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Peng J, Partanen A, Pichardo S, Staruch R, Perry K, McGuffin M, Huang Y, Chan KK, Wong S, Czarnota G, Hynynen K, Chu W. Mild hyperthermia with magnetic resonance- guided high intensity focused ultrasound combined with salvage chemoradiation for recurrent rectal cancer. Int J Hyperthermia 2024; 41:2365385. [PMID: 38897584 DOI: 10.1080/02656736.2024.2365385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 06/03/2024] [Indexed: 06/21/2024] Open
Abstract
INTRODUCTION Pelvic recurrences from rectal cancer present a challenging clinical scenario. Hyperthermia represents an innovative treatment option in combination with concurrent chemoradiation to enhance therapeutic effect. We provide the initial results of a prospective single center feasibility study (NCT02528175) for patients undergoing rectal cancer retreatment using concurrent chemoradiation and mild hyperthermia with MR-guided high intensity focused ultrasound (MR-HIFU). METHODS All patients were deemed ineligible for salvage surgery and were evaluated in a multidisciplinary fashion with a surgical oncologist, radiation oncologist and medical oncologist. Radiation was delivered to a dose of 30.6 Gy in 1.8 Gy per fraction with concurrent capecitabine. MR-HIFU was delivered on days 1, 8 and 15 of concurrent chemoradiation. Our primary objective was feasibility and toxicity. RESULTS Six patients (total 11 screened) were treated with concurrent chemoradiation and mild hyperthermia with MR-HIFU. Tumor size varied between 3.1-16.6 cm. Patients spent an average of 228 min in the MRI suite and sonication with the external transducer lasted an average of 35 min. There were no complications on the day of the MR-HIFU procedure and all acute toxicities (no grade >/=3 toxicities) resolved after completion of treatment. There were no late grade >/=3 toxicities. CONCLUSION Mild hyperthermia with MR-HIFU, in combination with concurrent chemoradiation for appropriately selected patients, is safe for localized pelvic recurrences from rectal cancer. The potential for MR-HIFU to be applied in the recurrent setting in rectal cancer treatment requires further technical development and prospective evaluation.
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Affiliation(s)
- Jonathan Peng
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Canada
| | | | - Samuel Pichardo
- Cumming School of Medicine, University of Calgary, Calgary, Canada
| | | | - Kaitlyn Perry
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Canada
| | - Merrylee McGuffin
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Canada
| | - Yuexi Huang
- Department of Medical Biophysics, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Kelvin Kw Chan
- Department of Medical Oncology, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Canada
| | - Shun Wong
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Canada
| | - Greg Czarnota
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Canada
- Department of Medical Biophysics, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Kullervo Hynynen
- Department of Medical Biophysics, Sunnybrook Research Institute, Toronto, ON, Canada
| | - William Chu
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Canada
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Piqeur F, Creemers DMJ, Banken E, Coolen L, Tanis PJ, Maas M, Roef M, Marijnen CAM, van Hellemond IEG, Nederend J, Rutten HJT, Peulen HMU, Burger JWA. Dutch national guidelines for locally recurrent rectal cancer. Cancer Treat Rev 2024; 127:102736. [PMID: 38696903 DOI: 10.1016/j.ctrv.2024.102736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 04/15/2024] [Accepted: 04/18/2024] [Indexed: 05/04/2024]
Abstract
Due to improvements in treatment for primary rectal cancer, the incidence of LRRC has decreased. However, 6-12% of patients will still develop a local recurrence. Treatment of patients with LRRC can be challenging, because of complex and heterogeneous disease presentation and scarce - often low-grade - data steering clinical decisions. Previous consensus guidelines have provided some direction regarding diagnosis and treatment, but no comprehensive guidelines encompassing all aspects of the clinical management of patients with LRRC are available to date. The treatment of LRRC requires a multidisciplinary approach and overarching expertise in all domains. This broad expertise is often limited to specific expert centres, with dedicated multidisciplinary teams treating LRRC. A comprehensive, narrative literature review was performed and used to develop the Dutch National Guideline for management of LRRC, in an attempt to guide decision making for clinicians, regarding the complete clinical pathway from diagnosis to surgery.
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Affiliation(s)
- Floor Piqeur
- Department of Radiation Oncology, Catharina Hospital, Michelangelolaan 2 5623EJ, Eindhoven, the Netherlands; Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121 1066 CX, Amsterdam, the Netherlands; Department of Radiation Oncology, Leiden University Medical Centre, Albinusdreef 2 2333ZA, Leiden, the Netherlands
| | - Davy M J Creemers
- GROW School of Oncology and Developmental Biology, University of Maastricht, Universiteitssingel 40 6229ER, Maastricht, the Netherlands; Department of Surgery, Catharina Hospital, Michelangelolaan 2 5623EJ, Eindhoven, the Netherlands
| | - Evi Banken
- GROW School of Oncology and Developmental Biology, University of Maastricht, Universiteitssingel 40 6229ER, Maastricht, the Netherlands; Department of Medical Oncology, Catharina Hospital, Michelangelolaan 2 5623 EJ, Eindhoven, the Netherlands
| | - Liën Coolen
- Department of Radiology, Catharina Hospital, Michelangelolaan 2 5623 EJ, Eindhoven, the Netherlands
| | - Pieter J Tanis
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus Medical Centre, Dr. Molewaterplein 40 3015 GD, Rotterdam, the Netherlands
| | - Monique Maas
- GROW School of Oncology and Developmental Biology, University of Maastricht, Universiteitssingel 40 6229ER, Maastricht, the Netherlands; Department of Radiology, The Netherlands Cancer Institute, Plesmanlaan 121 1066 CX, Amsterdam, the Netherlands
| | - Mark Roef
- Department of Nuclear Medicine, Catharina Hospital, Michelangelolaan 2 5623EJ, Eindhoven, the Netherlands
| | - Corrie A M Marijnen
- Department of Radiation Oncology, Leiden University Medical Centre, Albinusdreef 2 2333ZA, Leiden, the Netherlands
| | - Irene E G van Hellemond
- Department of Medical Oncology, Catharina Hospital, Michelangelolaan 2 5623 EJ, Eindhoven, the Netherlands
| | - Joost Nederend
- Department of Radiology, Catharina Hospital, Michelangelolaan 2 5623 EJ, Eindhoven, the Netherlands
| | - Harm J T Rutten
- GROW School of Oncology and Developmental Biology, University of Maastricht, Universiteitssingel 40 6229ER, Maastricht, the Netherlands; Department of Surgery, Catharina Hospital, Michelangelolaan 2 5623EJ, Eindhoven, the Netherlands
| | - Heike M U Peulen
- Department of Radiation Oncology, Catharina Hospital, Michelangelolaan 2 5623EJ, Eindhoven, the Netherlands
| | - Jacobus W A Burger
- Department of Surgery, Catharina Hospital, Michelangelolaan 2 5623EJ, Eindhoven, the Netherlands.
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Webb SP, Ahmad I. Novel and Innovative Surgical Strategies for Recurrent Rectal Cancer: Uncommon Resections, Local Interventions for Pelvic Reoccurrence, and Intraoperative Radiation Therapy. Clin Colon Rectal Surg 2024; 37:66-70. [PMID: 38322600 PMCID: PMC10843878 DOI: 10.1055/s-0043-1761473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
The frequency of recurrent rectal cancer has dropped significantly with improved surgical approaches and adjunctive therapies. These recurrences have proven challenging to obtain R0 resection with salvage operations. Meticulous planning, clear understanding of anatomy with imaging, and multispecialty support have become essential in local control and long-term survival with pelvic recurrence of rectal cancer. Technical considerations and prognosis indicators along with role of intraoperative radiation or boost radiation are discussed within.
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Affiliation(s)
- Shawn Philip Webb
- Division of Colon and Rectal Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Imran Ahmad
- Division of Colon and Rectal Surgery, Henry Ford Hospital, Detroit, Michigan
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Choi SH, Yang G, Koom WS, Yang SY, Kim S, Lim JS, Kim HS, Shin SJ, Chang JS. Active involvement of patients, radiation oncologists, and surgeons in a multidisciplinary team approach: Guiding local therapy in recurrent, metastatic rectal cancer. Cancer Med 2023; 12:21057-21067. [PMID: 37909227 PMCID: PMC10709736 DOI: 10.1002/cam4.6667] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 09/11/2023] [Accepted: 09/27/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND Despite the extensive implementation of an organized multidisciplinary team (MDT) approach in cancer treatment, there is little evidence regarding the optimal format of MDT. We aimed to investigate the impact of patient participation in MDT care on the actual application rate of metastasis-directed local therapy. METHODS We identified all 1211 patients with locally advanced rectal cancer treated with neoadjuvant radiochemotherapy at a single institution from 2006 to 2018. Practice patterns, tumor burden and OMD state were analyzed in recurrent, metastatic cases. RESULTS With a median follow-up of 60.7 months, 281 patients developed metastases, and 96 (34.2%), 92 (32.7%), and 93 (33.1%) patients had 1, 2-5, and >5 lesions, respectively. In our study, 27.1% were managed in the MDT clinic that mandated the participation of at least four to five board-certified multidisciplinary experts and patients in decision-making processes, while the rest were managed through diverse MDT approaches such as conferences, tumor board meetings, and discussions conducted via phone calls or email. Management in MDT clinic was significantly associated with more use of radiotherapy (p = 0.003) and more sessions of local therapy (p < 0.001). At the time of MDT clinic, the number of lesions was 1, 2-5, and >5 in 9 (13.6%), 35 (53.1%), and 19 (28.8%) patients, respectively. The most common states were repeat OMD (28.8%) and de novo OMD (27.3%), followed by oligoprogression (15%) and induced OMD (10.6%). CONCLUSION Our findings suggest that active involvement of patients and radiation oncologists, and surgeons in MDT care has boosted the probability of using local therapies for various types of OMD throughout the course of the disease.
