Randomized clinical trial on preoperative radiotherapy 25 Gy in rectal cancer—treatment results at 5-year follow-up

Purpose

The purpose of this study was to establish the influence of time interval between preoperative hyperfractionated radiotherapy (5?×?5?Gy) and surgery on long-term overall survival (5?years) and recurrence rate in patients with locally advanced rectal cancer operated on according to total mesorectal excision technique.

Methods

The treatment group comprised 154 patients with locally advanced rectal cancer who were operated on between 1999 and 2006 in the 1st Department of General Surgery, Jagiellonian University, Cracow, Poland. The data on survival has been systematically collected until 31st of December 2010. In addition, the following aspects were analyzed: the significance of time interval between the end of radiotherapy and surgical treatment and its influence on downsizing, downstaging, rate of curative resections, and sphincter-sparing procedures. Patients were qualified to preoperative radiotherapy 5?×?5?Gy and then randomly assigned to subgroups with different time intervals between radiotherapy and surgery: one subgroup consisted of 77 patients operated on 7–10?days after the end of irradiation, and the second subgroup consisted of 77 patients operated on after 4–5?weeks. Both groups were homogenous in sex, age, cancer stage and localization, distal and circumferential resection margins, and number of resected lymph nodes.

Results

The 5-year survival rate in patients operated on 7–10?days after irradiation was 63%, whereas in those operated on after 4–5?weeks, it was 73%—the difference was not statistically significant (log rank, p?=?0.24). A statistically significant increase in 5-year survival rate was observed only in patients with downstaging after radiotherapy—90% in comparison with 60% in patients without response to neoadjuvant treatment (log rank, p?=?0.004). Recurrence was diagnosed in 13.2% of patients. A lower rate of systemic recurrence was observed in patients operated on 4–5?weeks after the end of irradiation (2.8% vs. 12.3% in the subgroup with a shorter interval, p?=?0.035). No differences in local recurrence rates were observed in both subgroups of irradiated patients (p?=?0.119). The longer time interval between radiotherapy and surgery resulted in higher downstaging rate (44.2% vs. 13% in patients with a shorter interval, p?=?0.0001) although it did not increase the rate of sphincter-saving procedures (p?=?0.627) and curative resections (p?=?0.132).

Conclusions

1. Improved 5-year survival rate is observed only in patients with downstaging after preoperative irradiation dose of 25?Gy.
2. Longer time interval after preoperative radiotherapy 25?Gy does not improve the rate of sphincter-saving procedures and curative resections (R0) despite higher downstaging rate observed in this regimen.

     

Intraoperative lokale Tumorzelldissemination in der Rektumkarzinomchirurgie

Background

The influence of surgical principles and neoadjuvant therapy on the frequency of local tumor cell dissemination (LTCD) in rectal carcinoma surgery and its consequences for local recurrence and survival rates were analyzed.

Patients and methods

Data from the Erlangen registry for colorectal carcinomas (ERCRC) from 1969–2008 were compared with data from the literature published in 1980–2008.

Results

LTCD was observed in 6.7% in the ERCRC (n=2764) and a frequency of 6.9% was reported in in the literature (n=13,395). In the course of time and especially since the introduction of total mesorectal excision (TME) surgery, the incidence of LTCD has significantly decreased. Neoadjuvant treatment did not influence the frequency of LTCD. Following LTCD the rate of local recurrence significantly increased and the 5 year survival rate significantly decreased. This also applied to patients with neoadjuvant therapy.

Conclusions

Even in the era of TME surgery attention must to be paid to avoidance of LTCD. It is obligatory to document the occurrence of LTCD and it must be taken into consideration in routine quality assurance. In cases of LTCD postoperative chemoradiation is indicated for patients without neoadjuvant irradiation.     

Outcomes after Total Skin-sparing Mastectomy and Immediate Reconstruction in 657 Breasts

Background

Total skin-sparing mastectomy (TSSM), a technique comprising removal of all breast and nipple tissue while preserving the entire skin envelope, is increasingly offered to women for therapeutic and prophylactic indications. However, standard use of the procedure remains controversial as a result oft concerns regarding oncologic safety and risk of complications.

