Adenocarcinoma of the Body and Tail of the Pancreas: Is There Room for Adjuvant Radiotherapy?

Aims and background

Adenocarcinoma of the body and tail of the pancreas is a rare malignancy with a poor prognosis. Few long-term survivors have been reported in the literature. The role of adjuvant treatment after curative resection has not yet been assessed. This retrospective study aims to describe the patterns of failure and the survival of 10 patients treated with resection and adjuvant radiotherapy.

Materials and methods

from 1982 to June 1994, 10 patients with adenocarcinoma of the body and tail of the pancreas received adjuvant radiotherapy in our department. There were 4 females and 6 males, with a median age of 63 years (range, 45–77). The pT distribution was 2 pT1, 4 pT2, 4 pT3 and for pN it was 7 pN0 and 3 pN1. Four patients had stage I, 3 stage II and 3 stage III disease. All the patients underwent a resection: distal pancreatectomy in 7, partial resection of the body in 1, and total pancreatectomy in 2. Gross residual disease was present in 2 cases. Three patients received intraoperative radiotherapy up to a dose of 12–15 Gy. Postoperative radiotherapy was given in 9 patients with a dose ranging from 40 to 50 Gy (median, 45). One patient who received intraoperative radiotherapy had no postoperative radiotherapy. In 4 patients, chemotherapy with 5-fluorouracil was given during the first week of irradiation.

Results

Six patients experienced a local-regional relapse and 3 developed metastases. The median survival was 21 months. The 5-year overall survival was 15%. Eight patients died of progressive disease. One patient who presented with stage I disease was alive and free of disease at 24 months from diagnosis and, interestingly, one with stage III disease was alive at 111 months. No severe treatment-related complications were observed.

Conclusions

As in carcinoma of the head of the pancreas, adjuvant radiotherapy should be considered as an adjuvant treatment of resected adenocarcinoma of the body and tail of the pancreas. Further evaluation is necessary to assess the role of intraoperative radiotherapy.

[Adjuvant contact radiotherapy for conjunctival malignancies: Preliminary results of a series of 14 patients treated with the Papillon 50 machine]

PURPOSE

To evaluate the results of an adjuvant contact irradiation using 50kV photons after resection of conjunctival malignancies.

MATERIALS AND METHOD

From 2012 to 2014, 14 patients (male: nine; female: five) have been treated by contact irradiation after resection of a malignant tumor of the conjunctiva (melanoma: five patients; malignant fibrous histiocytoma: one patient; carcinoma: eight patients) The treatment was performed using the Papillon 50 machine (Ariane). Three to four sessions were delivered, each giving a dose of 10Gy. The median follow-up in survivors was 33 months.

RESULTS

The tolerance was good. A cataract was seen in one patient, and a moderate eye dryness in one. There was no corneal ulcer. One patient died of intercurrent disease. One patient with carcinoma recurred locally.

CONCLUSION

Adjuvant contact radiotherapy provides a good local control after resection of conjunctival malignancies (melanoma, malignant histiocytofibroma, carcinoma). Thanks to its precision, this technique is well tolerated with a low rate of complications. Furthermore, it is delivered on an ambulatory basis.

Planned organ preservation for selected T2-3 rectal cancer: French experience using chemoradiotherapy and contact xray boost

