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Elashwah A, Alsuhaibani A, Alzahrani A, Azzam AZ, Moftah B, Breakeit M, Hussain M, Mahmood R, ALramahi S, Hassan Z, Amin TM. The Use of Intraoperative Radiation Therapy (IORT) in Multimodality Management of Cancer Patients: a Single Institution Experience. J Gastrointest Cancer 2023; 54:433-441. [PMID: 35290599 DOI: 10.1007/s12029-021-00786-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Intraoperative radiation therapy (IORT) is a highly conformal type of radiation therapy given at time of surgery aiming for better tumor local control. It increases the tumor radiation dose without exceeding normal tissues tolerance doses. PURPOSE To assess the feasibility of IORT and short-term toxicities in patients with different cancer sites treated with multidisciplinary protocol including IORT. PATIENTS AND METHODS Medical records of cancer patients who received IORT as a part of their multidisciplinary treatment at King Faisal Specialized Hospital and Research center (KFSH&RC), Riyadh, Saudi Arabia, from January 2013 until December 2017 were retrospectively reviewed. RESULTS A total of 188 patients with 210 IORT applications were analyzed. Twenty-two patients had two applications at the same time. One hundred sixteen patients were males. Median age at time of diagnosis was 49.5 years (19-77). One hundred thirty-four patients had primary, while 54 cases had recurrent disease. Gastroesophageal cancer and soft tissue sarcoma were the most frequent diagnosis in 49 patients followed by colorectal cancer in 35 patients. Major surgeries with curative intent done in 183 patients (97.3%). Hyperthermic intraperitoneal chemotherapy (HIPEC) was performed in 118 (62.8%) patients. The 30-day postoperative mortality rate was 3.2%. Fifty-four (28.7%) patients develop grades III-IV complications according to Clavien-Dindo grading system. CONCLUSION The data presented discusses using of IORT treatment for different malignant tumors as a part of multimodality treatment. IORT seems safe and feasible; however, a longer follow-up period is needed for proper evaluation and to define the role of IORT in a tailored multimodality approach.
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Affiliation(s)
- Ahmed Elashwah
- Section of Radiation Oncology, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia.
- Kasr Al-Eini Center of Clinical Oncology (NEMROCK), Cairo University, Cairo, Egypt.
| | | | - Ali Alzahrani
- Department of Surgical Oncology, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Ayman Zaki Azzam
- Department of Surgical Oncology, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
- Department of General Surgery, Alexandria University, Alexandria, Egypt
| | - Belal Moftah
- King Faisal Specialist Hospital & Research Centre, Department of medical physics, Riyadh, Saudi Arabia
| | - Mohammad Breakeit
- Department of Surgical Oncology, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Muhammad Hussain
- King Faisal Specialist Hospital & Research Centre, Department of medical physics, Riyadh, Saudi Arabia
| | - Rana Mahmood
- Section of Radiation Oncology, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Shada ALramahi
- King Faisal Specialist Hospital & Research Centre, Department of medical physics, Riyadh, Saudi Arabia
| | - Zeinab Hassan
- King Faisal Specialist Hospital & Research Centre, Department of medical physics, Riyadh, Saudi Arabia
| | - Tarek Mahmoud Amin
- Department of Surgical Oncology, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
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Martin-Gonzalez P, de Mariscal EG, Martino ME, Gordaliza PM, Peligros I, Carreras JL, Calvo FA, Pascau J, Desco M, Muñoz-Barrutia A. Association of visual and quantitative heterogeneity of 18F-FDG PET images with treatment response in locally advanced rectal cancer: A feasibility study. PLoS One 2020; 15:e0242597. [PMID: 33253194 PMCID: PMC7704000 DOI: 10.1371/journal.pone.0242597] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 11/05/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND AND PURPOSE Few tools are available to predict tumor response to treatment. This retrospective study assesses visual and automatic heterogeneity from 18F-FDG PET images as predictors of response in locally advanced rectal cancer. METHODS This study included 37 LARC patients who underwent an 18F-FDG PET before their neoadjuvant therapy. One expert segmented the tumor from the PET images. Blinded to the patient´s outcome, two experts established by consensus a visual score for tumor heterogeneity. Metabolic and texture parameters were extracted from the tumor area. Multivariate binary logistic regression with cross-validation was used to estimate the clinical relevance of these features. Area under the ROC Curve (AUC) of each model was evaluated. Histopathological tumor regression grade was the ground-truth. RESULTS Standard metabolic parameters could discriminate 50.1% of responders (AUC = 0.685). Visual heterogeneity classification showed correct assessment of the response in 75.4% of the sample (AUC = 0.759). Automatic quantitative evaluation of heterogeneity achieved a similar predictive capacity (73.1%, AUC = 0.815). CONCLUSION A response prediction model in LARC based on tumor heterogeneity (assessed either visually or with automatic texture measurement) shows that texture features may complement the information provided by the metabolic parameters and increase prediction accuracy.
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Affiliation(s)
- Paula Martin-Gonzalez
- Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Madrid, Spain
| | - Estibaliz Gomez de Mariscal
- Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Madrid, Spain
- Instituto de Investigación, Sanitaria Gregorio Marañón, Madrid, Spain
| | - M. Elena Martino
- Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Madrid, Spain
- Instituto de Investigación, Sanitaria Gregorio Marañón, Madrid, Spain
| | - Pedro M. Gordaliza
- Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Madrid, Spain
- Instituto de Investigación, Sanitaria Gregorio Marañón, Madrid, Spain
| | - Isabel Peligros
- Instituto de Investigación, Sanitaria Gregorio Marañón, Madrid, Spain
- Department of Pathology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- School of Medicine, Universidad Complutense, Madrid, Spain
| | - Jose Luis Carreras
- Instituto de Investigación, Sanitaria Gregorio Marañón, Madrid, Spain
- Department of Pathology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Department of Radiology and Medical Physics, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Felipe A. Calvo
- Instituto de Investigación, Sanitaria Gregorio Marañón, Madrid, Spain
- School of Medicine, Universidad Complutense, Madrid, Spain
- Department of Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Javier Pascau
- Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Madrid, Spain
- Instituto de Investigación, Sanitaria Gregorio Marañón, Madrid, Spain
| | - Manuel Desco
- Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Madrid, Spain
- Instituto de Investigación, Sanitaria Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain
- Centro de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain
| | - Arrate Muñoz-Barrutia
- Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Madrid, Spain
- Instituto de Investigación, Sanitaria Gregorio Marañón, Madrid, Spain
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Schaap DP, Ogura A, Nederend J, Maas M, Cnossen JS, Creemers GJ, van Lijnschoten I, Nieuwenhuijzen GAP, Rutten HJT, Kusters M. Prognostic implications of MRI-detected lateral nodal disease and extramural vascular invasion in rectal cancer. Br J Surg 2018; 105:1844-1852. [PMID: 30079958 DOI: 10.1002/bjs.10949] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 06/13/2018] [Accepted: 06/18/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Lateral nodal disease in rectal cancer remains a subject of debate and is treated differently in the East and the West. The predictive value of lateral lymph node and MRI-detected extramural vascular invasion (mrEMVI) features on oncological outcomes was assessed in this study. METHODS In this retrospective cohort study, data on patients with cT3-4 rectal cancer within 8 cm from the anal verge were considered over a 5-year period (2009-2013). Lateral lymph node size, malignant features and mrEMVI features were evaluated and related to oncological outcomes. RESULTS In total, 192 patients were studied, of whom 30 (15·6 per cent) underwent short-course radiotherapy and 145 (75·5 per cent) received chemoradiotherapy. A lateral lymph node short-axis size of 10 mm or more was associated with a significantly higher 5-year lateral/presacral local recurrence rate of 37 per cent, compared with 7·7 per cent in nodes smaller than 10 mm (P = 0·041). Enlarged nodes did not result in a higher 5-year rate of distant metastasis (23 per cent versus 27·7 per cent in nodes smaller than 10 mm; P = 0·563). However, mrEMVI positivity was related to more metastatic disease (5-year rate 43 versus 26·3 per cent in the mrEMVI-negative group; P = 0·014), but not with increased lateral/presacral recurrence. mrEMVI occurred in 46·6 per cent of patients with nodes smaller than 10 mm, compared with 29 per cent in patients with nodes of 10 mm or larger (P = 0·267). CONCLUSION Although lateral nodal disease is more a local problem, mrEMVI mainly predicts distant recurrence. The results of this study showed an unacceptably high local recurrence rate in patients with a short axis of 10 mm or more, despite neoadjuvant (chemo)radiotherapy.
