A pilot study of continuous, hyperfractionated, accelerated radiotherapy in rectal adenocarcinoma

Concurrent Boost Radiotherapy as Preoperative Treatment for Locally Advanced Rectal Carcinoma: A New Beam Arrangement

Purpose

To describe a new beam arrangement for preoperative concurrent boost radiotherapy in locally advanced rectal carcinoma.

Material and methods

Three different volumes, ie posterior pelvis, total mesorectal space, and gross tumor volume plus 2 cm, are selected to receive radiation doses of 47 Gy, 51 Gy, and 54 Gy, respectively, in 24 fractions. There are two prerequisites for the use of such a radiotherapy schedule: complete displacement of the small bowel outside the boost volume, and horizontal positioning of the rectal long axis. Both conditions can be attained by patient positioning on a new device, the “Up-Down Table” (UDT). The dose gradient between the three volumes is realized with two daily arc rotation fields with an isocenter that is different from the three additional multileaf collimator pelvic fields (postero-anterior + 2 laterolateral).

Results

The treatment data are reported according to the ICRU 62 criteria. A comparison was made between concurrent arc rotation and concomitant static boost techniques.

Conclusion

The new beam arrangement, with the use of the UDT, allows to administer different radiation doses to three volumes with different tumor cell density in order to obtain the same probability of local response in all target volumes without increasing the toxicity.

Short course continuous, hyperfractionated, accelerated radiation therapy (CHART) as preoperative treatment for rectal cancer

Determine feasibility and toxicity of preoperative short course pelvic CHART (25 Gy in 15 fractions over 5 days) for treatment of clinically resectable primary rectal tumours. Between 1998 and 2004, 20 patients with clinically staged T3 resectable rectal carcinoma were treated in this prospective pilot study with preoperative short course CHART to their pelvis. The aim was for total mesorectal excision within 7 days. Radiation toxicity, surgical morbidity, locoregional control (LRC), overall (OS), cause specific (CSS) and disease free survival (DFS) outcomes were documented. Nineteen of the 20 patients completed planned radiotherapy. One discontinued radiotherapy due to toxicity. All patients underwent potentially curative radical surgery. One patient developed grade 3, and three patients grade 2 gastrointestinal toxicity. With a median follow-up of 31 months (range 0.9-88), there is no grade 3, 4 or 5 late toxicity. Two patients experienced grade 2, and three patients grade 1 late bowel toxicity. Two patients died from postoperative complications, and two developed grade 2 abdominal wound infections. At 3 years LRC is 95% (95% CI 83-100), OS 72% (95% CI 51-94), CSS 86% (95% CI 68-100) and DFS 80% (95% CI 60-100). Two patients died from metastatic disease, one patient from a second primary and one patient is alive after successful resection of hepatic metastases. This small study suggests preoperative short course CHART for clinically resectable rectal carcinoma is feasible with acceptable compliance and tolerable side effects.

A pilot study of accelerated preoperative hyperfractionated pelvic irradiation with or without low-dose preoperative prophylactic liver irradiation in patients with locally advanced rectal cancer

BACKGROUND AND PURPOSE

To evaluate the feasibility of low-dose preoperative prophylactic liver irradiation (PLI) combined with preoperative accelerated hyperfractionated pelvic irradiation (HART) in patients with locally advanced rectal cancer.

PATIENTS AND METHODS

Between 1999 and 2003 62 patients were enrolled: 38 (61%) received HART and 24 (39%) HART+PLI. The pelvis was irradiated twice a day, with a minimal interfraction interval of 6h: the total dose of 42 Gy was given in 1.5 Gy per fractions over 18 days. The PLI (14 Gy in 10 daily fractions of 1.4 Gy) was given simultaneously with the morning fraction of HART. Twenty patients (32%), including 7 in PLI group, received 5-Fu based postoperative chemotherapy.

RESULTS

In general, acute normal tissue reactions appeared tolerable irrespectively of PLI. Six to twelve months after completion of combined therapy the mean ALAT levels in patients treated with HART alone (25 pts), HART+chemotherapy (13 pts), HART+PLI (17 pts), and HART+PLI+chemotherapy (7 pts) were 15, 21, 26 and 55 IU/l, respectively. A mild increase of ALAT levels observed in the HART+PLI+chemotherapy sub-group was non-symptomatic. Three-year actuarial loco-regional control rate in a group of 62 patients was 94%. None of the patients who received PLI developed metastases during the follow-up, compared to 10 out of 38 patients (26%) with no PLI. A difference in metastases-free survival in favor of HART+PLI can be, however, attributed to selection of patients for PLI who were in better general health and stage of disease than those treated with HART.

CONCLUSIONS

Further use of PLI may be limited due to asymptomatic, but detectable biochemical changes of liver function when PLI is sequentially combined with chemotherapy. HART, on the other hand, provides acceptable rate of local control, and is well tolerated, also when combined with postoperative chemotherapy.

Three-dimensional conformal radiotherapy combined with FOLFOX4 chemotherapy for unresectable recurrent rectal cancer

AIM: To investigate the effect of three-dimensional conformal radiotherapy (3-DCRT) in combination with FOLFOX4 chemotherapy for unresectable recurrent rectal cancer.

