Results of adjuvant radiation therapy in cancer of the rectum. Thomas Jefferson University Hospital experience

Preoperative cobalt60 irradiation delays the healing of rectal anastomoses in rats

The healing of colorectal anastomoses after irradiation therapy continues to be a major concern. The authors evaluated the healing of rectal anastomoses in a rat model after a preoperative 500-cGy dose of cobalt60 irradiation. Thirty-six male Wistar rats were divided into two equal groups: control (group A), and irradiation group (group B). Group B received a single 500-cGy dose of irradiation, and a rectal resection and end-to-end anastomosis was performed in both groups on the 7th day after irradiation. Parameters of the healing process included bursting pressure and collagen content on the 5th, 7th, and 14th days after surgery. In the irradiation group, the mean bursting pressure on the 5th, 7th, and 14th days was 116, 218, and 273 mmHg, respectively. The collagen content assessed by histomorphometry was 9.0, 20.8, and 32%, respectively. In contrast, the control group had a mean bursting pressure of 175, 225 and 263 mmHg, and a collagen content of 17.8, 28.1, and 32.1%, respectively. The adverse effect of irradiation on healing was detectable only on the 5th postoperative day, as demonstrated by lower bursting pressure (P < 0.013) and collagen content (P < 0.008). However, there was no failure of anastomotic healing such as leakage or dehiscence due to irradiation. We conclude that a single preoperative 500-cGy dose of irradiation delays the healing of rectal anastomosis in rats.

Estudo comparativo de anastomoses colorretais com anel biofragmentável e com grampeador em cães submetidos à irradiação gama pré-operatória

OBJETIVO: Comparar os resultados precoces entre anastomoses colorretais realizadas com anel biofragmentável e com grampeador circular após irradiação pélvica. MÉTODOS: Foram utilizados 40 cães beagle, em dois grupos de 20 animais, submetidos ou não à irradiação gama pré-operatória, com dose única de 500 cGy. Cada grupo foi dividido em dois subgrupos de dez animais, sendo denominado A o grupo em que se utilizou o anel biofragmentável e B aquele em que se empregou o grampeador. Os animais foram submetidos à secção completa do intestino grosso ao nível da junção retossigmóide, com reconstrução do trânsito sendo efetuada por uma das técnicas, após sorteio. Os animais foram sacrificados no sétimo dia de período pós-operatório. RESULTADOS: Houve dois óbitos antes da reoperação: um em animal do grupo teste, por ruptura da anastomose realizada com anel biofragmentável; outro por peritonite generalizada em animal do grupo controle com anastomose efetuada por grampeador. Aderências e infecções de parede ocorreram de forma similar. A análise histológica convencional e a análise morfométrica realizada por computador das áreas de cicatrização anastomótica identificaram comportamento análogo entre os grupos e subgrupos estudados. CONCLUSÃO: Os resultados precoces das técnicas empregadas para anastomose intestinal foram semelhantes nas condições de risco estudadas.

Late complications after a combined pre and postoperative (sandwich) radiotherapy for rectal cancer

BACKGROUND AND PURPOSE

The purpose of this study was to analyse the treatment related side effects, the outcome and the prognostic significance of clinical parameters in two groups of patients with rectal cancer receiving either preoperative or pre and postoperative radiotherapy after radical resection. The authors of this study were not involved in the radiation treatments.

PATIENTS AND METHODS

From 1986 to 1990, 63 patients received a combined pre and postoperative (sandwich) radiotherapy. Preoperative irradiation was given in four fractions of 5 Gy each applied within 2 or 3 days. Postoperative irradiation consisted mostly of 15 x 2 Gy (31 patients) but the range was 20-40 Gy. The results were compared with those on 73 patients who only received preoperative radiotherapy in the same time period. The distribution of prognostic factors was not very different between treatment groups. Out of 63 patients in the sandwich group, 22 received concurrent chemotherapy and 18 also received radiotherapy to the liver. Radical surgery usually followed on the day after the last preoperative radiotherapy session. Median follow-up of survivors was 6 years.

RESULTS

Local tumour control was 88% after 5 years and 84% after 8 years in the sandwich group, and 90 and 85%, respectively, in the preoperative radiotherapy group. Thus, tumour control was similar for the two radiotherapy regimens applied. However, the percentage of patients suffering from one or more complications after 5 years was 84% in the sandwich and 17% in the preoperative radiotherapy group. The incidence of severe late complications (grade > or = 3) was recorded as a function of time after start of treatment. In the sandwich group the actuarial rates of late complications at 5 years (and the median time to diagnosis) were 53% (27 months) for anorectum, 43% (37 months) for bladder, 28% (51 months) for bone, 19% (36 months) for dermis, 47% (48 months) for ileum, 41% (32 months) for lymphatic and soft tissue, and 44% (53 months) for ureters.

CONCLUSIONS

Severe late reactions did not occur within a certain period of time, but continued to appear for at least 10 years after radiotherapy. Sandwich therapy, as given in this series, did not appear to give a greater tumour control than preoperative radiotherapy alone, whereas the rate of complications was drastically enhanced. Thus, the rationale of a sandwich therapy with a long time interval between surgery and postoperative irradiation appears questionable.

