The postoperative adjuvant radiation therapy and radiochemotherapy for UICC stage II and III rectal cancer. A retrospective analysis

The importance of a multidisciplinary team in rectal cancer management

INTRODUCTION

The aim of this study was to evaluate the impact of the interval between surgery and adjuvant treatments regarding the overall survival and recurrence-free survival in patients from a developing country. For stages II and III rectal cancer, international guidelines recommend neoadjuvant chemoradiotherapy (CRT) regardless of the tumor location. In the developing countries there is a shortage of radiotherapy centers, specialists, which lead to long waiting lists for radiotherapy. These problems might lead to protocol deviations.

METHODS

We conducted a retrospective study on 161 patients with rectal cancer treated with surgery, postoperative CRT and with or without chemotherapy for a total of 6 months, at The Oncology Institute Cluj-Napoca between 2006-2010. All patients had 5 years of follow-up.

RESULTS

A total of 161 patients were enrolled in this study. The majority of patients were locally advanced stages (89.44%). The well known prognostic factors, such as TNM stage, performance status, CEA serum level, perineural, vascular and lymphatic invasion, and node capsular effraction had a statistically significant influence on overall survival. In 21.12% of patients the first adjuvant treatment was started in the first 4 weeks after surgery. Only 13.04% of patients started the concomitant CRT within the limit of 6 weeks after surgery. Concerning the time between surgery and CRT, we did not observe a statistically significantly difference in OS if the radiotherapy started after the first 6 weeks (p=0.701). The OS rate for locally advanced rectal cancer patients was 69.44%.

CONCLUSIONS

In rectal cancer, the importance of the first therapeutic act is crucial. Following international guidelines provides a survival advantage and a better quality of life. In case of adjuvant treatment, it is recommended to start this treatment as soon as the local infrastructure allows it.

Effect of belly board with bladder compression device on small bowel displacement from the radiotherapy field for rectal cancer

BACKGROUND

The aim of this study was to investigate the effect of a belly board (BB) with the addition of a bladder compression device (BCD) for small bowel (SB) displacement from the radiotherapy field for rectal cancer.

PATIENTS AND METHODS

Computed tomography (CT) scans of 38 rectal cancer patients positioned on a BB were analyzed and compared with CT scans from the same patients after the addition of a BCD. The BCD moves the inferior border of the BB from the pubic symphysis to the lumbosacral junction. The treated and irradiated volumes of the SB and bladder were compared. The irradiated volume ratio of SB to abdominopelvic cavity (APC) and that of bladder to APC were analyzed.

RESULTS

With the BCD, the treated and irradiated volumes of SB decreased significantly (49.1 ± 48.0 vs. 60.9 ± 50.9 cc, p = 0.006 and 207.5 ± 140.8 vs. 482.8 ± 214.2 cc, p < 0.001, respectively). The irradiated volume ratio of bladder to APC with the BCD increased considerably compared to that without the BCD (25.2 ± 11.5 vs. 18.7 ± 10.5%, p < 0.001), and the ratio of irradiated volume of SB to APC decreased significantly with the BCD (18.8 ± 12.4 vs. 31.8 ± 12.1%, p < 0.001).

CONCLUSION

This study showed that the addition of a BCD to the BB could effectively provide further displacement of SB from the rectal cancer radiotherapy field.

Retrospective Long-Term Results and Prognostic Factors of Postoperative Treatment for UICC Stages II and III Rectal Cancer

Aims

To retrospectively evaluate 5-year local control, disease-free survival, cancer-specific survival and overall survival rates in patients with UICC stages II and III rectal cancer treated with adjuvant therapy and especially to analyze the impact of some prognostic factors on clinical outcome at univariate and multivariate analyses.

Methods and Materials

We retrospectively reviewed 306 patients treated with postoperative 5-fluorouracil-based chemoradiation (278 patients) or radiotherapy alone (28 patients) after curative surgery. The following prognostic factors were considered at univariate and multivariate analyses: age, sex, tumor location, surgery procedure, pathological stage, histology, tumor grade, surgical margins and radiotherapy technique.

Results

The 5-year actuarial rates for local control, disease-free survival, cancer-specific survival and overall survival were respectively 89.7%, 59.7%, 68.6% and 61.4% for the 278 patients (91%) treated with postoperative chemoradiation. Univariate analysis showed that abdominal-perineal resection impacted disease-free survival and that the T4 variable had an impact on cancer-specific survival and disease-free survival. Instead, age ≥70, N2, IIIB (p T3 p N1) and IIIC (pT3 p N2) stage impacted cancer-specific survival, disease-free survival and rate of distant metastases. Multivariate analysis showed as significant variables age ≥70 years, pN1 and pN2 and extraperitoneal tumor location.

Conclusions

Our retrospective study showed a good 5-year local control. Factors such as individual pT4, pN1, pN2, age ≥70 years, abdominal-perineal resection, stages IIIB-IIIC versus II-IIIA and extraperitoneal tumor location negatively influenced disease-free survival, distant metastases and cancer-specific survival. Differences exist between stages II and III rectal cancer and treatment modulation and intensification are required in order to offer the most appropriate and effective adjuvant treatment and to improve survival of rectal cancer patients.

Intensified concurrent chemoradiotherapy with 5-fluorouracil and irinotecan as neoadjuvant treatment in patients with locally advanced rectal cancer

This study aimed to evaluate the feasibility and efficacy of neoadjuvant chemoradiotherapy intensified with irinotecan in patients with locally advanced rectal cancer. Eligible patients had nonmetastatic disease at a locally advanced stage that made R0 resection and sphincter preservation uncertain. They received preoperative radiation over 6 weeks to 45 Gy and boost of 5.4 Gy and concurrent continuous infusion 5-fluorouracil 250 mg m⁻² day⁻¹ and weekly irinotecan 40 mg m⁻². In all, 37 patients entered the study. T stage at baseline as determined by ultrasound was T2/T3/T4 in 2/19/16 patients; 31 patients had lymph node involvement. The predominant toxicity was diarrhoea (grade 3/4 in 10/2 patients). Haematologic toxicity and surgical complications were moderate. Among 36 patients undergoing surgery, 32 (89%) had R0 resection and 23 (64%) sphincter preservation. Pathologic complete response (pCR) was achieved in eight (22%) of 36 patients, and 10 patients (28%) had only microscopic residual disease. At 4 years, overall survival was 66%, disease-free survival 73%, local relapse rate 7%, and distant failure rate 24%. Extent of resection and postoperative nodal status were significant predictors of overall and disease-free survival. Intensified neoadjuvant chemoradiotherapy with irinotecan can be safely administered and results in a high pCR rate.