Tumor lymphocyte immune response to preoperative radiotherapy in locally advanced rectal cancer: The LYMPHOREC study

Introduction: Some studies have suggested that baseline tumor-infiltrating-lymphocytes (TILs), such as CD8+ and FoxP3+ T-cells, may be associated with a better prognosis in colorectal cancer. We sought to investigate modulation of the immune response by preoperative radiotherapy (preopRT) and its impact on survival in locally advanced rectal cancer (LARC). Materials & Methods: We analyzed data for 237 patients with LARC who received RT. Density of TILS (CD8+ and FoxP3+) in intraepithelial (iTILs) and stromal compartments (sTILs) were evaluated from surgery pathological specimens and biopsies performed at baseline. The primary endpoint was to assess the impact of infiltration of the tumor or tumor site after preopRT on progression-free survival (PFS) and overall survival (OS). Secondary endpoints were the impact of dose fractionation scheme on TILs. Results: In univariate analysis, several factors significantly correlated (p<0.05) with PFS and/or OS (T-stage, M-stage, the delay between RT and surgery). A high level of post-treatment FoxP3+ TIL density correlated significantly with a better PFS (p = 0.007). In multivariate analysis, a decrease in the CD8+/FoxP3+ iTILs ratio after preopRT correlated with better PFS and OS (p = 0.049 and p = 0.024, respectively). More particularly, patients with a delta CD8+/FoxP3+ <-3.8 had better PFS and OS. Interestingly, the dose fractionation scheme significantly influenced the CD8⁺/FoxP3⁺ ratio after treatment (p = 0.027) with a lower ratio with hypofractionated RT (≥2 Gy). Conclusion: Patients with LARC who had a significant decrease in the CD8+/FoxP3+ ratio after preopRT were more likely to live longer. This ratio needs to be validated prospectively to guide physicians in adjuvant treatment decision-making.

[Rectal squamous cell carcinoma treatment: Retrospective experience in two French university hospitals, review and proposals]

After publishing a retrospective series of 23 patients treated for a rectal squamous cell carcinoma with exclusive curative and conservative intent chemoradiation, we aim to propose a review of the literature about this rare tumour. We identified 11 retrospective studies, on 106 patients, treated between 2007 and 2016. Treatment of rectal squamous cell carcinoma should be similar to anal carcinoma, based on exclusive chemoradiation, displaying a 5-year overall survival rate over 80%, while it was 32% in surgical series. Baseline explorations should be similar as for anal carcinoma, with an interest in PET-CT at diagnosis and monitoring, after a delay over 6 weeks after chemoradiation. Intensity-modulated radiotherapy is legitimate, to a prophylactic dose between 36 and 45Gy, and over 54Gy to the tumour. Concomitant chemotherapy should combine an antimetabolite (5-fluorouracil or capecitabine) and mitomycin C, or cisplatin. This treatment seems well tolerated, associated with grade 2 or above toxicity below 30%. Follow-up should be established on anal squamous cell carcinoma schedule, with endoscopic ultrasonography and PET-CT. Rectal squamous cell carcinoma is a rare tumour; it management should be based on anal curative and conservative intent chemoradiation.

[Preoperative chemoradiotherapy for rectal cancer: experience from one centre]

PURPOSE

In recent decades, the management of rectal cancer has been significantly improved by optimizing the surgical treatment with the total mesorectal excision and the development of neoadjuvant radiotherapy with or without chemotherapy. In this study, we investigated the impact of changes in practice over a period of 15 years in an expert centre.

PATIENTS AND METHODS

A monocentric study was conducted retrospectively on cT3-resectable T4 patients who received chemoradiotherapy for a locally advanced rectal adenocarcinoma between 1993 and 2008. We studied sphincter preservation, pathological complete response (ypT0), survival, and toxicities by different concomitant chemotherapy and treatment period.

RESULTS

Among the 179 patients who had a chemoradiotherapy, 56.4% were received concomitant 5-fluoro-uracil-leucovorin, 28.5% with concomitant capecitabine, and 15.1% with concomitant oxaliplatin and capecitabine. The average dose of radiotherapy was 45 Gy (25×1.8 Gy). Five-year disease-free survival was 74.3% and overall survival 68.8%. The rate of local recurrence and distant metastases were 6.1 and 23.6%. In multivariate analysis, concomitant chemotherapy oxaliplatin and capecitabine improved the pathological complete response rate (ypT0; capecitabine: 6%, 5-fluoro-uracil-leucovorin: 10.3%, capecitabine-oxaliplatin: 22.2%), but not significantly (P=0.12) and with more toxicities, and treatment interruptions. Sphincter preservation rate was not improved significantly during the study period (1993-2004 vs. 2005-2008), but disease-free survival improved from 72.2% up to 87.5% (P=0.03).

CONCLUSION

Our results are consistent with those published in the literature. Concomitant chemotherapy with 5-fluoro-uracil or capecitabine remains the standard scheme. Upfront chemotherapy, before chemoradiotherapy, should be investigated with regard to the predominance of metastasis.

[Glassy cell carcinoma: a rare cervical neoplasm. Case report of two patients and review of the literature]

The main histological types of cervix cancer are squamous cell carcinoma and adenocarcinoma. The glassy cell carcinoma is a rare form found in less than 2% of cases and it is an entity, aggressive and unknown, of worse prognosis, whose current treatment is not distinguished from other histological types. We report the cases of two patients with glassy cell carcinoma of the cervix with a review of the literature.

DCF (docetaxel, cisplatin and 5-fluorouracil) chemotherapy is a promising treatment for recurrent advanced squamous cell anal carcinoma

BACKGROUND

Squamous cell carcinoma of the anal canal (SCCA) is a rare disease, mostly diagnosed at early stage. After concurrent chemoradiation (CRT) with mitomycin C and 5-fluorouracil (5FU), local or metastatic recurrences occur in >20% of the patients. After treatment failure, cisplatin (CDDP)-based chemotherapy is the standard option, but complete response (CR) is a rare event and the prognosis remains poor.

PATIENTS AND METHODS

Eight consecutive patients with advanced recurrent SCCA after CRT were treated with DCF regimen (docetaxel 75 mg/m(2) day 1, CDDP 75 mg/m(2) day 1 and 5FU at 750 mg/m(2)/day for 5 days every 3 weeks). Tumour samples were analysed for human papillomavirus (HPV) genotyping, as well as p16 and p53 expression.

