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Amarnath SR. The Role of Intraoperative Radiotherapy Treatment of Locally Advanced Rectal Cancer. Clin Colon Rectal Surg 2024; 37:239-247. [PMID: 38882939 PMCID: PMC11178387 DOI: 10.1055/s-0043-1770718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
Intraoperative radiation therapy (IORT) has been used in the treatment of locally advanced and recurrent rectal cancers for the last several decades. Given the heterogeneity of patients treated and different indications for use and dosing at different institutions, it has been difficult to discern if IORT adds any appreciable benefit to standard of care therapies. Herein, the rationale for IORT in rectal cancer is discussed along with the most modern and best available data in 2023. IORT is likely indicated in patients with locally advanced and locally recurrent rectal cancer with threatened margins (R0 or R1 resection) to help improve local control. High-quality imaging and multidisciplinary discussion are necessary to ensure optimal patient selection. Appropriate counseling of the patient and excellent team communication are of the utmost importance given the challenging nature of these cases and the prognostic implications of R1 and R2 resections in this patient population.
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Affiliation(s)
- Sudha R. Amarnath
- Department of Radiation Oncology, Cleveland Clinic Foundation, Cleveland, Ohio
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Jeans EB, Ebner DK, Takiyama H, Qualls K, Cunningham DA, Waddle MR, Jethwa KR, Harmsen WS, Hubbard JM, Dozois EJ, Mathis KL, Tsuji H, Merrell KW, Hallemeier CL, Mahajan A, Yamada S, Foote RL, Haddock MG. Comparing Oncologic Outcomes and Toxicity for Combined Modality Therapy vs. Carbon-Ion Radiotherapy for Previously Irradiated Locally Recurrent Rectal Cancer. Cancers (Basel) 2023; 15:cancers15113057. [PMID: 37297019 DOI: 10.3390/cancers15113057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/01/2023] [Accepted: 06/02/2023] [Indexed: 06/12/2023] Open
Abstract
No standard treatment paradigm exists for previously irradiated locally recurrent rectal cancer (PILRRC). Carbon-ion radiotherapy (CIRT) may improve oncologic outcomes and reduce toxicity compared with combined modality therapy (CMT). Eighty-five patients treated at Institution A with CIRT alone (70.4 Gy/16 fx) and eighty-six at Institution B with CMT (30 Gy/15 fx chemoradiation, resection, intraoperative electron radiotherapy (IOERT)) between 2006 and 2019 were retrospectively compared. Overall survival (OS), pelvic re-recurrence (PR), distant metastasis (DM), or any disease progression (DP) were analyzed with the Kaplan-Meier model, with outcomes compared using the Cox proportional hazards model. Acute and late toxicities were compared, as was the 2-year cost. The median time to follow-up or death was 6.5 years. Median OS in the CIRT and CMT cohorts were 4.5 and 2.6 years, respectively (p ≤ 0.01). No difference was seen in the cumulative incidence of PR (p = 0.17), DM (p = 0.39), or DP (p = 0.19). Lower acute grade ≥ 2 skin and GI/GU toxicity and lower late grade ≥ 2 GU toxicities were associated with CIRT. Higher 2-year cumulative costs were associated with CMT. Oncologic outcomes were similar for patients treated with CIRT or CMT, although patient morbidity and cost were lower with CIRT, and CIRT was associated with longer OS. Prospective comparative studies are needed.
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Affiliation(s)
- Elizabeth B Jeans
- Department of Radiation Oncology, Mayo Clinic, 200 2nd Street SW, Rochester, MN 55905, USA
| | - Daniel K Ebner
- Department of Radiation Oncology, Mayo Clinic, 200 2nd Street SW, Rochester, MN 55905, USA
| | - Hirotoshi Takiyama
- QST Hospital, National Institutes for Quantum Science and Technology, 4-9-1 Anagawa, Inageku, Chiba 263-8555, Japan
| | - Kaitlin Qualls
- Department of Radiation Oncology, Mayo Clinic, 200 2nd Street SW, Rochester, MN 55905, USA
| | - Danielle A Cunningham
- Department of Radiation Oncology, Mayo Clinic, 200 2nd Street SW, Rochester, MN 55905, USA
| | - Mark R Waddle
- Department of Radiation Oncology, Mayo Clinic, 200 2nd Street SW, Rochester, MN 55905, USA
| | - Krishan R Jethwa
- Department of Radiation Oncology, Mayo Clinic, 200 2nd Street SW, Rochester, MN 55905, USA
| | - William S Harmsen
- Department of Statistics, Mayo Clinic, 200 2nd Street SW, Rochester, MN 55905, USA
| | - Joleen M Hubbard
- Division of Medical Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Eric J Dozois
- Division of Colon & Rectal Surgery, Mayo Clinic, 200 2nd Street SW, Rochester, MN 55905, USA
| | - Kellie L Mathis
- Division of Colon & Rectal Surgery, Mayo Clinic, 200 2nd Street SW, Rochester, MN 55905, USA
| | - Hiroshi Tsuji
- QST Hospital, National Institutes for Quantum Science and Technology, 4-9-1 Anagawa, Inageku, Chiba 263-8555, Japan
| | - Kenneth W Merrell
- Department of Radiation Oncology, Mayo Clinic, 200 2nd Street SW, Rochester, MN 55905, USA
| | | | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, 200 2nd Street SW, Rochester, MN 55905, USA
| | - Shigeru Yamada
- QST Hospital, National Institutes for Quantum Science and Technology, 4-9-1 Anagawa, Inageku, Chiba 263-8555, Japan
| | - Robert L Foote
- Department of Radiation Oncology, Mayo Clinic, 200 2nd Street SW, Rochester, MN 55905, USA
| | - Michael G Haddock
- Department of Radiation Oncology, Mayo Clinic, 200 2nd Street SW, Rochester, MN 55905, USA
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Abstract
A curative treatment of locally recurrent rectal cancer (LRRC) can only be achieved with a complete resection and microscopically tumor-free surgical margins (R0). Imaging techniques are the most important investigations for the preoperative staging of local and systemic diseases. Due to substantial improvements in surgical strategies and techniques, previously unresectable tumors can now be excised. Several publications have demonstrated the oncological benefits of high sacral resection for LRRC. High subcortical sacrectomy (HiSS), extended lateral resection and extended lateral pelvic sidewall excision (ELSiE) belong to the newer surgical options. Biological meshes, various myocutaneous flaps, titanium and bone allografts can be used for reconstruction. Specialized centers provide an efficient management of complications and postoperative treatment.
