Conservative management of tumors of the rectum by radiotherapy and local excision

Preoperative radiotherapy and local excision of rectal cancer with immediate radical re-operation for poor responders

BACKGROUND AND PURPOSE

To report an early analysis of prospective study exploring preoperative radiotherapy and local excision in rectal cancer.

MATERIALS AND METHODS

Mucosa at tumour edges was tattooed. Patients with cT1-3N0 tumour <3-4 cm were treated with either 5x5Gy+4Gy boost (N=31) or chemoradiation (50.4Gy+5.4Gy boost, 1.8Gy per fraction+5-fluorouracyl and leucovorin; N=13). Thirteen patients from the short-course group were unfit for chemotherapy. The interval from radiation to full-thickness local excision was 6 weeks. The protocol called for conversion to a transabdominal surgery in case of ypT2-3 disease or positive margin.

RESULTS

The postoperative complications requiring hospitalization were recorded in 9% of patients. The rate of pathological complete response was 41%. The rate of patients requiring conversion was 34%; however, 18% actually underwent conversion and the remaining 16% refused or were unfit. During the 14 months of median follow-up, local recurrence was detected in 7% of patients and all underwent salvage surgery. Of 19 patients in whom initially anterior resection was likely, 16% had abdominoperineal resection performed for a conversion or as a rescue procedure.

CONCLUSION

Our study suggests that the short-course radiation prior to local excision is a treatment option for high-risk patients.

Treatment of T1–T2 rectal tumors by contact therapy and interstitial brachytherapy

BACKGROUND AND PURPOSE

We retrospectively analysed our experience of contact therapy alone and/or combined with interstitial brachytherapy as exclusive treatment of low lying rectal tumours.

PATIENTS AND METHODS

From 1971 to 2001, 124 patients (103 adenocarcinomas, 21 villous tumours) were treated by contact therapy alone or combined with interstitial brachytherapy. All patients were staged according to the Dijon classification. The average size of the lesions was 2.4 cm (max 7 cm), clinical aspect was polypoïd in 75% of the cases, flat in 17%. Sixty four patients received contact therapy in three fractions and 44 patients received four fractions, for an average delivered dose of 95 Gy. Interstitial brachytherapy boost delivered 24 Gy on a reference isodose of 55 cGy/h in 10 patients.

RESULTS

The local control was 83% for T1 and 38% for T2 tumours (p=0.004). For mobile tumours, the local control rate is 76%, significantly higher than for tumours with impaired mobility (55%, P=0.03). Thirty-nine patients experienced a local failure (31%). For patients amenable to surgery, a Miles procedure was performed in 25 patients. Ultimate local control rate is 93% for T1, 69% for T2 (P<0.05), 15 patients failed despite treatment for local recurrence (15%). No significant differences were observed in a comparison of adenocarcinoma and villous tumours according to initial and ultimate local control. The mean disease free survival rate for the whole population is 66 months. The 5-year disease free survival for T1a and T1b is, respectively, 82 and 78%, 40 and 25% for T2a and T2b, respectively. The overall 5-year survival for the whole group is 62.4%. At the end of the treatment, 75% of the patients described a very good sphincter function. No deleterious effect on continence was reported during the follow-up.

CONCLUSIONS

The control rate for T1 rectal cancer treated with contact therapy with or without brachytherapy is comparable to surgical series. The sphincter was preserved in 80% of the patients. Radiotherapy remains an efficient and cheap alternative to surgery, mainly for old and fragile patients, or refusing colostomy. The results of these approaches for tumors larger than 3 cm (T2) are not satisfactory. For patients not amenable to surgery, external beam radiation therapy and/or combined modality with chemoradiation should be discussed to increase the loco-regional control rate. A careful selection of patients based on rectal examination and trans-rectal ultrasound could select more accurately patients amenable to such an approach.

[Local excision with postoperative radiotherapy for T2 or T3 distal rectal cancer. Long-term results]

STUDY AIM

To evaluate, in a prospective study of a cohort of patients, the local recurrence rate of T2 or T3 rectal cancers treated by transanal excision after preoperative irradiation.

PATIENTS AND METHODS

Between 1992 and 1999, 34 patients were treated after radiotherapy by a local excision for a distal rectal carcinoma limited to (stage T2) or invading through the muscular layer (stage T3). Four patients were excluded either for palliative treatment or lost for follow-up. Thirty patients were included in the study (8 uT2, 8 uT3, 14 undetermined preirradiation stage).