RESULTS

After a median follow-up of 41 months, the overall survival rate at 12 months was 62.5% (95% CI 22.9-86.1 months). Four patients achieved a complete remission and remain relapse-free at the time of analysis with a progression-free survival of 19, 33, 43 and 88 months. Three of these patients underwent surgery for all involved metastatic sites. For all of them, pathological CR was confirmed. DCF regimen appeared feasible in these patients previously exposed to pelvic CRT, and no grade IV toxicity occurred. All patients in complete remission had HPV-16-positive SCCA, while HPV could only be detected among 50% of the non-responding patients. Of interest, immunohistochemical study revealed a p16(+)/p53(-) phenotype in these patients, while none of non-responders expressed p16.

CONCLUSION

The high level of complete and long-lasting remission among SCCA patients treated with DCF regimen supports the assessment of this strategy in prospective cohorts.

[Multidisciplinary management of rectal cancer]

In the last 10 years, a number of important European randomized published studies investigated the optimal management of rectal cancer. In order to define an evidence-based approach of the clinical practice based, an international consensus conference was organized in Italy under the endorsement of European Society of Medical Oncology (ESMO), European Society of Surgical Oncology (ESSO) and European Society of Therapeutic Radiation Oncology (ESTRO). The aim of this article is to present highlights of multidisciplinary rectal cancer management and to compare the conclusions of the international conference on 'Multidisciplinary Rectal Cancer Treatment: looking for an European Consensus' (EURECA-CC2) with the new National Comprehensive Cancer Network (NCCN) guidelines.

Dosimetric consequences of breath-hold respiration in conformal radiotherapy of esophageal cancer

The objective of this paper is to study the dosimetric impact of respiratory gated radiotherapy in locally advanced esophageal carcinomaand to define the optimal respiratory phase for this treatment. The study included 8 consecutive patients with squamous-cell carcinoma (SCC) or histologically proved adenocarcinoma, for both at least T3-T4 NX or TX N1 M0 stage. Informed consent was obtained before beginning the study. Three spiral scans were performed in breath-hold respiration: one acquisition in end expiration (EBH), one in end inspiration (IBH) and one in deep inspiration breathhold (DIBH); and one acquisition was performed in Free Breathing (FB). A 3 mm-margin was defined as Internal Target Volume (ITV) on FB CT-scan. No ITV was applied on EBH, IBH and DIBH CT-scan. Target volumes were analyzed and we performed dosimetric comparisons on DVH data of each CT-scan for PTV and Organs at Risk (OAR) (Conformity Index, V(dose), D(mean), Equivalent Uniform Dose). DIBH and IBH correlated with a 32% (p=0.77) and 20% (p=0.52) decrease in lung V(20) respectively as compared to FB (13.5%and 15.6% respectively versus 19.9%). DIBH and IBH correlated with a 25% (p=0.25) and 17% (p=0.39) decrease in cardiac V(40) respectively, as compared with FB (16.9% and 18.9% respectively versus 22.7%). For spinal cord irradiation, the minimum dose was obtained in IBH (36.5 Gy). Conformal radiotherapy with respiratory gating for esophageal cancer decreases the irradiated dose to OAR. We suggest that DIBH technique should be used when irradiation is performed using the spirometric system. In the Tidal Volume, the inspiration phase is the most favourable and should be chosen for irradiation with a free breathing gating system.

What is the clinical benefit of preoperative chemoradiotherapy with 5FU/leucovorin for T3-4 rectal cancer in a pooled analysis of EORTC 22921 and FFCD 9203 trials: surrogacy in question?

BACKGROUND

Two phase III trials of neoadjuvant treatment in T3-4 rectal cancer established that adding chemotherapy (CRT) to radiotherapy (RT) improves pathological complete response (pCR) and local control (LC). We combined trials to assess the clinical benefit of CRT on overall (OS) and progression free survival (PFS) and to explore the surrogacy of pCR and LC.

PATIENTS AND METHODS

Individual patient data from European Organisation for Research and Treatment of Cancer (EORTC) 22921 (1011 patients) and FFCD 9203 (756 patients) were pooled. Meta-analysis methodology was used to compare neoadjuvant CRT to RT for OS, PFS LC and distant progression (DP). Weighted linear regression was used to estimate trial-level association (surrogacy R(2)) between treatment effects on candidate surrogate (pCR, LC, DP) and OS.

RESULTS

The median follow-up was 5.6 years. Compared to RT (881 pts), CRT (886 pts) did not prolong OS, DP or PFS. The 5-y OS-rate was 66.3% with CRT versus 65.9% in RT (hazard ratios (HR) = 1.04 {0.88-1.21}). CRT significantly improved LC (HR = 0.54, 95%confidence interval (CI): 0.41-0.72). PFS was validated as surrogate for OS with R(2) = 0.88. Neoadjuvant treatment effects on LC (R(2) = 0.17) or DP (R(2) = 0.31) did not predict effects on OS.

CONCLUSION

Preoperative CRT does not prolong OS or PFS. pCR or LC do not qualify as surrogate for PFS or OS while PFS is surrogate. Phase III trials should use OS or PFS as primary endpoint.

Incidence, prevalence and survival of patients with rare epithelial digestive cancers diagnosed in Europe in 1995-2002

BACKGROUND AND AIMS

Little is known about the epidemiology of rare epithelial digestive cancers. The aim of this study was to report on their incidence, prevalence and survival across Europe.

METHODS

The analysis was carried out on 50,646 cases diagnosed from 1995 to 2002 within a population of 162,000,000 in 21 European countries. Age-standardised incidence rates were computed using the European standard population. Prevalence rates, relative survival and period survival indicators for the years 2000-2002 were calculated. The expected number of new cases per year and of prevalent cases in Europe was estimated.

RESULTS

There were large variations in gallbladder epithelial cancer incidence rates: the incidence in Eastern Europe was 7 times higher than in the UK & Ireland. Differences between incidence rates were smaller for the other sites. The estimated number of new epithelial cancers arising in the EU each year was estimated to be 11,050 for extrahepatic bile duct cancer, 10,713 for gallbladder cancer, 5427 for anal cancer and 3595 for small intestine cancer. The corresponding estimated number of total prevalent cases was 18,483, 15,620, 40,589 and 13,276. There was also a large variation in the 5-year relative survival rate. For epithelial cancer of the anal canal, this varied between 66% (Central Europe) and 44% (Eastern Europe). The corresponding rates for small intestine cancers were 33% and 20%, for extrahepatic bile duct cancers, 17% and 12% and for gallbladder cancer 13% and 10%.

CONCLUSION

There are large variations within Europe in the incidence and survival of rare digestive cancers according to geographic area.

