1
|
Rogers AC, Jenkins JT, Rasheed S, Malietzis G, Burns EM, Kontovounisios C, Tekkis PP. Towards Standardisation of Technique for En Bloc Sacrectomy for Locally Advanced and Recurrent Rectal Cancer. J Clin Med 2021; 10:jcm10214921. [PMID: 34768442 PMCID: PMC8584798 DOI: 10.3390/jcm10214921] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/11/2021] [Accepted: 10/12/2021] [Indexed: 12/20/2022] Open
Abstract
Treatment strategies for advanced or recurrent rectal cancer have evolved such that the ultimate surgical goal to achieve a cure is complete pathological clearance. To achieve this where the sacrum is involved, en bloc sacrectomy is the current standard of care. Sacral resection is technically challenging and has been described; however, the technique has yet to be streamlined across units. This comprehensive review aims to outline the surgical approach to en bloc sacrectomy for locally advanced or recurrent rectal cancer, with standardisation of the operative steps of the procedure and to discuss options that enhance the technique.
Collapse
Affiliation(s)
- Ailín C. Rogers
- Department of Surgery, Royal Marsden Hospital, London SW3 6JJ, UK; (A.C.R.); (S.R.); (G.M.); (P.P.T.)
- Department of Colorectal Surgery, Mater Misericordiae University Hospital, D07 R2WY Dublin, Ireland
- School of Medicine, University College Dublin, D04 V1W8 Dublin, Ireland
| | - John T. Jenkins
- Department of Surgery, St. Mark’s Hospital, Watford Road, Harrow HA1 3UJ, UK; (J.T.J.); (E.M.B.)
| | - Shahnawaz Rasheed
- Department of Surgery, Royal Marsden Hospital, London SW3 6JJ, UK; (A.C.R.); (S.R.); (G.M.); (P.P.T.)
| | - George Malietzis
- Department of Surgery, Royal Marsden Hospital, London SW3 6JJ, UK; (A.C.R.); (S.R.); (G.M.); (P.P.T.)
- Colorectal Surgical Unit, Chelsea and Westminster Hospital, Chelsea, London SW10 9NH, UK
| | - Elaine M. Burns
- Department of Surgery, St. Mark’s Hospital, Watford Road, Harrow HA1 3UJ, UK; (J.T.J.); (E.M.B.)
| | - Christos Kontovounisios
- Department of Surgery, Royal Marsden Hospital, London SW3 6JJ, UK; (A.C.R.); (S.R.); (G.M.); (P.P.T.)
- Colorectal Surgical Unit, Chelsea and Westminster Hospital, Chelsea, London SW10 9NH, UK
- Department of Surgery and Cancer, The Royal Marsden Campus, Chelsea and Westminster Hospital and Imperial College, Paddington, London SW10 9NH, UK
- Correspondence:
| | - Paris P. Tekkis
- Department of Surgery, Royal Marsden Hospital, London SW3 6JJ, UK; (A.C.R.); (S.R.); (G.M.); (P.P.T.)
- Colorectal Surgical Unit, Chelsea and Westminster Hospital, Chelsea, London SW10 9NH, UK
- Department of Surgery and Cancer, The Royal Marsden Campus, Chelsea and Westminster Hospital and Imperial College, Paddington, London SW10 9NH, UK
| |
Collapse
|
2
|
Wootton LS, Meyer J, Kim E, Phillips M. Commissioning, clinical implementation, and performance of the Mobetron 2000 for intraoperative radiation therapy. J Appl Clin Med Phys 2017; 18:230-242. [PMID: 28291922 PMCID: PMC5689882 DOI: 10.1002/acm2.12027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 11/17/2016] [Indexed: 12/28/2022] Open
Abstract
The Mobetron is a mobile electron accelerator designed to deliver therapeutic radiation dose intraoperatively while diseased tissue is exposed. Experience with the Mobetron 1000 has been reported extensively. However, since the time of those publications a new model, the Mobetron 2000, has become commercially available. Experience commissioning this new model and 3 years of data from historical use are reported here. Descriptions of differences between the models are emphasized, both in physical form and in dosimetric characteristics. Results from commissioning measurements including output factors, air gap factors, percent depth doses (PDDs), and 2D dose profiles are reported. Output factors are found to have changed considerably in the new model, with factors as high as 1.7 being measured. An example lookup table of appropriate accessory/energy combinations for a given target dimension is presented, and the method used to generate it described. Results from 3 years of daily QA measurements are outlined. Finally, practical considerations garnered from 3 years of use are presented.