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Affiliation(s)
- Seo Hee Choi
- Department of Radiation OncologyYonsei University College of MedicineSeoulKorea
| | - Gowoon Yang
- Department of Radiation OncologyYonsei University College of MedicineSeoulKorea
| | - Woong Sub Koom
- Department of Radiation OncologyYonsei University College of MedicineSeoulKorea
| | - Seung Yoon Yang
- Department of SurgeryYonsei University College of MedicineSeoulKorea
| | - Seung‐Seob Kim
- Department of RadiologyYonsei University College of MedicineSeoulKorea
| | - Joon Seok Lim
- Department of RadiologyYonsei University College of MedicineSeoulKorea
| | - Han Sang Kim
- Division of Medical Oncology, Department of Internal MedicineYonsei University College of MedicineSeoulKorea
| | - Sang Joon Shin
- Division of Medical Oncology, Department of Internal MedicineYonsei University College of MedicineSeoulKorea
| | - Jee Suk Chang
- Department of Radiation OncologyYonsei University College of MedicineSeoulKorea
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Bryant JM, Weygand J, Keit E, Cruz-Chamorro R, Sandoval ML, Oraiqat IM, Andreozzi J, Redler G, Latifi K, Feygelman V, Rosenberg SA. Stereotactic Magnetic Resonance-Guided Adaptive and Non-Adaptive Radiotherapy on Combination MR-Linear Accelerators: Current Practice and Future Directions. Cancers (Basel) 2023; 15:2081. [PMID: 37046741 PMCID: PMC10093051 DOI: 10.3390/cancers15072081] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023] Open
Abstract
Stereotactic body radiotherapy (SBRT) is an effective radiation therapy technique that has allowed for shorter treatment courses, as compared to conventionally dosed radiation therapy. As its name implies, SBRT relies on daily image guidance to ensure that each fraction targets a tumor, instead of healthy tissue. Magnetic resonance imaging (MRI) offers improved soft-tissue visualization, allowing for better tumor and normal tissue delineation. MR-guided RT (MRgRT) has traditionally been defined by the use of offline MRI to aid in defining the RT volumes during the initial planning stages in order to ensure accurate tumor targeting while sparing critical normal tissues. However, the ViewRay MRIdian and Elekta Unity have improved upon and revolutionized the MRgRT by creating a combined MRI and linear accelerator (MRL), allowing MRgRT to incorporate online MRI in RT. MRL-based MR-guided SBRT (MRgSBRT) represents a novel solution to deliver higher doses to larger volumes of gross disease, regardless of the proximity of at-risk organs due to the (1) superior soft-tissue visualization for patient positioning, (2) real-time continuous intrafraction assessment of internal structures, and (3) daily online adaptive replanning. Stereotactic MR-guided adaptive radiation therapy (SMART) has enabled the safe delivery of ablative doses to tumors adjacent to radiosensitive tissues throughout the body. Although it is still a relatively new RT technique, SMART has demonstrated significant opportunities to improve disease control and reduce toxicity. In this review, we included the current clinical applications and the active prospective trials related to SMART. We highlighted the most impactful clinical studies at various tumor sites. In addition, we explored how MRL-based multiparametric MRI could potentially synergize with SMART to significantly change the current treatment paradigm and to improve personalized cancer care.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Stephen A. Rosenberg
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (J.M.B.)
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Fadel MG, Ahmed M, Malietzis G, Pellino G, Rasheed S, Brown G, Tekkis P, Kontovounisios C. Oncological outcomes of multimodality treatment for patients undergoing surgery for locally recurrent rectal cancer: A systematic review. Cancer Treat Rev 2022; 109:102419. [PMID: 35714574 DOI: 10.1016/j.ctrv.2022.102419] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/01/2022] [Accepted: 06/05/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND There are several strategies in the management of locally recurrent rectal cancer (LRRC) with the optimum treatment yet to be established. This systematic review aims to compare oncological outcomes in patients undergoing surgery for LRRC who underwent neoadjuvant radiotherapy or chemoradiotherapy (CRT), adjuvant CRT, surgery only or surgery and intraoperative radiotherapy (IORT). METHODS A literature search of MEDLINE, EMBASE and CINAHL was performed for studies that reported data on oncological outcomes for the different treatment modalities in patients with LRRC from January 1990 to January 2022. Weighted means were calculated for the following outcomes: postoperative resection status, local control, and overall survival at 3 and 5 years. RESULTS Fifteen studies of 974 patients were included and they received the following treatment: 346 neoadjuvant radiotherapy, 279 neoadjuvant CRT, 136 adjuvant CRT, 189 surgery only, and 24 surgery and IORT. The highest proportion of R0 resection was found in the neoadjuvant CRT group followed by neoadjuvant radiotherapy and adjuvant CRT groups (64.07% vs 52.46% vs 47.0% respectively). The neoadjuvant CRT group had the highest mean 5-year local control rate (49.50%) followed by neoadjuvant radiotherapy (22.0%). Regarding the 5-year overall survival rate, the neoadjuvant CRT group had the highest mean of 34.92%, followed by surgery only (29.74%), neoadjuvant radiotherapy (28.94%) and adjuvant CRT (20.67%). CONCLUSIONS The findings of this systematic review suggest that neoadjuvant CRT followed by surgery can lead to improved resection status, long-term disease control and survival in the management of LRRC. However, treatment strategies in LRRC are complex and further comparisons, particularly taking into account previous treatments for the primary rectal cancer, are required.
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Affiliation(s)
- Michael G Fadel
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK; Department of Surgery and Cancer, Imperial College, London, UK.
| | - Mosab Ahmed
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK
| | - George Malietzis
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK; Department of Surgery and Cancer, Imperial College, London, UK; Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy; Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Shahnawaz Rasheed
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK; Department of Surgery and Cancer, Imperial College, London, UK; Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
| | - Gina Brown
- Department of Surgery and Cancer, Imperial College, London, UK
| | - Paris Tekkis
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK; Department of Surgery and Cancer, Imperial College, London, UK; Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
| | - Christos Kontovounisios
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK; Department of Surgery and Cancer, Imperial College, London, UK; Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
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Wang J, Prabhakaran S, Larach T, Warrier SK, Bednarski BK, Ngan SY, Leong T, Rodriguez-Bigas M, Peacock O, Chang G, Heriot AG, Kong JCH. Treatment strategies for locally recurrent rectal cancer. Eur J Surg Oncol 2022; 48:2292-2298. [DOI: 10.1016/j.ejso.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 05/03/2022] [Accepted: 05/13/2022] [Indexed: 10/18/2022] Open
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Chuong MD, Bryant JM, Herrera R, McCulloch J, Contreras J, Kotecha R, Romaguera T, Alvarez D, Hall MD, Rubens M, Mehta MP, Kaiser A, Tom M, Gutierrez AN, Mittauer KE. Dose-Escalated Magnetic Resonance Image–Guided Abdominopelvic Reirradiation With Continuous Intrafraction Visualization, Soft Tissue Tracking, and Automatic Beam Gating. Adv Radiat Oncol 2022; 7:100840. [PMID: 35146215 PMCID: PMC8802055 DOI: 10.1016/j.adro.2021.100840] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/01/2021] [Accepted: 10/05/2021] [Indexed: 11/03/2022] Open
Abstract
Purpose Methods and Materials Results Conclusions
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Yamada S, Takiyama H, Isozaki Y, Shinoto M, Ebner DK, Koto M, Tsuji H, Miyauchi H, Sekimoto M, Ueno H, Itabashi M, Ikeda M, Matsubara H. Carbon Ion Radiotherapy for Locally Recurrent Rectal Cancer of Patients with Prior Pelvic Irradiation. Ann Surg Oncol 2021; 29:99-106. [PMID: 34664141 PMCID: PMC8677685 DOI: 10.1245/s10434-021-10876-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 08/18/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND This study aimed to assess the safety and efficacy of carbon-ion radiotherapy (CIRT) for salvage of previously X-ray-irradiated (XRT) locally recurrent rectal cancer (LRRC). METHODS Between September 2005 and December 2017, 77 patients with LRRC were treated with CIRT re-irradiation. All the patients had received prior XRT with a median dose of 50.0 Gy (range 20-74 Gy), principally for neoadjuvant or adjuvant recurrence prophylaxis in 34 patients and for recurrence in 43 patients. The total CIRT dose of 70.4 Gy (RBE) (gray relative biologic effectiveness) was administered in 16 fixed fractions during 4 weeks (4.4 Gy [RBE] per fraction). RESULTS All the patients completed the scheduled treatment course. None of the patients received resection after CIRT. Acute grade 3 toxicities occurred for eight patients (10 %), including five grade 3 pelvic infections (2 involving pain and 1 involving neuropathy). Late grade 3 toxicities occurred for 16 patients (21 %): 13 with late grade 3 pelvic infections, 9 with gastrointestinal toxicity, 1 with skin toxicity, 2 with pain, and 4 with neuropathy. No grade 4+ toxicity was noted. The overall local control rates (infield + out-of-field recurrence) were 69 % at 3 years and 62 % at 5 years. In the planning target volume (PTV), the infield recurrence rates were 90 % and 87 % respectively. The control rates for regional recurrence were 85 % at 3 years and 81 % at 5 years. The median overall survival time was 47 months. The survival rates were 61 % at 3 years and 38 % at 5 years. CONCLUSION Carbon-ion re-irradiation of previously X-ray-irradiated locally recurrent rectal cancer appears to be safe and effective, providing good local control and survival advantage without unacceptable morbidity.