Adjuvant therapy for resectable rectal and colonic cancer

BACKGROUND

Recurrence of rectal and colonic carcinoma remains substantial despite apparently curative surgery. Adjuvant therapy has been applied to improve prognosis.

METHODS

This review evaluates the use of adjuvant therapy in the management of resectable rectal and colonic carcinoma. It assesses critically the evidence supporting the addition of radiotherapy, chemotherapy, chemoradiotherapy and other treatment modalities to optimal surgery.

RESULTS

In the case of rectal tumours, preoperative is more effective than postoperative radiotherapy; It can significantly reduce the incidence of local tumour recurrence. A number of trials have tended towards showing a survival advantage and a recent large randomized trial has shown a significant improvement in survival in patients with Dukes C tumours. Postoperative chemoradiotherapy is associated with a survival benefit and is standard therapy in the USA, although it is associated with increased toxicity. The effectiveness of preoperative chemoradiotherapy is currently being investigated. Postoperative fluorouracil-containing chemotherapy has resulted in a survival advantage in patients with Dukes C colonic tumours; such therapy may be administered either systemically or intraportally. The evidence of benefit with rectal tumours is more limited. Immunotherapy has been studied to a limited extent and the use of a tumour-directed monoclonal antibody has produced a survival advantage in a single trial.

CONCLUSION

Preoperative radiotherapy and postoperative chemoradiotherapy can produce a survival advantage in patients with Dukes C rectal carcinoma and reduce local recurrence. Postoperative fluorouracil-containing chemotherapy can produce a survival advantage in those with Dukes C colonic cancer. The optimal use and combination of adjuvant therapy remains uncertain.

The role of hypoxic stop-flow perfusion and high dose chemotherapy in the treatment of regionally advanced colorectal cancer

The primary or secondary forms of colorectal cancers involving local structures or spreading in the abdomen or pelvic area without extra-regional metastases are identified as regionally advanced colorectal cancers (RACRC). They are unresectable and thus radiotherapy and chemotherapy are the fundamental treatment methods. However, these regimens have failed to check the diffusion of tumor satisfactorily in most forms of RACRC. The abdominal and pelvic regions can be isolated from corporal circulation by temporary occlusion of the aorta and cava and perfused with high doses of chemotherapeutic drugs. The hypoxic abdominal or pelvic stop-flow method for delivering high-dose antiblastic agents to these body districts to avoid toxicity by chemofiltration has been suggested. This study examines the possibility of using this method to treat various forms of RACRC.

Adjuvant postoperative radiotherapy in rectal cancer: 148 cases treated at Florence University with 8 years median follow-up

BACKGROUND AND PURPOSE

To analyse the outcome, the treatment related side effects, the prognostic significance of clinical parameters in a group of patients with rectal cancer receiving postoperative radiotherapy after radical resection.

MATERIALS AND METHODS

From 1980 to 1990 148 consecutive patients with rectal carcinoma stage B2-B3 or C1-C2-C3 were treated with postoperative radiotherapy after radical surgery. All patients received 50 Gy in 25 sessions in 5 weeks. In 42 a "flash' dose of 5 Gy was also given within 24 h before surgery. Median follow up was 8.1 years.

RESULTS

At 5 years the overall survival was 54%, the determined (cancer specific) survival 61%, the local recurrence-free survival 88%. The influence of stage, histotype, distance from anal margin, type of surgery, number of involved nodes and flash dose were analysed. Overall and determined survival and distant metastasis rate were significantly influenced (P < 0.005) by the pathological stage. Patients with more than 3 involved nodes presented a significantly lower determined survival (P < 0.001) and a higher distant relapse rate (P < 0.005) than those with 3 or less involved nodes. A higher determined survival (P < 0.01) was also found in patients receiving the preoperative "flash'; this group was however unbalanced in respect to the relative number of cases with 3 or less involved nodes. The incidence of major side effects requiring surgery or hospitalization for medical treatment was 35% before 1985 and 12% thereafter. The systematic use of small bowel visualization during simulation and the discontinuation of the flash dose were the main modifications introduced in the second period. As a consequence of the small bowel visualization the size of lateral fields was slightly reduced and some patients were excluded from the treatment.

CONCLUSIONS

Value of postoperative radiotherapy to decrease the incidence of local recurrence was confirmed in this retrospective study; the incidence of side effects was however considerable and did not support the addition of chemotherapy as advised by the NIH consensus meeting. Our policy was therefore moved to preoperative irradiation whose combination with chemotherapy was recently reported to be better tolerated and highly effective.