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Affiliation(s)
- D P Schaap
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | - A Ogura
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
- Department of Surgery, Division of Surgical Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - J Nederend
- Department of Radiology, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | - M Maas
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - J S Cnossen
- Department of Radiation Oncology, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | - G J Creemers
- Department of Medical Oncology, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | - I van Lijnschoten
- Pathology Department, Laboratory for Pathology and Medical Microbiology (PAMM), Eindhoven, the Netherlands
| | | | - H J T Rutten
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
- School for Oncology and Developmental Biology (GROW), Maastricht University, Maastricht, the Netherlands
| | - M Kusters
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
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Pilar A, Gupta M, Ghosh Laskar S, Laskar S. Intraoperative radiotherapy: review of techniques and results. Ecancermedicalscience 2017; 11:750. [PMID: 28717396 PMCID: PMC5493441 DOI: 10.3332/ecancer.2017.750] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Indexed: 12/14/2022] Open
Abstract
Intraoperative radiotherapy (IORT) is a technique that involves precise delivery of a large dose of ionising radiation to the tumour or tumour bed during surgery. Direct visualisation of the tumour bed and ability to space out the normal tissues from the tumour bed allows maximisation of the dose to the tumour while minimising the dose to normal tissues. This results in an improved therapeutic ratio with IORT. Although it was introduced in the 1960s, it has seen a resurgence of popularity with the introduction of self-shielding mobile linear accelerators and low-kV IORT devices, which by eliminating the logistical issues of transport of the patient during surgery for radiotherapy or building a shielded operating room, has enabled its wider use in the community. Electrons, low-kV X-rays and HDR brachytherapy are all different methods of IORT in current clinical use. Each method has its own unique set of advantages and disadvantages, its own set of indications where one may be better suited than the other, and each requires a specific kind of expertise. IORT has demonstrated its efficacy in a wide variety of intra-abdominal tumours, recurrent colorectal cancers, recurrent gynaecological cancers, and soft-tissue tumours. Recently, it has emerged as an attractive treatment option for selected, early-stage breast cancer, owing to the ability to complete the entire course of radiotherapy during surgery. IORT has been used in a multitude of roles across these sites, for dose escalation (retroperitoneal sarcoma), EBRT dose de-escalation (paediatric tumours), as sole radiation modality (early breast cancers) and as a re-irradiation modality (recurrent rectal and gynaecological cancers). This article aims to provide a review of the rationale, techniques, and outcomes for IORT across different sites relevant to current clinical practice.
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Affiliation(s)
- Avinash Pilar
- Department of Radiation Oncology, Tata Memorial Hospital, Dr Ernest Borges' Marg, Parel, Mumbai, MS, India 400012
| | - Meetakshi Gupta
- Department of Radiation Oncology, Tata Memorial Hospital, Dr Ernest Borges' Marg, Parel, Mumbai, MS, India 400012
| | - Sarbani Ghosh Laskar
- Department of Radiation Oncology, Tata Memorial Hospital, Dr Ernest Borges' Marg, Parel, Mumbai, MS, India 400012
| | - Siddhartha Laskar
- Department of Radiation Oncology, Tata Memorial Hospital, Dr Ernest Borges' Marg, Parel, Mumbai, MS, India 400012
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Abdelfatah E, Page A, Sacks J, Pierorazio P, Bivalacqua T, Efron J, Terezakis S, Gearhart S, Fang S, Safar B, Pawlik TM, Armour E, Hacker-Prietz A, Herman J, Ahuja N. Postoperative complications following intraoperative radiotherapy in abdominopelvic malignancy: A single institution analysis of 113 consecutive patients. J Surg Oncol 2017; 115:883-890. [PMID: 28252805 DOI: 10.1002/jso.24597] [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: 06/20/2016] [Revised: 12/28/2016] [Accepted: 02/09/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Intraoperative radiotherapy (IORT) has advantages over external beam radiation therapy (EBRT). Few studies have described side effects associated with its addition. We evaluated our institution's experience with abdominopelvic IORT to assess safety by postoperative complication rates. METHODS Prospectively collected IRB-approved database of all patients receiving abdominopelvic IORT (via high dose rate brachytherapy) at Johns Hopkins Hospital between November 2006 and May 2014 was reviewed. Patients were discussed in multidisciplinary conferences. Those selected for IORT were patients for whom curative intent resection was planned for which IORT could improve margin-negative resection and optimize locoregional control. Perioperative complications were classified via Clavien-Dindo scale for postoperative surgical complications. RESULTS A total of 113 patients were evaluated. Most common diagnosis was sarcoma (50/113, 44%) followed by colorectal cancer (45/113, 40%), most of which were recurrent (84%). There were no perioperative deaths. A total of 57% of patients experienced a complication Grade II or higher: 24% (27/113) Grade II; 27% (30/113) Grade III; 7% (8/113) Grade IV. Wound complications were most common (38%), then gastrointestinal (25%). No radiotherapy variables were significantly associated with complications on uni/multi-variate analysis. CONCLUSIONS Our institution's experience with IORT demonstrated historically expected postoperative complication rates. IORT is safe, with acceptable perioperative morbidity.
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Affiliation(s)
- Eihab Abdelfatah
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Andrew Page
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Justin Sacks
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Phillip Pierorazio
- Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Trinity Bivalacqua
- Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jonathan Efron
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stephanie Terezakis
- Department of Radiation Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Susan Gearhart
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sandy Fang
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bashar Safar
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Timothy M Pawlik
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elwood Armour
- Department of Radiation Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Amy Hacker-Prietz
- Department of Radiation Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joseph Herman
- Department of Radiation Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nita Ahuja
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Adjuvant chemoradiation plus intraoperative radiotherapy versus adjuvant chemoradiation alone in patients with locally advanced rectal cancer. Am J Clin Oncol 2015; 38:11-6. [PMID: 25616201 DOI: 10.1097/coc.0b013e318287bb8d] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To document the efficacy of intraoperative radiotherapy (IORT) followed by adjuvant chemoradiation in the management of locally advanced rectal cancer. MATERIALS AND METHODS A total of 148 patients with pT4N0/T1-4N+ rectal adenocarcinoma were enrolled. Seventy-seven patients received total mesorectal excision surgery followed by adjuvant chemoradiation alone, 71 patients received total mesorectal excision surgery followed by IORT (range, 10 to 20 Gy) and adjuvant chemoradiation. RESULTS The 5-year local control (LC) and disease-free survival were 79.2% versus 89.7% (P=0.032), 58.5% versus 69.0% (P=0.049) for external-beam radiation (EBRT) and IORT+EBRT groups, respectively. Multivariate analysis revealed that adjuvant IORT has a trend toward improvement of LC (P=0.079); 5 (3%) patients (EBRT n=2; IORT n=3) experienced incomplete intestinal obstruction and 3 patients had chronic diarrhea. There was no clinically relevant neuropathy or sacral osteoradionecrosis. Hydronephrosis occurred in 13 patients (EBRT n=8; IORT+EBRT n=5), 8 of whom had documented concomitant disease recurrence. CONCLUSIONS For patients with locally advanced rectal cancer, higher radiation dose may contribute to the improvement of both LC and disease-free survival, without significantly increasing the incidence of acute and long-term complications compared with adjuvant chemoradiotherapy alone.
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The predictive value of 18F-FDG PET/CT for assessing pathological response and survival in locally advanced rectal cancer after neoadjuvant radiochemotherapy. Eur J Nucl Med Mol Imaging 2015; 42:657-66. [PMID: 25687534 DOI: 10.1007/s00259-014-2820-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 05/19/2014] [Indexed: 02/07/2023]
Abstract
PURPOSE To evaluate whether metabolic changes in the primary tumour during and after preoperative radiochemotherapy (RCT) can predict the histopathological response in patients with locally advanced rectal cancer as well as disease-free survival (DFS) and overall survival (OS). METHODS Consecutive patients with cT2-4 N0-2 rectal adenocarcinoma were included. (18)F-FDG PET/CT was performed at baseline, at the end of the second week of RCT (early PET/CT) and before surgery (late PET/CT). The PET/CT results were compared with histopathological data (ypT0 N0 vs. ypT1-4 N0-2 as well as TRG1 vs.TRG2-5) and survival. RESULTS The study included 126 patients. Among 124 patients in whom TNM classification was available, 28 (22.6 %) were ypT0 N0, and among all 126 patients, 31 (24.6 %) were TRG1. The areas under the curve of the early response index (RI) for identifying non-complete pathological response (non-cPR) were 0.74 (95 % CI 0.61 - 0.87) for ypT1-4 N0-2 patients and 0.75 (95 % CI 0.62 - 0.88) for TRG2-5 patients. The optimal cut-off for differentiating patients with non-cPR and cPR was found to be a reduction of 61.2 % (83.1 % sensitivity and 65 % specificity in ypT1-4 N0-2 patients; 85.4 % sensitivity and 65.2 % specificity in TRG2-5 patients). The optimal cut-off for late RI could not be found. The qualitative analysis of images obtained after RCT demonstrated 81.5 % sensitivity and 61.3 % specificity in predicting TRG2-5. After a median follow-up of 68 months, the low number of patients with local/distant recurrence or who had died did not allow the value of PET/CT for predicting DFS and OS to be calculated. CONCLUSION The early assessment of response to RCT by (18)F-FDG PET/CT can predict non-cPR allowing practical modification of preoperative treatment. Conversely, late RI is not sufficiently accurate for guiding the decision as to whether local excision or even observation is appropriate in an individual patient. Qualitative analysis of late PET/CT images is also not sensitive enough alone to rule out the presence of residual disease.
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Terezakis S, Morikawa L, Wu A, Zhang Z, Shi W, Weiser MR, Paty PB, Guillem J, Temple L, Nash GM, Zelefsky MJ, Goodman KA. Long-Term Survival After High-Dose-Rate Brachytherapy for Locally Advanced or Recurrent Colorectal Adenocarcinoma. Ann Surg Oncol 2015; 22:2168-78. [PMID: 25631062 DOI: 10.1245/s10434-014-4271-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND We evaluated outcomes of intraoperative radiotherapy delivered with focal high-dose-rate (HDR) brachytherapy [intraoperative radiotherapy (IORT)] in the management of locally recurrent (LR) and locally advanced (LA) primary T4 colorectal carcinoma (CRC). LR CRC or LA primary disease is a clinical challenge due to the difficulty in obtaining negative margins after radical surgery and the high risk of subsequent recurrence. Few data exist on long-term outcomes of patients treated with surgery and HDR-IORT for LR or LA primary CRC. METHODS Three hundred CRC patients underwent HDR-IORT to the pelvis with gross surgical resection during November 1992-December 2007. Median follow-up for surviving patients was 53 (range 5-216) months. Eighty-eight patients (29 %) were treated for LA primary and 212 (71 %) LR disease. HDR-IORT was delivered using an iridium-192 remote afterloader and a Harrison-Anderson-Mick applicator. Median IORT dose was 1,500 (range 1,000-2,000) cGy. RESULTS Five-year overall survival probability was 49 %. Positive margin status was associated with inferior overall survival and disease-free survival. Competing-risks analysis for time to local failure and distant metastases identified a 5-year cumulative incidence of local failure and distant metastases of 33 and 47 %, respectively. Five-year cumulative incidence of local failure was 22 % for the LA group and 38 % in the LR group. Five-year probability of disease-free survival was 48 and 31 % for LA and LR patients, respectively, and 5-year probability of overall survival was 56 and 45 % for LA and LR patients, respectively. CONCLUSIONS HDR-IORT combined with resection results in encouraging local control rates with acceptable toxicity for patients with locally aggressive CRC.