[Preoperative radiochemotherapy for rectal cancer: forecasting the next steps through ongoing and forthcoming studies]

Protracted preoperative radiochemotherapy with a 5-FU-based scheme, or a short course of preoperative radiotherapy without chemotherapy, are the standard neoadjuvant treatments for resectable stage II-III rectal cancer. Local failure rates are low and reproducible, between 6 and 15% when followed with a "Total Mesorectal Excision". Nevertheless, the therapeutic strategy needs to be improved: distant metastatic recurrence rates remain stable around 30 to 35%, while both sphincter and sexual sequels are still significant. The aim of the present paper was to analyse the ongoing trials listed on the following search engines: the Institut National du Cancer in France, the National Cancer Institute and the National Institute of Health in the United States, and the major cooperative groups. Keywords for the search were: "rectal cancer", "preoperative radiotherapy", "phase II-III", "preoperative chemotherapy", "adjuvant chemotherapy" and "surgery". Twenty-three trials were selected and classified in different groups, each of them addressing a question of strategy: (1) place of adjuvant chemotherapy; (2) optimization of preoperative radiotherapy; (3) evaluation of new radiosensitization protocols and/or neoadjuvant chemotherapy; (4) optimization of techniques and timing of surgery; (5) place of radiotherapy for non resectable or metastatic tumors.

Multicentre analysis of oncological and survival outcomes following anastomotic leakage after rectal cancer surgery

BACKGROUND

The association between diverting stomas and symptomatic anastomotic leakage after rectal cancer surgery was studied, as well as the impact of leakage on local recurrence, distant metastasis, and disease-free, overall and cancer-specific survival.

METHODS

Data from the Swedish Rectal Cancer Trial, Dutch TME trial, CAO/ARO/AIO-94 trial, EORTC 22921 trial and Polish Rectal Cancer Trial were pooled (n = 5187). All eligible patients without distant metastases at the time of low anterior resection were selected (n = 2726); overall survival was studied in patients aged 75 years or less (n = 2480). Multivariable models were used to study the association between diverting stomas and anastomotic leakage, and between leakage and recurrence or survival.

RESULTS

Some 9.7 per cent of patients were diagnosed with a symptomatic anastomotic leak; diverting stomas were negatively associated with leakage (11.6 per cent without and 7.8 per cent with a stoma; P = 0.002). Anastomotic leakage was negatively associated with overall survival in the multivariable analysis (hazard ratio (HR) 1.29 (95 per cent confidence interval 1.02 to 1.63); P = 0.034), but not with cancer-specific survival (HR 1.12 (0.83 to 1.52); P = 0.466).

CONCLUSION

Diverting stomas were associated with less symptomatic anastomotic leakage. Oncological outcome was not significantly influenced by leakage, but overall survival was reduced.

Mitomycin C with continuous fluorouracil or with cisplatin in combination with radiotherapy for locally advanced anal cancer (European Organisation for Research and Treatment of Cancer phase II study 22011-40014)

PURPOSE

To assess the feasibility and activity of radio-chemotherapy with mitomycin C (MMC) and cisplatin (CDDP) in locally advanced squamous cell anal carcinoma with reference to radiotherapy (RT) combined with MMC and fluorouracil (5-FU).

PATIENTS AND METHODS

Patients with measurable disease >4 cmN0 or N+ received RT (36Gy+2 week gap+23.4Gy) with either MMC/CDDP or MMC/5-FU (MMC 10mg/m(2) d1 of each sequence; 5-FU 200mg/m(2)/day c.i.v. daily; CDDP 25mg/m(2) weekly). Forty patients/arm were needed to exclude a RECIST objective response rate (ORR), 8 weeks after treatment, of <75% (Fleming 1, alpha=10%, beta=10%).

RESULTS

The ORR was 79.5% (31/39) (lower bound confidence interval [CI]: 68.8%) with MMC/5-FU versus 91.9% (34/ 37) (lower bound CI: 82.8%) with MMC/CDDP. In the MMC/5-FU group, two patients (5.1%) discontinued treatment due to toxicity versus 11 (29.7%) in the MMC/CDDP group. Nine grade 3 haematological events occurred with MMC/CDDP versus none with 5-FU/MMC. The rate of other toxicities did not differ. There was no toxic death. Thirty-one patients in the MMC/5-FU arm (79.5%) and 18 in the MMC/CDDP arm (48.6%) were fully compliant with the protocol treatment (p=0.005).

CONCLUSIONS

Radio-chemotherapy with MMC/CDDP seems promising as only MMC/CDDP demonstrated enough activity (RECIST ORR >75%) to be tested further in phase III trials; MMC/5-FU did not. MMC/CDDP also had an overall acceptable toxicity profile.

[Radiochemotherapy for oesophageal cancer: a locoregional failure history]

Esophageal cancer is characterized by various degrees of lymph node invasion and metastasis, both of which are associated with a poor prognosis. Exclusive concomitant radiochemotherapy (RCT) at a dose of 50 Gy delivered over 25 sessions, according to the RTOG 85-01 protocol, has led to improved five-year survival in 25% of patients, whereas no patients survive for five years using radiotherapy alone. Surgery, even when combined with preoperative RCT, also gives disappointing results for locally advanced tumors, which casts serious doubts on the usefulness of preoperative radiotherapy. By varying the fractionation schedule, the length of treatment or the radiotherapy volumes, it has become possible to obtain levels of locoregional relapse of around 35 to 45%. The increasing incidence of adenocarcinoma, which differs from epidermoid cancer with regard to the degree of lymph node invasion, has revived discussion on radiotherapy volumes. Given this difference between these two histological forms, we propose here a number of recommendations concerning radiotherapy volumes for patients presenting with cancer of the esophagus. Finally, analysis of the results for locoregional relapse according to the dose of radiation and the recommended radiotherapy volumes, has led us to investigate why increasing the dose of radiation has no impact in esophageal cancers.

The diagnosis and management of rectal cancer: expert discussion and recommendations derived from the 9th World Congress on Gastrointestinal Cancer, Barcelona, 2007

Knowledge of the biology and management of rectal cancer continues to improve. A multidisciplinary approach to a patient with rectal cancer by an experienced expert team is mandatory, to assure optimal diagnosis and staging, surgery, selection of the appropriate neo-adjuvant and adjuvant strategy and chemotherapeutic management. Moreover, optimal symptom management also requires a dedicated team of health care professionals. The introduction of total mesorectal excision has been associated with a decrease in the rate of local failure after surgery. High quality surgery and the achievement of pathological measures of quality are a prerequisite to adequate locoregional control. There are now randomized data in favour of chemoradiotherapy or short course radiotherapy in the preoperative setting. Preoperative chemoradiotherapy is more beneficial and has less toxicity for patients with resectable rectal cancer than postoperative chemoradiotherapy. Furthermore chemoradiotherapy leads also to downsizing of locally advanced rectal cancer. New strategies that decrease the likelihood of distant metastases after initial treatment need be developed with high priority. Those involved in the care for patients with rectal cancer should be encouraged to participate in well-designed clinical trials, to increase the evidence-based knowledge and to make further progress. Health care workers involved in the care of rectal cancer patients should be encouraged to adopt quality control processes leading to increased expertise.

