The effect of primary tumor radiotherapy in patients with Unresectable stage IV Rectal or Rectosigmoid Cancer: a propensity score matching analysis for survival

BACKGROUND

To evaluate the impact of primary tumor radiotherapy on survival in patients with unresectable metastatic rectal or rectosigmoid cancer.

METHODS

From September 2008 to September 2017, 350 patients with unresectable metastatic rectal or rectosigmoid cancer were retrospectively reviewed in our center. All patients received at least 4 cycles of chemotherapy and were divided into two groups according to whether they received primary tumor radiotherapy. A total of 163 patients received primary tumor radiotherapy, and the median radiation dose was 56.69 Gy (50.4-60). Survival curves were estimated with the Kaplan-Meier method to roughly compare survival between the two groups. Subsequently, the 18-month survival rate was used as the outcome variable for this study. This study mainly evaluated the impact of primary tumor radiotherapy on the survival of these patients through a series of multivariate Cox regression analyses after propensity score matching (PSM).

RESULTS

The median follow-up time was 21 months. All 350 patients received a median of 7 cycles of chemotherapy (range 4-12), and 163 (46.67%) patients received primary tumor radiotherapy for local symptoms. The Kaplan-Meier survival curves showed that the primary tumor radiotherapy group had a significant overall survival (OS) advantage compared to the group without radiotherapy (20.07 vs 17.33 months; P = 0.002). In this study, the multivariate Cox regression analysis after adjusting for covariates, multivariate Cox regression analysis after PSM, inverse probability of treatment weighting (IPTW) analysis and propensity score (PS)-adjusted model analysis consistently showed that primary tumor radiotherapy could effectively reduce the risk of death for these patients at 18 months (HR: 0.62, 95% CI 0.40-0.98; HR: 0.79, 95% CI: 0.93-1.45; HR: 0.70, 95% CI 0.55-0.99 and HR: 0.74, 95% CI: 0.59-0.94).

CONCLUSION

Compared with patients with stage IV rectal or rectosigmoid cancer who did not receive primary tumor radiotherapy, those who received primary tumor radiotherapy had a lower risk of death. The prescription dose (59.4 Gy/33 fractions or 60 Gy/30 fractions) of radiation for primary tumors might be considered not only to relieve symptoms improve the survival of patients with inoperable metastatic rectal or rectosigmoid cancer.

Adjuvant Postoperative Radiotherapy in Locally Advanced Rectal and Rectosigmoidal Cancer

A pelvic recurrence is the cause of death in about 1/3 of radically operated patients for rectal and rectosigmoidal cancer without clinical evidence of distant metastases. Preoperative and postoperative radiotherapy are largely used to reduce the incidence of locoregional relapses and to improve disease-free and overall survival and quality of life. Benefits from radiotherapy have been widely demonstrated, and adjuvant postoperative radiotherapy is at present strongly recommended. Twenty-one patients with locally advanced (stage B2, B3, C) rectal (11 cases) and rectosigmoidal cancer (10 cases) were treated with postoperative radiotherapy at the National Cancer Institute of Milan from 1975 to 1978. The pelvis received a median dose of 4500 rad (range, 4000–5200 rad) in 5 to 7 weeks through AP, PA opposed fields; 6 patients received a boost of 1000 rad on the perineum. Median follow-up after surgery is 83 months (range, 24–63 months). Only 1 case (« 5%) had a pelvic recurrence, at the perineum. The expected recurrence rate after surgery alone is 40 %, and our favorable results after postoperative radiotherapy are comparable with recent data from other institutions. Radiotherapy side effects were moderate and transient; no late damages to small bowel were observed.

Reduced Ovarian Cancer Incidence in Women Exposed to Low Dose Ionizing Background Radiation or Radiation to the Ovaries after Treatment for Breast Cancer or Rectosigmoid Cancer

BACKGROUND

High dose ionizing radiation can induce ovarian cancer, but the effect of low dose radiation on the development of ovarian cancer has not been extensively studied. We evaluated the effect of low dose radiation and total background radiation, and the radiation delivered to the ovaries during the treatment of rectosigmoid cancer and breast cancer on ovarian cancer incidence.

MATERIALS AND METHODS

Background radiation measurements are from Assessment of Variations in Radiation Exposure in the United States, 2011. Ovarian cancer incidence data are from the Centers for Disease Control and Prevention. Standardized incidence ratios (SIR) of ovarian cancer following breast cancer and rectosigmoid cancer are from Surveillance, Epidemiology, and End Results (SEER) data. Obesity data by US state are from the Centers for Disease Control and Prevention. Mean ages of US state populations are from the United States Census Bureau.

RESULTS

We calculated standardized incidence ratios (SIR) from Surveillance, Epidemiology, and End Results (SEER) data, which reveal that in 194,042 cases of breast cancer treated with beam radiation, there were 796 cases of ovarian cancer by 120+ months of treatment (0.41%); in 283, 875 cases of breast cancer not treated with radiation, there were 1,531 cases of ovarian cancer by 120+ months (0.54%). The difference in ovarian cancer incidence in the two groups was significant (<0.001, two tailed Fisher exact test). The small dose of scattered ovarian radiation (about 3.09 cGy) from beam radiation to the breast appears to have reduced the risk of ovarian cancer by 24%. In 13,099 cases of rectal or rectosigmoid junction cancer treated with beam radiation in the SEER data, there were 20 cases of ovarian cancer by 120+ months of treatment (0.15%). In 33,305 cases of rectal or rectosigmoid junction cancer not treated with radiation, there were 91 cases of ovarian cancer by 120+ months (0.27%). The difference in ovarian cancer incidence in the two groups was significant (p = 0.017, two tailed Fisher exact test). In other words, the beam radiation to rectum and rectosigmoid that also reached the ovaries reduced the risk of ovarian cancer by 44%. In addition, there was a significant inverse relationship between ovarian cancer in white women and radon background radiation (r = - 0.465. p = 0.002) and total background radiation (r = -0.456, p = 0.002). Because increasing age and obesity are risk factors for ovarian cancer, multivariate linear regression was performed. The inverse relationship between ovarian cancer incidence and radon background was significant (β = - 0.463, p = 0.002) but unrelated to age (β = - 0.080, p = 0.570) or obesity (β = - 0.180, p = 0.208).

CONCLUSIONS

The reduction of ovarian cancer risk following low dose radiation may be the result of radiation hormesis. Hormesis is a favorable biological response to low toxin exposure. A pollutant or toxin demonstrating hormesis has the opposite effect in small doses as in large doses. In the case of radiation, large doses are carcinogenic. However, lower overall cancer rates are found in U.S. states with high impact radiation. Moreover, there is reduced lung cancer incidence in high radiation background US states where nuclear weapons testing was done. Women at increased risk of ovarian cancer have two choices. They may be closely followed (surveillance) or undergo immediate prophylactic bilateral salpingo-oophorectomy. However, the efficacy of surveillance is questionable. Bilateral salpingo-oophorectomy is considered preferable, although it carries the risk of surgical complications. The data analysis above suggests that low-dose pelvic irradiation might be a good third choice to reduce ovarian cancer risk. Further studies would be worthwhile to establish the lowest optimum radiation dose.

