Aggressive multimodality treatment for locally advanced irresectable rectal cancer

Clinical outcome of interstitial pulsed dose rate brachytherapy in multimodality treatment of locally advanced primary or recurrent rectal and sigmoid cancer with high risk of incomplete microscopic resection

OBJECTIVE

To evaluate the role of interstitial pulsed dose rate brachytherapy (PDR-BT) in multimodality treatment of locally advanced primary or recurrent rectal and sigmoid cancer with high risk of microscopic incomplete resection (R1).

METHODS AND MATERIAL

A total of 73 consecutive patients (recurrent/primary: 40/33) were treated with PDR-BT between 2001 and 2010. Patients received preoperative external beam radiotherapy (EBRT) and concomitant chemotherapy. Following resection of the tumor and the involved pelvic organs, a median of four (3-8) catheters were sutured to the tumor bed with a distance of approximately 1 cm between the catheters. A target respecting the catheters with a margin of 5 mm was contoured on computed tomography (CT) and three-dimensional (3D) dose planning with a planning aim for BT of D90 > 30 Gy, (0.6 Gy/pulse, 1 pulse/h) was performed. Previously irradiated patients (27%) underwent surgery that was directly followed by PDR-BT. Postoperative EBRT was then applied to the tumor bed 3-5 weeks after PDR-BT.

RESULTS

A total of 23 patients (31%) received a radical resection (R0) and 45 patients (62%) received an R1 resection. Five patients (7%) received a macroscopic incomplete resection (R2). The five-year overall survival was 33%. Local control at five years was 67% for patients who received a R0 resection and 32% for patients who received an R1 resection. The five-year actuarial risk of a grade 3-4 BT-related complication was 5%.

CONCLUSIONS

Meaningful disease control and survival can be obtained at an acceptable rate of late morbidity in selected patients with locally advanced primary and recurrent rectal or sigmoid cancer using (chemo) RT, extensive surgery and PDR-BT when a high risk of an R1 resection is expected.

Comparative study of conventional lateral internal sphincterotomy, V-Y anoplasty, and tailored lateral internal sphincterotomy with V-Y anoplasty in the treatment of chronic anal fissure

BACKGROUND

Lateral internal sphincterotomy has been proven highly effective in curing anal fissure but with a high incidence of postoperative incontinence.

OBJECTIVE

We compared conventional lateral internal sphincterotomy, V-Y advancement flap, and combined tailored lateral internal sphincterotomy with V-Y advancement flap in treating anal fissure.

PATIENTS

Consecutive patients treated for anal fissure at our colorectal unit were evaluated for inclusion. Participants were randomly allocated to receive conventional sphincterotomy (GI), V-Y advancement flap (GII), or combined tailored lateral sphincterotomy with V-Y advancement l flap (GIII).

MAIN OUTCOME MEASURES

The primary outcome measure was the incontinence rate; secondary outcomes included healing rate, operative time, anal manometery, and recurrence rate.

RESULTS

One hundred fifty patients with chronic anal fissure were randomized. Healing rate after 1 year was 84% in GI, 48% in GII, and 94% in GIII, respectively (P = 0.001). The recurrence rate was 4% in G1, 22% in GII, and 2% in GIII (P = 0.01). Incontinence rate was 14% in GI, 0% in GII, and 2% in GIII (P = 0.03).

CONCLUSION

Although all three procedures are simple and easy to perform, tailored lateral internal sphincterotomy with V-YF appears to produce the greatest healing rate, with the fewest complications and less rate of recurrence.

Examination of outcome following abdominoperineal resection for adenocarcinoma in Oxford

AIM

Abdominoperineal resection (APR) has been shown to have poor outcomes compared with anterior resection (AR) in the treatment of rectal cancer. We compared APR outcomes with those for low AR.

METHOD

Lower third rectal cancers treated at the John Radcliffe Hospital with APR and low AR were examined using a prospectively collected database augmented with review of patient records. For all cases (APR and low AR), a range of patient, cancer and outcome data were collected. A selected group was created on the basis of exclusions. Outcomes for the global and selected APR and low AR groups were compared using the Kaplan-Meier method. CRM+ve and CRM-ve APR cases were compared.

RESULTS

Between 1994 and 2003, 70 APR and 93 low AR were performed. After exclusions, 42 APR and 81 low AR remained. Median follow-up was 4.8 years. Five year survival for the APR group was significantly worse than for the low AR group. The APR group showed significantly fewer T0 cancers and significantly more T3 cancers. CRM R1 involvement was significantly higher for the APR group. The CRM+ve APR group contained significantly more later stage cancers, more defective resection specimens, more abscesses and fistulas and was associated with more local recurrence.

CONCLUSIONS

These data showed that APR led to worse results than low AR in terms of overall survival and circumferential margin involvement, but that the cancers treated with APR tended to be more locally advanced.

Comparison of the erectile function in male patients with rectal cancer treated by preoperative radiotherapy followed by surgery and surgery alone

PURPOSE

This study evaluates the erectile function of male patients treated by preoperative radiotherapy followed by surgery and surgery alone for locally advanced rectal cancer.

METHODS

A total of 112 men treated by total mesorectal excision with autonomic nerve preservation were included. Seventy-three patients were treated by preoperative radiotherapy followed by surgery (RTS group), and 39 were treated by surgery alone (surgery group). Patients filled out the five-item version of the international index of erectile function (IIEF-5) questionnaire at least 6 months after initial erectile function assessment. We analyzed the impact of age, surgery type, location, and size of tumor on erectile function.

RESULTS

Total score was decreased significantly at follow-up compared to initial assessment in both RTS and surgery group (20.31 +/- 4.39 vs. 11.52 +/- 4.83, P = 0.012; 19.86 +/- 4.61 vs. 14.07 +/- 6.37, P = 0.031, respectively). Score difference was statistically higher in RTS group compared with surgery group (P = 0.028). In terms of surgery type for RTS group, score difference was statistically higher in the patients with abdominoperineal resection (APR) compared with those with lower anterior resection (P = 0.023). In comparison of score difference according to tumor location, difference was statistically higher in the patients with lower rectal cancer compared with those with upper rectal cancer (P = 0.017).

CONCLUSION

The erectile functions of patients treated by preoperative radiotherapy followed by surgery are more affected than that of patients treated by surgery alone in locally advanced rectal cancer. Also APR and lower rectal cancer were significantly associated with erectile dysfunction in the patients treated by preoperative radiotherapy followed by surgery.

Fissurectomy combined with anoplasty and injection of botulinum toxin in treatment of anterior chronic anal fissure with hypertonia of internal anal sphincter: a pilot study

BACKGROUND

In patients affected by anterior chronic anal fissure (CAAF) with hypertonia of the internal anal sphincter (IAS), the role of IAS hypertonia remains unclear. The aim of this study was to evaluate the efficacy of fissurectomy combined with advancement flap and IAS injection of botulinum toxin in healing the CAAF with hypertonia of IAS resistant to medical therapy.