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Affiliation(s)
- Stephanie Terezakis
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Klink CD, Binnebösel M, Holy R, Neumann UP, Junge K. Influence of intraoperative radiotherapy (IORT) on perioperative outcome after surgical resection of rectal cancer. World J Surg 2014; 38:992-6. [PMID: 24178183 DOI: 10.1007/s00268-013-2313-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Intraoperative radiotherapy (IORT) for locally advanced or recurrent rectal cancer as an integral part of multimodal treatment might be an option to reduce local cancer recurrence. The aim of the present study was to determine the influence of IORT on the postoperative outcome and complications rates in the treatment of patients with adenocarcinoma of the rectum in comparison to patients with rectum resection only. METHODS A total of 162 patients underwent operation for International Union against Cancer stage III/IV rectal cancer or recurrent rectal cancer at our surgical department between 2004 and 2012. They were divided into two groups depending on whether they received IORT or not. General patient details, tumor, and operation details, as well as perioperative major and minor complications, were registered and compared. RESULTS Of the 162 patients treated for stage III/IV rectal cancer, 52 underwent rectal resection followed by IORT. Complication rates were similar in the two groups. Operative time was significantly longer in the IORT group (248 ± 84 vs 177 ± 68 min; p < 0.001). No significant differences were found concerning anastomotic leakage rate, hospital stay, or wound infection rate. CONCLUSIONS Intraoperative radiotherapy appears to be a safe treatment option in patients with locally advanced or recurrent rectal cancer with acceptable complication rates. The effect on local recurrence rate has to be estimated in long-term follow-up.
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Affiliation(s)
- Christian Daniel Klink
- Department of General, Visceral and Transplant Surgery, RWTH Aachen University Hospital, Pauwelsstr. 30, 52074, Aachen, Germany,
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Sole CV, Calvo FA, Serrano J, Del Valle E, Rodriguez M, Muñoz-Calero A, Turégano F, García-Sabrido JL, Garcia-Alfonso P, Peligros I, Rivera S, Deutsch E, Alvarez E. Post-chemoradiation intraoperative electron-beam radiation therapy boost in resected locally advanced rectal cancer: long-term results focused on topographic pattern of locoregional relapse. Radiother Oncol 2014; 112:52-8. [PMID: 24997989 DOI: 10.1016/j.radonc.2014.05.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 03/25/2014] [Accepted: 05/04/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Patients with locally advanced rectal cancer (LARC) have a dismal prognosis. We investigated outcomes and risk factors for locoregional recurrence (LRR) in patients treated with preoperative chemoradiotherapy (CRT), surgery and IOERT. METHODS A total of 335 patients with LARC [⩾cT3 93% and/or cN+ 69%) were studied. In multivariate analyses, risk factors for LRR, IFLR and OFLR were assessed. RESULTS Median follow-up was 72.6 months (range, 4-205). In multivariate analysis distal margin distance ⩽10 mm [HR 2.46, p = 0.03], R1 resection [HR 5.06, p = 0.02], tumor regression grade 1-2 [HR 2.63, p = 0.05] and tumor grade 3 [HR 7.79, p < 0.001] were associated with an increased risk of LRR. A risk model was generated to determine a prognostic index for individual patients with LARC. CONCLUSIONS Overall results after multimodality treatment of LARC are promising. Classification of risk factors for LRR has contributed to propose a prognostic index that could allow us to guide risk-adapted tailored treatment.
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Affiliation(s)
- Claudio V Sole
- Department of Radiation Oncology, Instituto de Radiomedicina, Santiago, Chile; Department of Radiation Oncology, Institut Gustave Roussy, Villejuif, France; Instituto de Investigacion Sanitaria, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
| | - Felipe A Calvo
- Department of Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; School of Medicine, Complutense University, Madrid, Spain; Instituto de Investigacion Sanitaria, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Javier Serrano
- School of Medicine, Complutense University, Madrid, Spain; Service of Radiation Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigacion Sanitaria, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Emilio Del Valle
- Department of Surgery, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigacion Sanitaria, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Marcos Rodriguez
- Department of Surgery, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigacion Sanitaria, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Alberto Muñoz-Calero
- School of Medicine, Complutense University, Madrid, Spain; Department of Surgery, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigacion Sanitaria, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Fernando Turégano
- Department of Surgery, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigacion Sanitaria, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Jose Luis García-Sabrido
- School of Medicine, Complutense University, Madrid, Spain; Department of Surgery, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigacion Sanitaria, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Pilar Garcia-Alfonso
- School of Medicine, Complutense University, Madrid, Spain; Service of Medical Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigacion Sanitaria, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Isabel Peligros
- Department of Pathology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigacion Sanitaria, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Sofia Rivera
- Department of Radiation Oncology, Institut Gustave Roussy, Villejuif, France; Molecular Radiotherapy Laboratory INSERM1030, Gustave Roussy Cancer Campus, Villejuif, France; School of Medicine, Paris-Sud University, Villejuif, France
| | - Eric Deutsch
- Department of Radiation Oncology, Institut Gustave Roussy, Villejuif, France; Molecular Radiotherapy Laboratory INSERM1030, Gustave Roussy Cancer Campus, Villejuif, France; School of Medicine, Paris-Sud University, Villejuif, France
| | - Emilio Alvarez
- School of Medicine, Complutense University, Madrid, Spain; Department of Pathology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigacion Sanitaria, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Wiig JN, Giercksky KE, Tveit KM. Intraoperative radiotherapy for locally advanced or locally recurrent rectal cancer: Does it work at all? Acta Oncol 2014; 53:865-76. [PMID: 24678823 DOI: 10.3109/0284186x.2014.895037] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Intraoperative radiotherapy (IORT) has been given for primary and locally recurrent rectal cancer for 30 years. Still, its effect is not clear. MATERIAL AND METHODS PubMed and EMBASE search for papers after 1989 on surgical treatment and external beam radiotherapy (EBRT) for primary advanced and locally recurrent rectal cancer, with and without IORT. From each center the most recent paper was generally selected. Survival and local recurrence at five years was tabulated for the total groups and separate R-stages. Also, the technique for IORT, use of EBRT and chemotherapy as well as surgical approach was registered. RESULTS In primary cancer 18 papers from 14 centers were tabulated, including one randomized and five internally comparing studies, as well as seven studies without IORT. In locally recurrent cancer 18 papers from 13 centers were tabulated, including four internally comparing studies and also five without IORT. Overall survival (OS) and local recurrence rate (LRR) were higher for primary cancer compared to recurrent cancer. Patients with R0 resections had better outcome than patients with R1 or R2 resections. For primary cancer OS and LR rate of the total groups and R0 stages was not influenced by IORT. An effect on R1/R2 stages cannot be excluded. The only randomized study (primary cancer) did not show any effect of IORT. CONCLUSION IORT does not convincingly improve OS and LR rate for primary and locally recurrent rectal cancer. If there is an effect of IORT, it is small and cannot be shown outside randomized studies analyzing the separate R stages.
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Affiliation(s)
- Johan N Wiig
- Department of Gastroenterological Surgery, The Norwegian Radium Hospital, Oslo University Hospital , Oslo , Norway
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12
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Calvo FA, Morillo V, Santos M, Serrano J, Gomez-Espí M, Rodriguez M, Del Vale E, Gracia-Sabrido JL, Ferrer C, Sole C. Interval between neoadjuvant treatment and definitive surgery in locally advanced rectal cancer: impact on response and oncologic outcomes. J Cancer Res Clin Oncol 2014; 140:1651-60. [PMID: 24880919 DOI: 10.1007/s00432-014-1718-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Accepted: 05/18/2014] [Indexed: 02/01/2023]
Abstract
PURPOSE The optimal waiting period between neoadjuvant treatment completion and surgery in locally advanced rectal cancer (LARC) is controversial. The specific purpose of this study was to evaluate the effect of prolonging this interval on the pathologic response, postoperative morbidity, and long-term oncologic outcomes. METHODS Retrospective data analysis is reported from LARC patients who had been treated with chemoradiation followed by surgery and intra-operative radiotherapy, between February 1995 and December 2012. In total, two groups were studied, according to the time elapsed between neoadjuvant treatment and surgery: conventional interval (CI; <6 weeks) and delayed interval (DI; ≥6 weeks). Clinicopathological data related to tumor response, postoperative morbidity, and oncologic outcomes were compared. RESULTS This study included 335 consecutive LARC patients. There was a higher proportion of patients with clinical staging nodal involvement (cN+) in the DI group (76.6 vs. 64.1 %; p = 0.01). The pathologic complete response (pCR) was not significantly different among groups (8.8 vs. 12.1 %; p = 0.34). Longer intervals did not affect complication incidence or severity or hospital admission length. Certain postneoadjuvant tumor effect parameters were significantly increased in the DI group, including N-downstaging and T-downsizing. After a median follow-up of 71 months, patients in the DI group presented with superior 5-year overall survival (OS) (55.9 vs. 70.4 %, p = 0.014); however, no statistically significant differences were observed in 5-year disease-free survival (DFS) or 5-year local control (LC) (69.9 vs. 74.9 %, p = 0.223; 90.4 vs. 94.5 %, p = 0.123, respectively). CONCLUSIONS A modest surgical interval delay (≥6 weeks) did not increase postoperative complications and was identified as a favorable prognostic factor for OS, although no differences were observed in pCR, LC, or DFS. Innovative multidisciplinary strategies incorporating further time extension of the surgical interval can be safely explored.
