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Boubaddi M, Eude A, Marichez A, Amintas S, Boissieras L, Celerier B, Rullier E, Fernandez B. Omentoplasty versus cecal mobilization after abdominoperineal resection: A propensity score matching analysis. Langenbecks Arch Surg 2024; 409:245. [PMID: 39120617 DOI: 10.1007/s00423-024-03439-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 08/05/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND Despite the minimally invasive approach and early rehabilitation, abdominal-perineal resection (APR) remains a procedure with high morbidity, notably due to postoperative trapped bowel ileus and perineal healing complications. Several surgical techniques have been described for filling the pelvic void to prevent abscess formation and ileus by trapped bowel loop. OBJECTIVE The aim of our study was to compare the post APR complications for cancer of two of these techniques, omentoplasty and cecal mobilization, in a single-center study from an expert colorectal surgery center. PATIENTS From 2012 to 2022, 84 patients were included, including 58 (69%) with omentoplasty and 26 (31%) with cecal mobilization. They all underwent APR at Bordeaux University Hospital Center. SETTINGS A propensity score was used to avoid confounding factors as far as possible. Patient and procedure characteristics were initially comparable. RESULTS The 30-day complication rate was significantly higher in the cecal mobilization group (53.8% vs. 5.2% p < 0.01), as was the rate of pelvic abscess (34.6% vs. 0% p < 0.001). CONCLUSION These findings suggest that, when feasible, omentoplasty should be considered the preferred method for pelvic reconstruction following APR.
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Affiliation(s)
- Mehdi Boubaddi
- Department of Digestive Surgery, Colorectal Unit, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France.
| | - Audrey Eude
- Department of Digestive Surgery, Colorectal Unit, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France
| | - Arthur Marichez
- Department of Digestive Surgery, Colorectal Unit, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France
| | - Samuel Amintas
- Tumor Biology and Tumor Bank Laboratory, CHU Bordeaux, 33600, Pessac, France
- BRIC (BoRdeaux Institute of onCology), UMR1312, INSERM, University of Bordeaux, 33000, Bordeaux, France
| | - Lara Boissieras
- Department of Digestive Surgery, Colorectal Unit, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France
| | - Bertrand Celerier
- Department of Digestive Surgery, Colorectal Unit, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France
| | - Eric Rullier
- Department of Digestive Surgery, Colorectal Unit, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France
| | - Benjamin Fernandez
- Department of Digestive Surgery, Colorectal Unit, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France
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Anker CJ, Tchelebi LT, Selfridge JE, Jabbour SK, Akselrod D, Cataldo P, Abood G, Berlin J, Hallemeier CL, Jethwa KR, Kim E, Kennedy T, Lee P, Sharma N, Small W, Williams VM, Russo S. Executive Summary of the American Radium Society on Appropriate Use Criteria for Nonoperative Management of Rectal Adenocarcinoma: Systematic Review and Guidelines. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00673-4. [PMID: 38797496 DOI: 10.1016/j.ijrobp.2024.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 04/15/2024] [Accepted: 05/17/2024] [Indexed: 05/29/2024]
Abstract
For patients with rectal cancer, the standard approach of chemotherapy, radiation therapy, and surgery (trimodality therapy) is associated with significant long-term toxicity and/or colostomy for most patients. Patient options focused on quality of life (QOL) have dramatically improved, but there remains limited guidance regarding comparative effectiveness. This systematic review and associated guidelines evaluate how various treatment strategies compare to each other in terms of oncologic outcomes and QOL. Cochrane and Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) methodology were used to search for prospective and retrospective trials and meta-analyses of adequate quality within the Ovid Medline database between January 1, 2012, and June 15, 2023. These studies informed the expert panel, which rated the appropriateness of various treatments in 6 clinical scenarios through a well-established consensus methodology (modified Delphi). The search process yielded 197 articles that advised voting. Increasing data have shown that nonoperative management (NOM) and primary surgery result in QOL benefits noted over trimodality therapy without detriment to oncologic outcomes. For patients with rectal cancer for whom total mesorectal excision would result in permanent colostomy or inadequate bowel continence, NOM was strongly recommended as usually appropriate. Restaging with tumor response assessment approximately 8 to 12 weeks after completion of radiation therapy/chemoradiation therapy was deemed a necessary component of NOM. The panel recommended active surveillance in the setting of a near-complete or complete response. In the setting of NOM, 54 to 56 Gy in 27 to 31 fractions concurrent with chemotherapy and followed by consolidation chemotherapy was recommended. The panel strongly recommends primary surgery as usually appropriate for a T3N0 high rectal tumor for which low anterior resection and adequate bowel function is possible, with adjuvant chemotherapy considered if N+. Recent data support NOM and primary surgery as important options that should be offered to eligible patients. Considering the complexity of multidisciplinary management, patients should be discussed in a multidisciplinary setting, and therapy should be tailored to individual patient goals/values.
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Affiliation(s)
- Christopher J Anker
- Division of Radiation Oncology, University of Vermont Cancer Center, Burlington, Vermont
| | - Leila T Tchelebi
- Northwell, New Hyde Park, New York; Department of Radiation Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York.
| | - J Eva Selfridge
- Division of Solid Tumor Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio
| | - Salma K Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute, New Brunswick, New Jersey
| | - Dmitriy Akselrod
- Department of Radiology, University of Vermont Larner College of Medicine, Burlington, Vermont
| | - Peter Cataldo
- Department of Surgery, University of Vermont Larner College of Medicine, Burlington, Vermont
| | - Gerard Abood
- Department of Surgery, Loyola University Stritch School of Medicine, Maywood, Illinois
| | - Jordan Berlin
- Division of Hematology Oncology, Department of Medicine Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | | | - Krishan R Jethwa
- Department of Radiation Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Ed Kim
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Timothy Kennedy
- Department of Surgery, Rutgers Cancer Institute, New Brunswick, New Jersey
| | - Percy Lee
- Department of Radiation Oncology, City of Hope National Medical Center, Los Angeles, California
| | - Navesh Sharma
- Department of Radiation Oncology, WellSpan Cancer Center, York, Pennsylvania
| | - William Small
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago, Maywood, Illinois
| | - Vonetta M Williams
- Department of Radiation Oncology, Memorial Sloan Kettering, New York, New York
| | - Suzanne Russo
- Department of Radiation Oncology, MetroHealth, Case Western Reserve University School of Medicine, Cleveland, Ohio
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Li A, Mao M, Chen R, Chi P, Huang Y, Wu J, Xu B. Excluding external iliac node irradiation during neoadjuvant radiotherapy decreases lower intestinal toxicity without compromising efficacy in T4b rectal cancer patients with tumours involving the anterior structures. Discov Oncol 2024; 15:76. [PMID: 38492016 PMCID: PMC10944434 DOI: 10.1007/s12672-024-00885-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 02/07/2024] [Indexed: 03/18/2024] Open
Abstract
PURPOSE To explore the impact of excluding the external iliac node (EIN) from the clinical target volume (CTV) during preoperative radiotherapy in T4b rectal cancer with anterior structure invasion. METHODS We retrospectively identified 132 patients with T4b rectal cancer involving the anterior structures who received radiotherapy followed by surgery between May 2010 and June 2019. Twenty-nine patients received EIN irradiation (EIN group), and 103 did not (NEIN group). Failure patterns, survival and toxicities were compared between the two groups. RESULTS The most common failure was distant metastasis (23.5%). 11 (8.3%) patients developed locoregional recurrence, 10 (9.7%) patients were in the NEIN group, and 1 (3.4%) was in the EIN group (P = 0.34). The EIN region failure was rare (1/132, 0.8%). The locoregional recurrence-free survival (LRFS), distant metastasis-free survival (DMFS), overall survival (OS) and progression-free survival (PFS) rates were 96.3% vs. 90.5%, 82.1% vs.73.7%, 75.9% vs. 78.0% and 72.4% vs. 68.3% (all P > 0.05) for the EIN group and NEIN group, respectively. The incidence of grade 3-4 acute toxicity in the lower intestine was significantly higher in the EIN group than in the NEIN group (13.8% vs. 1.9%, P = 0.02). The Dmax, V35 and V45 of the small bowel was decreased in the NEIN group compared to the EIN group. CONCLUSIONS Exclusion of the EIN from the CTV in T4b rectal cancer with anterior structure invasion could reduce lower intestinal toxicity without compromising oncological outcomes. These results need further evaluation in future studies.
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Affiliation(s)
- Anchuan Li
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Xinquan Road 29, Fuzhou, 350001, China
- Department of Radiation Oncology, College of Clinical Medicine, Fujian Medical University, Fuzhou, 350001, China
- Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for Tumors, Fujian Medical University, Fuzhou, 350001, China
- Clinical Research Center for Radiology and Radiotherapy of Fujian Province (Digestive, Hematological and Breast Malignancies), Fuzhou, 350001, China
| | - Miaobin Mao
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Xinquan Road 29, Fuzhou, 350001, China
- Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for Tumors, Fujian Medical University, Fuzhou, 350001, China
- Clinical Research Center for Radiology and Radiotherapy of Fujian Province (Digestive, Hematological and Breast Malignancies), Fuzhou, 350001, China
| | - Runfan Chen
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Xinquan Road 29, Fuzhou, 350001, China
| | - Pan Chi
- Department of Gastrointestinal Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, China
| | - Ying Huang
- Department of Gastrointestinal Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, China
| | - Junxin Wu
- Department of Radiation Oncology, Fujian Cancer Hospital, Fuma Road 420, Fuzhou, 350014, China.
| | - Benhua Xu
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Xinquan Road 29, Fuzhou, 350001, China.
- Department of Radiation Oncology, College of Clinical Medicine, Fujian Medical University, Fuzhou, 350001, China.
- Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for Tumors, Fujian Medical University, Fuzhou, 350001, China.
- Clinical Research Center for Radiology and Radiotherapy of Fujian Province (Digestive, Hematological and Breast Malignancies), Fuzhou, 350001, China.
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Wu CY, Ye K. Laparoscopic total pelvic exenteration after neoadjuvant chemoradiotherapy for locally advanced rectal cancer. Asian J Surg 2022; 45:2485-2486. [PMID: 35691803 DOI: 10.1016/j.asjsur.2022.05.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 05/19/2022] [Indexed: 11/19/2022] Open
Affiliation(s)
- Chu-Ying Wu
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Fujian Medical University, No. 950 Donghai Street, Fengze District, Quanzhou, 362000, Fujian Province, China
| | - Kai Ye
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Fujian Medical University, No. 950 Donghai Street, Fengze District, Quanzhou, 362000, Fujian Province, China.