[A case in which chemotherapy-resistant sigmoid colon cancer was controlled effectively by radiotherapy and resection]

A 53-year-old woman underwent sigmoid colectomy for sigmoid colon cancer with peritoneal metastasis. Liver and intrapelvic metastases were found upon examination 6 months after surgery during adjuvant chemotherapy with XELOX plus bevacizumab. After hepatic subsegmentectomy, the patient received S-1 treatment in combination with radiotherapy for the intrapelvic metastasis. One year after the second surgery, abdominoperineal rectal resection was performed as the intrapelvic tumor had increased in size. At 16 months after the third surgery, computed tomography( CT) revealed a small lung nodule that gradually increased in size. The patient underwent partial lung resection. The nodule was a recurrence of the sigmoid colon cancer. During this period, the patient was treated again with S-1 combined with radiotherapy because 2 intrapelvic metastases had been identified. At present, these metastases have been well controlled for 3 years after the initial recurrence. Thus, it is suggested that aggressive radiotherapy and resection are effective therapies for recurrence of chemotherapy-resistant colon cancer.

[Systemic radiotherapy options in the treatment of metastatic skeletal involvement]

OBJECTIVE

To evaluate the efficiency of treatment using various systemic radiotherapies for metastatic skeletal involvement in patients with breast or prostate cancer.

MATERIAL AND METHODS

The case histories of 350 patients treated at the Department of Radiation Medicine in 2006 to 2010 for multiple metastatic skeletal involvement in cancers at various sites were analyzed. The efficiency of treatment for pain syndrome and the magnitude of a myelosuppressive effect were estimated in the use of various systemic radiotherapies. For this, the authors compared: 1) two patient groups treated by 89Sr chloride monotherapy in the standard activity of 150 MBq or by that in combination with teleradiotherapy (TRT); 2) two patient groups treated by the monotherapy in the standard activity of 150 MBq or by 89Sr chloride fractional injection.

RESULTS

The efficiency of treatment using various systemic radiotherapies was estimated. That was comparatively evaluated in the patient groups having various treatments. Algorithms of indications were elaborated to choose a systemic radiotherapy option depending on the clinical situation. An 89Sr chloride injection procedure was developed for patients with significant myelosuppression.

CONCLUSION

1. Various systemic radiotherapies as second-line therapy may be used to treat metastatic skeletal involvement in patients with cancer at various sites. 2. The most pronounced analgesic effect was found when 89Sr chloride in the standard activity of 150 MBq had been injected in combination with TRT (a 36% reduction in the intensity of pain syndrome); a less pronounced effect was produced by 89Sr chloride monotherapy (27%). The lowest analgesic effect was observed when 89Sr chloride had been fractionally injected (14%). 3. The levels of white blood cells and platelets were decreased in all the groups. 4. 89Sr chloride fractional injection is the method of choice when its single administration is impossible in patients with evident leukocyto- and thrombocytopenia.

[A case of effective neoadjuvant chemoradiotherapy with capecitabine for locally advanced sigmoid colon cancer]

A 60-year-old man was hospitalized for urodynia. Clinical examinations demonstrated a locally advanced sigmoid colon cancer with direct extension to the bladder, rectum, and pelvic wall. We considered that curative resection was not possible and performed temporary colostomy for fecal diversion. After colostomy, he was treated with neoadjuvant chemoradiotherapy(NACRT)for down staging. The radiation therapy was delivered with 45 Gy(1. 8 Gy/fraction; 5 days/week×5 weeks), and the concurrent chemotherapy was performed with capecitabine(825mg/m2 twice daily on radiotherapy days). CT scan confirmed a dramatic response with downstaging of the tumor following NA-CRT(clinical response, PR in the RECIST criteria). Invasion of the tumor to pelvic wall disappeared on CT scan, and[18F]fluorodeoxyglucose positron emission tomography( FDG-PET)failed to demonstrate any distant metastasis. We considered that the tumor was hence resectable and performed total pelvic exenteration(TPE)1 month after NACRT. A pathological examination of surgical specimens confirmed a R0 resection. The patient made an unremarkable postoperative recovery. He went on to receive adjuvant capecitabine chemotherapy, completing four cycles. He remains well and disease-free 10 months following surgery. NACRT with capecitabine appears effective even for unresectable locally advanced sigmoid colon cancer.

Recombinant activated factor VII to control life-threatening haemorrhagic radiation cystitis

INTRODUCTION

The use of recombinant activated factor VII has been described for many clinical scenarios, but the value of this therapeutic agent for life-threatening haemorrhagic cystitis remains novel.

METHOD

We describe a case of persistent life-threatening haemorrhagic radiation cystitis, and discuss current knowledge of this therapy including potential complications.

RESULT

Control of haemorrhage was successfully achieved only after use of this agent.

CONCLUSION

This therapy deserves mention in any future management algorithm devised for this condition.

[A case of successfully treated sigmoid colon cancer with multiple regional metastases by chemotherapy and radiation therapy]

Multiple regional metastases due to colon cancer usually show poor prognosis. Various treatments such as chemotherapy and radiation therapy are not sufficient, and the outcome is generally poor in many cases. We report here on a patient with multiple regional metastases who was successfully treated with several therapies and remains still alive. A 69-year-old man presented with fever and epigastralgia. A colonoscopy revealed primary sigmoid colon cancer. A computed tomography showed multiple hepatic metastases, and metastases to supraclavicular, mediastinal and para-aortic regional lymph nodes. The bone metastases were detected by scintigram. He was treated with combination chemotherapy of 5-FU via hepatic artery and CPT-11 by systemic administration. The primary tumor had completely disappeared (complete response), and metastases to liver and lymph nodes showed a remarkable shrinkage (partial response) after the chemotherapy. In contrast, bone metastases showed progressive growth (progressive disease). Radiation therapy and bisphosphonate infusion for bone metastases were achieved, and the treatments have controlled the growth of the metastases. Primary tumors and metastases are still controlled well for 3 years after the initial chemotherapy.

[A case of advanced colon cancer invading the rectum effectively treated with chemoradiation therapy before surgery]

A 56-year-old man was hospitalized for anemia with appetite loss and body weight loss. He was diagnosed as advanced sigmoid colon cancer which invaded the rectal colon (Ra) and prostate (SI, N 0, P 0, H 0, M (-), cStage IIIa). We administered neoadjuvant chemoradiotherapy for fear of non-curative resection of the sigmoid colon and rectum after colostomy was performed. He was given radiation of the whole pelvis at a total dose of 39 .6 Gy (1.8 Gy x 22 times) combined with chemotherapy using continuous intravenous 5-FU (500 mg x 22 times). Two weeks after the chemoradiation, we administered chemotherapy (FOLFOX 4). Resectable resection was confirmed on Computed Tomography. We were able to conduct a low anterior resection of sigmoid colon and rectum. Postoperative histopathological examination of the resected sigmoid colon and rectum revealed no remnant cancer tissue. Neo-adjuvant chemoradiotherapy is considered to be effective for a study of non-curative resection of rectum.

Uncertainties when using only one MRI-based treatment plan for subsequent high-dose-rate tandem and ring applications in brachytherapy of cervix cancer

BACKGROUND AND PURPOSE

This retrospective study compares individual MRI based 3D treatment planning for each intracavitary applicator insertion and the use of only one MRI treatment plan for cervical cancer brachytherapy.

MATERIALS AND METHODS

GTV, high risk (HR) CTV and OAR were delineated and analysed for 14 patients. Data using the individual approach were taken from the actual irradiated plans. The "single plan procedure" was simulated by matching the dose distribution of the first plan to the MRI datasets of each subsequent implantation. Total doses from brachytherapy were added up and normalized to 2Gy fractionation (EQD2).

