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Rotaru V, Chitoran E, Zob DL, Ionescu SO, Aisa G, Andra-Delia P, Serban D, Stefan DC, Simion L. Pelvic Exenteration in Advanced, Recurrent or Synchronous Cancers-Last Resort or Therapeutic Option? Diagnostics (Basel) 2024; 14:1707. [PMID: 39202196 PMCID: PMC11353817 DOI: 10.3390/diagnostics14161707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2024] [Revised: 07/29/2024] [Accepted: 08/05/2024] [Indexed: 09/03/2024] Open
Abstract
First described some 80 years ago, pelvic exenteration remain controversial interventions with variable results and ever-changing indications. The previous studies are not homogenous and have different inclusion criteria (different populations and different disease characteristics) and methodologies (including evaluation of results), making it extremely difficult to properly assess the role of pelvic exenteration in cancer treatment. This study aims to describe the indications of pelvic exenterations, the main prognostic factors of oncologic results, and the possible complications of the intervention. Methods: For this purpose, we conducted a retrospective study of 132 patients who underwent various forms of pelvic exenterations in the Institute of Oncology "Prof. Dr. Al. Trestioreanu" in Bucharest, Romania, between 2013 and 2022, collecting sociodemographic data, characteristics of patients, information on the disease treated, data about the surgical procedure, complications, additional cancer treatments, and oncologic results. Results: The study cohort consists of gynecological, colorectal, and urinary bladder malignancies (one hundred twenty-seven patients) and five patients with complex fistulas between pelvic organs. An R0 resection was possible in 76.38% of cases, while on the rest, positive margins on resection specimens were observed. The early morbidity was 40.63% and the mortality was 2.72%. Long-term outcomes included an overall survival of 43.7 months and a median recurrence-free survival of 24.3 months. The most important determinants of OS are completeness of resection, the colorectal origin of tumor, and the presence/absence of lymphovascular invasion. Conclusions: Although still associated with high morbidity rates, pelvic exenterations can deliver important improvements in oncological outcomes in the long-term and should be considered on a case-by-case basis. A good selection of patients and an experienced surgical team can facilitate optimal risks/benefits.
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Affiliation(s)
- Vlad Rotaru
- Medicine School, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- General Surgery and Surgical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Al. Trestioreanu”, 022328 Bucharest, Romania
| | - Elena Chitoran
- Medicine School, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- General Surgery and Surgical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Al. Trestioreanu”, 022328 Bucharest, Romania
| | - Daniela-Luminita Zob
- Medical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Al. Trestioreanu”, 022328 Bucharest, Romania
| | - Sinziana-Octavia Ionescu
- Medicine School, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- General Surgery and Surgical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Al. Trestioreanu”, 022328 Bucharest, Romania
| | - Gelal Aisa
- General Surgery and Surgical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Al. Trestioreanu”, 022328 Bucharest, Romania
| | - Prie Andra-Delia
- General Surgery and Surgical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Al. Trestioreanu”, 022328 Bucharest, Romania
| | - Dragos Serban
- Medicine School, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Surgery Department 4, Bucharest University Emergency Hospital, 050098 Bucharest, Romania
| | - Daniela-Cristina Stefan
- Medicine School, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Laurentiu Simion
- Medicine School, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- General Surgery and Surgical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Al. Trestioreanu”, 022328 Bucharest, Romania
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Fleming C, Harji D, Fernandez B, François MO, Assenat V, Gilles P, Clément M, Robert G, Denost Q. Feasibility of a tailored operative strategy from organ preservation to pelvic exenteration for cT4 rectal cancer depending on neoadjuvant response. Int J Colorectal Dis 2024; 39:123. [PMID: 39085478 PMCID: PMC11291515 DOI: 10.1007/s00384-024-04675-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/26/2024] [Indexed: 08/02/2024]
Abstract
PURPOSE Improvements in neoadjuvant therapy for locally advanced cT4 rectal cancer have led to improved tumour response and thus a variety of suitable management strategies. The aim of this study was to report management and outcomes of patients with cT4 rectal cancer undergoing a spectrum of treatment strategies from organ preservation (OP) to pelvic exenteration (PE). METHODS Patients who underwent elective treatment for cT4 rectal cancer between 2016 and 2021 were included. All patients were treated with curative intent. Surgical management was adapted to tumour response. Kaplan-Meier curves were generated to compare 3-year overall survival (3y-OS), local recurrence (3y-LR) and distant metastases (3y-DM) between different strategies. RESULTS Among 152 patients included, 13 (8%) underwent OP, 71 (47%) TME and 68 (45%) APR/PE. The median follow-up was 31.3 months. Patients undergoing OP had a lower tumour pretreatment (p < 0.001). Compared to patients with TME, those with APR/PE had a higher rate of ypT4 (p = 0.001) with a lower R0 rate (p = 0.044). The 3y-OS and 3y-DM were 78% and 15.1%, respectively, without significant differences. The 3y-LR was 6.6%, and patients with OP had a significantly worse 3y-local regrowth compared to 3y-LR in patients with TME and APR/PE (30.2% vs. 5.4% vs. 2%, p = 0.008). CONCLUSION cT4 tumours may be suitable for the full spectrum of rectal cancer management from organ preservation to pelvic exenteration depending on tumour response to neoadjuvant therapy. However, careful attention is required in OP as local regrowth in up to 30% of cases reinforces the need for sustained active surveillance in Watch&Wait programmes.
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Affiliation(s)
- Christina Fleming
- Bordeaux Colorectal Institute, Clinique Tivoli, 220 Rue Mandron, 33000, Bordeaux, France.
- Department of Digestive Surgery, Colorectal Unit, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France.
- Royal College of Surgeons in Ireland, Dublin, Ireland.
| | - Deena Harji
- Bordeaux Colorectal Institute, Clinique Tivoli, 220 Rue Mandron, 33000, Bordeaux, France
- 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
| | - Marc-Olivier François
- Bordeaux Colorectal Institute, Clinique Tivoli, 220 Rue Mandron, 33000, Bordeaux, France
| | - Vincent Assenat
- Bordeaux Colorectal Institute, Clinique Tivoli, 220 Rue Mandron, 33000, Bordeaux, France
| | - Pasticier Gilles
- Department of Urologic Surgery, Clinique Tivoli, Bordeaux, France
| | - Michiels Clément
- Department of Urologic Surgery, Clinique Tivoli, Bordeaux, France
| | - Grégoire Robert
- Department of Urologic Surgery, CHU Bordeaux University Hospital, Bordeaux, France
| | - Quentin Denost
- Bordeaux Colorectal Institute, Clinique Tivoli, 220 Rue Mandron, 33000, Bordeaux, France.
- Department of Digestive Surgery, Colorectal Unit, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France.
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Picardi C, Caparrotti F, Montemurro M, Christen D, Schaub NB, Fargier-Voiron M, Lestrade L, Meyer J, Meurette G, Liot E, Helbling D, Schmidt J, Gutzwiller JP, Bernardi M, Matzinger O, Ris F. High Rates of Organ Preservation in Rectal Cancer with Papillon Contact X-ray Radiotherapy: Results from a Swiss Cohort. Cancers (Basel) 2024; 16:2318. [PMID: 39001380 PMCID: PMC11240432 DOI: 10.3390/cancers16132318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 06/19/2024] [Accepted: 06/20/2024] [Indexed: 07/16/2024] Open
Abstract
Rectal cancer typically necessitates a combination of radiotherapy (RT), chemotherapy, and surgery. The associated functional disorders and reduction in quality of life have led to an increasing interest in organ preservation strategies. Response strongly correlates with RT dose, but dose escalation with external beam remains limited even with modern external beam RT techniques because of toxicity of the surrounding tissues. This study reports on the use of Papillon, an endocavitary Radiotherapy device, in the treatment of rectal cancer. The device delivers low energy X-rays, allowing for safe dose escalation and better complete response rate. Between January 2015 and February 2024, 24 rectal cancer patients were treated with the addition of a boost delivered by Papillon to standard RT, with or without chemotherapy, in an upfront organ preservation strategy. After a median follow-up (FU) of 43 months, the organ preservation rate was 96% (23/24), and the local relapse rate was 8% (2/24). None of our patients developed grade 3 or more toxicities. Our results demonstrate that the addition of Papillon contact RT provides a high rate of local remission with sustained long-term organ preservation, offering a promising alternative to traditional surgical approaches in patients with rectal cancer.
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Affiliation(s)
- Cristina Picardi
- Klinik Bethanien, Swiss Medical Network, 8044 Zürich, Switzerland; (C.P.)
- Hirslanden Klinik, Witellikerstrasse 40, 8032 Zürich, Switzerland
| | | | - Michael Montemurro
- Clinique de Genolier, Swiss Medical Network, 1272 Genolier, Switzerland (O.M.)
| | - Daniel Christen
- Klinik Bethanien, Swiss Medical Network, 8044 Zürich, Switzerland; (C.P.)
| | | | | | - Laetitia Lestrade
- Clinique de Genolier, Swiss Medical Network, 1272 Genolier, Switzerland (O.M.)
| | - Jeremy Meyer
- Geneva University Hospital and Medical School, 1205 Geneva, Switzerland
| | | | - Emilie Liot
- Geneva University Hospital and Medical School, 1205 Geneva, Switzerland
| | - Daniel Helbling
- Medical Oncology, GITZ—Gastrointestinales Tumorzentrum Zürich, 8038 Zürich, Switzerland
| | - Jan Schmidt
- Visceral Surgery, GITZ—Gastrointestinales Tumorzentrum Zürich, 8038 Zürich, Switzerland
| | | | - Marco Bernardi
- Gastroenterology, GITZ—Gastrointestinales Tumorzentrum Zürich, 8038 Zürich, Switzerland
| | - Oscar Matzinger
- Clinique de Genolier, Swiss Medical Network, 1272 Genolier, Switzerland (O.M.)
| | - Frederic Ris
- Geneva University Hospital and Medical School, 1205 Geneva, Switzerland
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Roeder F, Jensen AD, Lindel K, Mattke M, Wolf F, Gerum S. Geriatric Radiation Oncology: What We Know and What Can We Do Better? Clin Interv Aging 2023; 18:689-711. [PMID: 37168037 PMCID: PMC10166100 DOI: 10.2147/cia.s365495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 04/22/2023] [Indexed: 05/13/2023] Open
Abstract
Elderly patients represent a growing subgroup of cancer patients for whom the role of radiation therapy is poorly defined. Older patients are still clearly underrepresented in clinical trials, resulting in very limited high-level evidence. Moreover, elderly patients are less likely to receive radiation therapy in similar clinical scenarios compared to younger patients. However, there is no clear evidence for a generally reduced radiation tolerance with increasing age. Modern radiation techniques have clearly reduced acute and late side effects, thus extending the boundaries of the possible regarding treatment intensity in elderly or frail patients. Hypofractionated regimens have further decreased the socioeconomic burden of radiation treatments by reducing the overall treatment time. The current review aims at summarizing the existing data for the use of radiation therapy or chemoradiation in elderly patients focusing on the main cancer types. It provides an overview of treatment tolerability and outcomes with current standard radiation therapy regimens, including possible predictive factors in the elderly population. Strategies for patient selection for standard or tailored radiation therapy approaches based on age, performance score or comorbidity, including the use of prediction tests or geriatric assessments, are discussed. Current and future possibilities for improvements of routine care and creation of high-level evidence in elderly patients receiving radiation therapy are highlighted.