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Is elective inguinal or external iliac irradiation during neoadjuvant (chemo)radiotherapy necessary for locally advanced lower rectal cancer with anal sphincter invasion? Pract Radiat Oncol 2021; 12:125-134. [PMID: 34670136 DOI: 10.1016/j.prro.2021.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/19/2021] [Accepted: 10/08/2021] [Indexed: 11/22/2022]
Abstract
PURPOSE To investigate the impact of excluding irradiation of inguinal lymph nodes (ILNs) and external iliac lymph nodes (ELNs) during neoadjuvant (chemo)radiotherapy in a locally advanced lower rectal cancer (LALRC) with anal sphincter invasion. MATERIALS AND METHODS A total of 214 LALRC patients with anal sphincter invasion according to pre-treatment magnetic resonance imaging who underwent neoadjuvant (chemo)radiotherapy followed by surgery between September 2010 and May 2019 were enrolled. ILNs and ELNs were clinically negative pre-treatment and were excluded from irradiation. Failure rates and patterns of ILNs and ELNs and survival were analyzed. Nomograms for predicting ILN and ELN failure risk were also constructed. RESULTS The median follow-up was 53.3 months. The three-year failure rates were 3.7% for ILNs and 3.3% for ELNs. Only one patient developed isolated ILN failure, and no patient experienced isolated ELN failure. Multivariate analyses demonstrated that lower edge of tumors invaded or located below the dentate line (odds ratio [OR] 7.513, P = 0.013), high histological grade (OR 6.892, P = 0.017), and perineural invasion (OR 7.111, P = 0.023) were significantly related to ILN failure. Both perineural invasion (OR 8.923, P = 0.011) and high histological grade (OR 8.129, P = 0.011) showed a strong correlation with ELN failure. The concordance index of nomograms for predicting ILN and ELN failure risk were 0.842 and 0.880, respectively. The three-year local recurrence free survival, disease-free survival, and overall survival were 94.6% (95% confidence interval [CI], 91.3%‒97.9%), 77.7% (95% CI, 71.8%‒83.6%), and 91.9% (95% CI, 87.8%‒96.0%), respectively, for the whole cohort. CONCLUSIONS Excluding ILNs and ELNs from irradiation was associated with an acceptably low failure risk for LALRC invading the anal sphincter. These findings help to refine existing guidelines for clinical target volume delineation of ILNs and ELNs during neoadjuvant (chemo)radiotherapy in rectal cancer.
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Meillan N, Orthuon A, Chauchat P, Atlani D, Bouche O, Chaulin B, David C, Deberne M, Debrigode C, Kao W, Keller A, Laharie H, Lamezec B, Lemanski C, Magné N, Mahé MA, Mere P, Moureau-Zabotto L, Peiffert D, Pointreau Y, Quéro L, Racadot S, Roca S, Sargos P, Servagi S, Tang E, Vendrely V, Doyen J, Huguet F. Locoregional relapses in the ACCORD 12/0405-PRODIGE 02 study: Dosimetric study and risk factors. Radiother Oncol 2021; 161:198-204. [PMID: 34144078 DOI: 10.1016/j.radonc.2021.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 05/21/2021] [Accepted: 06/02/2021] [Indexed: 11/19/2022]
Abstract
PURPOSE The aim of this study is to correlate locoregional relapse with radiation therapy volumes in patients with rectal cancer treated with neoadjuvant chemoradiation in the ACCORD 12/0405-PRODIGE 02 trial. PATIENTS AND METHODS We identified patients who had a locoregional relapse included in ACCORD 12's database. We studied their clinical, radiological, and dosimetric data to analyze the dose received by the area of relapse. RESULTS 39 patients (6.5%) presented 54 locoregional relapses. Most of the relapses were in-field (n = 21, 39%) or marginal (n = 13, 24%) with only six out-of-field (11%), 14 could not be evaluated. Most of them happened in the anastomosis, the perirectal space, and the usual lymphatic drainage areas (presacral and posterior lateral lymph nodes). Only patients treated for a lower rectum adenocarcinoma had a relapse outside of the treated volume. 2 patients with T4 tumors extending into anterior pelvic organs had relapses in anterior lateral and external iliac lymph nodes. CONCLUSIONS Lowering the upper limit of the treatment field for low rectal tumors increased the risk of out of the field recurrence. For very low tumors, including the inguinal lymph nodes in the treated volume should be considered. Recording locoregional involvement, treated volumes, and relapse areas in future prospective trials would be of paramount interest to refine delineation guidelines.
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Affiliation(s)
- Nicolas Meillan
- APHP, Pitié-Salpêtrière Hospital, Department of Radiation Oncology, Paris, France; Sorbonne Université, AP-HP, Pitié Salpêtrière Hospital, Department of Radiation Oncology, Paris, France.
| | | | - Paul Chauchat
- APHP, Pitié Salpêtrière Hospital, Department of Medical Physics, Paris, France
| | - David Atlani
- Department of Radiation Oncology, Civil Colmar Hospital, Colmar, France
| | - Olivier Bouche
- Department of Gastroenterology, Reims University Hospital, France
| | - Bertrand Chaulin
- Department of Radiation Oncology, Bordeaux Nord Aquitaine Polyclinic, France
| | - Céline David
- Department of Medical Physics, Mulhouse and South Alsace Hospital, France
| | - Mélanie Deberne
- Department of Radiation Oncology, South Lyon Hospital, France
| | | | - William Kao
- Department of Radiation Oncology, François Baclesse Cancer Center, Caen, France
| | - Audrey Keller
- Department of Radiation Oncology, ICANS, Strasbourg, France
| | - Hortense Laharie
- Department of Radiation Oncology, Tivoli Ducos Clinic, Bordeaux, France
| | - Bruno Lamezec
- Department of Radiation Oncology, Armorican Radiation Therapy, Radiology and Oncology Center, Plérin, France
| | - Claire Lemanski
- Department of Radiation Oncology, Montpellier-Val d'Aurelles Cancer Institute, France
| | - Nicolas Magné
- Department of Radiation Oncology, Loire Cancer Institute Saint-Priest-en-Jarez France
| | - Marc-André Mahé
- Department of Radiation Oncology, Western Cancer Institute, Nantes, France
| | - Pascale Mere
- Department of Radiation Oncology, Jean Mermoz Private Hospital, Lyon, France
| | | | - Didier Peiffert
- Department of Radiation Oncology, Lorraine Cancer Institute, Nancy, France
| | - Yoann Pointreau
- Department of Radiation Oncology, Inter-régionaL Cancer Institute (ILC) - Jean Bernard Center-Victor Hugo Clinic, Le Mans, France
| | - Laurent Quéro
- Department of Radiation Oncology, Saint-Louis Hospital, APHP, Paris, France
| | - Séverine Racadot
- Department of Radiation Oncology, Léon Bérard Center, Lyon, France
| | - Sophie Roca
- Department of Medical Oncology, Sainte-Anne Clinic, Langon, France
| | - Paul Sargos
- Department of Radiation Oncology, Bergonié Institute, Bordeaux, France
| | - Stéphanie Servagi
- Department of Radiation Oncology, Jean Godinot Institute, Reims, France
| | - Eliane Tang
- Hôpitaux Universitaires Henri Mondor, APHP, Henri Mondor Hospital, Department of Radiation Oncology, Paris, France
| | - Véronique Vendrely
- Department of Radiation Oncology, Bordeaux University Hospital, France; INSERM 1035, University of Bordeaux, France
| | - Jérôme Doyen
- Department of Radiation Oncology, Antoine Lacassagne Center, Nice, France
| | - Florence Huguet
- Sorbonne Université, AP-HP, Pitié Salpêtrière Hospital, Department of Radiation Oncology, Paris, France; UMR_S 938, Centre de Recherche de Saint Antoine, Paris, France; APHP, Tenon Hospital, Department of Radiation Oncology, Paris, France
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Zhang YZ, Song M, Geng JH, Zhu XG, Li S, Li YH, Cai Y, Wang WH. Patterns of failure and implications for clinical target volume definition of locally advanced T4b rectal cancer identified with magnetic resonance imaging and treated using neoadjuvant chemoradiotherapy and surgery. Radiother Oncol 2021; 161:132-139. [PMID: 34126137 DOI: 10.1016/j.radonc.2021.06.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/24/2021] [Accepted: 06/06/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND PURPOSE Elective irradiation of the external iliac lymph nodes (EIN) has always been advocated for T4b rectal cancer with anterior organ invasion without convincing evidence. This study aimed to explore the patterns of treatment failure for locally advanced T4b rectal cancer treated using neoadjuvant chemoradiotherapy (NCRT) and surgery. This information may help to clarify whether the current definition of the clinical target volume (CTV) is still appropriate. MATERIALS AND METHODS We retrospectively analyzed data from 126 patients with locally advanced T4b rectal cancer who received NCRT, without elective EIN irradiation, followed by surgery between January 2010 and October 2018. Pretreatment magnetic resonance imaging was used to identify the T4b disease in all cases. The locoregional recurrence (LRR) rate and EIN failure rate were evaluated, and the LRR locations were identified using a three-dimensional model. RESULTS After a median follow-up of 53.9 months, LRR occurred in 11.1% of patients (14/126). All LRRs were located in the previously irradiated fields and below the S2-S3 junction. The EIN failure rate was 0.8% (1/126) among all patients and 1.8% (1/56) in the group with anterior genitourinary organ invasion. The estimated 4-year distant relapse-free survival, disease-free survival and overall survival were 79.3%, 73.2% and 86.9%, respectively. CONCLUSIONS It may be feasible to exclude the external iliac region from the CTV during NCRT for locally advanced T4b rectal cancer. However, further studies are needed to clarify whether the cranial border of the CTV can be lowered.
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Affiliation(s)
- Yang-Zi Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing 100142, PR China
| | - Maxiaowei Song
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing 100142, PR China
| | - Jian-Hao Geng
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing 100142, PR China
| | - Xiang-Gao Zhu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing 100142, PR China
| | - Shuai Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing 100142, PR China
| | - Yong-Heng Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing 100142, PR China
| | - Yong Cai
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing 100142, PR China.
| | - Wei-Hu Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing 100142, PR China.
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Nadiradze G, Yurttas C, Königsrainer A, Horvath P. Significance of multivisceral resections in oncologic surgery: A systematic review of the literature. World J Meta-Anal 2019; 7:269-289. [DOI: 10.13105/wjma.v7.i6.269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 06/07/2019] [Accepted: 06/17/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Multivisceral resections (MVR) are often necessary to reach clear resections margins but are associated with relevant morbidity and mortality. Factors associated with favorable oncologic outcomes and elevated morbidity rates are not clearly defined.
AIM To systematically review the literature on oncologic long-term outcomes and morbidity and mortality in cancer surgery a systematic review of the literature was performed.
METHODS PubMed was searched for relevant articles (published from 2000 to 2018). Retrieved abstracts were independently screened for relevance and data were extracted from selected studies by two researchers.
