Locally advanced rectal cancer: resection and intraoperative radiotherapy using the flab method combined with preoperative or postoperative radiochemotherapy

Midterm Results of High-Dose-Rate Intraoperative Brachytherapy in the Treatment of Soft Tissue Sarcomas

INTRODUCTION

According to the literature only sparse data are available on the use of high-dose-rate intraoperative brachytherapy (IOHDR-BT) as a boost to external-beam irradiation (EBRT) in combination with a wide resection in patients with high-grade soft tissue sarcomas (STS).

MATERIALS AND METHODS

Applying a retrospective study design, we investigated all patients who between 2010 and 2016 underwent marginal resection of a high-grade STS and intraoperative radiotherapy, followed by EBRT. We included only patients with a traceable follow-up time of at least two years. Of 89 patients, 35 met our inclusion criteria and showed an average follow-up of four years.

RESULTS

We found an overall 2-year local control rate of 94.3%. The local recurrence rate for R0 resections was 6%, whereas recurrences occurred in 13% of R1 resections and in 100% of R2 resections. One affected patient received only intraoperative radiotherapy. The recurrence rate by tumour entity was 36% for LPS, 11% for myxofibrosarcoma and 17% for undifferentiated pleomorphic sarcoma.

CONCLUSION

The treatment regimen consisting of limb-preserving surgery, IORT and pre- or postoperative radiotherapy consistently shows excellent local control rates.

Efficacy and safety of intraoperative radiotherapy in rectal cancer: A systematic review and meta-analysis

BACKGROUND

In recent years, intraoperative radiotherapy (IORT) has been increasingly used for the treatment of rectal cancer. However, the efficacy and safety of IORT for the treatment of rectal cancer are still controversial.

AIM

To evaluate the value of IORT for patients with rectal cancer.

METHODS

We searched PubMed, Embase, Cochrane Library, Web of Science databases, and conference abstracts and included randomized controlled trials and observational studies on IORT vs non-IORT for rectal cancer. Dichotomous variables were evaluated by odds ratio (OR) and 95% confidence interval (CI), hazard ratio (HR) and 95%CI was used as a summary statistic of survival outcomes. Statistical analyses were performed using Stata V.15.0 and Review Manager 5.3 software.

RESULTS

In this study, 3 randomized controlled studies and 12 observational studies were included with a total of 1460 patients, who are mainly residents of Europe, the United States, and Asia. Our results did not show significant differences in 5-year overall survival (HR = 0.80, 95%CI = 0.60-1.06; P = 0.126); 5-year disease-free survival (HR = 0.94, 95%CI = 0.73-1.22; P = 0.650); abscess (OR = 1.10, 95%CI = 0.67-1.80; P = 0.713), fistulae (OR = 0.79, 95%CI = 0.33-1.89; P = 0.600); wound complication (OR = 1.21, 95%CI = 0.62-2.36; P = 0.575); anastomotic leakage (OR = 1.09, 95%CI = 0.59-2.02; P = 0.775); and neurogenic bladder dysfunction (OR = 0.69, 95%CI = 0.31-1.55; P = 0.369). However, the meta-analysis of 5-year local control was significantly different (OR = 3.07, 95%CI = 1.66-5.66; P = 0.000).

CONCLUSION

The advantage of IORT is mainly reflected in 5-year local control, but it is not statistically significant for 5-year overall survival, 5-year disease-free survival, and complications.

Intraoperative radiotherapy: review of techniques and results

Intraoperative radiotherapy (IORT) is a technique that involves precise delivery of a large dose of ionising radiation to the tumour or tumour bed during surgery. Direct visualisation of the tumour bed and ability to space out the normal tissues from the tumour bed allows maximisation of the dose to the tumour while minimising the dose to normal tissues. This results in an improved therapeutic ratio with IORT. Although it was introduced in the 1960s, it has seen a resurgence of popularity with the introduction of self-shielding mobile linear accelerators and low-kV IORT devices, which by eliminating the logistical issues of transport of the patient during surgery for radiotherapy or building a shielded operating room, has enabled its wider use in the community.

Electrons, low-kV X-rays and HDR brachytherapy are all different methods of IORT in current clinical use. Each method has its own unique set of advantages and disadvantages, its own set of indications where one may be better suited than the other, and each requires a specific kind of expertise.

IORT has demonstrated its efficacy in a wide variety of intra-abdominal tumours, recurrent colorectal cancers, recurrent gynaecological cancers, and soft-tissue tumours. Recently, it has emerged as an attractive treatment option for selected, early-stage breast cancer, owing to the ability to complete the entire course of radiotherapy during surgery. IORT has been used in a multitude of roles across these sites, for dose escalation (retroperitoneal sarcoma), EBRT dose de-escalation (paediatric tumours), as sole radiation modality (early breast cancers) and as a re-irradiation modality (recurrent rectal and gynaecological cancers).