[Systematic review: value of perioperative chemotherapy in the management of resectable rectal adenocarcinoma (brief report)]

At the request of the National Thesaurus of Gastrointestinal Cancer (TNCD), the SOR program undertaken by the French federation of cancer centers and now led by the French National Cancer Institute, completed a systematic review to evaluate the value of perioperative chemotherapy in the management of resectable rectal adenocarcinoma in collaboration with clinician experts.

METHODS

Results of a systematic literature search using Medline and Embase (from January 1996 to October 2007) were completed by a survey of Evidence- Based Medicine websites. All phase III randomized trials and systematic reviews comparing surgery (alone or associated with adjuvant therapy) to the same treatment plus chemotherapy, or comparing different perioperative chemotherapy modalities in patients with resectable rectal adenocarcinoma, were included in the study. The quality and clinical relevance of the trials were evaluated using validated checklists, allowing to associate each result with its level of evidence. Data synthesis was performed taking into account both efficacy and toxicity outcomes for each intervention. Finally, research recommendations were formulated.

RESULTS

Of 29 studies meeting the selection criteria, 19 were included after critical methodological and clinical appraisal. As compared with preoperative radiotherapy, preoperative chemoradiotherapy with 5-fluorouracil and folinic acid does not improve overall or relapse-free survivals but decreases local recurrence rates. Postoperative chemotherapy with 5-fluorouracil and folinic acid does not improve overall or relapse-free survivals, whether the patients received preoperative radiotherapy or preoperative chemoradiotherapy, whereas it seems to decrease local recurrence rates after preoperative radiotherapy but not after preoperative chemoradiotherapy. As compared with postoperative chemoradiotherapy, preoperative chemoradiotherapy with continuous infusion of 5-fluorouracil does not improve overall or relapse-free survivals, but decreases local recurrence rates as well as acute and long-term toxicities. In the absence of preoperative radiotherapy, fluoropyrimidine-based postoperative chemotherapy improves both overall and relapse-free survivals and decreases local recurrence rates.

CONCLUSIONS

Preoperative chemoradiotherapy reduces the risk of local recurrence as compared with preoperative radiotherapy or postoperative chemoradiotherapy.

Traitements préopératoires des cancers rectaux

Surgery alone is no longer appropriate to the treatment of T3-T4 resecable rectal cancer. Preoperative chemoradiotherapy has recently been approved as the new standard treatment. This approach improves local control with local failure rate raranging now around 6-8%. However, it does not impact on overall survival. It becomes urgent to develop new concepts and a basic research in the understanding of the biological mechanisms that may explain the resistance of the micrometastatic process.

Equivalent uniform dose concept evaluated by theoretical dose volume histograms for thoracic irradiation

BACKGROUND AND PURPOSE

The goal of our study was to quantify the limits of the EUD models for use in score functions in inverse planning software, and for clinical application.

MATERIALS AND METHODS

We focused on oesophagus cancer irradiation. Our evaluation was based on theoretical dose volume histograms (DVH), and we analyzed them using volumetric and linear quadratic EUD models, average and maximum dose concepts, the linear quadratic model and the differential area between each DVH.

RESULTS

We evaluated our models using theoretical and more complex DVHs for the above regions of interest. We studied three types of DVH for the target volume: the first followed the ICRU dose homogeneity recommendations; the second was built out of the first requirements and the same average dose was built in for all cases; the third was truncated by a small dose hole. We also built theoretical DVHs for the organs at risk, in order to evaluate the limits of, and the ways to use both EUD(1) and EUD/LQ models, comparing them to the traditional ways of scoring a treatment plan. For each volume of interest we built theoretical treatment plans with differences in the fractionation.

CONCLUSION

We concluded that both volumetric and linear quadratic EUDs should be used. Volumetric EUD(1) takes into account neither hot-cold spot compensation nor the differences in fractionation, but it is more sensitive to the increase of the irradiated volume. With linear quadratic EUD/LQ, a volumetric analysis of fractionation variation effort can be performed.

Esophageal cancer: Determination of internal target volume for conformal radiotherapy

BACKGROUND AND PURPOSE

To evaluate esophageal tumor and OAR movement during the respiratory cycle in order to obtain optimal values for ITV and PRV. To correlate tumor motion with chest wall displacement - information of value in the free-breathing gating system.

MATERIAL AND METHOD

Inclusion criteria were: histologically proven squamous-cell carcinoma (SCC) or adenocarcinoma at stage T3 - T4 NX or TX N1 M0 according to the UICC 1997 classification. Two spiral scans were performed with breath-hold respiration under spirometric control: one at end expiration (EBH) and the other at end inspiration (IBH). Displacements between exhalation and inhalation were calculated according to ICRU report 42 recommendations. For the correlation study, CT-scan acquisition was performed at the isocenter over a 20 - 40 s period. After Fourier Transform, frequency spectra for amplitude and phase of tumor and chest wall motions were performed for each patient.

RESULTS

Cumulative distribution of CTV motion in absolute values showed that 95% of data ranged from 0 to 1 cm. Cumulative distribution of GTV motion in absolute values showed that 95% of data ranged from 0 to 0.8 cm. The correlation study demonstrated no specific relationship between respiratory and esophageal motions.

CONCLUSION

The ITV margin for 3D conformal radiotherapy in esophageal cancer was 1 cm when 95% of motions were taken into account in this clinical study involving eight patients. Before using a free-breathing gating system, the correlation between external markers and target displacement during irradiation must be established for each patient.

La chimiothérapie concomitante de la radiothérapie augmente la toxicité tardive après chirurgie conservatrice du cancer du sein

PURPOSE

In 1996, a multicenter randomized study comparing after breast-conservative surgery, sequential vs concurrent adjuvant chemotherapy (CT) with radiation therapy (RT) was initiated (ARCOSEIN study). Seven hundred sixteen patients were included in this trial. After a median follow-up of 6.7 (4.3-9) years, we decided to prospectively evaluate the late effects of these two strategies.

