Long-term survival and patterns of failure after postoperative radiation therapy for subtotally resected rectal adenocarcinoma (original) (raw)

Preoperative Irradiation for Rectal Cancer

Annals of Surgery, 1989

112 patients with adenocarcinoma of the rectum were treated using preoperative irradiation followed by excisional surgery on the colorectal surgery service of Jewish Hospital at Washington University Medical Center in St. Louis. There were 68 men and 44 women in this study, with ages ranging from 19 to 94 years of age. In all cases, the rectal cancers were believed to be transmurally invasive based on initial clinical examination. Included in this group were 13 patients with poorly differentiated tumors and 51 patients with tumors fixed to surrounding tissues. Between 1975 and 1980, we used 2000 cGy preoperative irradiation followed by imm te excisional surgery to treat 22 patients. Excisional surgery for cure was divided between abdomino-perineal resection of the rectosigmoid in eleven patients, low anterior resection of the rectosigmoid in eight patients, and a low Hartmann's procedure in three patients. Five-year survival for 20 patients with potentially curable lesions (Dukes' A, B, and C), was 85%, and there was no local recurrence. Between 1980 and 1986, 90 patients were treated with 4500 cGy preoperative irradiation over a 5week period followed by a 6-week waiting period, before excisional surgery. There were 72 patients with Dukes' A, B, and C lesions. Fifty patients underwent abdomino-perineal resection of the rectosigmoid, 33 patients underwent low anterior resection of the rectum, and seven patients underwent a low Hartmann's procedure. Five-year survival was 86%. Local recurrence was 1.8%. Tumor fixation and histologic dedifferentiation were the only factors that influenced survival. Five-year survival of patients with fixed poorly differentiated tumors was 27% as compared to 87% in patients with nonfixed well-differentiated tumors (p < 0.0001). Tumor fixation was not a significant factor in itself. Preoperative external beam irradiation improves survival, local control, and resectability in patients with rectal cancer. This effect may be due to the treatment of the "tangential" margins and local lymph node metastases. Preoperative staging can be accomplished by determining fixation and differentiation of the tumor when preoperative irradiation is used. A DJUVANT RADIATION THERAPY for rectal cancer is still controversial. However, surgical treatment alone continues to result in a high risk of local

Preoperative Irradiation for Rectal Cancer: Improved Local Control and Long-Term Survival

Annals of Surgery, 1989

Prognostic factors after preoperative irradiation and surgery for locally advanced rectal cancer

European Journal of Surgical Oncology (EJSO), 2008

The experience of preoperative irradiation in clinically locally advanced rectal cancer for the period 1991e2003 is reported. Prognostic factors for survival and recurrence, and parameters for obtaining a free circumferential margin were evaluated. Methods: A prospective cohort study of 204 M0 patients given >45 Gy preoperatively (median age 66 years; 29% women; tumour level <16 cm from the anal verge). Results: Multivisceral and/or pelvic wall resections were performed in 61% of the patients. R0, R1 and R2 resections were achieved in 74%, 21% and 5%. Five-year survival was 52% for all patients, 60% for R0 resections, 31% for R1 and 0% for R2. The calculated 5-year recurrence rates were 13% for R0 resections and 24% for R1 resections ( p < 0.035). R-stage, N-stage, age, type of rectal resection and pelvic wall resection remained significant in Cox multivariate analysis for survival. Regarding local recurrence, the following parameters were independent: N-stage, carcinoembryonic antigen (CEA) response and pelvic wall resection. Medium high tumour level and reduced histopathological differentiation are important individual factors that seem to predict increased risk for not obtaining a R0 resection. Conclusions: After preoperative irradiation and surgery, about 50% of the patients with locally advanced rectal cancer without overt metastases (M0) can be cured.

Local excision and external beam radiotherapy in early rectal cancer

International Journal of Radiation Oncology*Biology*Physics, 1996

Purpose: To assess the local control and survival of local excision and postoperative radiation in patients with earlvstaee rectal cancer. Methods"and Materials: From 1980 patients with clinical stage Tl-2NxM0 adenocarcinoma of the middle and lower rectum were treated with transanal excision and postoperative external beam radiotherans (44.6 Gy). The pathologic T stages were: 9 Tl (43%) and 12 T2 (57%). One patient had unassessahle resection margins. The median follow-up was 54 months (range: 18-128 months). Results: The actuarial local recurrence-free survival at 5 years was 85.2%, and the overall survival at 5 years was 80.6%. One patient developed a local recurrence and distant metastases at 22 months, and two patients had local recurrence at 11 and 15 months, respectively; both had ahdomino-perineal resection (APR) and one remained free of disease 16 months after APR. The incidence of Grade 3 diarrhea was 5%. Sphincter function was good to excellent in the 18 patients with local control. No patients developed clinical evidence of pelvic lymph node recurrence. Conclusion: These results are similar to other published series and suggest that this approach is feasible in selected patients with Tl-2NxMO rectal cancer and results in good long-term control of the disease.