This article aims to provide a review of the rationale, techniques, and outcomes for IORT across different sites relevant to current clinical practice.

Intraoperative radiotherapy for locally advanced or locally recurrent rectal cancer: Does it work at all?

BACKGROUND

Intraoperative radiotherapy (IORT) has been given for primary and locally recurrent rectal cancer for 30 years. Still, its effect is not clear.

MATERIAL AND METHODS

PubMed and EMBASE search for papers after 1989 on surgical treatment and external beam radiotherapy (EBRT) for primary advanced and locally recurrent rectal cancer, with and without IORT. From each center the most recent paper was generally selected. Survival and local recurrence at five years was tabulated for the total groups and separate R-stages. Also, the technique for IORT, use of EBRT and chemotherapy as well as surgical approach was registered.

RESULTS

In primary cancer 18 papers from 14 centers were tabulated, including one randomized and five internally comparing studies, as well as seven studies without IORT. In locally recurrent cancer 18 papers from 13 centers were tabulated, including four internally comparing studies and also five without IORT. Overall survival (OS) and local recurrence rate (LRR) were higher for primary cancer compared to recurrent cancer. Patients with R0 resections had better outcome than patients with R1 or R2 resections. For primary cancer OS and LR rate of the total groups and R0 stages was not influenced by IORT. An effect on R1/R2 stages cannot be excluded. The only randomized study (primary cancer) did not show any effect of IORT.

CONCLUSION

IORT does not convincingly improve OS and LR rate for primary and locally recurrent rectal cancer. If there is an effect of IORT, it is small and cannot be shown outside randomized studies analyzing the separate R stages.

Lotus petal perforator flap for reconstruction of an extended chronic presacral defect after radiotherapy and rectal cancer resection

AIM

As a result of their extent and complexity, pelvic wounds after surgery for anorectal malignancy often require a multidisciplinary approach to accomplish closure. This report describes a successful reconstruction using the lotus petal perforator flap.

METHOD

This flap is based on perforators of the internal pudendal artery and was partially depithelialized for plugging the defect.

RESULTS

Wound healing was achieved after 12 days.

CONCLUSION

The lotus petal flap is a relatively simple and successful choice for reconstruction of an extended chronic presacral defect after radiotherapy and rectal cancer resection.

Prospective single-arm study of intraoperative radiotherapy for locally advanced or recurrent rectal cancer

INTRODUCTION

This study aims to evaluate the feasibility and outcomes of intraoperative radiotherapy (IORT) using high-dose-rate (HDR) brachytherapy for locally advanced or recurrent rectal cancers. Despite preoperative chemoradiation, patients with locally advanced or recurrent rectal cancers undergoing surgery remain at high risk of local recurrence. Intensification of radiation with IORT may improve local control.

METHODS

This is a prospective non-randomised study. Eligible patients were those with T4 rectal cancer or pelvic recurrence, deemed suitable for radical surgery but at high risk of positive resection margins, without evidence of metastasis. Chemoradiation was followed by radical surgery. Ten gray (Gy) was delivered to tumour bed via an IORT applicator at time of surgery.

RESULTS

There were 15% primary and 85% recurrent cancers. The 71% received preoperative chemoradiation. R0, R1 and R2 resections were 70%, 22% and 7%, respectively. IORT was successfully delivered in 27 of 30 registered patients (90% (95% confidence interval (CI) = 73-98) ) at a median reported time of 12 weeks (interquartile range (IQR) = 10-16) after chemoradiation. Mean IORT procedure and delivery times were 63 minutes (range 22-105 minutes). Ten patients (37% (95% CI = 19-58) ) experienced grade 3 or 4 toxicities (three wound, four abscesses, three soft tissue, three bowel obstructions, three ureteric obstructions and two sensory neuropathies). Local recurrence-free, failure-free and overall survival rates at 2.5 years were 68% (95% CI = 52-89), 37% (95% CI = 23-61) and 82% (95% CI = 68-98), respectively.

CONCLUSION

The addition of IORT to radical surgery for T4 or recurrent rectal cancer is feasible. It can be delivered safely with low morbidity and good tumour outcomes.

Intraoperative radiotherapy in colorectal cancer: systematic review and meta-analysis of techniques, long-term outcomes, and complications

BACKGROUND

The precise contribution of IORT to the management of locally advanced and recurrent colorectal cancer (CRC) remains uncertain. We performed a systematic review and meta-analysis to assess the value of IORT in this setting.

METHODS

Studies published between 1965 and 2011 that reported outcomes after IORT for advanced or recurrent CRC were identified by an electronic literature search. Studies were assessed for methodological quality and design, and evaluated for technique of IORT delivery, oncological outcomes, and complications following IORT. Outcomes were analysed with fixed-effect and random-effect model meta-analyses and heterogeneity and publication bias examined.