PATIENTS AND METHODS

A total of 297 patients were asked to follow-up from the five larger including institutions. Seventy-two percent (214 patients) were eligible for late toxicity. After breast-conserving surgery with axillary dissection, patients were treated either with sequential treatment with CT first followed by RT (arm A) or CT administered concurrently with RT (arm B). In all patients, CT regimen combined mitoxantrone (12 mg/m(2)), 5-FU (500 mg/m(2)), and cyclophosphamide (500 mg/m(2)), 6 cycles (day 1-day 21). In arm B, patients received concurrently the first 3 cycles of CT with RT. In arm A, RT started 3 to 5 weeks after the 6th cycle of CT. Conventional RT was delivered to the whole breast using a 2 Gy-fraction protocol to a total dose of 50 Gy (+/-boost to the primary tumour bed). The assessment of toxicity was blinded to treatment and was graded by the radiation oncologist according to the LENT-SOMA scale. Skin pigmentation was also evaluated using a personal 5-points scoring system (excellent, good, moderate, poor, very poor).

RESULTS

Among the 214 evaluated patients, 107 were treated in each arm. The two populations were homogeneous for patients', tumors' and treatment characteristics. Subcutaneous fibrosis (SF), telengectasia (T), skin pigmentation (SP), and breast atrophy (BA) were significantly increased in arm B. Twenty patients experienced grade superior or equal to 2 (SF) in arm B vs five in arm A (P=0.003). Twenty-five and seven patients showed grade superior or equal to 2 (T) in arm B and A, respectively (P=0.001). Forty-four and twenty patients showed grade superior or equal to 2 (BA) in arm B and A, respectively (P=0.0006). Thirty patients experienced grade superior or equal to 3 (SP) in arm B vs fifteen in arm A (P=0.02). No statistical difference was observed between the two arms concerning grade superior or equal to 2 pain, breast oedema, and lymphoedema. No deaths were caused by late toxicity.

CONCLUSION

Following breast conserving surgery, the concurrent use of CT with RT is significantly associated with an increase incidence of grade 2 or greater late side effects.

Conduite à tenir devant une ascension du PSA après rémission complète postprostatectomie ?

Between twenty and to forty percent of patients will develop an isolated PSA failure after a radical prostatectomy. Pelvic irradiation is a therapeutic option with curative intention. It is the best therapeutic option for young people with good prognostic factors. Combined radiation with hormonal or chemotherapy should be evaluated in patients with poor prognostic factors. For patients with a short life expectancy, hormonotherapy or a watch and see policy are acceptable options.

Radiothérapie pelvienne pour récidive biochimique isolée après prostatectomie pour cancer de prostate : quels volumes ?

After prostatectomy, radiotherapy is a potential curable treatment. From the surgery series, it is possible to identify all the localization at risk in case of biochemical relapse after prostatectomy. The target volume of irradiation has to be defined according to the pathological findings. The CTV is limited to the pelvic fascia laterally, to the anterior wall of the rectum behind. The inferior limit includes the anastomosis, and the superior is easier to define with the length of the prostatic gland. The inclusion of area of seminal vesicles and pelvic node areas should be discussed. The use of surgical clips on the anastomosis and image fusionning techniques including the preoperative imaging would help physicians to define the CTV's limits.

[Second malignancies after radiotherapy for testicular seminoma: 2 cases]

Orchiectomy with adjuvant radiotherapy of retroperitoneal paraaortic and ipsilateral iliac nodes is the standard treatment for localized testicular seminoma (I, IIA, IIB). Post therapeutic follow-up allows to detect local relapse and radio-induced second cancer. Nevertheless, evaluation of risk of second malignancy still remains difficult. We report 2 cases of rectal cancer after radiotherapy for testicular seminoma.

Radiation therapy and upper gastrointestinal tract: esophageal, gastric, and pancreatic cancer. Toward new standards?

PURPOSE OF REVIEW

To emphasize the role and place of chemoradiation in the treatment of patients with upper gastrointestinal tract cancer.

RECENT FINDINGS

For esophagus cancer, in resectable stages IIA to IIB, squamous cell types, surgery remains standard treatment, and preoperative chemoradiation is investigational. After the results of two randomized trials conducted in France and Germany, however, chemoradiation alone is challenging surgery. In adenocarcinomas, preoperative chemoradiation is under investigation. In both types, new studies incorporating targeted therapies to chemoradiation are starting. For gastric cancer, chemoradiation after operation is standard of care in the United States but is still discussed in Europe. Preoperative chemoradiation is in current development, and future trials will compare preoperative strategies and strategies after operation. For pancreatic cancer, after a curative resection, chemoradiation in the United States and chemotherapy in Europe are standard of care, respectively. An ongoing European trial is comparing these two strategies after operation.

SUMMARY

Recommendations are issued from the analysis of recently published clinical trials. New areas of development are discussed.

[Clinical practice guidelines: 2004 Standards, Options and Recommendations for the management of patient with adenocarcinoma of the stomach--radiotherapy]

CONTEXT

"The Standards, Options and Recommendations" (SOR) project, started in 1993, is a collaboration between the Federation of French Cancer Centers (FNCLCC), the 20 French regional cancer centers, and specialists from French Public Universities, General Hospitals and Private Clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and the outcome of cancer patients.

OBJECTIVES

To elaborate clinical practice guidelines for patients with stomach adenocarcinoma. These recommendations cover the diagnosis, treatment and follow-up of these tumors.

METHODS

The methodology is based on a literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery. The Standards, Options and Recommendations are thus based on the best available evidence and expert agreement.

RESULTS

Adjuvant radiation therapy alone is not a standard treatment for patients with stomach adenocarcinoma. Adjuvant concomitant chemoradiotherapy is not a standard treatment for patients with stage II or III stomach adenocarcinoma R0, with Dl or D2 lymphadenectomy who have undergone surgery. Following surgical resection, adjuvant concomitant chemoradiotherapy should be proposed to patients without denutrition with a lymphadenectomy < Dl (fewer than 15 lymph nodes examined) and those with T3 and/or N+ tumours following the protocol used in the MacDonald trials (SWOG-9008) (Level of evidence B1). Adjuvant concomitant chemoradiotherapy can be administered to patients without denutrition with DI or D2 lymphadenectomy and with involvement of regional lymph nodes (N2 or N3).

Preoperative chemoradiotherapy versus preoperative radiotherapy in rectal cancer patients: assessment of acute toxicity and treatment compliance

The European Organisation for Research and Treatment of Cancer (EORTC) 22921 four-arm randomised trial questioned the value of preoperative chemoradiation (XRT-CT) versus preoperative radiation (XRT) and the value of additional postoperative chemotherapy (CT) versus none in T3-T4 M0 resectable rectal cancer patients. We report on the preoperative toxicity, treatment compliance and early deaths (all deaths up to 30 days after surgery) of the two treatment modalities in patients who were entered into trial before January 2001. In the XRT Group (group A), patients received 45 Gy, 25 fractions over 5 weeks. In the XRT-CT Group (group B), two 5-day courses of CT were added to the first and fifth weeks of XRT. For each CT course: 5-fluorouracil (5-FU) 350 mg/m2/day and Leucovorin (LV) 20 mg/m2/day were given. 398 and 400 patients started treatment in groups A and B, respectively. Grade 2+acute diarrhoea occurred in 17.3 and 34.3% of patients in groups A and B, respectively (P<0.005). The other side-effects remained unchanged or were only marginally increased. The compliance with RT was 98.5 and 95.5% in groups A and B, respectively. In group B, 78.7 and 71.1% of the patients received 95-105% of the planned CT doses at the first and second courses, respectively. 6 patients died preoperatively, 2 from toxicity in group B. 8 patients (1%) died within the 30 days after surgery in both groups. At the doses recommended in the protocol, the addition of 5-FU-LV to preoperative XRT slightly increased the amount of acute toxicity. However, the compliance with the radiation protocol or the feasibility of surgery did not decrease.