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Affiliation(s)
- Shigeru Yamada
- QST Hospital, National Institutes for Quantum and Radiological Science and Technology, Chiba, Japan.
| | - Hirotoshi Takiyama
- QST Hospital, National Institutes for Quantum and Radiological Science and Technology, Chiba, Japan
| | - Yuka Isozaki
- QST Hospital, National Institutes for Quantum and Radiological Science and Technology, Chiba, Japan
| | - Makoto Shinoto
- QST Hospital, National Institutes for Quantum and Radiological Science and Technology, Chiba, Japan
| | - Daniel K Ebner
- QST Hospital, National Institutes for Quantum and Radiological Science and Technology, Chiba, Japan
| | - Masashi Koto
- QST Hospital, National Institutes for Quantum and Radiological Science and Technology, Chiba, Japan
| | - Hiroshi Tsuji
- QST Hospital, National Institutes for Quantum and Radiological Science and Technology, Chiba, Japan
| | | | | | - Hideki Ueno
- National Defense Medical College, Saitama, Japan
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Johnstone P, Okonta L, Aitken K, Holmes J, Harrison M, Harji D, O'Cathail SM, Taylor C, Tsang Y, Wing M, Muirhead R. A multicentre retrospective review of SABR reirradiation in rectal cancer recurrence. Radiother Oncol 2021; 162:1-6. [PMID: 34182013 DOI: 10.1016/j.radonc.2021.06.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 06/17/2021] [Accepted: 06/21/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND PURPOSE Locally recurrent rectal cancer (LRRC) is associated with considerable morbidity, poor quality of life and an overall survival of 9 months. The non-operative treatment of LRRC is an understudied area, there is no consensus on management in this setting. We aim to perform a retrospective, multicentre analysis of patients treated with SABR reirradiation. MATERIALS AND METHODS All patients were identified who received SABR re-irradiation for LRRC, at 3 UK centres, between August 2015 and September 2020. Eligible patients had pelvic recurrence and were either not suitable/opted not for surgery, or margin positive after exenturative surgery. Patients were treated with 30 Gy in 5 fractions and followed up with clinical review and CT scan at 3, 6, 12, 18 and 24 months. RESULTS 69 patients with 81 lesions were identified and median follow up was 28 months. Median progression free survival (PFS) and overall survival (OS) were 12.1 months (10.4, 17.7) and 38.7 months (28.9,-) respectively. 2-year OS was 0.77 (0.66, 0.89). 58.3% of deaths were as a result of consequences of local relapse. 42.6% of patients had local relapse at death or last follow up. CONCLUSION Our outcomes are encouraging for a population who had R1 resections, refused or were refused surgery; as they are similar to those in surgical series. Prospective data including details of survival, local relapse and QOL; with an optimised SABR technique, is required to establish SABR as an alternative to surgery.
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Affiliation(s)
| | | | | | - Jane Holmes
- Centre for Statistics in Medicine, University of Oxford, UK
| | - Mark Harrison
- Mount Vernon Cancer Centre, Mount Vernon Hospital, Northwood, UK
| | | | | | | | - Yat Tsang
- Mount Vernon Cancer Centre, Mount Vernon Hospital, Northwood, UK
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Dijkstra EA, Mul VEM, Hemmer PHJ, Havenga K, Hospers GAP, Muijs CT, van Etten B. Re-Irradiation in Patients with Recurrent Rectal Cancer is Safe and Feasible. Ann Surg Oncol 2021; 28:5194-5204. [PMID: 34023946 PMCID: PMC8349344 DOI: 10.1245/s10434-021-10070-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 03/11/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND There is no consensus yet for the best treatment regimen in patients with recurrent rectal cancer (RRC). This study aims to evaluate toxicity and oncological outcomes after re-irradiation in patients with RRC in our center. Clinical (cCR) and pathological complete response (pCR) rates and radicality were also studied. METHODS Between January 2010 and December 2018, 61 locally advanced RRC patients were treated and analyzed retrospectively. Patients received radiotherapy at a dose of 30.0-30.6 Gy (reCRT) or 50.0-50.4 Gy chemoradiotherapy (CRT) in cases of no prior irradiation because of low-risk primary rectal cancer. In both groups, patients received capecitabine concomitantly. RESULTS In total, 60 patients received the prescribed neoadjuvant (chemo)radiotherapy followed by surgery, 35 patients (58.3%) in the reRCT group and 25 patients (41.7%) in the long-course CRT group. There were no significant differences in overall survival (p = 0.82), disease-free survival (p = 0.63), and local recurrence-free survival (p = 0.17) between the groups. Patients in the long-course CRT group reported more skin toxicity after radiotherapy (p = 0.040). No differences were observed in late toxicity. In the long-course CRT group, a significantly higher cCR rate was observed (p = 0.029); however, there was no difference in the pCR rate (p = 0.66). CONCLUSIONS The treatment of RRC patients with re-irradiation is comparable to treatment with long-course CRT regarding toxicity and oncological outcomes. In the reCRT group, less cCR was observed, although there was no difference in pCR. The findings in this study suggest that it is safe and feasible to re-irradiate RRC patients.
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Affiliation(s)
- Esmée A Dijkstra
- Department of Medical Oncology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Véronique E M Mul
- Department of Radiation Oncology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Patrick H J Hemmer
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Klaas Havenga
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Geke A P Hospers
- Department of Medical Oncology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Christina T Muijs
- Department of Radiation Oncology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Boudewijn van Etten
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.
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Sorrentino L, Belli F, Valvo F, Villa S, Guaglio M, Scaramuzza D, Gronchi A, Di Bartolomeo M, Cosimelli M. Neoadjuvant (re)chemoradiation for locally recurrent rectal cancer: Impact of anatomical site of pelvic recurrence on long-term results. Surg Oncol 2020; 35:89-96. [DOI: 10.1016/j.suronc.2020.08.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/23/2020] [Accepted: 08/19/2020] [Indexed: 12/11/2022]
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Tselis N, Arnold C, Martin D, Rödel C. Neoadjuvante Radio(chemo)therapie beim Rektumkarzinomrezidiv. COLOPROCTOLOGY 2020. [DOI: 10.1007/s00053-020-00494-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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14
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Abstract
Pulsed low-dose rate radiation therapy has been shown to reduce normal tissue damage while decreasing DNA damage repair in tumor cells. In a cohort of patients treated with palliative or definitive pelvic reirradiation using pulsed low-dose rate radiation therapy, we observed substantial local control and low rates of toxicity.
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15
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Smith T, O'Cathail SM, Silverman S, Robinson M, Tsang Y, Harrison M, Hawkins MA. Stereotactic Body Radiation Therapy Reirradiation for Locally Recurrent Rectal Cancer: Outcomes and Toxicity. Adv Radiat Oncol 2020; 5:1311-1319. [PMID: 33305093 PMCID: PMC7718547 DOI: 10.1016/j.adro.2020.07.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/16/2020] [Accepted: 07/27/2020] [Indexed: 12/29/2022] Open
Abstract
Purpose Stereotactic body radiation therapy (SBRT) has emerged as a potential therapeutic option for locally recurrent rectal cancer (LRRC) but contemporaneous clinical data are limited. We aimed to evaluate the local control, toxicity, and survival outcomes in a cohort of patients previously treated with neoadjuvant pelvic radiation therapy for nonmetastatic locally recurrent rectal cancer, now treated with SBRT. Methods and Materials Inoperable rectal cancer patients with ≤3 sites of pelvic recurrence and >6 months since prior pelvic radiation therapy were identified from a prospective registry over 4 years. SBRT dose was 30 Gy in 5 fractions, daily or alternate days, using cumulative organ at risk dose constraints. Primary outcome was local control (LC). Secondary outcomes were progression free survival, overall survival, toxicity, and patient reported quality of life scores using the EQ visual analog scale (EQ-VAS) tool. Results Thirty patients (35 targets) were included. Median gross tumor volume size was 14.3 cm3. In addition, 27 of 30 (90%) previously received 45 to 50.4 Gy in 25 of 28 fractions, with 10% receiving an alternative prescription. All patients received the planned reirradiation SBRT dose. The median follow-up was 24.5 months (interquartile range, 17.8-28.8). The 1-year LC was 84.9% (95% confidence interval [CI], 70.6-99) and a 2-year LC was 69% (95% CI, 51.8-91.9). The median progression free survival was 12.1 months (95% CI, 8.6-17.66), and median overall survival was 28.3 months (95% CI, 17.88-39.5 months). No patient experienced >G2 acute toxicity and only 1 patient experienced late G3 toxicity. Patient-reported QoL outcomes were improved at 3 months after SBRT (Δ EQ-VAS, +10 points, Wilcoxon signed-rank, P = .009). Conclusions Our study demonstrates that, for small volume pelvic disease relapses from rectal cancer, reirradiation with 30 Gy in 5 fractions is well tolerated and achieves an excellent balance between high local control rates with limited toxicity.
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Affiliation(s)
- Thomas Smith
- Mount Vernon Cancer Centre, East and North Herefordshire NHS Trust, Middlesex, UK
| | - Sean M O'Cathail
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Sabrina Silverman
- Mount Vernon Cancer Centre, East and North Herefordshire NHS Trust, Middlesex, UK
| | | | - Yatman Tsang
- Mount Vernon Cancer Centre, East and North Herefordshire NHS Trust, Middlesex, UK
| | - Mark Harrison
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Maria A Hawkins
- Medical Physics and Biomedical Engineering, University College London and University, London, England, UK.,College London Hospitals NHS Foundation Trust, London, England, UK
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Isozaki Y, Takiyama H, Bhattacharyya T, Ebner D, Kasuya G, Makishima H, Tsuji H, Kamada T, Yamada S. Heavy charged particles for gastrointestinal cancers. J Gastrointest Oncol 2020; 11:203-211. [PMID: 32175123 DOI: 10.21037/jgo.2019.03.14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Carbon ion beams constitute the primary delivery method of heavy ion radiotherapy. It offers improved dose distribution, and enables concentration of dose within target volumes with minimal extraneous exposure of normal tissue, while delivering superior biological effect in comparison with photon and proton technologies. Here, we review the application of this technology to various gastrointestinal cancers.
