A PROSPECTIVE COMPARATIVE STUDY ON LOCALLY ADVANCED RECTAL CARCINOMA TREATED WITH PRE-OPERATIVE SHORT-COURSE RADIOTHERAPY VERSUS LONG-COURSE RADIOTHERAPY WITH CONCOMITANT CHEMOTHERAPY (original) (raw)
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Preoperative Radiotherapy in Carcinoma Rectum
Indian Journal of Surgical Oncology, 2012
The present study was undertaken to address the various concerns that has limited the use of preoperative radiotherapy in rectal cancer in our institution. All patients diagnosed as having carcinoma rectum between August 2005 and July 2007 were included in the study. Group 1 patients consisted of those presenting with T2, T3 and T4 who received preoperative radiation of 25 Gy. Group 2 consisted of those with T4 tumours, who received Long course radiotherapy. Complication of radiation like dermatitis, enteritis and proctitis were noted. Before surgery CT scan and TRUS were repeated. In the postoperative period a record of abdominal, perineal wound complications and other complications were noted. The results were compared with a similar group of patients who did not receive preoperative radiotherapy. There were 21 patients (12males) with a mean age of 48.4 years (Range 18-70) in the radiotherapy group. Sixteen patients received short course (25 Gy) and five patients received long course of preoperative radiotherapy. Fourteen patients underwent definitive surgery in the form of abdominoperineal resection (APR) or anterior resection (AR). In the non-RT group there were 17 patients (8 males) with a mean age of 50.2 year. Fourteen patients underwent definitive surgery like APR (11) and AR (3). In the RT group CT scan and TRUS failed show any significant downsizing or down staging of tumour. In the RT group, incidence of acute skin toxicity was 23.8 % (5/21), all were seen in those who received long course of radiotherapy (Group 2). Grade 2 or 3 lower G I symptoms occurred in 3 (18.6 %) patients of Group 1 and 1(20 %) patient of group 2. There was higher incidence of perineal wound complication in the RT group (19.0 % vs 5.9 %). Preoperative long course of radiotherapy may be associated with high rates of dermatitis and perineal wound infection. Short course may be associated with lower G I toxicity.
Background: Chemoradiotherapy followed by surgery followed by adjuvant chemotherapy is the mainstay of treatment in stage II and III rectal cancer.There are two approaches to pelvic RT for resectable rectal cancer: short-course radiation and long course chemoradiotherapy(CRT).Polish and Australian randomized studies compared short-course radiation and immediate surgery with long-course CRT and delayed surgery.In these studies similar long-term survival and local control have been reported for both these approaches but pathological complete response(pCR) is not better with short course RT. Moreover studies have shown better tumor downstaging with delayed surgery.So the idea is to combine the benefits of delayed surgery for improved tumor downstaging with short course RT by adding two cycles of chemotherapy between short course RT and surgery to improve pCR rates.In this context the use of short-course radiotherapy may have some advantages and needs to be tested in clinical trials. Aim: To compare the tumour response clinically, radiologically and histopathologically To compare the toxicities between the two arms Materials and Methods: This prospective randomized study was a two arm study in which short course radiotherapy followed by two cycles of chemotherapy was compared with conventional neoadjuvant chemoradiotherapy in rectal cancer.Patients assigned to study group(short course RT) were given 25 Gy (5 Gy/fraction) in 5 days.Following a gap of 1 week after RT, patients were given two cycles of Capecitabine and Oxaliplatin (CAPOX) based chemotherapy.Patients assigned to control group(conventional CRT) were given radiation of 50.4 Gy in 28 fractions along with tablet Capecitabine on RT days.Patients were assessed for surgery after 4-6 weeks of completion of chemoradiation.Overall treatment time to surgery was similar in both the arms i.e. 10-12 weeks. Results: Of the 28 entered patients, 27 were eligible for analysis; 14 in study arm and 13 in control arm.The pCR rate was 6.7% in study arm while it was 0 in control arm(p=0.343). 33.3% patients in study arm and 53.8% patients in control arm had partial response(p=0.274). 53.3% patients in study arm and 46.2% patients in control arm had stable disease(p=0.705).None of the patients in both the arms had progressive disease.Acute toxicities were lower in study arm.The absence of hematological toxicity in 60% patients in study arm was statistically significant (p=.001).20% patients in study arm and 92.3% patients in control arm had grade 2-3 toxicity (p=0.005).The absence of skin toxicity in 73.3% patients in study arm was statistically significant(p=.001).Grade 3 toxicity was seen in 15.4% patients in control arm and no patient in study arm(p=0.116). Conclusions: pCR rates in the two arms are comparable.But the major advantage for the 5*5 Gy regimen with chemotherapy in neo-adjuvant setting is the improved toxicity profile compared with conventional CRT with significant reduction in acute toxicities in short course RT arm.