RESULTS

The mean D90 for HR CTV was 6Gy higher when using one plan than when using individual treatment plans. The D(2cc) increased 3.5Gy for the bladder, 4.2Gy for the rectum and 5.8Gy for the sigmoid. The use of only one treatment plan would have resulted in 2, 1 and 5 extra cases exceeding total D(2cc) constraints for bladder (90Gy), rectum (75Gy) and sigmoid (75Gy), respectively.

CONCLUSION

The use of only one treatment plan for several applications results in higher dose to target and OAR structures. CT, clinical examination and X-ray findings can help to reduce certain situations of overdosage, when individual MRI based treatment planning is not available for each fraction.

Long-term Disease-free Survival After Adrenalectomy for Isolated Colorectal Metastases

Metastasis to the adrenal glands occurs in approximately 16% of patients with metastatic colorectal carcinoma. Historically, these metastases are found at autopsy, but due to improved imaging and diagnostic techniques, many of these lesions are now discovered on routine follow-up imaging. In general, adrenal metastasis is an indicator of widespread disease, but in rare cases, isolated adrenal metastasis can be found. Although potential improvement in overall survival after adrenalectomy for isolated colorectal metastases has been reported, there has only been one long-term disease-free survivor reported. Here, we report a patient who is a 7-year disease-free survivor after adrenalectomy for an isolated colorectal metastasis.

MRI identified prognostic features of tumors in distal sigmoid, rectosigmoid, and upper rectum: treatment with radiotherapy and chemotherapy

PURPOSE

Neoadjuvant therapy is traditionally reserved for locally advanced mid and low rectal cancers. In tumors above this level, the need for adjuvant treatment is based on poor histopathologic features, but this approach has potential disadvantages. The aim of this study was to determine whether magnetic resonance imaging (MRI) could accurately stage tumors of the distal sigmoid, rectosigmoid, and upper rectum and help direct preoperative treatment.

MATERIALS AND METHODS

A total of 75 patients with distal sigmoid, rectosigmoid, and upper rectal tumors were assessed preoperatively by MRI. If tumor extended beyond the planned surgical resection plane, chemoradiotherapy was offered.

RESULTS

Of the 75 patients, 57 (76%) underwent primary surgery. Agreement between the MRI prognosis and histopathologic findings was 84% (95% confidence interval [CI], 72.6-92.7%). The other 18 patients underwent neoadjuvant chemoradiotherapy for poor prognostic features with predicted surgical resection margin involvement. The histopathologic examination confirmed tumor downstaging in 9 of the 18 patients who underwent chemoradiotherapy. The 3-year survival rate in the good prognosis group (91%; 95% CI, 77.1-97.3%) was not significantly different from that of the chemoradiotherapy group (81.4%; 95% CI, 52.4-93.6%). The poor prognosis group undergoing primary surgery had significantly worse survival (62.2%; 95% CI, 30.3-82.8%, p < 0.03).

CONCLUSION

Our findings indicate that tumors of the distal sigmoid, rectosigmoid, and upper rectum can be staged accurately using high spatial resolution MRI and that those with poor prognostic disease may benefit from preoperative therapy.

Subcutaneous Pneumocele Associated With Ventriculoperitoneal Shunt Migration Into the Mechanically Occluded Colon-Case Report-

A 62-year-old man presented with shunt failure manifesting as consciousness disturbance 4 years after placement of a ventriculoperitoneal shunt for subarachnoid hemorrhage. Physical examination found subcutaneous pneumocele around the peritoneal catheter extending from the abdomen to the neck. He had undergone pelvic radiation therapy for bladder cancer 2 years before. The peritoneal catheter was removed from the cervical region, and external ventricular drainage and a descending colon stoma for ileus release were positioned. The cerebrospinal fluid was clear and yielded no cultures. No inflammatory changes were seen. He developed carcinomatous peritonitis and died 4 months later. Retrograde colon gas reflux due to catheter perforation into the colon occluded by metastatic sigmoid cancer was probably the cause. Fragility of the wall of colon associated with the prior abdominal radiation therapy might have been a contributing factor. Subcutaneous pneumocele around the peritoneal catheter, i.e. pneumocele within the fibrous sheath surrounding the catheter, is a differential diagnosis to cerebrospinal fluid collection in patients with subcutaneous swelling around the catheter.

Radiologic assessment of rectosigmoid cancer before and after neoadjuvant radiation therapy: comparison between quantitation techniques

OBJECTIVE

Volumetric analysis was compared with conventional unidimensional measurements for follow-up of rectosigmoid cancer before and after radiation therapy.

SUBJECTS AND METHODS

Fifteen patients with rectosigmoid cancer underwent helical CT before and after neoadjuvant radiation therapy. The helical CT examination was performed after colon distention with air and IV administration of an antiperistaltic drug. Two scans were obtained: one with the patient in the supine position and the other with the patient in the prone position after contrast medium injection. The maximal wall thickness and the volumetric analysis of the tumor were obtained through manual segmentation.

RESULTS

The mean of the differences between the volumetric analysis of the scans obtained before and after radiation therapy was 8.3 +/- 10.3 (SD) mL (-22.7%) (p <0.05). The mean of the differences between the maximal wall thickness of the pre- and post-radiation therapy scans was 3.4 +/- 2.6 mm (-19.1%) (p <0.05). A significant difference was observed between the variation of the maximal wall thickness and the variation of volumetric analysis in pre- and post-radiation therapy scans (p <0.05). The patients could be classified in different response categories depending on the measurement method and on the response criteria.

CONCLUSION

Volumetric analysis of rectosigmoid cancer is feasible. A long-term study is needed to correlate volumetric assessment with patient outcome.

Outcome of rectal and sigmoid carcinoma patients receiving adjuvant chemoradiotherapy in Marmara University Hospital

Adjuvant chemoradiotherapy is the standard treatment in resected stage II/III rectosigmoid carcinoma. We report a retrospective analysis of 33 patients who received adjuvant chemoradiotherapy. Patients received 5-fluorouracil (375mg/m2/day x 5days) and calcium leucovorin (20mg/m2/day x 5days), q4weeks, two courses before and two courses after radiotherapy. The 5-fluorouracil dose was reduced to 225mg/m2/day given continuously as protracted short-term infusion on the first and last 3 days during radiotherapy. Radiotherapy was started at 7th week and 45-50.4 Gy was given to pelvic region. Median age was 63 years. Median follow-up was 38 months starting from the operation date. Four-year local and distant control rates were 78% and 69%, respectively. Four-year disease-free survival and overall survival were 60% and 62%, respectively. Protracted short-term infusion of 5-fluorouracil during pelvic irradiation is a safe treatment modality. Further studies are needed to improve the local control of high-risk rectal and sigmoid carcinomas.

Using intraoperative radiation therapy--a case study

The introduction of a mobile linear accelerator in the OR has made intraoperative radiation therapy (IORT) more plausible. An IORT treatment can deliver a single high dose of radiation to a tumor or tumor bed after surgical resection or surgical exposure of high risk areas. This article details a case study in which IORT was used on a patient with sigmoid carcinoma and the procedure outcomes.