RESULTS

After a 74-month mean follow-up (median: 46), the 5-year local recurrence rate was 33%. Even among subgroups of patients with a significant risk factor for local recurrence (size > 40 mm, clear margin < 2 mm, uT3 stage versus uT2) there were no benefits from irradiation.

CONCLUSION

Local excision of T2 or T3 rectal cancers is associated with an elevated local recurrence rate. This result is demonstrated even after adjunction of a preoperative irradiation. So, local treatment must be restricted to clearly informed patients who definitively refuse a radical intervention.

The indication of local excision for T2 rectal carcinomas

BACKGROUND

Several researchers reported that local excision with or without postoperative chemo-radiation therapy is an alternative approach for sphincter preservation in patients with locally invasive rectal carcinoma. However, indications and long-term results have not yet been determined.

METHODS

Seventy-two patients with T2 colorectal carcinomas underwent bowel resection with regional lymph node dissection. The associations between lymph node metastasis (LNM) and clinicopathologic factors were examined with special reference to the presence or absence of moderate to severe degree of focal dedifferentiation or mucinous component at the invasive margin (unfavorable histology).

RESULTS

Multivariate logistic regression analysis revealed that both sex and unfavorable histology were significantly associated with LNM (P = 0.0102, 0.0226, respectively). However, the associations between LNM and lymphatic invasion or tumor location were not statistically significant (P = 0.0947, 0.1738).

CONCLUSIONS

When locally resected T2 rectal carcinoma specimens have unfavorable histology at the invasive margin, additional bowel resection with lymph node dissection should be recommended.

Outcome of local excision for locally invasive rectal carcinomas with special reference to histological features at the invasive margin

BACKGROUND

Several researchers reported promising results that local excision with or without postoperative chemo-radiation therapy is an alternative approach for sphincter preservation in patients with locally invasive rectal carcinomas. However, indications and long-term results have not yet been determined.

METHODS

Demographic and pathological characteristics of eight patients with locally invasive tumors undergoing initially local excision were reviewed with reference to histological features at the invasive margin.

RESULTS

All the tumors were well differentiated adenocarcinomas. In all but two tumors, the invasion was limited within the proper muscle layer. Radiation therapy was given preoperatively in one patient and postoperatively in two patients. Additional bowel resection was not attempted in these three cases. Among the remaining five patients, two received additional bowel resection with lymph node dissection. No lymph node metastasis was observed in these two patients. During the average follow-up period of 55 months, three patients had regional lymph node metastases at 7, 36 and 72 months, respectively. Another patient had regional lymph node and distant metastases at 5 months. Three out of five patients with moderate to severe grade of dedifferentiated histology at the invasive margin (H-inv) had regional lymph node metastases. On the other hand, one out of three patients with mild H-inv had lymph node metastases.

CONCLUSIONS

H-inv may be useful as a clinical predictor of lymph node metastasis. However, more experience is needed to confirm the usefulness of H-inv in selecting invasive rectal cancer patients in whom local excision is safe and appropriate.

Induction therapy for rectal carcinoma

Induction, or preoperative therapy for rectal carcinoma, is a controversial topic which appears to have clinical utility in a number of distinct settings that range from early stage to locally advanced disease. Common to all treatment scenarios is the intent of reducing the likelihood of recurrence in the pelvis following surgery. An additional and evolving role is a reduction in the extent of surgery following a complete or partial clinical response to the induction regimen. While radiation as a single modality can lead to downstaging and, perhaps, a reduction in local recurrence, combined modality with 5-fluorouracil (5-FU) and radiation appears to have a greater therapeutic benefit that may be further enhanced by the administration of leucovorin.

Sphincter preservation in rectal cancer. Preoperative radiation therapy followed by local excision

Radiation therapy followed by local excision results in local control rates that appear comparable to those of local excision alone (in highly selected patients) or local excision followed by adjuvant radiation therapy. A significant drawback of this approach, however, is the potential loss of important histological information, such as risk of lymph node metastasis, depth of tumor penetration, and presence of lymphatic or vascular invasion. Radiation therapy followed by local excision may be an option for treatment of more advanced T3 rectal cancers in patients who either refuse radical surgery or are medically unfit. The available data in the literature do not support the routine use of local excision after radiation therapy in otherwise healthy patients with locally advanced rectal cancer.