Treatment of non-resectable pelvic malignancies by isolated pelvic perfusion. A preliminary study

Management of non-resectable pelvic tumours by intra-arterial local chemotherapy was shown to be beneficial but systemic toxicity limits its use. To overcome this problem isolated pelvic perfusion (IPP) was introduced as an alternative. This study summarizes our preliminary experience with IPP in the treatment of 18 non-resectable pelvic tumours [recurrent rectal adenocarcinoma (six), soft tissue sarcoma (STS) (five), bone tumour (three), epidermoid carcinoma (two), prostatic adenocarcinoma (one), malignant melanoma (one)]. Results of IPP were regarded as complete remission (CR), partial remission (PR), stable disease (SD) and disease progression (DP) according to the changes in three parameters including; scoring in pain, tumour marker and tumour size measurements. Complete and partial remission were established in five (27%) and seven (39%) patients respectively indicating a benefit ratio of 66%. Objective pain relief was encountered in 53% of the cases. All patients with STS had undergone further surgical treatment after IPP with successful curative resections in four. No residual tumour was found at the laparotomy of the fifth patient. Presenting symptom of the prostatic adenocarcinoma patient was symptomatic hypoglycaemia which resolved completely after IPP. To our knowledge, this represents the first case reported in the English literature in whom tumour related hypoglycaemia was successfully managed by IPP. In conclusion; management of non-resectable pelvic tumours by IPP seems to offer serious palliation and increase in the quality of life without any systemic toxicity. Our preliminary experience suggests even resectability may be achieved in a number of patients especially in those with STS.

The importance of patient selection for adjunctive postoperative radiation therapy for cancer of the rectum. Patient selection in adjunctive therapy

BACKGROUND

Clinical stage of disease is an important selection criterion for choice of primary treatment and strategies for adjunctive therapy for most cancers. For adenocarcinoma of the rectum, strategies for adjuvant treatment are based primarily on pathologic stage alone, without consideration of presenting clinical factors. This analysis was undertaken to assess the effect of patient selection on results of adjunctive therapy.

METHODS

Three groups of patients with Astler-Coller Stage B2 and C rectal cancer were compared to assess the effect of patient selection factors on outcome of treatment after adjuvant postoperative radiation. Thirty-two patients in Group 1 received only 5 Gy preoperatively; 54 patients in Group 2 received low-dose (5 Gy) preoperative and high-dose (45 Gy) postoperative radiation; and 53 patients in Group 3 received high-dose (45 Gy) postoperative radiation. All patients have a minimum follow-up of 5 years. Whereas Group 1 and Group 2 patients were similar in distribution by clinical tumor characteristics, Group 3 had more patients with poor clinical features: higher median age, more men, and a higher proportion of tumors in the distal rectum. Group 3 also had a slightly higher percentage of C2 tumors compared with the other two groups.

RESULTS

Treatment was well tolerated with minimal side effects. Patients in Group 1 had no long-term complications. Four percent of patients (2 of 54) in Group 2 and 6% of patients (3 of 53) in Group 3 experienced major small bowel complications. The incidence of local recurrence was 34% (11 of 32) in Group 1, 9% (5 of 54) in Group 2, and 21% (11 of 53) in Group 3. The incidence of distant metastasis was 28% (9 of 32), 22% (12 of 54), and 38% (20 of 53), respectively. Absolute 5-year survival rates were 54%, 72%, and 41% in these three groups, respectively.

CONCLUSIONS

Low-dose preoperative adjunctive radiation alone (Group 1) resulted in a high incidence of local recurrence and poor survival compared with patients treated more appropriately with low-dose preoperative plus adjunctive postoperative irradiation (Group 2). In spite of postoperative radiation, patients with clinically unfavorable rectal cancer (Group 3) did worse than carefully selected patients, although both were nominally Stage B2 and C. Careful patient selection before surgery, histopathologic stage of disease postsurgery, and adequate adjunctive therapy are all important factors in obtaining the best results from adjunctive therapy.

Local recurrence of colorectal cancer: the problem, mechanisms, management and adjuvant therapy

Local recurrence of colorectal cancer after 'curative' surgery is a major clinical problem. Typically, 50-70 per cent of patients presenting to a surgical clinic will undergo apparently curative surgery for disease and of these about 10-25 per cent will develop local recurrence, in either the tumour bed or bowel wall. The wide differences in local recurrence rate both between and within institutions is probably caused by variation in surgical technique. The main causes of local recurrence are inadequate excision of the primary tumour or the draining lymph nodes, and intraoperative tumour cell implantation. The most significant single factor prognostic of local recurrence is Dukes' tumour stage. Other important factors include tumour grade and fixity, level of the tumour in the rectum, blood and lymphatic vessel invasion, inadvertent perforation of the tumour during resection, and the surgeon's experience. The prognosis of patients with local recurrence is poor. Prevention of recurrence by adequate surgery and adjuvant therapy as well as its early detection offer the best prospect of improving results.

A selective approach to adjunctive therapy for cancer of the rectum

PURPOSE

To present results of a selective approach to adjunctive therapy and surgery based on a new model of clinical staging for rectal cancer.