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Affiliation(s)
- Falk Roeder
- Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University Hospital, Salzburg, Austria
| | - Alexandra D Jensen
- Department of Radiation Oncology, University Hospital Marburg-Giessen, Giessen, Germany
| | - Katja Lindel
- Department of Radiation Oncology, Städtisches Klinikum, Karlsruhe, Germany
| | - Matthias Mattke
- Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University Hospital, Salzburg, Austria
| | - Frank Wolf
- Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University Hospital, Salzburg, Austria
| | - Sabine Gerum
- Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University Hospital, Salzburg, Austria
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Sacroperineal Reconstruction With Inferior Gluteal Artery Perforator Flaps After Resection of Locally Advanced Primary and Recurrent Anorectal Malignancy. Ann Plast Surg 2022; 89:306-311. [PMID: 35993686 DOI: 10.1097/sap.0000000000003258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Modern interdisciplinary concepts with involvement of various surgical specialties can considerably reduce perioperative morbidity after sacroperineal resection of locally advanced primary or recurrent anorectal malignancies. Resultant defects can represent a major challenge for reconstruction particularly with chemoradiotherapy. The aim is to assess the long-term outcomes of sacroperineal reconstruction using inferior gluteal artery perforator flaps.We performed a retrospective data analysis on 31 patients who were treated with inferior gluteal artery perforator flaps (n = 61) over the period 2009-2021. The demographic data, comorbidities, operative details, and outcomes with special focus on wound infection and dehiscence were recorded.The median age was 42 year (range, 25-82 years) with preponderance of males (n = 21). The follow-up period ranged from 6 to 80 months. Early minor complications included superficial wound dehiscence (3), which was managed conservatively, whereas the major (2) included deep wound collection and infection (1), which required surgical drainage, and perineal hernia, which required repair. All flaps survived completely.Inferior gluteal artery perforator flaps are safe, robust, and reliable with less donor side morbidity and positive impact on quality of life. It should be considered as a valuable tool in the reconstructive armamentarium of sacroperineal defects within a multidisciplinary setting.
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Gerard JP, Myint AS, Barbet N, Dejean C, Thamphya B, Gal J, Montagne L, Vuong T. Targeted Radiotherapy Using Contact X-ray Brachytherapy 50 kV. Cancers (Basel) 2022; 14:cancers14051313. [PMID: 35267621 PMCID: PMC8908981 DOI: 10.3390/cancers14051313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 02/23/2022] [Accepted: 02/25/2022] [Indexed: 02/01/2023] Open
Abstract
Rectal adenocarcinoma is a quite radioresistant tumor. In order to achieve non-operative management (NOM) radiotherapy plays a major role. Targeted radiotherapy aiming at high precision 3D radiotherapy uses stereotactic image-guided external beam radiotherapy machines. To further safely increase the tumor dose, endocavitary brachytherapy (ECB) is an original approach. There are two different ways to perform such an ECB: contact X-ray brachytherapy (CXB) using a 50 kV X-ray generator with an X-ray tube positioned under eye guidance into the rectal cavity and high-dose-rate brachytherapy (HDRB) using iridium-192 sources positioned into the rectal cavity under image guidance. This study focused on CXB. CXB uses a small mobile generator that produces 50 kV X-rays with limited penetration. This technique is well adapted to accessible tumors of limited size and especially needs a high dose rate (≥15 Gy/minutes) for rectal tumors. It is performed on an ambulatory basis. A total dose between 80−110 Gy is delivered in 3−4 fractions over 3 to 6 weeks into a small volume (5 cm3). CXB was pioneered in the 1970s by Papillon using the Philips RT 50TM. Since 2009, the Papillon P50TM has been used in 11 institutions in Europe. The OPERA Phase III trial tested the hypothesis that a CXB boost (90 Gy/3 fr) compared to an EBRT boost (9 Gy/5 fr) for T2−T3 ab < 5 cm and N0−N1 < 8 mm will increase the 3-year organ preservation (OP) rate when combined with 45 Gy/5 weeks with concomitant capecitabine. Out of more than 300 patients with tumors < 3 cm (1962−1992), Papillon reported a long-term local control close to 85%. Similar results were published in Europe and USA at that time. The Lyon R96-2 Phase III trial (2004) demonstrated that, when combined with preoperative EBRT, a CXB boost (90 Gy/3 fr) significantly increased the rate of clinical complete response (cCR) and sphincter preservation, with some patients having OP at 10 years. With more than 2000 patients treated in Europe (2010−2020) using the Papillon 50TM, organ preservation appears possible in close to 80% of cases in selected early T2−T3. The OPERA trial closed after 141 inclusions (2015−2020) after an independent data monitoring committee recommendation because of promising results. At the 2-year follow-up (blinded data), the rate of cCR and OP were 77% and 72%, respectively, for the 141 tumors, and for T < 3 cm (61 pts), they were 86% and 85%, respectively, with good bowel function. The final results should be available in 2022. Organ preservation using NOM appears to be a promising approach for rectal cancer. A CXB boost with chemoradiotherapy in selected early T2−T3 could become an attractive option to achieve a planned OP. This approach should be proposed to well-informed patients after discussion in an MDT.
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Affiliation(s)
- Jean-Pierre Gerard
- Department of Radiation Oncology, Centre Antoine-Lacassagne, Côte d’Azur University, 06000 Nice, France; (C.D.); (L.M.)
- Correspondence:
| | - Arthur Sun Myint
- Clatterbrige Cancer Center, Liverpool University, Liverpool L7 8YA, UK;
| | - Nicolas Barbet
- Department of Radiation Oncology, ORLAM, Bayard Lyon-Villeurbanne, 69100 Lyon, France;
| | - Catherine Dejean
- Department of Radiation Oncology, Centre Antoine-Lacassagne, Côte d’Azur University, 06000 Nice, France; (C.D.); (L.M.)
| | - Brice Thamphya
- Department of Clinical Research-Statistics, Centre Antoine-Lacassagne, Côte d’Azur University, 06000 Nice, France; (B.T.); (J.G.)
| | - Jocelyn Gal
- Department of Clinical Research-Statistics, Centre Antoine-Lacassagne, Côte d’Azur University, 06000 Nice, France; (B.T.); (J.G.)
| | - Lucile Montagne
- Department of Radiation Oncology, Centre Antoine-Lacassagne, Côte d’Azur University, 06000 Nice, France; (C.D.); (L.M.)
| | - Te Vuong
- Jewish General Hospital, McGill University, Montreal, QC H3T 1E2, Canada;
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Xiong Y, Shao L, Liu J, Zhou Q, Li C, Liao M, Zhang L, Dai X, Li M, Lei X. The Evolving Strategy of Californium-252 Neutron Intracavitary Brachytherapy in Treating Patients With Low-Lying T2 or T3 Rectal Adenocarcinoma: From Fixed to Individualized Regime With Intrarectal Peritumoral Injection of Amifostine. Front Oncol 2021; 11:758698. [PMID: 34868971 PMCID: PMC8636320 DOI: 10.3389/fonc.2021.758698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 10/13/2021] [Indexed: 11/16/2022] Open
Abstract
Purpose To retrospectively and comparatively evaluate the improvement of the efficacy and safety on the addition of 252Cf neutron intracavitary brachytherapy (ICBT), individualized or individualized with intrarectal peritumoral injection of amifostine (IPIA) to external-beam radiotherapy (EBRT) or concurrent chemo-EBRT in 314 patients with T2N0-1 or T3N0-1 low-lying rectal adenocarcinoma. Methods Phase I: from 2009 to 2011, 157 patients were treated with additional 252Cf neutron ICBT for four fixed fractions with a total dose of 40–45 Gy-eq during the EBRT. Phase II: from 2011 to 2013, 75 patients were treated with individualized neutron ICBT delivered for two to five fractions with a total dose of 26–45 Gy-eq according to the response of tumor after concurrent chemo-EBRT. Phase III: from 2013 to 2014, 82 patients were treated with individualized ICBT protected by pretreatment IPIA. Results The 4-year local control rates for the entire T2 and T3 patients were 69.4, 72.0, and 79.3%, while the 4-year overall survival rates were 63.1, 54.7, and 72.0% (P=0.08), and the 4-year disease-free survival rates were 55.4, 52.0, and 69.5% (P=0.053) in Phases I, II, and III, respectively. The late complication (LAC, ≥G2) rates were 33.8, 26.7, and 15.9%, respectively (P=0.012), and the serious LAC (≥G3) rates were 4.5, 4.2, and 0%, respectively, in Phases I, II, and III. Conclusion Concurrent chemo-EBRT combined with individualized 252Cf neutron ICBT protected by IPIA shows promising efficacy and safety in treating low-lying T2 and T3 rectal adenocarcinoma patients without surgery opportunity or willing.