Methods

Outcomes from a prospectively maintained database of patients undergoing TSSM and immediate breast reconstruction from 2001 to 2010 were reviewed. Outcome measures included postoperative complications, tumor involvement of the nipple?Careolar complex (NAC) on pathologic analysis, and cancer recurrence.

Results

TSSM was performed on 657 breasts in 428 patients. Indications included in situ cancer [111 breasts (16.9?%)], invasive cancer [301 breasts (45.8?%)], and prophylactic risk-reduction [245 breasts (37.3?%)]. A total of 210 patients (49?%) had neoadjuvant chemotherapy, 78 (18.2?%) had adjuvant chemotherapy, and 114 (26.7?%) had postmastectomy radiotherapy. Nipple tissue contained in situ cancer in 11 breasts (1.7?%) and invasive cancer in 9 breasts (1.4?%); management included repeat excision (7 cases), NAC removal (9 cases), or radiotherapy without further excision (4 cases). Ischemic complications included 13 cases (2?%) of partial nipple loss, 10 cases (1.5?%) of complete nipple loss, and 78 cases (11.9?%) of skin flap necrosis. Overall locoregional recurrence rate was 2?% (median follow-up 28?months), with a 2.4?% rate observed in the subset of patients with at least 3?years?? follow-up (median 45?months). No NAC skin recurrences were observed.

Conclusions

In this large, high-risk cohort, TSSM was associated with low rates of NAC complications, nipple involvement, and locoregional recurrence.     

MRI-Based Treatment of Rectal Cancer: Is Prognostication of the Recurrence Risk Solid Enough to Render Radiation Redundant?

Background

Most current guidelines recommend neoadjuvant short course radiotherapy (sRT) or radio-chemotherapy (nRCT) for rectal cancer stage II and III. After the introduction of total mesorectal excision (TME) and magnetic resonance imaging (MRI), this proceeding has been questioned and omission of neoadjuvant treatment according to preoperative MRI-criteria has been propagated. Aim of the present paper is to review the state of evidence regarding MRI-based treatment decision depending on the predicted width of the circumferential resection margin (CRM).

Methods

A comprehensive survey of the literature was performed using the search terms “rectal cancer”, “radiotherapy”, “radio-chemotherapy”, “MRI-based therapy”, “circumferential resection margin”. Data from lately published observational studies were compared to results from randomized trials and outcome analyses of the Norwegian national cancer registry.

Results

Only one observational study using MRI-based treatment according to the anticipated CRM provided 5 year local recurrence data, however only for 65 patients. The second study did not yet evaluate recurrence rates. Two randomized trials comparing sRT to primary TME showed significantly worse outcome for non-irradiated patients. Data from the Norwegian rectal cancer registry demonstrate that TME alone is associated with higher LRR than achievable with preoperative RT.

Conclusions

Current evidence does not support the omission of neoadjuvant treatment for stage II–III rectal cancer on the basis of an MRI-predicted negative CRM. Randomized studies are warranted to clarify whether and for which subgroups TME alone is safe in terms of local recurrences.     

Oncologically Safe Distal Resection Margins in Rectal Cancer Patients Treated with Chemoradiotherapy

Introduction

Although current guidelines recommend distal resection margins (DRM) of 2?C5?cm in rectal cancer operation, smaller margins may be safe. We therefore assessed the impact of distal margins on outcomes in patients with rectal cancer treated with neoadjuvant chemoradiotherapy (CRT) followed by radical resection or resection followed by adjuvant CRT.

Materials and methods

This study involved 376 patients who underwent sphincter-saving resection for rectal adenocarcinoma and pre- or postoperative CRT between 2000 and 2006. DRMs were measured on pinned fixed specimens. We excluded patients who did not complete planned CRT and those with stage IV disease. A retrospective cross-sectional analysis was performed.

Results

No significant differences in local recurrence (9.8 versus 7.3?%; P?=?0.324) and systemic recurrence (16.4 versus 18.7?%; P?=?0.731) were observed in patients with DRMs of ??5 and >5?mm, respectively. Moreover, in each DRM category, there were no differences in local and systemic recurrence rates between patients who received pre- or postoperative CRT. DRM did not affect overall survival (P?=?0.880) or 5-year survival rate (80.3 versus76.8?%; P?=?0.340).

