Prognostic factors in limited rectal cancer treated with intracavitary irradiation

At the Centre Georges-Fran?ois Leclerc of Dijon, 91 limited rectal tumors received a complete intracavitary 50 kV contact radiotherapy alone or associated with interstitial brachytherapy according to the guidelines of J. Papillon. Nineteen had a villous adenoma and 72 a well or moderately differentiated rectal adenocarcinoma. The majority of patients had contra-indications for major surgical procedures. The median age was 70 years. Seventy-six percent (69/91) of the rectal tumors remained free from local recurrence. After salvage therapy, the local control was 91% (83/91). Sphincter preservation was obtained in 85% (77/91). "De novo" adenocarcinomas developed on pre-existing benign pathology and villous adenomas were not significantly different with regard to local control (76% resp. 75% versus 59.5%; p = 0.22). According to the Dijon clinical staging system, the local relapse-free survival at 5 years was 97% for CS T1A, 77% for CS T1B, 65% for CS T2A, and 60% for CS T2B. Tumors of the anterior rectal wall had a better local control rate than lateral and posterior primaries (100% versus 63% versus 67%). For the middle rectum, the local relapse-free survival was 94% compared to 54% of the upper and 77% of the lower rectum. Four additional patients had a preoperative intracavitary therapy and salvage surgery for incomplete tumor regression; the complete remission rate is 96% (91/95). Intracavitary radiotherapy alone is an effective treatment for limited rectal cancers. Contact X ray therapy can be used alone in CS T1A whereas a combination of contact X ray therapy and interstitial brachytherapy is often the optimal approach in CS T1B and CS T2A. In CS T2B, our data do not support the use of intracavitary techniques alone. In these cases, the sequence external irradiation followed by an interstitial implant seems of interest and deserves further evaluation with more patients and follow-up.     

低位直肠癌术前同步放化疗的远期疗效及安全性研究

目的评估术前口服卡培他滨（希罗达）与放疗联合治疗局部进展期低位直肠癌的远期疗效及安全性。方法对局部进展期（T3／T4）低位直肠腺癌（距肛缘≤9Ccm）患者51例,术前给予口服卡培他滨（希罗达）并联合放疗。放疗结束后休息3—4周,按TME原则进行手术。结果3例患者临床完全消退（cCR）,占5．88％,未行手术;其余48例患者均行根治性切除术（R0）,实际保肛率90．20％（46／51）,10例术后病理检查未见肿瘤细胞,为病理消退（pCR）,总消退率为25．49％（13／51）。肿瘤降期41例,占80．39％。5年无病生存率为70．59％,总生存率为80．39％。放化疗过程中出现3、4级不良反应5例,无疾病进展、手术死亡者。结论术前口服卡培他滨联合放疗治疗局部进展期低位直肠癌是有效安全的。     

Sphincter and rectal preservation approaches for early stage distal rectal cancers

In rectal cancer, the problem of sphincter preservation is of increasing interest. This paper is a review of recent data regarding sphincter preservation. Randomized trials give the best evidence of any improvement in sphincter preservation. Such trials have been performed for T3 and T2 rectal cancers. For T2-3 rectal tumors immediate surgery after preoperative radiotherapy or the addition of chemotherapy to radiotherapy did not improve the chance of sphincter preservation. Only dose escalation with endocavitary contact x-ray and delayed surgery was able to achieve a 30% increase in sphincter preservation. Ongoing clinical research is exploring the role of preoperative chemoradiotherapy in early T2 (T3) rectal cancers combined with local excision. This approach is of special interest in elderly patients. Sphincter preservation is a very complex issue in rectal cancer requiring great clinical experience to select properly the patients to perform the optimal treatment.     

Clinical predictors of upgrading to Gleason grade 4 or 5 disease at radical prostatectomy: potential implications for patient selection for radiation and androgen suppression therapy

BACKGROUND: To determine the local control, survival, and functional outcome of local excision plus postoperative therapy for patients with rectal cancer. METHODS: A total of 39 patients underwent a local excision (2 with snare excision of a T1 polyp and 37 with full-thickness local excision) followed by postoperative radiation therapy +/- 5-FU-based chemotherapy. The median follow-up was 41 months, and 11 patients had positive margins. RESULTS: The 5-year actuarial colostomy-free survival was 87% and overall survival was 70%. Crude local failure increased with T stage: 0% T1, 24% T2, and 25% T3. Of the 8 patients (21%) who developed local failure, 5 underwent salvage APR and were locally controlled. Actuarial local failure at 5 years was 31% for T2 disease and 27% for the total patient group. In the 32 patients with an intact sphincter, 94% had good to excellent sphincter function. CONCLUSION: Although local failure in patients with T2 tumors has increased since our prior report, the survival, sphincter function, and local salvage rates are acceptable. Local excision and postoperative therapy remains a reasonable alternative to APR in selected patients.     

