Postoperative adjuvant radiotherapy in Astler-Coller stages B2 and C rectal cancer

Anemia and long-term outcome in adjuvant and neoadjuvant radiochemotherapy of stage II and III rectal adenocarcinoma: The Freiburg experience (1989-2002)

AIM: To evaluate the long-term outcome of standard 5-FU based adjuvant or neoadjuvant radiochemotherapy and to identify the predictive factors, especially anemia before and after radiotherapy as well as hemoglobin increase or decrease during radiotherapy.

METHODS: Two hundred and eighty-six patients with Union International Contre Cancer (UICC) stage II and III rectal adenocarcinomas, who underwent resection by conventional surgical techniques (low anterior or abdominoperineal resection), received either postoperative (n = 233) or preoperative (n = 53) radiochemotherapy from January 1989 until July 2002. Overall survival (OAS), cancer-specific survival (CSS), disease-free survival (DFS), local-relapse-free (LRS) and distant-relapse-free survival (DRS) were evaluated using Kaplan-Meier, Log-rank test and Cox’s proportional hazards as statistical methods. Multivariate analysis was used to identify prognostic factors. Median follow-up time was 8 years.

RESULTS: Anemia before radiochemotherapy was an independent prognostic factor for improved DFS (risk ratio 0.76, P = 0.04) as well as stage, grading, R status (free radial margins), type of surgery, carcinoembryonic antigen (CEA) levels, and gender. The univariate analysis revealed that anemia was associated with impaired LRS (better local control) but with improved DFS. In contrast, hemoglobin decrease during radiotherapy was an independent risk factor for DFS (risk ratio 1.97, P = 0.04). During radiotherapy, only 30.8% of R0-resected patients suffered from hemoglobin decrease compared to 55.6% if R1/2 resection was performed (P = 0.04). The 5-year OAS, CSS, DFS, LRS and DRS were 47.0%, 60.0%, 41.4%, 67.2%, and 84.3%, respectively. Significant differences between preoperative and postoperative radiochemotherapy were not found.

CONCLUSION: Anemia before radiochemotherapy and hemoglobin decrease during radiotherapy have no predictive value for the outcome of rectal cancer. Stage, grading, R status (free radial margins), type of surgery, CEA levels, and gender have predictive value for the outcome of rectal cancer.

Complications of absorbable pelvic mesh slings following surgery for rectal carcinoma

PURPOSE

To evaluate the intraoperative, postoperative, and long-term complications of an absorbable pelvic mesh sling after surgery for rectal carcinoma.

METHODS

A retrospective review of medical records from April 8, 1991, through April 8, 1996.

RESULTS

Twenty patients with a mean age of 57 (range, 37-79) years underwent pelvic mesh sling placement. The tumor stages were as follows: Stage I, 5; Stage II, 2; Stage III, 11; and Stage IV, 1. A recurrent perianal basal cell carcinoma was not included in the staging group. Surgery consisted of 18 abdominoperineal resections, 1 total proctocolectomy, and one Hartmann's procedure. Mean follow-up was 18 (range, 2-49) months. There were no intraoperative complications related to mesh placement. Twenty-nine complications occurred in 14 patients during the immediate postoperative period. Five were possibly mesh-related and included a pelvic abscess, perineal seroma, toxic perineal wound, pulmonary embolus, and lower extremity deep venous thrombosis, respectively. A mild postoperative ileus developed in 17 patients (85 percent), and a diet was initiated at a mean of seven (range, 4-24) days. Fourteen patients received postoperative radiotherapy with a mean dose of 5,339 (range, 2,500-7,020) cGy delivered in 180-cGy fractions. There were 14 immediate complications caused by radiotherapy in 11 patients, but only two patients required delays in treatment. Two patients had diarrhea alone, six developed perineal dermatitis alone, and three patients had both diarrhea and perineal dermatitis. All patients with diarrhea had received chemoradiation. One patient developed a partial small-bowel obstruction following radiation.

CONCLUSIONS

Absorbable pelvic mesh sling placement can be performed with minimum morbidity and is recommended following surgery for rectal cancer when radiation is anticipated as part of multimodality therapy.

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

BACKGROUND AND PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

The long-term effect of adjuvant postoperative chemoradiotherapy for rectal carcinoma on bowel function

OBJECTIVE

The authors assessed the long-term effect of postoperative chemoradiotherapy on bowel function.

SUMMARY BACKGROUND DATA

Adjuvant postoperative radiation therapy, often combined with chemotherapy, is being used increasingly often for rectal carcinoma. However, the long-term effect of this treatment on bowel function has not been investigated.

METHODS

The records were reviewed of all patients undergoing anterior resection for rectal carcinoma 2 to 5 years previously. During this period, patients with Astler-Coller stage B2 or C tumors generally were given postoperative radiation therapy with chemotherapy, whereas those with earlier stage tumors were not. To minimize possible confounding factors that may have been more common in the group receiving chemoradiotherapy and that may affect bowel function, extensive exclusion criteria were used, such as invasion of contiguous organs, local or distant metastases, use of a dysfunctioning stoma, and anastomotic or pelvic complications. One hundred remaining patients were suitable for inclusion in the study and participated in a telephone questionnaire; 41 patients had postoperative chemoradiotherapy, and 59 did not.

RESULTS

The two groups were well matched for sex, level of anastomosis, and length of follow-up, although the group receiving chemoradiotherapy was slightly younger. The group that had chemoradiotherapy had more bowel movements per day than the group that did not have radiation therapy (median 7 vs. median 2, p < 0.001); the former group had "clustering" of bowel movements more often (42% vs. 3%, p < 0.001), had nighttime movements more often (46% vs. 14%, p < 0.001), had occasional or frequent incontinence more often (39% and 17% vs. 7% and 0%, p < 0.001), wore a pad more often (41% vs. 10%, p < 0.001), and were unable to defer defecation for more than 15 minutes more often (78% vs. 19%, p < 0.001). The group that had chemoradiotherapy also had stool of liquid consistency, used antidiarrheal medications, had perianal skin irritation, were unable to differentiate stool from gas, and needed to defecate again within 30 minutes of a movement significantly more often than the group that did not receive chemoradiotherapy.

CONCLUSION

Adjuvant postoperative chemoradiotherapy for rectal carcinoma has a major long-term detrimental effect on bowel function.