Conclusion

A distal margin of at least 5?mm with negative resection margin on frozen section does not reduce oncological safety in rectal cancer patients who receive pre- or postoperative CRT.     

Surveillance of Small Rectal Carcinoid Tumors in the Absence of Metastatic Disease

Background

The incidence of rectal carcinoids is rapidly increasing, typically presenting as small (<1.0?cm), localized tumors. Although the evaluation of rectal carcinoids on presentation is well standardized, surveillance after resection has not been well established.

Methods

A prospective database documented patients with rectal carcinoids at our institution between January 1995 and September 2011. Information collected included patient and tumor characteristics, treatment method, surveillance schedule, recurrence, and survival.

Results

Twenty-eight patients with rectal carcinoid were identified. Ten patients were excluded for tumors >1?cm, known metastases at presentation, <6?months follow-up, or previous resections. The mean age of the remaining patients was 56?±?3?years, and 61?% of the patients were female. All patients were diagnosed at endoscopy, with 50?% diagnosed incidentally on screening endoscopy. Treatment methods included endoscopic therapy (n?=?13, 72?%), transanal excision (n?=?3, 17?%), and transanal endoscopic microsurgery (n?=?1, 5.5?%). One patient (5.5?%) received no additional invasive therapy after diagnostic endoscopy. The mean tumor diameter was 4.6?±?0.5?mm. The average length of follow-up was 5.4?±?0.9?years, with a median number of 2 follow-up endoscopies (range 0?C6). Two patients (11?%) died within the follow-up period from noncarcinoid causes. Importantly, no surviving patients developed local or distant recurrence with up to 12.3?years of follow-up.

Conclusions

On the basis of this experience, patients presenting with small (??1.0?cm), nonmetastatic rectal carcinoids are unlikely to develop local or distant recurrence after resection. Aggressive surveillance with repeat endoscopies or other imaging studies after resection may be unnecessary in this patient population.     

Concept de conservation sphinct��rienne dans la chirurgie du bas et du moyen rectum

Objective

To assess oncologic outcome of patients treated by conservative radical surgery for tumors below 5 cm from the anal verge.

Summary background data

Standard surgical treatment of low rectal cancer below 5 cm from the anal verge is abdominoperineal resection.

Methods

From 1990 to 2003, patients with a nonfixed rectal carcinoma at 4.5 cm or less from the anal verge and without external sphincter infiltration underwent conservative surgery. Surgery included total mesorectal excision with intersphincteric resection, that is, removal of the internal sphincter, to achieve adequate distal margin. Patients with T3 disease or internal sphincter infiltration received preoperative radiotherapy.

Results

Ninety-two patients with a tumor at 3 cm (range 1.5?C4.5) from the anal verge underwent conservative surgery. There was no mortality and morbidity was 27%. The rate of complete microscopic resection (R0) was 89%, with 98% negative distal margin and 89% negative circumferential margin. In 58 patients with a follow-up of more than 24 months, the rate of local recurrence was 2%, and the 5-year overall survival and disease-free survival were 81% and 70%, respectively.

Conclusion

The technique of intersphincteric resection allows us to achieve conservative surgery in patients with a tumor close to or in the anal canal without compromising local control and survival. The distance of tumor from the anal verge is no longer a limit for sphincter-saving resection.     