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Affiliation(s)
- Yanli Xiong
- Cancer Center, Daping Hospital, Army Medical University, Chongqing, China
| | - Li Shao
- Zhong Ke Pu Rui (ZKPR) Neutron Brachytherapy Center, Daping Hospital, Army Medical University, Chongqing, China
| | - Jia Liu
- Zhong Ke Pu Rui (ZKPR) Neutron Brachytherapy Center, Daping Hospital, Army Medical University, Chongqing, China
| | - Qian Zhou
- Cancer Center, Daping Hospital, Army Medical University, Chongqing, China
| | - Chongyi Li
- Cancer Center, Daping Hospital, Army Medical University, Chongqing, China
| | - Maojun Liao
- Cancer Center, Daping Hospital, Army Medical University, Chongqing, China
| | - Lei Zhang
- Cancer Center, Daping Hospital, Army Medical University, Chongqing, China
| | - Xiaoyan Dai
- Cancer Center, Daping Hospital, Army Medical University, Chongqing, China
| | - Mengxia Li
- Cancer Center, Daping Hospital, Army Medical University, Chongqing, China
| | - Xin Lei
- Cancer Center, Daping Hospital, Army Medical University, Chongqing, China.,Zhong Ke Pu Rui (ZKPR) Neutron Brachytherapy Center, Daping Hospital, Army Medical University, Chongqing, China
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Personalized Reconstruction of Genital Defects in Complicated Wounds with Vertical Rectus Abdominis Myocutaneous Flaps including Urethral Neo-Orifice. J Pers Med 2021; 11:jpm11111076. [PMID: 34834428 PMCID: PMC8620180 DOI: 10.3390/jpm11111076] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 10/18/2021] [Accepted: 10/22/2021] [Indexed: 12/04/2022] Open
Abstract
Non-healing extensive wounds in the perineal region can lead to severe soft tissue infections and disastrous complications, which are not manageable with conservative measures. Specifically in recurrent or advanced pelvic malignancies, irradiation often leads to extensive scarring and wound breakdown, resulting in significant soft tissue defects during surgical tumor excision. Among several surgical options to reconstruct the perineum, the transpelvic vertical rectus abdominis myocutaneous (VRAM) flap has proven to be one of the most reliable methods. Specific modifications of this flap allow an individualized procedure depending on the patient’s needs. We modified this technique to include the urethral orifice into the skin paddle of VRAM flaps in three patients as a novel option to circumvent urinary diversion and maintain an acceptable quality of life.
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Dhadda A, Sun Myint A, Thamphya B, Hunter I, Hershman M, Gerard JP. A multi-centre analysis of adjuvant contact X-ray brachytherapy (CXB) in rectal cancer patients treated with local excision - Preliminary results of the CONTEM1 study. Radiother Oncol 2021; 162:195-201. [PMID: 34329654 DOI: 10.1016/j.radonc.2021.07.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 07/19/2021] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Early rectal cancers are increasingly diagnosed through screening programmes and are often treated using local excision (LE). In the case of adverse pathological features completion total mesorectal excision surgery (TME) is the standard recommendation. The morbidity and mortality risks of TME have stimulated the use of adjunctive treatments following LE to achieve organ preservation. MATERIAL AND METHODS Patients treated with adjuvant CXB following local excision between 2004 and 2017 in three centres were identified (Clatterbridge, Hull, Nice). All patients had adverse pathological features including: lymphovacular invasion, Sm2-3 Kikuchi level, tumour budding, pT2, positive resection margins (R1). CXB was performed with the Papillon50 tm machine to a dose of 40-60 Gy in 2 or 3 fractions over 2-4 weeks preceding/following external beam chemo/radiotherapy. Kaplan Meier survival estimates were used for outcomes measures. RESULTS 194 patients were identified. Median age was 70 years. pT staging was: pT1:143, pT2:45, pT3:6. CXB alone was given in 24 pts and combined with EBRT in 170. Median follow-up time was 77 months (range 7-122 months). Local relapse rate was 8% and distant metastases 9%. Organ preservation was achieved in 95%. 6 year local recurrence free and overall survival was 91% and 81% respectively. Cancer specific survival was 97%. No treatment related mortality was seen. CONCLUSION This large multi-centre cohort study using adjuvant CXB following local excision suggests excellent oncological outcomes for these patients without completion TME. This treatment approach can be considered as an alternative for selective patients compliant with long term follow up.
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Affiliation(s)
- Amandeep Dhadda
- Queen's Centre for Oncology & Haematology, Hull University Teaching Hospitals NHS Trust, Hull, United Kingdom.
| | | | - Brice Thamphya
- Service de Radiotherapie, Centre Antoine-Lacassagne, Nice, France
| | - Iain Hunter
- Queen's Centre for Oncology & Haematology, Hull University Teaching Hospitals NHS Trust, Hull, United Kingdom
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Seo N, Kim H, Cho MS, Lim JS. Response Assessment with MRI after Chemoradiotherapy in Rectal Cancer: Current Evidences. Korean J Radiol 2020; 20:1003-1018. [PMID: 31270972 PMCID: PMC6609432 DOI: 10.3348/kjr.2018.0611] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 04/07/2019] [Indexed: 12/20/2022] Open
Abstract
Baseline magnetic resonance imaging (MRI) has become the primary staging modality for surgical plans and stratification of patient populations for more efficient neoadjuvant treatment. Patients who exhibit a complete response to chemoradiotherapy (CRT) may achieve excellent local tumor control and better quality of life with organ-preserving treatments such as local excision or even watch-and-wait management. Therefore, the evaluation of tumor response is a key factor for determining the appropriate treatment following CRT. Although post-CRT MRI is generally accepted as the first-choice method for evaluating treatment response after CRT, its application in the clinical decision process is not fully validated. In this review, we will discuss various oncologic treatment options from radical surgical technique to organ-preservation strategies for achieving better cancer control and improved quality of life following CRT. In addition, the current status of post-CRT MRI in restaging rectal cancer as well as the main imaging features that should be evaluated for treatment planning will also be described for the tailored treatment.
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Affiliation(s)
- Nieun Seo
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Honsoul Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Min Soo Cho
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Joon Seok Lim
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
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Bacalbasa N, Balescu I, Vilcu M, Neacsu A, Dima S, Croitoru A, Brezean I. Pelvic Exenteration for Locally Advanced and Relapsed Pelvic Malignancies - An Analysis of 100 Cases. In Vivo 2019; 33:2205-2210. [PMID: 31662557 PMCID: PMC6899142 DOI: 10.21873/invivo.11723] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 09/01/2019] [Accepted: 09/03/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM Although pelvic exenteration is an aggressive surgical procedure, it remains almost the only curative solution for patients diagnosed with large pelvic malignancies. PATIENTS AND METHODS We present a series of 100 patients submitted to pelvic exenteration with curative intent. RESULTS The origin of the primary tumor was most commonly represented by cervical cancer, followed by, endometrial cancer, rectal cancer, ovarian cancer and vulvo-vaginal cancer. An R0 resection was confirmed in 68 cases, while the remaining 32 cases presented lateral positive resection margins or perineal positive margins. The postoperative morbidity rate was 37% while the mortality rate was 3%. As for the-long term outcomes, the median overall survival time was 38.7 months, being most significantly influenced by the origin of the primary tumor. CONCLUSION Although pelvic exenteration is still associated with an increased morbidity, an important improvement in the long-term survival can be achieved, especially if radical resection is feasible.
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Affiliation(s)
- Nicolae Bacalbasa
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- "I. Cantacuzino" Clinical Hospital, Bucharest, Romania
- "Fundeni" Clinical Institute - Center of Excellence in Translational Medicine, Bucharest, Romania
| | | | - Mihaela Vilcu
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- "I. Cantacuzino" Clinical Hospital, Bucharest, Romania
| | - Adrian Neacsu
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Simona Dima
- "Fundeni" Clinical Institute - Center of Excellence in Translational Medicine, Bucharest, Romania
| | - Adina Croitoru
- "Fundeni" Clinical Institute - Center of Excellence in Translational Medicine, Bucharest, Romania
- "Titu Maiorescu" University, Bucharest, Romania
| | - Iulian Brezean
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- "I. Cantacuzino" Clinical Hospital, Bucharest, Romania
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Li Z, Ma X, Xia Y, Qian K, Akakuru OU, Luo L, Zheng J, Cui P, Shen Z, Wu A. A pH-sensitive polymer based precise tumor targeting strategy with reduced uptake of nanoparticles by non-cancerous cells. J Mater Chem B 2019; 7:5983-5991. [DOI: 10.1039/c9tb01202h] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
A T2-weighted MRI contrast agent (SPION-AN-FA@mPEG) can precisely target cancer cells with folate receptor α (FRα) diminishing non-specific uptake by normal healthy cells.
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Gérard JP, Barbet N, Gal J, Dejean C, Evesque L, Doyen J, Coquard R, Gugenheim J, Benizri E, Schiappa R, Baudin G, Benezery K, François E. Planned organ preservation for early T2-3 rectal adenocarcinoma: A French, multicentre study. Eur J Cancer 2018; 108:1-16. [PMID: 30580125 DOI: 10.1016/j.ejca.2018.11.022] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 10/31/2018] [Accepted: 11/10/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Neoadjuvant chemoradiotherapy (nCRT) and watch-and-wait policy as reported by Habr-Gama are references for organ preservation in rectal cancer. To increase the clinical complete response (cCR) and reduce the local recurrence rates, we report a retrospective analysis of a prospective cohort of selected T2-3 tumours treated in three French institutions using contact X-ray brachytherapy (CXB) with nCRT. METHODS Tumour selection was based on digital rectal examination (DRE), rigid rectoscopy, magnetic resonance imaging (MRI) and/or endorectal ultrasound. Adenocarcinoma T2-3 < 5 cm largest diameter, M0 were treated, all with organ preservation intent. CXB delivering 90 Gy/3 fractions/4 weeks was combined with CRT (capecitabine 50). Strict evaluation of tumour response using DRE and rectoscopy ± MRI was performed at regular interval with prolonged surveillance. FINDINGS Between 2002 and 2016, 74 consecutive patients were treated (median age: 74 years. T2: 45 and T3: 29). A cCR or near-cCR (mainly rectal wall ulceration) was noted at week 14 in 71 patients (95%). A local excision was performed in 13 patients. Of three partial responses (PRs), one salvage anterior resection was performed. With a median follow-up of 3 years, local recurrence (mainly in the rectal wall) was seen in seven patients. The 3-year local recurrence rate was 10%, and the cancer-specific survival, 88%. Two patients underwent radical proctectomy for PR or local recurrence and 96% preserved their rectum. Grade III acute toxicity was recorded in five patients. Rectal bleeding was the main late toxicity (grade III in 12%). Bowel function was scored as good or excellent in 85% of patients. INTERPRETATION Combining CXB and nCRT in selected early T2-T3 rectal cancers may safely provide a high rate of cCR, organ preservation, and good bowel function with a risk of local recurrence below 15%. Such an approach could be offered to operable patients as a planned option for organ preservation.
