Abdominoperineal resection combined with pre- and postoperative radiation therapy in the treatment of low-lying rectal carcinoma

Long-term results of high-dose-rate brachytherapy and external-beam radiotherapy in the primary treatment of endometrial cancer

In this report we update our long-term follow-up results of the prospective study whose aim was to evaluate the efficacy of high-dose-rate (HDR) brachytherapy in combination with external-beam radiotherapy (EBRT) in the treatment of medically inoperable endometrial cancer. Between 1995 and 1998, 29 patients with stages I-III medically inoperable carcinoma of endometrium were treated with definitive irradiation. All patients underwent combined intracavitary HDR brachytherapy and EBRT. The EBRT dose was 50 Gy with midline shield from 16 Gy. The HDR brachytherapy dose was 50 Gy, delivered in 5 fractions in a weekly schedule. Overall survival (OS) at 5 and 10 years was 48.3% and 20.7%, respectively. Disease-specific survival (DSS) at 5 and 10 years was 73.5% and 67.9%, respectively. The 10-year DSS rate was 73.5% for all stages, 85.7% for Stage I disease, 71.4% for Stage II, and 16.7% for stage III disease. Late Grade 1-2 radiation complications were observed in 4 patients (13.8%). Our long-term follow-up confirms that HDR brachytherapy with EBRT appears to be an effective and safe treatment for stage I and II medically inoperable endometrial cancer.

Preoperative hyper-fractionated accelerated radiotherapy (HART) in locally advanced rectal cancer (LARC) immediately followed by surgery. A prospective phase II trial

BACKGROUND AND PURPOSE

We aim to report on local control in a phase II trial on preoperative hyper-fractionated and accelerated radiotherapy schedule (HART) in locally advanced resectable rectal cancer (LARC). This fractionation schedule was designed to keep the overall treatment time (OTT) as short as possible.

PATIENTS AND METHODS

This is a prospective trial on patients with UICC stages II and III rectal cancer. The patients were submitted to a total dose of 41.6 Gy, delivered in 2.5 weeks at 1.6 Gy per fraction twice a day with a 6-h interfraction interval. Surgery was performed within 1 week after the end of irradiation. Adjuvant chemotherapy was delivered in a subset of patients.

RESULTS

Two hundred and seventy nine patients were entered and 250 are fully assessable, with a median follow-up of 39 months. The 5-years actuarial local control (LC) rate is 91.7%. The overall survival (OS) is 59.6%. The freedom from disease relapse (FDR) is 71.5%. Downstaging was observed in 38% of the tumors.

CONCLUSION

The actuarial LC at 5 years is 91.7%, although we are dealing with stages II-III LARC, mainly located in the lower rectum (median distance = 5 cm). The pattern of failure is dominated by distant metastases and treatment intensification will obviously require a systemic approach.

Combined modality therapy of rectal cancers

Rectal cancer accounts for about 10% of new cancer cases each year. It strikes men and women at nearly the same rate, generally in the range of 50-80 years of age, with rising incidence with age. Despite simple screening procedures rectal cancer is often advanced when discovered. Current trends in the management of cancer have focused on organ preservation and improved quality of life without compromising the overall survival. During the last decade substantial progress has been made in treatment modalities: new and improved radiation techniques (conformal radiotherapy, altered fractionation, brachytherapy), chemotherapy (protracted infusion, use of radiosensitizers) and development of surgical procedures-enabling safer postoperative irradiation. In patients with advanced/unresectable disease aggressive combined chemoradiation can be added prior to surgery to downstage the tumour and increase the proportion treated with anal-rectal-sparing procedures. Preoperative chemoradiation therapy regimens are as safe and tolerable as the standard postoperative treatment. In this presentation indications for preoperative radiochemotherapy will be discussed in detail, together with treatment-related side effects, prognostic parameters, tumour response and outcome. Different irradiation settings and chemotherapy schedules are described. In patients with primary resectable disease (mainly Dukes C) several prospective randomised trials have shown less local recurrence with postoperative combined modality therapy.

Late complications after a combined pre and postoperative (sandwich) radiotherapy for rectal cancer

BACKGROUND AND PURPOSE

The purpose of this study was to analyse the treatment related side effects, the outcome and the prognostic significance of clinical parameters in two groups of patients with rectal cancer receiving either preoperative or pre and postoperative radiotherapy after radical resection. The authors of this study were not involved in the radiation treatments.

PATIENTS AND METHODS

From 1986 to 1990, 63 patients received a combined pre and postoperative (sandwich) radiotherapy. Preoperative irradiation was given in four fractions of 5 Gy each applied within 2 or 3 days. Postoperative irradiation consisted mostly of 15 x 2 Gy (31 patients) but the range was 20-40 Gy. The results were compared with those on 73 patients who only received preoperative radiotherapy in the same time period. The distribution of prognostic factors was not very different between treatment groups. Out of 63 patients in the sandwich group, 22 received concurrent chemotherapy and 18 also received radiotherapy to the liver. Radical surgery usually followed on the day after the last preoperative radiotherapy session. Median follow-up of survivors was 6 years.

RESULTS

Local tumour control was 88% after 5 years and 84% after 8 years in the sandwich group, and 90 and 85%, respectively, in the preoperative radiotherapy group. Thus, tumour control was similar for the two radiotherapy regimens applied. However, the percentage of patients suffering from one or more complications after 5 years was 84% in the sandwich and 17% in the preoperative radiotherapy group. The incidence of severe late complications (grade > or = 3) was recorded as a function of time after start of treatment. In the sandwich group the actuarial rates of late complications at 5 years (and the median time to diagnosis) were 53% (27 months) for anorectum, 43% (37 months) for bladder, 28% (51 months) for bone, 19% (36 months) for dermis, 47% (48 months) for ileum, 41% (32 months) for lymphatic and soft tissue, and 44% (53 months) for ureters.

CONCLUSIONS

Severe late reactions did not occur within a certain period of time, but continued to appear for at least 10 years after radiotherapy. Sandwich therapy, as given in this series, did not appear to give a greater tumour control than preoperative radiotherapy alone, whereas the rate of complications was drastically enhanced. Thus, the rationale of a sandwich therapy with a long time interval between surgery and postoperative irradiation appears questionable.