Lokalrezidiv- und Überlebensraten nach Rektumkarzinomoperationen und multimodaler Therapie

Introduction. In the guidelines of the German specialist medical societies, postoperative chemoradiotherapy is recommended for rectal carcinomas in stages II and III. In the meantime, there are important study findings favoring preoperative radiotherapy as against postoperative irradiation. In the present unicentric study, the clinical results after preoperative irradiation and postoperative chemotherapy are to be determined. In period I, sandwich radiation without total mesorectal excision was applied. In period II, the treatment was developed further with exclusive preoperative radiation and total mesorectal excision. Since from 1994 the therapy regimen has changed with the introduction of total mesorectal excision and improved radiotherapy, the present study was carried out to check whether this has led to better results of therapy. Patients and Methods. Over a period of 7 years, data from 607 patients with rectal carcinoma were recorded and stored in an Excel file. The carcinomas were grouped into lower, middle and upper segment levels and classified endosonographically. Multimodal treatment was administered in stage uT3. In period I, sandwich radiation was carried out with 24 Gy preoperatively and 24 Gy postoperatively, followed by adjuvant chemotherapy. Total mesorectal excision was not performed. In period II, 50.4 Gy were applied preoperatively, followed by adjuvant chemotherapy. The operation comprised total mesorectal excision of the lower two thirds of the rectum. Calcium folinate and 5-fluoroucil were administered in six chemotherapy cycles. Primarily inoperable patients received preoperative irradiation with up to 50.4 Gy in both periods to attain down-staging. The following surgical procedures were applied: abdominal perineal extirpations, deep anterior resections, coloanal anastomoses, colon pouch anal anastomoses and transanal microsurgical resections. Results. In 469 curatively operated patients, including primarily inoperable patients after down-staging radiotherapy, the rates of local recurrence were 5.8% with a mean follow-up observation of 4.29 years, and the carcinoma-specific 4-year actuarial survival was 84%. The rate of recurrence was highest in the lowest segment level of the rectum (7.6 as compared to 2.4%, P=0.042). The rates of local recurrence were 7.4% in period I and 4.3% in period II (P=0.44). The carcinoma-specific 4-year actuarial survivals were 81% in period I and 87% in period II (P=0.202). Investigation of the subgroups of irradiated patients showed complete freedom from recurrence after a mean follow-up observation time of 3.58 years for patients in stage uT3 with total mesorectal excision, preoperative radiotherapy and postoperative chemotherapy (n=51). The difference from patients without postoperative chemotherapy was significant (P=0.018). After radiotherapy, the complication observed was a raised rate of sacral cavity infections after total resection of the rectum (p=0.039). Conclusion. Total mesorectal excision, preoperative radiotherapy and postoperative chemotherapy can effectively influence the rate of local recurrences after rectal carcinoma operations (0–4.3% after a mean period of follow-up observation of 3.58 years). No appraisal can be made with regard to the benefit resulting from the individual measures.     

Neoadjuvant Radiotherapy for Rectal Cancer: Meta-analysis of Randomized Controlled Trials

Background

Although neoadjuvant radiotherapy may improve local control of rectal cancer, its clinical value requires further evaluation as a result of potential side effects and advances in surgical technique. A meta-analysis was performed to assess effectiveness and safety of neoadjuvant radiotherapy in the management of rectal cancer.

Methods

The following databases were searched: the Cochrane Library, Biosis, Web of Science, Embase, ASCO Abstracts and WHO International Clinical Trials Registry Platform. Randomized controlled trials on the following comparisons were included: (1) neoadjuvant therapy versus surgery alone and (2) neoadjuvant chemoradiotherapy versus neoadjuvant radiotherapy.

Results

We identified 17 and 5 relevant trials that enrolled 8,568 and 2,393 patients, respectively. Neoadjuvant radiotherapy improved local control (hazard ratio 0.59; 95 % confidence interval 0.48–0.72) compared to surgery alone even after total mesorectal excision, whereas its benefit in overall survival just failed to reach statistical significance (0.93; 0.85–1.00). However, it was associated with increased perioperative mortality (1.48; 1.08–2.03), in particular if a dose of 5 Gy per fraction was administered (1.85; 1.23–2.78). Chemoradiotherapy improved local control as opposed to radiotherapy (0.53; 0.39–0.72), with no impact on perioperative outcome and long-term survival.

Conclusions

Neoadjuvant radiotherapy improves local control in patients with rectal cancer, particularly when chemoradiotherapy is administered. The question if the use of more effective chemotherapy protocols improves overall survival warrants further investigation.     