METHODS

Ten consecutive patients were enrolled. Anorectal manometry was performed preoperatively and at 6 months. CAAF with hypertonia was defined as those associated with maximum resting pressure (MRP) values higher than 85 mmHg. All patients underwent fissurectomy and anoplasty with advancement skin flap combined with the intrasphincter injection of 30 UI of botulinum toxin. Complete healing, MRP changes, relief of symptoms and immediate and long-term complications were recorded.

RESULTS

Complete healing was observed in all patients within 30 days of the operation. The intensity and duration of pain post-defecation was reduced significantly starting from the first defecation. In all subjects, the preoperative MRP values were significantly reduced at 6 months. One month after surgery, three patients reported anal incontinence, two of them had complained preoperatively. The only postoperative complications were minor.

CONCLUSIONS

Fissurectomy combined with advancement flap and intrasphincter injection of botulinum toxin results in complete healing, significant MRP reduction and full relief of symptom in all patients, thus it represents a valid procedure in preventing the occurrence of anal incontinence.

Interstitial permanent implantation of 125I seeds as salvage therapy for re-recurrent rectal carcinoma

PURPOSE

To assess the feasibility, efficacy, and morbidity of (125)I seeds interstitial permanent implant as salvage therapy for re-recurrent rectal cancer.

METHODS AND MATERIALS

From September 2003 to October 2007, (125)I seeds implant procedures were performed under CT or ultrasound guidance for thirteen patients with locally re-recurrent rectal carcinoma. The minimal peripheral doses (MPD) of (125)I seeds implanted ranged from 120 to 160 Gy, with a median MPD of 140 Gy to total decay. Three patients also received two to four cycles of chemotherapy after seed implantation.

RESULTS

After a median follow-up of 10 months (range 3-45), the pain-free interval was 0-14 months with a median of 7 months (95% CI: 3-11 months). The response rate of pain relief was 46.2% (6/13). Local control was 3-14 months with a median of 7 months (95% CI: 3.5-10.5 months). The 1- and 2-year local control rates were 14.4% and 0%, respectively. Three (23.1%) patients died of local recurrence; seven (53.8%) patients died of local recurrence and metastases; one (7.7%) patient died of metastases. Two (15.4%) patients survived to follow-up. At the time of analysis, the median survival was 10 months (95% CI: 3.9-16.1 months). The 1- and 2-year actuarial overall survival rates were 46.2% and 11.5%, respectively. Two (15.4%) patients experienced a grade 4 toxic event. Seed migration to the pelvic wall was observed in one (7.7%) patient. There was no associated neuropathy.

CONCLUSION

(125)I seed implantation is feasible, effective, and safe as a salvage or palliative treatment for patients with re-recurrent rectal cancer.

Outcomes of clinical T4M0 extra-peritoneal rectal cancer treated with preoperative radiochemotherapy and surgery: a prospective evaluation of a single institutional experience

BACKGROUND

Our objective was evaluate the outcome of primary clinical T4M0 extraperitoneal rectal cancer treated by neoadjuvant radiochemotherapy. Prognosis of clinical T4 rectal cancer is poor. Preoperative chemoradiation therapy may be beneficial. The results obtained are unclear due to lack of objective and strictly applied staging methods.

METHODS

Patients with primary, clinical, T4MO, extraperitoneal rectal cancer, defined by transrectal ultrasonography, computed tomography or magnetic resonance imaging, were considered. Intraoperative radiotherapy and adjuvant chemotherapy were employed in some patients after curative resection (R0). Variables influencing the possibility to perform an R0 resection and a sphincter-saving procedure were investigated as predictors of outcome.

RESULTS

100 patients were included. R0 resection was performed in 78 patients. R0 resection rate was greater in females (93% vs 67%) and in responders to neoadjuvant chemoradiation (94% vs 60%). The ability to perform a sphincter-saving procedure was 57%, greater in middle rectal location (85% vs 51%) and in responders to the chemoradiation (70% vs 47%). Median follow-up was 31 months (range, 4-136). Local recurrences were found in 7 patients (10%). Five-year local control in R0 patients was 90% and better in the IORT group (100%). Distant relapse occurred in 24 patients (30%). Five-year overall survival was 59%, and was better after an R0 versus an R1 or R2 resection (68% vs 22%). Overall and disease free survival in R0 patients improved after overall downstaging. Adjuvant chemotherapy given in addition to the neoadjuvant therapy did not appear to offer benefit in improving survival.

CONCLUSION

A multimodal approach enabled us to obtain a 5-year overall survival of about 60%. IORT increased local control. The role of adjuvant chemotherapy needs to be further investigated.

The role of intraoperative radiotherapy in solid tumors

BACKGROUND

Combined multimodality therapy is becoming standard treatment for many solid tumors, but the role of intraoperative radiotherapy in the management of solid tumors remains uncertain. The aim is to review the indication, application, and outcomes of intraoperative radiotherapy in the management of nongynecological solid tumors.

METHODS

A literature search was performed using Medline, Embase, Ovid, and Cochrane database for studies between 1965 and 2008 assessing intraoperative radiotherapy, using the keywords "intraoperative radiotherapy," "colorectal cancer," "breast cancer," "gastric cancer," "pancreatic cancer," "soft tissue tumor," and "surgery." Only publications in English with available abstracts and regarding adult humans were included, and the evidence was critically evaluated.

RESULTS

Our search retrieved 864 publications. After exclusion of nonclinical papers, duplicated papers and exclusion of brachytherapy papers, 77 papers were suitable to assess the current role of intraoperative radiotherapy. The clinical application and evidence base of intraoperative radiotherapy for each cancer is presented.

CONCLUSIONS

Current studies in all common cancers show an additional benefit in local recurrence rates when intraoperative radiotherapy is included in the multimodal treatment. However, intraoperative radiotherapy may not improve overall survival and has significant morbidity depending on the site of the tumor. Intraoperative radiotherapy does have a role in the multidisciplinary management of solid tumors, but further studies are required to more precisely determine the extent of benefit.

Modern perspectives in the treatment of chronic anal fissures

INTRODUCTION

Anal fissures are commonly encountered in routine colorectal practice. Developments in the pharmacological understanding of the internal anal sphincter have resulted in more conservative approaches towards treatment. Simple measures are often effective for early fissures. Glyceryl trinitrate is well established as a first-line pharmacological therapy. The roles of diltiazem and botulinum, particularly as rescue therapy, are not well understood. Surgery has a defined role and should not be discounted completely.

METHODS

Data were obtained from Medline publications citing 'anal fissure'. Manual cross-referencing of salient articles was conducted. We have sought to highlight various controversies in the management of anal fissures.

FINDINGS

Acute fissures may heal spontaneously, although simple conservative measures are sufficient. Idiopathic chronic anal fissures need careful evaluation to decide what therapy is suitable. Pharmacological agents such as glyceryl trinitrate (GTN), diltiazem and botulinum toxin have been subjected to most scrutiny. Though practices in the UK vary, GTN or diltiazem would be suitable as first-line therapy with botulinum toxin used as rescue treatment. Sphincterotomy is indicated for unhealed fissures; fissurectomy has been revisited and advancement flaps have a role in patients in whom sphincter division is not suitable.