Collapse
Affiliation(s)
- Landon S Wootton
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Juergen Meyer
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Edward Kim
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Mark Phillips
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| |
Collapse
|
3
|
Brady JT, Crawshaw BP, Murrell B, Dosokey EMG, Jabir MA, Steele SR, Stein SL, Reynolds HL. Influence of intraoperative radiation therapy on locally advanced and recurrent colorectal tumors: A 16-year experience. Am J Surg 2017; 213:586-589. [PMID: 28160966 DOI: 10.1016/j.amjsurg.2016.10.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 09/15/2016] [Accepted: 10/14/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Intraoperative radiation therapy (IORT) has been proposed as a tool to improve local control in patients with locally advanced primary or recurrent colorectal cancer. METHODS A retrospective review (1999-2015) of all patients undergoing IORT for locally advanced or recurrent colorectal cancer at a single academic center was performed. Patient demographics, oncologic staging, short-term and long-term outcomes were reviewed. RESULTS There were 77 patients (mean age 63 ± 11 years) identified, of whom 19 had colon cancer, 57 had rectal cancer, and 2 had appendiceal cancers. R0 resection was performed in 53 patients (69%), R1 in 19 (25%) and R2 in 5 (6%). Ten (13%) patients had a local recurrence at 18 ± 14 months and 34 (44%) had a distant recurrence at 18 ± 18 months. Mean survival was 47 ± 41 months. CONCLUSION IORT resulted in low local failure rates and should be considered for patients with locally advanced or recurrent colorectal cancers.
Collapse
Affiliation(s)
- Justin T Brady
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
| | - Benjamin P Crawshaw
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | | | - Eslam M G Dosokey
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Murad A Jabir
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Scott R Steele
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Sharon L Stein
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Harry L Reynolds
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
| |
Collapse
|
4
|
Intraoperative radiotherapy with low energy photons in recurrent colorectal cancer: a single centre retrospective study. Contemp Oncol (Pozn) 2016; 20:52-7. [PMID: 27095940 PMCID: PMC4829748 DOI: 10.5114/wo.2016.58500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 10/29/2015] [Indexed: 11/17/2022] Open
Abstract
AIM OF THE STUDY Intraoperative radiotherapy (IORT) may improve outcome of surgical treatment of recurrent colorectal cancer (CRC). The aim of this study is to determine the feasibility, safety and long-term results of surgical treatment of recurrent CRC with orthovolt IORT. MATERIAL AND METHODS Fifty-nine consecutive CRC patients with local recurrence (LR), undergoing surgery, were included in the retrospective analysis of prospectively collected data. The modified Wanebo classification was used to stage LR (Tr). Twenty-five (43%) patients received IORT using INTRABEAM(®) PRS 500. The complications were classified according to the Clavien-Dindo classification. RESULTS There were 32 males and 27 females, with a median age of 63 years. Multi-visceral resections were performed in 37 (63%) patients. Median hospitalization time after surgery with IORT was 7 days. One (1.7%) in-hospital postoperative death was reported. Grade 3/4 postoperative complications were found in 11 (19%) patients. Intraoperative radiotherapy had no effect on the postoperative hospitalization time, morbidity and mortality. Median survival after R0 resection was 32 months. Complete resection (R0), no synchronous liver metastases (M0), and no lateral and posterior pelvic wall involvement, were significant predictors of improved survival. Stage of LR was found to be an independent prognostic factor in the multivariate analysis (p = 0.03); Cox regression model). In patients with LR stage < Tr5, a 3-year overall survival (OS) rate was 52%. CONCLUSIONS Combination of surgical resection and orthovolt IORT is a safe and feasible procedure that does not increase the risk of postoperative complications or prolongs the hospital stay. Despite aggressive surgery supported by IORT, the advanced stage of LR is a limiting factor of long-term survival.