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Background: The Lyon R96-02 randomized trial has demonstrated in T2-3 rectal cancer that external beam radiotherapy (EBRT) with Contact X Ray brachytherapy (CXB) boost was increasing clinical complete response, sphincter preservation and in early cases organ preservation. We report French experience in 3 radiotherapy departments using CXB boost with chemoradiotherapy (CRT) in early T2T3N0. Methods: Selection based on digital rectal examination, colonoscopy, MRI (and/or Endorectal-ultrasound). Inclusion : adenocarcinoma (distal, middle rectum), T2 T3a-b, tumor diameter ≤ 4cm, N0, M0. Treatment : CXB (80-110 Gy/3-4 fr) followed by CRT (CAP 50). Tumor response assess on week 14 : DRE, rigid rectoscopy and MRI. Clinical complete response (cCR) defined as no visible tumor, supple rectal wall and TRG 1-2 on MRI. In case of cCR a close surveillance or local excision was proposed. Results: Between 2002 -2016, 84 patients treated. Median age: 75 years, Male: 59, Female: 25. Operable patients: 69 (83%). T2 : 52, T3 : 32 (Lyon Villeurbanne : 16, Macon : 11, Nice : 57). Median follow-up time : 53 months. cCR was achieved in 94% of cases. Local excision performed in 17 patients (ypT0 : 16). At 4 years, the cancer specific survival was 82% [CI:96-70] and the local relapse rate 12% [CI: 2-22]. No isolated perirectal lymph node relapse observed. After 4 years, 3 more local relapses observed (4, 6, 7 years). Main late toxicity ( > 6 months after treatment) was rectal bleeding (radiation telangiectasia) which required plasma argon coagulation in 5 patients. No TME surgery was performed and organ preservation was achieved in all cases. Bowel function was good in 85% of patients (LARS score < 20). Conclusions: When combining CXB with CRT, rectal cancer T2T3a-b N0 ≤4cm achieve a high rate of cCR (≥85%) with organ preservation, good bowel function, low rate of local relapse ( < 15%) and low toxicity. As rectal adenocarcinoma is radioresistant, the treatment must use a CXB boost. Like anal squamous cell cancer, planned organ preservation can be proposed to operable patients. The ongoing European OPERA trial aims at bringing evidence to this option.

Improved sphincter preservation in low rectal cancer with high-dose preoperative radiotherapy: the lyon R96-02 randomized trial

PURPOSE

The potential advantage of high-dose preoperative radiotherapy to increase tumor response and improve the chance of sphincter preservation for low rectal cancer remains controversial. The aim of this trial was to evaluate the role of escalating the dose of preoperative radiation to increase sphincter-saving procedures.

PATIENTS AND METHODS

Patients with rectal carcinoma located in the lower rectum, staged T2 or T3, Nx, or M0 with endorectal sonography, and not involving more than two-thirds circumference, were randomly assigned to one of two groups: preoperative external-beam radiotherapy (EBRT; 39 Gy in 13 fractions over 17 days) versus the same EBRT with boost (85 Gy in three fractions) using endocavitary contact x-ray.

RESULTS

Between 1996 and 2001, 88 patients were enrolled onto the study. A significant improvement was seen in favor of the contact x-ray boost for complete clinical response (24% v 2%) and for a complete or near-complete sterilization of the operative specimen (57% v 34%). A significant increase in sphincter preservation was observed in the boost group (76% v 44%; P =.004). At a median follow-up of 35 months, there was no difference in morbidity, local relapse, and 2-year overall survival.

CONCLUSION

A dose escalation with endocavitary irradiation provides increased tumor response and sphincter preservation with no detrimental effect on treatment toxicity and early clinical outcome.

[Brachytherapy in carcinomas of anal canal and rectum: techniques and results]

Conservative treatment of small anal canal and low rectal cancers is a valid alternative to radical surgery through combinated strategies including external beam and/or intracavitary irradiation, concomitant chemotherapy and 192 iridium implantation as a booster dose. Feasibility, tolerance and results are effective. Local control of the disease and the quality of the anal functions are good. The treatment requires great care in patient selection and follow-up.

[Cancer of the rectum: complete resection of the mesorectum with or without preoperative radiotherapy]

We report and discuss the results of a randomized trial evaluating the effect of preoperative radiotherapy as an adjunct to total mesorectal excision for rectal cancers. This Dutch trial showed that the radiotherapy does decrease the local recurrence rate even after an optimal surgery.

[Radiotherapy for age-related macular degeneration: risk factors of complications, prevention and treatment of side-effects]

PURPOSE

To analyze the retinal and choroidal side-effects of radiotherapy given for age-related macular degeneration (ARMD) and to describe the risk factors of these complications and their treatment.

