Intraoperative brachytherapy alone for incomplete resected recurrent rectal cancer

Comparison of Different External Beam Treatment Techniques to Deliver High-Dose Irradiation to Local Recurrent Rectal Carcinoma

Aims and background

Treatment of local-regional recurrent rectal carcinoma is a challenging problem, and local control may be dose dependent; doses should probably exceed 60 Gy. Our aim was to verify the possibility to deliver 66 Gy to the target, but less than 35 Gy to the small bowel, comparing different 3D irradiation techniques, in a selected group of patients.

Methods

Five patients with local recurrent rectal carcinoma were selected as representative of different presentations of the disease. Gross tumor volume and clinical target volume were defined [by RS]. Tumors ranged between 182 and 540 cc, and small bowel volumes between 748 and 1050 cc. A three-field technique, coplanar multiple fields, noncoplanar fields and a proton beam were compared using dose volume histograms. A positive result was scored when ≥90% of the target received the prescribed dose with no more than 5% of the small bowel receiving more than 35 Gy. Doses were escalated in steps of 2 Gy from 60 to 66 Gy.

Results

The number of plans fitting the constraints were 7/19, 11/19, 18/19 for doses of 66 Gy, 64 Gy and 62 Gy, respectively. The stage of the tumor did not seem to correlate with the possibility to homogeneously cover the target with the prescribed dose.

Conclusions

Simple coplanar and complex coplanar techniques (up to six fields), positioning the patient in a prone position with dislocation of the bowel, seem to be the best solutions to treat almost all of the patients with doses of 64 Gy. Where higher doses are concerned, it is not possible to suggest a “standard” solution. More personalized techniques have to be tested to define the best option.

[Radiometric methods of calibrating high dose iridium (192Ir) brachytherapy]

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[Curative treatment of local and regional rectal cancer recurrences]

How to select patients likely to benefit from reoperation? When a neoadjuvant treatment is still feasible, is it useful to perform preoperative radiation or chemoradiation? What can be expected after resection of local recurrences in terms of survival and quality of life? Does surveillance of patients operated for rectal carcinoma influence resectability of local recurrences and results? These are the main questions concerning the management of local recurrences after resection of a rectal carcinoma.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

[Locoregional recurrence of adenocarcinomas of the rectum treated with irradiation combined with or without excision surgery]

PURPOSE

Retrospective study to analyze the results of external beam radiation treatment with or without surgery for loco-regional recurrence of adenocarcinoma of the rectum following previous surgery without pre- or post-operative radiotherapy.

PATIENTS AND METHODS

Between March 1973 and November 1991, 211 patients with loco-regional recurrence of rectum cancer were treated with external beam radiation treatment. Radical surgery was the only initial treatment modality. Surgical resection of local recurrence was done in 36 patients and only 17 patients could undergo complete resection. Forty-seven patients underwent radiotherapy (RT) combined with surgery and 164 received external beam radiation treatment alone to a mean total dose of 46 Gy.

RESULTS

Among the 151 patients whose recurrence was revealed by pain, 64 (42%) were considered to have a complete symptomatic response after loco-regional treatment with radiosurgery or RT alone. The mean duration of response was 12 months. The 3-year overall survival rate was 16%. Five prognostic factors decreased the overall survival rate in multivariate analysis: high age, sex (male), concomitant distant metastasis, no tumor resection, and low total radiation dose with external beam radiation treatment alone. The 3-year overall survival rate for patients with completely resected recurrences was 39%.

CONCLUSION

External beam RT treatment can only be considered a palliative symptomatic treatment. New techniques of early detection of local recurrence and new combined modalities approaches (radiation sensitizers or intra-operative radiotherapy) with surgical resection in some favorable cases should be studied.

Clinical indications for brachytherapy

Brachytherapy, or placing radioactive sources either temporarily or permanently into or near a malignant tumor, is a long-established cancer treatment method. During the past 25 years, brachytherapy has become safer and more versatile than earlier radium therapy, and its indications have increased dramatically during this period. One estimate is that at least 5-10% of all patients needing radiation therapy require brachytherapy. The site-specific clinical indications and methods for brachytherapy implementation are described.

Preoperative infusional chemoradiation, selective intraoperative radiation, and resection for locally advanced pelvic recurrence of colorectal adenocarcinoma

OBJECTIVE

The results of preoperative infusional chemoradiation, resection, and selective intraoperative radiation (IORT) boost in 43 previously nonirradiated patients with locally advanced pelvic recurrence of colorectal adenocarcinoma are described.

SUMMARY BACKGROUND DATA

After surgery alone 10% to 30% of patients with carcinoma of the distal colon and rectum will develop isolated pelvic recurrence. In most cases, the disease is locally advanced and not amenable to curative resection. Preoperative infusional chemoradiation has been shown to increase resectability and decrease local recurrence in primary locally advanced colorectal cancer. Based on this experience, we initiated a multimodality treatment protocol to treat patients with pelvic recurrence of colorectal adenocarcinoma.