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Affiliation(s)
- Jean-Pierre Gérard
- Department of Radiation Oncology, Centre Antoine-LACASSAGNE Nice University, Nice, Sophia, France.
| | - Nicolas Barbet
- Department of Radiation Oncology, Bayard Lyon, Lyon-Villeurbanne, France; Department of Radiation Oncology, Mâcon, France
| | - Jocelyn Gal
- Department of Clinical Research-Statistics, Centre Antoine LACASSAGNE Nice University, Nice, Sophia, France
| | - Catherine Dejean
- Department of Radiation Oncology, Centre Antoine-LACASSAGNE Nice University, Nice, Sophia, France
| | - Ludovic Evesque
- Department of Medical Oncology and Gastro-Intestinal Cancer, Centre Antoine LACASSAGNE Nice University, Nice, Sophia, France
| | - Jérôme Doyen
- Department of Radiation Oncology, Centre Antoine-LACASSAGNE Nice University, Nice, Sophia, France
| | - Régis Coquard
- Department of Radiation Oncology, Bayard Lyon, Lyon-Villeurbanne, France
| | - Jean Gugenheim
- Department of Surgery, CHU Nice, Nice University, Nice, Sophia, France
| | - Emmanuel Benizri
- Department of Surgery, CHU Nice, Nice University, Nice, Sophia, France
| | - Renaud Schiappa
- Department of Clinical Research-Statistics, Centre Antoine LACASSAGNE Nice University, Nice, Sophia, France
| | - Guillaume Baudin
- Department of Radiology Diagnosis, Centre Antoine LACASSAGNE, Nice University, Nice, Sophia, France
| | - Karène Benezery
- Department of Radiation Oncology, Centre Antoine-LACASSAGNE Nice University, Nice, Sophia, France
| | - Eric François
- Department of Medical Oncology and Gastro-Intestinal Cancer, Centre Antoine LACASSAGNE Nice University, Nice, Sophia, France
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Montroni I, Ugolini G, Saur NM, Spinelli A, Rostoft S, Millan M, Wolthuis A, Daniels IR, Hompes R, Penna M, Fürst A, Papamichael D, Desai AM, Cascinu S, Gèrard JP, Myint AS, Lemmens VE, Berho M, Lawler M, De Liguori Carino N, Potenti F, Nanni O, Altini M, Beets G, Rutten H, Winchester D, Wexner SD, Audisio RA. Personalized management of elderly patients with rectal cancer: Expert recommendations of the European Society of Surgical Oncology, European Society of Coloproctology, International Society of Geriatric Oncology, and American College of Surgeons Commission on Cancer. Eur J Surg Oncol 2018; 44:1685-1702. [DOI: 10.1016/j.ejso.2018.08.003] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 07/22/2018] [Accepted: 08/03/2018] [Indexed: 12/23/2022] Open
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Wang SJ, Hathout L, Malhotra U, Maloney-Patel N, Kilic S, Poplin E, Jabbour SK. Decision-Making Strategy for Rectal Cancer Management Using Radiation Therapy for Elderly or Comorbid Patients. Int J Radiat Oncol Biol Phys 2018; 100:926-944. [PMID: 29485072 PMCID: PMC11131033 DOI: 10.1016/j.ijrobp.2017.12.261] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 11/14/2017] [Accepted: 12/11/2017] [Indexed: 02/07/2023]
Abstract
Rectal cancer predominantly affects patients older than 70 years, with peak incidence at age 80 to 85 years. However, the standard treatment paradigm for rectal cancer oftentimes cannot be feasibly applied to these patients owing to frailty or comorbid conditions. There are currently little information and no treatment guidelines to help direct therapy for patients who are elderly and/or have significant comorbidities, because most are not included or specifically studied in clinical trials. More recently various alternative treatment options have been brought to light that may potentially be utilized in this group of patients. This critical review examines the available literature on alternative therapies for rectal cancer and proposes a treatment algorithm to help guide clinicians in treatment decision making for elderly and comorbid patients.
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Affiliation(s)
- Shang-Jui Wang
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Lara Hathout
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Usha Malhotra
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Nell Maloney-Patel
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Sarah Kilic
- Rutgers New Jersey Medical School, Rutgers, the State University of New Jersey, Newark, New Jersey
| | - Elizabeth Poplin
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Salma K Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey.
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Stijns RCH, Tromp MSR, Hugen N, de Wilt JHW. Advances in organ preserving strategies in rectal cancer patients. Eur J Surg Oncol 2017; 44:209-219. [PMID: 29275912 DOI: 10.1016/j.ejso.2017.11.024] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 10/23/2017] [Accepted: 11/19/2017] [Indexed: 02/06/2023] Open
Abstract
Treatment of rectal cancer patients has been subjected to change over the past thirty years. Total mesorectal excision is considered the cornerstone of rectal cancer treatment, but is also associated with significant morbidity resulting in an impaired quality of life. The addition of neoadjuvant chemoradiotherapy to surgery has shown to improve survival and local control and may lead to a partial or even complete response (CR). This raises questions regarding the necessity for subsequent radical surgery. After careful patient selection local excision and wait-and-see approaches are explored, aiming to improve quality of life without compromising oncological outcome. A multimodality diagnostic approach for optimal staging is crucial in determining the appropriate neoadjuvant treatment regimen. Adequate endoscopic restaging of rectal tumours after multimodality treatment will aid in selecting patients who are eligible for an organ preserving approach. The role and accuracy of imaging in the detection of the primary tumour, residual rectal cancer or local recurrence seems vital. Alternative neoadjuvant regimens are currently explored to increase the rate of clinical CRs, which may support organ preserving approaches. This review aims to generate insight into the advances in diagnostics and treatment modalities in all stages of rectal cancer and will highlight future studies that may support further implementation of organ preservation treatment in rectal cancer.
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Affiliation(s)
- Rutger C H Stijns
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - Mike-Stephen R Tromp
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Niek Hugen
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
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Short- and long-term outcomes following pelvic exenteration for gynae-oncological and colorectal cancers: A 9 year consecutive single-centre cohort study. Int J Surg 2017; 43:38-45. [PMID: 28529192 DOI: 10.1016/j.ijsu.2017.05.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 05/04/2017] [Accepted: 05/16/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Radical pelvic exenteration can be undertaken for locally invasive or recurrent disease in both colorectal and gynaecological malignancies. In the UK this procedure is usually undertaken by the respective surgical specialties who have undergone divergent surgical training. This study describes and compares outcomes between colorectal and gynae-oncological teams following pelvic exenteration for primary and recurrent gynaecological and colorectal cancers in a single-centre multi-disciplinary team. METHOD A retrospective review of consecutive pelvic exenteration patients undertaken over a nine-year period in a tertiary referral centre. Analyses comparing short- and long-term morbidity and mortality outcomes were undertaken by chi-square test for categorical variables and Mann-Whitney U for continuous variables. Cumulative survival rates were calculated according to the Kaplan-Meier method and factors associated with recurrence and survival determined using a Cox regression model. RESULTS Thirty-four exenterations were undertaken; fourteen colorectal and twenty gynae-oncological. Morbidity was seen in 50% of colorectal and 75% of gynae-oncological patients. Recurrence was seen earlier and with greater frequency in the gynaeoncology group (44.4% and median time 11 months) than the colorectal group (21.4%, median time 41 months; p > 0.05). Survival in the gynae-oncology group was also lower than the colorectal group at 1-year (69.6% vs. 92.9%) and 5-years (58.0% vs. 92.9%; p = 0.115). The majority of gynae-oncological mortality occurred within 3-years of surgery, whilst the majority of mortality in the colorectal group was after 5-years. CONCLUSION Long-term patient outcome measures, including disease recurrence and 5-year survival, for colorectal exenteration appear better than for gynaeoncology patients, however, no statistical significant difference exists between short-term outcome measures between specialties. This is likely to be caused by different baseline pathologies and disease pattern influencing longer term prognosis but may also be a function of differing surgical thresholds and patient selection bias between specialties. Peri-operative and short-term morbidity appear equivalent despite divergent surgical backgrounds and training.
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Gérard JP, André T, Bibeau F, Conroy T, Legoux JL, Portier G, Bosset JF, Cadiot G, Bouché O, Bedenne L. Rectal cancer: French Intergroup clinical practice guidelines for diagnosis, treatments and follow-up (SNFGE, FFCD, GERCOR, UNICANCER, SFCD, SFED, SFRO). Dig Liver Dis 2017; 49:359-367. [PMID: 28179091 DOI: 10.1016/j.dld.2017.01.152] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 01/10/2017] [Accepted: 01/11/2017] [Indexed: 12/11/2022]
Abstract
INTRODUCTION This document is a summary of the French Intergroup guidelines regarding the management of rectal adenocarcinoma published in February 2016. METHOD This collaborative work, under the auspices of most of the French medical societies involved in the management of rectal cancer, is based on the previous guidelines published in 2013. Recommendations are graded into 3 categories according to the level of evidence of data found in the literature. RESULTS In agreement with the ESMO guidelines (2013), non-metastatic rectal cancers have been stratified in 4 risk groups according to endoscopy, MRI or endorectal-ultrasonography. Locally-advanced tumors are limited to groups 3 and 4 (T3≥4cm or T3c-d or N1-2 or T4). These tumors are usually treated using neoadjuvant treatment and total proctectomy (TME). Adjuvant treatment depends on the pathological findings. Very early (group 1) or early (group 2) tumors are managed mainly by surgery, and organ preservation may be an option in selected cases. For metastatic tumors, the recommendations are based on less robust evidence and chemotherapy plays a major role. CONCLUSION Such recommendations are constantly being optimized and each individual case must be discussed within a Multi-Disciplinary Team.