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Affiliation(s)
- Yuka Isozaki
- Department of Radiation Oncology, Hospital of the National Institute of Radiological Science, National Institutes for Quantum and Radiological Science and Technology, Chiba, Japan
| | - Hirotoshi Takiyama
- Department of Radiation Oncology, Hospital of the National Institute of Radiological Science, National Institutes for Quantum and Radiological Science and Technology, Chiba, Japan
| | - Tapesh Bhattacharyya
- Department of Radiation Oncology, Hospital of the National Institute of Radiological Science, National Institutes for Quantum and Radiological Science and Technology, Chiba, Japan
| | - Daniel Ebner
- Department of Radiation Oncology, Hospital of the National Institute of Radiological Science, National Institutes for Quantum and Radiological Science and Technology, Chiba, Japan
| | - Goro Kasuya
- Department of Radiation Oncology, Hospital of the National Institute of Radiological Science, National Institutes for Quantum and Radiological Science and Technology, Chiba, Japan
| | - Hirokazu Makishima
- Department of Radiation Oncology, Hospital of the National Institute of Radiological Science, National Institutes for Quantum and Radiological Science and Technology, Chiba, Japan
| | - Hiroshi Tsuji
- Department of Radiation Oncology, Hospital of the National Institute of Radiological Science, National Institutes for Quantum and Radiological Science and Technology, Chiba, Japan
| | - Tadashi Kamada
- Department of Radiation Oncology, Hospital of the National Institute of Radiological Science, National Institutes for Quantum and Radiological Science and Technology, Chiba, Japan
| | - Shigeru Yamada
- Department of Radiation Oncology, Hospital of the National Institute of Radiological Science, National Institutes for Quantum and Radiological Science and Technology, Chiba, Japan
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Chung SY, Koom WS, Keum KC, Chang JS, Shin SJ, Ahn JB, Min BS, Lee KY, Kim NK, Yoon HI. Treatment Outcomes of Re-irradiation in Locoregionally Recurrent Rectal Cancer and Clinical Significance of Proper Patient Selection. Front Oncol 2019; 9:529. [PMID: 31275858 PMCID: PMC6593136 DOI: 10.3389/fonc.2019.00529] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 05/31/2019] [Indexed: 12/22/2022] Open
Abstract
Background and Purpose: Majority of patients with locoregionally recurrent rectal cancer will require re-irradation (reRT). This study aimed to analyze the treatment outcomes, particularly infield progression, and severe late toxicity rates after reRT for recurrent rectal cancer and further identify a subgroup of patients who may optimally benefit from reRT. Materials and Methods: Patients with rectal cancer who underwent reRT to the pelvis between January 2000 and December 2017 were included for analysis. Results: The records of 41 patients were retrospectively reviewed. The median follow-up period after reRT was 53.7 months (range 3.5–130.3 months). The 2-year infield progression-free rate (IPFR) was 49.4%. The 2-year overall survival (OS) and progression-free survival (PFS) rates were 55.3 and 28.5%, respectively. Severe late toxicity events occurred in 17 patients, and the median time from reRT to severe late toxicity event was 10.5 months (range 2.3–33.3 months). The 2-year severe late toxicity free-rate (SLTFR) was 55.5%, and the median SLTFR was 33.3 months. Patients who did not experience severe late toxicity events showed a significantly higher number of recurred tumors at the posterior or lateral location compared to axial or anterior location. The selected subgroup with recurrent tumor size <3.3 cm and treated with total reRT dose of >50 Gyab10 (n = 13) showed superior IPFR, OS, and PFS to the other patients. Conclusion: ReRT was a reasonable treatment option for patients with locoregionally recurrent rectal cancer. However, severe late toxicity rates were substantially high. Thus, patients indicated for ReRT with curative dose should be selected properly according to tumor size and location.
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Affiliation(s)
- Seung Yeun Chung
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Woong Sub Koom
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Ki Chang Keum
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Jee Suk Chang
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Sang Joon Shin
- Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Joong Bae Ahn
- Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Byung Soh Min
- Department of Surgery, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Kang Young Lee
- Department of Surgery, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Nam Kyu Kim
- Department of Surgery, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Hong In Yoon
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
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Lee J, Kim CY, Koom WS, Rim CH. Practical effectiveness of re-irradiation with or without surgery for locoregional recurrence of rectal cancer: A meta-analysis and systematic review. Radiother Oncol 2019; 140:10-19. [PMID: 31176204 DOI: 10.1016/j.radonc.2019.05.021] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 05/13/2019] [Accepted: 05/20/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE Re-irradiation might yield local control (LC) or palliation for locoregionally recurrent rectal cancer (LRRC), but iatrogenic complications are a possible hindrance. We aimed to evaluate the efficacy of re-irradiation to determine optimal treatment of LRRC. METHODS We performed a systematic review of PubMed, MEDLINE, Cochrane Library, and Embase. RESULTS A total of 17 studies involving 744 patients with LRRC were included; median OS ranging from 10 to 45 months (median: 24.5 months). Pooled 1-, 2-, and 3-year OS rates for all patients were 76.1%, 49.1%, and 38.3%, respectively. For patients who underwent re-irradiation and surgery (OP group), these pooled rates were 85.9%, 71.8%, and 51.7%, respectively. For patients who underwent re-irradiation but not surgery (non-OP group), pooled 1-, 2-, and 3-year OS rates were 63.5%, 34.2%, and 23.8%, respectively. The OS difference between both groups was significant for all 3 years (P < 0.05). Pooled 1-, 2-, and 3-year LC rates for the OP group were 84.4%, 63.8%, and 46.9%, and for the non-OP group were 72.0%, 54.8%, and 44.6%, respectively, without significant differences. Pooled grade ≥3 acute and late complication rates were 11.7% and 25.5% in the OP and non-OP groups, respectively. Patients who underwent surgery had a higher risk of grade ≥3 late complications (odds ratio: 6.39). Pooled symptomatic palliation rate was 75.2%. CONCLUSIONS Re-irradiation with or without surgery for LRRC showed oncologic and palliative efficacy. Salvage treatment including re-irradiation and surgery showed higher survival, but the late complication was significantly increased with concomitant surgery.
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Affiliation(s)
- Jeongshim Lee
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Republic of Korea; Department of Radiation Oncology, Inha University Hospital, Inha University College of Medicine, Incheon, Republic of Korea
| | - Chul Yong Kim
- Department of Radiation Oncology, Anam Hospital, Korea University Medical College, Seoul, Republic of Korea
| | - Woong Sub Koom
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chai Hong Rim
- Department of Radiation Oncology, Ansan Hospital, Korea University Medical College, Ansan, Republic of Korea.
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19
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Davis BR, Schlosser KA. Management of locally recurrent rectal cancer. SEMINARS IN COLON AND RECTAL SURGERY 2019. [DOI: 10.1053/j.scrs.2019.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Park Y, Kim K, Park HJ, Jeong SY, Park KJ, Han SW, Kim TY, Chie EK. Results of re-irradiation for pelvic recurrence in anorectal cancer patients. Br J Radiol 2019; 92:20180794. [PMID: 30864822 DOI: 10.1259/bjr.20180794] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To evaluate outcomes and toxicity profiles after re-irradiation in patients with pelvic recurrence of anorectal cancer. METHODS 25 anorectal cancer patients who received re-irradiation for pelvic recurrence between 2005 and 2015 were included. For initial treatment, all patients underwent surgical resection and preoperative or postoperative radiotherapy. RESULTS The median follow-up duration was 21.5 months (range, 2.9-84.4). After a median of 43.3 months (range, 11.7-218.5), patients received re-irradiation with a median dose of 45 Gy (range, 36-60). The equivalent dose in 2 Gy fractions (EQD2) of re-irradiation-calculated using α/β = 10 Gy-ranged from 34.5 to 84.0 Gy (median, 46.4). Surgical resection was performed for 11 patients, and 14 patients received concurrent chemotherapy with re-irradiation. The 3-year local progression-free survival was 29.7%. The 3-year overall survival was 49.7%. Concurrent chemotherapy with re-irradiation and re-irradiation doses >50 Gy EQD2α/β=10 were significant prognostic factors for local progression free survival and overall survival according to multivariate analysis. 90% (9 of 10) of patients with symptoms had improvement after re-irradiation. Among 23 patients available for evaluation of late toxicity, 12 developed late toxicities. There were no Grade 4 late toxicities, and 6 patients had Grade 3 late toxicities (small bowel obstruction, bowel perforation and fistula). CONCLUSION Re-irradiation for pelvic recurrence of anorectal cancer improved symptoms of patients but the rate of late toxicity was high. Further investigation for patient selection is required. ADVANCES IN KNOWLEDGE Re-irradiation could be considered as a possible option for pelvic recurrence of anorectal cancer in selected patients.