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Affiliation(s)
- Felipe A Calvo
- Hospital General Universitário Gregório Marañón, Madrid, Spain
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13
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Abstract
The management of rectal cancer has changed dramatically over the last few decades. Due to improvements in the multimodality treatment and the introduction of neoadjuvant chemoradiation, previously irresectable tumours can nowadays be cured by extensive multivisceral resections. These highly complex operations are associated with significant morbidity and mortality. Due to optimization of chemoradiotherapy, the introduction of IORT, increasing knowledge of tumour pathology and patterns of recurrence the need for extensive surgery diminishes. The question arises which patients with T4 rectal cancer really need extensive surgery and who can safely be considered for an organ preserving approach.
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Post-chemoradiation anastomotic recurrence in locally advanced rectal cancer: no increased risk associated with distal margin. Clin Transl Oncol 2013; 16:573-80. [PMID: 24129427 DOI: 10.1007/s12094-013-1119-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Accepted: 09/29/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND PURPOSE Anastomotic recurrence after radical sphincter-preserving surgery preceded by neoadjuvant therapy in locally advanced rectal cancer is an uncommon event that merits further assessment. The aim of this study is to analyze the effect of preoperative chemoradiation on the risk of anastomotic recurrence. Based on the initial extension of the tumor, we analyzed whether the distal surgical section was calculated through the virtual initial extension of the rectal tumor. PATIENTS AND METHODS Eligible patients with locally advanced rectal cancer were offered preoperative chemoradiation, sphincter sparing surgery and intraoperative radiation therapy boost. RESULTS 180 patients were treated with anterior resection (40 %), low anterior resection (45.6 %) and ultra-low anterior resection (14.4 %). With a median follow-up of 41.1 months (0.36-143 months), anastomotic recurrence was diagnosed in 9 patients (5 %). There was no statistical correlation with downstaging (T or N), downsizing effects, or with distance from the lower limit of the residual lesion to the distal margin. Virtual intratumoral surgical section was speculated in 44 patients (3 developed anastomotic recurrence; 6.8 vs 4.8 %, p = 0.482). CONCLUSION Anastomotic recurrence in patients with rectal cancer treated with neoadjuvant chemoradiation is an infrequent event. Virtual intratumoral surgical sections followed by anastomosis do not contribute to an excessive risk of recurrence. Our findings encourage the development of policies for preservation of the ano-rectal complex in rectal cancer patients.
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Calvo F, Sole C, Herranz R, Lopez-Bote M, Pascau J, Santos A, Muñoz-Calero A, Ferrer C, Garcia-Sabrido J. Intraoperative radiotherapy with electrons: fundamentals, results, and innovation. Ecancermedicalscience 2013; 7:339. [PMID: 24009641 PMCID: PMC3757959 DOI: 10.3332/ecancer.2013.339] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Indexed: 11/23/2022] Open
Abstract
Rationale and objectives To analyse the programme activity and clinical innovation and/or technology developed over a period of 17 years with regard to the introduction and the use of intraoperative radiotherapy (IORT) as a therapeutic component in a medical–surgical multidisciplinary cancer hospital. Material and methods To standardise and record this procedure, the Radiation Oncology service has an institutional programme and protocols that must be completed by the different specialists involved. For 17 years, IORT procedures were recorded on a specific database that includes 23 variables with information recorded on institutional protocols. As part of the development and innovation activity, two technological tools were implemented (RADIANCE and MEDTING) in line with the standardisation of this modality in clinical practice. Results During the 17 years studied, 1,004 patients were treated through 1,036 IORT procedures. The state of the disease at the time of IORT was 77% primary and 23% recurrent. The origin and distribution of cancers were 62% gastrointestinal, 18% sarcomas, 5% pancreatic, 2% paediatric, 3% breast, 7% less common locations, and 2% others. The research and development projects have generated a patent on virtual planning (RADIANCE) and proof of concept to explore as a professional social network (MEDTING). During 2012, there were 69 IORT procedures. There was defined treatment volume (target or target region) in all of them, and 43 were conducted by the virtual planning RADIANCE system. Eighteen have been registered on the platform MEDTING as clinical cases. Conclusion The IORT programme, developed in a university hospital with an academic tradition, and interdisciplinary surgical oncology, is a feasible care initiative, able to generate the necessary intense clinical activity for tending to the cancer patient. Moreover, it is a competitive source for research, development, and scientific innovation.
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Affiliation(s)
- Fa Calvo
- Department of Oncology, Gregorio Marañón General University Hospital, Madrid 28007, Spain ; School of Medicine, Complutense University, Madrid, Spain ; Institute of Research Investigation, Gregorio Marañón General University Hospital, Madrid 28007, Spain
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16
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Calvo FA, Sallabanda M, Sole CV, Gonzalez C, Murillo LA, Martinez-Villanueva J, Santos JA, Serrano J, Alavrez A, Blanco J, Calin A, Gomez-Espi M, Lozano M, Herranz R. Intraoperative radiation therapy opportunities for clinical practice normalization: Data recording and innovative development. Rep Pract Oncol Radiother 2013; 19:246-52. [PMID: 25061517 DOI: 10.1016/j.rpor.2013.07.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Revised: 05/26/2013] [Accepted: 07/16/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Intraoperative radiotherapy (IORT) refers to the delivery of a high dose of radiation at the time of surgery. AIM To analyze clinical and research-oriented innovative activities developed in a 17-year period using intraoperative electron-radiation therapy (IOeRT) as a component of treatment in a multidisciplinary approach for cancer management. MATERIALS AND METHODS From 01/1995 to 03/2012 IOeRT procedures were registered in a specific Hospital-based database. Research and developments in imaging and recording for treatment planning implementation are active since 2006. RESULTS 1004 patients were treated and 1036 IORT procedures completed. Median age of patients was 61 (range 5 months to 94 years). Gender distribution was male in 54% of cases and female in 46%. Disease status at the time of IORT was 796 (77%) primary and 240 (23%) recurrent. Cancer type distribution included: 62% gastrointestinal, 18% sarcoma, 5% pancreas, 2% paediatric, 3% breast, 77 7% oligotopic recurrences, 2% other. IORT technical characteristics were: Applicator size 5 cm 22%, 6 cm 21%, 7 cm 21%, 8 cm 15%, 9 cm 6%, 10 cm 7% 12 cm 5% 15 cm 3%. Electron energies: 6 MeV 19%, 8 MeV 15%, 10 MeV 15%, 12 MeV 23%, 15 MeV 19%, 18 MeV 6%, other 3%. Multiple fields: 108 (11%). Dose: 7.5 Gy 3%, 10 Gy 35%, 12 Gy 3%, 12.5 Gy 49%, 15 Gy 5%, other 5%. CONCLUSION An IORT programme developed in an Academic Hospital based on practice-oriented medical decisions is an attractive interdisciplinary oncology initiative proven to be able to generate an intensive clinical activity for cancer patient quality care and a competitive source of scientific patient-oriented research, development and innovation.
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Affiliation(s)
- Felipe A Calvo
- Department of Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain ; School of Medicine Complutense University, Madrid, Spain ; Institute for Sanitary Research, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Claudio V Sole
- Department of Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain ; School of Medicine Complutense University, Madrid, Spain ; Institute for Sanitary Research, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Carmen Gonzalez
- School of Medicine Complutense University, Madrid, Spain ; Service of Radiation Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | | | - Juan A Santos
- Service of Radiation Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain ; Institute for Sanitary Research, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Javier Serrano
- Service of Radiation Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Ana Alavrez
- Service of Radiation Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Jose Blanco
- Service of Radiation Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Ana Calin
- Service of Radiation Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Marina Gomez-Espi
- Service of Radiation Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Miguel Lozano
- Service of Radiation Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Rafael Herranz
- Service of Radiation Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Clinical and technical characteristics of intraoperative radiotherapy. Analysis of the ISIORT-Europe database. Strahlenther Onkol 2013; 189:729-37. [PMID: 23842635 DOI: 10.1007/s00066-013-0395-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 05/22/2013] [Indexed: 01/23/2023]
Abstract
BACKGROUND A joint analysis of clinical data from centres within the European section of the International Society of Intraoperative Radiation Therapy (ISIORT-Europe) was undertaken in order to define the range of intraoperative radiotherapy (IORT) techniques and indications encompassed by its member institutions. MATERIALS AND METHODS In 2007, the ISIORT-Europe centres were invited to record demographic, clinical and technical data relating to their IORT procedures in a joint online database. Retrospective data entry was possible. RESULTS The survey encompassed 21 centres and data from 3754 IORT procedures performed between 1992 and 2011. The average annual number of patients treated per institution was 42, with three centres treating more than 100 patients per year. The most frequent tumour was breast cancer with 2395 cases (63.8 %), followed by rectal cancer (598 cases, 15.9 %), sarcoma (221 cases, 5.9 %), prostate cancer (108 cases, 2.9 %) and pancreatic cancer (80 cases, 2.1 %). Clinical details and IORT technical data from these five tumour types are reported. CONCLUSION This is the first report on a large cohort of patients treated with IORT in Europe. It gives a picture of patient selection methods and treatment modalities, with emphasis on the main tumour types that are typically treated by this technique and may benefit from it.