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Frin AC, Evesque L, Gal J, Benezery K, François E, Gugenheim J, Benizri E, Château Y, Marcié S, Doyen J, Gérard JP. Organ or sphincter preservation for rectal cancer. The role of contact X-ray brachytherapy in a monocentric series of 112 patients. Eur J Cancer 2016; 72:124-136. [PMID: 28027515 DOI: 10.1016/j.ejca.2016.11.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 10/31/2016] [Accepted: 11/16/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Contact X-ray brachytherapy (CXB) has been used at Centre Antoine Lacassagne since 2002 to increase the chance of conservative treatment (organ or sphincter preservation) in rectal cancer. A consecutive series of 112 patients (pts) is reported. METHODS Three protocols were used in selected rectal adenocarcinomas. Group 1: T1 N0 treated with local excision (LE) followed by adjuvant CXB. Group 2: T2 or 'early' T3 N0 treated with CXB combined with chemoradiotherapy (CRT) followed by surveillance or LE. Group 3: distal 'locally advanced' T3 N0-2 treated with CXB and CRT before total proctectomy. RESULTS Group 1: 27 pt (pTis: 3; pT1: 21; pT2: 3). After LE with CXB alone (20 pt) or CXB + CRT (7 pt) one local recurrence occurred. Organ preservation was achieved in 26 pt (96%). Group 2: 45 pt (T1: 2; T2: 23; T3: 20) treated with CXB alone (4 pt) or CXB + CRT or external beam radiotherapy (EBRT) (41 pt). A clinical complete response (cCR) was observed in 43/45 (96%) and 3 pt developed a local recurrence (11% at 5 years). The specific survival was 76% at 5 years and the rate of organ preservation was 89% (40/45 pt) with good bowel function in 36 pt. Group 3: 40 pt, anterior resection (with sphincter preservation) was possible in 35 pt (86%) with a 3-year local recurrence of 6%. CONCLUSION CXB usually combined as a boost with CRT or EBRT may safely increase the chance of a conservative treatment (organ or sphincter preservation) for selected rectal cancers.
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Affiliation(s)
- Anne Claire Frin
- CHU Nice, Department of Gastroenterology, Nice Sophia-Antipolis University, France
| | - Ludovic Evesque
- Centre Antoine Lacassagne, Department of Medical Oncology, Nice Sophia-Antipolis University, France
| | - Jocelyn Gal
- Centre Antoine Lacassagne, Department of Research and Methodology, Nice Sophia-Antipolis University, France
| | - Karène Benezery
- Centre Antoine Lacassagne, Department of Radiation Oncology, Nice Sophia-Antipolis University, France
| | - Eric François
- CHU Nice, Department of Gastroenterology, Nice Sophia-Antipolis University, France
| | - Jean Gugenheim
- CHU Nice, Department of Surgery, Nice Sophia-Antipolis University, France
| | - Emmanuel Benizri
- CHU Nice, Department of Surgery, Nice Sophia-Antipolis University, France
| | - Yan Château
- Centre Antoine Lacassagne, Department of Research and Methodology, Nice Sophia-Antipolis University, France
| | - Serge Marcié
- Centre Antoine Lacassagne, Department of Radiation Oncology, Nice Sophia-Antipolis University, France
| | - Jérome Doyen
- Centre Antoine Lacassagne, Department of Radiation Oncology, Nice Sophia-Antipolis University, France
| | - Jean-Pierre Gérard
- Centre Antoine Lacassagne, Department of Radiation Oncology, Nice Sophia-Antipolis University, France.
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Organ Preservation Using Contact Radiotherapy for Early Rectal Cancer: Outcomes of Patients Treated at a Single Centre in the UK. Clin Oncol (R Coll Radiol) 2016; 29:198-204. [PMID: 27726909 DOI: 10.1016/j.clon.2016.09.014] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 09/01/2016] [Accepted: 09/06/2016] [Indexed: 11/21/2022]
Abstract
AIMS Contact radiotherapy for early rectal cancer uses 50 kV X-rays to treat rectal cancers under direct vision. We present data of a series of patients treated at a single centre with prospective follow-up and functional assessment. MATERIALS AND METHODS All patients were treated at the Queen's Centre for Oncology, Hull, UK between September 2011 and October 2015. Patients received a biopsy, magnetic resonance imaging (MRI) of the liver/pelvis, computed tomography of the chest and endorectal ultrasound. Patients were deemed to be either unfit for radical surgery or refused it due to the need for a permanent stoma. Follow-up consisted of 3 monthly flexible sigmoidoscopy and MRI of the liver/pelvis and 12 monthly computed tomography of the chest. RESULTS In total, 42 patients were treated with contact radiotherapy ± external beam chemo/radiotherapy without any primary surgical excision. The median age was 78 years (range 50-94 years). Local recurrence-free survival was 88%, disease-free survival was 86% and overall survival was 88% with a median follow-up of 24 months (range 5-54 months). The median time to recurrence was 12 months (range 4-14 months). The estimated 30 day surgical mortality for this cohort with radical surgery was 12%. Mortality from the contact radiotherapy procedure was 0%. Functional outcomes as investigated by the Low Anterior Resection Syndrome (LARS) score were good, with 65% having no LARS. CONCLUSIONS Contact radiotherapy for early rectal cancer is a safe, well-tolerated outpatient procedure, allowing organ preservation, with excellent oncological and functional outcomes. For elderly co-morbid patients with suitable rectal cancers this should be considered as a standard of care.
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Quyn A, Austin K, Young J, Badgery-Parker T, Masya L, Roberts R, Solomon M. Outcomes of pelvic exenteration for locally advanced primary rectal cancer: Overall survival and quality of life. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2016; 42:823-8. [DOI: 10.1016/j.ejso.2016.02.016] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 01/22/2016] [Accepted: 02/11/2016] [Indexed: 10/22/2022]
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Gérard JP, Doyen J, Barbet N. New Neoadjuvant Treatment Strategies for Non-Metastatic Rectal Cancer (M0). CURRENT COLORECTAL CANCER REPORTS 2015. [DOI: 10.1007/s11888-015-0287-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Brodbeck R, Horch RE, Arkudas A, Beier JP. Plastic and Reconstructive Surgery in the Treatment of Oncological Perineal and Genital Defects. Front Oncol 2015; 5:212. [PMID: 26500887 PMCID: PMC4597132 DOI: 10.3389/fonc.2015.00212] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 09/17/2015] [Indexed: 12/19/2022] Open
Abstract
Defects of the perineum may result from ablative procedures of different malignancies. The evolution of more radical excisional surgery techniques resulted in an increase in large defects of the perineum. The perineogenital region per se has many different functions for urination, bowel evacuation, sexuality, and reproduction. Up-to-date individual and interdisciplinary surgical treatment concepts are necessary to provide optimum oncological as well as quality of life outcome. Not only the reconstructive method but also the timing of the reconstruction is crucial. In cases of postresectional exposition of e.g., pelvic or femoral vessels or intrapelvic and intra-abdominal organs, simultaneous flap procedure is mandatory. In particular, the reconstructive armamentarium of the plastic surgeon should include not only pedicled flaps but also free microsurgical flaps so that no compromise in terms of the extent of the oncological resection has to be accepted. For intra-abdominally and/or pelvic tumors of the rectum, the anus, or the female reproductive system, which were resected through an abdominally and a sacrally surgical access, simultaneous vertical rectus abdominis myocutaneous (VRAM) flap reconstruction is recommendable. In terms of soft tissue sarcoma of the pelvic/caudal abdomen/proximal thigh region, two-stage reconstructions are possible. This review focuses on the treatment of perineum, genitals, and pelvic floor defects after resection of malignant tumors, giving a distinct overview of the different types of defects faced in this region and describing a number of reconstructive techniques, especially VRAM flap and pedicled flaps like antero-lateral thigh flap or free flaps. Finally, this review outlines some considerations concerning timing of the different operative steps.
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Affiliation(s)
- Rebekka Brodbeck
- Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nuernberg , Erlangen , Germany
| | - Raymund E Horch
- Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nuernberg , Erlangen , Germany
| | - Andreas Arkudas
- Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nuernberg , Erlangen , Germany
| | - Justus P Beier
- Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nuernberg , Erlangen , Germany
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Radiation Techniques for Increasing Local Control in the Non-Surgical Management of Rectal Cancer. CURRENT COLORECTAL CANCER REPORTS 2015. [DOI: 10.1007/s11888-015-0284-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Maas M, Lambregts DMJ, Nelemans PJ, Heijnen LA, Martens MH, Leijtens JWA, Sosef M, Hulsewé KWE, Hoff C, Breukink SO, Stassen L, Beets-Tan RGH, Beets GL. Assessment of Clinical Complete Response After Chemoradiation for Rectal Cancer with Digital Rectal Examination, Endoscopy, and MRI: Selection for Organ-Saving Treatment. Ann Surg Oncol 2015. [PMID: 26198074 PMCID: PMC4595525 DOI: 10.1245/s10434-015-4687-9] [Citation(s) in RCA: 265] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background The response to chemoradiotherapy (CRT) for rectal cancer can be assessed by clinical examination, consisting of digital rectal examination (DRE) and endoscopy, and by MRI. A high accuracy is required to select complete response (CR) for organ-preserving treatment. The aim of this study was to evaluate the value of clinical examination (endoscopy with or without biopsy and DRE), T2W-MRI, and diffusion-weighted MRI (DWI) for the detection of CR after CRT. Methods This prospective cohort study in a university hospital recruited 50 patients who underwent clinical assessment (DRE, endoscopy with or without biopsy), T2W-MRI, and DWI at 6–8 weeks after CRT. Confidence levels were used to score the likelihood of CR. The reference standard was histopathology or recurrence-free interval of >12 months in cases of wait-and-see approaches. Diagnostic performance was calculated by area under the receiver operator characteristics curve, with corresponding sensitivities and specificities. Strategies were assessed and compared by use of likelihood ratios. Results Seventeen (34 %) of 50 patients had a CR. Areas under the curve were 0.88 (0.78–1.00) for clinical assessment and 0.79 (0.66–0.92) for T2W-MRI and DWI. Combining the modalities led to a posttest probability for predicting a CR of 98 %. Conversely, when all modalities indicated residual tumor, 15 % of patients still experienced CR. Conclusions Clinical assessment after CRT is the single most accurate modality for identification of CR after CRT. Addition of MRI with DWI further improves the diagnostic performance, and the combination can be recommended as the optimal strategy for a safe and accurate selection of CR after CRT.
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Affiliation(s)
- Monique Maas
- Department of Radiology, Maastricht University Medical Centre, Maastricht, The Netherlands.
| | - Doenja M J Lambregts
- Department of Radiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Patty J Nelemans
- Department of Epidemiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Luc A Heijnen
- Department of Radiology, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Milou H Martens
- Department of Radiology, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jeroen W A Leijtens
- Department of Surgery, Laurentius Hospital Roermond, Roermond, The Netherlands
| | - Meindert Sosef
- Department of Surgery, Atrium Medical Centre, Heerlen, The Netherlands
| | - Karel W E Hulsewé
- Department of Surgery, Orbis Medical Centre, Sittard, The Netherlands
| | - Christiaan Hoff
- Department of Surgery, Leeuwarden Medical Centre, Leeuwarden, The Netherlands
| | - Stephanie O Breukink
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Laurents Stassen
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Regina G H Beets-Tan
- Department of Radiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Geerard L Beets
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands.