Intraoperative radiation therapy for patients with recurrent rectal and sigmoid colon cancer in previously irradiated fields

A retrospective study evaluated 15 patients with pelvic recurrence of colorectal cancer in a previously irradiated region who received intraoperative radiation therapy (IORT) as part of salvage therapy. Total prior external beam radiation therapy (EBRT) doses ranged from 45 to 79.2 Gy. Tumor resection was accomplished in 14 patients, with an exenteration performed in seven. IORT dose was 15-20 Gy. Three patients received additional EBRT as a post-operative course of 25.2 Gy in 14 fractions. Actuarial 3-year local control rate was 25%. The 3-year overall survival rate was 29%. Patients with fixed and/or bulky pelvic tumors had a local control rate of 19% at 12 months and median overall survival of 9 months. Patients with less extensive clinical presentations of anastomotic non-fixed transmural recurrence, isolated pelvic node metastasis and rectal recurrence following local excision had a local control rate of 42% at 36 months and median survival of 43 months. We conclude that clinical presentation of recurrent disease is an important prognostic factor. The value of IORT may be limited to patients with less extensive clinical presentations.

Issues of normal tissue toxicity in patient and animal studies--effect of carbogen breathing in rats after 5-fluorouracil treatment

Non-invasive magnetic resonance spectroscopy (MRS) can be used in the clinic to monitor the pharmacokinetics of the chemotherapeutic drug 5-fluorouracil (5-FU) and the effects of modifiers. We report two studies of 5-FU toxicity in normal tissue--one with patients and the other an animal study. 1) 19F MRS signals from fluoronucleotides, cytotoxic anabolites of 5-FU metabolism, were observed in the livers of two patients treated with 5-FU for colorectal cancer, shown by computed tomography (CT) and ultrasound (US) to have no liver metastases. This is the first report of non-invasive monitoring of toxic 5-FU metabolites in normal human tissues. 2) In animals, carbogen-breathing enhances tumour uptake and the efficacy of 5-FU, and the method is under trial in patients. This study demonstrates that there were no significant effects of carbogen breathing on the levels of 5-FU and its metabolites in normal rat tissues, or on the histology of the tissues assessed after treatment.

Dislocation of small bowel volume within box pelvic treatment fields, using new "up down table" device

PURPOSE

To present the impact of a novel minimization device, the up down table (UDT), on the volume of small bowel included within a 4-field pelvic irradiation plan.

METHODS

A polystyrene bowel displacement standard mold was created and added to a customized vacuum cushion (Vac Lok) formed around the abdomen and legs of each patient in the prone position. Two hundred seventy-seven consecutive patients with pelvic malignancies treated with the UDT device were compared with 1 historic series (68 cases) treated at our division. Small bowel contrast dyes at the time of simulation were used in all patients.

RESULTS

The average volume of small bowel within the planning target volume (high-dose volume, calculated with Gallagher method) was 100 cm(3) (median 49 +/- 114) in the series treated with standard box technique and 23 cm(3) (median 0 +/- 64) in the series treated with the UDT (p < 0.001). The average volume of small bowel included in any isodose (any-dose volume) was 505 cm(3) (median 447 +/- 338) and 158 cm(3) (median 69 +/- 207), respectively (p < 0.001). The incidence of G1, G2, and G3 acute enteric toxicity (Radiation Therapy Oncology Group criteria) in the UDT series was 16%, 15%, and 1.5%; in the standard box technique, it was 28%, 25%, and 3%, respectively (p < 0.05). The incidence of acute enteric toxicity directly correlated with the irradiated small bowel volume. In the UDT series, the 5-year actuarial incidence of G3 chronic enteric toxicity was 1.8%. The setup procedures, analyzed in 18 cases, revealed no systematic errors and a standard deviation equal to +/-5 mm for random errors.

CONCLUSIONS

The UDT technique is comfortable, inexpensive, highly reproducible, and permits an almost full bowel displacement from standard radiotherapy fields.

[Morphological aspects of intense preoperative hypoxyradiotherapy in combined treatment of patients with sigmoid colon carcinoma]

Morphological study has confirmed the advantage of using doses of single radiation doses 5 Gy (total dose 25 Gy) and inhalation of a hypoxic gas mixture vs other methods of treatment. The study of radiation pathomorphosis showed significants devitalization of the tumor cells realized clinically with a fall in the number of postoperative recurrences and metastases.

Intraoperative radiation therapy for locally advanced recurrent rectal or rectosigmoid cancer

BACKGROUND AND PURPOSE

To update and summarize the experience at the Massachusetts General Hospital of a treatment program of high-dose preoperative irradiation, surgical re-resection, and intraoperative radiation therapy (IORT) as a salvage treatment for patients with recurrent rectal or rectosigmoid carcinoma.

PATIENTS AND METHODS

From June 1978 to February 1997, the records of 69 patients with locally recurrent rectal carcinomas or rectosigmoid carcinomas without metastases referred for consideration of IORT were reviewed. Forty-nine patients received IORT and local control and disease-free survival curves were calculated using the actuarial method of Kaplan-Meier.

RESULTS

The 5-year overall survival, local control and disease-free survival rates of 49 patients receiving IORT were 27, 35, and 20%, respectively. Thirty-four patients who underwent a macroscopic complete resection had a significantly better 5-year overall survival than the remaining 15 patients with gross residual disease (33 vs. 13%, P=0.05, log rank). For those patients, local control and disease-free survival rates were 46 and 27%, respectively. Patients with a microscopic complete resection had a superior 5-year overall survival than partially resected patients (40 vs. 14%, P=0.0001, log rank). Chemotherapy had no significant influence on overall or disease-free survival.

CONCLUSION

The current analysis shows the importance of a microscopic complete resection in a multi-modality approach with IORT for survival and local control. Salvage is rare for patients undergoing subtotal resection.

Clinical course of solitary extramedullary plasmacytoma

BACKGROUND AND PURPOSE

Solitary extramedullary plasmacytoma (EMP) represents a rare category of malignant disease on which there are limited data in regard to diagnosis, staging and natural history. This study attempted to clarify the clinical course of solitary extramedullary plasmacytoma after radiation or surgical therapy given with curative intent.

MATERIALS AND METHODS

The diagnosis was based on a mass of clonal plasma cells separate from bone or bone marrow without evidence of occult disease elsewhere. Between 1963 and 1996, 22 previously untreated patients with an EMP were diagnosed. Disease presented in the head or neck in 86%, usually in the nasal cavity (NC) or maxillary sinus (MS), and in these areas local bone destruction was found in 10 of 11 patients. Among all patients, serum myeloma protein was present in three patients (14%) and Bence Jones protein alone was found in two patients (9%). Radiation therapy was the sole treatment for 18 of 22 patients, and the median radiotherapy dose was 50 Gy (range, 40-60 Gy); five of seven patients with an EMP of oral cavity (OC), oropharynx (OP), nasopharynx (NP), parotid or larynx also received elective neck irradiation. Two patients underwent surgery plus postoperative irradiation of a plasmacytoma of the sigmoid colon or pleura, and two patients had resection alone of a plasmacytoma of the colon or cervical lymph node.

RESULTS

Local control was achieved in 21 of 22 patients (95%), and disease never recurred in regional nodes. Disappearance of myeloma protein occurred in three of five patients with an evaluable abnormality. Multiple myeloma developed in seven patients (32%), all within 5 years. The 5-year rate of freedom from progression to multiple myeloma was 56% and the median survival was 9.5 years.

CONCLUSION

Radiation therapy achieved excellent locoregional control of EMP with an approximate cure fraction of 50%.

Intraoperative irradiation after surgery for locally recurrent rectal cancer

PURPOSE

This study retrospectively evaluated the effects of intraoperative electron beam irradiation on patients with locally recurrent (pelvic) rectal cancer.

