warranted in this high-risk population.
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Affiliation(s)
- Michael G Haddock
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA.
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18
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Dresen RC, Gosens MJ, Martijn H, Nieuwenhuijzen GA, Creemers GJ, Daniels-Gooszen AW, van den Brule AJ, van den Berg HA, Rutten HJ. Radical resection after IORT-containing multimodality treatment is the most important determinant for outcome in patients treated for locally recurrent rectal cancer. Ann Surg Oncol 2008; 15:1937-47. [PMID: 18389321 PMCID: PMC2467498 DOI: 10.1245/s10434-008-9896-z] [Citation(s) in RCA: 124] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2008] [Revised: 03/06/2008] [Accepted: 03/06/2008] [Indexed: 12/22/2022]
Abstract
Background The optimal treatment for locally recurrent rectal cancer (LRRC) is still a matter of debate. This study assessed the outcome of LRRC patients treated with multimodality treatment, consisting of neoadjuvant radio (chemo-) therapy, extended resection, and intraoperative radiotherapy. Methods One hundred and forty-seven consecutive patients with LRRC who underwent treatment between 1994 and 2006 were studied. The prognostic values of patient-, tumor- and treatment-related characteristics were tested with uni- and multivariate analysis. Results Median overall survival was 28 months (range 0-146 months). Five-year overall, disease-free, and metastasis-free survival and local control (OS, DFS, MFS, and LC respectively) were 31.5%, 34.1%, 49.5% and 54.1% respectively. Radical resection (R0) was obtained in 84 patients (57.2%), microscopically irradical resection (R1) in 34 patients (23.1%), and macroscopically irradical resection (R2) in 29 patients (19.7%). For patients with a radical resection median OS was 59 months and the 5-year OS, DFS, MFS, and LC were 48.4%, 52.3%, 65.5% and 68.9%, respectively. Radical resection was significantly correlated with improved OS, DFS, and LC (P < 0.001). Patients who received re-irradiation or full-course radiotherapy survived significantly longer (P = 0.043) and longer without local recurrence (P = 0.038) or metastasis (P < 0.001) compared to patients who were not re-irradiated. Conclusions Radical resection is the most significant predictor of improved survival in patients with LRRC. Neoadjuvant radio (chemo-) therapy is the best option in order to realize a radical resection. Re-irradiation is feasible in patients who already received irradiation as part of the primary rectal cancer treatment.
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Affiliation(s)
- Raphaëla C Dresen
- Department of Surgery, Catharina Hospital Eindhoven, Postbox 1350, 5602 ZA, Eindhoven, The Netherlands
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19
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Polistena A, Johnson LB, Ohiami-Masseron S, Wittgren L, Bäck S, Thornberg C, Gadaleanu V, Adawi D, Jeppsson B. Local radiotherapy of exposed murine small bowel: apoptosis and inflammation. BMC Surg 2008; 8:1. [PMID: 18173838 PMCID: PMC2248567 DOI: 10.1186/1471-2482-8-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2007] [Accepted: 01/03/2008] [Indexed: 12/15/2022] Open
Abstract
Background Preoperative radiotherapy of the pelvic abdomen presents with complications mostly affecting the small bowel. The aim of this study was to define the features of early radiation-induced injury on small bowel. Methods 54 mice were divided into two groups (36 irradiated and 18 sham irradiated). Animals were placed on a special frame and (in the radiated group) the exteriorized segment of ileum was subjected to a single absorbed dose of 19 or 38 Gy radiation using 6 MV high energy photons. Specimens were collected for histology, immunohistochemistry (IHC) and ELISA analysis after 2, 24 and 48 hours. Venous blood was collected for systemic leucocyte count in a Burker chamber. Results Histology demonstrated progressive infiltration of inflammatory cells with cryptitis and increased apoptosis. MIP-2 (macrophage inflammatory protein) concentration was significantly increased in irradiated animals up to 48 hours. No significant differences were observed in IL-10 (interleukin) and TNF-α (tumour necrosis factor) levels. IHC with CD45 showed a significant increase at 2 hours of infiltrating leucocytes and lymphocytes after irradiation followed by progressive decrease with time. Caspase-3 expression increased significantly in a dose dependent trend in both irradiated groups up to 48 hours. Conclusion Acute small bowel injury caused by local irradiation is characterised by increased apoptosis of crypt epithelial cells and by lymphocyte infiltration of the underlying tissue. The severity of histological changes tends to be dose dependent and may affect the course of tissue damage.