RESULTS

29 studies comprising 14 prospective and 15 retrospective studies met the inclusion criteria and were assessed, yielding a total of 3003 patients. The indication for IORT was locally advanced disease in 1792 patients and locally recurrent disease in 1211 patients. Despite heterogeneity in methodology and reporting practice, IORT is principally applied for the treatment of close or positive margins. When comparative studies were evaluated, a significant effect favouring improved local control (OR 0.22; 95% CI = 0.05-0.86; p = 0.03), disease free survival (HR 0.51; 95% CI = 0.31-0.85; p = 0.009), and overall survival (HR 0.33; 95% CI = 0.2-0.54; p = 0.001) was noted with no increase in total (OR 1.13; 95% CI = 0.77-1.65; p = 0.57), urologic (OR 1.35; 95% CI = 0.84-2.82; p = 0.47), or anastomotic complications (OR 0.94; 95% CI = 0.42-2.1; p = 0.98). Increased wound complications were noted after IORT (OR 1.86; 95% CI = 1.03-3.38; p = 0.049).

CONCLUSIONS

Despite methodological weaknesses in the studies evaluated, our results suggest that IORT may improve oncological outcomes in advanced and recurrent CRC.

Intraoperative radiotherapy for locally advanced rectal cancer

Purpose

Although intraoperative radiotherapy (IORT) is known to be a method that can reduce local recurrence in locally advanced colorectal cancer, it is not widely used. The aim of this study was to report our experience with IORT for locally advanced rectal cancer.

Methods

From 1991 to 1994, nine patients with locally advanced rectal cancer received IORT. External beam radiotherapy was given postoperatively in five patients and preoperatively in three. Seven patients received chemotherapy. IORT was done with 6-MeV or 9-MeV electrons, and 12 Gy was irradiated at the tumor bed. The median follow-up period was 84 months (range, 15 to 208 months).

Results

The median age of patients was 51 years (range, 42 to 73 years). All patients had advanced clinical T-stage (cT3/4) cancer. The overall and the disease-free survival rates were 66.7% and 66.7% at 5 years, respectively. One patient developed a local recurrence near the anastomosis site, which was out of the IORT field. Four patients died before the last follow-up; three from distant metastasis and one from secondary primary cancer. Adverse effects related to IORT did not occur.

Conclusion

Although the number of patients was small in this study, IORT is thought to be safe and effective in reducing local recurrence in locally advanced rectal cancer. However, the role of IORT should be refined in the era of preoperative radio-chemotherapy followed by total mesorectal excision.

Evidence and research in rectal cancer

The main evidences of epidemiology, diagnostic imaging, pathology, surgery, radiotherapy, chemotherapy and follow-up are reviewed to optimize the routine treatment of rectal cancer according to a multidisciplinary approach. This paper reports on the knowledge shared between different specialists involved in the design and management of the multidisciplinary ESTRO Teaching Course on Rectal Cancer. The scenario of ongoing research is also addressed. In this time of changing treatments, it clearly appears that a common standard for large heterogeneous patient groups have to be substituted by more individualised therapies based on clinical-pathological features and very soon on molecular and genetic markers. Only trained multidisciplinary teams can face this new challenge and tailor the treatments according to the best scientific evidence for each patient.

intraoperative radiation therapy part 2. Clinical results

Intraoperative radiation therapy (IORT) has been used for over 30 years in Asia, Europe and America as a supplementary activity in the treatment of cancer patients with promising results. Modern IORT is carried out with electron beams (IOERT) produced by a linear accelerator generally used for external beam irradiation (EBRT) or a specialized mobile electron accelerator. HDR brachytherapy (HDR-IORT) has also been applied on selected locations. Retrospective analysis of clinical experiences in cancer sites such as operable pancreatic tumour, locally advanced/recurrent rectal cancer, head and neck carcinomas, sarcomas and cervical cancer are consistent with local tumour control promotion compared to similar clinical experiences without IORT. New emerging indications such as the treatment of breast cancer are presented. The IORT component of the therapeutical approach allows intensification of the total radiation dose without additional exposure of healthy tissues and improves dose-deposit homogeneity and precision. Results of the application of IORT on selected disease sites are presented with an analysis on future possibilities. To improve the methodology, clinical trials are required with multivariate analysis including patient, tumour and treatment characteristics, prospective evaluation of early and late toxicity, patterns of tumour recurrence and overall patient outcome.