RESULTS Included were 37 studies with 3112 patients receiving MVR for colorectal cancer (1095 for colon cancer, 1357 for rectal cancer, and in 660 patients origin was not specified). The most common resected organs were the small intestine, bladder and reproductive organs. Median postoperative morbidity rate was 37.9% (range: 7% to 76.6%) and median postoperative mortality rate was 1.3% (range: 0% to 10%). The median conversion rate for laparoscopic MVR was 7.9% (range: 4.5% to 33%). The median blood loss was lower after laparoscopic MVR compared to the open approach (60 mL vs 638 mL). Lymph-node harvest after laparoscopic MVR was comparable. Report on survival rates was heterogeneous, but the 5-year overall-survival rate ranged from 36.7% to 90%, being worst in recurrent rectal cancer patients with a median 5-year overall survival of 23%. R0 -resection, primary disease setting and no lymph-node or lymphovascular involvement were the strongest predictors for long-term survival. The presence of true malignant adhesions was not exclusively associated with poorer prognosis.
Included were 16 studies with 1.600 patients receiving MVR for gastric cancer. The rate of morbidity ranged from 11.8% to 59.8%, and the main postoperative complications were pancreatic fistulas and pancreatitis, anastomotic leakage, cardiopulmonary events and post-operative bleedings. Total mortality was between 0% and 13.6% with an R0 -resection achieved in 38.4% to 100% of patients. Patients after R0 resection had 5-year overall survival rates of 24.1% to 37.8%.
CONCLUSION MVR provides, in a selected subset of patients, the possibility for good long-term results with acceptable morbidity rates. Unlikelihood of achieving R0 -status, lymphovascular- and lymph -node involvement, recurrent disease setting and the presence of metastatic disease should be regarded as relative contraindications for MVR.
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Affiliation(s)
- Giorgi Nadiradze
- Department of General, Visceral and Transplant Surgery, University of Tübingen, Comprehensive Cancer Center, Tübingen 72076, Germany
| | - Can Yurttas
- Department of General, Visceral and Transplant Surgery, University of Tübingen, Comprehensive Cancer Center, Tübingen 72076, Germany
| | - Alfred Königsrainer
- Department of General, Visceral and Transplant Surgery, University of Tübingen, Comprehensive Cancer Center, Tübingen 72076, Germany
| | - Philipp Horvath
- Department of General, Visceral and Transplant Surgery, University of Tübingen, Comprehensive Cancer Center, Tübingen 72076, Germany
- National Center for Pleura and Peritoneum, Tübingen 72076, Germany
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Surgery for Locally Advanced GIT Cancers Has Potentially Good Postoperative Outcomes in a Tertiary Hospital. J Gastrointest Cancer 2018; 51:23-29. [DOI: 10.1007/s12029-018-0181-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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10
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Bujko K, Glynne-Jones R, Papamichael D, Rutten HJT. Optimal management of localized rectal cancer in older patients. J Geriatr Oncol 2018; 9:696-704. [PMID: 30150020 DOI: 10.1016/j.jgo.2018.08.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 07/19/2018] [Accepted: 08/01/2018] [Indexed: 12/13/2022]
Abstract
In advising the optimal management for older patients, health care professionals try to balance the risks from frailty, vulnerability, and comorbidity against the patient's ultimate prognosis, potential functional outcomes and quality of life (QOL). At the same time it is important to involve the patient and incorporate their preferences. But how can we present and balance the potential downside of radical radiotherapy and risks of unsalvageable recurrence against the potential risks of postoperative morbidity and mortality associated with radical surgery? There are currently no nationally approved and evidence-based guidelines available to ensure consistency in discussions with older adults or frail and vulnerable patients. In this overview we hope to provide an insightful discussion of the relevant issues and options currently available.
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Affiliation(s)
- Krzysztof Bujko
- Department of Radiotherapy, Maria Skłodowska-Curie Memorial Cancer Centre, Warsaw, Poland
| | - Rob Glynne-Jones
- Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital, Northwood HA6 2RN, United Kingdom.
| | | | - Harm J T Rutten
- Catharina Hospital Cancer Center Eindhoven, GROW Scholl of oncology and developmental Biology, University of Maastricht, the Netherlands
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11
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Balyasnikova S, Vuong T, Wale A, Chong I, Rutten H, Brown G. Session 3: Boosting primary and recurrent rectal cancer: how far can we push the radiotherapy envelope? Colorectal Dis 2018; 20 Suppl 1:88-91. [PMID: 29878674 DOI: 10.1111/codi.14086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Neoadjuvant pelvic radiotherapy is widely used for patients with advanced rectal cancer. The trade-off between dose and response is well-established, yet little consensus remains on the precise methods of delivery and doses given in different scenarios. Professor Vuong reviews the evidence base and trial evidence on the escalation of radiotherapy dose and the methods of achieving this.
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Affiliation(s)
| | - T Vuong
- Jewish General Hospital, Montreal, Quebec, Canada
| | - A Wale
- The Royal Marsden NHS Foundation Trust, London, UK
| | - I Chong
- The Royal Marsden NHS Foundation Trust, London, UK
| | - H Rutten
- Catharina Ziekenhuis, Eindhoven, The Netherlands
| | - G Brown
- The Royal Marsden NHS Foundation Trust, London, UK.,Imperial College London, London, UK
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Peng J, Lin J, Zeng Z, Wu X, Chen G, Li L, Lu Z, Ding P, Wan D, Pan Z. Addition of oxaliplatin to capecitabine-based preoperative chemoradiotherapy for locally advanced rectal cancer: Long-term outcome of a phase II study. Oncol Lett 2017; 14:4543-4550. [PMID: 29085451 PMCID: PMC5649637 DOI: 10.3892/ol.2017.6764] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 06/02/2017] [Indexed: 12/18/2022] Open
Abstract
Our previous study reported the favorable short-term outcome and good tolerance of integrating oxaliplatin into capecitabine-based (XELOX regimen) preoperative chemoradiotherapy (CRT) for locally advanced rectal cancer (LARC). The present study reported the long-term oncological outcome of this phase II study. A total of 47 patients with rectal adenocarcinoma (stage II or III) were enrolled and received radiotherapy (46 Gy in 23 fractions) in combination with capecitabine (1,000 mg/m2, twice daily, on days 1–14 and 22–35) and oxaliplatin (130 mg/m2 on days 1 and 22). Overall survival (OS) rate, disease-free survival (DFS) rate and cumulative incidence of recurrences and long-term complications were calculated or observed. As a result, 41 patients underwent surgery after preoperative CRT, and the cumulative OS rates at 1, 3 and 5 years for these patients were 100.0, 84.5 and 81.8%, respectively. For the 38 patients who received R0 resection, the cumulative OS rates at 1, 3 and 5 years were 100.0, 89.0 and 86.2%, respectively, while the cumulative DFS rates at 1, 3 and 5 years were 94.6, 75.3 and 69.7%, respectively. After follow-up at 84 months, the cumulative incidence rates of local and distant recurrences at 5 years were 6.6 and 28.2%, respectively. Oxaliplatin-associated long-term complications were seldom observed. Overall, the addition of oxaliplatin to capecitabine-based preoperative radiotherapy achieved favorable OS and DFS without increased long-term complications in patients with LARC. Therefore, this preoperative CRT strategy is a feasible option for such patients.
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Affiliation(s)
- Jianhong Peng
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, Guangdong 510060, P.R. China
| | - Junzhong Lin
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, Guangdong 510060, P.R. China
| | - Zhifan Zeng
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, Guangdong 510060, P.R. China
| | - Xiaojun Wu
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, Guangdong 510060, P.R. China
| | - Gong Chen
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, Guangdong 510060, P.R. China
| | - Liren Li
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, Guangdong 510060, P.R. China
| | - Zhenhai Lu
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, Guangdong 510060, P.R. China
| | - Peirong Ding
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, Guangdong 510060, P.R. China
| | - Desen Wan
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, Guangdong 510060, P.R. China
| | - Zhizhong Pan
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, Guangdong 510060, P.R. China
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13
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Nahas CSR, Nahas SC, Ribeiro-Junior U, Bustamante-Lopez L, Marques CFS, Pinto RA, Imperiale AR, Cotti GC, Nahas WC, Chade DC, Piato DS, Busnardo F, Cecconello I. Prognostic factors affecting outcomes in multivisceral en bloc resection for colorectal cancer. Clinics (Sao Paulo) 2017; 72:258-264. [PMID: 28591336 PMCID: PMC5439112 DOI: 10.6061/clinics/2017(05)01] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 12/20/2016] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES: This study sought to determine the clinical and pathological factors associated with perioperative morbidity, mortality and oncological outcomes after multivisceral en bloc resection in patients with colorectal cancer. METHODS: Between January 2009 and February 2014, 105 patients with primary colorectal cancer selected for multivisceral resection were identified from a prospective database. Clinical and pathological factors, perioperative morbidity and mortality and outcomes were obtained from medical records. Estimated local recurrence and overall survival were compared using the log-rank method, and Cox regression analysis was used to determine the independence of the studied parameters. ClinicalTrials.gov: NCT02859155. RESULTS: The median age of the patients was 60 (range 23-86) years, 66.7% were female, 80% of tumors were located in the rectum, 11.4% had stage-IV disease, and 54.3% received neoadjuvant chemoradiotherapy. The organs most frequently resected were ovaries and annexes (37%). Additionally, 30.5% of patients received abdominoperineal resection. Invasion of other organs was confirmed histologically in 53.5% of patients, and R0 resection was obtained in 72% of patients. The overall morbidity rate of patients in this study was 37.1%. Ureter resection and intraoperative blood transfusion were independently associated with an increased number of complications. The 30-day postoperative mortality rate was 1.9%. After 27 (range 5-57) months of follow-up, the mortality and local recurrence rates were 23% and 15%, respectively. Positive margins were associated with a higher recurrence rate. Positive margins, lymph node involvement, stage III/IV disease, and stage IV disease alone were associated with lower overall survival rates. On multivariate analysis, the only factor associated with reduced survival was lymph node involvement. CONCLUSIONS: Multivisceral en bloc resection for primary colorectal cancer can be performed with acceptable rates of morbidity and mortality and may lead to favorable oncological outcomes.