肿瘤浸润淋巴细胞对直肠癌术前放疗预后的影响

目的 探讨直肠痛肿瘤组织内术前放疗后浸润淋巴细胞(TIL)数量改变对预后的影响.方法 搜集近8年余接受30 Gy分10次12 d完成的术前放疗的直肠癌患者107例,分析TIL分级与术前放疗后病理消退程度及预后关系.结果 直肠癌放疗前TIL 1级75例,2级16例,3级16例,4级0例,术前放疗后TIL 1级19例,2级43例,3级35例,4级10例.放疗后病理消退分级1级36例,2级57例,3级14例.单因素分析发现放疗前及放疗后TIL对局部病理消退影响有统计学意义(X2=36.80,P<0.01;X2=14.00,P<0.01);术前放疗后癌巢内TIL及病理消退对预后影响显著(X2=24.00,P<0.01;X2=12.17,P<0.01).Logistic多元分析提示放疗后TIL与病理消退关系密切(X2=8.05,P<0.01).结论 放疗前及放疗后TIL与直肠癌术前放疗局部病理消退相关.直肠癌术前放疗后癌巢TIL是影响生存预后的因素之一.     

Tumor downstaging and sphincter preservation with preoperative chemoradiation in locally advanced rectal cancer: the M. D. Anderson Cancer Center experience

Purpose: To evaluate the rates of tumor downstaging after preoperative chemoradiation for locally advanced rectal cancer.

Materials and Methods: Preoperative chemoradiotherapy (CTX/XRT) that delivered 45 Gy in 25 fractions over 5 weeks with continuous infusion 5-fluorouracil (300 mg/m²/day) was given to 117 patients. The pretreatment stage distribution, as determined by endorectal ultrasound (u), included uT2N0 in 2%, uT3N0 in 47%, uT3N1 in 49%, and uT4N0 in 2% of cases; endorectal ultrasound was not performed in 13% of cases (15 patients). Approximately 6 weeks after completion of CTX/XRT, surgery was performed.

Results: The pathological tumor stages were Tis-2N0 in 26%, T2N1 in 5%, T3N0 in 21%, T3N1 in 15%, T4N0 in 5%, and T4N1 in 1%; a complete response (CR) to preoperative CTX/XRT was pathologically confirmed in 32 (27%) of patients. Tumor downstaging occurred in 72 (62%) cases. Only 3% of cases had pathologic evidence of progressive disease. Pretreatment tumor size (< 5 cm vs. ≥ 5 cm) was the only factor predictive of tumor downstaging (p < 0.04). A decrease of >1 T-stage level was accomplished in 45% of those downstaged. Overall, a sphincter-saving (SP) procedure was possible in 59% of patients and an abdominoperineal resection (APR) was required in 41% of cases. Factors predictive of SP included downstaging (p < 0.03), age > 40 years (p < 0.007), pretreatment tumor distance, 3 to 6 cm from the anal verge (p < 0.00001), tumor size <6 cm (p < 0.02), mobility (p < 0.004), tumor stage p < 0.01), and uN negative (p < 0.008). SP was performed in 23 patients (72%) with a CR and in 48 (67%) of downstaged cases. Among the 69 tumors located < 6 cm from the anal verge, 29 (42%) were resected with a SP. The level of response was important for tumors located < 6 cm from the anal verge because a SP was performed in 9 of the 17 (53%) CRs in this group while only 20 of 52 patients (38%) had a SP when residual disease was present after CTX/XRT. For tumors located > 6 cm from the anal verge, SP was performed in 14 of the 15 (93%) patients with a CR and 32 of 33 (97%) of patients with residual disease (p < 0.00004).

Conclusions: Significant tumor downstaging results from preoperative chemoradiation allowing sphincter sparing surgery in over 40% of patients whose tumors were located < 6 cm from the anal verge and who otherwise would have required colostomy.     

