Radiation enhancement of laser palliation for advanced rectal and rectosigmoid cancer: a pilot study

Combined endoscopic laser and radiotherapy palliation of advanced rectal cancer

BACKGROUND

In the palliative treatment of patients with advanced, inoperable rectal cancer, combined endoscopic laser and radiotherapy have been claimed to be more effective than laser therapy alone. The number of laser treatments, laser energy used, relapse rate, treatment of relapse, morbidity and survival in consecutive patients who were treated either by laser therapy alone or laser plus radiotherapy was compared.

METHODS

Prospective data were analysed with regard to number of treatments, laser energy used, relapse rate, morbidity and survival for 56 consecutive patients.

RESULTS

The crude relapse rate was significantly higher in the laser only group than in the laser plus radiotherapy group (58 and 15%, respectively; P = 0.002). There was no difference between the groups in the median total number of laser treatments or the mean total laser energy used. In patients experiencing a relapse, there was no difference in the median number of relapses, the number of laser treatments post-relapse or the total energy used post-relapse. Survival did not differ between the groups and there were no treatment-related deaths.

CONCLUSIONS

These findings demonstrate a clear reduction in relapse after using combined laser and radiotherapy to palliate patients with advanced rectal cancer with no appreciable additional morbidity and have encouraged continuing use of this treatment.

Local methods of treatment of rectal cancer

Over 11 000 new cases of rectal cancer are reported in the UK each year. Recent technical advances have increased interest in local management of the disease. The introduction of screening for colorectal cancer will potentially lead to an increased number of early rectal cancers suitable for local curative treatment. In addition, as the proportion of elderly patients in the population rises, local methods of treatment of rectal cancer will become increasingly important in this group of patients with comorbid disease. A literature search was performed on Medline database for English language publications on local treatments of rectal carcinoma. Preoperative assessment, selection of patients, local therapeutic and palliative methods of treatment were evaluated. Local methods of treatment can be used for potentially curative operations for rectal cancer. Preoperative endoanal ultrasound appears to be the most useful investigation for determining depth of local invasion. Transanal endoscopic microsurgery has extended the boundaries of local surgery and permits access to the mid and upper rectum with results similar to those of conventional local techniques. Laser therapy and transanal resection provide the best form of palliation for more advanced rectal carcinomas.

Endoscopic laser therapy for palliation of patients with distal colorectal carcinoma: analysis of factors influencing long-term outcome

BACKGROUND

Incurable rectal cancer often reduces the quality of life because of obstruction, bleeding, pain and tenesmus. For such symptoms palliative therapy is often carried out.

METHODS

From 1986 to 1995, 219 patients, 118 men and 101 women, mean age 67 years, with distal colorectal adenocarcinoma were referred for palliative endoscopic laser therapy. In this retrospective analysis of outcome, patients were allocated to 3 subgroups according to their dominant symptom: obstruction, bleeding and others (soiling, diarrhea, tenesmus). After initial successful treatment, maintenance therapy was carried out in cases of obstruction at intervals of 2 to 4 months; patients with bleeding, tenesmus or diarrhea were retreated if there was recurrence of symptoms.

RESULTS

Initial successful palliation was obtained in 198 patients (92%), with similar results in the 3 subgroups. Long-term, effective palliation was achieved in 160 patients (75%) of the total study population. Seventy-six patients (65.0%) with obstruction, 63 (82.9%) with bleeding and 21 (80.8%) with other symptoms remained symptom free until death or this analysis of results. There was a significantly negative relation between long-term successful outcome and local spread of the tumor in the obstruction (p = 0.040) and bleeding groups (p = 0.014). The total number of treatments was significantly higher if obstruction was present at presentation (p< 0.05) and if tumors were circumferential (p = 0.05). Major complications were perforation (4.1%), fistula (3.2%), abscess (1.7%) and bleeding (4.1%). There were 5 (possibly) procedure-related deaths. The survival rate was 44.4% at 1 year and 20.4% at 2 years.

CONCLUSIONS

Laser therapy is effective for initial palliation but careful patient selection is necessary. Long-term palliation is less feasible in patients with obstruction.

Local effects of colorectal cancer are well palliated by endoscopic laser therapy

We review the results of treating the local effects of 26 cases of inoperable colorectal cancer with Nd:YAG laser. There were 16 men and 10 women of mean age 75, with 17 (65%) rectal, eight (31%) sigmoid and one (4%) ascending colon cancer. They presented with symptoms primarily of obstruction in 12 patients (46%), bleeding in 10 (39%) and diarrhoea in four (15%). Initial therapy to relieve symptoms required a mean of 1.5 (1-3) laser treatments over a mean of 1.5 (1-2) weeks. Twelve patients (46%) had total relief and 12 (46%) had partial relief. Sixteen patients received follow-up maintenance therapy, with laser treatments performed over a mean interval of 7.3 (1-20) weeks. One died at first follow-up treatment; all but two of the others were well maintained by laser treatment alone. Three patients (12%) suffered complications, with two deaths (8%), one due to cardiac failure and the other due to stercoral perforation of the colon. Four patients remained alive after a mean follow-up period of 51 (9-84) months. The mean survival of the others was 5 (0-23) months. Laser palliation for colorectal cancer is efficacious and relatively safe, allows improved quality of survival in 92% of patients after initial treatment, and, alone, can satisfactorily keep patients relatively free of local symptoms in 88% of patients surviving into the follow-up period.