Sacral resection for recurrent rectal cancer: analysis of morbidity and treatment results

PURPOSE

Composite sacropelvic resection for locally advanced recurrent rectal cancer is a high-risk procedure that benefits select patients. We reviewed our recent institutional experience to evaluate case selection, morbidity, and outcomes.

METHODS

Between 1987 and 2004, 29 patients underwent composite resection for recurrent locoregional rectal cancer (17 females; median age, 60 years). Clinicopathologic indicators were evaluated as indicators of survival by log-rank test and Cox proportional hazards model.

RESULTS

Of 29 total patients, 27 (93 percent) received radiotherapy with their previous surgery (n = 10; 34 percent) or before sacrectomy (n = 17; 59 percent), and 12 (41 percent) received intraoperative therapy. Sacral resections were performed at S2/S3 (55 percent) or S4/S5 (45 percent) using anterior (41 percent) or combined anterior-posterior approach (59 percent), with adherence to (62 percent) or cortical invasion in (38 percent) the sacrum. A majority of those who had undergone previous abdominoperineal resection had total exenteration (9/13), whereas most patients who had undergone a previous sphincter-preserving procedure had abdominoperineal resection (12/16) and none had exenteration. Pedicle flaps (omental, 11; abdominal rectus, 7) often were used. A median of five (range, 1-33) units of blood was given intraoperatively. Transfusions were associated with previous abdominoperineal resection (P < 0.03), correlating strongly with postoperative morbidity (P < 0.02). There were 33 complications in 17 (59 percent) patients, most commonly perineal wound breakdown (9 (31 percent)) and pelvic abscess (5 (17 percent)). Median hospital stay was 18 (range, 7-56) days, significantly longer in patients with previous abdominoperineal resection (P < 0.02) or postoperative morbidity (P < 0.03). The only postoperative death was from pelvic sepsis. Resection was complete (R0) in 18 patients (62 percent), with microscopically positive margins (R1) in 10 (34 percent) and grossly positive margins (R2) in 1 (3 percent). Two-year and five-year recurrence rates were 47 and 85 percent, respectively; disease-specific survival was 63 and 20 percent, respectively. Less transfusion (P = 0.03), R0 resection (P = 0.005), lack of anterior organ involvement (P = 0.02), and absence of cortical bone invasion (P < 0.001) were associated with better survival on univariate analysis; original colorectal cancer stage was not.

CONCLUSIONS

Sacrectomy for rectal cancer is a high-risk procedure that can achieve clear resection margins with low mortality in select patients. This procedure has a low cure rate but may provide local disease control with acceptable morbidity.

Women's sexual dysfunction: a review of the "surgical landscape"

OBJECTIVES

To assess the impact of urogynaecologic surgery for stress urinary incontinence, oncologic pelvic surgery, and hysterectomy on women's overall sexual health.

METHODS

We used Ovid and PubMed (updated January 2006) to conduct a literature electronic search on MEDLINE that included peer-reviewed English-language articles. We analysed all studies identified that provided any functional outcome data about urogynaecologic surgery for the treatment of stress urinary incontinence, radical cystectomy for bladder cancer, surgery for rectal cancer, and hysterectomy. Because of the substantial heterogeneity of outcome measures and follow-up intervals in case studies, we did not apply meta-analytic techniques to the data.

RESULTS

Most studies showed that either urogynaecologic or oncologic pelvic surgery may have a significant impact on women's sexual health. Epidemiology varied widely among the studies and reported either improvement or impairment of postoperative sexual functioning, due to different definitions, study designs, and small cohorts of patients. An increasing number of studies have prospectively examined this issue and have found often controversial findings about the role of pelvic and perineal surgery in women's sexual health.

CONCLUSIONS

Although numerous controversies exist, data demonstrate an overall positive impact of the surgical repair for stress urinary incontinence on resolution of coital incontinence, coupled with an improvement of overall sexual life. In contrast, genitourinary and rectal cancers are commonly associated with treatment-related sexual dysfunction, but few studies rigorously assessed women's postoperative sexual function after major oncologic pelvic surgery. Data about the functional outcome after hysterectomy are often contradictory. Adequately powered prospective clinical trials are needed.

Surgery and pre-operative irradiation for locally advanced or recurrent rectal cancer in patients over 75 years of age

OBJECTIVE

Reports of multimodal treatment regimens especially focusing on locally advanced or recurrent rectal cancer in the elderly, aged>75 years, are unavailable. We have tried to identify and evaluate pre- and peri-operative risk factors for morbidity and mortality and outcome after irradiation/surgery regimens in such patients.

PATIENTS AND METHODS

Prospective registration of 86 consecutive patients aged>75 years undergoing elective surgery after irradiation 46-50 Gy for either primary locally advanced rectal cancer (n=51) or recurrent rectal cancer (n=35) from January 1991 to August 2003, 51 men and 35 women, median age 78 years (range 75-85 years) in a national cancer hospital.

RESULTS

Multivisceral resections were needed in 63% of patients and 70% R0 resections were obtained in locally advanced cases and 46% in recurrent ones. Both in-hospital- and 30-day-mortality was 3.5%. Sixty-two postoperative complications occurred in 38 patients, three of them fatal. Both operation times over 5 h and transfusion of more than 3 SAG were prognostic factors regarding infections. Estimated five-year survival in R0 patients was 46%. Estimated five-year survival for patients with nonmetastatic tumours with locally advanced primary cancer was 29% and for locally recurrent rectal cancer 32%. Old males had a higher mortality rate the first year after surgery than females with only 65% relative survival compared to a matched normal population. The estimated five-year local recurrence rates were 24% for R0 resections and 54% for R1 resections (P=0.434 ns) and 24% and 45% for locally advanced and recurrent rectal cancer (P=0.248 ns), respectively.

CONCLUSION

Thorough pre-operative evaluation and preparation and judicious surgery are important for achieving potentially curative treatment with acceptable morbidity in locally advanced and recurrent rectal cancer in patients over 75 years of age. We suggest that these patients should be evaluated and considered for treatment by multidisciplinary teams as younger patients.

Outcome after the introduction of a multimodality treatment program for locally advanced rectal cancer

AIM

This prospective study reports the results of a multimodality treatment protocol in patients with locally advanced rectal cancer and assesses outcome after curative vs non-curative surgery and in relation to primary advanced vs locally recurrent cancer.

METHODS

Between 1991 and 2002, 122 patients completed the protocol. Fifty-eight had primary advanced and sixty-four had locally recurrent rectal cancer. Median follow up was 82 months (5-143).

RESULTS

A potentially curative resection was achieved in 59% of the patients with primary advanced and in 34% of patients with locally recurrent cancer. After curative resection, 53 and 59%, respectively, were free from recurrence during the observation time (median 82 months) and the overall 5-year survival was 34 and 40%. Overall 5-year survival in all patients with primary advanced cancer was 29 and 16% in all patients with locally recurrent rectal cancer.