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Calvo FA, Sole CV, de la Mata D, Cabezón L, Gómez-Espí M, Alvarez E, Madariaga P, Carreras JL. 18F-FDG PET/CT-based treatment response evaluation in locally advanced rectal cancer: a prospective validation of long-term outcomes. Eur J Nucl Med Mol Imaging 2013; 40:657-67. [DOI: 10.1007/s00259-013-2341-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Accepted: 01/04/2013] [Indexed: 12/11/2022]
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Jiang Y, Ji X, Zhao S, Zhao R, Jin Y. Laparoscopic resection with intraoperative radiotherapy for local advanced rectal cancer: a preliminary case report. J Laparoendosc Adv Surg Tech A 2013; 23:267-70. [PMID: 23272726 DOI: 10.1089/lap.2012.0286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To report the feasibility of laparoscopic resection with intraoperative radiotherapy for local advanced rectal cancer in an Asian man. PATIENT AND METHODS A 55-year-old man with adenocarcinoma of the rectum presented at Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China. The tumor, with a size of 5 × 5 cm, was located 3 cm from the anus and covered a circular area around approximately two-thirds of the bowel. The carcinoembryonic antigen level was 29.86 ng/mL; a nodule was detected, but no distant metastasis was detected. Preoperative staging was T4N1M0. After the patient signed the consent form, laparoscopic resection with intraoperative radiotherapy was performed. RESULTS The operation time was about 180 minutes, intraoperative blood loss was 100 mL, and postoperative hospital stay was 8 days. The patient had no postoperative complications. conclusions: Performance of laparoscopic resection with intraoperative radiotherapy for local advanced rectal cancer is feasible in selected patients.
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Affiliation(s)
- Yimei Jiang
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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20
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Skrovina M, Soumarova R, Duda M, Bezdek R, Bartos J, Wendrinski A, Andel P, Parvez J, Straka M, Adamcik L. Laparoscopic abdominoperineal resection with intraoperative radiotherapy for locally advanced low rectal cancer. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2012; 158:447-50. [PMID: 23128826 DOI: 10.5507/bp.2012.082] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Accepted: 07/25/2012] [Indexed: 01/25/2023] Open
Abstract
AIMS Intraoperative radiotherapy (IORT) for locally advanced rectal cancer as an integral part of multimodal treatment, may lead to reduced local recurrence but it is not routinely used. The aim of this paper is to describe our experience with IORT in the treatment of patients with locally advanced adenocarcinoma of the lower third of the rectum. MATERIAL AND METHODS Laparoscopic abdominoperineal amputation of the rectum with intraoperative radiotherapy was performed on 17 patients, 13 men and 4 women, median age 64 years (49-75 years) between 2010-2011. All patients underwent complete therapy according to the treatment protocol. RESULTS In one patient, the laparoscopic procedure had to be converted to an open resection. The duration of the surgical procedure with IORT was 185 to 345 min (median 285 min). In 14 cases, the intraoperative dose was 10 Gy and in two patients a dose of 12 Gy was used. There were no severe intraoperative complications. Blood loss ranged from 30 to 500 mL (median 100 mL). There were postoperative complications in 4 patients (23.5%); 2 necessitated surgical reintervention (11.8%). The duration of postoperative hospitalization was 6 to 35 days (median 7 days). In the follow-up of 2 to 16 months (median 12 months), no local recurrence or disease generalization have been found to date. CONCLUSIONS The results show the technical feasibility of laparoscopically assisted abdominoperineal amputation of the rectum in combination with IORT in the treatment of locally advanced rectal carcinoma with an acceptable risk of postperative complications.
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Affiliation(s)
- Matej Skrovina
- Department of Surgery, Hospital and Oncological Centre, Novy Jicin, Czech Republic
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21
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Kang MK, Kim MS, Kim JH. Intraoperative radiotherapy for locally advanced rectal cancer. JOURNAL OF THE KOREAN SOCIETY OF COLOPROCTOLOGY 2010; 26:274-8. [PMID: 21152229 PMCID: PMC2998003 DOI: 10.3393/jksc.2010.26.4.274] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2009] [Accepted: 06/07/2010] [Indexed: 11/04/2022]
Abstract
Purpose Although intraoperative radiotherapy (IORT) is known to be a method that can reduce local recurrence in locally advanced colorectal cancer, it is not widely used. The aim of this study was to report our experience with IORT for locally advanced rectal cancer. Methods From 1991 to 1994, nine patients with locally advanced rectal cancer received IORT. External beam radiotherapy was given postoperatively in five patients and preoperatively in three. Seven patients received chemotherapy. IORT was done with 6-MeV or 9-MeV electrons, and 12 Gy was irradiated at the tumor bed. The median follow-up period was 84 months (range, 15 to 208 months). Results The median age of patients was 51 years (range, 42 to 73 years). All patients had advanced clinical T-stage (cT3/4) cancer. The overall and the disease-free survival rates were 66.7% and 66.7% at 5 years, respectively. One patient developed a local recurrence near the anastomosis site, which was out of the IORT field. Four patients died before the last follow-up; three from distant metastasis and one from secondary primary cancer. Adverse effects related to IORT did not occur. Conclusion Although the number of patients was small in this study, IORT is thought to be safe and effective in reducing local recurrence in locally advanced rectal cancer. However, the role of IORT should be refined in the era of preoperative radio-chemotherapy followed by total mesorectal excision.
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Affiliation(s)
- Min Kyu Kang
- Department of Radiation Oncology, Yeungnam University College of Medicine, Daegu, Korea
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Kusters M, Wallner C, Lange MM, DeRuiter MC, van de Velde CJH, Moriya Y, Rutten HJT. Origin of presacral local recurrence after rectal cancer treatment. Br J Surg 2010; 97:1582-7. [DOI: 10.1002/bjs.7180] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Abstract
Background
The objective of this study was to obtain detailed anatomical information about the lateral lymph nodes, in order to determine whether they might play a role in presacral local recurrence of rectal cancer after total mesorectal excision without lateral lymph node dissection.
Methods
Ten serially sectioned human fetal pelvises were studied at high magnification and a three-dimensional reconstruction of the fetal pelvis was made.
Results
Examination of the histological sections and the three-dimensional reconstruction showed that lateral lymph node tissue comprises a major proportion of the pelvic tissue volume. There were no lymph nodes located in the presacral area. Connections between the mesorectal and extramesorectal lymph node system were found in all fetal pelvises, located below the peritoneal reflection on the anterolateral side of the fetal rectum. At this site middle rectal vessels passed to and from the mesorectum, and branches of the autonomic nervous system bridge to innervate the rectal wall.
Conclusion
The findings of this study support the hypothesis that tumour recurrence might arise from lateral lymph nodes.
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Affiliation(s)
- M Kusters
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - C Wallner
- Department of Anatomy, Embryology and Physiology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - M M Lange
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - M C DeRuiter
- Department of Anatomy and Embryology, Leiden University Medical Centre, Leiden, The Netherlands
| | - C J H van de Velde
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Y Moriya
- Department of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - H J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
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de Wilt JHW, Vermaas M, Ferenschild FTJ, Verhoef C. Management of locally advanced primary and recurrent rectal cancer. Clin Colon Rectal Surg 2010; 20:255-63. [PMID: 20011207 DOI: 10.1055/s-2007-984870] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Treatment for patients with locally advanced and recurrent rectal cancer differs significantly from patients with rectal cancer restricted to the mesorectum. Adequate preoperative imaging of the pelvis is therefore important to identify those patients who are candidates for multimodality treatment, including preoperative chemoradiation protocols, intraoperative radiotherapy, and extended surgical resections. Much effort should be made to select patients with these advanced tumors for treatment in specialized referral centers. This has been shown to reduce morbidity and mortality and improve long-term survival rates. In this article, we review the best treatment options for patients with locally advanced and recurrent rectal cancer. We also emphasize the necessity of a multidisciplinary team, including a radiologist, radiation oncologist, urologist, surgical oncologist, plastic surgeon, and gynecologist in the diagnosis and treatment of patients with these pelvic tumors.
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Affiliation(s)
- Johannes H W de Wilt
- Department of Surgical Oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, The Netherlands.
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Kusters M, Valentini V, Calvo F, Krempien R, Nieuwenhuijzen G, Martijn H, Doglietto G, del Valle E, Roeder F, Buchler M, van de Velde C, Rutten H. Results of European pooled analysis of IORT-containing multimodality treatment for locally advanced rectal cancer: adjuvant chemotherapy prevents local recurrence rather than distant metastases. Ann Oncol 2010; 21:1279-1284. [DOI: 10.1093/annonc/mdp501] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Kusters M, Holman FA, Martijn H, Nieuwenhuijzen GA, Creemers GJ, Daniels-Gooszen AW, van den Berg HA, van den Brule AJ, van de Velde CJH, Rutten HJT. Patterns of local recurrence in locally advanced rectal cancer after intra-operative radiotherapy containing multimodality treatment. Radiother Oncol 2009; 92:221-5. [PMID: 19339070 DOI: 10.1016/j.radonc.2009.03.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2009] [Revised: 03/07/2009] [Accepted: 03/07/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND PURPOSE The purpose of this study is to analyze the patterns of local recurrence (LR) after intra-operative radiotherapy (IORT) containing multimodality treatment of locally advanced rectal carcinoma (LARC). METHODS AND MATERIALS Two hundred and ninety patients with LARC who underwent multimodality treatment between 1994 and 2006 were studied. For patients who developed LR, the subsite was classified into presacral, postero-lateral, lateral, anterior, anastomotic or perineal. Patient and treatment characteristics were related to subsite of LR. RESULTS After 5years, 34 patients (13.2%) developed LR. The most prominent subsite of LR was the presacral subsite. 47% of the local recurrences occurred outside the IORT field. Most recurrences developed when IORT was given dorsally, while least occurred when IORT was given ventrally. Especially after dorsal IORT a high amount of infield recurrences were observed (6 of 8; 75%). In multi-variate analysis tumor distance of more than 5cm from the anal verge and a positive circumferential margin were associated with presacral local recurrence. CONCLUSIONS Multimodality treatment is effective in the prevention of local recurrence in LARC. IORT application to the area most at risk is feasible and seems effective in the prevention of local recurrence. Dorsal tumor location results in unfavourable oncologic results.