Sphincter preservation in rectal cancer. Endocavitary radiation therapy

Endocavitary radiation therapy (Endo RT) is performed mainly with a contact x-ray tube. Interstitial brachytherapy is a supplementary method to boost the tumor bed. Only strictly selected patients can be treated for cure by Endo RT. More than 1,000 patients have been treated in Europe and North America since 1950. In T1 N0 adenocarcinoma, the primary local control rate is close to 90%. The overall 5-year survival is between 60% and 90% depending on patient selection. Careful follow-up is necessary because the majority of local failures can be salvaged, usually by radical surgery. The main advantages of Endo RT are a fully ambulatory and simple treatment that can be applied even in frail or elderly inoperable patients, a low risk of complications, and an inexpensive treatment. Results show it is possible to perform curative treatment in patients with more advanced rectal carcinoma. With the combination of external-beam radiation therapy and Endo RT in stage T2-3 N0-1 tumors, the primary local control rate is around 70%, and the incidence of severe radiation toxicity is less than 5%. Overall 5-year survival is between 50% and 70%. Endo RT can also be used as an adjuvant treatment after local excision, in the treatment of villous adenomas, and for palliation of advanced inoperable tumors.

Sphincter preservation therapy for distal rectal carcinoma: a review

BACKGROUND

There has been increasing interest in the use of sphincter-preserving therapy for patients with distal rectal carcinomas. The outcomes of conservative treatments for early stage rectal carcinoma appear to be comparable to that achieved with abdominoperineal resection.

METHODS

Retrospective and prospective clinical series of patients with distal rectal carcinoma treated by local excision alone, local excision with postoperative adjuvant therapy, preoperative radiation followed by local excision, or radical circumferential sphincter-sparing surgeries were reviewed. The local control rates, salvage rates, and treatment complications in patients treated by these various methods were examined.

RESULTS

Patients with T1 distal rectal carcinoma with favorable clinical and histopathologic characteristics treated with local excision alone had a local control rate of greater than 90% in most series. Postoperative chemoradiation improved local control for those with T1 disease with unfavorable characteristics, or those with T2 disease. Most T3 patients had failure rates of greater than 30% despite adjuvant local and systemic therapy. With high dose preoperative radiation, approximately 80% of patients with locally advanced or unresectable tumors were able to undergo sphincter-preservation treatment.

CONCLUSIONS

Patients with favorable T1 rectal carcinoma are likely to be adequately treated with local excision alone. Patients with T1 disease with unfavorable characteristics as well as T2 patients will benefit from postoperative chemoradiation. The use of local therapy in T3 patients needs to be carefully considered because these patients are at relatively high risk for local recurrence despite adjuvant therapy. Preoperative radiation followed by either local excision or radical circumferential sphincter-sparing resections appears promising in allowing sphincter preservation in patients with locally advanced tumors.

Local excision and external beam radiotherapy in early rectal cancer

PURPOSE

To assess the local control and survival of local excision and postoperative radiation in patients with early stage rectal cancer.

METHODS AND MATERIALS

From 1980 to 1992, 21 patients with clinical stage T1-2NxM0 adenocarcinoma of the middle and lower rectum were treated with transanal excision and postoperative external beam radiotherapy (44.6 Gy). The pathologic T stages were: 9 T1 (43%) and 12 T2 (57%). One patient had unassessable resection margins. The median follow-up was 54 months (range: 18-128 months).

RESULTS

The actuarial local recurrence-free survival at 5 years was 85.2%, and the overall survival at 5 years was 80.6%. One patient developed a local recurrence and distant metastases at 22 months, and two patients had local recurrence at 11 and 15 months, respectively; both had abdomino-perineal resection (APR) and one remained free of disease 16 months after APR. The incidence of Grade 3 diarrhea was 5%. Sphincter function was good to excellent in the 18 patients with local control. No patients developed clinical evidence of pelvic lymph node recurrence.

CONCLUSION

These results are similar to other published series and suggest that this approach is feasible in selected patients with T1-2NxM0 rectal cancer and results in good long-term control of the disease.

Endocavitary irradiation for early rectal carcinomas T1 (T2). A series of 101 patients treated with the Papillon's technique

PURPOSE

This work is a retrospective analysis of a series of patients treated with endocavitary irradiation stressing the role of transrectal ultrasound (TRUS), which has been used routinely in the staging since 1987.

METHODS AND MATERIALS

Between 1977 and 1993, 101 patients with infiltrating adenocarcinomas were treated. Clinical staging was 65 T1 N0 and 36 T2 N0. TRUS used in 36 patients showed: 22 UT1 N0, 10 UT2 N0, and 3 UT2 N1. Contact x-ray was delivered with a 50 kV radiotherapy unit. The median dose was 92 Gy (60-125) in five fractions, 55 days. In 28 patients a boost was given with 192Ir implant delivering a median dose of 25 Gy/21 h.