METHODS AND MATERIALS

Three hundred and sixty-two patients with rectal cancer treated with adjunctive radiation therapy and surgery have been analyzed to define patient selection criteria based on clinical assessment of disease. Clinical prognostic features of tumor mobility and level of lesion in the rectum with reference to the anorectal junction were used. Mobile, early fixed (partial), advanced fixed (total) and frozen pelvis are defined as clinical Stages I, II, III, and IV. Tumors above 6 cm (middle valve), 3-6 cm (inferior to middle valve), 0-3 cm (anorectum to inferior valve), and into the anal canal are defined as levels a, b, c, d, respectively. Based on this model, patients with mobile tumors of the proximal rectum (CS Ia, b) are treated with 500 cGy preoperative radiation and selective postoperative radiation (4500 cGy) for Stages B2 and C cancer. All other patients are treated with escalating doses of preoperative radiation. Follow-up in these patients ranges from 1 year to 14 years with a median of 5 years.

RESULTS

Overall 5-year survival of the total group of patients is 69%. Survival by pathological stage is 82% for O, A, B1, 67% for B2, 74% for C1, and 51% for C2. Survival by clinical stages is 77% for CS I, 67% for CS II, 57% for CS III, and 21% for CS IV. Overall local recurrence is 43/362 (12%). L.R. by pathological stages is 5% for O, A, B1, 18% for B2, 10% for C1, and 17% for C2. L.R. by clinical stages is 9% for CS I, 14% for CS II, 17% for CS III, and 50% for CS IV.

CONCLUSION

An integrated adjunctive therapy and selective surgical approach based on careful clinical staging of rectal cancer results in a global improvement in overall local control and survival of patients.

Anastomotic-vaginal fistula after colorectal surgery

The most feared complication of anterior and low anterior resection is anastomotic dehiscence. Although most leakages remain clinically silent, some may lead to formation of a colovaginal fistula. At the Lahey Clinic Medical Center, the records of nine patients with colovaginal fistula as a complication of colorectal surgery were reviewed to determine clinical characteristics and optimal management. The mean age was 63.7 years (range, 47-72 years). The initial indications for surgery were carcinoma of the rectum (n = 4), diverticular disease (n = 3), and closure of the colostomy after Hartmann's procedure (n = 2). Hysterectomy had been performed earlier in seven patients (78 percent). The end-to-end anastomosis (EEA) stapling device was used in five patients, and four patients had a handsewn anastomosis. The fistula developed within 23 days after surgery and usually originated within 8 cm of the anal verge. Two patients underwent immediate diverting transverse colostomy. None of the seven patients who were initially managed medically had spontaneous closure of the fistula. High fistulas were successfully treated by colorectal resection in two patients, whereas low fistulas healed after transanal repair without colostomy in two patients. These results suggest that previous hysterectomy predisposes to development of a colovaginal fistula after colorectal surgery. Not all patients require fecal diversion. Colorectal resection for high fistulas and transanal repair for low fistulas appear to be viable options for treatment.

Conservative management of extensive low-lying rectal carcinomas with transanal local excision and combined preoperative and postoperative radiation therapy. A report of a phase I-II trial

Between 1986 and 1990, 16 patients were enrolled in a prospective Phase I/II study of transanal local excision and combined preoperative and postoperative radiation therapy (RT). All patients had biopsy-proven adenocarcinoma extending to within 6 cm of the anal verge and involvement of at least one third of the rectal circumference with tumor. Five of 16 patients (32%) had T3 tumors, and only two patients had T1 tumors. Patients received a single 500 cGy fraction of RT to the pelvis within 24 hours before surgery and underwent transanal excision followed by postoperative RT (median dose, 5040 cGy). With a median follow-up of 33 months, overall 3-year actuarial survival was 94%. Two patients had isolated local recurrences (both successfully salvaged), and four had distant metastases but maintained local control. The 3-year actuarial rates of continuous freedom from any relapse, continuous local control, and no evidence of disease at last follow-up were 53%, 80%, and 71%, respectively. Only three of 16 patients required colostomy, resulting in a 3-year actuarial colostomy-free rate of 77%. There was a trend toward a higher rate of relapse (P = 0.066) in patients with T3 tumors than those with T1 and T2 tumors. Sphincter-preserving therapy for low-lying rectal carcinomas using local excision and combined preoperative and postoperative RT is feasible, although improved local and adjuvant therapy is needed for patients with T3 lesions.

Time to loco-regional recurrence after resection of Dukes' B and C colorectal cancer with or without adjuvant postoperative radiotherapy. A multivariate regression analysis

Factors influencing time to loco-regional recurrence were identified in a multivariate regression analysis of data from a series of 468 radically operated patients (260 Dukes' B and 208 Dukes' C) with carcinoma of the rectum and the rectosigmoid. A number of clinical and pathological characteristics were prospectively collected and recorded. In addition, carcinoembryonic antigen (CEA) was measured within 1 week before surgery. The endpoint used was recurrence below the level of the umbilicus. All patients were followed for at least 5 years or until time of death. The two Dukes' stages B and C were analysed in two separate analyses using the Cox proportional hazards model. In patients with Dukes' B tumours, an increased risk of loco-regional recurrence was associated with perineural invasion, tumour located less than 10 cm from the anal verge, patient aged above 70 years, and small tumour size. In patients with Dukes' C tumours, the necessity to resect neighbour organs, perineural and venous invasion, tumour located less than 10 cm from the anal verge, and large tumour size were all associated with a poor loco-regional outcome. Postoperative radiotherapy was not a significant prognosticator for loco-regional control. An update of the 5-year results of the randomised study of post-operative radiotherapy (50 Gy with 2 Gy per fraction in an overall treatment time of 7 weeks) showed no survival benefit from adjuvant radiotherapy in either Dukes' category and no statistically significant improvement in the 5-year loco-regional control rate. However, when the comparison was restricted to a group of high-risk patients there was a statistically significant benefit from radiotherapy with respect to loco-regional control (P = 0.03) but not with respect to survival (P = 0.23). The potential advantage, in terms of the required number of patients, of restricting clinical trials of intensified loco-regional therapies to the high-risk patients, is illustrated.