Intraoperative radiation therapy first part: rationale and techniques

Intraoperative radiotherapy (IORT) is a technique where a high, single-fraction radiation dose is delivered during a surgical procedure to macroscopic tumours or tumour beds with minimal exposure of surroundings tissues which are displaced and shielded during the procedure. In this paper, the rationale for and use of IORT, both with electron beams (IOERT) and high-dose-rate brachytherapy (HDR-IORT) are discussed. For most tumours, the likelihood of obtaining local control (LC) improves when increasing doses can be administered. In many clinical situations, however, the dose that can be delivered safely to the tumour target is limited by the risk of damaging normal tissues. Special consideration is therefore given on this paper to the relationship between dose, LC and possible complications. Criteria for patient's selection and evaluation and information on sequencing and techniques are presented as well as some considerations on the need for a proper programme on quality assurance and periodical reporting of data.

Primary and secondary reconstruction after surgery of the irradiated pelvis using a gracilis muscle flap transposition

INTRODUCTION

The aim of this study is to describe our experience with reconstruction of pelvic defects after surgery for previously irradiated malignancies using a gracilis muscle flap transposition.

PATIENTS AND METHODS

Between 1993 and 2002, 25 patients were treated by primary (n=7) or secondary reconstruction (n=18) using a gracilis muscle transfer. All patients were previously irradiated with a median dosage of 50 Gy.

RESULTS

Direct reconstruction following resection of the tumour was accompanied with minor complications in three patients and without major complications. Median time to complete healing of the donor site and perineal defect was 11 and 46 days, respectively. Reconstruction of persistent perineal infections resulted in minor complications at the donor site (n=3) and at the perineal wound (n=11). Three patients experienced a major complication. Median time to complete healing of the donor site and perineal defect was, respectively, 17 and 190 days. Necrosis of the gracilis muscle flaps was not observed.

CONCLUSION

Direct reconstruction with a gracilis transfer resulted in primary wound healing with low morbidity, hereby preventing potentially disabling persistent defects. After debridement of persistent wounds, indirect reconstruction with gracilis muscle resulted in the majority of patients in healing of the defects with acceptable morbidity.

Determination of operation time in colorectal diseases: Preoperative chemotherapy application

BACKGROUND

Our aim was to determine the time it takes for wound healing to return to normal in cases where patients have undergone preoperative chemotherapy.

MATERIALS AND METHODS

Eighty-four Wistar-albino rats were included in the study. Twelve of them were placed in the control group (Group I), with no further drug administration. Another 12 rats were placed in a sham group (Group II) and were peritoneally injected with 1 cc of isotonic saline solution 5 days a month, for a period of 6 months. The remaining 60 rats were placed in five chemotherapy groups (Groups III-VII) and were administered 20 mg/kg 5-fluorouracil through peritoneal injection, 5 days a month for a period of 6 months. At the end of the sixth cure, 12 rats from the control (Group I), sham (Group II), and chemotherapy groups (Group III) were operated on, and an intestinal transsection was applied to the rectosigmoid junction, followed by one-by-one anastomosis using 5/0 vicryl. Other groups (Groups IV-VI) with chemotherapy treatment were operated on at 1-week intervals and subjected to the same procedure. The subjects were reoperated on on the eleventh day. A full-layer 4 x 4 cm piece was removed from the abdominal wall containing the previous incision line at the middle, for tensile strength pressure measurements. In addition, a 4 cm colon segment was removed for bursting pressure measurements. Plasma albumin and tissue hydroxyproline levels were measured, and fibroblast numbers were counted in the sections prepared from the abdominal wall.

RESULTS

The control and sham groups were found to be similar to each other with respect to all parameters measured (P > 0.05). Significant reductions were observed in all parameters in the early chemotherapy groups compared with the control and sham groups (P <0.05). All parameters measured in Groups V, VI, and VII were found to be similar to those in the control and sham groups (P <0.05).

CONCLUSION

Wound healing is impaired in rats with chemotherapy, but following the second week after the chemotherapy, disrupted parameters return to their normal levels.

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

INTRODUCTION

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

AIM

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

MAIN OUTCOME MEASURE

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

RESULTS

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

CONCLUSIONS

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

Evidence supports adjuvant radiotherapy in selected patients with rectal cancer

BACKGROUND

Much recent data have been published on the risk of local recurrence (LR) following curative surgery for rectal cancer and the impact of adjuvant radiation therapy (RT). With improvements in surgical technique apparently reducing the risk of LR, the relevance of older data upon which the current recommendations for adjuvant RT are based has been questioned.

METHODS

A focused review was undertaken of the published literature on the risk of LR following surgery for rectal cancer and the impact of adjuvant radiation. In particular the authors attempt to define how accurately the risk for an individual patient can be predicted, trends in reported LR rates over the time period of randomized trials, and the relevance of changing surgical and RT techniques.

RESULTS

Many of the perceived differences in published results can be explained by variations in study entry criteria, length of follow up and data recording. Comparisons between studies are most accurate when defined subsets of patients, such as those with stage III disease, followed for the same period of time, are considered. In parallel with improvements in surgical technique, which may have reduced the risk of LR, modifications to RT delivery have resulted in recent series not reporting an increased mortality in those patients treated with modern RT techniques.