MATERIAL

and methods: Two hundred and ninety five eyes in 270 patients with ARMD were treated using radiotherapy. Nineteen patients had diabetes. The doses were as follows: 15 Gy or less (4 eyes); 16 Gy/4 fractions (113 eyes); 18 Gy/5 fractions (35 eyes); 20 Gy/5 fractions (123 eyes); 24 Gy/6 fractions (2 eyes); 28.8 Gy/8 fractions (17 eyes); more than 28.8 Gy (1 eye). Patients had a regular follow-up visit with visual acuity, contrast sensitivity evaluation, biomicroscopic fundus examination, fluorescein and ICG angiographies every six months over a mean period of 15 months.

RESULTS

Radiation retinopathy was noted in 15 eyes, a bilateral neovascular glaucoma in one patient, ischemic optic neuropathy in 5 eyes, choroidal telangiectasiae in 19 eyes, venous occlusion in 2 eyes, oedematous retinopathy with major exudation (ORME) in 31 eyes, and choroidal hematoma in 8 eyes. Radiation retinopathy, choroidal telangiectasiae and ORME were related to radiation dose. Radiation retinopathy was more severe and more frequent in patients with diabetes. Choroidal telangiectasiae were diagnosed with ICG angiography and were treated early with laser.

CONCLUSION

Radiotherapy for ARMD should not be done in patients with diabetes. Hypofractionation is not recommended. ICG angiography should be considered essential in the follow-up of patients treated with radiotherapy.

[Therapeutic strategy in stage I seminomas: which lymph node areas are to be irradiated?]

OBJECTIVES

Our aims were to describe the results of adjuvant irradiation given to the paraaortic lymph nodes without pelvic irradiation in patients treated for stage 1 seminoma.

MATERIALS AND METHODS

From 1990 to 1997, thirteen patients with stage I testis seminoma have been treated with external beam irradiation to the paraaortic lymph nodes (volume treated: from D10-D11 to L5-S1). The stage was: pT1 in 10 patients, pT2 in 2, pT3 in 1. Median follow-up was 35 months (range: 13-90).

RESULTS

Twelve of 13 patients are alive without recurrence. One patient with previous orchidopexy treated for seminoma of the right testis relapsed to the external iliac lymph area. No grade 3-4 adverse event of radiation in the SOMA LENT scale were observed.

CONCLUSION

Despite the short number of patients in this series, these results had an impact on our routine practice. External beam irradiation given to the paraaortic lymph nodes is considered the standard adjuvant procedure in our institution.

[Late effects of radiotherapy on the skeletal muscle]

There are few data regarding the adverse effects of radiotherapy on skeletal muscle. This tissue is considered to be radioresistant. Muscle toxicity of radiation is unfrequent and does not represent a limiting factor for dose escalation.

[Late effects of ionizing radiations on the bone marrow]

Bone marrow is a tissue with a high mitotic activity, and consequently exquisitely radiosensitive. The clinical effects of bone marrow irradiation and its ability of regeneration are related to the volume irradiated. Management of hematopoietic side effects of radiation include surveillance, antibiotics, blood products transfusion, and more scarcely hematopoietic growth factors, bone marrow transplantation and peripheral blood stem cells reinfusion.

Role of radiation therapy in the treatment of primary tracheal carcinoma

PURPOSE

The objective of this work is to investigate the role of radiation therapy in the treatment of primary tracheal carcinoma.

METHODS AND MATERIALS

From 1963 to 1993, 106 patients presenting with a tracheal carcinoma received a radiation course as part of their treatment in three institutions. Eighty-four patients were treated with megavoltage radiation only, receiving doses ranging from 30 to 70 Gy, with a median dose of 56 Gy. Five patients received high-dose-rate (HDR) brachytherapy, five patients underwent a surgical procedure, and eight received chemotherapy.