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Gerard JP, Frin AC, Doyen J, Zhou FX, Gal J, Romestaing P, Barbet N, Coquard R, Chapet O, François E, Marcié S, Benezery K. Organ preservation in rectal adenocarcinoma (T1) T2-T3 Nx M0. Historical overview of the Lyon Sud - nice experience using contact x-ray brachytherapy and external beam radiotherapy for 120 patients. Acta Oncol 2015; 54:545-51. [PMID: 25389568 DOI: 10.3109/0284186x.2014.975840] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Kusters M, Austin KKS, Solomon MJ, Lee PJ, Nieuwenhuijzen GAP, Rutten HJT. Survival after pelvic exenteration for T4 rectal cancer. Br J Surg 2015; 102:125-31. [PMID: 25451182 DOI: 10.1002/bjs.9683] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Revised: 07/14/2014] [Accepted: 09/23/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND The purpose of this study was to analyse retrospectively the pooled results after pelvic exenteration for locally advanced T4 rectal cancer. Historically, patients with T4 rectal cancers requiring pelvic exenteration have been offered only palliative surgery or no operation. METHODS The basic treatment principle was preoperative (chemo)radiotherapy, radical surgery and, in some patients, adjuvant chemotherapy. Risk factors for local recurrence, distant metastases and overall survival were studied in univariable and multivariable analyses. RESULTS Ninety-five patients with T4 rectal cancer who underwent pelvic exenteration in two tertiary referral centres up to 2013 were studied. Clear margins (R0) were achieved in 87 per cent of patients. Adjuvant chemotherapy was administered in 33 per cent, independent of the resection margin, lymph node status and postoperative T category. The 5-year local recurrence rate was 17 per cent, with a distant metastasis rate of 16 per cent and overall survival rate of 62 per cent. In multivariable analysis the only factor associated with death was omission of adjuvant chemotherapy (P = 0.016). The effect of adjuvant chemotherapy was more pronounced in the elderly: patients aged over 70 years who had chemotherapy had a 5-year overall survival rate of 80 per cent, compared with 39 per cent of elderly patients who did not receive chemotherapy (P = 0.019). CONCLUSION Pelvic exenteration led to an R0 resection rate of 87 per cent for T4 rectal cancer, giving good local control and overall survival comparable to population-based colorectal cancer survival rates. Adjuvant chemotherapy may improve overall survival further, even in the elderly.
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Affiliation(s)
- M Kusters
- Departments of Surgery, Catharina Hospital, Eindhoven, The Netherlands; Departments of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
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Abstract
Improved treatment strategies have eliminated local control as the major problem in rectal cancer. With increasing awareness of long-term toxic effects in survivors of rectal cancer, organ-preservation strategies are becoming more popular. After chemoradiotherapy, both watchful waiting and local excision are used as possible alternatives for radical surgery. Although these seem attractive strategies, many issues about the safety of organ preservation remain. Additionally, radiotherapy strategies are mainly aimed at intermediate and high-risk rectal tumours, and adaptation of this standard practice for a completely new treatment indication has yet to start. This Review will discuss the options and problems of organ preservation, and address the research questions that need to be answered in the coming years, with a specific focus on radiotherapy.
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Affiliation(s)
- Corrie A M Marijnen
- Department of Clinical Oncology, Leiden University Medical Center, Leiden, Netherlands.
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Burbach JPM, den Harder AM, Intven M, van Vulpen M, Verkooijen HM, Reerink O. Impact of radiotherapy boost on pathological complete response in patients with locally advanced rectal cancer: a systematic review and meta-analysis. Radiother Oncol 2014; 113:1-9. [PMID: 25281582 DOI: 10.1016/j.radonc.2014.08.035] [Citation(s) in RCA: 115] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 08/25/2014] [Accepted: 08/31/2014] [Indexed: 02/07/2023]
Abstract
PURPOSE We conducted a systematic review and meta-analysis to quantify the pathological complete response (pCR) rate after preoperative (chemo)radiation with doses of ⩾60Gy in patients with locally advanced rectal cancer. Complete response is relevant since this could select a proportion of patients for which organ-preserving strategies might be possible. Furthermore, we investigated correlations between EQD2 dose and pCR-rate, toxicity or resectability, and additionally between pCR-rate and chemotherapy, boost-approach or surgical-interval. METHODS AND MATERIALS PubMed, EMBASE and Cochrane libraries were searched with the terms 'radiotherapy', 'boost' and 'rectal cancer' and synonym terms. Studies delivering a preoperative dose of ⩾60 Gy were eligible for inclusion. Original English full texts that allowed intention-to-treat pCR-rate calculation were included. Study variables, including pCR, acute grade ⩾3 toxicity and resectability-rate, were extracted by two authors independently. Eligibility for meta-analysis was assessed by critical appraisal. Heterogeneity and pooled estimates were calculated for all three outcomes. Pearson correlation coefficients were calculated between the variables mentioned earlier. RESULTS The search identified 3377 original articles, of which 18 met our inclusion criteria (1106 patients). Fourteen studies were included for meta-analysis (487 patients treated with ⩾60 Gy). pCR-rate ranged between 0.0% and 44.4%. Toxicity ranged between 1.3% and 43.8% and resectability-rate between 34.0% and 100%. Pooled pCR-rate was 20.4% (95% CI 16.8-24.5%), with low heterogeneity (I2 0.0%, 95% CI 0.00-84.0%). Pooled acute grade ⩾3 toxicity was 10.3% (95% CI 5.4-18.6%) and pooled resectability-rate was 89.5% (95% CI 78.2-95.3%). CONCLUSION Dose escalation above 60 Gy for locally advanced rectal cancer results in high pCR-rates and acceptable early toxicity. This observation needs to be further investigated within larger randomized controlled phase 3 trials in the future.
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Affiliation(s)
| | | | - Martijn Intven
- Department of Radiation Oncology, University Medical Center, Utrecht, The Netherlands
| | - Marco van Vulpen
- Department of Radiation Oncology, University Medical Center, Utrecht, The Netherlands
| | | | - Onne Reerink
- Department of Radiation Oncology, University Medical Center, Utrecht, The Netherlands
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Bénézery K, Frin A, Gal J, Zhou F, François E, Benchimol D, Marcié S, Gérard J. Conservation du rectum dans le traitement des adénocarcinomes rectaux de stade T 1-2-3 Nx M0 : rôle de la radiothérapie de contact, expérience niçoise sur 60 patients. Cancer Radiother 2014. [DOI: 10.1016/j.canrad.2014.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Horch RE, Hohenberger W, Eweida A, Kneser U, Weber K, Arkudas A, Merkel S, Göhl J, Beier JP. A hundred patients with vertical rectus abdominis myocutaneous (VRAM) flap for pelvic reconstruction after total pelvic exenteration. Int J Colorectal Dis 2014; 29:813-23. [PMID: 24752738 DOI: 10.1007/s00384-014-1868-0] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/02/2014] [Indexed: 02/04/2023]
Abstract
PURPOSE We analysed the outcomes of a series of 100 consecutive patients with anorectal cancer with neoadjuvant radiochemotherapy and abdominoperineal exstirpation or total pelvic exenteration, who received a transpelvic vertical rectus abdominis myocutaneous (VRAM) flap for pelvic, vaginal and/or perineal reconstruction and compare a cohort to patients without VRAM flaps. METHODS Within a 10-year period (2003-2013) in our institution 924 patients with rectal cancer stage y0 to y IV were surgically treated. Data of those 100 consecutive patients who received a transpelvic VRAM flap were collected and compared to patients without flaps. RESULTS In 100 consecutive patients with transpelvic VRAM flaps, major donor site complications occurred in 6 %, VRAM-specific perineal wound complications were observed in 11 % of the patients and overall 30-day mortality was 2 %. CONCLUSIONS The VRAM flap is a reliable and safe method for pelvic reconstruction in patients with advanced disease requiring pelvic exenteration and irradiation, with a relatively low rate of donor and recipient site complications. In this first study, to compare a large number of patients with VRAM flap reconstruction to patients without pelvic VRAM flap reconstruction, a clear advantage of simultaneous pelvic reconstruction is demonstrated.
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Affiliation(s)
- R E Horch
- Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich Alexander University Erlangen-Nuernberg, Krankenhausstrasse 12, 91054, Erlangen, Germany,
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Pinkney TD, Bach SP. Neoadjuvant Therapy Without Surgery for Early Stage Rectal Cancer? COLORECTAL CANCER 2014. [DOI: 10.1002/9781118337929.ch7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Gerard JP, Benezery K, Doyen J, Francois E. Aims of combined modality therapy in rectal cancer (M0). Recent Results Cancer Res 2014; 203:153-69. [PMID: 25103004 DOI: 10.1007/978-3-319-08060-4_11] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
UNLABELLED OPTIMIZING THE COST/BENEFIT RATIO OF TREATMENT: Evidence Based The aim of a cancer treatment is always to achieve the maximum of cure rate with a minimum of toxicity and best quality of life at an acceptable cost for the society. It is always a multifactorial challenge depending on the patient, the tumor, the doctor, and the society cultural and financial backgrounds. The goal is to find the best cost/benefit ratio between all possible strategies in agreement with a well-informed patient. In rectal cancer (M0) surgery is the cornerstone of treatment. Combined modality therapies aim at optimizing the cost/benefit ratio of possible strategies and only randomized trials can bring strong evidence regarding their results and recommendations. LESSONS FROM RANDOMIZED TRIALS: quite modest During the past decades many phase III trials have shown that: (1) neoadjuvant treatment even with "TME" surgery was better than adjuvant, (2) chemoradiotherapy (CRT) was better than RT alone, (3) long course CRT was probably more efficient (in terms of ypCR) than short course (25/5), and (4) capecitabine was as efficient as 5 FU but oxaliplatin was not adding benefit. Overall, the gains of nCRT remain modest and it is mainly a reduction in local relapse not exceeding 5 %, but no benefit in survival and neither in sphincter saving surgery has been proven. The way forwards organ preservation in case of CCR. Local control: can probably be improved for T4 tumors by RT dose escalation. Survival: can be increased by innovative medical treatment either before or after surgery. TOXICITY may be reduced by a less aggressive treatment in elderly. Conservative treatment: A new field of clinical research is to achieve "organ preservation" (and not only sphincter saving). To modify the surgical approach and preserve the whole rectum, neoadjuvant treatment must achieve safely a clinical complete response. As rectal adenocarcinoma is a relatively radioresistant tumor endocavitary irradiation (contact X-Ray) is a promising safe approach and this hypothesis will be addressed by the OPERA randomized trial.