METHODS

From November 1, 1975, to December 31, 1997, 51 patients underwent surgery for locally recurrent rectal or rectosigmoid cancer, and 27 patients received intraoperative electron beam irradiation. The intraoperative electron beam irradiation dose was 15 to 30 Gy. Kaplan-Meier survival estimates at three and five years were analyzed for the 47 patients who recovered postoperatively.

RESULTS

Statistically significant factors related to survival included intraoperative electron beam irradiation vs. no intraoperative electron beam irradiation (P=0.0007), amount of residual tumor (slight vs. gross; P=0.0022), and symptom status (P=0.0024). Factors not associated with survival included distant metastases at reoperation, type of surgery for the recurrent tumor, external beam irradiation, pathologic grade, age, and gender. Surgical resection without intraoperative electron beam irradiation resulted in three-year and five-year survival rates of 5 and 0 percent, respectively. For patients who received intraoperative electron beam irradiation, the three-year survival rate was 43 percent and five-year survival rate was 21 percent. Intraoperative electron beam irradiation was a statistically significant factor related to survival in patients with and without distant metastasis (P=0.04 and P=0.0035, respectively), with slight residual tumor (P=0.0003), or with palliative surgery (P=0.0276).

CONCLUSION

The trends seen in resection with intraoperative electron beam irradiation are encouraging with regard to improvements in survival as compared with studies not using intraoperative electron beam irradiation treatment.

Results of external beam radiotherapy alone for incompletely resected carcinoma of rectosigmoid or rectum: Peter MacCallum Cancer Institute experience 1981-1990

PURPOSE

To study the results of external beam radiotherapy treatment for incompletely resected nonmetastatic rectosigmoid and rectal carcinoma.

METHODS AND MATERIALS

A retrospective review was carried out of all patients (57) presenting to Peter MacCallum Cancer Institute from 1981 to 1990 with incompletely resected nonmetastatic rectosigmoid or rectal cancer who were treated with external beam radiotherapy. Three radiotherapy schedules were used: radical (50 to 60 Gy, 27 patients), high-dose palliative (45 Gy, 25 patients), and low-dose palliative (less than 45 Gy, 5 patients). Symptomatic response, overall survival, and the effect of prognostic factors on treatment outcome were evaluated. The median follow-up period for survivors was 49 months.

RESULTS

Symptomatic response rates were 83% and 79% for the radical and high-dose palliative groups respectively. The estimated median survival time from presentation for all patients was 16.4 months (radical 26.1 months, high-dose palliative 15.7 months). Patients with microscopic residual disease survived significantly longer than patients with macroscopic residual disease (estimated median survival time 30.7 months vs. 14.3 months, p = 0.013).

CONCLUSIONS

No dose response effect was seen between the radical group and high-dose palliative group. Microscopic residual disease at presentation was the only significant predictor of better survival. The conventionally fractionated course of 50 to 60 Gy was not significantly better in terms of palliation and overall survival than a shorter palliative course of 45 Gy. In future, preoperative chemoradiation should improve outcome by reducing the number of patients with incompletely resected cancer.

The impact of 5-fluorouracil and intraoperative electron beam radiation therapy on the outcome of patients with locally advanced primary rectal and rectosigmoid cancer

OBJECTIVE

To analyze the effects of 5-fluorouracil (5-FU) chemotherapy combined with preoperative irradiation and the role of intraoperative electron beam irradiation (IOERT) on the outcome of patients with primary locally advanced rectal or rectosigmoid cancer.

METHODS

From 1978 to 1996, 145 patients with locally advanced rectal cancer underwent moderate- to high-dose preoperative irradiation followed by surgical resection. Ninety-three patients received 5-FU as a bolus for 3 days during the first and last weeks of radiation therapy (84 patients) or as a continuous infusion throughout irradiation (9 patients). At surgery, IOERT was administered to the surgical bed of 73 patients with persistent tumor adherence or residual disease in the pelvis.

RESULTS

No differences in sphincter preservation, pathologic downstaging, or resectability rates were observed by 5-FU use. However, there were statistically significant improvements in 5-year actuarial local control and disease-specific survival in patients receiving 5-FU during irradiation compared with patients undergoing irradiation without 5-FU. For the 73 patients selected to receive IOERT, local control and disease-specific survival correlated with resection extent. For the 45 patients undergoing complete resection and IOERT, the 5-year actuarial local control and disease-specific survival were 89% and 63%, respectively. These figures were 65% and 32%, respectively, for the 28 patients undergoing IOERT for residual disease. The overall 5-year actuarial complication rate was 11%.

CONCLUSIONS

Treatment strategies using 5-FU during irradiation and IOERT for patients with locally advanced rectal cancer are beneficial and well tolerated.

Radiation therapy for rectosigmoid and rectal cancer: results of the 1992-1994 Patterns of Care process survey

PURPOSE

To determine the US national practice standards for patients with adenocarcinoma of the rectum treated in radiation oncology facilities.

MATERIALS AND METHODS

A national survey of 57 institutions identified 507 eligible patients who received radiation therapy as a component of their treatment for rectal cancer. A stratified two-stage cluster sampling with simple random sampling at each stage for each stratum was used and on-site surveys were performed.

RESULTS

Of the 507 patients, 378 (75%) received postoperative therapy, 110 (22%) received preoperative therapy, 17 (2%) received both preoperative and postoperative therapy, and less than 0.5% received intraoperative radiation alone. To more accurately assess the utilization of modern radiation techniques as well as recommendations of the National Cancer Institute (NCI)-sponsored, randomized, postoperative, adjuvant combined modality therapy rectal cancer trials into current practice, the analysis was limited to the 243 (48%) patients with tumor, node, and metastasis staging system classification T3 and/or N1-2M0 disease who underwent conventional surgery with negative margins. Although only 7% were treated on a clinical trial, 90% received chemotherapy for a median of 21 weeks. Most were treated with modern radiation treatment techniques. In contrast, techniques to identify and help exclude the small bowel from the radiation field were not routinely used.

CONCLUSION

Despite the fact that only 7% of patients with T3 and/or N1-2M0 disease were treated on a clinical trial, such trials appear to have resulted in a positive influence on the standard of practice within the oncology community. Although there are still some deficiencies, the majority of these patients received combined modality therapy and were treated with modern radiation therapy techniques.

[Perisacral angiosarcoma after radiotherapy for sigmoid carcinoma]

Secondary malignancy is a well-recognized complication of radiation therapy. The risk of postirradiation sarcoma in long-term follow-up is 0.03-0.8%. We report a case of radiation-induced perisacral angiosarcoma 6 years after pelvic irradiation for sigmoid cancer in a 77-year-old man. The tumor was diagnosed postmortem and was locally advanced and metastatic. He died 6 months after onset of symptoms. This case demonstrates the importance of long-term follow-up in those given radiotherapy.

Radiotherapy treatment for isolated loco-regional recurrence of rectosigmoid cancer following definitive surgery: Peter MacCallum Cancer Institute experience, 1981-1990

PURPOSE

To assess the success of external beam radiation treatment in the management of loco-regional recurrence of rectosigmoid cancer.

METHODS AND MATERIALS

A retrospective analysis of 135 patients with locally recurrent rectosigmoid cancer presenting to Peter MacCallum Cancer Institute between January 1981 and December 1990 was undertaken. Patients were treated with three different dose ranges of radiotherapy: 50-60 Gy ("Radical" group), 45 Gy ("High-dose palliative" group), and <45 Gy ("Low-dose palliative" group). Symptomatic response rates and overall survival for each group were determined.