CONCLUSION

All of the available evidence supports the use of adjuvant RT in selected patients with rectal cancer. Ongoing studies will better define individual patient risk and the risk-benefit ratio of adjuvant RT.

High-dose-rate intraoperative radiotherapy for close or positive margins in patients with locally advanced or recurrent rectal cancer

PURPOSE

A high-dose-rate intraoperative radiotherapy (HDR-IORT) technique for rectum cancer was developed and the technique, local failure, and survival were analyzed.

METHODS AND MATERIALS

After the exclusion of metastatic patients, 37 patients were treated with external beam RT, surgery, and HDR-IORT between 1997 and 2000. Primary locally advanced rectum cancer was found in 18 patients and recurrent disease in 19. HDR-IORT was only administered if the resection margins were < or =2 mm. The flexible intraoperative template is a 5-mm-thick pad with 1-cm-spaced parallel catheters. Clips were placed during surgery to define the target area. A dose of 10 Gy was prescribed at a 1 cm depth from the template surface and calculated using standard plans. After treatment, the dose at the clips was calculated using the reconstructed template geometry and the actual treatment dwell times. The median follow-up of surviving patients was 3 years. No patients were lost to follow-up.

RESULTS

Overall, 12 patients (32%) had local recurrence, 5 (14%) of which were in the HDR-IORT field. The 3-year local failure rate for primary tumors and recurrent tumors was 19% and 52%, respectively (p = 0.0042). The 3-year local failure rate was 37% for negative margins and 26% for positive margins (p = 0.51). A high mean dose at the clip (17.3 Gy) was found. The overall survival was significantly different for primary vs. recurrent tumors, stage, and grade.

CONCLUSION

Because of the HDR technique, a high dose at the clips was found, with good local control. More out-of-field than in-field failures were seen. The local failure rate was significantly different for primary vs. recurrent disease.

Intraoperative HDR brachytherapy for rectal cancer using a flexible intraoperative template: standard plans versus individual planning

HDR intraoperative brachytherapy (IOBT) is applied to locally advanced rectal tumors using a 5 mm thick flexible intraoperative template (FIT). To reduce the procedure time, treatment planning is performed using standard plans that neglect the curvature of the FIT. We have calculated the individual treatment plan, based on the real geometry of the FIT, and the dose at clips placed during surgery. A mean treatment dose of 9.55+/-0.21 Gy was found for the individual plan, compared to the prescribed 10 Gy (P<0.0001) The mean central dose was 10.03+/-0.10 Gy in the standard plan and 9.20+/-0.32 Gy in the individual plan (P<0.0001) The mean dose at the corners of the FIT was 10.3 Gy in the standard plan and ranged between 10.3 and 10.5 Gy in the individual plan. In 63% of the clips, the dose was larger than 15.0 Gy, which is equivalent to a gap between the FIT and the target smaller than 5 mm. In 18% of the clips, the dose was smaller than 13.0 Gy indicating that locally the gap was larger than 5 mm. Clinical practice will have to prove if these small dose deviations influence the clinical outcome.

Intraoperative high-dose-rate brachytherapy

Although several modalities have been discussed, a comprehensive intraoperative program should have IOERT, IOHDR, and perioperative brachytherapy facilities available to treat all sites. Interstitial brachytherapy is preferable for the treatment of gross residual tumor; IORT (IOERT for accessible sites and IOHDR for poorly accessible sites) is added to irradiate intraoperatively the surrounding margins after gross resection; and fractionated EBRT could be used in moderate doses post-operatively to irradiate the entire area of potential microscopic disease. Depending on the volume and location of the tumor, and the available expertise and equipment, IOERT, IOHDR, or perioperative brachytherapy could be used along with EBRT and surgery for the optimal management of malignancies. Finally, the best results of IOHDR are obtained when used as a conformal boost to the tumor bed after resection in conjunction with supplementary EBRT.

Fractionated perioperative high dose rate brachytherapy using a tissue equivalent bendy applicator

Intraoperative radiation techniques allow an additional local dose in areas at high-risk for local failure. With brachytherapy techniques, perioperative radiation can be fractionated. Fractionated treatment might offer an interesting alternative to a single dose, both to increase the therapeutic ratio and to protect late reacting tissues at risk. The dose distribution for brachytherapy applicators can be optimized using spacer materials. In this prospective study a new tissue equivalent bendy applicator (TEBA) that can remain in situ for several days is introduced, and the feasibility of fractionated perioperative high dose rate (HDR) brachytherapy is examined. 31 patients with different tumours (soft tissue sarcoma, Ewings sarcoma, rectal cancer, and locally infiltrating diseases) were treated. The TEBA was applied, depending on resection status and intraoperative findings. Planning was based on digitized radiographs and CT scans. Perioperative HDR brachytherapy was performed using an individual treatment schedule. In 29 patients perioperative radiation was given and in 26 cases fractionated brachytherapy application was possible. TEBA application time varied from 1 day to 11 days. During this time between 1 and 8 fractions were given with total doses from 10 Gy to 25 Gy. Fractionated perioperative brachytherapy with this technique is feasible and adequate. Further studies will show whether fractionated perioperative treatment using the TEBA technique fulfils its theoretical advantages over single dose intraoperative radiotherapy by decreased late toxicity and increased local tumour control.