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Affiliation(s)
- J P Gerard
- Departement of Radiation Oncology, Centre Antoine-Lacassagne, 33 Avenue de Valombrose, 01689, Nice Cedex 2, France,
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Weiser MR, Beets-Tan R, Beets G. Management of Complete Response After Chemoradiation in Rectal Cancer. Surg Oncol Clin N Am 2014; 23:113-25. [DOI: 10.1016/j.soc.2013.09.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Ceelen WP. Progress in rectal cancer treatment. ISRN GASTROENTEROLOGY 2012; 2012:648183. [PMID: 22970381 PMCID: PMC3437282 DOI: 10.5402/2012/648183] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/24/2012] [Accepted: 08/08/2012] [Indexed: 12/17/2022]
Abstract
The dramatic improvement in local control of rectal cancer observed during the last decades is to be attributed to attention to surgical technique and to the introduction of neoadjuvant therapy regimens. Nevertheless, systemic relapse remains frequent and is currently insufficiently addressed. Intensification of neoadjuvant therapy by incorporating chemotherapy with or without targeted agents before the start of (chemo)radiation or during the waiting period to surgery may present an opportunity to improve overall survival. An increasing number of patients can nowadays undergo sphincter preserving surgery. In selected patients, local excision or even a "wait and see" approach may be feasible following active neoadjuvant therapy. Molecular and genetic biomarkers as well as innovative imaging techniques may in the future allow better selection of patients for this treatment option. Controversy persists concerning the selection of patients for adjuvant chemotherapy and/or targeted therapy after neoadjuvant regimens. The currently available evidence suggests that in complete pathological responders long-term outcome is excellent and adjuvant therapy may be omitted. The results of ongoing trials will help to establish the ideal tailored approach in resectable rectal cancer.
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Affiliation(s)
- Wim P Ceelen
- Department of Surgery, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium
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36
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Beets GL. Critical appraisal of the 'wait and see' approach in rectal cancer for clinical complete responders after chemoradiation (Br J Surg 2012; 99: 897-909). Br J Surg 2012; 99:910. [PMID: 22648639 DOI: 10.1002/bjs.8793] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- G L Beets
- Department of Surgery, Maastricht University Medical Centre, PO Box 5800, 6202 AZ Maastricht, The Netherlands.
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Abstract
Neoadjuvant short-course radiotherapy and long-course chemoradiation (CRT) reduce local recurrence rates when compared to surgery alone and remain widely accepted as standard of care for patients with locally advanced rectal cancer. However, surgery is not without complications and a non-surgical approach in carefully selected patients warrants evaluation. A pathological complete response to CRT is associated with a significant improvement in survival and it has been suggested that a longer time interval between the completion of CRT and surgery increases tumor downstaging. Intensification of neoadjuvant treatment regimens to increase tumor downstaging has been evaluated in a number of clinical trials and more recently the introduction of neoadjuvant chemotherapy prior to CRT has demonstrated high rates of radiological tumor regression. Careful selection of patients using high-resolution MRI may allow a non-surgical approach in a subgroup of patients achieving a complete response to neoadjuvant therapies after an adequate time period. Clearly this needs prospective evaluation within a clinical trial setting, incorporating modern imaging techniques, and tissue biomarkers to allow accurate prediction and assessment of response.
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Higgins KA, Willett CG, Czito BG. Nonoperative Management of Rectal Cancer: Current Perspectives. Clin Colorectal Cancer 2010; 9:83-8. [DOI: 10.3816/ccc.2010.n.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Radiothérapie seule ou associée aux traitements médicaux dans les cancers du rectum. ONCOLOGIE 2010. [DOI: 10.1007/s10269-009-1832-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Baatrup G, Endreseth BH, Isaksen V, Kjellmo Ä, Tveit KM, Nesbakken A. Preoperative staging and treatment options in T1 rectal adenocarcinoma. Acta Oncol 2009; 48:328-42. [PMID: 19180365 DOI: 10.1080/02841860802657243] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Major rectal resection for T1 rectal cancer offers more than 95% cancer specific five-year survival to patients surviving the first 30 days after surgery. A significant further improvement by development of the surgical technique may not be possible. Improvements in the total survival rate have to come from a more differentiated treatment modality, taking patient and procedure related risk factors into account. Subgroups of patients have operative mortality risks of 10% or more. Operative complications and long-term side effects after rectum resection are frequent and often severe. RESULTS Local treatment of T1 cancers combined with close follow-up, early salvage surgery or later radical resection of local recurrences or with chemo-radiation may lead to fewer severe complications and comparable, or even better, long-term survival. Accurate preoperative staging and careful selection of patients for local or non-operative treatment are mandatory. As preoperative staging, at present, is not sufficiently accurate, strategies for completion, salvage or rescue surgery is important, and must be accepted by the patient before local treatment for cure is initiated. RECOMMENDATIONS It is recommended that polyps with low-risk T1 cancers should be treated with endoscopic snare resection in case of Haggitt's stage 1 or 2. TEM is recommended if resection margins are uncertain after snare resection for Haggitt's stage 3 and 4, and for sessile and flat, low-risk T1 cancers. Average risk patients with high-risk T1 cancers should be offered rectum resection, but old and comorbid patients with high-risk T1 cancers should be treated individually according to objective criteria as age, physical performance as well as patient's preference. All patients treated for cure with local resection or non-surgical methods should be followed closely.
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Christoforidis D, McNally MP, Jarosek SL, Madoff RD, Finne CO. Endocavitary contact radiation therapy for ultrasonographically staged T1 N0 and T2 N0 rectal cancer. Br J Surg 2009; 96:430-6. [DOI: 10.1002/bjs.6478] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
Background
The purpose of this study was to determine the long-term outcomes of patients undergoing endocavitary contact radiation therapy (ECR) for stage I rectal cancer.
Methods
A database of patients treated with ECR for biopsy-proven rectal adenocarcinoma from July 1986 to June 2006 was reviewed retrospectively. Only patients with primary, non-metastatic, ultrasonographically staged T1 N0 and T2 N0 cancer who had no adjuvant treatment were included. Patients received a median of 90 (range 60–190) Gy contact radiation, delivered transanally by a 50-kV X-ray tube in two to five fractions.
Results
Of 149 patients, 77 (40 T1, 37 T2) met the inclusion criteria. Median age was 74 (range 38–104) years, and median follow-up 69 (range 10–219) months. ECR failed in 21 patients (27 per cent) (persistent disease, four; recurrence, 17), of whom ten remained disease free after salvage therapy. The estimated 5-year disease-free survival rate was 74 (95 per cent confidence interval 63 to 83) per cent after ECR alone, and 87 (76 to 93) per cent when survival after salvage therapy for recurrence was included.
Conclusion
ECR is a minimally invasive treatment option for early-stage rectal cancer. However, similar to other local therapies, ECR has a worse oncological outcome than radical surgery.
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Affiliation(s)
- D Christoforidis
- Division of Colon and Rectal Surgery, Department of Surgery, Minneapolis, Minnesota, USA
- Department of Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - M P McNally
- Division of Colon and Rectal Surgery, Department of Surgery, Minneapolis, Minnesota, USA
- Department of Surgery, National Naval Medical Center, Bethesda, Maryland, USA
| | - S L Jarosek
- Division of Health Policy and Management, School of Public Health, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - R D Madoff
- Division of Colon and Rectal Surgery, Department of Surgery, Minneapolis, Minnesota, USA
| | - C O Finne
- Division of Colon and Rectal Surgery, Department of Surgery, Minneapolis, Minnesota, USA
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Abstract
INTRODUCTION Rectal cancer is a common disease in Western populations. Improved treatment modalities have resulted in increased survival and tumour control. With increasing survival there is a growing need for knowledge about the long-term side effects and functional results after the treatment. AIM To describe the long-term functional outcome in patients treated for rectal cancer through a systematic review of the current literature and to provide an outline of the promising developments within this area. RESULTS Standard resectional surgery with loss of the rectal reservoir function results in poor functional results in up to 50-60% of the patients. New methods of surgery including the construction of a neoreservoir and improvement of the technique for local excision have been developed to minimize the functional disturbances without compromising the oncological result. The addition of chemo and/or radiotherapy approximately doubles the risk of poor functional results. During the last decades the techniques for chemo/radiotherapy has been markedly improved with a positive impact on functional outcome. New methods for treatment of functional disturbances e.g. bowel irrigation and sacral nerve stimulation are currently under development. PERSPECTIVES To improve the functional outcome in this growing patient population several approaches can be taken. The primary cancer treatment must be improved by minimizing the surgical trauma and optimizing the imaging and radiation techniques. Population screening should be considered in order to find the cancers at an earlier stage, hereby increasing the proportion of patients eligible for local excision without the need for chemo/irradiation. All patients recovering from rectal resection should be examined and registered systematically regarding their functional results and treatment should be offered to the severely affected patients. More studies are still needed to evaluate the efficacy of irrigation and nerve stimulation in this patient group.
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Gérard JP, Ortholan C, Benezery K, Ginot A, Hannoun-Levi JM, Chamorey E, Benchimol D, François E. Contact X-ray therapy for rectal cancer: experience in Centre Antoine-Lacassagne, Nice, 2002-2006. Int J Radiat Oncol Biol Phys 2008; 72:665-70. [PMID: 18455327 DOI: 10.1016/j.ijrobp.2008.01.030] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2007] [Revised: 01/23/2008] [Accepted: 01/23/2008] [Indexed: 12/22/2022]
Abstract
PURPOSE To report the results of using contact X-ray (CXR), which has been used in the Centre-Lacassagne since 2002 for rectal cancer. METHODS AND MATERIALS A total of 44 patients were treated between 2002 and 2006 using four distinct clinical approaches. Patients with Stage T1N0 tumors were treated with transanal local excision (TLE) and adjuvant CXR (45 Gy in three fractions) (n = 7). The 11 inoperable (or who had refused surgery) patients with Stage T2-T3 disease were treated with CXR plus external beam radiotherapy (EBRT). Those with Stage T3N0-N2 tumors were treated with preoperative CXR plus EBRT (with or without concurrent chemotherapy) followed by surgery (n = 21). Finally, the patients with Stage T2 disease were treated with CXR plus EBRT followed by TLE (n = 5). RESULTS The median follow-up was 25 months. In the 7 patients who underwent TLE first, no local failure was observed, and their anorectal function was good. Of the 11 inoperable patients who underwent CXR plus EBRT alone, 10 achieved local control. In the third group (preoperative CXR plus EBRT), anterior resection was performed in 16 of 21 patients. Complete sterilization of the operative specimen was seen in 4 cases (19%). No local recurrence occurred. Finally, of the 5 patients treated with CXR plus EBRT followed by TLE, a complete or near complete clinical response was observed in all. TLE with a R0 resection margin was performed in all cases. The rectum was preserved with good function in all 5 patients. CONCLUSION These early results have confirmed that CXR combined with surgery (or alone with EBRT) can play a major role in the conservative and curative treatment of rectal cancer.