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Affiliation(s)
- Younghee Park
- 1 Department of Radiation Oncology, Soonchunhyang University Seoul Hospital , Seoul , Republic of Korea
| | - Kyubo Kim
- 2 Department of Radiation Oncology, Ewha Womans University College of Medicine , Republic of Korea
| | - Hae Jin Park
- 3 Department of Radiation Oncology, Hanyang University College of Medicine , Seoul, Republic of Korea
| | - Seung-Yong Jeong
- 4 Department of Surgery, Seoul National University College of Medicine , Seoul , Republic of Korea
| | - Kyu Joo Park
- 4 Department of Surgery, Seoul National University College of Medicine , Seoul , Republic of Korea
| | - Sae-Won Han
- 5 Department of Internal Medicine, Seoul National University College of Medicine , Seoul , Republic of Korea
| | - Tae-You Kim
- 5 Department of Internal Medicine, Seoul National University College of Medicine , Seoul , Republic of Korea
| | - Eui Kyu Chie
- 6 Department of Radiation Oncology, Seoul National University College of Medicine , Seoul , Republic of Korea
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21
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External Beam Re-irradiation in Rectal Cancer. Clin Oncol (R Coll Radiol) 2018; 30:116-123. [DOI: 10.1016/j.clon.2017.11.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 11/17/2017] [Accepted: 11/17/2017] [Indexed: 01/15/2023]
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22
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Kishan AU, Voog JC, Wiseman J, Cook RR, Ancukiewicz M, Lee P, Ryan DP, Clark JW, Berger DL, Cusack JC, Wo JY, Hong TS. Standard fractionation external beam radiotherapy with and without intraoperative radiotherapy for locally recurrent rectal cancer: the role of local therapy in patients with a high competing risk of death from distant disease. Br J Radiol 2017; 90:20170134. [PMID: 28613934 DOI: 10.1259/bjr.20170134] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE We sought to evaluate the effectiveness and safety of utilizing radiotherapy (RT) with standard fractionation, with or without intraoperative RT (IORT), to treat locally recurrent rectal cancer (LRRC). METHODS Retrospective review of 25 patients with LRRC treated with standard fractionation RT from 2005 to 2011. 15 patients (60%) had prior pelvic RT and 10 (40%) had synchronous metastases. The median equivalent dose in 2-Gy fractions was 30 and 49.6 Gy in patients with and without prior RT, respectively. 23 patients (92%) received concurrent chemotherapy and 16 (64%) underwent surgical resection. Eight patients (33.3%, four with and four without prior RT) received IORT. A competing risks model was developed to estimate the cumulative incidence of local failure with death treated as a competing event. RESULTS Median follow-up was 36.9 months after the date of local recurrence. 3-year rates of overall survival (OS), local control (LC) and death with LC were 51.6%, 73.3% and 69.2%, respectively. On multivariable analysis, surgical resection was significantly predictive of improved OS (p < 0.05). If surgical resection were removed from the multivariable model, given the collinearity between IORT delivery and surgical resection, then IORT also became a significant predictor of OS (p < 0.05). Systemic disease at the time of local recurrence was not associated with either LC or OS. No patient had grade ≥3 acute or late toxicity. CONCLUSION RT with standard fractionation is safe and effective in the treatment of patients with LRRC, even in patients with significant risk of systemic disease and/or history of prior RT. Advances in knowledge: The utility of RT with standard fractionation, generally with chemotherapy, in the treatment of LRRC is demonstrated. In this high-risk cohort of patients with a 40% incidence of synchronous metastatic disease, surgical resection of the recurrence was the major predictor of OS, though a benefit to IORT was also suggested. No patients had grade ≥3 acute or late toxicity, though 40% had undergone prior RT, underscoring the tolerability of standard fractionation RT in this setting.
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Affiliation(s)
- Amar U Kishan
- 1 Department of Radiation Oncology, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Justin C Voog
- 2 Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | | | - Ryan R Cook
- 1 Department of Radiation Oncology, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Marek Ancukiewicz
- 2 Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Percy Lee
- 1 Department of Radiation Oncology, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - David P Ryan
- 4 Department of Medical Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Jeffrey W Clark
- 5 Division of General and Gastrointestinal Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - David L Berger
- 5 Division of General and Gastrointestinal Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - James C Cusack
- 6 Division of Surgical Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Jennifer Y Wo
- 2 Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Theodore S Hong
- 2 Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
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Vroomen LGPH, Scheffer HJ, Melenhorst MCAM, van Grieken N, van den Tol MP, Meijerink MR. Irreversible Electroporation to Treat Malignant Tumor Recurrences Within the Pelvic Cavity: A Case Series. Cardiovasc Intervent Radiol 2017; 40:1631-1640. [PMID: 28470395 PMCID: PMC5581368 DOI: 10.1007/s00270-017-1657-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 04/19/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To describe the initial experience with irreversible electroporation (IRE) to treat pelvic tumor recurrences. METHODS A retrospective single-center analysis was performed. Adverse events were recorded using Common Terminology Criteria of Adverse Events (CTCAE) 4.0. Clinical outcome was determined using pain- and general- symptom assessment, including Seddon's peripheral nerve injury (PNI) types. Radiological outcome was evaluated by comparing baseline with three-month 18F-FDG PET-CT follow-up. RESULTS Eight patients (nine tumors [recurrences of primary rectal (n = 4), anal (n = 1), sigmoid (n = 1), cervical (n = 1), and renal cell carcinoma (n = 1)]) underwent percutaneous IRE as salvage therapy. Median longest tumor diameter was 3.7 cm (range 1.2-7.0). One CTCAE grade III adverse event (hemorrhage) and eight CTCAE grade II complications occurred in 6/8 patients: vagino-tumoral fistula (n = 1), lower limb motor loss (n = 3; PNI type II) with partial recovery in one patient, hypotonic bladder (n = 2; PNI types I and II) with complete recovery in one patient, and upper limb motor loss (n = 2; PNI type II) with partial recovery in both patients. No residual tumor tissue was observed at 3-month follow-up. After a median follow-up of 12 months, local progression was observed in 5/9 lesions (4/5 were >3 cm pre-IRE); one lesion was successfully retreated. Debilitating preprocedural pain (n = 3) remained unchanged (n = 1) or improved (n = 2). CONCLUSION IRE may represent a suitable technique to treat pelvic tumor recurrences, although permanent neural function loss can occur. Complete ablation seems realistic for smaller lesions; for larger lesions symptom control should be the focus.
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Affiliation(s)
- L G P H Vroomen
- Department of Radiology and Nuclear Medicine, VU University Medical Center, de Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
| | - H J Scheffer
- Department of Radiology and Nuclear Medicine, VU University Medical Center, de Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - M C A M Melenhorst
- Department of Radiology and Nuclear Medicine, VU University Medical Center, de Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - N van Grieken
- Department of Pathology, VU University Medical Center, de Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - M P van den Tol
- Department of Surgical Oncology, VU University Medical Center, de Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - M R Meijerink
- Department of Radiology and Nuclear Medicine, VU University Medical Center, de Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
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Pelvic Reirradiation for the Treatment of Locally Recurrent Rectal Cancer. CURRENT COLORECTAL CANCER REPORTS 2017. [DOI: 10.1007/s11888-017-0360-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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25
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Tao R, Tsai CJ, Jensen G, Eng C, Kopetz S, Overman MJ, Skibber JM, Rodriguez-Bigas M, Chang GJ, You YQN, Bednarski BK, Minsky BD, Delclos ME, Koay E, Krishnan S, Crane CH, Das P. Hyperfractionated accelerated reirradiation for rectal cancer: An analysis of outcomes and toxicity. Radiother Oncol 2017; 122:146-151. [PMID: 28057329 DOI: 10.1016/j.radonc.2016.12.015] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 11/28/2016] [Accepted: 12/04/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE To evaluate outcomes and toxicity in patients treated with hyperfractionated pelvic reirradiation for recurrent rectal cancer. MATERIALS AND METHODS 102 patients with recurrent rectal adenocarcinoma were treated with pelvic reirradiation with a hyperfractionated accelerated approach, consisting of 1.5Gy twice daily fractions to a total dose of 30-45Gy (median 39Gy), with the most common total dose 39Gy (n=90, 88%). The median dose of prior pelvic radiation therapy (RT) was 50.4Gy (range: 25-63Gy). RESULTS The median follow-up was 40months for living patients (range, 3-150months). The 3-year freedom from local progression (FFLP) rate was 40% and the 3-year overall survival (OS) rate was 39%. Treatment with surgery was significantly associated with improved FFLP and OS, with 3-year FFLP rate of 49% vs. 30% (P=0.013), and 3-year OS rate of 62% vs. 20% (P<0.0001), compared to those without surgery. The actuarial 3-year rate of grade 3-4 late toxicity was 34%; patients who underwent surgery had a significantly higher rate of grade 3-4 late toxicity compared to those without surgery (54% vs. 16%, P=0.001). CONCLUSIONS This large, retrospective, single-institution study shows that hyperfractionated accelerated reirradiation was well tolerated. The rate of FFLP was promising, given that the study comprised heavily pre-treated patients with recurrences. Rates of FFLP and OS were particularly impressive in patients who underwent both reirradiation and surgery.
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Affiliation(s)
- Randa Tao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA; Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, USA.
| | - Chiaojung Jillian Tsai
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA; Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Garrett Jensen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Cathy Eng
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Scott Kopetz
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Michael J Overman
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - John M Skibber
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Miguel Rodriguez-Bigas
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - George J Chang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Yi-Qian Nancy You
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Brian K Bednarski
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Bruce D Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Marc E Delclos
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Eugene Koay
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Sunil Krishnan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Christopher H Crane
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA; Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
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Abstract
For tumors of the lower third of the rectum, the only safe surgical procedure is abdominal-perineal resection. High-dose-rate interstitial brachytherapy is a promising treatment for local recurrence of previously irradiated lower rectal cancer, due to the extremely high concentrated dose delivered to the tumor and the sparing of normal tissue, when compared with a course of external beam radiation therapy.
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Rizzuto A, Palaia I, Vescio G, Serra R, Malanga D, Sacco R. Multivisceral resection for occlusive colorectal cancer: Is it justified? Int J Surg 2016; 33 Suppl 1:S142-7. [PMID: 27398688 DOI: 10.1016/j.ijsu.2016.06.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The only possibility of curative surgery in primary T4, locally advanced, adherent colorectal carcinoma (LAACRC) or recurrent disease with infiltration of adjacent organs is the en bloc resection of the invaded structures to achieve clear surgical margins (R0). The role of extended resections for occlusive LAACRC remains unclear. We report on our experience on Multivisceral resections (MVR) for LAACRC patients between 2003 and 2012. METHODS Twenty-two patients, who were treated with MVR with curative purpose for non-metastatic disease were recruited. General epidemiologic data, clinical findings, surgical treatment and/or multimodal therapy, histo-pathological examination and follow-up were collected. In addition post-operative complications were classified. Patients with occlusive LAACRC (n = 6) were compared to patients with uncomplicated presentation (n = 16) defined according to the UICC classification. RESULTS No statistically significant differences were observed between the two groups, in terms of median age, gender and localization of tumors. R0 resection was performed in 14 (87.5%) patients with uncomplicated tumors and in all patients with occlusive LAACRC. R1 resection was performed in 2/16 (12.5%) patients with uncomplicated disease. No peri-operative mortality was reported in patients of both groups. In the group of uncomplicated tumors, 11 patients (68.7%) were classified as pathological (p)T4 and 5 patients (31.2%) were classified pT3 whereas in the group of occlusive LAACRC the majority of patients were classified as pT4 (83.3%). Lymph node involvement occurred in 9 patients (56.2%) of the fist group and in two patients (33.3%) of the second group, respectively. The 3-year survival rates in all patients with both uncomplicated and occlusive diseases were 58.4% and 33.3%, respectively. The 3-years survival of patients with locally advanced adherent rectal cancer was significantly lower than the observed survival of patients with colon cancer (p < 0.0001). CONCLUSION MVR offers cure (R0 resections) in uncomplicated and obstructive LAACRC with three years survival in 40% of patients. Patients affected by rectal cancer with occlusive disease showed significantly decreased survival in comparison with those affected by colon cancer.