High-dose-rate intraoperative irradiation: current status and future directions

Intraoperative irradiation (IORT) refers to the delivery of a single high dose of radiation therapy at the time of surgery when the tumor bed can be precisely defined and adjacent normal tissue maximally protected. It can be effectively delivered using either electrons (IOERT) or photons produced from a high-dose-rate gamma emitting radioisotope (HDR-IORT) and has been explored primarily for locally advanced or recurrent tumors at high risk for local failure despite extensive resection and full dose external beam radiation. With coordinated multidisciplinary interaction, IORT can be integrated in a combined-modality setting without undue additional toxicity. The purpose of this review will be to summarize the growing HDR-IORT experience in the treatment of various cancers, to compare its efficacy and toxicity vis a vis the IOERT data, and to discuss future trials as well as new areas of potential application.

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

AIMS

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Intraoperative radiotherapy for gastrointestinal cancer

Local recurrence following potentially curative tumor resection is a major problem in patients with gastrointestinal cancer. To augment surgical excision and to avoid the disadvantages of external beam irradiation, intraoperative radiotherapy (IORT) has been applied to primary and recurrent gastrointestinal cancer, both with curative intent and for palliation. There is ample evidence that the combination of radical surgery and IORT can improve local control. Whether this eventually can translate into improved overall survival has not yet been studied in adequately powered randomized and controlled trials.

Functional and quality-of-life outcomes in patients with rectal cancer after combined modality therapy, intraoperative radiation therapy, and sphincter preservation

PURPOSE

Locally advanced primary and recurrent rectal cancers treated with external beam radiation therapy, intraoperative radiation therapy, and chemotherapy represent a complex group of patients in the setting of extensive pelvic surgery and sphincter preservation. We sought to define functional outcome and quality of life in this subset of patients.

METHODS

We retrospectively reviewed our experience with locally advanced primary and recurrent rectal cancer patients who underwent intraoperative radiation therapy with either low anterior resection (n = 12) or coloanal anastomosis (n = 6) between 1991 and 1998. Current functional outcome and quality of life were evaluated by a detailed questionnaire.

RESULTS

Median time from operation to assessment was 24 (range, 6-93) months. Using a standardized Sphincter Function Scale, incorporating the number of bowel movements per day and degree of incontinence, patients were graded as poor, fair, good, or excellent function. Of all patients, 56 percent reported unfavorable (poor or fair) function. Of the subset of patients with coloanal anastomosis or very low low anterior resection, 88 percent had unfavorable function as compared with 30 percent with standard low anterior resection. (P = 0.02; Fisher's exact probability test). A quality-of-life satisfaction score based on social, professional, and recreational restrictions demonstrated 56 percent of patients to be dissatisfied with their bowel function.

CONCLUSIONS

The majority of patients with advanced rectal cancers who require external beam radiation therapy, extensive pelvic surgery, and intraoperative radiation therapy report unfavorable functional and quality-of-life outcomes after sphincter preservation. In this setting patients being considered for coloanal anastomosis or very low anterior resection may be better served by permanent diversion.

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

PURPOSE

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

METHODS AND MATERIALS

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

RESULTS

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

CONCLUSION

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

Pelvic exenteration for advanced pelvic malignancy

Pelvic exenteration is a demanding, yet potentially curative operation, for patients with advanced pelvic cancer. The majority will present with recurrence after prior surgery and radiotherapy. After exenteration, 5-year survival is 40% to 60% in patients with gynecologic cancer as compared to 25% to 40% for patients with colorectal cancer. Physiologic age and absence of co-morbidities appear to be more important when selecting patients for exenteration than chronological age. Careful pre-operative staging, including either computed tomography (CT) scan or magnetic resonance imaging (MRI), usually will identify patients with distant metastases, extrapelvic nodal disease, or disease involving the pelvic sidewall (which generally precludes surgery). The recent application of intra-operative radiotherapy or postoperative high-dose brachytherapy for patients with more advanced pelvic disease, which may include sidewall involvement, may expand the standard indications for exenteration. However, the intent of this procedure, with or without radiotherapy, should be resection of all tumor with the aim of cure since the place of palliative exenteration is controversial at best. The operative details of exenteration are presented, as are two surgical approaches to composite resection of pelvic structures in continuity with sacrectomy. Filling the pelvis with large tissue flaps, usually a rectus abdominus flap, has decreased morbidity rates, particularly with small bowel complications. Peri-operative mortality is usually 5% to 10%, and significant morbidity occurs in over 50% of patients. Restorative techniques for both urinary and gastrointestinal tracts can diminish the need for stomas and, along with vaginal reconstruction, can significantly improve quality of life for many patients after exenteration. These advances in surgery and radiotherapy help make the procedure a viable option for patients with otherwise incurable pelvic malignancy.