Extraskeletal myxoid chondrosarcoma: a review of 23 patients treated at a single referral center with long-term follow-up

Background

Extraskeletal myxoid chondrosarcoma (EMC) is a rare soft tissue sarcoma. Although it has been regarded as a low-grade sarcoma unassociated with tumor-related death, a recent study has suggested an insidious nature with a high propensity for relapse during a long disease course. The aim of this study was to clarify the long-term clinical features of EMC treated at a single referral center using state-of-the-art techniques.

Methods

A retrospective review of 23 consecutive patients (10 males, 13 females; mean age 58?years) treated between 1979 and 2008 (mean follow-up; 109?months) was performed.

Results

Surgery for the primary tumor was performed in 22 patients, and 7 cases recurred locally due to inadequate resection. Eleven patients had metastatic disease, either at diagnosis (3) or developing later (8). The 5/10-year overall survival rates were 91/84?%, and the 5/10-year local recurrence-free and metastasis-free survival rates for patients with localized disease were 89/62 and 89/61?%, respectively. Larger tumor size (>10?cm) and metastases at diagnosis were significant negative prognostic factors. Four patients received ifosfamide-based chemotherapy with no objective response. There was no local recurrence in three patients who underwent R1 resection followed by adjuvant radiotherapy. Clinical palliation and retarded progression of the metastatic disease were achieved in three patients who underwent radiotherapy.

Conclusions

EMC is indolent but has a high propensity for relapse over 5?years of follow-up. Definitive initial surgery and careful monitoring for a prolonged period are important. Radiotherapy seems beneficial in an adjuvant setting and as palliative therapy for metastatic disease.     

Timing of Surgery and the Role of Adjuvant Radiotherapy in Ewing Sarcoma of the Chest Wall: A Single-institution Experience

Background

Ewing sarcoma (ES) is the most common chest wall malignancy in adolescents. Current therapy incorporates chemotherapy to treat systemic disease and radiotherapy to assist with local control. We sought to evaluate the timing of surgery and role of adjuvant radiotherapy.

Methods

We reviewed the St. Jude Children??s Research Hospital chest wall ES experience from 1979 to 2009. Patient demographics, tumor characteristics, treatment variables, and outcomes were analyzed with respect to timing of surgery and use of adjuvant radiotherapy.

Results

Our cohort consisted of 36 patients with chest wall ES; median follow-up was 14.2?years, and 15-year estimate of overall survival was 66?%. In patients with localized disease, the timing of surgery (up-front vs. delayed) did not impact margin negativity or the use of adjuvant radiotherapy, but it did decrease the extent of chest wall resection. When considering radiotherapy in patients with localized disease, we found that patients who did not receive radiotherapy had smaller tumor size (median 6 vs. 10?cm) (p?=?0.04) and were more likely to have had negative margins (p?=?0.01) than patients who received adjuvant radiotherapy. One patient in each group developed a locoregional recurrence. The 15-year estimated of overall survival for patients who received adjuvant radiotherapy was 80 versus 100?% for those who did not.

Conclusions

Delayed surgery decreased the extent of chest wall resection and helped define a patient population with favorable tumor biology. Patients with complete pathologic responses to chemotherapy, and those with tumors <8?cm and negative surgical margins may be spared adjuvant radiotherapy without any decrement in overall survival.     

Desmoid Tumor: Analysis of Prognostic Factors and Outcomes in a Surgical Series

Background

Desmoid tumors are rare and exhibit a highly unpredictable natural history. We sought to analyze prognostic factors associated with recurrence in a large single-institution study of patients with desmoid tumors.

Methods

We performed a retrospective review of 177 patients with desmoid tumor who underwent macroscopically complete surgical resection, with or without the addition of radiotherapy (RT) or systemic therapy, from 1970 to 2009. We examined patterns of presentation, all known risk factors for recurrence, and their association with recurrence-free survival (RFS).