3-D comparative study of proton vs. x-ray radiation therapy for rectal cancer

To assess the usefulness of proton beams for treatment of patients with rectal cancer, we have performed comparative 3D treatment planning for proton beam and x-ray beam therapy. Three common x-ray techniques (AP-PA, 3-field, and 4-field box), a proton beam only plan, and a proton boost plan were compared. The plan which would have been treated without the aid of the 3D planning system was also simulated. Dose distributions were analyzed and dose-volume histograms computed for the target volumes and critical normal tissues. Analyses of these plans demonstrate that the proton beam techniques reduce the volume of small bowel irradiated. This may allow higher doses to be delivered to the tumor, with a probable increase in local control, or a reduction in normal tissue complications probability. All the plans developed with the 3D planning system treated significantly less bowel than the one planned without it.

Radiotherapy and brachytherapy for recurrent colorectal cancer

Radical surgical excision of locoregional recurrence of colorectal carcinoma usually produces the best survival and should be attempted whenever possible. However, recurrences are often unresectable; hence palliative local therapy may be indicated. There are several options for the radiation therapy of local, unresectable, recurrent, or metastatic colorectal cancer. Whole pelvis irradiation of 4,000-5,000 cGy followed by a coned-down boost of 1,000-1,500 cGy generally provides good symptomatic palliation in 80-90% of patients, but long-term control or cure is rarely achieved. External beam irradiation of 2,000-3,000 cGy to the whole liver with or without concurrent chemotherapy may be used for palliation of metastatic disease to the liver. A combination of intraoperative radiation therapy applied directly to the tumor bed and external beam irradiation may improve local control and survival rates. Multiple options are available for the intraoperative use of brachytherapy which can deliver high radiation doses to the residual tumor, or tumor bed, sparing normal tissue.

Radiosurgical treatment compared to surgery alone for rectal cancer

Between February 1981 and September 1989, 144 patients with rectal cancer were treated according to a radiosurgical sandwich protocol (27Gy + surgery + 18Gy) or postoperative radiotherapy (45Gy) at the University Hospital 'A. Gemelli' in Rome. This group is compared with a group of 133 patients operated on between January 1968 and January 1981, by the same team of surgeons but who received no radiotherapy. The historical group is comparable to the radiosurgical group in terms of stage, histology, and surgical procedures. The median follow-up period of the radiosurgical group is 38 months and 68% of cases have been observed longer than 2 years. At 2 years local recurrence in the historical control group was 22% versus 17% in the prospective group (p = 0.8). For Stage C disease, local recurrence dropped from 54% to 35% with adjuvant radiotherapy (p = 0.3). Metastases were observed in 22% of the control group versus 13% of the radiosurgical group (p = 0.2). For Stage C disease the incidence of distant metastases dropped from 59% to 26% at 2 years with the use of the prospective radiosurgical protocol (p = 0.05). The Kaplan-Meier survival rate at 5 years was 46% for the historical group and 72% for the radiosurgical group (p = 0.003) (Stage A 71% & 94%, Stage B 48% & 77%, and Stage C 16% & 38%, respectively). Neither serious nor late toxicity has been detected in the radiotherapy group, nor were surgical complications observed in the pre-operative radiotherapy group. The data strongly suggest a survival advantage for patients treated with the radiosurgical combination (p = 0.003).

Association between extent of colonic mucosal sialomucin change and subsequent local recurrence after curative excision of primary colorectal cancer

Two interrelated studies were carried out to determine whether extent of sialomucin change adjacent to a primary colorectal carcinoma predicted local tumour invasiveness and risk of local recurrence. In the first, depth of tumour penetration was correlated with the length of the sialomucin band adjacent to 72 primary colorectal cancers. There was a significant (P less than 0.05) increase in sialomucin band length adjacent to tumours invading adjacent structures compared with those which had not (Mann-Whitney U test), although there was no overall correlation between depth of penetration, Duke's classification or degree of differentiation (Kruskal-Wallis test). A sialomucin band of greater than 3 cm was associated with a 70 per cent probability of adjacent structure (T4) invasion. These observations were then tested prospectively in a second study involving 256 patients to determine whether the presence of a greater than 3 cm sialomucin band could predict local recurrence. Presence of a greater than 3 cm sialomucin band was a significant (x2 = 7.12, d.f. = 1, P less than 0.001) and independent predictor of local but not distant recurrence. In addition both the interval to local recurrence and survival were significantly shorter if a greater than 3 cm sialomucin band was present. However the accuracy of greater than 3 cm sialomucin band as a predictive test for local recurrence was only 70 per cent. The extent of sialomucin adjacent to a primary colorectal cancer does provide a crude assessment of tumour invasiveness and risk of local recurrence.