Shortened irradiation scheme, continuous infusion of 5-fluorouracil and fractionation of mitomycin C in locally advanced anal carcinomas. Results of a phase II study of the European Organization for Research and Treatment of Cancer. Radiotherapy and Gastrointestinal Cooperative Groups

The European Organization for Research and Treatment of Cancer (EORTC) 22861 randomised trial established that combined radiochemotherapy is the standard treatment for locally advanced anal cancer. This EORTC phase II study (#22953) tests the feasibility of reducing the gap between sequences to 2 weeks, to deliver Mitomycin C (MMC) in each radiotherapy sequence and 5-FU continuously during the treatment. The first sequence consisted of 36 Gy over 4 weeks. 5-FU 200 mg/m(2)/days 1-26, MMC 10 mg/m(2)/day 1 gap 16 days. Then a second sequence of 23.4 Gy over 17 days, 5-FU 200 mg/m(2)/days 1-17 and, MMC 10 mg/m(2)/day 1 was given. 43 patients with a World Health Organization (WHO) status of 0 (n=27) or 1 (n=16) and with T2-T4, N0-3 tumours were included. Compliance with the planned treatment, doses and duration was 93%. The complete response rate was 90.7%. Grade 3 toxicities of 28, 12 and 2% were observed for skin, diarrhoea and haematological toxicities, respectively. The 3-year estimated rates for trials 22861 and 22953 are: 68 and 88% for local control; 72 and 81% for colostomy-free interval, 62 and 84% for severe late toxicity-free interval, and 70 and 81% for survival, respectively. The 22953 scheme is feasible and the results are promising. This is now considered as the new standard scheme by the EORTC.

[Cancer of the rectum: target volumes for preoperative radiotherapy]

Preoperative radiotherapy is the standard treatment for locally advanced resectable rectal adenocarcinoma. The total mesorectal excision leads to a dramatic increase of local control rate. Thus, the mesorectal space is the usual field for the spread of rectal cancers cells. It could therefore be considered as the clinical target volume (CTV) in the preoperative conformational radiotherapy. From the anatomical basis and radiological contributions, we propose several CTVs for different locations of rectal carcinoma.

[Chemoradiotherapy in the adjuvant treatment of gastric adenocarcinomas: real progress?]

Frequency of local and distant failures after gastrectomy has led to extended lymph nodes dissection to obtain a better locoregional control. However, five year survival rates were not significantly different between patients undergoing D2 and D1 lymphadenectomy, and higher morbidity and post operative deaths were reported in large randomised trials (respectively 25% vs 48% and 4 vs 13%). Additionally, several metanalysis failed to demonstrate a significant survival advantage with adjuvant chemotherapy. The results of the first trial demonstrating one advantage to adjuvant post-operative chemoradiotherapy should modify the standard care. Disease free and overall survival after surgery alone and after surgery and concurrent chemoradiotherapy were respectively 31% vs 48% and 41% vs 50%. The intergroup trial demonstrate that better local control improve survival if radiation fields include stamps, tumour bed, proximal nodal chains and nodes corresponding to D2 extended lymph nodes dissection. Treatment was feasible with few severe toxic effects (1%). Of the 281 patients, 17% stopped treatment because toxic effects. Technical modalities of radiotherapy and post-operative nutrition support, which are critical points of interest for this treatment, are also discussed.

A randomised trial comparing 5-FU with 5-FU plus cisplatin in advanced pancreatic carcinoma

BACKGROUND

Chemotherapy is moderately efficient as a treatment for pancreatic adenocarcinoma, but patient survival and quality of life has improved with this modality in some trials. In a previous phase II trial, 5-fluorouracil (5-FU) plus cisplatin (FUP) yielded a 26.5% response rate and a 29% survival rate at 1 year. The present study aimed to compare FUP with 5-FU alone, which was the control arm in former Mayo Clinic trials.

PATIENTS AND METHODS

Patients with untreated cytologically or histologically proven metastatic or locally advanced adenocarcinoma of the pancreas were deemed measurable or evaluable. Chemotherapy regimens consisted of a control FU arm (5-FU 500 mg/m(2)/day for 5 days) and the investigational FUP arm (continuous 5-FU 1000 mg/m(2)/day for 5 days plus cisplatin 100 mg/m(2) on day 1 or day 2). In both arms, chemotherapy was repeated at day 29.

RESULTS

Two-hundred and seven patients from 18 centres were randomised: 103 in the FU arm and 104 in FUP arm. Treatment arms were balanced with respect to performance status grade 0-1 (83% versus 86%, respectively) and the presence of metastases (92% versus 89%, respectively). The median number of cycles administered was two in both arms (range 0-14). Five patients did not receive any chemotherapy and 45 received only one cycle. Toxicity (WHO grade 3-4) was lower with FU than with FUP (20% versus 48%, P <0.001), as was neutropenia (6% versus 23%), vomiting (4% versus 17%) and toxicity-related deaths (one versus four early in the trial). The response rate was low in both arms, but superior in the FUP arm: 12% versus 0% (intention-to-treat analysis, P <0.01). The survival rates at 6 months were 28% and 38% for the FU and FUP arms, respectively, and 1-year survival rates were 9% and 17% (log-rank test, P = 0.10). One-year progression-free survival was 0% with FU versus 10% with FUP (log-rank test, P = 0.0001).

CONCLUSIONS

In advanced pancreatic carcinomas with a poor prognosis, FUP was superior to FU in terms of response and progression-free survival, but not in terms of overall survival. The low response rate is partly related to the number of patients who received only one cycle of chemotherapy. A more effective, better tolerated version of this FUP combination is needed.