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Affiliation(s)
- I Gockel
- Klinik für Viszeral‑, Transplantations‑, Thorax‑ und Gefäßchirurgie, Universitätsklinikum Leipzig, AöR, Liebigstr. 20, 04103, Leipzig, Deutschland.
| | - C Pommer
- Klinik für Viszeral‑, Transplantations‑, Thorax‑ und Gefäßchirurgie, Universitätsklinikum Leipzig, AöR, Liebigstr. 20, 04103, Leipzig, Deutschland
| | - S Langer
- Klinik für Orthopädie, Unfall- und Plastische Chirurgie, Universitätsklinikum Leipzig, AöR, Leipzig, Deutschland
| | - B Jansen-Winkeln
- Klinik für Viszeral‑, Transplantations‑, Thorax‑ und Gefäßchirurgie, Universitätsklinikum Leipzig, AöR, Liebigstr. 20, 04103, Leipzig, Deutschland
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Kishan AU, Voog JC, Wiseman J, Cook RR, Ancukiewicz M, Lee P, Ryan DP, Clark JW, Berger DL, Cusack JC, Wo JY, Hong TS. Standard fractionation external beam radiotherapy with and without intraoperative radiotherapy for locally recurrent rectal cancer: the role of local therapy in patients with a high competing risk of death from distant disease. Br J Radiol 2017; 90:20170134. [PMID: 28613934 DOI: 10.1259/bjr.20170134] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE We sought to evaluate the effectiveness and safety of utilizing radiotherapy (RT) with standard fractionation, with or without intraoperative RT (IORT), to treat locally recurrent rectal cancer (LRRC). METHODS Retrospective review of 25 patients with LRRC treated with standard fractionation RT from 2005 to 2011. 15 patients (60%) had prior pelvic RT and 10 (40%) had synchronous metastases. The median equivalent dose in 2-Gy fractions was 30 and 49.6 Gy in patients with and without prior RT, respectively. 23 patients (92%) received concurrent chemotherapy and 16 (64%) underwent surgical resection. Eight patients (33.3%, four with and four without prior RT) received IORT. A competing risks model was developed to estimate the cumulative incidence of local failure with death treated as a competing event. RESULTS Median follow-up was 36.9 months after the date of local recurrence. 3-year rates of overall survival (OS), local control (LC) and death with LC were 51.6%, 73.3% and 69.2%, respectively. On multivariable analysis, surgical resection was significantly predictive of improved OS (p < 0.05). If surgical resection were removed from the multivariable model, given the collinearity between IORT delivery and surgical resection, then IORT also became a significant predictor of OS (p < 0.05). Systemic disease at the time of local recurrence was not associated with either LC or OS. No patient had grade ≥3 acute or late toxicity. CONCLUSION RT with standard fractionation is safe and effective in the treatment of patients with LRRC, even in patients with significant risk of systemic disease and/or history of prior RT. Advances in knowledge: The utility of RT with standard fractionation, generally with chemotherapy, in the treatment of LRRC is demonstrated. In this high-risk cohort of patients with a 40% incidence of synchronous metastatic disease, surgical resection of the recurrence was the major predictor of OS, though a benefit to IORT was also suggested. No patients had grade ≥3 acute or late toxicity, though 40% had undergone prior RT, underscoring the tolerability of standard fractionation RT in this setting.
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Affiliation(s)
- Amar U Kishan
- 1 Department of Radiation Oncology, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Justin C Voog
- 2 Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | | | - Ryan R Cook
- 1 Department of Radiation Oncology, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Marek Ancukiewicz
- 2 Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Percy Lee
- 1 Department of Radiation Oncology, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - David P Ryan
- 4 Department of Medical Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Jeffrey W Clark
- 5 Division of General and Gastrointestinal Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - David L Berger
- 5 Division of General and Gastrointestinal Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - James C Cusack
- 6 Division of Surgical Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Jennifer Y Wo
- 2 Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Theodore S Hong
- 2 Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
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