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Affiliation(s)
- Andrea Polistena
- Department of Surgery, Malmö University Hospital, Lund University, Malmö, Sweden.
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20
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Minsky BD. Treatment of Unresectable/Recurrent Rectal Cancer with External Beam and/or Intraoperative Radiation Techniques. SEMINARS IN COLON AND RECTAL SURGERY 2005. [DOI: 10.1053/j.scrs.2005.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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21
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Shibata SI, Pezner R, Chu D, Doroshow JH, Chow WA, Leong LA, Margolin KA, McNamara MV, Morgan RJ, Raschko JW, Somlo G, Tetef ML, Yen Y, Synold TW, Wagman L, Vora N, Carroll M, Lin S, Longmate J. A study of radiotherapy modalities combined with continuous 5-FU infusion for locally advanced gastrointestinal malignancies. Eur J Surg Oncol 2004; 30:650-7. [PMID: 15256240 DOI: 10.1016/j.ejso.2003.11.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2003] [Indexed: 11/26/2022] Open
Abstract
AIM We describe the feasibility of combining infusional 5-fluorouracil (5-FU) with intraoperative radiation therapy (IORT). METHODS Patients with surgically resectable locally advanced gastrointestinal cancers were treated concurrently during surgery with IORT and a 72 h infusion of 5-FU. Patients without previous external beam radiation therapy (EBRT) were subsequently treated with EBRT (40-50Gy) concurrent with a 21-day continuous infusion of 5-FU. Pancreatic, gastric, duodenal, ampullary, recurrent colorectal, and recurrent anal cancer were included. RESULTS During IORT/5-FU, no chemotherapy-related grade III or IV hematologic or gastrointestinal toxicity was noted. Post-surgical recovery or wound healing was not affected. One of nine patients who received post-operative radiation required a treatment break. During follow-up, there were more complications in patients with pelvic tumours, especially those with previous radiation. Nine patients have had local and/or local regional recurrences, two of these in the IORT field. CONCLUSIONS Treatment with a combination of IORT and 5-FU followed by EBRT and 5-FU is feasible. However, long-term complications may be increased in previously irradiated recurrent pelvic tumours.
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Affiliation(s)
- S I Shibata
- Department of Medical Oncology and Therapeutics Research, City of Hope National Medical Center, 1500 E. Duarte Road, Duarte, CA 91010, USA
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22
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Nuyttens JJ, Kolkman-Deurloo IKK, Vermaas M, Ferenschild FT, Graveland WJ, De Wilt JH, Hanssens PE, Levendag PC. High-dose-rate intraoperative radiotherapy for close or positive margins in patients with locally advanced or recurrent rectal cancer. Int J Radiat Oncol Biol Phys 2004; 58:106-12. [PMID: 14697427 DOI: 10.1016/s0360-3016(03)01494-9] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE A high-dose-rate intraoperative radiotherapy (HDR-IORT) technique for rectum cancer was developed and the technique, local failure, and survival were analyzed. METHODS AND MATERIALS After the exclusion of metastatic patients, 37 patients were treated with external beam RT, surgery, and HDR-IORT between 1997 and 2000. Primary locally advanced rectum cancer was found in 18 patients and recurrent disease in 19. HDR-IORT was only administered if the resection margins were < or =2 mm. The flexible intraoperative template is a 5-mm-thick pad with 1-cm-spaced parallel catheters. Clips were placed during surgery to define the target area. A dose of 10 Gy was prescribed at a 1 cm depth from the template surface and calculated using standard plans. After treatment, the dose at the clips was calculated using the reconstructed template geometry and the actual treatment dwell times. The median follow-up of surviving patients was 3 years. No patients were lost to follow-up. RESULTS Overall, 12 patients (32%) had local recurrence, 5 (14%) of which were in the HDR-IORT field. The 3-year local failure rate for primary tumors and recurrent tumors was 19% and 52%, respectively (p = 0.0042). The 3-year local failure rate was 37% for negative margins and 26% for positive margins (p = 0.51). A high mean dose at the clip (17.3 Gy) was found. The overall survival was significantly different for primary vs. recurrent tumors, stage, and grade. CONCLUSION Because of the HDR technique, a high dose at the clips was found, with good local control. More out-of-field than in-field failures were seen. The local failure rate was significantly different for primary vs. recurrent disease.
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Affiliation(s)
- Joost J Nuyttens
- Department of Radiation Oncology, Erasmus Medical Center-Daniel Den Hoed, Rotterdam, The Netherlands.