METHODS

Forty-three consecutive patients with histologically proven pelvic recurrence of colorectal adenocarcinoma were enrolled on a multimodality treatment protocol. The treatment plan consisted of 5 weeks of concurrent pelvic external beam radiotherapy (45 Gy) with continuous intravenous infusion of 5-fluorouracil and/or cisplatin. This was followed by surgery that included IORT boost (10-20 Gy) for 21 patients and brachytherapy for 4 patients.

RESULTS

Forty patients (93%) underwent operation and 33 (77%) underwent resection with curative intent. There were 29 (88%) margin-negative resections. Fifteen patients (48%) underwent sphincter-preserving operations. There were no treatment-related deaths. Twenty-two patients experience perioperative complications. Median follow-up for the 43 patients was 26 months. The local recurrence rate was 36%. Median survival for the patients who underwent resection was 34 months, and actuarial 5-year disease-free and overall survival were 37% and 58%, respectively.

CONCLUSIONS

Tumor cytoreduction by preoperative chemoradiation can increase resectability and enable sphincter-preserving surgery in patients with locally advanced pelvic recurrence of colorectal cancer.

Rectal cancer

This synthesis of the literature on radiotherapy for rectal cancer is based on 73 scientific articles, including 1 meta-analysis, 32 randomized studies, 22 prospective studies, and 1 retrospective study. These studies involve 15042 patients. The reviewed studies show that adjuvant radiotherapy for operable rectal cancer can reduce the risk for local recurrence. A meta-analysis of 11 randomized studies reported a 25% risk reduction. The same meta-analysis suggests that adjuvant radiotherapy can reduce mortality by 10%, but this has not been statistically confirmed. The clinical effects of radiotherapy may depend on when it is given in relation to surgery. The issue of preoperative or postoperative radiotherapy is being investigated in several prospective randomized studies. Fractionation, administration of anticancer drugs during radiotherapy, and surgical methods, including associated radicality, also appear to be of importance. Local recurrence of rectal cancer is accompanied by severe suffering for the patient, eg, severe pain that is difficult to control by medication and surgery. Hence, there are major benefits from avoiding local recurrence. Given current knowledge, radiotherapy (preferably preoperative) is indicated in conjunction with operable rectal cancer, mainly Dukes' group C. External radiotherapy provides valuable palliation in many patients with locally advanced rectal cancer. In isolated cases, treatment appears to lead to prolonged disease-free survival, mainly in patients with local recurrence who have not already received pre- or postoperative radiotherapy. Experiences from different models of combination therapy involving chemotherapy and intraoperative radiotherapy are too limited to permit reliable conclusions: mainly since observation times are relatively short.

Intraoperative radiation therapy for locally advanced recurrent rectal or rectosigmoid cancer

Recurrent rectal or rectosigmoid cancer is a difficult therapeutic problem. A treatment program of external beam irradiation, surgery, and intraoperative irradiation has been used for 41 patients. The 5-year actuarial local control and disease-free survival of all 41 patients was 30% and 16%, respectively. Subset analysis demonstrated differences in outcome by extent of surgical resection. The 5-year actuarial local control and disease-free survival of 27 patients undergoing complete resection was 47% and 21%, respectively. By contrast, the outcome of 14 patients undergoing partial resection was poor, with a 5-year actuarial local control and survival of 21% and 7%, respectively. Late complications included soft tissue or peripheral nerve injury, with many of these resolving within 4-18 months. Local control and disease-free survival rates are favorable in comparison with the results achieved by aggressive surgery. Patients who achieve a gross total resection at intraoperative irradiation have a markedly better prognosis than that of patients with residual gross disease.

Treatment of local recurrences of rectal carcinoma

From 1978-1992, 159 patients were treated for local recurrences of rectal carcinoma. They could be subdivided into three groups according to the type of primary treatment given; 82 patients underwent primary surgery without irradiation, 37 patients had preoperative and 40 patients postoperative radiotherapy. The localizations of the recurrences and the curative and palliative potentials of surgery and radiotherapy in the treatment of local recurrences were studied. There was no difference in the localisation of the recurrences in the three groups. Median time between initial surgery and recurrence was also almost the same in the three groups and 75% of the recurrences appeared within 2 years. Twenty percent of the patients in the primary surgery alone group, compared with 49% and 38% in the preoperative and postoperative irradiation groups, respectively, had distant metastases at the time of the diagnosis of local recurrence. The predominant symptom from the local recurrence was pain and, after treatment of the recurrence, pain relief was registered in 63%. In 66%, 16% and 22%, respectively, of the patients in the three groups, the intention of the treatment was curative, with either radiotherapy alone, radiotherapy combined with surgery or surgery alone. The 5-years-survival after recurrence was 6% in the primary surgery alone group and 0% in the other 2 groups. Of the 69 patients treated with a curative intention, 32% were locally symptom-free at death or the last follow-up. Our conclusion is that a local recurrence must be avoided due to the morbidity associated with local failure and the potentially low likelihood of curative treatment of a local recurrence.