RESULTS

With a mean follow-up of 141 months, the overall 1-, 2-, and 5-year survival rates are 46%, 21%, and 8%, respectively. Prognostic factors included tumor size (less than 3 cm), performance status, and total radiation dose: the 5-year survival rate dropped from 12% for patients receiving doses greater than 56 Gy to 5% for lower doses. Performance status and radiation doses are the only independent significant factors in multivariate analysis; these results must however be analyzed with precaution in this retrospective study.

CONCLUSIONS

Radiation is a good alternative to surgery for primary tracheal cancer. A review of the literature and our current results allow us to recommend a radiation dose greater than 60 Gy for primary irradiation. Collaborative studies are warranted to (1) determine the optimal radiation dose for definitive irradiation, (2) define the potential role of radiation after complete and partial surgery, (3) determine the role and optimal treatment scheme for HDR brachytherapy, (4) describe and record the late effects, (5) establish the potential benefit of chemoradiation.

Treatment of anal canal carcinoma with high dose radiation therapy and concomitant fluorouracil-cisplatinum. Long-term results in 95 patients

PURPOSE

To evaluate the long-term results of the treatment of anal canal carcinoma (ACC) with a combined concomitant radiochemotherapy (CCRT) treatment using fluorouracil (5 FU) and cisplatinum (CDDP) with a high dose of radiation therapy.

PATIENTS AND METHODS

Between 1982 and 1993 a series of 95 patients were treated. Staging showed a majority of advanced squamous ACC, i.e. 6 T1, 47 T2, 28 T3, 14 T4, 53 NO, 32 N1, 6 N2 and 4 N3. Irradiation was done with high dose external beam radiation therapy (EBRT) followed by a boost with 192 Iridium implant. During EBRT all patients received one course of 5 FU continuous infusion (1 g/m2/day, days 1-4) and CDDP (25 mg/m2/day, bolus days 1-4).

RESULTS

The median follow-up time was 64 months. At 5 and 8 years the overall survival was 84 and 77%, the cancer specific survival was 90 and 86% and the colostomy-free survival was 71 and 67%, respectively. The stage and the response of the tumor after EBRT were of prognostic significance. Patients with pararectal lymph nodes had an overall 5-year survival of 76% (versus 88% for non-N1). Among 78 patients who preserved their anus, the anal sphincter function was excellent or good in 72 (92%).

CONCLUSION

According to these results and recent randomized trials, CCRT appears as the standard treatment of ACC. Radical surgery should be reserved for local recurrence or persisting disease after irradiation. High dose irradiation in a small volume with concomitant 5 FU-CDDP appears to give a high rate of long-term local control and survival. Careful evaluation of pararectal nodes is essential for a good staging of the disease.

Outcome of treatment of upper third vaginal recurrences of cervical and endometrial carcinomas with interstitial brachytherapy

PURPOSE

To describe an original brachytherapy technique using a dedicated intravaginal template for the treatment of vaginal vault recurrences and to evaluate the results of such a treatment.

METHODS AND MATERIALS

Between 1978 and 1993, 78 patients with isolated recurrence of cervical or endometrial carcinoma located in the vaginal vault have been treated in Lyon. Initial treatment was surgery alone in 49 cases and irradiation with surgery in 37 cases. Treatment of the vaginal recurrence was performed with interstitial Iridium 192 brachytherapy combined with pelvic external beam radiation therapy in 34 patients. The tumor was implanted with a dedicated intravaginal plastic template. Six parallel metallic needles were implanted in the vaginal vault and afterloaded with Iridium 192 wires of 4 to 6 cm long. The mucosa of the upper half of the vagina received the same dose as the one encompassing the tumor on the 85% isodose of the Paris system.

RESULTS

At 5 years the local control rate was 70% and the overall survival rate 56%. Grade 3 complications occurred in 10% of the cases and only in patients who had received irradiation during the initial treatment of the primary tumor.

CONCLUSIONS

This brachytherapy technique makes it possible to perform Iridium 192 implants in a difficult situation with a favorable long-term control rate and an acceptable rate of complications.