Results

Twenty-two patients (12?%) had intra-abdominal desmoid tumors, and 155 (88?%) had extra-abdominal tumors. Patterns of presentation included primary (n?=?133, 75?%) and locally recurrent (n?=?44, 25?%) disease. Treatment was surgery alone in 125 patients (71?%), surgery and RT in 36 (20?%), and surgery and systemic therapy with or without RT in 20 (11?%). Median follow-up was 40?months. Overall, the local relapse rate was 29?%, and 10-year RFS was 60?%. R0 resection status was the only predictor of freedom from local recurrence on multivariate analysis (odds ratio 0.32; 95?% confidence interval 0.15?C0.66; P?=?0.002). The selective use of adjuvant RT appeared to improve local control in patients with positive margins.

Conclusions

For patients with desmoid tumors undergoing surgery, wide excision with negative margins should be the goal, but not at the expense of function, as fewer than half of patients with positive margins will experience recurrence.     

The Diagnosis and Surgical Treatment of Pancreatoblastoma in Adults: A Case Series and Review of the Literature

Introduction

Pancreatoblastoma is an extremely rare pancreatic neoplasm in adults. The aim of this study is to report our experience with adult pancreatoblastoma as well as review the cases reported in the literature in order to provide guidelines for the management of patients with this rare neoplasm.

Methods

We have encountered three cases of pancreatoblastoma in adults at our institution in addition to the 30 cases reported to date in literature.

Results

The median age of pancreatoblastoma in adults is 37 years (range, 18–78 years); men and women are similarly affected (male/female = 16/17). The behavior of pancreatoblastoma is clearly that of a malignant neoplasm, with local invasion, recurrence, and metastasis. Among the adult reported cases, at diagnosis or operation, metastasis and/or local invasion was found in 14 of 31 adult patients (46 %) (2 patients had no data) The survival was significantly higher in patients with resected tumor (resection only and resection + adjuvant chemo/radiotherapy) when compared to unresected patients (palliative chemo/radiotherapy and no treatment), (p = 0.008, HR = 0.20).

Conclusion

When disease is localized, the treatment of choice is a complete surgical resection. The role of adjuvant chemotherapy or radiotherapy is still unclear based on the very small number of patients treated.     

Recurrence after transanal endoscopic microsurgery for large rectal adenomas

Background

Transanal endoscopic microsurgery (TEM) has revolutionized the technique and outcome of transanal surgery, becoming the standard of treatment for large sessile rectal adenomas. Nevertheless, only a few studies have evaluated the risk factors for local recurrence in order to recommend a “tailored” approach. The aim of this study was to identify predictor variables for recurrence after TEM to treat rectal adenoma.

Methods

This study is a retrospective analysis of a prospective database of patients treated for large sessile rectal adenomas by TEM at our institution, with a minimum follow-up of 12?months. Age, gender, tumor diameter, distance from the anal verge, degree of dysplasia, histology, and margin involvement were investigated.

Results

Between January 1993 and July 2010, 293 patients with a rectal adenoma ≥3?cm underwent TEM. Postoperative morbidity rate was 7.2?% (21/293) and there was no 30-day mortality. Over a median follow-up period of 110 (range?=?12–216) months, 13 patients (5.6?%) were diagnosed with local recurrence. The median time to recurrence was 10 (range?=?4–33) months, with 76.9?% of recurrences detected within 12?months after TEM. At univariate analysis, tumor diameter (p?=?0.007), and positive margins (p?p?=?0.003).

Conclusions

TEM provides excellent oncological outcomes in the treatment of large sessile benign rectal lesions, assuring a minimal risk of resection margin infiltration at pathology examination, which represents the only risk factor for recurrence.     

Preoperative chemoradiotherapy in patients with rectal cancer - 3D conformal external beam radiotherapy (EBRT)

Aim — Background

In local advanced rectal cancer at clinical stages IIa-IIIc, chemoradiotherapy precedes total mesorectal resection. If there is a high risk of local recurrence or an attempt to convert a transabdominal resection to intervention for sphincter preservation, preoperative combined chemoradiotherapy with 3D conformal external beam radiotherapy and concurrent chemotherapy is recommended; this can downstage an unresectable cancer to one that is resectable.