Small-cell carcinoma of the esophagus: report of three cases and review of the literature with emphasis on therapy

Primary small-cell carcinoma (SCC) of the esophagus is rare, with about 200 cases reported up till now in the literature. Like pulmonary SCC, it is an aggressive tumor associated with a poor prognosis. Between 1994 and 1997, three patients with SCC of the esophagus were treated at Besançon University Hospital and this represented 1.85% of all esophageal malignancies diagnosed during this period: one patient had a limited tumor and underwent initial surgical resection, then chemotherapy with cisplatine and etoposide, and radiotherapy for recurrences. The other patients had extensive disease at diagnosis and were treated by the same chemotherapy. This retrospective study reports our experience of patients with this particular tumor and outlines the management strategy based on the available literature.

[Clinical target volume for preoperative radiotherapy of rectal cancers]

The total mesorectal excision allows the marked increase of the local control rate in rectal cancer. Therefore, the mesorectal space is the usual field for the spread of rectal cancer cells. It could therefore be considered as the clinical target volume in the preoperative plan by the radiation oncologist. We propose to identify the mesorectum on anatomical structures of a treatment-position CT scan.

Postoperative pelvic radiotherapy with or without elective irradiation of para-aortic nodes and liver in rectal cancer patients. A controlled clinical trial of the EORTC Radiotherapy Group

OBJECTIVE

The purpose of this randomized multicenter study was to assess the impact on disease free and overall survival of low dose irradiation to para-aortic nodes and liver in patients with a locally advanced resected rectal cancer receiving a 50 Gy postoperative pelvic radiotherapy.

PATIENTS AND METHODS

Main inclusion criteria were: a curative resection for a histologically proved carcinoma of the rectum, Gunderson-Sosin stages B2-B3, C1-C3, age <70 years. The patients were randomized between pelvic irradiation (Lim-XRT): 50 Gy in 25 fractions over 5 weeks and extended irradiation (Ext-XRT): same scheme/doses in the pelvis and extended fields on para-aortic nodes and liver, delivering 25 Gy in 19 fractions over 25 days. From 1983 to 1992, 484 patients were enrolled by 18 EORTC institutions and 29 patients were ineligible. The end-points were local and distant relapses, toxicity and survival.

RESULTS

Compliance to treatment: 87.2% in Lim-XRT arm and 71.8% in Ext-XRT arm. Moderate acute hematological and hepatic toxicities were significantly increased in Ext-XRT arm. Among 325 patients at risk, 44 suffered a severe intestinal complication requiring surgery in 29. The 5- and 10-year estimates of disease free survival were respectively 42 and 31% in Lim-XRT arm and 47 and 31% in Ext-XRT arm (ns). The corresponding figures for overall survival were respectively 45 and 40% in Lim-XRT arm and 48 and 37% in Ext-arm (ns). The 10 years estimate of intra-pelvic failures was approximately 30% in both arms. Patients in Ext-arm appeared to have a slight shorter interval free of liver metastases (P=0.047).

CONCLUSION

Low dose irradiation to the para-aortic nodes and liver did not improve survival for patients with resected adenocarcinoma of the rectum.

Small-cell carcinoma of the esophagus: report of three cases and review of the literature with emphasis on therapy

Primary small-cell carcinoma (SCC) of the esophagus is rare, with about 200 cases reported up till now in the literature. Like pulmonary SCC, it is an aggressive tumor associated with a poor prognosis. Between 1994 and 1997, three patients with SCC of the esophagus were treated at Besançon University Hospital and this represented 1.85% of all esophageal malignancies diagnosed during this period: one patient had a limited tumor and underwent initial surgical resection, then chemotherapy with cisplatine and etoposide, and radiotherapy for recurrences. The other patients had extensive disease at diagnosis and were treated by the same chemotherapy. This retrospective study reports our experience of patients with this particular tumor and outlines the management strategy based on the available literature.

[Prevention of pelvic recurrence by preoperative radiochemotherapy and total mesorectal excision of rectal carcinoma?]

Preoperative radiotherapy (RT) alone or in combination with a pre- or postoperative chemotherapy reduces the recurrence rate and increases the survival rate for patients with resectable rectal cancer. The therapeutic index, i.e. relationship between effects and side effects is objective of studies. Especially toxicities to the small intestine and to the sphincter function are evaluated. Preoperative radiotherapy achieves the best results. The treatment volume includes the mesorectum in case of continence maintaining surgery and includes the anal sphincter in case of abdominoperineal resection. To exclude the small intestine from the RT-field, we prefer the use of 3 or 4 field technique in a prone position with filled bladder, using an optimal field limitation. The Swedish study, which uses 25 Gy in five fractions per week leads to an increased rate of acute and late toxicities. A fractionation schedule using 45-50 Gy in five weeks should be preferred. During the radiotherapy the patient is followed-up once per week. If surgery is foreseen, it should take place as soon as 3 weeks after the end of radiotherapy. If a primary surgery is performed preoperatively, the operative finding should be discussed with the surgeon. Quality control programs have to certify optimal treatment of the patient by radiotherapist and surgeon.

Concurrent cisplatin/etoposide chemotherapy plus twice daily thoracic radiotherapy in limited stage small cell lung cancer: a phase II study

Thirty-one previously untreated patients with limited stage small-cell lung cancer (LSCLC) were included in a prospective study, to investigate the feasability and the efficacy of a combined modality treatment using concurrent hyperfractionated chest irradiation and cisplatin (P) plus etoposide (E) chemotherapy. All patients received intravenously P=75 mg/m(2) at day 1, plus E=120 mg/m(2) days 1-3, at 3-week intervals for six cycles. Irradiated patients received 45 Gy in two daily fractions, 5 days a week, from week 4 to week 6. During week 5, prophylactic cranial irradiation was initiated, in one daily fraction of 2.5 Gy for a total dose of 25 Gy. Twenty-nine patients were evaluable for response. Twenty-two (76%) achieved a complete response, five (17%) had a partial response. Five patients are currently alive. The overall response rate was 93% (CI 95% (83.7-100)). The median survival time was 14 months and the 2-year survival rate was 25%. Main toxicities were grade 3-4 esophagitis in half of the patients and myelosuppression. The results are not as optimistic as other studies using a similar regimen.

Preoperative radiochemotherapy in rectal cancer: long-term results of a phase II trial

PURPOSE

To assess toxicity and long-term results of preoperative chemoradiotherapy in rectal cancer.

METHODS AND MATERIALS

Between 1989 and 1997, as a phase II study, 66 patients with T3 M0, rectal cancer received preoperatively a 45 Gy dose pelvic radiotherapy (XRT) combined with two 5-day chemotherapy courses (CT) of 5-Fluorouracil (5-FU) and Leucovorin (LV) delivered the first and fifth week of XRT. For each CT course, LV:20 mg/m2/d1-d5,. While the 5-FU dose was variable from 450 to 350 mg/m2/d first course and 370 to 350 mg/m2/d second course. Surgery was planned 3 weeks later.