Local Excision and Postoperative Radiation Therapy for Rectal Cancer

American Journal of Clinical Oncology, 1994

Sixty-seven patients with early-stage adenocarcinoma of the rectum who had lesions thought to be unsuitable for either local excision alone or endocavitary irradiation were treated with local excision followed by postoperative radiation therapy. The purpose of this study was to evaluate the effectiveness of local excision followed by radiation therapy for treatment of rectal adenocarcinoma. The patients were treated between 1974 and 1999; follow-up time was 6 to 273 months (median, 65 months). All living patients had follow-up for at least 2 years. The indications for postoperative irradiation included equivocal or positive margins, invasion of the muscularis propria, endothelial-lined space invasion, poorly differentiated histology, and perineural invasion. Cox proportional hazards regression analysis was performed using six explanatory variables including tumor size, configuration (exophytic vs. ulcerative), histologic differentiation, pathologic T stage, endothelial-lined space invasion, and margin status. The time interval between treatment and development of recurrent disease was in the range of 11 to 48 months. The 5-year results were as follows: local-regional control, 86%; ultimate local-regional control, 93%; distant metastasis-free survival, 93%; absolute survival, 80%; and cause-specific survival, 90%. When the Cox proportional hazards regression analysis was performed for these endpoints, margin status influenced absolute survival (P ‫؍‬ 0.0074), cause-specific survival (P ‫؍‬ 0.0405), and ultimate local-regional control (P ‫؍‬ 0.0439). Tumor configuration marginally influenced cause-specific survival (P ‫؍‬ 0.0577). None of the variables had an influence on the endpoints' local-regional control, ultimate local-regional control with sphincter preservation, or distant metastasis. Five patients (7%) had severe complications; no complication was fatal. Local excision and postoperative radiation therapy results in a high probability of local-regional control and survival for selected patients with relatively early-stage rectal adenocarcinoma. Patients with ulcerative tumors may have a lower likelihood of cause-specific survival.

Rectal cancer: preoperative versus postoperative irradiation as a component of adjuvant treatment

Seminars in Radiation Oncology, 2003

The search for improved disease control and survival for resectable but high-risk rectal cancers has led to studies that combine all 3 modalities. For surgically resected, high-risk rectal cancers, postoperative chemoradiation has been shown to improve both disease control (local and distant) and survival (disease free and overall) and was recommended as standard adjuvant treatment at the 1990 National Institute of Health Colorectal Cancer Consensus Conference. Three randomized studies showed improved overall survival (OS) and local control for patients treated with postoperative irradiation and chemotherapy when compared with surgery alone or surgery plus irradiation control arms. These include 2 US trials, Gastrointestinal Tumor Study Group and Mayo/North Central Cancer Treatment Group (NCCTG) and a Norway trial. Although most preoperative external beam radiation trials show reductions in local relapse with the addition of preoperative EBRT to resection, only the large Swedish trial of ϳ1,100 patients showed a survival improvement when compared with a surgery alone control arm for resectable primary rectal cancers. In a recent pooled analysis of 3 postoperative adjuvant rectal cancer trials (NCCTG 794751, NCCTG 864751, and GI Intergroup 0114) survival and disease relapse were dependent on both TN and NT stage of disease (N substage within T stage and T substage within N stage). Even among N2 patients (4 or more positive nodes), T substage influenced 5-year OS (T1-2, 69%; T3, 48%; and T4, 38%; P < .001). Ongoing randomized trials are being conducted for patients with high-risk, resectable primary rectal cancers. The intent is to help define optimal combinations of postoperative chemoradiation (US GI Intergroup), to test sequencing issues of preoperative versus postoperative chemoradiation (Germany trial), and to determine if concurrent and maintenance 5-FU and leucovorin add to the benefits found with preoperative irradiation (European Organization for Research and Treatment of Cancer). For subsequent trials, it may be preferable to perform separate studies, or a planned statistical analysis, for different risk groups of patients (low, intermediate, moderately high, and high), as defined in the rectal cancer pooled analysis.

High dose preoperative irradiation for cancer of the rectum, 1976–1988

International Journal of Radiation Oncology*Biology*Physics, 1991

and the Comprehensive Rectal Cancer Center Two hundred twenty patients with adenocarcinoma of the rectum have heen treated in a program using high dose (NUIOO cGy) preoperative irradiation followed by radical surgical resection. The patients were staged on the basis of pretreatment clinical mobility of the cancers. Seventy-four patients had mobile cancers, 49 had partial fixation (tethered), 85 patients had total tumor fixation, and 12 patients had a frozen pelvis (unresectable). Patients were treated with high energy photons using a four field box technique with total doses ranging from 4000 to 6000 cGy. The overall incidence of local recurrence was 15% (32/220). Patients with fixed and unresectabte tumors had a higher incidence of local recurrence, 20% (21/97) as compared with patients with mobile and partially fixed tumors, 10% (13/l 23). Local recurrence by pathological stage of disease was 6% for patients with Stages 0, A, Bl versus 20% for patients with Stages B2 and C cancer. Overall S-year survival of the total group was 67%. The 5-year survival by clinical stages of disease was 87% for mobile tumors, 74% for partially fixed tumors, 70% for fixed tumors, and 22% for the unresectable group. The 5-year survival by pathological stages of disease was 90% for those with Stage 0, A, Bl and 71, 75, and 47%. respectively, for Stages B2, Cl, and C2 disease. Rectal cancer, Preoperative radiation therapy, High dose preoperative radiation therapy.

Role of Radiation in Intermediate-Risk Rectal Cancer

Annals of Surgical Oncology, 2012

The treatment of rectal cancer has greatly evolved during the last several decades as a result of the understanding of the pathways of cancer spread, natural history of the disease, stages prognosis and prognostic markers. The tendency is clearly to move toward a more personalized approach to these patients based on preoperative staging and response to therapy. Although in the past we have been adding more treatment modalities to surgery to the point that every stage II/III cancer was treated with neoadjuvant chemo and radiotherapy followed by radical surgery by total mesorectal excision with or without sphincter preservation and more chemotherapy to follow, more recently this algorithm has been under discussion and scrutiny. Two of the major topics of controversy are: the use of local excision or even a watch-and-wait approach after a clinical complete response and the need for radiotherapy in the intermediate risk group. In this manuscript we will present the historical perspective that has brought the treatment of rectal cancer to the current standard of care and present the evidence supporting further investigation in the intermediate risk group.

Long-term survival and patterns of failure after postoperative radiation therapy for subtotally resected rectal adenocarcinoma (original) (raw)

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