RESULTS

Symptomatic response rates of 85, 81, and 56% were achieved in the radical, high-dose palliative, and low-dose palliative groups, respectively. Estimated median survival times were 17.9, 14.8, and 9.1 months for the radical, high-dose palliative, and low-dose palliative groups, respectively.

Treatment planning for adenocarcinoma of the rectum and sigmoid: a patterns of care study. PCS Committee

PURPOSE

To conduct a study of the process of treatment planning and treatment of adenocarcinoma of the rectum and sigmoid in the United States, and to compare survey results to consensus guidelines.

METHODS AND MATERIALS

A consensus committee developed guidelines for the radiotherapeutic management of adenocarcinoma of the rectum and sigmoid, and also developed a survey form that was used to gather data to evaluate the practice patterns for patients treated in 1989 and 1990 against the consensus guidelines. Seventy-three facilities were randomly selected for site visits from the 1321 radiation therapy facilities in the US: 21 academic, 26 hospital based, and 26 free standing. During the site visits, the radiotherapy records were examined by the surveyor physicist and radiation oncologist to extract and record the required data. Data collected included items related to treatment specific parameters, including treatment planning considerations. Analyses included stratification as to the types of institutions, academic, hospital based, or free standing.

RESULTS

For many treatment parameters there are discrepancies between the patterns of practice determined by the surveys and the consensus guidelines for radiotherapy treatment of adenocarcinoma of the rectum and sigmoid. Significant differences in practice among the stratified institution types were found in only a few parameters.

Fluorouracil and high-dose leucovorin with radiotherapy as adjuvant therapy for rectal cancer. Results of a phase II study

The purpose of this phase II study was to evaluate the efficacy and toxicity of fluorouracil and high-dose leucovorin (5-FU/LV) with pelvic irradiation as adjuvant therapy for patients with macroscopical resected rectal or recto-sigmoid cancer. Following surgery for stages II-III primary (52) or recurrent rectal cancer (4), 56 patients received 8 cycles of 5-FU/LV and pelvic irradiation. 5-FU doses were 200 mgr/m2 for cycles 2-3 and 300 mgr/m2 for cycles 1 and 4-8. LV doses remained fixed at 200 mgr/m2. Pelvic radiation was started in the third week, between the first and second cycle. The total dose was 50.4 Gy. No severe complications had been recorded. The incidence of grade 3 diarrhea was 19%. Three patients presented leukopenia grade 3 (5%). In 44 patients (78%) the planned treatment could be administered. The median follow-up was 40 months (range 22-66). Seven patients had a local relapse (13%) and 6 developed distant metastasis (10%). The 3-year disease-free survival was 72% and the overall survival was 76%. These preliminary results show that combined post-operative 5-FU/LV and pelvic radiotherapy are well tolerated and present a reasonable local control and survival rates. This adjuvant treatment should be evaluated in randomized trials.

Intraoperative radiation therapy for locally advanced recurrent rectal or rectosigmoid cancer

Recurrent rectal or rectosigmoid cancer is a difficult therapeutic problem. A treatment program of external beam irradiation, surgery, and intraoperative irradiation has been used for 41 patients. The 5-year actuarial local control and disease-free survival of all 41 patients was 30% and 16%, respectively. Subset analysis demonstrated differences in outcome by extent of surgical resection. The 5-year actuarial local control and disease-free survival of 27 patients undergoing complete resection was 47% and 21%, respectively. By contrast, the outcome of 14 patients undergoing partial resection was poor, with a 5-year actuarial local control and survival of 21% and 7%, respectively. Late complications included soft tissue or peripheral nerve injury, with many of these resolving within 4-18 months. Local control and disease-free survival rates are favorable in comparison with the results achieved by aggressive surgery. Patients who achieve a gross total resection at intraoperative irradiation have a markedly better prognosis than that of patients with residual gross disease.

Adjuvant postoperative radiotherapy for adenocarcinoma of the rectum and rectosigmoid. A retrospective analysis of locoregional control, survival, and prognostic factors on 178 patients

Results are presented of a retrospective study on 178 patients receiving adjuvant postoperative radiotherapy after curative surgery for adenocarcinoma of the rectum and rectosigmoid. Tumorstages according to Gunderson-Sosin were B2: 67, B3: 5, C1: 9, C2: 94, and C3: 3. Median total dosage was 50 Gy (range: 10-66 Gy), with a median dose per fraction of 2.0 Gy, 5 fractions per week. The censored overall 5-year survival rate was 42%, and 5-year disease-free survival rate was 37%. The respective rates for stage B2 patients (n = 67) were 59% and 53%, and for stage C2 patients (n = 94), 25% and 25%. Recurrences occurred in 89% within 3 years, 8% in the fourth, and 1% in the fifth year of follow-up. Five-year local relapse rates were 27% for the stage B2 tumors and 40% for the stage C2 tumors. For survival, stage (P = .006), grade (P = .02), fixation at surgery (P = .03), and gender (P = .03) were independent prognostic factors. With local relapse-free probability (LRFP) as endpoint, grade (P < .02) was an independent prognostic factor. Dose of radiation was not of prognostic significance, neither for survival (P = .63) nor for LRFP (P = .61). Since improvement should be made in locoregional control, initiatives are taken to start preoperative radiotherapy; furthermore, the key role of surgery is emphasized.

[Ileal obstruction following radiosurgical treatment for rectosigmoid neoplasm]

A series of 191 patients submitted to adjuvant radiotherapy after surgery for rectal and rectosigmoid carcinoma from January, 1975, to December, 1990, has been analyzed to evaluate the incidence of high grade small bowel late toxicity (grades III/IV according to RTOG/EORTC scoring system). Surgical approach was abdominoperineal Miles resection in 92 patients, while a sphincter preserving bowel resection was performed in 99. The total radiation dose to the pelvis ranged from 40 to 60 Gy in 4 to 8 weeks, with conventional fractionation. Three different beams arrangements were used: two sagittal parallel opposite AP-PA fields in 106 patients, three fields (one posterior sagittal plus two parallel lateral fields) in 56, four fields (box technique) in 29. Fourteen patients (7.3%) developed sequelae grades III/IV: three of them died of toxicity. Average free interval between radiation and complication was 23 months (range: 4-87). The following risk factors were investigated: sex, age, type of surgery on primary rectosigmoid cancer, previous abdominal or pelvic surgery, radiation technique, treated volume, administered radiation dose. Dose was calculated as BED (time corrected biologically equivalent dose) according to the linear quadratic model. The only factors significantly related to late intestinal complications were the beam arrangement and, consequently, the treated volume. Detailed analysis showed that radiation sequelae developed in 12/106 (11.3%) patients treated with the two sagittal fields technique, while small bowel toxicity was observed in only 2/85 (2.3%) patients treated with the three--or four--fields technique. The difference is stastically significant (p < 0.05). Another significant correlation was the ratio between treated volume and late complications incidence observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation and treatment of patients receiving radiation for cancer of the rectum or sigmoid colon in the United States: results of the 1988-1989 Patterns of Care Study process survey

PURPOSE

For the first time, a Patterns of Care Study (PCS) was conducted in 1989 to determine the national practice standards of radiation oncologists in evaluating and treating adenocarcinoma of the rectum and sigmoid colon.

MATERIALS AND METHODS

A national survey of 73 institutions using two-stage cluster sampling was conducted, and specific information on 408 patients from 69 facilities with adenocarcinoma of the rectum and sigmoid colon who received radiation as part of definitive or adjuvant management was collected.