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23
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Pezner RD, Chu DZJ, Ellenhorn JDI. Intraoperative radiation therapy for patients with recurrent rectal and sigmoid colon cancer in previously irradiated fields. Radiother Oncol 2002; 64:47-52. [PMID: 12208575 DOI: 10.1016/s0167-8140(02)00139-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A retrospective study evaluated 15 patients with pelvic recurrence of colorectal cancer in a previously irradiated region who received intraoperative radiation therapy (IORT) as part of salvage therapy. Total prior external beam radiation therapy (EBRT) doses ranged from 45 to 79.2 Gy. Tumor resection was accomplished in 14 patients, with an exenteration performed in seven. IORT dose was 15-20 Gy. Three patients received additional EBRT as a post-operative course of 25.2 Gy in 14 fractions. Actuarial 3-year local control rate was 25%. The 3-year overall survival rate was 29%. Patients with fixed and/or bulky pelvic tumors had a local control rate of 19% at 12 months and median overall survival of 9 months. Patients with less extensive clinical presentations of anastomotic non-fixed transmural recurrence, isolated pelvic node metastasis and rectal recurrence following local excision had a local control rate of 42% at 36 months and median survival of 43 months. We conclude that clinical presentation of recurrent disease is an important prognostic factor. The value of IORT may be limited to patients with less extensive clinical presentations.
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Affiliation(s)
- Richard D Pezner
- Division of Radiation Oncology, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA 91010, USA
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24
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Abstract
Radical surgery with negative margins remains the most important prognostic factor in the treatment of rectal cancer. Combined modality treatment is the recommended standard adjuvant therapy for patients with locally advanced rectal cancer in the USA and in Germany. During the last decade substantial progress has been made in treatment modalities: surgical management currently includes a broad spectrum of operative procedures ranging from radical operations to innovative sphincter-preserving techniques. Specialized groups have reported excellent local control rates with total mesorectal excision (TME) alone. New and improved radiation techniques (conformal radiotherapy, intraoperative radiotherapy) and innovative schedules (protracted intravenous infusion, chronomodulated infusion) and combinations (oxaliplatin, irinotecan) of chemotherapy may have the potential to further increase the therapeutic benefit of adjuvant treatment. Moreover, the basic issue of timing of radio-(chemo-)therapy - preoperative versus postoperative - within a multimodality regimen is currently being addressed in prospective trials. Evidently, the current monolithic approaches, established by studies conducted more than a decade ago, to apply either the same schedule of postoperative radiochemotherapy to all patients with stage II/III rectal cancer or to give preoperative intensive 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. This review will discuss different irradiation settings in more recent and ongoing studies of perioperative radiotherapy for rectal cancer and will focus on the issue which patient should receive radiotherapy at all, and if so, how and when?
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Affiliation(s)
- Rolf Sauer
- University of Erlangen, Department of Radiation Oncology Universit tsstr. 27, Erlangen, 91054, Germany
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25
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Minsky BD. Management of Locally Unresectable Rectal Cancer. COLORECTAL CANCER 2002. [DOI: 10.1007/978-1-59259-160-2_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Lehnert T, Treiber M, Tiefenbacher U, Herfarth C, Wannenmacher M. Intraoperative radiotherapy for gastrointestinal cancer. SEMINARS IN SURGICAL ONCOLOGY 2001; 20:40-9. [PMID: 11291131 DOI: 10.1002/ssu.1015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Local recurrence following potentially curative tumor resection is a major problem in patients with gastrointestinal cancer. To augment surgical excision and to avoid the disadvantages of external beam irradiation, intraoperative radiotherapy (IORT) has been applied to primary and recurrent gastrointestinal cancer, both with curative intent and for palliation. There is ample evidence that the combination of radical surgery and IORT can improve local control. Whether this eventually can translate into improved overall survival has not yet been studied in adequately powered randomized and controlled trials.
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Affiliation(s)
- T Lehnert
- Section of Surgical Oncology, University of Heidelberg, Heidelberg, Germany.