Local excision of rectal carcinoma

Sixteen published series were reviewed in which local excision was used as definitive treatment for patients with invasive rectal carcinoma located within 6 cm of the anal verge. Ninety-four percent of tumors were T1 or T2 adenocarcinomas with no identified regional metastases. Five-year cancer-specific survival was 89%. Local recurrence was 19%, although more than half of these patients were cured with additional surgery. These results were comparable with those for historical controls treated with abdominoperineal resection (APR). Four pathologic features of the surgical specimen were analyzed to assess their correlation with patient outcome. Positive surgical margins, poorly differentiated histology, and increasing depth of bowel wall invasion were associated with increased local recurrence and decreased survival. Tumor size greater than 3 cm was not a significant factor. When criteria for appropriate patient selection are followed, local excision may provide survival and recurrence rates comparable with those achieved with APR with less morbidity and operative mortality.

Randomized trials of adjuvant radiation therapy for rectal carcinoma: a review

An estimated 44,000 cases of rectal carcinoma arise annually in the United States. The traditional management of this disease has been surgery alone, but advances in adjuvant therapy offer potential for improvement of local control, disease-free survival, and survival. In the last two decades, many multicenter randomized trials of adjuvant preoperative and postoperative radiation therapy for rectal carcinoma have been reported. The design and results of these trials are critically reviewed. Results from preoperative trials have been conflicting, reflecting the heterogeneity of the trial designs. Large postoperative adjuvant trials have been reported recently. The combined analysis of local recurrence data from the mature, published trials indicates that radiation therapy results in improved local control (P = 0.02), an important concern in rectal carcinoma as local recurrences present vexing and painful clinical problems often refractory to conventional management. These trials also have shown that radiation therapy can contribute to improved survival in the combined modality setting. Improvements in the clinical outcome of rectal cancer should be possible with appropriate adjuvant therapy. The success of combined modality adjuvant therapy for rectal carcinoma may serve as a model to aid in the design of therapeutic regimens for other solid tumors.

Preoperative irradiation for rectal cancer. Improved local control and long-term survival

Between July 1975 and July 1986, 112 patients with adenocarcinoma of the rectum were treated using preoperative irradiation followed by excisional surgery on the colorectal surgery service of Jewish Hospital at Washington University Medical Center in St. Louis. There were 68 men and 44 women in this study, with ages ranging from 19 to 94 years of age. In all cases, the rectal cancers were believed to be transmurally invasive based on initial clinical examination. Included in this group were 13 patients with poorly differentiated tumors and 51 patients with tumors fixed to surrounding tissues. Between 1975 and 1980, we used 2000 cGy preoperative irradiation followed by immediate excisional surgery to treat 22 patients. Excisional surgery for cure was divided between abdomino-perineal resection of the rectosigmoid in eleven patients, low anterior resection of the rectosigmoid in eight patients, and a low Hartmann's procedure in three patients. Five-year survival for 20 patients with potentially curable lesions (Dukes' A, B, and C), was 85%, and there was no local recurrence. Between 1980 and 1986, 90 patients were treated with 4500 cGy preoperative irradiation over a 5-week period followed by a 6-week waiting period, before excisional surgery. There were 72 patients with Dukes' A, B, and C lesions. Fifty patients underwent abdomino-perineal resection of the rectosigmoid, 33 patients underwent low anterior resection of the rectum, and seven patients underwent a low Hartmann's procedure. Five-year survival was 86%. Local recurrence was 1.8%. Tumor fixation and histologic dedifferentiation were the only factors that influenced survival. Five-year survival of patients with fixed poorly differentiated tumors was 27% as compared to 87% in patients with nonfixed well-differentiated tumors (p less than 0.0001). Tumor fixation was not a significant factor in itself. Preoperative external beam irradiation improves survival, local control, and resectability in patients with rectal cancer. This effect may be due to the treatment of the "tangential" margins and local lymph node metastases. Preoperative staging can be accomplished by determining fixation and differentiation of the tumor when preoperative irradiation is used.

Adjuvant external beam and intraoperative radiation therapy in rectal cancer

The use of radical surgery has maximized local control, sphincter preservation, and overall survival in patients with rectal cancer. Despite the advances in surgical techniques, local recurrence still remains a problem. Following potentially curative surgery, the incidence of local recurrence in patients with stages B2, C disease varies from 15% to 65%. There are four major approaches in which radiation therapy (RT) has been used in the adjuvant treatment of rectal cancer. These include postoperative RT +/- chemotherapy, preoperative RT +/- chemotherapy, both pre- and postoperative RT (sandwich technique), and intraoperative RT in conjunction with preoperative external beam RT. In patients with resectable rectal cancer, adjuvant RT has been shown to decrease the incidence of local recurrence and, in some series, may influence survival rates. In patients with locally advanced, unresectable, or recurrent rectal cancer, the use of preoperative radiation therapy, attempted surgical resection, and intraoperative RT further enhances local control.