CONCLUSION

Multimodality treatment may cure at least a third of patients with locally advanced rectal cancer provided a radical resection is performed. As the post-operative morbidity is high, an optimised patient selection for neo-adjuvant treatment and surgery is essential. However, palliative surgery may benefit the patient if local control is achieved. Future studies should focus on the problem of distant metastasis.

Pre-operative imaging of rectal cancer and its impact on surgical performance and treatment outcome

AIM

To discuss the ability of pre-operative MRI to have a beneficial effect on surgical performance and treatment outcome in patients with rectal cancer.

METHODS

A description on how MRI can be used as a tool so select patients for differentiated neoadjuvant treatment, how it can be used as an anatomical road map for the resection of locally advanced cases, and how it can serve as a tool for quality assurance of both the surgical procedure and overall patient management. As an illustration the proportion of microscopically complete resections of the period 1993-1997, when there was no routine pre-operative imaging, is compared to that of the period 1998-2002, when pre-operative MR imaging was standardized.

RESULTS

The proportion of R0 resections increased from 92.5 to 97% (p=0.08) and the proportion of resections with a lateral tumour free margin of >1mm increased from 84.4 to 92.1% (p=0.03). The incomplete resections in the first period were mainly due to inadequate surgical management of unsuspected advanced or bulky tumours, whereas in the second period insufficient consideration was given to extensive neoadjuvant treatment when the tumour was close to or invading the mesorectal fascia on MR.

CONCLUSIONS

There are good indications that in our setting pre-operative MR imaging, along with other improvements in rectal cancer management, had a beneficial effect on patient outcome. Audit and discussion of the incomplete resections can lead to an improved operative and perioperative management.

ORIGINAL RESEARCH—PATHOPHYSIOLOGY: Clinical Biologic Pathophysiologies of Women's Sexual Dysfunction

INTRODUCTION

Data concerning the biologic pathophysiology of desire, arousal, and orgasm in women are limited.

AIM

To gain knowledge of biologic pathophysiology of female sexual function. METHODS. To provide state-of-the-art knowledge concerning female sexual dysfunction, representing the opinions of seven experts from five countries developed in a consensus process over a 2-year period.

MAIN OUTCOME MEASURE

An International Consultation in alliance with key urological and sexual medicine societies convened over 200 multidisciplinary specialists from 60 countries into 17 consultation committees. The aims, goals and intentions of each committee were defined. Expert opinion was based on grading of evidence-based medical literature, extensive internal committee dialogue, open presentation, and debate.

RESULTS

Three critical physiologic requirements, including intact sex steroids, autonomic/somatic nerves, and arterial inflow/perfusion pressure to women's genital organs play fundamental roles in maintaining women's sexual function. Despite this, there are nominal data supporting a direct pathophysiologic involvement of abnormal sex steroid values, and/or damage/injury to neurologic and/or blood flow integrity in women with problems in sexual desire, arousal, and/or orgasm. This summary details the available literature concerning hormonal, neurologic, and vascular organic pathophysiologies of women's sexual dysfunctions.

CONCLUSIONS

Additional research on clinical pathophysiologies in women's sexual dysfunction is needed. This chapter encompasses data presented at the 2nd International Consultation on Sexual Medicine in Paris, France, June 28-July 1, 2003.

Colorectal cancer pelvic recurrences: determinants of resectability

PURPOSE

This study was designed to identify preoperative and intraoperative features of locally recurrent colorectal cancer that predict R0 resection in patients scheduled for attempted complete resection followed by intraoperative radiation therapy.

METHODS

Review of a prospective data base identified 119 patients brought to the intraoperative radiation therapy suite for planned complete resection of locally recurrent rectal (n = 101) and colon (n = 18) cancer between January 1994 and November 2000. R0 resection was achieved in 61 patients. This group was compared with patients in which an R1 (n = 38), R2 (n = 7), or palliative procedure (n = 13) was performed. Variables evaluated included: tumor location, features of the primary tumor, and preoperative findings on computed tomography, magnetic resonance imaging, and history/physical. Tumor location was established by review of operative/pathologic reports and classified as axial (anastomotic/perineal), anterior (bladder/genitourinary organs), posterior (presacral), or lateral (pelvic sidewall).

RESULTS

When recurrence was confined to the axial location only, or axial and anterior locations, R0 resection was achieved significantly more often than when other locations were involved (P < 0.001, P = 0.003, respectively). When a lateral component was present, R0 resection was achieved significantly less often than when there was no lateral component (P = 0.002). For patients with available preoperative computed tomography and/or magnetic resonance imaging results (n = 70), the finding of lateral tumor involvement was associated with R0 resection significantly less often than when lateral disease was not identified (P = 0.004).

CONCLUSIONS

Pelvic recurrences confined to the axial location, or axial and anterior locations, are more likely to be completely resectable (R0) than those involving the pelvic sidewall. Efforts to enhance preoperative identification and imaging of these patients are clearly justified.

Effects of nicotinamide and carbogen in different murine colon carcinomas: Immunohistochemical analysis of vascular architecture and microenvironmental parameters

PURPOSE

To investigate oxygenation, perfusion, and cell proliferation in two murine colon carcinoma lines with known differences in chemotherapy sensitivity and analyze the effect of nicotinamide and carbogen on these tumor characteristics.

METHODS AND MATERIALS

Mice with s.c. transplanted C38 and C26a murine colon tumors were treated with nicotinamide and carbogen and compared with control tumors. Two markers of hypoxia, CCI-103F and pimonidazole, were injected before and after treatment with nicotinamide/carbogen, respectively, allowing each tumor to serve as its own control. Hoechst33342 was used as a perfusion marker and bromodeoxyuridine (BrdUrd) as a proliferation marker. Frozen tumors were cut for multistep immunostaining and computer-controlled microscope scanning for hypoxic fractions (HF), perfused fractions (PF), vascular density, and BrdUrd-labeling index (LI).

RESULTS

Microscopic observation of C38 and C26a tumors showed extensive differences in vascular architecture, distribution patterns of hypoxia, and BrdUrd-labeling. Quantitative analysis of C38 and C26a tumors showed a decrease in HF in response to all treatment modalities. For C38 tumors, the average decrease in HF in response to carbogen containing treatments was larger than to nicotinamide alone. In C26a tumors, no difference in average decrease in HF was observed between the treatments. The PF of C38 and C26a did not change in response to treatment. The LI of C38 and C26a decreased upon all treatments, which was statistically significant in the combination treatment of C38.

CONCLUSIONS

The mechanism that can simultaneously explain all the observed changes in response to treatment may be the conversion of metabolism from less respiration toward more glycolysis due to increased glucose levels (Crabtree effect), although other mechanisms of actions cannot be excluded.

Pre-operative radiochemotherapy of locally advanced rectal cancer

AIM: To evaluate results of pre-operative radiochemotherapy followed by surgery for 15 patients with locally advanced un-resectable rectal cancer.