Intraoperative radiation therapy combined with limited lymph node resection in gastric cancer: an alternative to extended dissection?

PURPOSE

To describe the results of a series of 63 Western patients presenting with gastric adenocarcinoma and treated with surgery and intraoperative radiation therapy (IORT) over a 8-year period and to discuss the role of IORT when combined with limited lymph node dissection.

METHODS AND MATERIALS

From 1986 to 1993, 63 patients with gastric adenocarcinoma have been operated in the department of radiation oncology of the Hospices Civils de Lyon. The stage was: I in 17, II in 11, IIIA in 9, IIIB in 20, and IV in 6. The lymph node dissection was considered to be limited in 56 patients and extended in 7. The IORT dose ranged from 12 to 23 Gy (median: 15). Thirty patients also underwent a postoperative external beam irradiation with a standard dose of 44-46 Gy.

RESULTS

The postoperative mortality rate was 4.8%. The 5-year overall survival in the entire series was 47% and was 82, 55, 78, 20, and 0% in Stages I, II, IIIA, IIIB, and IV, respectively. Loco-regional relapse occurred in 15 of 63 patients and metastases in 15 of 63.

CONCLUSION

In Western patients treated by gastrectomy for adenocarcinoma of the stomach, IORT combined with limited lymph node dissection may provide overall survival similar to that observed after gastrectomy with extended lymph node dissection but with less postoperative mortality.

Intraoperative radiotherapy in resected pancreatic cancer: feasibility and results

BACKGROUND AND PURPOSE

To evaluate the impact of intraoperative radiotherapy (IORT) combined with postoperative external beam irradiation in patients with pancreatic cancer treated with curative surgical resection.

MATERIALS AND METHODS

From January 1986 to April 1995 25 patients (11 male and 14 female, median age 61 years) underwent a curative resection with IORT for pancreatic adenocarcinoma. The tumour was located in the head of the pancreatic gland in 22 patients, in the body in two patients and in the tail in one patient. The pathological stage was pT1 in nine patients, pT2 in nine patients, pT3 in seven patients, pN0 in 14 patients and pN1 in 11 patients. All the patients were pM0. A pancreaticoduodenectomy was performed in 22 patients, a distal pancreatectomy was performed in two patients and a total pancreatectomy was performed in one patient. The resection was considered to be complete in 20 patients. One patient had microscopic residual disease and gross residual disease was present in four patients. IORT using electrons with a median energy of 12 MeV was performed in all the patients with doses ranging from 12 to 25 Gy. Postoperative EBRT was delivered to 20 patients (median dose 44 Gy). Concurrent chemotherapy with 5-fluorouracil was given to seven patients.

RESULTS

The overall survival was 56% at 1 year, 20% at 2 years and 10% at 5 years. Nine local failures were observed. Twelve patients developed metastases without local recurrence. Twenty patients died from tumour progression and two patients died from early postoperative complications. Three patients are still alive; two patients in complete response at 17 and 94 months and one patient with hepatic metastases at 13 months.

CONCLUSION

IORT after complete resection combined with postoperative external beam irradiation is feasible and well tolerated in patients with pancreatic adenocarcinoma.

[Stereotaxic radiotherapy: status in France in January 1997]

Stereotactic radiosurgery has been used in France since 1986 in the treatment of arteriovenous malformations and brain neoplasms, and has been performed in 23 public and private centres. We briefly describe the techniques used in these centres and review the results of French teams, which are comparable to those reported in the world literature.