Collapse
|
5
|
Gaertner WB, Kwaan MR, Madoff RD, Melton GB. Rectal cancer: An evidence-based update for primary care providers. World J Gastroenterol 2015; 21:7659-7671. [PMID: 26167068 PMCID: PMC4491955 DOI: 10.3748/wjg.v21.i25.7659] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 04/04/2015] [Accepted: 05/21/2015] [Indexed: 02/07/2023] Open
Abstract
Rectal adenocarcinoma is an important cause of cancer-related deaths worldwide, and key anatomic differences between the rectum and the colon have significant implications for management of rectal cancer. Many advances have been made in the diagnosis and management of rectal cancer. These include clinical staging with imaging studies such as endorectal ultrasound and pelvic magnetic resonance imaging, operative approaches such as transanal endoscopic microsurgery and laparoscopic and robotic assisted proctectomy, as well as refined neoadjuvant and adjuvant therapies. For stage II and III rectal cancers, combined chemoradiotherapy offers the lowest rates of local and distant relapse, and is delivered neoadjuvantly to improve tolerability and optimize surgical outcomes, particularly when sphincter-sparing surgery is an endpoint. The goal in rectal cancer treatment is to optimize disease-free and overall survival while minimizing the risk of local recurrence and toxicity from both radiation and systemic therapy. Optimal patient outcomes depend on multidisciplinary involvement for tailored therapy. The successful management of rectal cancer requires a multidisciplinary approach, with the involvement of enterostomal nurses, gastroenterologists, medical and radiation oncologists, radiologists, pathologists and surgeons. The identification of patients who are candidates for combined modality treatment is particularly useful to optimize outcomes. This article provides an overview of the diagnosis, staging and multimodal therapy of patients with rectal cancer for primary care providers.
Collapse
|
6
|
Crawshaw BP, Augestad KM, Keller DS, Nobel T, Swendseid B, Champagne BJ, Stein SL, Delaney CP, Reynolds HL. Multivisceral resection for advanced rectal cancer: outcomes and experience at a single institution. Am J Surg 2014; 209:526-31. [PMID: 25577290 DOI: 10.1016/j.amjsurg.2014.10.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 10/10/2014] [Accepted: 10/13/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Multivisceral resection is often required in the treatment of locally advanced rectal cancers. Such resections are relatively rare and oncologic outcomes, especially when sphincter preservation is performed, are not fully demonstrated. METHODS A retrospective review was conducted of patients who underwent multivisceral resection for locally advanced rectal cancer with and without sphincter preservation. RESULTS Sixty-one patients underwent multivisceral resection for rectal cancer from 2005 to 2013 with a median follow-up of 27.8 months. Five-year overall and disease-free survival were 49.2% and 45.3%, respectively. Thirty-four patients (55.7%) had sphincter-sparing operations with primary coloanal anastomosis and temporary stoma. There was no significant difference in overall or disease-free survival, or recurrence with sphincter preservation compared with those with permanent stoma. CONCLUSIONS Multivisceral resection for locally advanced rectal cancer has acceptable oncologic and clinical outcomes. Sphincter preservation and subsequent reestablishment of gastrointestinal continuity does not impact oncologic outcomes and should be considered in many patients.
Collapse
Affiliation(s)
- Benjamin P Crawshaw
- Department of Colorectal Surgery, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
| | - Knut M Augestad
- Department of Colorectal Surgery, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Deborah S Keller
- Department of Colorectal Surgery, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Tamar Nobel
- Department of Colorectal Surgery, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Brian Swendseid
- Department of Colorectal Surgery, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Bradley J Champagne
- Department of Colorectal Surgery, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Sharon L Stein
- Department of Colorectal Surgery, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Conor P Delaney
- Department of Colorectal Surgery, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Harry L Reynolds
- Department of Colorectal Surgery, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| |
Collapse
|
7
|
Tan J, Heriot AG, Mackay J, Van Dyk S, Bressel MA, Fox CD, Hui AC, Lynch AC, Leong T, Ngan SY. Prospective single-arm study of intraoperative radiotherapy for locally advanced or recurrent rectal cancer. J Med Imaging Radiat Oncol 2013; 57:617-25. [PMID: 24119279 DOI: 10.1111/1754-9485.12059] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Accepted: 03/08/2013] [Indexed: 11/27/2022]
Abstract
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.