METHODS: 15 patients with advanced non-resectable rectal cancer were treated with pre-operative irriadiation of 40-46 Gy plus concomitant chemotherapy (5-FU + LV and 5’-DFuR) (RCS group). For comparison, 27 similar patients, treated by preoperative radiotherapy (40-50 Gy) plus surgery were served as control (RS group).

RESULTS: No radiochemotherapy or radiotherapy was interrupted and then was delayed because of toxicities in both groups. The radical resectability rate was 73.3% in the RCS group and 37.0% (P = 0.024) in RS group. Sphincter preservation rates were 26.6% and 3.7% respectively (P = 0.028). Sphincter preservation rates of lower rectal cancer were 27.3% and 0.0% respectively (P = 0.014). Response rates of RCS and RS groups were 46.7% and 18.5% (P = 0.053). The tumor downstage rates were 8 (53.3%) and 9 (33.3%) in these groups (P = 0.206). The 3-year overall survival rates were 66.7% and 55.6% (P = 0.485), and the disease free survival rates were 40.1% and 33.2% (P = 0.663). The 3-year local recurrent rates were 26.7% and 48.1% (P = 0.174). No obvious late effects were found in either groups.

CONCLUSION: High resectability is possible following pre-operative radiochemotherapy and can have more sphincters preserved. It is important to improve the quality of the patients’ life even without increasing the survival or local control rates. Preoperative radiotherapy with concomitant full course chemotherapy (5-Fu + LV and 5’-DFuR) is effective and safe.

Effects on functional outcome after IORT-containing multimodality treatment for locally advanced primary and locally recurrent rectal cancer

PURPOSE

In the treatment of patients with locally advanced primary or locally recurrent rectal cancer, much attention is focused on the oncologic outcome. Little is known about the functional outcome. In this study, the functional outcome after a multimodality treatment for locally advanced primary and locally recurrent rectal cancer is analyzed.

METHODS AND MATERIALS

Between 1994 and 1999, 55 patients with locally advanced primary and 66 patients with locally recurrent rectal cancer were treated with high-dose preoperative external beam irradiation, followed by extended surgery and intraoperative radiotherapy. To assess long-term functional outcome, all patients still alive (n = 97) were asked to complete a questionnaire regarding ongoing morbidity, as well as functional and social impairment. Seventy-six of the 79 patients (96%) returned the questionnaire. The median follow-up was 14 months (range: 4-60 months).

RESULTS

The questionnaire revealed fatigue in 44%, perineal pain in 42%, radiating pain in the leg(s) in 21%, walking difficulties in 36%, and voiding dysfunction in 42% of the patients as symptoms of ongoing morbidity. Functional impairment consisted of requiring help with basic activities in 15% and sexual inactivity in 56% of the respondents. Social handicap was demonstrated by loss of former lifestyle in 44% and loss of professional occupation in 40% of patients.

CONCLUSIONS

As a result of multimodality treatment, the majority of these patients have to deal with long-term physical morbidity, the need for help with daily care, and considerable social impairment. These consequences must be weighed against the chance of cure if the patient is treated and the disability eventually caused by uncontrolled tumor progression if the patient is not treated. These potential drawbacks should be discussed with the patient preoperatively and taken into account when designing a treatment strategy.

The management of persistent and recurrent chronic anal fissures

There are numerous definitive reviews concerning aetiology and management of acute and chronic anal fissures. The problem of persistence and recurrence after surgical and nonsurgical therapy has not been specifically addressed and there is little evidence-based guidance for the management of this difficult group of patients. A review of the literature with particular reference to persistence and recurrence of chronic anal fissures is presented and an algorithm of management incorporating evidence-based data is suggested.

Emerging standards of radiotherapy combined with radical rectal cancer surgery

For patients with resectable rectal cancer treated with total mesorectal excision, the routine use of radiotherapy should be omitted for stage I of the disease and for lesions located higher than 10 cm from the anal verge. Preoperative radiotherapy may be considered for all patients with a lesion with deep perirectal fat infiltration located in the lower two thirds of the rectum. The other option is to offer postoperative radiotherapy for patients with a positive surgical margin, N+ stage disease, mesorectal tumour implants, high tumour grade, perineural invasion, extramuscular blood and lymphatic vessel invasion and with inadvertent tumour perforation. The lower risk of small bowel damage and probable higher efficacy are arguments for the use of preoperative radiotherapy instead of postoperative radiotherapy. The impairment of anorectal function appears to be most frequent late postirradiation sequel. The analysis of acute complications (including toxic deaths) compliance, cost and convenience favours 5 x 5 Gy preoperative irradiation with immediate surgery for patients with resectable tumours in comparison to other commonly used schemes of radiotherapy. These advantages should be weighed against approximately 1.5% risk of late neurotoxicity. There is no clear answer to the question whether preoperative conventional radio(chemo)therapy offers an advantage in sphincter preservation. To answer this question, the results of two ongoing randomised trials are awaited. For patients with unresectable cancers, long-term preoperative radio(chemo)therapy with delayed surgery is a preferable scheme. The total mesorectal irradiation should be employed for mid- and low-lying lesions. Therefore, during radiotherapy planning, a contrast enema should be used to identify the anorectal ring, anatomically corresponding with the lowest edge of the mesorectum.

MR imaging and computed tomography in patients with rectal tumours clinically judged as locally advanced

AIM

To compare magnetic resonance (MR) imaging and computed tomography (CT) in the local staging of locally advanced rectal tumours.

MATERIALS AND METHODS

Sixteen consecutive patients who, after pre-operative radio-chemotherapy (RCT), had surgery for rectal tumours clinically judged as extending into neighbouring tissues in the pelvis, were examined using MR and CT before and after treatment. The examinations were reviewed by four radiologists. The relation of the tumours to 14 different anatomic structures in the pelvis in a total of 50 examinations was studied. The results were compared to surgical and histopathological findings.

RESULTS

Seven patients had tumour infiltration of adjacent organs in the pelvis at surgery, the most common being the urinary bladder, prostate, uterus and small bowel. MR predicted involvement of the urinary bladder and the uterus better than CT. However, there were more false positive findings on MR than on CT compared to surgical and histopathological findings.

CONCLUSION

For staging of advanced rectal cancers, the overall results were not significantly better for MR than CT. If involvement of the urinary bladder and the uterus cannot be ruled out using CT, MR is advocated due to its higher soft tissue contrast resolution and multi-planar capability.

Intraoperative radiotherapy: current thinking

Intraoperative radiotherapy (IORT) refers to the delivery of irradiation at surgery. A large single dose of irradiation is delivered to a surgically defined area, while uninvolved and dose-limiting tissues are displaced, the final goal of IORT being enhanced locoregional tumour control. IORT is used in most modern protocol studies as a boost radiation component of multidisciplinary treatment approaches. More recently, high activity radiation sources or mobile operating room treatment machines are used to facilitate the IORT procedure. Clinical experiences have shown that IORT may improve local control and disease-free survival, especially when used in adjuvant setting, combined with external beam irradiation in some neoplasms such as cancer of the stomach, pancreas, colorectum, and soft tissue sarcoma.