Neoadjuvant therapy in the treatment of high risk rectal carcinoma

The management of rectal cancer remains a challenging and controversial area of surgical oncology. The spectre of local recurrence, with its' poor prognostic and palliative outcomes, is known to be highly dependent on operative technique and to vary widely between surgeons. The roles of radiotherapy and chemotherapy have been the subject of trials for 30 years and yet no consensus on treatment exists. In this review article we will summarise the evolution of radiotherapy and chemoradiation in the treatment of rectal cancer and evaluate the evidence available for the use of "neoadjuvant" chemoradiation. In particular, the role of adjuvant therapies in the setting of total mesorectal excision will be discussed.

Immediate reconstruction of the perineal wound with gracilis muscle flaps following abdominoperineal resection and intraoperative radiation therapy for recurrent carcinoma of the rectum

BACKGROUND

Morbidity associated with a nonhealing perineal wound is the most common complication following proctectomy, particularly in the setting of recurrent carcinoma of the rectum and radiation therapy. Immediate reconstruction using the gracilis myocutaneous and muscle flaps significantly reduces the incidence of major infection associated with perineal wound closure. The purpose of this study was to assess the value of immediate reconstruction of the perineal wound using a gracilis flap in patients undergoing abdominoperineal resection and intraoperative radiation therapy.

METHODS

This study retrospectively reviewed our experience with immediate pelvic reconstruction using gracilis muscle flaps for patients undergoing rectal extirpation and irradiation for recurrent carcinoma of the rectum. From 1990 to 1995, 16 patients underwent abdominoperineal resection (APR) or pelvic exenteration accompanied by immediate wound closure with unilateral or bilateral gracilis muscle flaps. Morbidity and mortality outcomes were compared to those of 24 patients from our institution who, between 1988 and 1992, underwent proctectomy and irradiation for recurrent rectal carcinoma with primary closure of the perineal wound.

RESULTS

Major complications (i.e., major infection requiring hospitalization and/or operation) occurred in 2 (12%) of the patients with gracilis flaps versus 11 (46%) of the patients with primary closure (P = .028 by chi2 analysis for flap vs. primary closure). Minor complications (i.e., persistent sinus and subcutaneous abscess) occurred in 4 (25%) of the patients with gracilis flaps versus 5 (21%) of those with primary closure.

CONCLUSION

Immediate perineal reconstruction using the gracilis myocutaneous flap following proctectomy and irradiation for recurrent rectal carcinoma significantly reduces the incidence of major infection associated with perineal wound closure.

High dose rate intraoperative radiation therapy (HDR-IORT) as part of the management strategy for locally advanced primary and recurrent rectal cancer

PURPOSE

Primary unresectable and locally advanced recurrent rectal cancer presents a significant clinical challenge. Local failure rates are high in both situations. Under such circumstances, there is a significant need to safely deliver tumoricidal doses of radiation in an attempt to improve local control. For this reason, we have incorporated a new approach utilizing high dose rate intraoperative radiation therapy (HDR-IORT).

METHODS AND MATERIALS

Between 11/92-12/96, a total of 112 patients were explored, of which 68 patients were treated with HDR-IORT, and 66 are evaluable. The majority of the 44 patients were excluded for unresectable disease or for distant metastases which eluded preoperative imaging. There were 22 patients with primary unresectable disease, and 46 patients who presented with recurrent disease. The histology was adenocarcinoma in 64 patients, and squamous cell carcinoma in four patients. In general, the patients with primary unresectable disease received preoperative chemotherapy with 5-fluorouracil (5-FU) and leucovorin, and external beam irradiation to 4500-5040 cGy, followed by surgical resection and HDR-IORT (1000-2000 cGy). In general, the patients with recurrent disease were treated with surgical resection and HDR-IORT (1000-2000 cGy) alone. All surgical procedures were done in a dedicated operating room in the brachytherapy suite, so that HDR-IORT could be delivered using the Harrison-Anderson-Mick (HAM) applicator. The median follow-up is 17.5 months (1-48 mo).