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Affiliation(s)
- Caio Sergio Rizkallah Nahas
- Servico de Cirurgia Gastrointestinal, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
| | - Sergio Carlos Nahas
- Servico de Cirurgia Gastrointestinal, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Ulysses Ribeiro-Junior
- Servico de Cirurgia Gastrointestinal, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Leonardo Bustamante-Lopez
- Servico de Cirurgia Gastrointestinal, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Carlos Frederico Sparapan Marques
- Servico de Cirurgia Gastrointestinal, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Rodrigo Ambar Pinto
- Servico de Cirurgia Gastrointestinal, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Antonio Rocco Imperiale
- Servico de Cirurgia Gastrointestinal, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Guilherme Cutait Cotti
- Servico de Cirurgia Gastrointestinal, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - William Carlos Nahas
- Servico de Urologia, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Daher Cezar Chade
- Servico de Urologia, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Dariane Sampaio Piato
- Servico de Ginecologia, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Fabio Busnardo
- Servico de Cirurgia Plastica, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Ivan Cecconello
- Servico de Cirurgia Gastrointestinal, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
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Helewa RM, Park J. Surgery for Locally Advanced T4 Rectal Cancer: Strategies and Techniques. Clin Colon Rectal Surg 2016; 29:106-13. [PMID: 27247535 PMCID: PMC4882171 DOI: 10.1055/s-0036-1580722] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Locally advanced T4 rectal cancer represents a complex clinical condition that requires a well thought-out treatment plan and expertise from multiple specialists. Paramount in the management of patients with locally advanced rectal cancer are accurate preoperative staging, appropriate application of neoadjuvant and adjuvant treatments, and, above all, the provision of high-quality, complete surgical resection in potentially curable cases. Despite the advanced nature of this disease, extended and multivisceral resections with clear margins have been shown to result in good oncological outcomes and offer patients a real chance of cure. In this article, we describe the assessment, classification, and multimodality treatment of primary locally advanced T4 rectal cancer, with a focus on surgical planning, approaches, and outcomes.
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Affiliation(s)
- Ramzi M. Helewa
- Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Jason Park
- Section of Surgical Oncology, Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
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15
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Mañas MJ, Espín E, López-Cano M, Vallribera F, Armengol-Carrasco M. Multivisceral Resection for Locally Advanced Rectal Cancer: Prognostic Factors Influencing Outcome. Scand J Surg 2014; 104:154-60. [PMID: 25260784 DOI: 10.1177/1457496914552341] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2013] [Accepted: 08/19/2014] [Indexed: 12/16/2022]
Abstract
AIMS To assess outcome in patients with locally advanced rectal cancer undergoing multivisceral resection. METHODS Retrospective study of 30 consecutive patients (mean age 67.8 years) with primary locally advanced rectal cancer undergoing en bloc multivisceral resection of the organs involved with curative intent between 1998 and 2010. Overall survival, local and distal recurrence, and disease-free survival were analyzed by the Kaplan-Meier method. Risk factors for clinical outcome were obtained using a Cox multivariate model. RESULTS Postoperative complications occurred in 76.7% of patients and the in-hospital mortality rate was 10%. The median follow-up was 28.8 months. A total of 19 patients died at follow-up. Of the 11 patients who were alive, 7 were free of disease. In the multivariate analysis, lymph node involvement, stage II, and lymph vascular invasion were significantly associated with survival, and stage III showed a strong trend towards significance. Suture dehiscence (peritonitis and intra-abdominal abscess) showed a significant trend towards a higher local recurrence. Lymph vascular invasion was associated with a higher distant recurrence. CONCLUSION Lymph node involvement was associated with worse survival, whereas stage II and absence of lymph vascular invasion were associated with a better survival. Lymph vascular invasion was associated with a higher distant recurrence.
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Affiliation(s)
- M J Mañas
- Colorectal Surgery Unit, General Surgery Service, Department of Surgery, Hospital Universitari Vall d'Hebron, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - E Espín
- Colorectal Surgery Unit, General Surgery Service, Department of Surgery, Hospital Universitari Vall d'Hebron, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - M López-Cano
- Colorectal Surgery Unit, General Surgery Service, Department of Surgery, Hospital Universitari Vall d'Hebron, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - F Vallribera
- Colorectal Surgery Unit, General Surgery Service, Department of Surgery, Hospital Universitari Vall d'Hebron, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - M Armengol-Carrasco
- Colorectal Surgery Unit, General Surgery Service, Department of Surgery, Hospital Universitari Vall d'Hebron, Universitat Autónoma de Barcelona, Barcelona, Spain
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16
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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: 1.4] [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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17
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Bujko K, Nasierowska-Guttmejer A, Wyrwicz L, Malinowska M, Krynski J, Kosakowska E, Rutkowski A, Pietrzak L, Kepka L, Radziszewski J, Olszyna-Serementa M, Bujko M, Danek A, Kryj M, Wydmanski J, Zegarski W, Markiewicz W, Lesniak T, Zygulski I, Porzuczek-Zuziak D, Bebenek M, Maciejczyk A, Polkowski W, Czeremszynska B, Cieslak-Zeranska E, Toczko Z, Radkowski A, Kolodziejski L, Szczepkowski M, Majewski A, Jankowski M. Neoadjuvant treatment for unresectable rectal cancer: an interim analysis of a multicentre randomized study. Radiother Oncol 2013; 107:171-7. [PMID: 23590986 DOI: 10.1016/j.radonc.2013.03.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Revised: 02/18/2013] [Accepted: 03/03/2013] [Indexed: 01/08/2023]
Abstract
PURPOSE To present an interim analysis of the trial comparing two neoadjuvant therapies for unresectable rectal cancer. METHODS Patients with fixed cT3 or cT4 or locally recurrent rectal cancer without distant metastases were randomized to either 5 × 5 Gy and 3 courses of FOLFOX4 (schedule I) or 50.4 Gy delivered in 28 fractions given simultaneously with 5-Fu, leucovorin and oxaliplatin (schedule II). Surgery in both groups was performed 12 weeks after the beginning of radiation and 6 weeks after neoadjuvant treatment. RESULTS 49 patients were treated according to schedule I and 48 according to schedule II. Grade III+ acute toxicity was observed in 26% of patients in group I and in 25% in group II. There were two toxic deaths, both in group II. The microscopically radical resection (primary endpoint) rate was 73% in group I and 71% in group II. Overall and severe postoperative complications were recorded in 27% and 9% of patients vs. 16% and 7%, respectively. Pathological complete response was observed in 21% of the patients in group I and in 9% in group II. CONCLUSIONS The interim analysis revealed no major differences in acute toxicity and local efficacy between the two evaluated strategies.
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Affiliation(s)
- Krzysztof Bujko
- Department of Radiotherapy II, M. Sklodowska-Curie Memorial Cancer Centre, Warsaw, Poland.
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Abstract
Historically, squamous cell carcinoma of the anal canal was treated with abdominoperineal resection. Nigro discovered that radiation therapy combined with 5-fluorouracil and mitomycin resulted in high rates of local control and colostomy-free and overall survival without surgical intervention. Recent advances include the integration of PET into staging, radiation treatment planning, disease monitoring, and the use of intensity-modulated radiation therapy. For rectal cancer, clinical trials have established the role for neoadjuvant therapy for T3-4 and/or node-positive tumor presentations. Chemotherapy and targeted agents are under study in both anal and rectal cancers to improve on the standard combinations of chemotherapy and radiation.
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Affiliation(s)
- Brian G Czito
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA.
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19
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Selection criteria for the radical treatment of locally advanced rectal cancer. Int J Surg Oncol 2011; 2011:678506. [PMID: 22312517 PMCID: PMC3263678 DOI: 10.1155/2011/678506] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Revised: 06/30/2011] [Accepted: 07/18/2011] [Indexed: 01/12/2023] Open
Abstract
There are over 14,000 newly diagnosed rectal cancers per year in the United Kingdom of which between 50 and 64 percent are locally advanced (T3/T4) at presentation. Pelvic exenterative surgery was first described by Brunschwig in 1948 for advanced cervical cancer, but early series reported high morbidity and mortality. This approach was later applied to advanced primary rectal carcinomas with contemporary series reporting 5-year survival rates between 32 and 66 percent and to recurrent rectal carcinoma with survival rates of 22–42%. The Swansea Pelvic Oncology Group was established in 1999 and is involved in the assessment and management of advanced pelvic malignancies referred both regionally and UK wide. This paper will set out the selection, assessment, preparation, surgery, and outcomes from pelvic exenterative surgery for locally advanced primary rectal carcinomas.
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Harris DA, Davies M, Lucas MG, Drew P, Carr ND, Beynon J. Multivisceral resection for primary locally advanced rectal carcinoma. Br J Surg 2010; 98:582-8. [PMID: 21656723 DOI: 10.1002/bjs.7373] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2010] [Indexed: 01/30/2023]
Abstract
BACKGROUND Pelvic multivisceral resection offers the possibility of cure in patients with locally advanced rectal cancer. This study assessed the clinical outcome and determinants of survival and local recurrence in patients undergoing multivisceral resection for clinical T4 primary rectal cancer. METHODS This was a cohort study of consecutive multivisceral resections carried out in a single centre from 2000 to 2009. Determinants of local recurrence and survival were examined by means of Kaplan-Meier survival curves and Cox regression analysis. RESULTS The study included 42 patients, with a median age of 62 (range 41-83) years, who underwent surgery with a median follow-up of 30 (range 2-102) months. Thirty-one patients had preoperative chemoradiotherapy. Seven patients had rectal resection with en bloc radical prostatectomy. The 30-day mortality rate was zero. Thirty-nine of the 42 patients had a negative circumferential resection margin. The 5-year overall survival rate for those who had complete resection was 48 per cent. Local recurrence was predicted by metastatic disease (P < 0.001) and nodal disease (P < 0.001), but not positive resection margins (P = 0.077). CONCLUSION An aggressive surgical strategy with complete resection is predictive of long-term survival in selected patients with T4a rectal carcinoma. With optimal treatment local recurrence is a sign of systemic disease.
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Affiliation(s)
- D A Harris
- Abertawe Bro Morgannwg University Local Health Board, Swansea, UK.
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21
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Valentini V, Coco C, Rizzo G, Manno A, Crucitti A, Mattana C, Ratto C, Verbo A, Vecchio FM, Barbaro B, Gambacorta MA, Montoro C, Barba MC, Sofo L, Papa V, Menghi R, D'Ugo DM, Doglietto G. Outcomes of clinical T4M0 extra-peritoneal rectal cancer treated with preoperative radiochemotherapy and surgery: a prospective evaluation of a single institutional experience. Surgery 2009; 145:486-94. [PMID: 19375606 DOI: 10.1016/j.surg.2009.01.007] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2008] [Accepted: 01/23/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND Our objective was evaluate the outcome of primary clinical T4M0 extraperitoneal rectal cancer treated by neoadjuvant radiochemotherapy. Prognosis of clinical T4 rectal cancer is poor. Preoperative chemoradiation therapy may be beneficial. The results obtained are unclear due to lack of objective and strictly applied staging methods. METHODS Patients with primary, clinical, T4MO, extraperitoneal rectal cancer, defined by transrectal ultrasonography, computed tomography or magnetic resonance imaging, were considered. Intraoperative radiotherapy and adjuvant chemotherapy were employed in some patients after curative resection (R0). Variables influencing the possibility to perform an R0 resection and a sphincter-saving procedure were investigated as predictors of outcome. RESULTS 100 patients were included. R0 resection was performed in 78 patients. R0 resection rate was greater in females (93% vs 67%) and in responders to neoadjuvant chemoradiation (94% vs 60%). The ability to perform a sphincter-saving procedure was 57%, greater in middle rectal location (85% vs 51%) and in responders to the chemoradiation (70% vs 47%). Median follow-up was 31 months (range, 4-136). Local recurrences were found in 7 patients (10%). Five-year local control in R0 patients was 90% and better in the IORT group (100%). Distant relapse occurred in 24 patients (30%). Five-year overall survival was 59%, and was better after an R0 versus an R1 or R2 resection (68% vs 22%). Overall and disease free survival in R0 patients improved after overall downstaging. Adjuvant chemotherapy given in addition to the neoadjuvant therapy did not appear to offer benefit in improving survival. CONCLUSION A multimodal approach enabled us to obtain a 5-year overall survival of about 60%. IORT increased local control. The role of adjuvant chemotherapy needs to be further investigated.