RESULTS

Using the modified Astler-Coller (MAC) pathologic staging system, the stage distribution was as follows: A, 0.5%; B1, 4.4%; B2, 23.5%; B3, 5.1%; C1, 8.9%; C2, 30.2%; and C3, 6.6%. Preoperative radiation was used in 29% of patients, but the total dose was greater than 40 Gy in only 20%. Seventy-three percent of patients received postoperative radiation, with approximately 4% receiving combined preoperative and postoperative radiation. Chemotherapy was administered to 44% of patients overall, representing 55% of patients with disease through the bowel wall and/or involving lymph nodes. Only 37% of all patients received chemotherapy concurrent with radiation. An abdominoperineal resection was used in 43%; a low anterior resection was used in 43% as well, while 5% underwent other types of bowel resection. Approximately 8% of patients were treated with a local curative procedure less than bowel resection (eg, local excision, endoscopic resection, fulguration, or contact radiation). At least one third of patients had interruption in their pelvic irradiation of greater than 3 days. There was no statistically significant difference in the frequency of treatment interruptions by dose per fraction or whether chemotherapy was given concurrent with radiation. There was no significant difference in total dose delivered to patients staged B2 and higher treated without chemotherapy compared with concurrent chemotherapy and radiation. Also, there was no significant difference in total dose delivered to patients with B1 and B2, or C1 and C2 versus B3 or C3 cancer.

CONCLUSION

This study was conducted on patients treated just before the 1990 National Institutes of Health consensus guidelines issued on the management of colon and rectal cancer. This study indicates that the minority of patients treated with radiation in 1988 and 1989 received concurrent chemoradiation, as currently recommended. Additionally, insofar as present studies are investigating important issues such as the use of sphincter-sparing procedures, preoperative radiation and chemotherapy, and the importance of radiation dose and scheduling with chemotherapy, the information provided by this study will serve as a useful baseline to track future changes in rectal cancer evaluation and management.

Late complications of postoperative radiation therapy for cancer of the rectum and rectosigmoid

PURPOSE

We retrospectively examined the surgical, medical, radiotherapeutic and technical factors associated with late small bowel and nonsmall bowel morbidity.

METHODS AND MATERIALS

The medical records of 224 patients with cancer of the rectum and rectosigmoid treated mainly with abdominoperineal resection or anterior resection and postoperative radiotherapy at the University of Texas M.D. Anderson Cancer Center from 1973 to 1990 were reviewed. The median dose was 54 Gy (range 34-66 Gy) at 1.8-2 Gy per fraction using various techniques (23 had extended fields to L1 or L2; pelvic fields were treated with anterior-posterior in 85, 83 had a 3-field plan and 33 had a 4-field "box"). A positioning technique that treats patients on an open table-top device was used in 78 patients to move the small intestine out of the pelvis. Bladder distension was used in eight. Forty-seven patients received concomitant 5-fluorouracil. Small bowel series were performed in 122 patients to assess the volume of small bowel inside the pelvis below the conjugate line.

RESULTS

In 29 patients, the median time to the development of small bowel obstruction was 7 months (range 0-69 months); 18 patients required reoperations. The small bowel obstruction rate was 30% in patients treated with daily extended field radiotherapy, 21% in those with a single pelvic field and 9% with multiple pelvic fields. Small bowel obstruction was positively correlated with postsurgical adhesions prior to radiotherapy and absence of reperitonealization at the time of initial surgery (p < 0.05). There was no correlation of small bowel obstruction with a history of hypertension, diabetes, prior surgery, history of abdominal infections, postoperative infections, wound healing, pathologic tumor stage, types of surgical procedures, sites of primary tumor, age, or sex. Patients developing small bowel obstruction had larger amounts of small bowel assessed radiologically below the conjugate line than those without complications. With the open table-top device, the small bowel obstruction rate was 3%. In 47 patients treated with radiation and chemotherapy on the open table-top device, the small bowel obstruction rate was 15%, but these patients had more small bowel inside the pelvis than those without the complication. The median time to the development of nonsmall bowel obstruction in 29 patients was 8 months (range 0-85 months), and the nonsmall bowel obstruction complications were significantly correlated with postoperative infection. Most nonsmall bowel obstruction complications were in the genitourinary tract and occurred in patients who had abdominoperineal resection.

CONCLUSION

The open table-top device, by moving the small bowel out of the treatment field, reduces small bowel obstruction in patients treated with radical surgery and postoperative radiotherapy for cancer of the rectum and rectosigmoid. This technique is facile, reproducible, and does not require patient compliance.

[Reoperations of rectal resection for recurrence after previous resection for rectosigmoid cancer]

From June 1986 to December 1992, 16 patients (12 men and 4 women, 63 years-old [36 to 79]) who underwent a prior sphincter-saving resection for colorectal adenocarcinoma were operated on for locoregional recurrence with a surgical resection. Eight patients had a second anterior resection (5 colorectal, 2 coloanal and 1 ileoanal anastomosis), one a resection without anastomosis, and 7 an abdomino-perineal resection. Nine patients received an intraoperative irradiation (10 to 25 Gy). Excisions of surrounding organs were often necessary. Post-operative complications occurred in most of the patients. Excluding 3 post-operative deaths, 9 patients died of disease in a median of 12.9 months after surgery (range: 3 to 32 months). Four patients are still living 5 to 14 months after the second resection. There is little in the surgical literature dealing with these difficult surgical problem of which results are always uncertain. An earlier diagnosis of the recurrence would result in a more satisfactory procedure, but is difficult because of the limited possibilities of detection after surgical treatment and often external irradiation.

Preoperative irradiation and fluorouracil chemotherapy for locally advanced rectosigmoid carcinoma: phase I-II study

From June 1988 to July 1991, 20 patients with locally advanced rectal or rectosigmoid cancer were treated prospectively with a strategy of combining preoperative irradiation and fluorouracil chemotherapy before surgical resection. The preoperative radiation dose was 5,000 cGy, and fluorouracil chemotherapy was administered on the first and last 3 days of irradiation in an intravenous bolus dose of 500 mg/m2. In a median follow-up of 25 months, the local regional failure rate was 10%. The 3-year actuarial overall survival and disease-free survival were 92% and 82%, respectively. Twenty percent of the surgical specimens showed no residual tumor, and only 10% showed positive lymph nodes. Significant leukopenia occurred in 10% of patients. Preoperative irradiation and fluorouracil chemotherapy increased surgical downstaging and improved local regional control. The overall toxicity was acceptable. The results of this particular multimodality approach was encouraging and warrant further investigation in phase III trials.

The efficacy of preoperative 5-fluorouracil, high-dose leucovorin, and sequential radiation therapy for unresectable rectal cancer

BACKGROUND

The encouraging results seen in patients who received postoperative combined modality therapy in the adjuvant setting have prompted increased interest in preoperative combined modality therapy for patients with unresectable rectal cancer. The authors report the local control and survival of a previously reported Phase I dose escalation trial of combined preoperative 5-fluorouracil (5-FU), high-dose leucovorin (LV), and sequential radiation therapy followed by postoperative LV-5 FU for the treatment of patients with unresectable rectal cancer.

METHODS

Twenty patients (13, primary and 7, recurrent disease) received LV-5-FU for one cycle. Radiation therapy (5040 cGy) began on day 8. A second cycle of LV-5-FU was given concurrently with week 4 of radiation. Six patients received intraoperative brachytherapy. Postoperatively, the patients received LV-5-FU. The pathologic complete response rate was 20%, and 89% underwent a complete resection with negative margins.