RESULTS

XRT-CT was stopped in 1 patient due to progressive disease. CT was stopped in 1 patient due to toxicity. Grades 2 and 3 diarrhea were observed in 8 and 3 patients, respectively. One patient died from acute diarrhea due to deviation from recommendations; 60 patients went to surgery. Among the 58 patients operated on for cure, 5 had an R1-resection. After a 4.5-year median follow-up, the 5-year pelvic disease-free survival was 92% for the whole group and 96% in the R0-resection group.

CONCLUSION

Preoperative combined XRT-5-FU-LV is feasible if optimal XRT and patients are carefully managed. The recommended 5-FU daily dose is 350 mg/m2 for both CT courses. This approach is currently tested in a large EORTC phase III trial.

Prevalence of germline mutations of hMLH1, hMSH2, hPMS1, hPMS2, and hMSH6 genes in 75 French kindreds with nonpolyposis colorectal cancer

Hereditary nonpolyposis colorectal cancer (HNPCC) is a syndrome characterized by familial predisposition to colorectal carcinoma and extracolonic cancers of the gastrointestinal, urological, and female reproductive tracts. This dominant disorder is caused by germline defects in one of at least five DNA mismatch repair (MMR) genes: hMLH1, hMSH2, hPMS1, hPMS2, and hMSH6 (GTBP). Germline mutations of hMSH2 and hMLH1 are also frequently identified in families not fulfilling all the Amsterdam criteria, thereby demonstrating that the involvement of these genes is not confined to typical HNPCC. To evaluate the respective involvement of the various MMR genes in typical and incomplete HNPCC syndromes, we have performed an analysis of the hMLH1, hMSH2, hPMS1, hPMS2, and hMSH6 genes in a large series of French kindreds (n=75) with colorectal tumors and/or aggregation of extracolonic cancers belonging to the HNPCC spectrum. Mutational analysis has been performed in all families, without preselection for the tumor phenotype. We have detected 26 pathogenic germline mutations of the hMLH1 and hMSH2 genes and several novel variants of the hPMS1, hPMS2, and hMSH6 genes. Our data confirm that, regardless of the type of families and the tumor phenotype, hPMS1, hPMS2, and hMSH6 germline mutations are rare in familial aggregation of colorectal cancers. Furthermore, they suggest that the presence of multiple primary malignancies in a single individual and the observation of extracolonic tumors in relatives of a colorectal cancer patient should be included among the guidelines for referring patients for genetic testing.

[Clinical evaluation of concomitant chemoradiotherapy and practical recommendations]

The efficacy of concurrent radiochemotherapy should be evaluated in term of therapeutic ratio. The aims of treatment are increasing local control and possibly overall survival. Acute toxicity should be reported using the WHO recommendations, while late toxicity is reported using the scales recommended by the EORTC and RTOG Radiotherapy Groups. Moreover, functional, esthetic and quality of life considerations should be introduced. The application of these treatments needs a well-designed multidisciplinary staff.

[Adjuvant chemoradiotherapy of cancers of the rectum]

Increasing local control remains a major endpoint in the adjuvant setting of rectal cancer. Postoperative concurrent 5FU-based chemotherapy and irradiation demonstrated its value in Duke's B and C patients. Toxicity decreased from the first studies to the current one's in relation with better radiotherapy technique, reduction of chemotherapy duration and quality assurance programs. Because preoperative irradiation alone has demonstrated its value on local control and overall survival, preoperative combined chemoradiotherapy should be investigated. Phase III trials are ongoing comparing preoperative radiochemotherapy to either preoperative irradiation alone or to postoperative radiochemotherapy. At this moment, if the patient has been operated, radiochemotherapy and additional chemotherapy should be offered in the case of Duke's B-C tumor. On the other hand, it should be preferably offered preoperative radiotherapy in case of T3 resectable T4 and hopefully in the context of a controlled clinical trial investigating preoperative concurrent radiochemotherapy.

[Combined radiochemotherapy in treatment of esophageal cancers]

Concomitant radiochemotherapy has totally changed the treatment of oesophagus cancer. After numerous phase II studies that indicated their feasibility and efficacy, randomised phase III studies recently demonstrated their ability to improve survival. In operable cancer, preoperative radiochemotherapy increases the overall survival in adenocarcinoma, and the disease-free survival in squamous cell cancers, in comparison to surgery alone. In locally advanced disease, radiochemotherapy is considered as standard treatment. At this moment the effective drugs are 5-fluorouracil, mitomycin C and cisplatinum. The aims of current studies are to increase further the therapeutic ratio, the ways being refinements of radiotherapy and new chemotherapy delivery modalities. Finally the efficacy of radio-chemotherapy is questionning the role of surgery in this disease.

[Late effects of radiations on the esophagus]

Radiation-induced late effects of oesophagus are observed after treatment for various cancers. Acute reactions, mainly oesophagitis, are well known and accurately described; late effects share, for most of these, a common consequence: alteration of the main oesophageal function, namely to conduct the food bolus; clinically they are impaired in terms of mobility and stenosis. More rarely, ulcerations and pseudodiverticulae can be observed. Chemotherapy further increases the risk of late effects, especially in case of concomitant chemo-radiotherapy. All numbers and statistical data on oesophagus late effects should be regarded with caution due to recent changes in the therapeutic attitudes (more and more combined chemotherapy-radiotherapy) and some progress in given cancer locations. A common scale like the LENT-SOMA should enable the clinician to better know these late effects on oesophagus which is required to initiate effective prevention measures and adapted treatments.

[Rectal complications of radiotherapy]

Late rectal morbidity has been observed in 2%-25% of patients treated with radiotherapy using curative doses for prostate, cervix and rectal cancers. The major encountered clinical pictures are rectal proctitis, rectal/anal strictures, rectal bleeding, ulcers and fistula. Some may alter the patient's lifestyle while other may induce death. Recommendations concerning the clinical practice are described. The treatment of these late rectal effects include nutritional recommendations, laser, formalin application, and surgery.

[Late intestinal complications of adjuvant radiotherapy of rectal cancers]

Pre or postoperative pelvic irradiation has demonstrated a definitive efficacy in reducing the local failure rate of rectal cancer treated with surgery alone. However it can induce late small bowel morbidity that could alter the therapeutic ratio. The clinical pictures of radiation enteritis include obstruction and diarrhea/malabsorption. Prognostic factors that increase the risk of late small bowel complications include extended fields out of the pelvis, irradiation dose, inappropriate irradiation technique, and increased small bowel irradiated volumes. The addition of chemotherapy increases acute but not late toxicity. Recommendations concerning the clinical practice are described. Radiotherapy may also alter the residual sphincter function and we recommend to assess correctly these complications.