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Affiliation(s)
- Antonia Rizzuto
- Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Italy.
| | - Ilaria Palaia
- Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Italy
| | - Giuseppina Vescio
- Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Italy
| | - Raffaele Serra
- Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Italy
| | - Donatella Malanga
- Department of Experimental and Clinical Medicine, University Magna Græcia of Catanzaro, Italy
| | - Rosario Sacco
- Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Italy
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Magnetic Resonance–Guided High-Intensity Focused Ultrasound Hyperthermia for Recurrent Rectal Cancer: MR Thermometry Evaluation and Preclinical Validation. Int J Radiat Oncol Biol Phys 2016; 95:1259-67. [DOI: 10.1016/j.ijrobp.2016.03.019] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 03/08/2016] [Accepted: 03/16/2016] [Indexed: 11/19/2022]
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Susko M, Lee J, Salama J, Thomas S, Uronis H, Hsu D, Migaly J, Willett C, Czito B, Palta M. The Use of Re-irradiation in Locally Recurrent, Non-metastatic Rectal Cancer. Ann Surg Oncol 2016; 23:3609-3615. [DOI: 10.1245/s10434-016-5250-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Indexed: 11/18/2022]
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Jo S, Choi Y, Park SK, Kim JY, Kim HJ, Lee YH, Oh WY, Cho H, Ahn KJ. Efficacy of Dose-Escalated Radiotherapy for Recurrent Colorectal Cancer. Ann Coloproctol 2016; 32:66-72. [PMID: 27218097 PMCID: PMC4865467 DOI: 10.3393/ac.2016.32.2.66] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 12/23/2015] [Indexed: 11/14/2022] Open
Abstract
Purpose This study aimed to evaluate the effects of radiotherapy (RT) on progression-free survival (PFS) for patients with recurrent colorectal cancer. Methods We reviewed the records of 22 patients with recurrent colorectal cancer treated with RT between 2008 and 2014. The median radiation dose for recurrent disease was 57.6 Gy (range, 45–75.6 Gy). Patients were divided into 2 groups according to the type of RT: patients underwent RT without previous history of irradiation (n = 14) and those treated with secondary RT (reirradiation: n = 8) at the time of recurrence. Results The median follow-up period was 24.9 months (range, 4.5–66.6 months). Progression was observed in 14 patients (including 8 with loco-regional failure and 9 with distant metastases). Distant metastases were related to the RT dose (<70 Gy, P = 0.031). The 2-year loco-regional control (LRC), PFS, and overall survival (OS) rates were 74.6%, 45.1%, and 82.0%, respectively. The LRC rate was not different between the patients treated with RT for the first time and those treated with reirradiation (P = 0.101, 2-year LRC 79.5% vs. 41.7%). However, reirradiation was related to poor PFS (P = 0.022) and OS (P = 0.002). An escalated RT dose (≥70 Gy) was associated with a higher PFS (P = 0.014, 2-year PFS 63.5% vs. 20.8%). Conclusion Salvage RT for locally recurrent colorectal cancer can be offered when surgery is impossible. Dose-escalated RT shows a possible benefit in reducing the risk of progression.
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Affiliation(s)
- Sunmi Jo
- Department of Radiation Oncology, Inje University Haeundae Paik Hospital, Inje University School of Medicine, Busan, Korea
| | - Yunseon Choi
- Department of Radiation Oncology, Inje University Busan Paik Hospital, Inje University School of Medicine, Busan, Korea
| | - Sung-Kwang Park
- Department of Radiation Oncology, Inje University Busan Paik Hospital, Inje University School of Medicine, Busan, Korea
| | - Jin-Young Kim
- Department of Radiation Oncology, Inje University Haeundae Paik Hospital, Inje University School of Medicine, Busan, Korea
| | - Hyun Jung Kim
- Department of Radiation Oncology, Inje University Haeundae Paik Hospital, Inje University School of Medicine, Busan, Korea
| | - Yun-Han Lee
- Department of Radiation Oncology, Yonsei University Health System, Yonsei University College of Medicine, Seoul, Korea
| | - Won Yong Oh
- Department of Radiation Oncology, Inje University Haeundae Paik Hospital, Inje University School of Medicine, Busan, Korea
| | - Heunglae Cho
- Department of Radiation Oncology, Inje University Busan Paik Hospital, Inje University School of Medicine, Busan, Korea
| | - Ki Jung Ahn
- Department of Radiation Oncology, Inje University Busan Paik Hospital, Inje University School of Medicine, Busan, Korea
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Efficacy and toxicity of rectal cancer reirradiation using IMRT for patients who have received prior pelvic radiation therapy. Adv Radiat Oncol 2016; 1:94-100. [PMID: 28740875 PMCID: PMC5506712 DOI: 10.1016/j.adro.2016.02.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 02/12/2016] [Accepted: 02/16/2016] [Indexed: 01/04/2023] Open
Abstract
Purpose Locally recurrent rectal cancer may cause significant morbidity. Prior reports of rectal cancer reirradiation following local recurrence suggest treatment efficacy, with variable rates of late toxicity. Modern techniques including intensity modulated radiation therapy (IMRT) may improve the therapeutic index. We report outcomes for pelvic reirradiation as treatment for rectal cancer using IMRT. Methods and materials The records of 31 patients undergoing reirradiation for rectal cancer between 2004 and 2013 were reviewed. All patients underwent IMRT using an accelerated hyperfractionation (39 Gy in 1.5-Gy fractions delivered twice daily, n=15) or once-daily fractionation technique (median dose, 30.4 Gy; range, 27-40 Gy in 15-22 fractions; n = 16). The median cumulative dose was 77 Gy (range, 59-113), and the median interval from prior pelvic radiation therapy was 39.8 months (range, 10.1-307.6). Treatment intent was palliative in 20 patients and neoadjuvant or adjuvant in 11 patients. Surgery was generally reserved for patients with an isolated local recurrence. Concurrent chemotherapy was administered for 25/31 patients, most frequently capecitabine (n=11) or continuous infusion 5-fluorouracil (n=10). Results Median follow-up was 11.3 months. The prescribed treatment was completed in 29/31 patients (93.5%). Among 18 patients with symptoms attributable to recurrent disease, successful palliation was achieved in 10/18 (55.6%). The rate of grade 2 and grade 3 acute toxicities was 32.3% and 3.2%, respectively. Local control rates at 1 and 2 years were 61.3% and 47.3%, respectively. Median overall survival was 21.9 months, and 1-year survival was 66.7% for patients who had surgical resection versus 58.7% for those who did not (P = .0802). Conclusions Rectal cancer reirradiation using IMRT is well-tolerated in the setting of prior pelvic radiation therapy. Given significant risk of local progression, further dose escalation may be warranted for patients with life expectancy exceeding 1 year.
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Abstract
BACKGROUND Local recurrence after rectal cancer treatment occurs in ≈5% to 10% of patients. Neoadjuvant (chemo)radiotherapy for primary rectal cancer renders treatment of recurrent disease more difficult. OBJECTIVE The purpose of this study was to review contemporary multimodality therapies, including their outcome, for locally recurrent rectal carcinoma after (chemo)radiotherapy and complete surgical resection of primary rectal cancer. DATA SOURCES A comprehensive literature search of PubMed and EMBASE was performed. STUDY SELECTION All English language articles presenting original patient data regarding treatment and the respective outcome of previously irradiated locally recurrent rectal cancer were included. INTERVENTIONS All of the treatment modalities for locally recurrent rectal cancer were reviewed. MAIN OUTCOME MEASURES Primary outcome parameters were local control, metastasis-free survival, and overall survival. Secondary outcome parameters were perioperative morbidity and mortality, and prognostic factors for treatment outcome. RESULTS Of 854 studies, 9 studies and 474 patients with locally recurrent rectal carcinoma were included. Various treatment regimens were used, most with curative intent. Reirradiation was composed of (neo-)adjuvant external beam radiotherapy (with or without concurrent chemotherapy), additional intraoperative radiotherapy, or intraoperative radiotherapy only. Surgical technique highly varied, depending on the extent of the lesion. Radiation toxicity, perioperative morbidity, and mortality were generally acceptable. Outcome was better after curative intent treatment, any surgical resection, and R0 resections in particular. Moreover, reirradiation is associated with increased complete resection rates, which in turn positively affected local control and overall survival. LIMITATIONS Most studies were retrospectively designed, with highly variable therapies, patient populations, and duration of follow-up. CONCLUSIONS A complete resection is the most important prognostic factor and should be the goal of treatment in locally recurrent rectal carcinoma. Reirradiation seems safe and of additional value in reaching a complete resection. Considering the available evidence, at present reirradiation should be given on a case-specific basis, with all of the patients entering an international prospective database.