Collapse
Affiliation(s)
- Jennifer Tan
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne
| | | | | | | | | | | | | | | | | | | |
Collapse
|
8
|
Cantero-Muñoz P, Urién MA, Ruano-Ravina A. Efficacy and safety of intraoperative radiotherapy in colorectal cancer: a systematic review. Cancer Lett 2011; 306:121-33. [PMID: 21414718 DOI: 10.1016/j.canlet.2011.02.020] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Revised: 02/14/2011] [Accepted: 02/15/2011] [Indexed: 01/15/2023]
Abstract
Intraoperative radiotherapy (IORT) has been proposed as an encouraging treatment for colorectal cancer. The aim of this study is to assess the efficacy and safety of IORT for this cancer through a systematic review. Studies located in electronic databases were selected according to established criteria, read and analysed and the results extracted by two independent reviewers. Fifteen studies met the selection criteria. Five-to-six-year local control (LC) was over 80% and 5-year overall survival (OS) was close to 65%. For recurrences, the 5-year overall survival was 30%. The main acute complications were gastrointestinal. Adding IORT to conventional treatment reduces the incidence of local recurrences within the radiation area over 10%. IORT is a safe technique as it does not increase toxicity associated with conventional treatment.
Collapse
Affiliation(s)
- P Cantero-Muñoz
- Galician Agency for Health Technology Assessment, Galician Department of Health, Spain
| | | | | |
Collapse
|
9
|
A Phase I Study of Intraoperative Radiotherapy for Early Breast Cancer in Japan. World J Surg 2009; 33:2587-92. [DOI: 10.1007/s00268-009-0227-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
10
|
Skandarajah AR, Lynch AC, Mackay JR, Ngan S, Heriot AG. The role of intraoperative radiotherapy in solid tumors. Ann Surg Oncol 2009; 16:735-44. [PMID: 19142683 DOI: 10.1245/s10434-008-0287-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2008] [Revised: 12/08/2008] [Accepted: 12/09/2008] [Indexed: 01/23/2023]
Abstract
BACKGROUND Combined multimodality therapy is becoming standard treatment for many solid tumors, but the role of intraoperative radiotherapy in the management of solid tumors remains uncertain. The aim is to review the indication, application, and outcomes of intraoperative radiotherapy in the management of nongynecological solid tumors. METHODS A literature search was performed using Medline, Embase, Ovid, and Cochrane database for studies between 1965 and 2008 assessing intraoperative radiotherapy, using the keywords "intraoperative radiotherapy," "colorectal cancer," "breast cancer," "gastric cancer," "pancreatic cancer," "soft tissue tumor," and "surgery." Only publications in English with available abstracts and regarding adult humans were included, and the evidence was critically evaluated. RESULTS Our search retrieved 864 publications. After exclusion of nonclinical papers, duplicated papers and exclusion of brachytherapy papers, 77 papers were suitable to assess the current role of intraoperative radiotherapy. The clinical application and evidence base of intraoperative radiotherapy for each cancer is presented. CONCLUSIONS Current studies in all common cancers show an additional benefit in local recurrence rates when intraoperative radiotherapy is included in the multimodal treatment. However, intraoperative radiotherapy may not improve overall survival and has significant morbidity depending on the site of the tumor. Intraoperative radiotherapy does have a role in the multidisciplinary management of solid tumors, but further studies are required to more precisely determine the extent of benefit.
Collapse
Affiliation(s)
- A R Skandarajah
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne 3002, Australia.
| | | | | | | | | |
Collapse
|
11
|
Lindsetmo RO, Joh YG, Delaney CP. Surgical treatment for rectal cancer: An international perspective on what the medical gastroenterologist needs to know. World J Gastroenterol 2008; 14:3281-9. [PMID: 18528924 PMCID: PMC2716581 DOI: 10.3748/wjg.14.3281] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Rectal cancer accounts for one third of all colorectal cancers. The age adjusted death rates from colorectal cancer have declined over recent decades due to a combination of colorectal cancer screening, improved diagnostic tests, improved standardized surgical technique, improved medical support, neoadjuvant chemotherapies and radiation treatment or combinations of these. Because of complex treatment algorithms, use of multidisciplinary teams in the management of rectal cancer patients has also been popularized. Medical gastroenterologists performing colonoscopies are frequently the first health care provider to raise the suspicion of a rectal cancer. Although the diagnosis depends on histological confirmation, the endoscopic presentation is almost diagnostic in many cases. In order to meet the patient’s immediate needs for information, it is important that the endoscopist has knowledge about the investigations and treatment options that will be required for their patient. The aim of this paper is to describe the modern preoperative investigations and operative procedures commonly offered to rectal cancer patients taking into account perspectives of three colorectal surgeons, practicing in the USA, Europe and Asia.
Collapse
|