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Affiliation(s)
- Miranda Kusters
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
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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.
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Affiliation(s)
- A R Skandarajah
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne 3002, Australia.
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27
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Abstract
Patients with stage II and III rectal cancer benefit from a multidisciplinary approach to treatment. Studies of postoperative adjuvant therapy consistently demonstrate decreases in locoregional recurrence with the use of radiation therapy. The use of postoperative chemotherapy results in improved disease-free survival and overall survival in certain studies. Preoperative radiation therapy decreases locoregional recurrence and in one study demonstrated an improvement in survival. The addition of chemotherapy to preoperative radiation results in improved locoregional control, but not survival. Preoperative chemoradiation is the standard of care for patients with clinical stage II and III rectal cancer in the United States due to improved local recurrence, acute and late toxicity, and sphincter preservation compared with postoperative chemoradiation. Promising approaches include the incorporation of new chemotherapeutic and biologic agents into chemoradiation and adjuvant chemotherapy regimens; new radiation techniques, such as the use of intraoperative radiation therapy and an accelerated concomitant radiation boost; and gene and protein expression profiling, to better predict response to treatment and prognosis.
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Affiliation(s)
- Smitha S. Krishnamurthi
- Department of Medicine, University Hospitals Case Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
- Case Comprehensive Cancer Center, University Hospitals Case Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Yuji Seo
- Department of Radiation Oncology, University Hospitals Case Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Timothy J. Kinsella
- Case Comprehensive Cancer Center, University Hospitals Case Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Radiation Oncology, University Hospitals Case Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
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Abstract
Intraoperative radiation therapy (IORT) is the delivery of irradiation at the time of an operation. This is performed by different techniques including intraoperative electron beam techniques and high-dose rate brachytherapy. IORT is usually given in combination with external-beam radiation therapy with or without chemotherapy and surgical resection. IORT excludes part or all dose-limiting sensitive structures, thereby increasing the effective dose to the tumor bed (and therefore local control) without significantly increasing normal tissue morbidity. Despite best contemporary therapy, high rates of local failure occur in patients with locally advanced or recurrent rectal cancer, retroperitoneal sarcoma, select gynecologic cancers, and other malignancies. The addition of IORT to conventional treatment methods has improved local control as well as survival in many disease sites in both the primary and locally recurrent disease settings. More recently, there has been interest in the use of IORT as a technique of partial breast irradiation for women with early breast cancer. Given newer and lower cost treatment devices, the use of IORT in clinical practice will likely grow, with increasing integration into the treatment of nonconventional malignancies. Optimally, phase III randomized trials will be carried out to prove its efficacy in these disease sites.
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Affiliation(s)
- Christopher G Willett
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA.
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Roeder F, Treiber M, Oertel S, Dinkel J, Timke C, Funk A, Garcia-Huttenlocher H, Bischof M, Weitz J, Harms W, Hensley FW, Buchler MW, Debus J, Krempien R. Patterns of failure and local control after intraoperative electron boost radiotherapy to the presacral space in combination with total mesorectal excision in patients with locally advanced rectal cancer. Int J Radiat Oncol Biol Phys 2007; 67:1381-8. [PMID: 17275208 DOI: 10.1016/j.ijrobp.2006.11.039] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2006] [Revised: 11/09/2006] [Accepted: 11/16/2006] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate local control and patterns of failure in patients treated with intraoperative electron beam radiotherapy (IOERT) after total mesorectal excision (TME), to appraise the effectiveness of intraoperative target definition. METHODS AND MATERIALS We analyzed the outcome of 243 patients with rectal cancer treated with IOERT (median dose, 10 Gy) after TME. Eighty-eight patients received neoadjuvant and 122 patients adjuvant external beam radiotherapy (EBRT) (median dose, 41.4 Gy), and in 88% simultaneous chemotherapy was applied. Median follow-up was 59 months. RESULTS Local failure was observed in 17 patients (7%), resulting in a 5-year local control rate of 92%. Only complete resection and absence of nodal involvement correlated positively with local control. Considering IOERT fields, seven infield recurrences were seen in the presacral space, resulting in a 5-year local control rate of 97%. The remaining local relapses were located as follows: retrovesical/retroprostatic (5), anastomotic site (2), promontorium (1), ileocecal (1), and perineal (1). CONCLUSION Intraoperative electron beam radiotherapy as part of a multimodal treatment approach including TME is a highly effective regimen to prevent local failure. The presacral space remains the site of highest risk for local failure, but IOERT can decrease the percentage of relapses in this area.
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Affiliation(s)
- Falk Roeder
- Department of Radiation Oncology, University of Heidelberg, Heidelberg, Germany
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Krempien R, Roeder F, Oertel S, Roebel M, Weitz J, Hensley FW, Timke C, Funk A, Bischof M, Zabel-Du Bois A, Niethammer AG, Eble MJ, Buchler MW, Treiber M, Debus J. Long-term results of intraoperative presacral electron boost radiotherapy (IOERT) in combination with total mesorectal excision (TME) and chemoradiation in patients with locally advanced rectal cancer. Int J Radiat Oncol Biol Phys 2006; 66:1143-51. [PMID: 16979835 DOI: 10.1016/j.ijrobp.2006.06.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2006] [Revised: 06/02/2006] [Accepted: 06/15/2006] [Indexed: 11/23/2022]
Abstract
BACKGROUND We analyzed the long-term results of patients with locally advanced rectal cancer using a multimodal approach consisting of total mesorectal excision (TME), intraoperative electron-beam radiation therapy (IOERT), and pre- or postoperative chemoradiation (CRT). PATIENTS AND METHODS Between 1991 and 2003, 210 patients with locally advanced rectal cancer (65 International Union Against Cancer [UICC] Stage II, 116 UICC Stage III, and 29 UICC Stage IV cancers) were treated with TME, IOERT, and preoperative or postoperative CHT. A total of 122 patients were treated postoperatively; 88 patients preoperatively. Preoperative or postoperative fluoropyrimidine-based CRT was applied in 93% of these patients. RESULTS Median age was 61 years (range, 26-81). Median follow-up was 61 months. The 5-year actuarial overall survival (OS), disease-free survival (DFS), local control rate (LC), and distant relapse free survival (DRS) of all patients was 69%, 66%, 93%, and 67%, respectively. Multivariate analysis revealed that UICC stage and resection status were the most important independent prognostic factors for OS, DFS, and DRS. The resection status was the only significant factor for local control. T-stage, tumor localization, type of resection, and type of chemotherapy had no significant impact on OS, DFS, DRS, and LC. Acute and late complications > or =Grade 3 were seen in 17% and 13% of patients, respectively. CONCLUSION Multimodality treatment with TME and IOERT boost in combination with moderate dose pre- or postoperative CRT is feasible and results in excellent long-term local control rates in patients with intermediate to high-risk locally advanced rectal cancer.
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Affiliation(s)
- Robert Krempien
- Department of Radiation Oncology, University of Heidelberg, Heidelberg, Germany.
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Ferenschild FTJ, Vermaas M, Nuyttens JJME, Graveland WJ, Marinelli AWKS, van der Sijp JR, Wiggers T, Verhoef C, Eggermont AMM, de Wilt JHW. Value of intraoperative radiotherapy in locally advanced rectal cancer. Dis Colon Rectum 2006; 49:1257-65. [PMID: 16912909 DOI: 10.1007/s10350-006-0651-x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE This study was designed to analyze the results of a multimodality treatment using preoperative radiotherapy, followed by surgery and intraoperative radiotherapy in patients with primary locally advanced rectal cancer. METHODS Between 1987 and 2002, 123 patients with initial unresectable and locally advanced rectal cancer were identified in our prospective database, containing patient characteristics, radiotherapy plans, operation notes, histopathologic reports, and follow-up details. An evaluation of prognostic factors for local recurrence, distant metastases, and overall survival was performed. RESULTS All patients were treated preoperatively with a median dose of 50 Gy radiotherapy. Surgery was performed six to ten weeks after radiotherapy. Twenty-seven patients were treated with intraoperative radiotherapy because margins were incomplete or </=2 mm. Postoperative mortality was 2 percent. The median follow-up of all patients was 25.1 months. The overall five-year local control was 65 percent and the overall five-year survival was 50 percent. Positive lymph nodes and incomplete resections negatively influenced local control and overall survival. Intraoperative radiotherapy improved five-year local control (58 vs. 0 percent, P = 0.016) and overall survival (38 vs. 0 percent, P = 0.026) for patients with R1/2 resections. CONCLUSIONS The presented multimodality treatment is feasible with an acceptable mortality and a five-year overall survival of 50 percent. Addition of intraoperative radiotherapy for patients with a narrow or microscopic incomplete resection seems to overrule the unfavorable prognostic histologic finding.