Retrospective study of acute toxicity following short-course preoperative radiotherapy
British Journal of Surgery, 2002
Background: The use of short-course preoperative radiotherapy (25 Gy in ®ve fractions over 1 week) in resectable rectal cancer reduces local recurrence but is associated with an increased risk of postoperative complications and late toxicity. This study aimed to identify those patients who are unlikely to bene®t from short-course preoperative radiotherapy and the factors associated with acute toxicity. Methods: All patients who received short-course preoperative radiotherapy at a university hospital in 1998 and 1999 were included in this retrospective study. The association between complications occurring within 3 months and patient demographics, radiotherapy technique, surgical details and overall treatment time (OTT) was assessed by univariate and multivariate analysis. Results: The mortality rate at 30 days was 6 per cent in the 177 patients identi®ed. Thirty-seven per cent of patients had either Dukes' A tumours, surgically incurable disease or positive circumferential margins. One or more complications occurred in 38 per cent of patients. On multivariate analysis an OTT of more than 13 days (P = 0´03), age (P = 0´02) and length of the radiotherapy ®eld (P = 0´05) were associated with an increased risk of complications. Conclusion: Surgery within 1 week of completing short-course preoperative radiotherapy improved preoperative staging and use of an optimal radiotherapy technique will result in fewer patients at risk of acute toxicity.
No D ownstaging A fter S hort-Term P reoperative Radiotherapy i n R ectal C ancer P atients
Purpose: In retrospective studies, total mesorectal excision (TME) surgery has been demonstrated to result in a reduction in the number of local recurrences of rectal cancer. Reports on improved local control after preoperative, hypofractionated radiotherapy have led to the introduction of a randomized multicenter trial to evaluate the effect of TME surgery with and without preoperative radiotherapy. Treatment with preoperative radiotherapy might have an effect on the pathologic characteristics that determine staging of rectal cancer. We investigated the occurrence of downstaging in rectal cancer patients treated with and without preoperative radiotherapy. Patients and Methods: We analyzed the differences in tumor size, number of examined lymph nodes, tumor-node-metastasis stage, and histopathologic features in 1,321 patients entered onto a randomized trial. The trial compared preoperative radiotherapy (5 ؋ 5 Gy) followed by TME surgery with TME surgery alone. Patients who had an interval of more than 10 days between the start of radiotherapy and surgery were excluded from analysis. Results: Differences were observed in tumor size (P < .001) and total number of examined lymph nodes (P < .001). No difference in tumor or node classification was detected. The irradiated group demonstrated more poorly differentiated tumors as well as more mucinous tumors. Conclusion: In rectal cancer patients, short-term, preoperative radiotherapy with 5 ؋ 5 Gy does not lead to downstaging if the interval between the start of radiotherapy and surgery does not exceed 10 days.
BMC Cancer, 2009
The additional use of radiotherapy has changed the treatment of locally advanced rectal cancer (LARC) dramatically. But a major achievement has been the development of total mesorectal excision (TME) as a surgical standard and the recognition that the surgeon is the predominant prognostic factor. The benefit of preoperative hypofractionated radiotherapy (SCRT; five fractions each of 5 Gy), initially established by the Swedish Rectal Cancer Trial, has been demonstrated in conjunction with TME by the Dutch Colorectal Cancer Group. The concept of combined neoadjuvant radiochemotherapy (conventional radiation of about 50 Gy with chemotherapy) has not been compared over surgery alone with TME. However, the German Rectal Cancer Study Group recently demonstrated that preoperative radiochemotherapy (RCT) was better than postoperative radiochemotherapy in terms of local control.