Adjuvant and neoadjuvant radiotherapy and concurrent radiochemotherapy for rectal cancer

Radical surgery with negative margins remains the most important prognostic factor in the treatment of rectal cancer. Combined modality treatment is the recommended standard adjuvant therapy for patients with locally advanced rectal cancer in the USA and in Germany. During the last decade substantial progress has been made in treatment modalities: surgical management currently includes a broad spectrum of operative procedures ranging from radical operations to innovative sphincter-preserving techniques. Specialized groups have reported excellent local control rates with total mesorectal excision (TME) alone. New and improved radiation techniques (conformal radiotherapy, intraoperative radiotherapy) and innovative schedules (protracted intravenous infusion, chronomodulated infusion) and combinations (oxaliplatin, irinotecan) of chemotherapy may have the potential to further increase the therapeutic benefit of adjuvant treatment. Moreover, the basic issue of timing of radio-(chemo-)therapy - preoperative versus postoperative - within a multimodality regimen is currently being addressed in prospective trials. Evidently, the current monolithic approaches, established by studies conducted more than a decade ago, to apply either the same schedule of postoperative radiochemotherapy to all patients with stage II/III rectal cancer or to give preoperative intensive short-course radiation according to the Swedish concept for all patients with resectable rectal cancer irrespective of tumor stage and treatment goal (e.g. sphincter preservation), need to be questioned. This review will discuss different irradiation settings in more recent and ongoing studies of perioperative radiotherapy for rectal cancer and will focus on the issue which patient should receive radiotherapy at all, and if so, how and when?

Comparison of intraoperative radiation therapy-containing multimodality treatment with historical treatment modalities for locally recurrent rectal cancer

PURPOSE

Treatment protocols for patients with locally recurrent rectal cancer have changed in the last two decades. Subsequently, treatment goals shifted from palliation to possible cure. In this retrospective study, we explored the treatment variables that may have contributed to the improvement in outcome by comparing three treatment modalities from two collaborating institutions in patients with similar tumor characteristics.

METHODS

Ninety-four patients were treated with electron-beam radiation therapy only (1975-1990), 19 with combined preoperative electron-beam radiation therapy and surgery (1989-1996), and 33 with intraoperative radiation therapy-multimodality treatment (1994-1999). Intraoperative radiation therapy was delivered either as intraoperative electron-beam radiotherapy (10-17.5 Gy) in 20 patients or as intraoperative high-dose-rate brachytherapy (10 Gy) in 13 patients. No patient had received prior electron-beam radiation therapy.

RESULTS

The three-year survival, disease-free survival, and local control rates were 14, 8, and 10 percent, respectively, in the electron-beam radiation therapy-only group and 11, 0, and 14 percent, respectively, in the combined electron-beam radiation therapy-surgery group. The overall intraoperative radiation therapy-multimodality treatment group showed significantly better three-year survival, disease-free survival, and local control rates of 60, 43, and 73 percent, respectively, compared with the historical control groups (P < 0.001).

CONCLUSION

The outcome of patients with locally recurrent rectal cancer was improved after the introduction of intraoperative radiation therapy-multimodality treatment.

Urologic and sexual morbidity following multimodality treatment for locally advanced primary and locally recurrent rectal cancer

AIMS

In the treatment of patients with locally advanced primary or locally recurrent rectal cancer much attention is given to the oncological aspects. In long-term survivors, urogenital morbidity can have a large effect on the quality of life. This study evaluates the functional outcome after multimodality treatment in these patient groups.

PATIENTS AND METHODS

Between 1994 and August 1999, 55 patients with locally advanced primary and 66 patients with locally recurrent rectal cancer were treated with multimodality treatment: i.e. high-dose preoperative external beam radiation therapy, followed by extended surgery and intraoperative radiotherapy. The medical records of the 121 patients were reviewed. To assess long-term urogenital morbidity, all patients still alive, with a minimum follow-up of 4 months, were asked to fill out a questionnaire about their voiding and sexual function. Seventy-six of the 79 currently living patients (96%) returned the questionnaire (median FU 14 months, range 4-60).

RESULTS

The questionnaire revealed identifiable voiding dysfunction as a new problem in 31% of the male and 58% of the female patients. In 42% of patients after locally advanced primary and 48% after locally recurrent rectal cancer treatment bladder dysfunction occurred. The preoperative ability to have an orgasm had disappeared in 50% of the male and 50% of the female patients, and in 45% of patients after locally advanced primary and in 57% after locally recurrent rectal cancer treatment.

CONCLUSION

Multimodality treatment for locally advanced primary and recurrent rectal cancer results in acceptable urogenital dysfunction if weighed by the risk of uncontrolled tumour progression. Long-term voiding and sexual function is decreased in half of the patients. Preoperative counselling of these patients on treatment-related urogenital morbidity is important.

Abdominosacral resection for primary irresectable and locally recurrent rectal cancer

PURPOSE

The purpose of this study was to present a technique of abdominosacral resection and its results in patients with locally advanced primary or locally recurrent rectal cancer with dorsolateral fixation.

METHODS

Between 1994 and 1999, 13 patients with locally advanced primary rectal cancer and 37 patients with locally recurrent rectal cancer underwent abdominosacral resection as part of a multimodality treatment, i.e., preoperative irradiation, surgery, and intraoperative irradiation. After the abdominal phase, the patient was turned from supine to prone position to perform the transsacral phase of the resection.

RESULTS

Margins were microscopically negative in 26 patients (52 percent), microscopically positive in 18 (36 percent), and positive with gross residual disease in 6 patients. Operation time ranged from 210 to 590 (median, 390) minutes, and blood loss ranged from 400 to 10,000 (median, 3,500) ml. No operative or hospital deaths occurred. Postoperative complications occurred in 41 patients (82 percent); most notable were perineal wound infections or dehiscence (n = 24, 48 percent). Other complications were postoperative urinary retention or incontinence (n = 9, 18 percent), peritonitis (n = 4), grade II neuropathy (n = 1), and fistula formation (n = 3). Kaplan-Meier 3-year overall survival, disease-free survival, and local control rates were, respectively, 41 percent, 31 percent, and 61 percent. Completeness of the resection (negative vs. positive margins) was a significant factor influencing survival (P = 0.04), disease-free survival (P = 0.0006), and local control (P = 0.0002).

CONCLUSION

The abdominosacral resection provides wide access and may be the therapeutic solution for the accomplishment of a radical resection for distally situated, dorsally or dorsolaterally fixed primary or locally recurrent rectal cancers.