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Lee DS, Woo JY, Kim JW, Seong J. Re-Irradiation of Hepatocellular Carcinoma: Clinical Applicability of Deformable Image Registration. Yonsei Med J 2016; 57:41-9. [PMID: 26632381 PMCID: PMC4696970 DOI: 10.3349/ymj.2016.57.1.41] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 03/10/2015] [Indexed: 12/14/2022] Open
Abstract
PURPOSE This study aimed to evaluate whether the deformable image registration (DIR) method is clinically applicable to the safe delivery of re-irradiation in hepatocellular carcinoma (HCC). MATERIALS AND METHODS Between August 2010 and March 2012, 12 eligible HCC patients received re-irradiation using helical tomotherapy. The median total prescribed radiation doses at first irradiation and re-irradiation were 50 Gy (range, 36-60 Gy) and 50 Gy (range, 36-58.42 Gy), respectively. Most re-irradiation therapies (11 of 12) were administered to previously irradiated or marginal areas. Dose summation results were reproduced using DIR by rigid and deformable registration methods, and doses of organs-at-risk (OARs) were evaluated. Treatment outcomes were also assessed. RESULTS Thirty-six dose summation indices were obtained for three OARs (bowel, duodenum, and stomach doses in each patient). There was no statistical difference between the two different types of DIR methods (rigid and deformable) in terms of calculated summation ΣD (0.1 cc, 1 cc, 2 cc, and max) in each OAR. The median total mean remaining liver doses (M(RLD)) in rigid- and deformable-type registration were not statistically different for all cohorts (p=0.248), although a large difference in M(RLD) was observed when there was a significant difference in spatial liver volume change between radiation intervals. One duodenal ulcer perforation developed 20 months after re-irradiation. CONCLUSION Although current dose summation algorithms and uncertainties do not warrant accurate dosimetric results, OARs-based DIR dose summation can be usefully utilized in the re-irradiation of HCC. Appropriate cohort selection, watchful interpretation, and selective use of DIR methods are crucial to enhance the radio-therapeutic ratio.
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Affiliation(s)
- Dong Soo Lee
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Joong Yeol Woo
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Won Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Jinsil Seong
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea.
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Troja A, El-Sourani N, Abdou A, Antolovic D, Raab HR. Surgical options for locally recurrent rectal cancer--review and update. Int J Colorectal Dis 2015; 30:1157-63. [PMID: 25989927 DOI: 10.1007/s00384-015-2249-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/08/2015] [Indexed: 02/07/2023]
Abstract
Locally recurrent rectal tumours in the pelvis are found in about 6% following treatment for rectal cancer. This type of tumour can cause serious local complications and symptoms. The aim of modern surgical oncology is to offer a curative treatment option embedded in an interdisciplinary network of specialities to the patient. Due to advancements in surgical techniques and procedures, especially regarding surgical reconstruction, the possibilities of a curative treatment regarding recurrent cancers have been expanded and established. To aim for a curative treatment one must introduce a multimodal therapy including radio- and chemotherapy, and a radical oncological surgery with en bloc resection of the tumour and affected surrounding organs to achieve a R0-resection.
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Affiliation(s)
- A Troja
- University Department of General and Visceral Surgery, European Medical School, Klinikum Oldenburg, Rahel-Strauss-Str.10, Oldenburg, 26133, Germany,
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Amsbaugh MJ, Bhatt N, Hunter T, Gaskins J, Parker L, Metzinger D, Amsbaugh A, Sowards K, El-Ghamry M. Computed tomography planned interstitial brachytherapy for recurrent gynecologic cancer. Brachytherapy 2015; 14:600-5. [PMID: 26087868 DOI: 10.1016/j.brachy.2015.05.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 04/14/2015] [Accepted: 05/18/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE To report outcomes and identify predictors of toxicity in patients undergoing reirradiation with interstitial brachytherapy (ISBT) for recurrent cancers of the female reproductive tract. METHODS AND MATERIALS Twenty-one patients received ISBT performed using (192)Ir sources (10 low dose rate and 11 high dose rate) at our institution between 2009 and 2013. Demographic, disease specific, treatment, toxicity, and outcome data were collected. Kaplan-Meier and proportional hazard models were used to estimate survival and logistic regression to model toxicity. A least absolute shrinkage and selection operator penalty was used to identify relevant predictors of outcome and toxicity. RESULTS Eleven patients had uterine cancer, 7 patients had cervical cancer, and 3 patients had vulvar cancer. One-year actuarial freedom from local-regional failure, progression-free survival (PFS), and overall survival were 71.5%, 66.0%, and 82.2%, respectively. Tumor size was a significant predictor of worse PFS and overall survival (1 cm increase in tumor size = hazard ratio [HR], 1.61; 95% confidence interval [CI]: 1.16, 2.62 for PFS; HR, 2.02; 95% CI: 1.21, 3.38). Grade 3 or higher vaginal, urinary, and rectal toxicity occurred in 28.5%, 9.5%, and 19% of patients, respectively. Urethra D0.1cc predicted for grade 2 or higher urinary toxicity (one equivalent dose in 2 Gy fraction increase = HR, 1.156; 95% CI: 1.001, 1.335). CONCLUSIONS Reirradiation with ISBT is both safe and effective. In patients with recurrent cancer, urethra D0.1cc predicts for increased urinary toxicity. Increased tumor size is a negative prognostic factor in patients receiving ISBT for cancer recurrence.
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Affiliation(s)
- Mark J Amsbaugh
- Department of Radiation Oncology, University of Louisville, Louisville, KY
| | - Neal Bhatt
- Department of Radiation Oncology, University of Louisville, Louisville, KY
| | - Thomas Hunter
- Department of Radiation Oncology, University of Louisville, Louisville, KY
| | - Jeremy Gaskins
- Department of Bioinformatics and Biostatistics, University of Louisville, Louisville, KY
| | - Lynn Parker
- Department of Obstetrics Gynecology and Women's Health, University of Louisville, Louisville, KY
| | - Daniel Metzinger
- Department of Obstetrics Gynecology and Women's Health, University of Louisville, Louisville, KY
| | - Ashley Amsbaugh
- Department of Anesthesia and Perioperative Medicine, University of Louisville, Louisville, KY
| | - Keith Sowards
- Department of Radiation Oncology, University of Louisville, Louisville, KY
| | - Moataz El-Ghamry
- Department of Radiation Oncology, University of Louisville, Louisville, KY.
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Dagoglu N, Mahadevan A, Nedea E, Poylin V, Nagle D. Stereotactic body radiotherapy (SBRT) reirradiation for pelvic recurrence from colorectal cancer. J Surg Oncol 2015; 111:478-82. [PMID: 25644071 DOI: 10.1002/jso.23858] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 11/08/2014] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND OBJECTIVES When surgery is not adequate or feasible, stereotactic body radiotherapy (SBRT) reirradiation has been used for recurrent cancers. We report the outcomes of a series of patients with pelvic recurrences from colorectal cancer reirradiated with SBRT. METHODS The Cyberknife(TM) Robotic Stereotactic Radiosurgery system with fiducial based real time tracking was used. Patients were followed with imaging of the pelvis. RESULTS Four women and 14 men with 22 lesions were included. The mean dose was 25 Gy in median of five fractions. The mean prescription isodose was 77%, with a median maximum dose of 32.87 Gy. There were two local failures, with a crude local control rate of 89%. The median overall survival was 43 months. One patient had small bowel perforation and required surgery (Grade IV), two patients had symptomatic neuropathy (1 Grade III) and one patient developed hydronephrosis from ureteric fibrosis requiring a stent (Grade III). CONCLUSIONS Local recurrence in the pelvis after modern combined modality treatment for colorectal cancer is rare. However it presents a therapeutic dilemma when it occurs; often symptomatic and eventually life threatening. SBRT can be a useful non-surgical modality to control pelvic recurrences after prior radiation for colorectal cancer.
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Affiliation(s)
- Nergiz Dagoglu
- Department of Radiation Oncology, University of Istanbul, Istanbul, Turkey
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Fazeli MS, Keramati MR. Rectal cancer: a review. Med J Islam Repub Iran 2015; 29:171. [PMID: 26034724 PMCID: PMC4431429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 12/24/2014] [Indexed: 11/22/2022] Open
Abstract
Rectal cancer is the second most common cancer in large intestine. The prevalence and the number of young patients diagnosed with rectal cancer have made it as one of the major health problems in the world. With regard to the improved access to and use of modern screening tools, a number of new cases are diagnosed each year. Considering the location of the rectum and its adjacent organs, management and treatment of rectal tumor is different from tumors located in other parts of the gastrointestinal tract or even the colon. In this article, we will review the current updates on rectal cancer including epidemiology, risk factors, clinical presentations, screening, and staging. Diagnostic methods and latest treatment modalities and approaches will also be discussed in detail.
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Affiliation(s)
- Mohammad Sadegh Fazeli
- 1 Associate Professor of Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.
| | - Mohammad Reza Keramati
- 2 Assistant Professor of Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.