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Affiliation(s)
- Floris T J Ferenschild
- Department of Surgical Oncology, Erasmus MC-Daniel den Hoed Cancer Center, 3008 AE Rotterdam, The Netherlands
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Calvo FA, Aldaz A, Zufía L, de la Mata D, Serrano J, García R, Arranz JA, Alvarado A, Giráldez J. Tegafur and 5-fluorouracil pelvic tissue concentrations in rectal cancer patients receiving preoperative chemoradiation. Clin Transl Oncol 2006; 8:500-7. [PMID: 16870540 DOI: 10.1007/s12094-006-0050-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND PURPOSE To investigate the presence of 5-Fluorouracil (5-FU) in pelvic tissue after oral administration of tegafur. To measure tegafur and 5-FU concentrations in normal rectal mucosa, perirectal fat and residual tumor in rectal cancer patients receiving preoperative chemoradiation. To correlate drug concentrations with cancer downstaging effects. PATIENTS AND METHODS Three tissue samples taken from 16 surgical specimens after recto-sigmoid resection were analyzed. Tegafur and 5-FU concentrations were measured using high-performance liquid chromatography. 16 patients with locally advanced rectal cancer were treated with preoperative pelvic irradiation (45-50 Gy) sensitized with oral tegafur (400 mg for every 8 hours daily). Seven patients received a precharge dose of tegafur (400 mg oral every 8 hours) 24 hours before surgery. RESULTS In 8 of the 9 patients who did not receive a precharge dose, detectable levels of tegafur were observed in fat tissue, normal mucosa and tumor, but detectable 5-FU levels were only observed in one patient. Mean concentrations (ranges) for tegafur in fat, normal mucosa and tumor in patients without the precharge dose were 72.19 (12.1-205.6), 179.53 (11.30-727.7) and 252.35 (27.9-874.6) ng/g, respectively; mean concentrations for 5-FU in the same samples were 0.95, 1.92 and 2.68 ng/g (1 patient), respectively. In patients receiving a tegafur precharge, both tegafur and 5-FU were present in all tissue samples with the exception of 2 fat samples, in which drug concentrations were undetectable. 5-FU levels were higher in tumor than other sites, with a median value of 68.24 ng/g (range 3.8-283.05 ng/g). Tegafur levels were also higher in tumor samples than other sites (mean 3446.53 ng/g, range 1044.5-7847.0 ng/g), except in 2 patients who had higher levels of tegafur in normal mucosa. CONCLUSIONS Tegafur and 5-FU are not always present in pelvic tissues 5 to 6 weeks after oral administration of tegafur. Both drugs were present in the tissues analyzed, in relevant concentrations, 24 hours after oral administration of tegafur. The data obtained suggest a tendency (not significant) toward a correlation between levels of 5-FU present in the residual tumor and cancer downstaging.
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Affiliation(s)
- F A Calvo
- Department of Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
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Calvo FA, Meirino RM, Orecchia R. intraoperative radiation therapy part 2. Clinical results. Crit Rev Oncol Hematol 2006; 59:116-27. [PMID: 16859922 DOI: 10.1016/j.critrevonc.2006.04.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2005] [Revised: 03/30/2006] [Accepted: 04/13/2006] [Indexed: 12/12/2022] Open
Abstract
Intraoperative radiation therapy (IORT) has been used for over 30 years in Asia, Europe and America as a supplementary activity in the treatment of cancer patients with promising results. Modern IORT is carried out with electron beams (IOERT) produced by a linear accelerator generally used for external beam irradiation (EBRT) or a specialized mobile electron accelerator. HDR brachytherapy (HDR-IORT) has also been applied on selected locations. Retrospective analysis of clinical experiences in cancer sites such as operable pancreatic tumour, locally advanced/recurrent rectal cancer, head and neck carcinomas, sarcomas and cervical cancer are consistent with local tumour control promotion compared to similar clinical experiences without IORT. New emerging indications such as the treatment of breast cancer are presented. The IORT component of the therapeutical approach allows intensification of the total radiation dose without additional exposure of healthy tissues and improves dose-deposit homogeneity and precision. Results of the application of IORT on selected disease sites are presented with an analysis on future possibilities. To improve the methodology, clinical trials are required with multivariate analysis including patient, tumour and treatment characteristics, prospective evaluation of early and late toxicity, patterns of tumour recurrence and overall patient outcome.
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Affiliation(s)
- Felipe A Calvo
- Hospital General Universitario Gregorio Marañon, Madrid, Spain.
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Calvo FA, Serrano FJ, Diaz-González JA, Gomez-Espi M, Lozano E, Garcia R, de la Mata D, Arranz JA, García-Alfonso P, Pérez-Manga G, Alvarez E. Improved incidence of pT0 downstaged surgical specimens in locally advanced rectal cancer (LARC) treated with induction oxaliplatin plus 5-fluorouracil and preoperative chemoradiation. Ann Oncol 2006; 17:1103-10. [PMID: 16670204 DOI: 10.1093/annonc/mdl085] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
PURPOSE To compare efficacy in terms of pathologic response in LARC patients treated with preoperative chemoradiation, with or without a short-intense course of induction oxaliplatin. PATIENTS AND METHODS From 05/98 to 10/02, 114 patients were treated with preoperative chemoradiation (4500-5040 cGy + oral Tegafur 1200 mg/day) for cT(3)-(4)N(+/x)M(0) rectal cancer. Starting 05/01, 52 consecutive patients additionally received induction FOLFOX-4, oxaliplatin (85 mg/m(2) iv d1), 5-FU (400 mg/m(2) iv bolus d1) and 600 mg/m(2) iv continuous infusion in 22 h with leucovorin (200 mg iv) d1 and d2, every 15 days (2 cycles), followed by the previously described Tegafur chemoradiation regime. Surgery was performed in 5-6 weeks. Pathological assessment investigated post-treatment T and N status in the rectal wall and peri-rectal tissues. RESULTS Patients, tumor and treatment characteristics were comparable between groups. Incidence of pT(0) specimens was significantly increased by induction FOLFOX-4 (P = 0.006). Total T and N downstaging were 58% versus 75% and 42% versus 40%, respectively (P = ns). T downstaging of > or =2 categories was significantly superior in FOLFOX-4 group (P = 0.029). CONCLUSIONS Short-intense induction FOLFOX-4 significantly improves pathologic complete response in LARC patients treated with tegafur-sensitized preoperative chemoradiation. The 44% rate of pT(0)-(1) specimens observed in the oxaliplatin group should impulse innovative surgical approaches to promote ano-rectal sphincter conserving protocols.
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Affiliation(s)
- F A Calvo
- Department of Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
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Díaz-González JA, Calvo FA, Cortés J, García-Sabrido JL, Gómez-Espí M, Del Valle E, Muñoz-Jiménez F, Alvarez E. Prognostic factors for disease-free survival in patients with T3–4 or N+ rectal cancer treated with preoperative chemoradiation therapy, surgery, and intraoperative irradiation. Int J Radiat Oncol Biol Phys 2006; 64:1122-8. [PMID: 16406393 DOI: 10.1016/j.ijrobp.2005.09.020] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2005] [Revised: 08/28/2005] [Accepted: 09/15/2005] [Indexed: 10/25/2022]
Abstract
PURPOSE Fluoropyrimidine-radiosensitizing agents in conjunction with preoperative radiotherapy have proven to induce tumor and nodal downstaging effects, sphincter preservation promotion, and mid-term favorable survival rates. Intraoperative electron beam radiation therapy may improve pelvic control in patients with locally advanced rectal cancer stages. Potential predictive factors for response and disease-free survival, with intense local multidisciplinary approach, are analyzed. METHODS AND MATERIALS One hundred fifteen patients with rectal cancer were treated with oral 5-fluorouracil or Tegafur with preoperative radiotherapy, surgery, and intraoperative electron beam radiation therapy to identify potential pre- and on-treatment characteristics that might be of prognostic value for disease outcome. Univariate and multivariate analyses were performed. RESULTS Older patients and those treated with Tegafur were more likely to achieve a major histologic response, categorized as persistence of minimal residual microscopic disease foci in the surgical specimen ("mic" response). Factors unfavorably associated with disease-free survival in the multivariate model were male gender and persistence of macroscopic disease in the rectal wall ("mac" response). Accordingly, 3-year disease-free survival rates in the groups of patients with 0, 1, or 2 of these risk factors were 100%, 81%, and 53%, respectively (p < 0.001). CONCLUSIONS Females with an intense pathologic response (pT(mic) residue) to preoperative chemoradiotherapy have an excellent 3-year disease-free survival. This information might be of interest for stratification of patients in the development of adjuvant treatment trials.