RESULTS

The crude local failure rate was 26%, and the 3-year actuarial local failure rate was 29% (95% confidence interval [CI], +/- 8.94%). The crude abdominal and distant failure rates were 40% and 30%, respectively. The 3-year actuarial disease-free survival was 64% (95% CI, +/- 6.75%), and the overall survival was 69% (95% CI, +/- 7.65%).

CONCLUSIONS

These preliminary data revealed encouraging local control and survival rates. Preoperative combined modality therapy is an attractive approach in patients with unresectable rectal cancer.

A phase I/II study of intraoperative radiotherapy in advanced unresectable or recurrent carcinoma of the rectum: a Radiation Therapy Oncology Group (RTOG) study

The Radiation Therapy Oncology Group (RTOG) initiated a phase I/II study of intraoperative radiotherapy (IORT) in advanced or recurrent rectal cancer to assess therapeutic efficacy, toxicity, and establish quality control guidelines prior to beginning a phase III trial. From October 1985 through December 1989, 87 patients with histologically proven adenocarcinoma of the rectum or rectosigmoid with recurrent/persistent disease after surgery or those primarily inoperable were entered by 14 institutions. Of 86 evaluable patients, 42 patients received IORT either alone (n = 15) or in combination with external beam (n = 27). Local control was dependent on the amount of residual disease prior to IORT, with 2-year actuarial local control of 77% if no gross residual disease remained vs. 10% with gross residual disease (P = 0.001). For the recurrent/residual group (n = 33), this observation was also significant with a 2-year actuarial local control rate of 64% if no gross residual remained vs. 10% with gross residual disease (P = 0.004). Local control translated into an improved survival for all patients and the recurrent/residual group with 2-year actuarial survival of 88% and 89% if no gross residual disease remained vs. 48% and 45% with gross residual disease, respectively (P = .0005, 0.006). Six patients (14.6%) experienced four grade 3 and three grade 4 complications as a possible result of IORT during follow-up with a 2-year actuarial risk of major complications of 16%. We conclude that IORT is feasible within a cooperative group and can be performed with acceptable complication rates. A phase III trial to demonstrate a therapeutic advantage for IORT over external beam alone is currently in progress.

Postoperative radiotherapy for rectal and rectosigmoid cancer: the impact of total dose on local control

Between 1984 and 1988, 206 patients were treated with pelvic radiotherapy after macroscopically complete surgery for rectal or (recto)sigmoid cancer. Depending on an estimation of the amount of small bowel in the intended treatment volume a total dose was, in general, 45 or 50 Gy. An additional boost of 10 Gy was given to 6 patients because of microscopically involved surgical margins. For tumor stage B a statistically significant trend (p = 0.017) for higher local control with higher total dose was observed comparing patients treated with a total dose of 45 Gy or less, with more than 45 Gy but less than 50 Gy or with a total dose of 50 Gy or more. This finding illustrates the impact of total dose on local control for postoperative radiotherapy for rectal carcinoma.

Hypogastric arterial-vaginal fistula following multiple surgeries and pelvic radiotherapy

A patient with recurrent sigmoid colon cancer developed an arterial-vaginal fistula after multiple surgeries and postoperative radiotherapy. Angiography revealed a fistula between the hypogastric artery and vaginal wall. Gelfoam and coil embolization controlled the hemorrhage and she recovered without incident. This case illustrates development of malignant fistula and intervention with embolization in a patient with multiple surgeries and postoperative irradiation in the pelvis.

[Thermoradiotherapy for adenocarcinoma of the rectum and sigmoid--application to primarily inoperable and recurrent cases]

Between February 1983 and May 1990, 19 rectal cancers and three sigmoid colon cancers were treated with thermoradiotherapy. Among four patients with primary rectal cancer, one received preoperative treatment and three were judged inoperable. All the inoperable patients responded well to treatment and were judged operable. Pathological examination of the resected specimens confirmed the effectiveness of treatment. In one case in particular, no cancer cells were observed in the specimen or at autopsy, 21 months after thermoradiotherapy. Eighteen cases of recurrent colorectal cancer were also treated. Judged by tumor shrinkage alone, these patients were classified into five cases of PR and 13 of NR. When the low density area seen on CT images after treatment was added to the criteria, there was one case of CR, six of PR, and 11 of NR, and the effectiveness ratio shown by the sum of CR and PR was 38.9%. Fourteen cases in the thermoradiotherapy group and 16 in the radiation therapy group were compared as to the reduction in postoperative perineal pain caused by recurrence at the pre-sacral area. It was found that thermoradiotherapy was significantly superior to radiation therapy in the frequency and duration of pain relief. Although most patients complained of the sensation of heat, this was within tolerable limits, and no severe side effects were experienced.

The double-staple technique in colorectal anastomoses: a critical review

The widespread availability and use of stapling devices have changed colorectal surgery. In 1980, Knight and Griffen developed the "double-staple" technique, using a circular stapler to transect a linear rectal staple line. This eliminated the need for a hand-sewn, distal purse string, which was sometimes difficult or even impossible to accurately place low in the pelvis. To evaluate this procedure, the authors have reviewed their results with the double-staple technique over the past 5 years. One hundred four patients underwent this procedure between 1985 and 1990 at Thomas Jefferson University Hospital (Philadelphia, PA). There were 60 men and 44 women, with a mean age of 62.4 years. Seventy-two patients underwent operation for carcinoma of the rectum or sigmoid. Thirty-five of these had preoperative radiation therapy. Other diagnoses included 1) diverticular disease, 2) rectal prolapse, 3) villous adenoma, 4) endometrial carcinoma, 5) fistula, 6) stricture, 7) Crohn's disease, 8) colonic endometriosis, 9) lymphoma, 10) ovarian carcinoma, and 11) ulcerative colitis. Incomplete "donuts" were observed in 5 patients. Diverting colostomies were performed in 23 patients, ileostomies in 3. Postoperative complications relating to the double-staple technique itself included a rectovaginal fistula in 1 patient. There were 3 clinical leaks (2.8%), all treated nonoperatively. No strictures were observed. As previously observed, the authors believe the double-staple technique offers certain advantages over traditional, hand-sewn and stapled anastomoses, for instance: 1) there is significantly less contamination, 2) the anastomosis is technically easier, and 3) bowel segments of different diameters can be easily anastomosed.

[Salvage radiotherapy in postoperative recurrences of rectal and rectosigmoid carcinomas]

One hundred and twenty-five patients, previously operated for rectal or rectosigmoid cancer, have been submitted to external radiation therapy from 1964 to 1985 on pelvic and/or perineal recurrence (50 perineal, 66 pelvic, 9 both). Fifty-seven per cent received more than 50 Gy, but only 14% more than 60 Gy. Overall survival has been poor (66% at 1 year, 20% at 3 years, 15% at 5 years) whereas better results have been achieved for pain relief: complete remission in 49% and partial remission in 26% of 77 symptomatic patients. Among 94 patients, evaluable for tumor size before and after treatment, radiation significantly decreased the size of the recurrence in 63% (27% CR). Among prognostic factors (recurrence site, radiation dose, age, pain relief and disease-free interval since surgery) only perineal recurrence without pelvic involvement, if treated with high doses (greater than 50 Gy), seems to be related to a significantly improved prognosis.