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Affiliation(s)
- Vincenzo Valentini
- Department of Radiation Therapy, Università Cattolica del Sacro Cuore, Rome, Italy
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Tournat H, Vendrely V, Cherciu B, Smith D, Laurent C, Capdepont M, Kantor G, Maire J. Intérêt de la radiothérapie dans le traitement de la tumeur primitive rectale lorsque sont associées des métastases synchrones. Cancer Radiother 2008; 12:336-42. [DOI: 10.1016/j.canrad.2008.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2007] [Revised: 01/10/2008] [Accepted: 01/30/2008] [Indexed: 01/12/2023]
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Glynne-Jones R, Meadows H, Wood W. Chemotherapy or No Chemotherapy in Clear Margins after Neoadjuvant Chemoradiation in Locally Advanced Rectal Cancer: CHRONICLE. A Randomised Phase III Trial of Control vs. Capecitabine plus Oxaliplatin. Clin Oncol (R Coll Radiol) 2007; 19:327-9. [PMID: 17434299 DOI: 10.1016/j.clon.2007.03.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2007] [Accepted: 02/19/2007] [Indexed: 11/28/2022]
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Ratto C, Ricci R, Valentini V, Castri F, Parello A, Gambacorta MA, Cellini N, Vecchio FM, Doglietto GB. Neoplastic mesorectal microfoci (MMF) following neoadjuvant chemoradiotherapy: clinical and prognostic implications. Ann Surg Oncol 2007; 14:853-61. [PMID: 17103068 DOI: 10.1245/s10434-006-9163-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Neoplastic microfoci have frequently been found in the mesorectum, with poor outcome. In this study, incidence and clinical significance of mesorectal microfoci (MMF) were analyzed in patients operated on for rectal cancer following neoadjuvant chemoradiation. METHODS A case series of 68 patients with extraperitoneal rectal cancer treated with neoadjuvant chemoradiation and surgery (including total mesorectal excision) were investigated for presence of neoplastic MMF. RESULTS MMF were found in 26 cases (38.2%). Increasing incidence of microfoci was statistically related to pathologic involvement of the bowel wall (P = 0.0006), Mandard's tumor regression grading (P = 0.0006), and pathologic neoplastic mesorectal involvement (P < 0.00001). None of the nine patients with complete tumor disappearance displayed both microfoci and lymph node metastasis. Only one local recurrence developed in a patient with multiple MMF. One out of nine pT0 or TRG1 patients (11.1%) had distant metastases compared with 15 out of 59 pT1-4 or TRG2-5 (25.4%, P = 0.70). CONCLUSIONS A remarkable incidence of MMF was found following chemoradiation. However, when this therapy induced complete regression of primary tumor (pT0-TRG1), we found that node metastases and neoplastic MMF also disappeared. These features should be confirmed to assess the impact of these microfoci in treatment decision making in rectal cancers.
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Affiliation(s)
- Carlo Ratto
- Department of Clinica Chirurgica, Catholic University, Largo A. Gemelli, 8, 00168, Rome, Italy.
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Zbar AP, Shenoy RK, Chiappa A. Extended abdominoperineal resection in women: the Barbadian experience. INTERNATIONAL SEMINARS IN SURGICAL ONCOLOGY : ISSO 2007; 4:1. [PMID: 17214895 PMCID: PMC1779795 DOI: 10.1186/1477-7800-4-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2006] [Accepted: 01/10/2007] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND OBJECTIVES We report our results of a selective approach to primary direct appositional vaginal repair versus transverse rectus abdominis flap repair (TRAM) in patients with extensive rectal/anal cancer or in cases with primary cancer of cervix, vagina or vulva involving the anal canal and anal sphincters. METHODS Eighteen female patients (mean age: 62.9 years; range: 44-81 years) with a median follow-up of 14 months (range: 2-36 months) undergoing extended abdominoperineal reconstruction with total mesorectal excision between May 2002 and September 2005, were studied. RESULTS Twelve patients underwent an extended abdominoperineal resection with hysterectomy and vaginectomy, with 6 patients undergoing primary TRAM flap reconstruction following pelvic exenteration. Exenterative procedures were performed in 2 cases of primary vaginal cancer, following Wertheim hysterectomy for carcinoma of the cervix with recurrence after radiation and in 2 further cases of anal cancer with extensive pelvic recurrence after primary chemoradiation. Fifteen cases are alive on follow-up with no evidence of disease; 2 patients who had recurrent carcinoma of the cervix and who underwent TRAM flap reconstruction, have recurrent disease after 5 and 6 months of follow-up, respectively. DISCUSSION Our experience shows that careful primary closure of an extended abdominoperineal resection wound is effective and safe. Our one case of wound breakdown after primary repair underwent external beam and intracavitary irradiation primarily with wound breakdown of a primary repair followed by a delayed pedicled graciloplasty. TRAM flap reconstruction has been reserved in our unit for patients undergoing total pelvic extenteration. In general, we would recommend the use of TRAM flap reconstruction in younger sexually active patients where there has been external irradiation combined with brachytherapy.
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Affiliation(s)
- Andrew P Zbar
- Professorial department of surgery the university of thewest indies, Queen Elizabeth Hospital, Barbados
| | | | - Antonio Chiappa
- Department of General Surgery, European Institute of Oncology, Milano, Italy
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Ratto C, Ricci R, Valentini V, Castri F, Parello A, Gambacorta MA, Cellini N, Vecchio FM, Doglietto GB. Neoplastic mesorectal microfoci (MMF) following neoadjuvant chemoradiotherapy: clinical and prognostic implications. Ann Surg Oncol 2006; 13:1393-402. [PMID: 17013687 DOI: 10.1245/s10434-006-9164-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Neoplastic microfoci have frequently been found in the mesorectum, with poor outcome. In this study, incidence and clinical significance of mesorectal microfoci (MMF) were analyzed in patients operated upon for rectal cancer following neoadjuvant chemoradiation. METHODS A case series of 68 patients with extraperitoneal rectal cancer, treated with neoadjuvant chemoradiation and surgery (including total mesorectal excision), was investigated for the presence of neoplastic MMF. RESULTS Mesorectal microfoci were found in 26 cases (38.2%). Increasing incidence of microfoci was statistically related to pathologic involvement of bowel wall (P = 0.0006), Mandard's tumor regression grading (P = 0.0006) and pathologic neoplastic mesorectal involvement (P < 0.00001). None of the nine patients with complete tumor disappearance displayed both microfoci and lymph node metastasis. Only one local recurrence developed in a patient with multiple MMF. Out of 9 pT0 or TRG1 patients, 1 (11.1%) had distant metastases, compared to 15 out of 59 pT1-4 or TRG2-5 (25.4%, P = 0.70). CONCLUSIONS A remarkable incidence of MMF was found following chemoradiation. However, when this therapy induces complete regression of primary tumor (pT0-TRG1), node metastases and neoplastic MMF could also disappear, as shown in our cases. These features should be confirmed because they could significantly impact the treatment decision-making of rectal cancers.
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Affiliation(s)
- Carlo Ratto
- Department of Clinica Chirurgica, Catholic University, Largo A. Gemelli, 8, 00168, Rome, Italy.
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Movsas B, Diratzouian H, Hanlon A, Cooper H, Freedman G, Konski A, Sigurdson E, Hoffman J, Meropol NJ, Weiner LM, Coia L, Lanciano R, Stein J, Kister D, Eisenberg B. Phase II Trial of Preoperative Chemoradiation With a Hyperfractionated Radiation Boost in Locally Advanced Rectal Cancer. Am J Clin Oncol 2006; 29:435-41. [PMID: 17023775 DOI: 10.1097/01.coc.0000227480.41414.f2] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE The purpose of this phase II study was to prospectively determine the efficacy of preoperative chemoradiation with a hyperfractionated (Hfx) RT boost to 61.8 Gy in locally advanced rectal cancer. METHODS Eligibility stipulated that the primary lesion had to be either T4; or T3 and >4 cm or 40% of the bowel circumference. Radiation (RT) consisted of 45 Gy to the pelvis (1.8 Gy per fraction) followed by 1.2 Gy twice daily (to the gross tumor volume) to a total RT dose of 61.8 Gy. There was 5-FU infused at 1 g/m2/24 hours for 4 days during the 1st and 6th weeks of RT (concurrent with the Hfx boost). Surgical resection was planned 4 to 6 weeks later. Adjuvant chemotherapy (bolus 5-FU/leucovorin) was scheduled for 4 cycles at 28-day intervals. RESULTS There were 22 patients, ages 22 to 81 years (median, 64) enrolled in the study. Of the 20 patients evaluable for response, 10 (50%) had evidence of clinical downstaging and 5 patients (25%) had > or =90% fibrosis in the resected specimen. With a median f/u of 40 months (7-158), the 4 years actuarial rate for all patients (n = 22) of OS was 64%, of DFS 62%, and of LC 84%. 3/21 patients (14%) had positive margins, all of whom developed a local failure (P < 0.001). CONCLUSION This regimen of high dose preoperative chemoRT with a Hfx RT boost (to 61.8 Gy) in patients with bulky, locally advanced rectal cancer results in clinical downstaging in half of the patients with significant fibrosis in the operative specimen.
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Affiliation(s)
- Benjamin Movsas
- Henry Ford Health System, Radiation Oncology, Detroit, MI 48202, USA.