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Affiliation(s)
- Juan A Díaz-González
- Department of Oncology, Clinica Universitaria, University of Navarra, Navarra, Spain
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Díaz-González JA, Calvo FA, Cortés J, de La Mata D, Gómez-Espí M, Lozano MA, Lozano E, Serrano J, Herranz R. Preoperative chemoradiation with oral tegafur within a multidisciplinary therapeutic approach in patients with T3-4 rectal cancer. Int J Radiat Oncol Biol Phys 2005; 61:1378-84. [PMID: 15817340 DOI: 10.1016/j.ijrobp.2004.08.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2004] [Revised: 08/09/2004] [Accepted: 08/16/2004] [Indexed: 12/28/2022]
Abstract
PURPOSE The aim of this study was to evaluate the activity in terms of downstaging histologic patterns of residual tumor and clinical tolerance of a neoadjuvant chemoradiation program with oral tegafur for rectal cancer. METHODS AND MATERIALS From May 1998 to May 2001, 62 consecutive patients with cT(3-4) or cN(+) rectal cancer, or both, were treated with 45-50 Gy (1.8 Gy/day; 25 fractions) and oral tegafur 1200 mg/day. Surgery was performed 6 weeks after the completion of chemoradiation. All patients received a boost with intraoperative electron beam radiotherapy (IOERT) over the presacral space. RESULTS Grade 3-4 hematologic toxicity consisted on Grade 3 anemia in 1 patient. Nonhematologic toxicity was mild. Fifteen patients (23%) had Grade 3 dermatitis, 16 (25%) had Grade 3, and 2 (3%) had Grade 4 proctitis. The median dose of radiotherapy was 50.4 Gy. Surgery consisted on anterior resection in 38 patients (61%) and abdominoperineal amputation in 24 (39%). Five complete pathologic responses were observed (8%), and 29 patients (47%) had a minimal microscopic residual tumor (mic category). The total downstaging rate was 68%. With a median follow-up of 46 months, the pelvic control rate was 95%, disease-free survival 74.1%, and overall survival 76.5%. CONCLUSIONS Neoadjuvant chemoradiation with oral tegafur is feasible, well tolerated, and active, with the additional advantage of offering the convenience of oral chemotherapy.
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Affiliation(s)
- Juan A Díaz-González
- Department of Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
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Herranz Amo F, Muñoz Jiménez F, Subirá Ríos D, Gómez Espí M, Calvo Manuel FA. [Preservation of the bladder in rectal cancer with prostatic invasion]. Actas Urol Esp 2005; 28:447-51. [PMID: 15341395 DOI: 10.1016/s0210-4806(04)73108-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Colorectal cancer in the 2nd commonest cancer in Europe. In 5-10% of cases there is infiltration of urological organs. When infiltration affects the bladder or the prostate, anterior pelvic exenteration is the treatment that achieves the largest percentage of tumor free margins and the best 5-year survival. In very select cases of prostatic infiltration, the bladder can be preserved and prostatectomy and abdominoperineal block resection are carried out fulfilling oncological surgical requirements and producing an important improvement in the patient's quality of life. Owing to the very scarce published literature (two articles with three cases) we contribute our experience of 2 patients who received cytoreducing preoperative radiochemotherapy, prostatectomy and block abdominoperineal amputation and intraoperative radiotherapy. We describe the surgical technique used, which is substantially different from standard prostatectomy and requires good coordination between surgeons and urologists.
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Abstract
This contribution presents clinical and technical aspects of combining positron emission tomography (PET) and computed tomography (CT) for patients with colorectal tumors and characterization of unclear liver foci. In which manner and for which patients combined PET/CT is superior to PET or CT alone is also discussed. PET/CT can fulfil most prerequisites for imaging in pre- and postoperative management of patients with colorectal tumors and best meets the desire for optimal imaging procedures. Some of the disadvantages encountered in frequently employed CT can be overcome by the combination of PET and CT while increasing both sensitivity in detecting lesions and specificity in their characterization. Questions regarding treatment response offer an opportunity for devising novel study concepts and initiating research on new PET tracers. Although few publications are available, we are of the opinion that the combination of functional and anatomical imaging provided by PET/CT can improve both preoperative management and aftercare. To this end, however, optimum cooperation between practitioners of nuclear medicine and radiology is imperative.
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Affiliation(s)
- J Stollfuss
- Institut für Röntgendiagnostik, Klinikum rechts der Isar der TU München.
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39
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Sadahiro S, Suzuki T, Ishikawa K, Fukasawa M, Saguchi T, Yasuda S, Makuuchi H, Murayama C, Ohizumi Y. Preoperative radio/chemo-radiotherapy in combination with intraoperative radiotherapy for T3-4Nx rectal cancer. Eur J Surg Oncol 2004; 30:750-8. [PMID: 15296989 DOI: 10.1016/j.ejso.2004.04.012] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2004] [Indexed: 01/15/2023] Open
Abstract
AIMS To analyse the results of a single institution experience of combined preoperative radio/chemo-radiotherapy and intraoperative electron-radiation therapy (IORT) for locally advanced rectal cancer and to compare the results with surgery alone retrospectively. METHODS The study cohort comprised 99 patients with clinical T3-4NxM0 adenocarcinoma of the rectum who had received preoperative radio/chemo-radiotherapy, radical surgery, and IORT [Group I]. Until 1998, 67 patients were treated with radiation only [Group Ia], and after 1999, 32 patients were concurrently given tegafur and uracil (UFT) [Group Ib]. 68 patients with clinical T3-4NxM0 rectal cancer were treated with surgery alone [Group II]. RESULTS The median follow-up was 67 months in Group I and 83 months in Group II. Local recurrence rate was 2% in Group I, which was significantly lower than 16% in Group II (p=0.002) Both disease-free survival and overall survival in Group I were significantly better than those in Group II (p=0.04, p=0.02, respectively). Sphincter preservation was possible in 78% in Group Ib, which was significantly more than 42% in Group Ia (p=0.002). CONCLUSIONS The combined preoperative radio/chemo-radiotherapy and IORT for clinical T3-4Nx rectal cancer significantly reduces local recurrence and improves prognosis. Combination of preoperative radiotherapy and oral UFT improves the feasibility of sphincter-preservation.
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Affiliation(s)
- S Sadahiro
- Department of Surgery, Tokai University School of Medicine, Bohseidai, Isehara, Kanagawa, Japan.
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Klaassen RA, Nieuwenhuijzen GAP, Martijn H, Rutten HJT, Hospers GAP, Wiggers T. Treatment of locally advanced rectal cancer. Surg Oncol 2004; 13:137-47. [PMID: 15572096 DOI: 10.1016/j.suronc.2004.08.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Historically, locally advanced rectal cancer is known for its dismal prognosis. The treatment of locally advanced rectal cancer is subject to continuous change due to development of new and better diagnostic tools, radiotherapeutic techniques, chemotherapeutic agents and understanding of the subject. It is clear, that a multimodality approach is the only way to achieve satisfactory local recurrence and survival rates in this type of cancer. However, which multimodality strategy is to be used still remains a point of controversy. This review summarises recent developments in imaging, (neo-) adjuvant therapy and surgical techniques in the treatment of primary locally advanced rectal cancer.
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Affiliation(s)
- René A Klaassen
- Department of Surgery, Catharina Hospital Eindhoven, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands
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Hahnloser D, Haddock MG, Nelson H. Intraoperative radiotherapy in the multimodality approach to colorectal cancer. Surg Oncol Clin N Am 2004; 12:993-1013, ix. [PMID: 14989129 DOI: 10.1016/s1055-3207(03)00091-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The addition of intraoperative radiotherapy (IORT) to the multimodality approach for the treatment of locally advanced and locally recurrent colorectal cancer seems to result in improvements in local control and long-term survival. Local control and survival are most likely in patients in whom a gross total resection is accomplished. Peripheral nerve is the dose-limiting structure for patients treated with IORT. Further improvements in local control require the addition of dose modifiers during external beam radiotherapy or IORT. Distant relapse remains problematic, and effective systemic therapy is necessary to significantly improve long-term survival.
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Affiliation(s)
- Dieter Hahnloser
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Nuyttens JJ, Kolkman-Deurloo IKK, Vermaas M, Ferenschild FT, Graveland WJ, De Wilt JH, Hanssens PE, Levendag PC. High-dose-rate intraoperative radiotherapy for close or positive margins in patients with locally advanced or recurrent rectal cancer. Int J Radiat Oncol Biol Phys 2004; 58:106-12. [PMID: 14697427 DOI: 10.1016/s0360-3016(03)01494-9] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE A high-dose-rate intraoperative radiotherapy (HDR-IORT) technique for rectum cancer was developed and the technique, local failure, and survival were analyzed. METHODS AND MATERIALS After the exclusion of metastatic patients, 37 patients were treated with external beam RT, surgery, and HDR-IORT between 1997 and 2000. Primary locally advanced rectum cancer was found in 18 patients and recurrent disease in 19. HDR-IORT was only administered if the resection margins were < or =2 mm. The flexible intraoperative template is a 5-mm-thick pad with 1-cm-spaced parallel catheters. Clips were placed during surgery to define the target area. A dose of 10 Gy was prescribed at a 1 cm depth from the template surface and calculated using standard plans. After treatment, the dose at the clips was calculated using the reconstructed template geometry and the actual treatment dwell times. The median follow-up of surviving patients was 3 years. No patients were lost to follow-up. RESULTS Overall, 12 patients (32%) had local recurrence, 5 (14%) of which were in the HDR-IORT field. The 3-year local failure rate for primary tumors and recurrent tumors was 19% and 52%, respectively (p = 0.0042). The 3-year local failure rate was 37% for negative margins and 26% for positive margins (p = 0.51). A high mean dose at the clip (17.3 Gy) was found. The overall survival was significantly different for primary vs. recurrent tumors, stage, and grade. CONCLUSION Because of the HDR technique, a high dose at the clips was found, with good local control. More out-of-field than in-field failures were seen. The local failure rate was significantly different for primary vs. recurrent disease.
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Affiliation(s)
- Joost J Nuyttens
- Department of Radiation Oncology, Erasmus Medical Center-Daniel Den Hoed, Rotterdam, The Netherlands.
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Tumores sacropélvicos primarios y secundarios. Tratamiento con cirugía radical y radioterapia intraoperatoria. Cir Esp 2003. [DOI: 10.1016/s0009-739x(03)72096-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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