Objectives — Methods

Twelve patients with stage IIa-IIIc rectal cancer received preoperative 3D conformal EBRT and chemotherapy. Three patients received four cycles of adjuvant chemotherapy with bolus 5-FU 225mg/m2, continuous infusion during the first and fifth weeks of radiotherapy, and nine patients were treated with Capecitabine 825mg/m2 twice daily, per os (tb xeloda) 5 days/week. CT-simulation equation and 3D conformal treatment planning was performed during the days of radiotherapy with 5-FU(iv 225mg/m2). The total dose was 50.4 Gy of 1.8 Gy/Fr in 28 fractions daily, from Monday to Friday. The pelvis was first irradiated with 25Fr of 45 Gy followed by boost therapy in the tumour mass region with continuous infusions (= complementary tumour dose) of a total dose of 5.4 Gy in 3 fractions, using a linear accelerator with MLC-multileaf collimator. This ensures protection of the organs at risk near the tumour mass, such as the bladder, small bowel, and femur heads.

Results

At 20–30 day follow-up after completion of radiotherapy, nine patients were considered suitable for sphincter preservation surgical intervention. Toxicity was Grade I. Only one patient interrupted radiotherapy because of 5-FU toxicity. In two patients, MRI of the pelvis after chemoradiotherapy showed non-conventional images for sphincter preservation intervention.

Conclusions

Preoperative 3D conformal EBRT, combined with chemotherapy, 5-FU or Capecitabine per os (tb xeloda), in patients with rectal cancer at stages IIa-IIIc, proved a very good therapeutical approach. In this way, it was possible to downstage an unresectable tumour mass into one that was resectable. It is also allowed greater possibilities of sphincter preservation, with minimum toxicity, thereby improving the quality of life in these patients.     

Influence of Intraoperative Radiotherapy (IORT) on Perioperative Outcome after Surgical Resection of Rectal Cancer

Background

Intraoperative radiotherapy (IORT) for locally advanced or recurrent rectal cancer as an integral part of multimodal treatment might be an option to reduce local cancer recurrence. The aim of the present study was to determine the influence of IORT on the postoperative outcome and complications rates in the treatment of patients with adenocarcinoma of the rectum in comparison to patients with rectum resection only.

Methods

A total of 162 patients underwent operation for International Union against Cancer stage III/IV rectal cancer or recurrent rectal cancer at our surgical department between 2004 and 2012. They were divided into two groups depending on whether they received IORT or not. General patient details, tumor, and operation details, as well as perioperative major and minor complications, were registered and compared.

Results

Of the 162 patients treated for stage III/IV rectal cancer, 52 underwent rectal resection followed by IORT. Complication rates were similar in the two groups. Operative time was significantly longer in the IORT group (248 ± 84 vs 177 ± 68 min; p < 0.001). No significant differences were found concerning anastomotic leakage rate, hospital stay, or wound infection rate.

Conclusions

Intraoperative radiotherapy appears to be a safe treatment option in patients with locally advanced or recurrent rectal cancer with acceptable complication rates. The effect on local recurrence rate has to be estimated in long-term follow-up.     

Prognostic Factors for Locoregional Recurrences in Colon Cancer

Background

There is increased interest in locoregional recurrences of rectal cancer. Despite comparable locoregional recurrence rates in colon cancer, only a few studies on locoregional recurrences among colon cancer patients have been published. This study was designed to identify prognostic factors for locoregional recurrences among patients with colon cancer in the Netherlands.

Methods

The study population was composed of patients who underwent radical surgical resections for invasive colon carcinoma, diagnosed in three regions of the Netherlands from 2000 to 2003. The Kaplan-Meier method was used to calculate 5-year locoregional recurrence rates (LRR). Conditional hazard rates were estimated by the life-table method. Multivariate Cox regression analyses were performed to identify prognostic factors and to calculate a Locoregional Recurrence Risk Score (LRRS).

Results

In total 127 of 2,282 patients developed locoregional recurrences within 5?years (LRR 6.4%). The risk of developing a locoregional recurrence was highest at 0.5?C1?year after surgery. Patients with left-sided tumors, T3-T4 tumors, and positive lymph nodes and those who did not receive adjuvant chemotherapy were more likely to develop locoregional recurrences. Four risk groups based on the LRRS were defined. Five-year LRR was 2.5% for the very low-risk group and 25.1% for the high-risk group.