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Beddar AS, Briere TM, Ouzidane M. Intraoperative radiation therapy using a mobile electron linear accelerator: field matching for large-field electron irradiation. Phys Med Biol 2006; 51:N331-7. [PMID: 16953035 DOI: 10.1088/0031-9155/51/18/n01] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Intraoperative radiation therapy (IORT) consists of delivering a large, single-fraction dose of radiation to a surgically exposed tumour or tumour bed at the time of surgery. With the availability of a mobile linear accelerator in the OR, IORT procedures have become more feasible for medical centres and more accessible to cancer patients. Often the area requiring irradiation is larger than what the treatment applicators will allow, and therefore, two or more adjoining fields are used. Unfortunately, the divergence and scattering of the electron beams may cause significant dose variations in the region of the field junction. Furthermore, because IORT treatments are delivered in a large single fraction, the effects of underdosing or overdosing could be more critical when compared to fractionated external beam therapy. Proper matching of the fields is therefore an important technical aspect of treatment delivery. We have studied the matching region using the largest flat applicator available for three different possibilities: abutting the fields, leaving a small gap or creating an overlap. Measurements were done using film dosimetry for the available energies of 4, 6, 9 and 12 MeV. Our results show the presence of clinically significant cold spots for the low-energy beams when the fields are either gapped or abutted, suggesting that the fields should be overlapped. No fields should be gapped. The results suggest that an optimal dose distribution may be obtained by overlapping the fields at 4 and 6 MeV and simply abutting the fields at 9 and 12 MeV. However, due to uncertainties in the placement of lead shields during treatment delivery, one may wish to consider overlapping the higher energy fields as well.
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Affiliation(s)
- A S Beddar
- Department of Radiation Physics, Division of Radiation Oncology, The University of Texas M D Anderson Cancer Center, 1515 Holcombe Blvd, Box 94, Houston, TX 77030, USA.
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Voelter V, Zouhair A, Vuilleumier H, Matter M, Bouzourene H, Leyvraz S, Bauer J, Coucke P, Stupp R. CPT-11 and concomitant hyperfractionated accelerated radiotherapy induce efficient local control in rectal cancer patients: results from a phase II. Br J Cancer 2006; 95:710-6. [PMID: 16940980 PMCID: PMC2360515 DOI: 10.1038/sj.bjc.6603322] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Patients with rectal cancer are at high risk of disease recurrence despite neoadjuvant radiochemotherapy with 5-Fluorouracil (5FU), a regimen that is now widely applied. In order to develop a regimen with increased antitumour activity, we previously established the recommended dose of neoadjuvant CPT-11 (three times weekly 90 mg m−2) concomitant to hyperfractionated accelerated radiotherapy (HART) followed by surgery within 1 week. Thirty-three patients (20 men) with a locally advanced adenocarcinoma of the rectum were enrolled in this prospective phase II trial (1 cT2, 29 cT3, 3 cT4 and 21 cN+). Median age was 60 years (range 43–75 years). All patients received all three injections of CPT-11 and all but two patients completed radiotherapy as planned. Surgery with total mesorectal excision (TME) was performed within 1 week (range 2–15 days). The preoperative chemoradiotherapy was overall well tolerated, 24% of the patients experienced grade 3 diarrhoea that was easily manageable. At a median follow-up of 2 years no local recurrence occurred, however, nine patients developed distant metastases. The 2-year disease-free survival was 66% (95% confidence interval 0.48–0.83). Neoadjuvant CPT-11 and HART allow for excellent local control; however, distant relapse remains a concern in this patient population.
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Affiliation(s)
- V Voelter
- Multidisciplinary Oncology Centre, The University of Lausanne Hospitals, Rue du Bugnon 46, CH 1011, Lausanne, Switzerland.
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Hung AY, Canning CA, Patel KM, Holland JM, Kachnic LA. Radiation therapy for gastrointestinal cancer. Hematol Oncol Clin North Am 2006; 20:287-320. [PMID: 16730296 DOI: 10.1016/j.hoc.2006.01.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This article has reviewed the current role of radiation in the treatment of gastrointestinal malignancies and discussed the data supporting its use. Radiation treatment in this setting continues to evolve with the increasing implementation of more conformal delivery techniques. Further scientific investigation is needed to establish the optimal role of radiation and to better define its integration with novel systemic and biologic modalities.
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Affiliation(s)
- Arthur Y Hung
- Department of Radiation Oncology, Oregon Health & Science University, Portland, OR 97239-3098, USA.
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Calvo FA, Meirino RM, Orecchia R. intraoperative radiation therapy part 2. Clinical results. Crit Rev Oncol Hematol 2006; 59:116-27. [PMID: 16859922 DOI: 10.1016/j.critrevonc.2006.04.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2005] [Revised: 03/30/2006] [Accepted: 04/13/2006] [Indexed: 12/12/2022] Open
Abstract
Intraoperative radiation therapy (IORT) has been used for over 30 years in Asia, Europe and America as a supplementary activity in the treatment of cancer patients with promising results. Modern IORT is carried out with electron beams (IOERT) produced by a linear accelerator generally used for external beam irradiation (EBRT) or a specialized mobile electron accelerator. HDR brachytherapy (HDR-IORT) has also been applied on selected locations. Retrospective analysis of clinical experiences in cancer sites such as operable pancreatic tumour, locally advanced/recurrent rectal cancer, head and neck carcinomas, sarcomas and cervical cancer are consistent with local tumour control promotion compared to similar clinical experiences without IORT. New emerging indications such as the treatment of breast cancer are presented. The IORT component of the therapeutical approach allows intensification of the total radiation dose without additional exposure of healthy tissues and improves dose-deposit homogeneity and precision. Results of the application of IORT on selected disease sites are presented with an analysis on future possibilities. To improve the methodology, clinical trials are required with multivariate analysis including patient, tumour and treatment characteristics, prospective evaluation of early and late toxicity, patterns of tumour recurrence and overall patient outcome.
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Affiliation(s)
- Felipe A Calvo
- Hospital General Universitario Gregorio Marañon, Madrid, Spain.
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Beddar AS, Biggs PJ, Chang S, Ezzell GA, Faddegon BA, Hensley FW, Mills MD. Intraoperative radiation therapy using mobile electron linear accelerators: report of AAPM Radiation Therapy Committee Task Group No. 72. Med Phys 2006; 33:1476-89. [PMID: 16752582 DOI: 10.1118/1.2194447] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Intraoperative radiation therapy (IORT) has been customarily performed either in a shielded operating suite located in the operating room (OR) or in a shielded treatment room located within the Department of Radiation Oncology. In both cases, this cancer treatment modality uses stationary linear accelerators. With the development of new technology, mobile linear accelerators have recently become available for IORT. Mobility offers flexibility in treatment location and is leading to a renewed interest in IORT. These mobile accelerator units, which can be transported any day of use to almost any location within a hospital setting, are assembled in a nondedicated environment and used to deliver IORT. Numerous aspects of the design of these new units differ from that of conventional linear accelerators. The scope of this Task Group (TG-72) will focus on items that particularly apply to mobile IORT electron systems. More specifically, the charges to this Task Group are to (i) identify the key differences between stationary and mobile electron linear accelerators used for IORT, (ii) describe and recommend the implementation of an IORT program within the OR environment, (iii) present and discuss radiation protection issues and consequences of working within a nondedicated radiotherapy environment, (iv) describe and recommend the acceptance and machine commissioning of items that are specific to mobile electron linear accelerators, and (v) design and recommend an efficient quality assurance program for mobile systems.
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Affiliation(s)
- A Sam Beddar
- Department of Radiation Physics, Division of Radiation Oncology, Unit 94, The University of Texas M.D. Anderson Cancer Center, Houston, Texas 77030, USA.
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Roels S, Duthoy W, Haustermans K, Penninckx F, Vandecaveye V, Boterberg T, De Neve W. Definition and delineation of the clinical target volume for rectal cancer. Int J Radiat Oncol Biol Phys 2006; 65:1129-42. [PMID: 16750329 DOI: 10.1016/j.ijrobp.2006.02.050] [Citation(s) in RCA: 174] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2005] [Revised: 02/09/2006] [Accepted: 02/10/2006] [Indexed: 12/18/2022]
Abstract
PURPOSE Optimization of radiation techniques to maximize local tumor control and to minimize small bowel toxicity in locally advanced rectal cancer requires proper definition and delineation guidelines for the clinical target volume (CTV). The purpose of this investigation was to analyze reported data on the predominant locations and frequency of local recurrences and lymph node involvement in rectal cancer, to propose a definition of the CTV for rectal cancer and guidelines for its delineation. METHODS AND MATERIALS Seven reports were analyzed to assess the incidence and predominant location of local recurrences in rectal cancer. The distribution of lymphatic spread was analyzed in another 10 reports to record the relative frequency and location of metastatic lymph nodes in rectal cancer, according to the stage and level of the primary tumor. RESULTS The mesorectal, posterior, and inferior pelvic subsites are most at risk for local recurrences, whereas lymphatic tumor spread occurs mainly in three directions: upward into the inferior mesenteric nodes; lateral into the internal iliac lymph nodes; and, in a few cases, downward into the external iliac and inguinal lymph nodes. The risk for recurrence or lymph node involvement is related to the stage and the level of the primary lesion. CONCLUSION Based on a review of articles reporting on the incidence and predominant location of local recurrences and the distribution of lymphatic spread in rectal cancer, we defined guidelines for CTV delineation including the pelvic subsites and lymph node groups at risk for microscopic involvement. We propose to include the primary tumor, the mesorectal subsite, and the posterior pelvic subsite in the CTV in all patients. Moreover, the lateral lymph nodes are at high risk for microscopic involvement and should also be added in the CTV.
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Affiliation(s)
- Sarah Roels
- Department of Radiotherapy, University Hospital Gasthuisberg, Leuven, Belgium
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Hu JB, Sun XN, Yang QC, Xu J, Wang Q, He C. Three-dimensional conformal radiotherapy combined with FOLFOX4 chemotherapy for unresectable recurrent rectal cancer. World J Gastroenterol 2006; 12:2610-4. [PMID: 16688811 PMCID: PMC4087998 DOI: 10.3748/wjg.v12.i16.2610] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the effect of three-dimensional conformal radiotherapy (3-DCRT) in combination with FOLFOX4 chemotherapy for unresectable recurrent rectal cancer.
METHODS: Forty-eight patients with unresectable recurrent rectal cancer were randomized and treated by 3-DCRT or 3-DCRT combined with FOLFOX4 chemotherapy between September 2001 and October 2003. For the patients without prior radiation history, the initial radiation was given to the whole pelvis by traditional methods with tumor dose of 40 Gy, followed by 3-DCRT for the recurrent lesions to the median total cumulative tumor dose of 60 Gy (range 56-66 Gy); for the post-radiation recurrent patients, 3-DCRT was directly given for the recurrent lesions to the median tumor dose of 40 Gy (36-46 Gy). For patients in the study group, two cycles chemotherapy with FOLFOX4 regimen were given concurrently with radiotherapy, with the first cycle given simultaneously with the initiation of radiation and the second cycle given in the fifth week for patients receiving conventional pelvis radiation or given in the last week of 3-DCRT for patients receiving 3-DCRT directly. Another 2-4 cycles (average 3.6 cycles) sequential FOLFOX4 regimen chemotherapy were given to the patients in the study group, beginning at 2-3 wk after chemoradiation. The outcomes of symptoms relieve, tumor response, survival and toxicity were recorded and compared between the study group and the control group.