Adjuvant postoperative radiotherapy in carcinoma of the rectum and recto-sigmoid

The adjuvant postoperative irradiation is an efficient treatment method to diminish the chance on pelvic recurrences in high risk group patients having rectosigmoid or rectumcarcinomas Dukes B or C and/or in case of positive surgical margins. We reviewed the literature and our own patient material treated at the University Hospital Utrecht in the years 1980-1983. Our results are comparable with the results published in Boston. Because of the high percentage local recurrence in the perineum following APR, we changed our technique and dose. Our results from 1980-1983 and the technique and dose used since 1985 is described. We also recommend some preventive measures to lower the complication rate.

Resectable adenocarcinoma of the rectosigmoid and rectum. I. Patterns of failure and survival

In an effort to determine the patterns of failure and survival of rectosigmoid and rectal cancer, a retrospective review of 168 patients who underwent potentially curative surgery at the New England Deaconess Hospital was performed. The 5-year actuarial survival for the entire group was 67%. Survival rates decreased with increasing penetration of the bowel wall by tumor and the presence of lymph node metastasis, but only the latter reached statistical significance. Those patients who underwent an abdominoperineal resection also experienced a significant decrease in survival compared to a low anterior resection. Patterns of failure, expressed as the actuarial incidence of first failure at 5 years, were examined by stage. With the exception of stages B3 and C3, there was a trend towards increased abdominal, distant, and total failure with increasing bowel wall penetration by tumor. A similar trend was seen in local failure in those patients with positive nodes. Knowledge of these data may help identify those patients who may benefit most from adjuvant therapy.

Adjuvant therapy for colorectal cancer. The EORTC experience and a review of the literature

In spite of the improvements in surgical techniques and intensive care therapy, no appreciable improvement in the prognosis for patients with colorectal cancer has been made in recent years. Several types of adjuvant treatment, including radiotherapy, chemotherapy, and immunotherapy, have therefore been proposed and used in clinical trials, mainly in the United States and western Europe. The results obtained by the Gastrointestinal Group of the European Organization for Research and Treatment of Cancer (EORTC), using preoperative radiation therapy with 3450 rads, are reported here; this therapy results in a reduction in the number of local recurrences and also appears to prolong the five-year survival period, although a longer follow-up is required to confirm this. According to the Gastrointestinal Tumor Study Group (GITSG), postoperative radiation therapy with chemotherapy seems to prolong the tumor-free interval in stages B2 and C when compared to surgery alone. Nonspecific immunotherapy does not appear to improve surgical results either in terms of local recurrences or survival. Some clinical trials suggest that systemic polychemotherapy benefit subgroups of patients with colorectal cancer. Toxicity is still very high, however; 5-FU is the more active and safe single agent but, due to the low response rate, it appears essential to identify new, more active drugs. Particular attention has been focused recently on prophylactic infusion chemotherapy of the liver, and clinical trials are now being made by several groups, including the EORTC. Preliminary results seem to show a reduced incidence of liver metastases in patients infused with 5-FU after radical surgery. Adjuvant therapy in colorectal cancer patients undergoing radical surgery has so far given encouraging results. Future results are awaited with optimism, but they must be achieved through prospective clinical trials conducted by well-organized cooperative groups.

Local control with pre-operative radiotherapy alone versus "sandwich" radiotherapy for rectal carcinoma

Forty-nine patients with primary adenocarcinoma of the rectum, clinically localized to the pelvis were treated with pre-op radiotherapy (RT) 1500 cGy/5 fx with AP/PA fields, followed by immediate curative resection. Patients staged as Astler-Coller B2, C1, or C2 were considered for post-op RT, 4140 cGy/23 fxs with a 4-field technique. There were 47 evaluable patients in this non-randomized study. Two groups of patients were analyzed, namely pre-op RT only (24 patients) and combined pre- and post-op ("sandwich") RT (23 patients). Two patients with pre-op RT only were considered inevaluable for recurrence because they died NED at 1 and 7 mo. All patients have been followed for greater than 1 year; 77% have been followed for greater than 2 yr. There has been only one local recurrence (LR), surprisingly in a Stage A pre-op RT patient who had no residual tumor in the final operative specimen. In the pre-op group which included 10 B2s, and 1 C2, 1500 cGy in 5 days (equivalent to 1940 cGy by the NSD formulation) was associated with no local recurrence. No distant metastases (DM) have developed in this group. In the "sandwich" RT group, which included 3 B2s, 1 C1, 17 C2s, and 1 D (localized to the pelvis, i.e. ovary), there were no LRs and 7 DMs (1 B2 and 6 C2s). Actuarial survival is 92% in the pre-op RT group at 2 and 3 yr, and 82% in the "sandwich" group at 2 and 3 yr. There have been no serious early or late complications related to RT in our pre-op group. The use of 1500 cGy in 5 days as pre-op RT with immediate surgery may prove, upon longer follow-up, to be sufficient for increasing local control, with minimum morbidity, in patients with B2 disease. Patients with C2 disease are being controlled locally with the "sandwich" regimen, but it is not clear whether pre-op RT alone may be adequate in this group as well. We are now addressing this question in a randomized study.