RESULTS

In primary cases, the actuarial 2-year local control is 81%. For patients with negative margins, the local control was 92% vs. 38% for those with positive margins (p = 0.002). The 2-year actuarial disease-free survival was 69%; 77% for patients with negative margins vs. 38% for patients with positive margins (p = 0.03). For patients with recurrent disease, the 2-year actuarial local control rate was 63%. For patients with negative margins, it was 82%, while it was 19% for those with positive margins (p = 0.02). The disease-free survival was 47% (71% for negative margins and 0% for positive margins) (p = 0.04). Prospective data gathering indicated that significant complications occurred in approximately 38% of patients and were multifactorial in nature, and manageable to complete recovery.

CONCLUSION

HDR-IORT using our technique is versatile, safe, and effective. The local control rates for primary disease compare quite well with other published series, especially for patients with negative margins. For patients with recurrent disease, locoregional control and survival are especially encouraging in patients with negative resection margins. Further follow-up is needed to see whether these encouraging data will continue.

Intraoperative high dose rate brachytherapy in recurrent or metastatic colorectal carcinoma

BACKGROUND

The survival of patients with recurrent or metastatic colorectal cancer usually is less than 12 months. In an attempt to improve this dismal prognosis, we investigated the role of intraoperative high dose rate brachytherapy (IOHDR) in the management of these patients.

METHODS

From April 1992 to December 1996, 26 patients with locally recurrent or metastatic colorectal carcinoma were treated with maximal surgical resection and IOHDR. Intraoperative radiation dose ranged from 10 to 20 Gy, prescribed at 0.5 cm depth. The residual tumor irradiated was microscopic in 16 patients (62%) and gross residual in 10 patients (38%). Six patients received postoperative external beam radiation therapy.

RESULTS

After a median follow-up of 28 months (range 6 to 54 months), seven of 15 evaluable patients (47%) failed in the area treated with IOHDR. The median time to local failure was 21 months (range 4 to 52 months). The median survival was 23 months (microscopic 24 months; gross 17 months), with a 4-year actuarial survival rate of 36%. Major morbidity was observed in 7 patients (47%) and usually was surgery-related.

CONCLUSION

The use of IOHDR in association with radical resection increases local control in patients with recurrent or metastatic colorectal cancer. Patients with microscopic residual disease achieved a better result than do those with gross residual disease. Future strategies include the addition of limited EBRT dose to IOHDR, even for previously irradiated patients.

Preliminary results of a phase I/II study of post-operative high-dose rate brachytherapy for advanced or recurrent pelvic tumours

Electron beam intraoperative radiation therapy (EB-IORT) and intraoperative low-dose rate brachytherapy (IOLB) seem able to improve the local control of advanced or recurrent pelvic tumours (ARPT). We report the usefulness, technical considerations and potential advantages of employing post-operative high-dose rate brachytherapy (POHB) as a treatment for ARPT. From February 1995 to February 1997, 14 patients underwent POHB for ARPT. The mean age was 58 years (range: 37-74). Six patients presented with recurrent rectal carcinoma, three with cervix carcinoma (one primary T3; two recurrences), two with bladder carcinoma (one primary T4; one recurrence), one with prostate carcinoma, one with recurrent pre-sacral lymphoma and one with undifferentiated carcinoma. At the time of resection, blind-end HDR catheters were implanted in a single plan in the tumour bed and stabilized by absorbable sutures. Eight days later, POHB delivered 20Gy in 5 fractions or 40Gy in 10 fractions for advanced and recurrent tumours, respectively. To decrease the incidence of late side-effects, a change was made after the tenth patient to deliver 2 Gy per fraction twice a day, with an interval of 6 h between each fraction. With a median follow-up of 8 months (range: 1-22), local control was achieved in all cases. Six patients developed metastatic disease. One patient presented a perineal wound dehiscence requiring surgery 2 months after POHB. POHB is feasible for patients with recurrent or advanced pelvic diseases, and appears more cost-effective than EB-IORT for dosimetric and radiobiological considerations. Compared with IOLB, POHB allows the total radioprotection of the medical staff, and, in the context of cost reduction, a reduction of the overall time of hospitalization.

Aggressive multimodality treatment for locally advanced irresectable rectal cancer

BACKGROUND

Local failure rates are high for locally irresectable primary or recurrent colorectal cancer, even when chemoradiation therapy is employed.

AIM

This review evaluates evidence supporting aggressive preoperative chemoradiation followed by maximal surgical resection and intraoperative radiation therapy to achieve disease control and cure for patients with locally advanced irresectable primary or recurrent rectal cancer.

RESULTS

A 5-year survival rate of 42 per cent with a central failure rate of 2 per cent may be achieved in patients with locally irresectable primary rectal cancer. In patients with locally recurrent disease, these values at 5 years are 18 and 28 per cent respectively. The 5-year incidence of distant metastasis remains high, affecting 64 per cent of patients with primary cancer and 75 per cent of those with recurrent cancer.

CONCLUSION

A disease-free surgical resection margin remains paramount to achieve cure. Encouraging trends exist, however, for further evaluation of multimodality therapy as a means of reducing local recurrence of disease.