[Uterine sarcoma treated by surgery and postoperative radiation therapy. Patterns of relapse, prognostic factors and role of radiation therapy]

The objective was to evaluate the results of a combination of surgery and postoperative radiotherapy in patients with uterine sarcoma, to describe the patterns of relapse and to define prognostic factors. From 1980 to 1993, 29 patients (median age: 56 years) presenting with uterine sarcoma have been treated with surgery and postoperative irradiation. The histology was: leiomyosarcoma: 11; carcinosarcoma: 12; stromal sarcoma: 6. The distribution by stage was: pT1: 18; pT2: 5; pT3: 3; pT4: 3; pNO: 27; pN1: 2. Gross residual disease was present in 4 patients. External beam irradiation was performed in all the cases and brachytherapy in 19. Chemotherapy was given in 3 patients. The overall survival rate was 66% at 2 years and 57% at 5 years with a disease free survival of 54% at 2 years and 50% at 5 years. Seven patients relapsed locally and 8 developed metastases. One patient died of ileitis. In a multivariate analysis, the disease free survival was strongly influenced by the menopausal status. The survival in this study is higher than that described in series of patients treated with surgery alone. This study confirms the worse prognosis of uterine sarcoma in postmenopausal women.

[Peroperative radiotherapy in the conservative treatment of infiltrating bladder cancers]

OBJECTIVE

Descriptive analysis of an intraoperative radiotherapy protocol (IOR) in the context of conservative management of invasive bladder cancer.

METHOD

From November 1988 to September 1994, 24 patients with invasive bladder carcinoma (20 T2, 3 T3) were included in this protocol consisting of: transurethral resection (TUR), neoadjuvant chemotherapy (M.V.C.) in 14 patients, external irradiation (x 18 MV: 48 Gy/24 F/5 weeks) with concomitant chemotherapy (cisplatin 30 mg/day-3 days-2 cycles during irradiation)-follow-up cystoscopy then surgery with IOR (E 9 MeV: 15 Gy).

RESULTS

The global 3-year survival was 69%. An invasive intravesical relapse developed in 3 patients (1 salvaged by cystectomy) and a superficial relapse occurred in 1 patient. One patient developed pelvic lymph node progression and 7 developed distant metastases. The early and late toxicity was acceptable with 3 cases of ureteric necrosis or stenoses resolving after medical treatment.

CONCLUSION

This series shows encouraging preliminary results. IOR appears to be a technique well adapted to lesions of the fixed portion of the bladder.

Role of a 10-Gy boost in the conservative treatment of early breast cancer: results of a randomized clinical trial in Lyon, France

PURPOSE

To define the role of a 10-Gy boost to the primary tumor in the conservative treatment of early infiltrating breast carcinoma treated by limited surgery and radiotherapy.

PATIENTS AND METHODS

Between 1986 and 1992, 1,024 women with early breast carcinoma (< or = 3 cm in diameter) were treated by local excision, axillary dissection, and conventional 50-Gy irradiation given in 20 fractions over 5 weeks and then randomly assigned to receive either no further treatment or a boost of 10 Gy by electrons to the tumor bed. The median follow-up time was 3.3 years as of September 1994. The occurrence of telangiectasia was reported, and the patients were asked to evaluate the cosmetic result.

RESULTS

At 5 years, 10 patients of 521 who had received the boost (Kaplan-Meier estimate of local relapse rate, 3.6%) and 20 of 503 who had received no further treatment (Kaplan-Meier estimate of local relapse rate, 4.5%) had developed a local recurrence (P = .044). After adjustment for the main prognostic variables, the relative risk was still significantly lower for the boost group (0.3; range, 0.12 to 0.95). The boost group had a higher rate of grade 1 and 2 telangiectasia (12.4% v 5.9%), but no difference was seen between the two treatment arms in the self-assessment score for the cosmetic result.

CONCLUSION

Delivery of a boost of 10 Gy to the tumor bed after 50 Gy to the whole breast following limited surgery significantly reduces the risk of early local recurrence, with no serious deterioration in the cosmetic result. Additional follow-up evaluation will be required to assess the long-term results.

[Adjuvant radiotherapy after radical prostatectomy. Apropos of a series of 73 patients in Lyons (France)]

PURPOSE

Descriptive analysis of adjuvant radiation therapy after radical prostatectomy.