Perioperative radiotherapy and concurrent radiochemotherapy in rectal cancer

Combined modality treatment is the recommended standard adjuvant therapy for patients with locally advanced rectal cancer in the United States and Germany. During the last decade substantial progress has been made in treatment modalities, and surgical management currently includes a broad spectrum of operative procedures ranging from radical operations to innovative sphincter-preserving techniques. Specialized groups have reported excellent local control rates with total mesorectal excision (TME) alone. New and improved radiation techniques (conformal and intraoperative radiotherapy) and innovative schedules (protracted intravenous and chronomodulated infusion) and combinations (oxaliplatin and irinotecan) of chemotherapy may have the potential to further increase the therapeutic benefit of adjuvant treatment. Moreover, the basic issue of timing (pre- or postoperative) within a multimodal regimen is currently being addressed in prospective trials. Evidently there is a need to question the current monolithic approaches, which were established by studies conducted more than a decade ago. It is also under discussion whether to apply the same schedule of postoperative radiochemotherapy to all patients with stage II/III rectal cancer, or to give preoperative intensive short-course radiation according to the Swedish concept for all patients with resectable rectal cancer irrespective of tumor stage and treatment goal (e.g., sphincter preservation). This review discusses different irradiation settings in more recent and ongoing studies of perioperative radiotherapy for rectal cancer, and focuses on the issue of which patient should receive radiotherapy (if at all), and if so, how and when.

Pathologic significance of tumor progression in locally recurrent rectal cancer: different nature from primary cancer

PURPOSE

It has recently been demonstrated that the tumor growth rate is a stronger determinant of survival than the extent of the growth in local recurrence of rectal cancer. We studied which factors controlled the tumor growth rate using modern immunohistochemical methods.

METHODS

In 51 patients who underwent extended resection for this condition, paraffin-embedded specimens were examined for 1) tumor angiogenesis by CD31 staining and microvessel counting, 2) apoptosis by terminal deoxynucleotide transferase-mediated deoxyuridine triphosphate-biotin nick end-labeling staining, and 3) cellular proliferative activity using anti-proliferative cell nuclear antigen antibody. The results were compared with carcinoembryonic antigen doubling time and survival.

RESULTS

The five-year survival rate was 20 percent. The postoperative carcinoembryonic antigen doubling time, which was the strongest predictor of survival, correlated highly with proliferative cell nuclear antigen labeling index, but did not correlate with the apoptotic index or microvessel counts.

CONCLUSION

Our study shows that cancer cell proliferation rather than apoptosis or angiogenesis is a major determinant of tumor growth rate and survival in patients with locally recurrent rectal cancer.

Feasibility and first results of multimodality treatment, combining EBRT, extensive surgery, and IOERT in locally advanced primary rectal cancer

PURPOSE

To assess the outcome of aggressive multimodality treatment with preoperative external beam radiation therapy (EBRT), extended circumferential margin excision (ECME) and intraoperative electron beam radiation therapy (IOERT) in patients with locally advanced primary rectal cancer.

METHODS AND MATERIALS

Thirty-eight patients with primary locally advanced rectal cancer, but without distant metastases, received multimodality treatment. CT-scan showed extension to other structures in 15 patients (39%) and definite infiltration into the surrounding structures in 23 patients (61%). All patients received preoperative EBRT (dose range 25-61 Gy) and 82% received 50.4 Gy. The resection types were: 12 low anterior resections (31%), 14 abdomino-perineal resections (37%), 6 abdomino-transsacral resections (16%), and 6 pelvic exenterations (16%). The IOERT dose ranged from 10 to 17.5 Gy depending on the completeness of the resection.

RESULTS

There was no perioperative mortality. The resection margins were microscopically negative in 31 patients (82%), microscopically positive in 4 (10%), and positive with gross residual disease in 3 patients (8%). Pelvic recurrences were observed in 5 patients (13%) including 3 IOERT infield failures. The overall 3-year local control, disease-free survival (DFS), and survival rates were 82%, 65%, and 72%, respectively. Negative resection margins were the most significant prognostic factor with regard to DFS (p = 0.0003) and distant control (p = 0.002) compared with cancer involved surgical margins.

CONCLUSION

A high percentage of curative resections can be achieved in this group of patients with locally advanced rectal cancers. Adding IOERT to preoperative EBRT and ECME achieves high local control rates and possibly improves survival.

Combined modality therapy of rectal cancers

Rectal cancer accounts for about 10% of new cancer cases each year. It strikes men and women at nearly the same rate, generally in the range of 50-80 years of age, with rising incidence with age. Despite simple screening procedures rectal cancer is often advanced when discovered. Current trends in the management of cancer have focused on organ preservation and improved quality of life without compromising the overall survival. During the last decade substantial progress has been made in treatment modalities: new and improved radiation techniques (conformal radiotherapy, altered fractionation, brachytherapy), chemotherapy (protracted infusion, use of radiosensitizers) and development of surgical procedures-enabling safer postoperative irradiation. In patients with advanced/unresectable disease aggressive combined chemoradiation can be added prior to surgery to downstage the tumour and increase the proportion treated with anal-rectal-sparing procedures. Preoperative chemoradiation therapy regimens are as safe and tolerable as the standard postoperative treatment. In this presentation indications for preoperative radiochemotherapy will be discussed in detail, together with treatment-related side effects, prognostic parameters, tumour response and outcome. Different irradiation settings and chemotherapy schedules are described. In patients with primary resectable disease (mainly Dukes C) several prospective randomised trials have shown less local recurrence with postoperative combined modality therapy.

Extensive surgery after high-dose preoperative chemoradiotherapy for locally advanced recurrent rectal cancer

PURPOSE

This was a pilot study of high-dose preoperative concurrent radiation and chemotherapy before extensive surgery in patients with locally advanced recurrent rectal cancer. Here we report on curative resectability, acute toxicities during chemoradiotherapy, surgical complications, local control, and three-year survival rates achieved with this aggressive multimodal regimen.

METHODS

Between 1994 and 1997, 35 previously nonirradiated patients with pelvic recurrence of rectal cancer were entered in the study. All patients presented with tumor contiguous or adherent to adjacent pelvic organs and were not deemed amenable to primary curative surgery. A total radiation dose of 50.4 Gy with a small-volume boost of 5.4 to 9 Gy was delivered in conventional fractionation (single dose, 1.8 Gy). 5-Fluorouracil was scheduled as a continuous infusion of 1,000 mg/m2/day on Days 1 to 5 and 29 to 33. Six weeks after completion of chemoradiotherapy, patients were reassessed for resectability, and radical surgery was attempted whenever feasible.

RESULTS

After preoperative chemoradiotherapy 28 of 35 patients (80 percent) underwent resection with curative intent. In 16 of 35 patients (57 percent) extended resection of adjacent organs was performed. Resections with negative margins were achieved in 17 patients (61 percent); 9 patients had microscopic, and 2 patients had gross residual disease. There was no postoperative mortality. Fourteen patients (44 percent) experienced postoperative complications. Toxicity from chemoradiotherapy occurred mainly as diarrhea (National Cancer Institute Common Toxicity Criteria Grade 3; 23 percent), dermatitis (Grade 3; 11 percent), and leucopenia (Grade 3; 11 percent). One patient died of tumortoxic multiple organ failure during chemoradiotherapy. With a median follow-up of 27 months, local re-recurrence after curative resection was observed in only three patients (18 percent); six patients developed distant metastases. Three-year actuarial survival rate was significantly improved after complete resection (82 percent) as compared with noncurative surgery (38 percent; P = 0.03).