RESULTS

Complete response was observed in all patients at the completion of treatment. Loco-regional failures were seen in 14 patients (local in 7 patients, nodal pararectal in 6 patients, and local + nodal in 1 patient). A curative salvage treatment was attempted in 13 patients and resulted in an ultimate pelvic control rate of 99 patients. Rectal preservation was possible in 92 patients. Overall and specific 5-year survival was 83.3% and 94.4%. No serious complication was observed. TRUS was more sensitive than digital rectal examination to detect involvement of pararectal metastatic nodes (N1). No loco- regional relapse was observed out of 22 UT1 N0.

CONCLUSION

Endocavitary irradiation can cure early adenocarcinoma of the rectum without complication. TRUS appears as a significant improvement in the selection of patients amenable to this treatment. If restricted to UT1 N0 tumors, endocavitary irradiation should control locally more than 90% of these patients. Any UN1 is a contraindication for endocavitary irradiation alone.

Combined curative radiation therapy alone in (T1) T2-3 rectal adenocarcinoma: a pilot study of 29 patients

AIM

Analysis of a pilot study including 29 consecutive patients with high surgical risk or refusal of colostomy treated with radiation therapy alone with curative intent.

PATIENTS

Between 1986 and 1992, 29 patients were treated for infiltrating adenocarcinoma of the rectum. Median age was 72 years. Transrectal ultrasound staging was used in 24 patients (T1, 2; T2, 14; T3, 13; N0, 23; N1, 6). In 20 patients the lower border of the tumor was at 5 cm or less from the anal verge and in 19 patients the diameter exceeded 3 cm. CEA was elevated in seven cases.

TREATMENT

Contact X-ray (50 kV) was given first (70 Gy/3 fractions). External beam radiation therapy used a three-field technique in the prone position. Accelerated schedule (39 Gy/13 fractions/17 days) with a concomitant boost "field within the field' (4 Gy/4 fractions). Six weeks later an iridium-192 implant was performed in 21 (20 Gy/22 h).

RESULTS

Median follow-up time was 46 months. Overall and specific survival at 5 years was 68% (SE = 0.09) and 76% (SE = 0.08). Local control was obtained in 21/29 patients (72%). There was one grade 2 rectal bleeding and five grade 2 rectal necroses. The overall tolerance was good in these frail patients.

DISCUSSION

For T2. T3 or T1 > 3 cm diameter rectal adenocarcinoma, where contact X-ray alone is not recommended, a combined treatment with radiation therapy alone is able to give good local control with acceptable toxicity. This treatment should be restricted to inoperable patients.

Conservative treatment of rectal cancer. Extending the indications

Rectal cancer often in the past was believed to require abdominoperineal resection with permanent colostomy to achieve a cure. Several surgical alternatives to colostomy currently are available for selected patients. Understanding of the methods of preoperative staging is increasing, and new techniques, such as intrarectal ultrasound, have provided improved accuracy. By applying this and other methods of preoperative staging, selection of a surgical approach appropriate to the tumor stage increasingly is possible. Curative treatment for rectal cancer often can be achieved while preserving anorectal function.

Sphincter preservation in rectal cancer by local excision and postoperative radiation therapy

The authors report the preliminary results of 14 patients with localized, mobile, resectable rectal cancer treated with local excision and postoperative radiation therapy (RT). All had negative surgical resection margins and two received 5-fluorouracil (5-FU). The median follow-up was 29 months (4-43 months). The 3-year actuarial survival was 88%. The incidence of local failure was 7% (only site of failure) and 21% (component of failure). The incidence of local failure increased with T stage (T1, 0/3 [0%]; T2, 1/7 [14%]; and T3, 2/4 [50%]) and tumor size (greater than 3 cm, 33%, versus less than or equal to 3 cm, 0%). Three patients developed local failure at 6, 15, and 21 months. Three underwent a salvage abdominoperineal resection and were locally controlled at 2 and 28 months following salvage surgery. One patient underwent an abdominoperineal resection for a clinically presumed local failure; however, no tumor was found in the specimen. Therefore, the 13 patients who either were initially locally controlled or underwent salvage or nonsalvage surgery had no evidence of disease in the pelvis at the time of last follow-up. Local excision and postoperative RT may be an alternative to standard surgery in selected cases. However, additional follow-up and more experience are needed in order to determine if this approach will ultimately have local control and survival rates similar to those of a low anterior resection or an abdominoperineal resection.