RESULTS: For the study group and the control group, the pain-alleviation rates were 95.2% and 91.3% (P > 0.05); the overall response rates were 56.5% and 40.0% (P > 0.05); the 1-year and 2-year survival rates were 86.9%, 50.2% and 80.0%, 23.9%, with median survival time of 25 mo and 16 mo (P < 0.05); the 2-year distant metastasis rates were 39.1% and 56.0% (P = 0.054), respectively. The side effects, except peripheral neuropathy which was relatively severer in the study group, were similar in the the two groups and well tolerated.
CONCLUSION: Three-dimensional conformal radio-therapy combined with FOLFOX4 chemotherapy for unresectable recurrent rectal cancer is a feasible and effective therapeutic approach, and can reduce distant metastasis rate and improve the survival rate.
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Affiliation(s)
- Jian-Bin Hu
- Department of Radiation Oncology of Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
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Ferrigno R, Novaes PERDS, Silva MLG, Nishimoto IN, Nakagawa WT, Rossi BM, Ferreira FDO, Lopes A. Neoadjuvant radiochemotherapy in the treatment of fixed and semi-fixed rectal tumors. Analysis of results and prognostic factors. Radiat Oncol 2006; 1:5. [PMID: 16722598 PMCID: PMC1459184 DOI: 10.1186/1748-717x-1-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2005] [Accepted: 03/28/2006] [Indexed: 12/21/2022] Open
Abstract
PURPOSE To report the retrospective analysis of patients with locally advanced rectal cancer treated with neodjuvant radiochemotherapy. METHODS AND MATERIALS From January 1994 to December 2003, 101 patients with fixed (25%) or semi-fixed (75%) rectal adenocarcinoma were treated by preoperative radiotherapy with a dose of 45 Gy at the whole pelvis and 50.4 Gy at primary tumor, concomitant to four weekly chemotherapies with 5-Fluorouracil (425 mg/m2) and Leucovorin (20 mg/m2). In 71 patients (70.3%) the primary tumor was located up to 6 cm from the anal verge and in 30 (29.7%) from 6.5 cm to 10 cm. Age, gender, tumor fixation, tumor distance from the anal verge, clinical response, surgical technique, and postoperative TNM stage were the prognostic factors analyzed for overall survival (OS), disease-free survival (DFS), and local control (LC) at five years. RESULTS Median follow-up time was 38 months (range, 2-141). Complete response was observed in eight patients (7.9%), partial in 54 (53.4%) and absence in 39 (38.7%). OS, DFS and LC were 52.6%, 53.8%, and 75.9%, respectively. Distant metastasis occurred in 40 (39.6%) patients, local recurrence in 20 (19.8%) and both in 16 (15.8%). Patients with fixed tumors had lower OS (17% Vs 65.6%; p < 0.001), DFS (31.2% Vs 60.9%; p = 0.005), and LC (58% Vs 82%; p = 0.004). Patients with tumors more than 6 cm above the anal verge had better LC (93% Vs 69%; p = 0.04). The postoperative TNM stage was a significant factor for DFS (I:64.1%, II:69.6%, III:35.2%, IV:11.1%; p < 0.001) and for LC (I:75.7%, II: 92.9%, III:54.1%, IV:100%; p = 0.005). Patients with positive lymph nodes had worse OS (37.9% Vs 70.4%, p = 0.006), DFS (32% Vs 72.7%, p < 0.001) and LC (56.2% Vs 93.4%; p < 0.001). CONCLUSION This study suggests that the neoadjuvant treatment employed was effective for local control. Fixation of the lesion and lymph nodes metastasis were the main adverse prognostic factors. Distant failures were frequent, supporting the need of new drugs for adjuvant chemotherapy.
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Affiliation(s)
- Robson Ferrigno
- Department of Radiation Oncology, Hospital do Câncer A. C. Camargo, Rua Prof. Antonio Prudente, 211, São Paulo, SP 01509-900, Brazil
| | | | - Maria Letícia Gobo Silva
- Department of Radiation Oncology, Hospital do Câncer A. C. Camargo, Rua Prof. Antonio Prudente, 211, São Paulo, SP 01509-900, Brazil
| | - Ines Nobuko Nishimoto
- Department of Biostatistics, Fundação Antonio Prudente, Rua Prof. Antonio Prudente, 211, São Paulo, SP 01509-900, Brazil
| | - Wilson Toshihiko Nakagawa
- Department of Pelvic Surgery, Hospital do Câncer A. C. Camargo, Rua Prof. Antonio Prudente, 211, São Paulo, SP 01509-900, Brazil
| | - Benedito Mauro Rossi
- Department of Pelvic Surgery, Hospital do Câncer A. C. Camargo, Rua Prof. Antonio Prudente, 211, São Paulo, SP 01509-900, Brazil
| | - Fábio de Oliveira Ferreira
- Department of Pelvic Surgery, Hospital do Câncer A. C. Camargo, Rua Prof. Antonio Prudente, 211, São Paulo, SP 01509-900, Brazil
| | - Ademar Lopes
- Department of Pelvic Surgery, Hospital do Câncer A. C. Camargo, Rua Prof. Antonio Prudente, 211, São Paulo, SP 01509-900, Brazil
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Pawlik TM, Skibber JM, Rodriguez-Bigas MA. Pelvic Exenteration for Advanced Pelvic Malignancies. Ann Surg Oncol 2006; 13:612-23. [PMID: 16538402 DOI: 10.1245/aso.2006.03.082] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2005] [Accepted: 08/05/2005] [Indexed: 01/24/2023]
Affiliation(s)
- Timothy M Pawlik
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Unit 444, P.O. Box 301402, Houston, Texas, 77230-1402, USA
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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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Guerrero V, Perretta S, Garcia-Aguilar J. Extended Abdominoperineal Resection. SEMINARS IN COLON AND RECTAL SURGERY 2005. [DOI: 10.1053/j.scrs.2005.09.005] [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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Beddar AS, Krishnan S. Intraoperative radiotherapy using a mobile electron LINAC: a retroperitoneal sarcoma case. J Appl Clin Med Phys 2005; 6:95-107. [PMID: 16143794 PMCID: PMC5723491 DOI: 10.1120/jacmp.v6i3.2109] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The advent of mobile LINACs for use in intraoperative radiation therapy (IORT) promises to make IORT more accessible than before and easier to deliver to patients undergoing surgery. Although mobile IORT systems have been available since 1999, few treatment centers currently use them. Here, we present the case of a typical patient undergoing IORT for retroperitoneal sarcoma to show how easy these mobile systems are to use and how adaptable they are within the operating room (OR) environment. We also discuss the roles and coordination of multidisciplinary team members during IORT and the feasibility of using mobile LINACs for IORT. PACS number(s):
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Affiliation(s)
- A Sam Beddar
- Department of Radiation Physics, The University of Texas M.D. Anderson Cancer Center, Houston, Texas 77030, USA.
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Bell SW, Dehni N, Chaouat M, Lifante JC, Parc R, Tiret E. Primary rectus abdominis myocutaneous flap for repair of perineal and vaginal defects after extended abdominoperineal resection. Br J Surg 2005; 92:482-6. [PMID: 15736219 DOI: 10.1002/bjs.4857] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Significant morbidity can result from perineal wounds, particularly after radiotherapy and extensive resection for cancer. Myocutaneous flaps have been used to improve healing. The purpose of this study was to evaluate the morbidity and results of primary rectus abdominis myocutaneous flap reconstruction of the vagina and perineum after extended abdominoperineal resection. METHODS Thirty-one consecutive patients undergoing one-stage rectus abdominis myocutaneous flap reconstruction of extensive perineal wounds were studied prospectively. Twenty-six patients had surgery for recurrent or persistent epidermoid anal cancer or low rectal cancer, and 21 had high-dose preoperative radiotherapy. RESULTS Three weeks after the operation, complete healing of the perineal wound was seen in 27 of the 31 patients. There were nine flap-related complications including three patients with partial flap necrosis, two with vaginal stenosis, one with vaginal scarring, one with small flap disunion and two with weakness of the anterior abdominal wall. There were no unhealed wounds at the completion of follow-up (median 9 months). CONCLUSION The transpelvic rectus abdominis myocutaneous flap for the reconstruction of large perineal and vaginal wounds achieves wound healing with only moderate morbidity in the majority of patients after extensive abdominoperineal resection with or without radiotherapy.
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Affiliation(s)
- S W Bell
- Centre de Chirurgie Digestive, Hôpital Saint Antoine, Assistance Publique-Hôpitaux de Paris, 75571 Paris, France
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Rich TA, Shepard RC, Mosley ST. Four Decades of Continuing Innovation With Fluorouracil: Current and Future Approaches to Fluorouracil Chemoradiation Therapy. J Clin Oncol 2004; 22:2214-32. [PMID: 15169811 DOI: 10.1200/jco.2004.08.009] [Citation(s) in RCA: 159] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Purpose Chemoradiotherapy, the combination of external radiation therapy and concurrent chemotherapy, has been the basis for the oncologic management of many patients since its development in the 1960s. Fluorouracil (FU) chemoradiotherapy has demonstrated success in several organ sites with multiple dosing schedules that now guide the selection of oral analogs of FU to provide new chemoradiotherapy options. Methods This article reviews the metabolism and pharmacology of FU and the advantages of administration of FU by continuous infusion or bolus. The potential role and impact of the oral fluorouracil prodrugs UFT, S-1, BOF-A2, and capecitabine as replacements for intravenous administration are discussed. The results of recent chemoradiotherapy studies with FU from 2000 to 2003 are summarized in rectal, head and neck, esophageal, gastric, pancreatic, biliary, anal, and cervical cancers. Results Chemoradiotherapy with FU has the potential to widen the therapeutic window by minimizing normal tissue toxicity while maintaining effective tumor toxicity. Overall, FU chemoradiotherapy maximizes local control and, for some tumor sites (such as head and neck, pancreatic, biliary, cervical, esophageal, and gastric cancers), improves survival rates. Moreover, FU chemoradiotherapy results in improved organ preservation with excellent functional outcome in several anatomic sites including head and neck cancer, anal, and rectal cancer, with improved sphincter preservation. Conclusion FU chemoradiotherapy continues to play an important role in the management of many cancer sites. During the last four decades, optimal dosing schedules have produced a therapeutic gain. The introduction of oral prodrug analogs will likely further improve the results of FU therapy in several organ systems, such as the rectum, head and neck, and esophagus.