CONCLUSION

A combination of high-dose preoperative chemoradiotherapy followed by extended surgery can achieve clear resection margins in more than 60 percent of patients with recurrent rectal tumor not amenable to primary surgery. An encouraging trend evolved for this multimodal treatment to improve long-term local control and survival rate.

Intraoperative electron beam radiation therapy for locally recurrent rectal carcinoma

PURPOSE

Treatment results for locally recurrent rectal cancers are poor. This is a result of the fact that surgery is hampered due to the severance of the anatomical planes during the primary procedure and that radiotherapy is limited by normal tissue tolerance, especially after previous irradiation. This paper describes the results of a combined treatment modality in this patient group.

METHODS AND MATERIALS

From 1994 to 1998, 37 patients with locally recurrent rectal cancer, but without distant metastatic disease, received a combined treatment consisting of 50.4 Gy preoperative irradiation or, in case of previous radiotherapy, 30 Gy reirradiation or no irradiation, followed by radical surgery and intraoperative electron beam radiotherapy boost.

RESULTS

Fifteen patients received a radical resection (R0), eight a microscopic irradical resection (R1), and 14 a macroscopic irradical resection (R2). The overall 3-year local control (LC), disease-free survival (DFS), and overall survival rates were 60%, 32%, and 58% respectively. Radicality of resection (R0/R1 vs. R2) turned out to be the significant factor for improved survival (p < 0.05), DFS (p = 0.0008), and LC (p = 0.01). Preoperative (re-)irradiation is the other significant factor in survival (p = 0.005) and DFS (p = 0.001) and was almost significant for LC (p = 0.08). After external beam radiation therapy (EBRT) a significantly higher resection rate was obtained (R0/R1 vs. R2 p = 0.001). Symptomatic peripheral local recurrences have a significantly worse prognosis and higher rate of R2-resection (p = 0.0005).

CONCLUSION

Centralization of locally recurrent rectal cancer patients enabled the development of an aggressive multimodality treatment, which in turn led to promising results. Distant failure is still a drawback.

A histopathological assessment of the response of rectal adenocarcinoma to combination chemo-radiotherapy: relationship to apoptotic activity, p53 and bcl-2 expression

AIMS

To investigate the use of pre-operative chemo-irradiation in downstaging advanced rectal cancer prior to surgical resection.

METHODS

We examined the pathological effects of chemo-irradiation on 24 rectal tumours and correlated the efficacy of treatment with the level of apoptosis, mitosis, P53 and bcl-2 protein expression on pre-treatment biopsies.

RESULTS

All tumours were resectable following chemo-irradiation. Six cancers showed complete regression with no viable tumour in the resection specimen. A significant correlation was found between spontaneous tumour apoptosis and tumour regression.

CONCLUSIONS

Our results suggest that in rectal cancer the apoptotic rate in untreated tumour tissue may predict sensitivity to radiation and cytotoxic agents. No relationship was found between regression and mitotic rate, p53 or bcl-2 expression.

Accuracy of computed tomography in determining resectability for locally advanced primary or recurrent colorectal cancers

AIM

To determine the accuracy of computed axial tomography (CT) in determining tumor resectability in patients with locally advanced primary (T4) or locally recurrent colorectal cancer.

METHODS

Computed tomography scans of 84 patients with "resectable" locally advanced primary rectal cancer (n = 12) or recurrent colorectal cancer (n = 72) were compared with the operative findings to assess the accuracy of abdominal and pelvic CT in determining extent of disease and resectability.

RESULTS

At surgery, disease was confined to the pelvis in 63 patients, the abdomen in 7, and involved both the pelvis and abdomen in 14. Computed tomography correctly identified these anatomic sites of tumor in 87% of patients, with 89% and 80% accuracies for pelvic and abdominal disease, respectively. Tumor resection was performed in 71 patients (85%), but was not in 13 patients because of locally unresectable disease in 8 and metastatic disease in 5. The accuracy of predicting tumor-related operability was 85%. With regard to adjacent organ resection, CT was accurate in determining the need for sacrectomy or hysterectomy, but overestimated the need for urinary organ resection. Based on histological examination of resection margins, CT correctly staged (n = 45) or overstaged (n = 9) 54 patients (64%) and understaged the remaining 30. The ability of CT to preoperatively predict a locally advanced tumor after preoperative radiation therapy as not being fixed was 30%, fixed but resectable 75%, and fixed but not resectable 25%.

CONCLUSIONS

Computed tomography is generally reliable at identifying disease as being confined to one region, and for predicting the need for adjacent organ resection. It is less discriminating for predicting local tumor resectability.

Treatment of locally recurrent rectal carcinoma--results and prognostic factors

PURPOSE

To assess the local control and survival in patients who received pelvic irradiation for locally recurrent rectal carcinoma.

METHODS AND MATERIALS

The records of 519 patients with locally recurrent rectal carcinoma treated principally with external-beam radiation therapy between 1975 to 1985 at a single institute were retrospectively reviewed. These included 326 patients who relapsed locally following previous abdominoperineal resection, 151 after previous low anterior resection, and 42 after previous local excision or electrocoagulation for the primary. No patients had received adjuvant radiation therapy or chemotherapy for the primary disease. Concurrent extrapelvic distant metastases were found in 164 (32%) patients at local recurrence and, in the remaining 355, the relapse was confined to the pelvis. There were 290 men and 229 women whose age ranged from 23 to 91 years (median = 65). Median time from initial surgery to radiation therapy for local recurrence was 18 months (3-138 months). Radiation therapy was given with varying dose-fractionation schedules, total doses ranging from 4.4 to 65.0 Gy (median = 30 Gy) over 1 to 92 days (median = 22 days). For 214 patients who received a total dose > or = 35 Gy, radiation therapy was given in 1.8 to 2.5 Gy daily fractions.

RESULTS

The median survival was 14 months and the median time to local disease progression was 5 months from date of pelvic irradiation. The 5-year survival was 5%, and the pelvic disease progression-free rate was 7%. Twelve patients remained alive and free of disease at 5 years after pelvic irradiation. Upon multivariate analysis, overall survival was positively correlated with ECOG performance status (p = 0.0001), absence of extrapelvic metastases (p = 0.0001), long intervals from initial surgery to radiation therapy for local recurrence (p = 0.0001), total radiation dose (p = 0.0001), and absence of obstructive uropathy (p = 0.0013). Pelvic disease progression-free rates were positively correlated with ECOG performance status (p = 0.0001), total radiation dose (p = 0.0001), and previous conservative surgery for the primary (p = 0.02).

CONCLUSIONS

Survival is poor for patients who develop local recurrence following previous surgery for rectal carcinoma. Pelvic radiation therapy provides only short-term palliation, and future efforts should be directed to the use of effective adjuvant therapy for patients with rectal carcinoma who are at high risk of local recurrence.