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Cai G, Zhu J, Hu W, Zhang Z. Accelerated hyperfractionated intensity-modulated radiotherapy for recurrent/unresectable rectal cancer in patients with previous pelvic irradiation: results of a phase II study. Radiat Oncol 2014; 9:278. [PMID: 25497847 PMCID: PMC4268809 DOI: 10.1186/s13014-014-0278-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Accepted: 11/26/2014] [Indexed: 01/04/2023] Open
Abstract
Background This study was conducted to investigate the local effects and toxicity of accelerated hyperfractionated intensity-modulated radiotherapy for recurrent/unresectable rectal cancer in patients with previous pelvic irradiation. Methods Twenty-two patients with recurrent/unresectable rectal cancer who previously received pelvic irradiation were enrolled in our single-center trial between January 2007 and August 2012. Reirradiation was scheduled for up to 39 Gy in 30 fractions using intensity-modulated radiotherapy plans. The dose was delivered via a hyperfractionation schedule of 1.3 Gy twice daily. Patient follow-up was performed by clinical examination, CT/MRI, or PET/CT every 3 months for the first 2 years and every 6 months thereafter. Tumor response was evaluated 1 month after reirradiation by CT/MRI based on the RECIST criteria. Adverse events were assessed using the National Cancer Institute (NCI) common toxicity criteria (version 3.0). Results The median time from the end of the initial radiation therapy to reirradiation was 30 months (range, 18-93 months). Overall local responses were observed in 9 patients (40.9%). None of the patients achieved a complete response (CR), and 9 patients (40.9%) had a partial response (PR). Thirteen patients failed to achieve a clinical response: 12 (54.5%) presented with stable disease (SD) and 1 (4.5%) with progressive disease (PD). Among all the patients who underwent reirradiation, partial or complete symptomatic relief was achieved in 6 patients (27.3%) and 13 patients (59.1%), respectively. Grade 4 acute toxicity and treatment-related deaths were not observed. The following grade 3 acute toxicities were observed: diarrhea (2 patients, 9.1%), cystitis (1 patient, 4.5%), dermatitis (1 patient, 4.5%), and intestinal obstruction (1 patient, 4.5%). Late toxicity was infrequent. Chronic severe diarrhea, small bowel obstruction, and dysuria were observed in 2 (9.1%), 1 (4.5%) and 2 (9.1%) of the patients, respectively. Conclusions This study showed that accelerated hyperfractionated intensity-modulated radiotherapy significantly relieved local symptoms and led to a promising local response with an acceptable toxicity profile in patients with recurrent/unresectable rectal cancer and previous pelvic irradiation. Innovative treatment regimens should be evaluated in future studies to improve the clinical outcome while avoiding excessive toxicity in patients with recurrent rectal cancer and previous pelvic irradiation.
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Affiliation(s)
- Gang Cai
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, China.
| | - Ji Zhu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, China.
| | - Weigang Hu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, China.
| | - Zhen Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, China.
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Selvaggi F, Fucini C, Pellino G, Sciaudone G, Maretto I, Mondi I, Bartolini N, Caminati F, Pucciarelli S. Outcome and prognostic factors of local recurrent rectal cancer: a pooled analysis of 150 patients. Tech Coloproctol 2014; 19:135-44. [PMID: 25384359 DOI: 10.1007/s10151-014-1241-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 10/04/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Surgery is the only curative treatment in patients with locally recurrent rectal cancer (LRRC). The aim of this study was to evaluate the outcome and the prognostic factors of tumour-free resection margin (R0) and overall survival (OS) in LRRC. METHODS Consecutive LRRC patients observed between 1987 and 2005 in three Italian university hospitals were evaluated. Survival curves were estimated using the Kaplan-Meier method and compared with the log-rank test. In order to identify factors associated with both R0 resection and OS, a logistic regression analysis was performed in patients who underwent surgery with curative intent. RESULTS Out of 150 patients with LRRC, 107 underwent surgery, but since 7 were found to have unresectable disease only 100 underwent surgical resection. Of them, 51 underwent radical and 49 extended resection. Sixty of the 107 patients underwent multimodality treatment. In 61 patients, R0 resection was achieved. Median OS after surgery was 43.4 months. In patients, who had surgery with curative intent, independent variables associated with R0 resection were: surgery for the primary tumour performed in other hospitals (p = 0.042) extended resection (p = 0.025) and use of positron emission tomography (PET) as a staging modality (p = 0.03). Independent variables associated with OS were: post-operative radiotherapy (p = 0.004), stage of the primary tumour (p = 0.004), R0 resection (p = 0.00001), and use of PET (0.02). CONCLUSIONS Resection for LRRC results in improved survival. Other than the well-known prognostic factors R0 resection and OS, PET scan has an independent impact both on OS and R0 resection. It should therefore be included in routine clinical practice when staging LRRC.
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Affiliation(s)
- F Selvaggi
- Unit of General Surgery, Second University of Naples, Piazza Miraglia, 2, 80138, Naples, Italy,
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Guren MG, Undseth C, Rekstad BL, Brændengen M, Dueland S, Spindler KLG, Glynne-Jones R, Tveit KM. Reirradiation of locally recurrent rectal cancer: A systematic review. Radiother Oncol 2014; 113:151-7. [DOI: 10.1016/j.radonc.2014.11.021] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 10/10/2014] [Accepted: 11/15/2014] [Indexed: 10/24/2022]
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Bosman SJ, Holman FA, Nieuwenhuijzen GAP, Martijn H, Creemers GJ, Rutten HJT. Feasibility of reirradiation in the treatment of locally recurrent rectal cancer. Br J Surg 2014; 101:1280-9. [PMID: 25049111 DOI: 10.1002/bjs.9569] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Revised: 03/29/2014] [Accepted: 04/17/2014] [Indexed: 01/26/2023]
Abstract
BACKGROUND Many patients with locally recurrent rectal cancer receive radiotherapy for the treatment of the primary tumour. It is unclear whether reirradiation is safe and effective when a local recurrence develops. The aim of this study was to evaluate the toxicity and oncological outcome of reirradiation in patients with locally recurrent rectal carcinoma. METHODS From March 1994 until December 2013, data on patients with locally recurrent rectal cancer (without distant metastasis) were entered into a database. Patients were reirradiated with a reduced dose of 30 Gy and received an intraoperative electron radiotherapy boost during surgery. Morbidity associated with radiotherapy, postoperative complications and oncological outcome were evaluated. RESULTS Clear margins (R0) were obtained in 75 (55·6 per cent) of the 135 patients who were reirradiated. Forty-six patients developed serious postoperative complications and the 30-day mortality rate was 4·6 per cent. Multivariable analysis showed that margin status was the main factor influencing oncological outcome (hazard ratio for overall survival 2·51 for R1 and 3·19 for R2 versus R0 resection; both P < 0·001). There was no significant difference in survival between the reirradiated group and a group of 113 patients who had full-course irradiation (5-year overall survival rate 34·1 and 39·1 per cent respectively; P = 0·278). Both reirradiation and full-course irradiation were associated with better survival than no irradiation in a historical control group of 24 patients (5-year overall survival rate 23 per cent; P = 0·225 and P = 0·062). CONCLUSION Reirradiation (with concomitant chemotherapy) has few side-effects and complements radical resection of recurrent rectal cancer.
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Affiliation(s)
- S J Bosman
- Departments of Colorectal Surgery, Catharina Hospital, Eindhoven, The Netherlands
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van Dijk IWEM, van Os RM, van de Kamer JB, Franken NAP, van der Pal HJH, Koning CCE, Caron HN, Ronckers CM, Kremer LCM. The use of equivalent radiation dose in the evaluation of late effects after childhood cancer treatment. J Cancer Surviv 2014; 8:638-46. [DOI: 10.1007/s11764-014-0373-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 05/28/2014] [Indexed: 12/25/2022]
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Ng MKY, Leong T, Heriot AG, Ngan SYK. Once-daily reirradiation for rectal cancer in patients who have received previous pelvic radiotherapy. J Med Imaging Radiat Oncol 2013; 57:512-8. [PMID: 23870353 DOI: 10.1111/1754-9485.12057] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2012] [Accepted: 02/10/2013] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The purpose of this study is to assess the efficacy and toxicity using once-daily reirradiation for patients with rectal cancer having received previous pelvic radiotherapy. METHOD Between June 1997 and June 2008, 56 patients were identified having received previous pelvic radiotherapy and received reirradiation for rectal cancer. Reirradiation intent was palliative in 43 patients, and preoperative/postoperative in 13 patients. Eighty per cent of patients received concurrent chemotherapy (n = 45). RESULTS The median dose-fractionation reirradiation schedule was 39.6 Gy in 22 fractions once daily (range 20-39.6 Gy), and the median cumulative radiation dose was 87.3 Gy. Seven patients experienced a grade 3 acute toxicity, with no grade 4 event. Fifty-one patients (91%) completed the treatment and five patients required a treatment break. The overall symptomatic response rate was 88% at three months post-reirradiation. There was one late effect of skin ulceration among patients reirradiated palliatively. Median overall survival was 39 months in patients undergoing radical surgery versus 15 months in patients reirradiated palliatively (P < 0.001). CONCLUSION Once-daily reirradiation to a total dose of ≤39.6 Gy is relatively safe in the treatment of patients with rectal cancer after previous pelvic radiotherapy. It is effective in symptom control and provides an additional option in management of local recurrence.
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Affiliation(s)
- Michael K Y Ng
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.
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Abstract
BACKGROUND Pelvic exenteration is a potentially curative treatment for locally advanced primary or recurrent rectal cancer. OBJECTIVE This systematic review examines the current evidence regarding clinical and oncological outcomes in patients with locally advanced primary and recurrent rectal cancer who undergo pelvic exenteration. DATA SOURCES A literature search of PubMed, Medline, and the Cochrane library was undertaken, and studies published in the English language from January 2000 to August 2012 were identified. STUDY SELECTION Prospective and retrospective studies that report outcomes of pelvic exenteration for primary advanced and locally recurrent rectal cancer with or without subgroup evaluation were included for examination. MAIN OUTCOME MEASURES Oncological outcomes included 5-year survival, median survival, and local recurrence rates. Clinical outcomes included complication rates and perioperative mortality rates. RESULTS A total of 23 studies with 1049 patients were reviewed. The complication rates ranged from 37% to 100% (median, 57%) and the perioperative mortality rate ranged from 0% to 25% (median, 2.2%). The rate of local recurrence ranged from 4.8% to 61% (median, 22%). The median survival for primary advanced rectal cancers was 14 to 93 months (median, 35.5 months) and 8 to 38 months (median, 24 months) for locally recurrent rectal cancer. LIMITATIONS Our review was limited by the small sample sizes from single-institutional studies reporting outcomes over long periods of time with heterogeneity in both the disease and treatments reported. CONCLUSIONS Although the human costs and risks are significant, the potentially favorable survival outcomes make this acceptable in the absence of other effective treatment modalities that would otherwise result in debilitating symptoms that afflict patients who have advanced pelvic malignancy.
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