METHODS: Forty-eight patients with unresectable recurrent rectal cancer were randomized and treated by 3-DCRT or 3-DCRT combined with FOLFOX4 chemotherapy between September 2001 and October 2003. For the patients without prior radiation history, the initial radiation was given to the whole pelvis by traditional methods with tumor dose of 40 Gy, followed by 3-DCRT for the recurrent lesions to the median total cumulative tumor dose of 60 Gy (range 56-66 Gy); for the post-radiation recurrent patients, 3-DCRT was directly given for the recurrent lesions to the median tumor dose of 40 Gy (36-46 Gy). For patients in the study group, two cycles chemotherapy with FOLFOX4 regimen were given concurrently with radiotherapy, with the first cycle given simultaneously with the initiation of radiation and the second cycle given in the fifth week for patients receiving conventional pelvis radiation or given in the last week of 3-DCRT for patients receiving 3-DCRT directly. Another 2-4 cycles (average 3.6 cycles) sequential FOLFOX4 regimen chemotherapy were given to the patients in the study group, beginning at 2-3 wk after chemoradiation. The outcomes of symptoms relieve, tumor response, survival and toxicity were recorded and compared between the study group and the control group.

RESULTS: For the study group and the control group, the pain-alleviation rates were 95.2% and 91.3% (P > 0.05); the overall response rates were 56.5% and 40.0% (P > 0.05); the 1-year and 2-year survival rates were 86.9%, 50.2% and 80.0%, 23.9%, with median survival time of 25 mo and 16 mo (P < 0.05); the 2-year distant metastasis rates were 39.1% and 56.0% (P = 0.054), respectively. The side effects, except peripheral neuropathy which was relatively severer in the study group, were similar in the the two groups and well tolerated.

CONCLUSION: Three-dimensional conformal radio-therapy combined with FOLFOX4 chemotherapy for unresectable recurrent rectal cancer is a feasible and effective therapeutic approach, and can reduce distant metastasis rate and improve the survival rate.

Pain and quality of life after treatment in patients with locally recurrent rectal cancer

PURPOSE

Because survival in patients with locally recurrent rectal cancer (LRRC) is limited, pain control and quality of life (QOL) are important parameters. The purpose of this study was to assess the prevalence of posttreatment pain and QOL of patients with LRRC treated with nonsurgical palliation or resection and identify predictors of poor outcome.

PATIENTS AND METHODS

Posttreatment pain severity and QOL were prospectively assessed in 45 patients with LRRC using the Brief Pain Inventory and Functional Assessment of Cancer Therapy-Colorectal questionnaire.

RESULTS

Fifteen patients received nonsurgical palliation, and 30 patients underwent resection of their pelvic tumors. There was a significant association between higher posttreatment pain scores and worse QOL (P <.001). Patients treated with nonsurgical palliation reported moderate to severe pain beyond the third month of treatment. Resected patients reported comparable levels of pain during the first 3 postoperative years, particularly after bony resections; long-term survivors (beyond 3 years), however, reported minimal pain and good QOL. Female sex, pelvic/sciatic pain at presentation, total pelvic exenteration, and bony resection were associated with higher rates of moderate to severe posttreatment pain (P =.04, P <.001, P =.04, and P =.02, respectively). Pain at presentation was an independent predictor of posttreatment pain (odds ratio, 7.4 [95% confidence interval, 1.8 to 30.3]; P =.006).

CONCLUSION

Patients with LRRC treated with nonsurgical palliation or resection experience significant levels of pain after treatment. Close posttreatment pain monitoring is warranted in patients presenting with pelvic pain, and more aggressive pain management strategies may improve posttreatment QOL.

Liposome-encapsulated tumor necrosis factor-alpha enhances the effects of radiation against human colon tumor xenografts

Recent reports have shown that tumor necrosis factor-alpha (TNF-alpha) can augment the effects of radiation against certain tumor types. However, the high concentrations of intravenous infusion of TNF-alpha needed to cause tumor regression can induce many systemic side effects. The aims of this study were to determine if TNF-alpha encapsulated in sterically stabilized (Stealth, ALZA Corporation, Mountain View, CA), PEGylated liposomes (SL) augments the antitumor effects of radiation and to compare its efficacy and possible toxicity with free TNF-alpha in the LS174T human colon tumor xenograft model. Nude mice were injected subcutaneously (s.c.) with LS174T cells and treated intravenously (i.v.) with Stealth-liposomal TNF-alpha (SL-TNF-alpha) with and without radiation or TNF-alpha with or without radiation when tumor size was approximately 200 mm(3). In phase 1, a significant decrease (p = 0.047) in tumor growth was observed with radiation at day 21 but not with SL-TNF-alpha or free TNF-alpha alone. By the end of phase 1 (day 27) with continued treatments, the SL-TNF-alpha plus radiation group had significantly smaller tumors (p = 0.044) than those in the free TNF-alpha plus radiation group. In phase 2, where a similar tumor growth reduction pattern was observed, the addition of TNF-alpha to radiation, either as free protein or within SL, increased lymphocyte activation and natural killer (NK) cell numbers in both blood and spleen. The effect was generally more pronounced with SL-TNF-alpha. Systemic toxicity, based on hematologic analyses and body weight, was absent or minimal. Collectively, the data show that pretreatment with SL-TNF-alpha can enhance more effectively, and possibly more safely, the effects of radiation against human colon tumor xenografts than can free TNF-alpha and that the increased antitumor action may involve upregulation of lymphocytes.