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27
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Rödel C, Sauer R. Perioperative radiotherapy and concurrent radiochemotherapy in rectal cancer. SEMINARS IN SURGICAL ONCOLOGY 2001; 20:3-12. [PMID: 11291127 DOI: 10.1002/ssu.1011] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Combined modality treatment is the recommended standard adjuvant therapy for patients with locally advanced rectal cancer in the United States and Germany. During the last decade substantial progress has been made in treatment modalities, and surgical management currently includes a broad spectrum of operative procedures ranging from radical operations to innovative sphincter-preserving techniques. Specialized groups have reported excellent local control rates with total mesorectal excision (TME) alone. New and improved radiation techniques (conformal and intraoperative radiotherapy) and innovative schedules (protracted intravenous and chronomodulated infusion) and combinations (oxaliplatin and irinotecan) of chemotherapy may have the potential to further increase the therapeutic benefit of adjuvant treatment. Moreover, the basic issue of timing (pre- or postoperative) within a multimodal regimen is currently being addressed in prospective trials. Evidently there is a need to question the current monolithic approaches, which were established by studies conducted more than a decade ago. It is also under discussion whether to apply the same schedule of postoperative radiochemotherapy to all patients with stage II/III rectal cancer, or to give preoperative intensive 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). This review discusses different irradiation settings in more recent and ongoing studies of perioperative radiotherapy for rectal cancer, and focuses on the issue of which patient should receive radiotherapy (if at all), and if so, how and when.
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Affiliation(s)
- C Rödel
- Department of Radiation Therapy, University of Erlangen-Nürnberg, Germany.
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28
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Alektiar KM, Zelefsky MJ, Paty PB, Guillem J, Saltz LB, Cohen AM, Minsky BD. High-dose-rate intraoperative brachytherapy for recurrent colorectal cancer. Int J Radiat Oncol Biol Phys 2000; 48:219-26. [PMID: 10924992 DOI: 10.1016/s0360-3016(00)00634-9] [Citation(s) in RCA: 101] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Management of locally recurrent colorectal adenocarcinoma represents a significant challenge. Many of these tumors adhere to or invade into vital pelvic structures rendering surgery or external beam radiotherapy (EBRT) as palliative treatment. Therefore, a treatment approach was developed to evaluate the role of high-dose-rate intraoperative brachytherapy (HDR-IORT) and surgery as a component of therapy in the management of locally recurrent colorectal cancer. This is an update of our preliminary report with longer follow-up and larger patient numbers. METHODS AND MATERIALS Between January 1992 and September 1998, 74 patients with locally recurrent rectal cancer were treated with surgery and HDR-IORT. Additional EBRT was given to 29 patients, and 33 patients received 5-fluorouracil based chemotherapy. All patients underwent complete gross resection, and 21 of 74 had positive microscopic margin. The dose of HDR-IORT ranged from 10 to 18 Gy. RESULTS With a median follow-up of 22 months, the 5-year local control, distant metastasis disease-free, disease-free, and overall survival rates were 39%, 39%, 23%, and 23%, respectively. The only predictor of improved local control was a negative margin of resection with a 5-year local control rate of 43%, compared to 26% in those with positive margin (p = 0.02). For overall survival, a negative microscopic margin (p = 0.04) and the use of IORT + EBRT (p = 0.04) were significant predictors of improved survival. The incidence of peripheral neuropathy was 16%. CONCLUSION The results with HDR-IORT in this group of patients are encouraging. Further improvements in local and distant control are still needed.
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Affiliation(s)
- K M Alektiar
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
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Luna-Pérez P, Rodríguez-Ramírez S, González-Macouzet J, Rodríguez-Coria DF, Delgado S, Lopez MJ. The influence of pre-operative radiation therapy on the patterns of recurrence in rectal adenocarcinoma. SEMINARS IN SURGICAL ONCOLOGY 1999; 17:199-205. [PMID: 10504668 DOI: 10.1002/(sici)1098-2388(199910/11)17:3<199::aid-ssu9>3.0.co;2-d] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
From January 1976 to December 1994, we evaluated the institutional experience of local recurrence and survival in patients with rectal adenocarcinoma treated with pre-operative radiation therapy (PRT) as compared to those treated with radical surgery alone. There were 412 patients, divided into two groups: 259 patients (142 males and 117 females) in Group I and 153 patients (88 males and 65 females) in Group II. The median age was 56 years. Group I patients with locally advanced tumors, either tethered or fixed, received PRT at doses of 45 Gy delivered to the pelvis in two fields; 4 to 8 weeks later, radical surgery was performed. Patients with mobile tumors underwent radical surgery only (Group II). The operative mortality was 4.6% in Group I as compared to 1.9% in Group II (P = 0.18). At median follow-up of 89 months, there were local recurrences in 12.9% of Group I as compared to 36.2% in Group II (P = 0.0000001). The administration of PRT was associated with a low rate of local recurrence, but this improvement corresponded with a high morbidity rate, especially in patients who underwent abdominoperineal resection or pelvic exenteration.
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Affiliation(s)
- P Luna-Pérez
- Surgical Oncology Department, Colorectal Service, Hospital de Oncología, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, México, D.F., México.
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