British Journal of Surgery, 1997
Background There is controversy whether adjuvant radiotherapy should be given before or after surgery for locally advanced, resectable rectal cancer. Preoperative radiotherapy substantially reduces local recurrence rates but may increase postoperative complications. In addition, patients found to have early cancers are treated unnecessarily. This study is a randomized trial of postoperative radiotherapy in patients who had a potentially curative resection for locally advanced rectal carcinoma. Methods Following complete excision of a Dukes B or C rectal cancer, 172 patients were randomized to adjuvant radiotherapy (46 Gy 5 days per week in 30-38 days) (84 patients) or controls (88 patients). Results After a median follow-up of 85 months, no benefit from postoperative radiotherapy had been observed in disease-free survival (P = 041), overall survival (P = 052), local recurrence-free interval (P = 0.46) or in the number and sites of recurrence. Acute toxicity following radiotherapy included diarrhoea (20 per cent), cystitis (13 per cent), delayed wound healing (7 per cent), pneumonia (5 per cent) and seizures (1 per cent). Late complications included reoperation for small bowel obstruction (5 per cent), chronic diarrhoea (20 per cent), chronic cystitis (12 per cent) and persistent perineal sinus (9 per cent). In the group who had surgery alone, late morbidity was found in 11 per cent. Conclusion This trial failed to demonstrate any improvement in overall survival or local control when postoperative irradiation was given following resection of locally advanced rectal carcinoma.
International Journal of Radiation Oncology*Biology*Physics, 2012
This was a prospective randomized trial of 248 locally advanced rectal cancer patients comparing 2 radiation doses and concurrent chemotherapy. The tumor dose was increased by endorectal brachytherapy (10 Gy/2 fractions). The primary endpoint, complete pathologic remission, was 18% and 18%, but the major response rate (TRG1 and TRG2) increased significantly. The results also showed that the high-dose regimen was feasible without an increase in complication rates. The final results await additional follow-up.
International Journal of Radiation Oncology*Biology*Physics, 1996
Purpose: To explain a possible association between treatment technique and postoperative mortality after preme radiotherapy of rectal carcinoma, the dose distributions were compared in model experiments. Methods and Mate-Preoperative radiotherapy with a three-beam technique delivered in ftve fractlmts to 25 Gy (5 Gy/daily for 5 or 7 days) was given to patients with primary resectabk rectal carcinoma. The adverse effects of this treatment, both acute and late, have been low. In a parallel trial using an identical fraction&on schedule and total dose but with a two-beam technique, the postoperative mortal@ was higher. Two-, three-. and four-beam techniques were analyzed in 20 patients with computed tomography based, three-dllional dose planning. Dose d&rib&ions and dose-volume histograms in the plan&g target volume (PTV) and in the organs at risk were considered. A numerical "biological" model was used to compare the techulques. Results: The two-beam aud the four-beam box techniques give the most h dosed&t in the PTV, although all techniques result in dose distributions that would be considered adequate, provided 16 MV or higher p&&on energies are used. Three-and four-beam techniques show advantagea over the two-bean teclmique with respect to organs at risk, particularly the small bowel. With the two-beam technique aud the upper beam limit at mid-L4, the volume of the bowel that receives >95% of the prescribed dose, and hence, is irprluded in the treated volume (TV), is more than twice as large as that with three-and four-beam techulques, and that of the total body between 1.5 and 2 times as large. The results of the analyses using the biologleal model indicate that the three-and four-beam techniques result in less small bowel eomplieatlon rates than the two-beam technique. The integral energy to the total body is similar for all treatment mod&ties compared. Conclusions: The volume of bowel in&ded in the TV, rather than the energy imparted to the body, influences postoperative mortality, and emphasizes the importance of precise radiotherapy planning to minimize normal tissue toxicity.