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Affiliation(s)
- Tyvin A Rich
- FACR, Department of Radiation Oncology, University of Virginia Health System, PO Box 800383, Charlottesville, VA 22908-0383, USA.
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Parulekar W, de Marsh RW, Wong R, Mendenhall W, Davey P, Zlotecki R, Berry S, Rout WR, Bjarnason GA. Phase I study of 5-fluorouracil and leucovorin by continuous infusion chronotherapy and pelvic radiotherapy in patients with locally advanced or recurrent rectal cancer. Int J Radiat Oncol Biol Phys 2004; 58:1487-95. [PMID: 15050328 DOI: 10.1016/j.ijrobp.2003.09.073] [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] [Received: 02/12/2003] [Revised: 09/09/2003] [Accepted: 09/12/2003] [Indexed: 10/26/2022]
Abstract
PURPOSE To determine the maximal tolerated dose of chronomodulated 5-fluorouracil (5-FU) and leucovorin (LV) given concurrently with radiotherapy in patients with rectal cancer. METHODS AND MATERIALS Forty-five patients with T3, T4 or recurrent rectal cancer received concurrent radiotherapy to a minimal dose of 4500 cGy. Chemotherapy was administered by a programmable pump in chronomodulated fashion, with 62.5% of the total dose given within 7 hours around 9:30 pm. The starting doses were LV at 5 mg/m2/d and 5-FU at 150 mg/m2/d. LV was escalated in 5-mg/m2 increments to 20 mg/m2/d; 5-FU was then escalated in 25 mg/m2 increments to the maximal tolerated dose. RESULTS Diarrhea and stomatitis were dose limiting, with Grade 3 or worse toxicity occurring in 16% and 5% of patients, respectively. Thirty-seven patients (84%) received their scheduled dose of radiotherapy (range, 4500-6000 cGy). Thirty-two patients had clinical T3 disease; all were treated with definitive surgery; 23 (71%) underwent sphincter-sparing surgery with complete resection in 28 (87%). Ten patients (31%) had no evidence of tumor in the pathologic specimen. CONCLUSION Preoperative chemoradiotherapy in rectal cancer using chronomodulated 5-FU and LV is feasible. The recommended Phase II dose is 5-FU 200 mg/m2 and LV 20 mg/m2 daily for 5 weeks.
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Affiliation(s)
- Wendy Parulekar
- Department of Medical Oncology, Kingston Regional Cancer Center, Kingston, ON, Canada
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Crane CH, Skibber J. Preoperative chemoradiation for locally advanced rectal cancer: rationale, technique, and results of treatment. ACTA ACUST UNITED AC 2004; 21:265-70. [PMID: 14648785 DOI: 10.1002/ssu.10046] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Over the past decade, 392 patients with stage II and III rectal cancer have been managed with preoperative chemoradiation and surgery at the M. D. Anderson Cancer Center (MDACC). Aggressive surgical techniques such as total mesorectal excision, proctectomy with coloanal anastamosis, and multivisceral excisions have been used. Initial pelvic chemoradiation is also used in patients who present with metastases. Preoperative chemoradiation followed by surgery has resulted in excellent sphincter preservation (SP) and pelvic control with minimal acute, perioperative, and late morbidity. SP has been achieved in greater numbers of patients over the past 3 years due to the increased use of coloanal anastamosis in very low tumors. There has been no increase in pelvic failure or perioperative morbidity with this practice. Patients with clinical T4 disease have significantly worse pelvic control. An assessment of the impact of CB on pelvic control and survival requires further follow-up. Poor differentiation and poor response to preoperative therapy predict a worse overall survival. Durable symptom control without colostomy has been achieved using initial chemoradiation in patients who present with metastases. Aggressive bowel management and skin care can minimize hospitalization and treatment interruption due to acute toxicity. Multidisciplinary therapy using preoperative chemoradiation and aggressive surgery has resulted in excellent SP and pelvic control. However, more effective systemic therapies are needed, especially for patients who do not respond well to preoperative chemoradiation.
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Affiliation(s)
- Christopher H Crane
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA.
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Göhl J, Merkel S, Rödel C, Hohenberger W. Can neoadjuvant radiochemotherapy improve the results of multivisceral resections in advanced rectal carcinoma (cT4a). Colorectal Dis 2003; 5:436-41. [PMID: 12925076 DOI: 10.1046/j.1463-1318.2003.00525.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To investigate the influence of neoadjuvant radiochemotherapy (nRCT) in advanced rectal carcinoma (cT4a), the prospectively collected data of all patients treated by extended multivisceral resections during the last 16 years were analysed. METHODS Between 1985 and 2000, 113 patients with clinical T4a rectal carcinoma (invasion of adjacent organs or structures), were treated by extended multivisceral surgery. In 1995 nRCT was introduced as a standardized treatment modality in cT4a carcinomas and applied in 32 patients. Six weeks after completion of nRCT, resection was performed. In all patients at least one additional organ was removed because of clinically evident tumour infiltration. In one third of patients (36/113) more than one organ had to be removed. RESULTS The rate of curative (R0) resections was 89% (101/113). It was similar in patients with and without nRCT (91 vs. 89%). In 40 (35%) patients histopathological examination could verify tumour invasion in adjacent organs (34% with vs. 36% without nRCT). The 3-year rate of locoregional recurrence after R0-resection was 12.7%. In multivariate Cox regression analysis the regional lymph node status was the most important prognostic factor (relative risk 5.8, P = 0.007). Neoadjuvant or adjuvant treatment reduced the risk by factor 0.4 (P = 0.211). The 3-year cancer-related survival rate of all patients with curative resection was 72.9%. It was 89.4% in the series treated with nRCT, while it was only 66.7% in patients with neither neoadjuvant nor adjuvant therapy. The relative risk for patients with lymph node metastases was 7.0 (P < 0.001) while it was only 0.2 in patients treated with nRCT (P = 0.049). CONCLUSIONS Together with curative extended multivisceral resection nRCT can improve prognosis in patients with advanced rectal carcinoma (cT4a).
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Affiliation(s)
- J Göhl
- Department of Surgery, University of Erlangen, Krankenhausstrasse 12, D-91054 Erlangen, Germany.
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Abstract
OBJECTIVE To investigate the outcome of surgical treatment for patients with T4 rectal cancer and to evaluate prognostic factors influencing 5-year disease-free survival. PATIENTS Of 1600 rectal cancers seen between 1985 and 1998, there were 197 patients with T4 of whom 128 were treated with curative intent. In this retrospective study organ invaded, the type of treatment and outcome were analysed. RESULTS Of the 128 patients, 89% had visceral involvement and 11% had pelvic wall involvement. The most frequently involved organ was bladder, followed by prostate and vagina. Low anterior resection was performed in 52, abdomino-perineal resection in 35 and total pelvic exenteration in 41 patients. Of 81 with urinary tract invasion, 50% were treated with bladder-sparing surgery. Pathological examinations showed bladder involvement in only 44 of these and overall 5-year disease-free survival was 57%. Multivariate analysis revealed that body mass index, lymph node metastasis and inflammatory reaction were significant predictors of survival. CONCLUSION Completeness of resection is the essential factor influencing oncological outcome.
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Affiliation(s)
- Y Moriya
- Colorectal Surgical Unit, National Cancer Centre Hospital, Tsukiji 5-1-1, Chuo-Ku, Tokyo 104-0045, Japan.
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Abstract
Patients with T4 rectal cancer may be increasingly defined by the use of pelvic MRI. This approach has the potential to classify patients who have tumour extending beyond the mesorectal fascia and those very close to but not beyond the mesorectal fascia (for example 1-2 mm). Prospective studies of MRI are required to validate such an approach. It is important that the full extent of local disease is defined prior to the commencement of radiation. Assessment after radiation is much more difficult. Even if tumour regression has occurred, if invasion of another organ was originally present, then surgical removal is required as only a small minority of patients will have a histopathologically complete response after CRT. Many investigators are developing improved CRT regimens that integrate either oxaliplatin or irinotecan with a fluoropyrimidines and radiation. There are two choices that allow intensification of pre-operative radiation. One approach is to escalate the dose of radiation and the other is to exploit the interaction between chemotherapy and radiation by adding more chemotherapy during the period of irradiation. Current interest predominantly is focused on the latter approach. Future studies are likely to assess agents directed against molecular targets. Careful consideration is required to define the best end points for successful pre-operative chemo-radiation leading to surgical excision.
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Affiliation(s)
- David Sebag-Montefiore
- Leeds Cancer Centre, Cookridge Hospital, Hospital Lane, Leeds LS16 6QB West Yorkshire, UK.
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Reerink O, Verschueren RCJ, Szabo BG, Hospers GAP, Mulder NH. A favourable pathological stage after neoadjuvant radiochemotherapy in patients with initially irresectable rectal cancer correlates with a favourable prognosis. Eur J Cancer 2003; 39:192-5. [PMID: 12509951 DOI: 10.1016/s0959-8049(02)00557-9] [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: 01/24/2023]
Abstract
Initial treatments of locally advanced rectal cancers focus on local control, as local relapse of a rectal cancer is correlated with a high morbidity and mortality. We studied the effect of neoadjuvant radiochemotherapy on advanced rectal cancer patients in relation to downstaging, local relapse and survival. Post-treatment pathological staging, local relapse and survival were analysed in 66 patients from a single institution. 43 patients had irresectable cancer as determined by laparatomy (n=42) or rectal examination (n=1). These 43 patients received 45-56 Gy preoperatively with 5-fluorouracil (5-FU) and leucovorin (350/20 mg/m(2)x5 day (d)) in weeks 1 and 5 during the radiation therapy. 23 patients had primary resectable tumours with a T1-2 stage. Of the initially irresectable tumours 79% became macroscopically resectable, in 74% a R0 resection was performed. In 6 of 34 (18%) surgical specimens, no tumour was found (pT0), 7 patients had small tumour remnants (pT1-2). In these pT0-2 tumours, no local relapses occurred (observation period of median 4.5 years, range 18-87 months). In the 21 patients with pT3-4 tumours 3 local relapses were seen. In the 23 patients with primary resectable T1-2 tumours the relapse rate was 4%. Downstaging of an initially irresectable rectal tumour to pT2 or less results in a local relapse rate and overall survival that correspond with the rates in primary resectable cancer with the same T classification.
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Affiliation(s)
- O Reerink
- Department of Radiation Oncology, University Hospital Groningen, 9700 RB, Groningen, The Netherlands
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Fleshman JW. The effect of the surgeon and the pathologist on patient survival after resection of colon and rectal cancer. Ann Surg 2002; 235:464-5. [PMID: 11923601 PMCID: PMC1422460 DOI: 10.1097/00000658-200204000-00003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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