Symptomatic recurrences of carcinoma of the rectum and sigmoid. The influence of radiotherapy on the quality of life

One hundred forty-three patients irradiated for locoregional recurrences after curative surgery for cancer of the rectum and sigmoid were studied retrospectively. An analysis was made of the symptomatic response and survival in the total series and in three subgroups treated with different dose levels (40 Gy or lower, between 40 and 50 Gy, 50 Gy or higher). The symptom-free period was calculated as percent of the overall survival. Symptomatic control was obtained in 80.4 percent of the cases, and the crude patient survival rate was 17.5 percent at two years. No significant difference was found in the three subgroups treated with different dose levels. The cumulative time/patient asymptomatic periods in the total series and in the three subgroups were 31.5, 30.2, 31.8, and 31.9 percent respectively, of the survival period.

Unresectable and locally recurrent rectal cancer treated with radiotherapy or bilateral internal iliac artery infusion of 5-fluorouracil

Seventy-nine patients with histopathologically verified unresectable or locally recurrent rectal cancer were nonrandomly allocated to radiotherapy or regional intra-arterial infusion of 5-Fluorouracil (5-FU). Fifteen patients with unresectable and 32 with locally recurrent rectal cancer were subjected to radiotherapy. The absorbed dose was 30 Gy in patients with an unresectable tumor and 45 Gy in patients with locally recurrent rectal cancer. Six patients with unresectable and 26 with locally recurrent rectal cancer received bilateral internal iliac artery infusion of 5-FU in a median dose of 7.5 g. There was no difference in survival between the two methods of treatment. Resection of an initially unresectable tumor could be performed in 5 of 21 patients (4 after radiotherapy and 1 after chemotherapy). All except eight patients had pelvic or perineal pain before treatment. Forty of 43 (93%) patients reported pain relief after radiotherapy and 21 of 28 (75%) after infusion therapy. Ten nonresponders were subjected to alternative treatment (three to intra-arterial infusion and seven to radiotherapy). Five of these ten patients reported complete pain relief and five partial pain relief. After radiotherapy, no significant side effects or complications were observed. The infusion chemotherapy was the cause of death in one patient. In summary, similar palliation was achieved with bilateral iliac artery 5-FU-infusion and radiotherapy. Owing to the complications registered with infusion therapy, radiotherapy must be considered the treatment of choice for these patients. Patients who do not respond to radiotherapy or suffer recurrence of pelvic and perineal pain may receive further palliation from intra-arterial infusion.

Combined preoperative neoadjuvant radiotherapy and chemotherapy for anal and rectal cancer

Neoadjuvant therapy combining 5-fluorouracil, mitomycin C, and moderate-dose radiotherapy was given preoperatively to 29 patients with adenocarcinoma of the rectum, 3 patients with squamous cell cancer, and 1 patient with basaloid carcinoma of the anus. Significant downstaging, and even eradication, of these lesions was realized in a high percentage of cases. Population-based data for the period of 1979 to 1984 which encompasses the time of our study indicate the survival of those treated by the neoadjuvant therapy was superior to that of patients treated by surgery alone or by surgery followed by radiotherapy. In general, patients with the poorest clinical presentation had been referred for this therapy.

Local recurrence of adenocarcinoma of the rectosigmoid. Is postoperative adjuvant radiotherapy justified?

Adjuvant postoperative radiation therapy has been suggested for adenocarcinoma of the rectum and sigmoid colon to reduce the incidence of local recurrences. Determination of this incidence is necessary to optimally employ such adjuvant therapies. Ninety-nine patients with adenocarcinoma of the rectum or sigmoid who had surgery from 1976-1984 were reviewed. Follow-up ranged from one to eight years (average 4.1 years). Twenty-three patients had gross unresected residual tumor due to local invasion. Fifteen of the remaining 76 have developed recurrences (20 percent). Two patients (2.6 percent) had local recurrences without concurrent regional or distant metastases. Thus local recurrences rarely are encountered without concurrent regional or distant metastases. Therefore, postoperative radiation therapy to prevent local recurrences is not justified, given the small number of patients potentially benefited. Treatment modalities will need to address regional and distant metastases in addition to local recurrences.

Current issues in the treatment of colorectal cancer

For colorectal cancers that are confined to the bowel wall with uninvolved nodes, surgery alone is curative in most patients, and adjuvant treatment is usually not indicated. A combined modality approach for the initial treatment of many rectal and selected colonic carcinomas is based on data that "radical" operations do not necessarily prevent either local regrowth or distant failures and acceptance of a significant palliative but infrequent curative role for irradiation and chemotherapy when such failures occur. Published data for rectal cancer indicates that local recurrence can be markedly reduced by moderate to high dose pre- and post-operative irradiation +/- chemotherapy. For colon cancer, data from pilot trials suggest that post-operative irradiation may reduce local recurrence by stage when compared with surgery alone analyses, but randomized trials are needed. With locally advanced disease, aggressive treatment combinations appear to increase both local control and survival, but much interaction is required between involved physicians.