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Affiliation(s)
- Jean-Pierre Gérard
- Department of Radiotherapy, Centre Antoine-Lacassagne, Nice, France; Université de Nice Sophia Antipolis, Nice, France
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Abstract
BACKGROUND Early rectal cancer (ERC) is adenocarcinoma that has invaded into, but not extended beyond, the submucosa of the rectum (that is a T1 tumour). Local excision is curative for low-risk ERCs but for high-risk cancers such management is controversial. METHODS This review is based on published literature obtained by searching the PubMed and Cochrane databases, and the bibliographies of extracted articles. RESULTS AND CONCLUSION ERC presents as a focus of malignancy within an adenoma, as a polyp, or as a small ulcerating adenocarcinoma. Preoperative staging relies on endorectal ultrasonography and magnetic resonance imaging. Pathological staging uses the Haggitt and Kikuchi classifications for adenocarcinoma in pedunculated and sessile polyps respectively. Lymph node metastases increase with the Kikuchi level, with a 1-3 per cent risk for submucosal layer (Sm) 1, 8 per cent for Sm2 and 23 per cent for Sm3 lesions. Low-risk ERCs may be treated endoscopically or by a transanal procedure. Transanal excision or transanal endoscopic microsurgery may be inadequate for high-risk ERCs and adjuvant chemoradiotherapy may be appropriate. There is a low rate of recurrence after local surgery for low-risk ERCs but this increases to up to 29 per cent for high-risk cancers.
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Affiliation(s)
- M G Tytherleigh
- Department of Colorectal Surgery, John Radcliffe Hospital, Oxford, UK.
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Lindegaard J, Gerard JP, Sun Myint A, Myerson R, Thomsen H, Laurberg S. Whither Papillon? — Future Directions for Contact Radiotherapy in Rectal Cancer. Clin Oncol (R Coll Radiol) 2007; 19:738-41. [PMID: 17870428 DOI: 10.1016/j.clon.2007.07.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2007] [Accepted: 07/25/2007] [Indexed: 11/24/2022]
Abstract
Although contact radiotherapy was developed 70 years ago, and is highly effective with cure rates of over 90% for early rectal cancer, there are few centres that offer this treatment today. One reason is the lack of replacement of ageing contact X-ray machines, many of which are now over 30 years old. To address this problem, the International Contact Radiotherapy Evaluation (ICONE) group was formed at a meeting in Liverpool in 2005 with the aim of developing a new contact X-ray unit and to establish clinical protocols that would enable the new machine to safely engage in the treatment of rectal cancer. As a result of these efforts, a European company is starting production of the new Papillon RT-50 machine, which will be available shortly. In addition, the ICONE group is planning an observational study on contact X-ray and transanal endoscopic microsurgery (CONTEM) for curative treatment of rectal cancer. This protocol will ensure standardised diagnostic procedures, patient selection and treatment in centres across the world and the data will be collected prospectively for analysis and audit. It is hoped that the CONTEM trial will provide the scientific evidence that is needed to obtain a broader acceptance of local contact radiotherapy as a treatment option for selected cases with early stage rectal cancer.
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Affiliation(s)
- J Lindegaard
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
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Sun Myint A, Grieve RJ, McDonald AC, Levine EL, Ramani S, Perkins K, Wong H, Makin CA, Hershman MJ. Combined Modality Treatment of Early Rectal Cancer — the UK Experience. Clin Oncol (R Coll Radiol) 2007; 19:674-81. [PMID: 17888639 DOI: 10.1016/j.clon.2007.07.017] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2007] [Revised: 07/15/2007] [Accepted: 07/29/2007] [Indexed: 01/01/2023]
Abstract
With the introduction of colorectal screening in the UK, more patients will probably be diagnosed with early rectal cancer. The UK has an increasingly elderly population and not all patients diagnosed with early rectal cancer will be suitable for radical surgery. Therefore, a national plan is needed to develop the provision of alternative local treatment with equity of access across the country. Here we review the Clatterbridge Centre for Oncology multimodality treatment policy, which has been in clinical practice since 1993 and we discuss its rationale. Clatterbridge is the only centre in the UK offering Papillon-style contact radiotherapy. In total, 220 patients have been treated over 14 years, most of whom were referred from other centres. One hundred and twenty-four patients received Papillon (contact radiotherapy) as part of their multimodality management. The guidelines of the Association of Coloproctology of Great Britain and Ireland recommend local treatment for T1 tumours<3 cm in diameter, but this refers to treatment by surgery alone. There are no published national guidelines for radiotherapy. We plan each treatment in stages and achieve excellent local control (93% at 3 years) with low morbidity. We conclude that radical local treatment for cure can be offered safely to carefully selected elderly patients. Close follow-up is necessary so that effective salvage treatment can be offered. Because of a lack of randomised trial evidence, at present local radiotherapy is not yet accepted as an alternative option to the gold standard surgical treatment. Even with international collaboration, a randomised trial will be difficult to complete as the number of cases requiring local radiotherapy is small due to the highly selective nature of the treatment involved. However, an observational phase II trial is planned. In addition, the Transanal Endoscopic Microsurgery Users Group is also planning a phase II trial using preoperative radiotherapy. These studies will provide evidence to help establish the true role of radiotherapy in early rectal cancer.
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Affiliation(s)
- A Sun Myint
- Clatterbridge Centre for Oncology NHS Foundation Trust, Wirral, UK.
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48
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Cummings BJ. Is there a limit to dose escalation for rectal cancer? Clin Oncol (R Coll Radiol) 2007; 19:730-7. [PMID: 17869492 DOI: 10.1016/j.clon.2007.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2007] [Accepted: 07/20/2007] [Indexed: 10/22/2022]
Abstract
The radiation tolerance of the rectum is not fully understood. Published studies on the radiation treatment of cancers of the prostate, cervix and rectum have been reviewed to determine currently recommended dose-volume guidelines. The need for further studies directed specifically at the treatment of primary rectal cancer and perirectal node metastases is discussed. There seems to be room for escalation of the external beam doses currently given.
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Affiliation(s)
- B J Cummings
- Princess Margaret Hospital, Toronto, Ontario, Canada.
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Gerard JP, Chapet O, Ortholan C, Benezery K, Barbet N, Romestaing P. French experience with contact X-ray endocavitary radiation for early rectal cancer. Clin Oncol (R Coll Radiol) 2007; 19:661-73. [PMID: 17822887 DOI: 10.1016/j.clon.2007.07.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2007] [Revised: 04/17/2007] [Accepted: 07/19/2007] [Indexed: 11/21/2022]
Abstract
This paper is an overview of the French experience with contact X-ray radiation for rectal cancer. The analysis was mainly carried out on 50 years of experience in Lyon or since 1980 in the Centre Hospitalier Universitaire Lyon Sud. The results obtained in Dijon and Nancy are also reported. In early rectal cancer, contact X-ray radiation can play an important role in three different situations: (1) small T1 less than 2 cm: adjuvant contact X-ray radiotherapy after local excision; (2) T2 N0 or large T1: first-line contact X-ray radiotherapy combined with external beam radiotherapy (+/- chemotherapy) followed by surgery (anterior resection or local excision); (3) early T3 N0 in frail patients: the same approach as for T2 N0 with, in case of clinical complete response, local excision or follow-up.
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Affiliation(s)
- J P Gerard
- Department of Radiation Oncology, Centre Antoine Lacassagne, Nice, France.
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50
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Gannon CJ, Zager JS, Chang GJ, Feig BW, Wood CG, Skibber JM, Rodriguez-Bigas MA. Pelvic exenteration affords safe and durable treatment for locally advanced rectal carcinoma. Ann Surg Oncol 2007; 14:1870-7. [PMID: 17406945 DOI: 10.1245/s10434-007-9385-9] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2006] [Accepted: 01/20/2007] [Indexed: 01/24/2023]
Abstract
BACKGROUND Treatment of locally advanced rectal carcinoma (LARC) often involves exenterative surgery, which can be associated with high perioperative morbidity and mortality. To assist in patient selection for radical surgery, we sought to determine clinicopathologic factors influencing recurrence and disease-free survival (DFS) of LARC. METHODS Consecutive patients with LARC undergoing exenterative surgery were retrospectively identified in our institutional database. Factors evaluated included age, sex, primary versus recurrent tumors, neoadjuvant or adjuvant chemoradiotherapy, resection margin status, recurrence, time to recurrence, and survival. The primary outcome was DFS. Secondary outcomes were overall survival and perioperative morbidity. RESULTS A total of 72 patients were identified; median age was 52 years, and median follow-up time was 30 months. The overall complication rate was 43%; rates were similar among the patients with primary (47%) or recurrent (37%) LARC. Primary or recurrent tumor status was the only factor significantly predictive of outcome after exenteration. Local recurrence rates were lower in the primary group (primary 22%, recurrent 52%, P = .05). A significant difference in 5-year DFS was found between primary and recurrent tumor (52% vs. 13%; P < .01). The median time to recurrence was longer in the patients with primary LARC (17 months vs. 8 months; P < .01). CONCLUSIONS The complication rates for pelvic exenteration remain high, but the morbidity can typically be managed without a clinically important increase in hospitalization. In primary LARC, an aggressive surgical approach provides most patients 5-year DFS. Select patients with recurrent LARC will also benefit from pelvic exenteration.
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Affiliation(s)
- Christopher J Gannon
- Department of Surgical Oncology, Unit 444, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas 77030, USA
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