Conclusions

Although the locoregional recurrence rate in this study was relatively low, it remains a considerable problem. Identifying individual patients who might benefit from adjuvant chemotherapy may reduce the locoregional recurrence rate.     

Preoperative Treatment Does Not Improve the Therapeutic Results of Abdominosacral Amputation of the Rectum

Background

This study reviewed the impact of preoperative chemoradiotherapy/short-term radiotherapy on abdominosacral amputations of the rectum (ASAR) for the treatment of low-rectum cancers in terms of postoperative morbidity, local recurrence rates, and survival.

Methods

A total of 198 patients with stage II and III tumors located within 6?cm of the anorectal junction underwent ASAR between 1998 and 2008 and were selected for further analysis. Patients were compared according to the following groups: those who had surgery only (Group A) and those who had preoperative chemoradiotherapy/short-term radiotherapy (Group B).

Results

There were 44 and 154 patients in Groups A and B, respectively, including 135 males. The median age of the subjects was 63?years (range?=?35–88). The median follow-up period was 81?months (range?=?23–138). Neither the local recurrence rates (6.8% in Group A vs. 4.6% in Group B, p?=?0.544) nor the 5-year relative survival rates (72.4% in Group A vs. 69.3% in Group B, p?=?0.127) differed significantly between the groups.

Conclusion

Preoperative therapy in low-rectum cancer does not improve the therapeutic results of ASAR.     

Is Restaging with Chest and Abdominal CT Scan after Neoadjuvant Chemoradiotherapy for Locally Advanced Rectal Cancer Necessary?

Background

There is no evidence regarding restaging of patients with locally advanced rectal cancer after a long course of neoadjuvant radiotherapy with or without chemotherapy. This study evaluated the value of restaging with chest and abdominal computed tomographic (CT) scan after radiotherapy.

Methods

Between January 2000 and December 2010, all newly diagnosed patients in our tertiary referral hospital, who underwent a long course of radiotherapy for locally advanced rectal cancer, were analyzed. Patients were only included if they had chest and abdominal imaging before and after radiotherapy treatment.

Results

A total of 153 patients who met the inclusion criteria and were treated with curative intent were included. A change in treatment strategy due to new findings on the CT scan after radiotherapy was observed in 18 (12 %) of 153 patients. Twelve patients (8 %) were spared rectal surgery due to progressive metastatic disease.

Conclusions

Restaging with a chest and abdominal CT scan after radiotherapy for locally advanced rectal cancer is advisable because additional findings may alter the treatment strategy.     

Combined Modality Therapy for Rectal Cancer: The Relative Value of Posttreatment Versus Pretreatment CEA as a Prognostic Marker for Disease Recurrence

Purpose

To evaluate the prognostic significance of the first postsurgery carcinoembryonic antigen (CEA) level in patients with locally advanced rectal cancer treated with neoadjuvant chemoradiation (nCRT) and total mesorectal excision.

Methods

A total of 100 patients underwent nCRT and had baseline and posttreatment CEA levels recorded within 6?months of surgery. The median radiotherapy dose was 50.4?Gy. Eighty-six patients received adjuvant 5-fluorouracil-based chemotherapy. Prognostic factors were analyzed for possible associations with freedom from failure (FFF) by univariate and multivariate analyses. Median follow-up was 30?months.

Results

The median CEA (ng/ml) levels at baseline before nCRT, after nCRT, and after total mesorectal excision were 3.6, 1.7, and 1.3, respectively. Pathologic complete response was observed in 22%. FFF at 36?months was 78%. Local failure and distant failure occurred in 4 and 20% of the patients, respectively. On univariate analysis, pathologic complete response, margin status, and both pretreatment and postsurgery CEA levels were associated with recurrence (all P?P?P?P?=?0.003), but not baseline CEA level (P?=?0.2), were found to be associated with recurrence.

Conclusions

After nCRT for rectal cancer, postsurgery CEA level may have more prognostic value than pretreatment level. Patients with a postsurgery CEA level of >2.5?ng/ml have higher rates of recurrence and may warrant closer surveillance.