MATERIALS AND METHODS

From 1986 to 1993, 73 patients (median age, 64.5 years; Gleason score > or = 7 : 36 pts; T1:22; T2:40; T3:11) were included into the study. On the operative specimen, the cancer grades were pT2:5 (involvement of the apex), pT3:67, pT4:1, pN1-2:8. Radiation therapy was performed after a mean resting period of 112 days. The target volume was the prostatic area. The technique used was a four-field box with an 18 MV-X photon beam. The dose was 50 Gy/20 fractions/5 weeks. No hormonal treatment was administered, except for 5 patients for a short duration.

RESULTS

The median follow up was 46 months. One anastomotic local failure was salvaged by trans-urethral resection, three distant metastatic failures. Out of 72 patients with a PSA < 3 ng/mL at the end of radiotherapy, 13 showed an isolated elevation. The 5-year overall survival rate was 93%. The event-free survival was 72% after 5 years. Pathological differentiation and Gleason score were significantly correlated with the survival. There was no complication related to radiotherapy.

CONCLUSION

Elective adjuvant radiation therapy for pT3 prostate adenocarcinoma after radical prostatectomy provides a good local control with minimal morbidity.

[Role of radiotherapy in the management of adenocarcinoma of the breast accessible to conservative surgery]

Standard treatment for limited stage adenocarcinoma of the breast includes lumpectomy (or a quadrantectomy), axillary node dissection, regional radiation therapy and, if the prognostic factors are unfavourable, chemotherapy and/or hormone therapy. This is supported by the results of American and European randomised trials. There have been many attempts at improving the modalities of conservative surgery and postoperative radiation therapy in order to maximize local control and minimize late sequellae. It is also likely that induction chemotherapy and external beam radiotherapy applied in selected cases increase the proportion of patients who can be offered conservative surgery.

Stereotactic radiosurgery for arteriovenous malformations of the brain using a standard linear accelerator: the Lyon experience

Radiosurgery (RS) was initiated in Lyon in October 1989. The technique was adapted from that described by Lutz and Saunders in Boston (BRW stereotactic frame). Irradiation is delivered with 18-MV photons produced by a LINAC. From December 1989 to December 1992, 41 patients with arteriovenous malformations were treated by RS; the median age was 33 years. The largest lesion diameter was 11.2-38.5 mm. Fifteen to 20 Gy were delivered on the 70% isodose line. Angiography was performed at 2 years post-treatment in 32 patients demonstrating an overall complete thrombosis rate of 81.3%. This incidence was significantly correlated with the Spetzler and Martin grade before RS (P = 0.0055). Two patients (4.9%) experienced haemorrhage after radiosurgical treatment and one died from an intracerebral-intraventricular haemorrhage. Four patients (9.7%) experienced permanent radiation-induced neurological complications.

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

PURPOSE

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

METHODS AND MATERIALS

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

RESULTS

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

CONCLUSION

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

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

AIM

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

PATIENTS

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

TREATMENT

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

RESULTS

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

DISCUSSION

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

Prevention of radiation related complications in the treatment of rectal adenocarcinoma. The importance of the dose volume relationship

AIM

To illustrate and stress the role of the dose volume relationship in the risk of radiation induced rectal complications.

METHODS

With different techniques of irradiation like contact x ray therapy, Iridium implant, external beam irradiation, intra operative electrontherapy, it is possible to irradiate different volumes from few centicubes to liters.

RESULTS

The data from the literature clearly demonstrate that high doses can be given safely in small volumes, but that doses of 50 Gy or more in large volumes are dangerous. The irradiation of the whole pelvis through two antero posterior (AP - PA) fields ecompassing more than 4 liters should not be recommended. Other classical risk factors must be taken into account when planning the treatment. Previous surgery, obesity, diabetus, collagen disease, combined chemotherapy, all these factors can lead to a modification of the irradiation technique.

CONCLUSIONS

A perfect technique of irradiation is mandatory to achieve the best therapeutic ratio when treating rectal cancer. To avoid severe complications the dose must be closely adapted to the irradiated volume.