The Dijon clinical staging system for early rectal carcinomas amenable to intracavitary treatment techniques

The Dijon clinical and endoscopic staging system for intracavitary radiotherapy of rectal cancer takes into account the size and the depth of penetration of the rectal wall. Its prognostic value was evaluated in a series of 72 patients with rectal adenocarcinoma treated at the Centre de Lutte Contre le Cancer G. F. Leclerc in Dijon: 30 presented with a clinical stage (CS) T1A (purely exophytic tumors of less than 3 cm). The 5-year local relapse-free actuarial survival (LRFS) was 97%. Fourteen patients with CS T1B (infiltrative component and less than 3 cm diameter) had a LRFS of 77%. Nine patients with CS T2A tumors (with larger exophytic tumors) has a LRFS of 65%. Nineteen CS T2B cases (larger than 3 cm with an infiltrative component) presented a LRFS of 60%. The size of the tumor and the clinical estimate of the infiltration of the rectal wall both have a significant prognostic value: adenocarcinoma of less than 3 cm (n = 44) had a LRFS of 93% versus 59% in larger ones (n = 39; p = less than 0.01). Free mobile lesions (n = 39) did better (n = 33; LRFS = 86%) than infiltrated tumors (n = 33; LRFS = 66%; p = 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)     

Conservative Management of Anal and Rectal Cancer: The role of radiation therapy

The role of irradiation in the management of anal and rectal cancer has changed during the past ten years. in small epidermoid carcinomas of the anal canal (T1 T2) irradiation is in most departments considered the primary treatment, giving a 5-year survival rate of between 60 and 80% with good sphincter preservation. Even in larger tumors, irradiation can still offer some chance of cure without colostomy. Surgery remains the basic treatment of rectal cancer but irradiation is used in association with surgery in many cases. Radiotherapy is of value in the conservative management of cancer of the rectum in three situations; in small polypoid cancers contact x-ray therapy can give local control in about 90%. in cancers of the middle rectum, preoperative external irradiation may increase the chances of restorative surgery and reduce the risk of local relapse. in inoperable patients, external radiotherapy and/or intracavitary irradiation may cure some patients with infiltrating tumors (T2 T3) without colostomy.     

局部晚期低位直肠癌术前同步放化疗的疗效观察

目的 探讨术前同步放化疗治疗局部晚期低位直肠癌的安全性和有效性.方法 对临床分期属T3/T4低位直肠癌患者分为A组和B组.A组28例患者,给予术前放疗,同步口服卡培他滨.B组26例患者直接给予手术.结果 A组和B组根治术率分别为82.1％和50.0％ (P ＜0.01),保肛率分别为64.3％和26.9％ (P＜0.0...     

Local excision and postoperative radiotherapy for distal rectal cancer

To assess the outcome following local excision and postoperative radiotherapy (RT) for distal rectal carcinoma.

Seventy-three patients received postoperative radiotherapy following local surgery for primary rectal carcinoma at Princess Margaret Hospital from 1983 to 1998. Selection factors for postoperative RT were patient preference, poor operative risks, and “elective” where conservative therapy was regarded as optimal therapy. Median distance of the primary lesion from the anal verge was 4 cm (range, 1–8 cm). There were 24 T1, 36 T2, and 8 T3 lesions. The T category could not be determined in 5. Of 55 tumor specimens in which margins could be adequately assessed, they were positive in 18. RT was delivered using multiple fields by 6- to 25-MV photons. Median tumor dose was 50 Gy (range, 38–60 Gy), and 62 patients received 50 Gy in 2.5-Gy daily fractions. The tumor volume included the primary with 3–5 cm margins. No patients received adjuvant chemotherapy. Median follow-up was 48 months (range, 10–165 months).

Overall 5-year survival and disease-free survival were 67% and 55%, respectively. Tumor recurrence was observed in 23 patients. There were 14 isolated local relapses; 6 patients developed local and distant disease; and 3 relapsed distantly only. For patients with T1, T2, and T3 lesions, 5-year local relapse-free rates were 61%, 75%, and 78%, respectively, and 5-year survival rates were 76%, 58%, and 33%, respectively. The 5-year local relapse-free rate was lower in the presence of lymphovascular invasion (LVI) compared to no LVI, 52% vs. 89%, p = 0.03, or where tumor fragmentation occurred during local excision compared to no fragmentation, 51% vs. 76%, p = 0.02. Eleven of 14 patients with local relapse only underwent abdominoperineal resection, 8 achieved local control, and 4 remained cancer free. The ultimate local control, including salvage surgery, was 86% at 5 and 10 years. The 5-year colostomy-free rate was 82%. There were 2 patients who experienced RTOG Grade 3 late complications, and 1 with Grade 4 complication (bowel obstruction requiring surgery).

The local relapse rate for patients with T1 disease was high compared to other series of local excision and postoperative RT. Patients with LVI or tumor fragmentation during excision have high local relapse rates and may not be good candidates for conservative surgery and postoperative RT.     

Results of definitive irradiation in a series of 305 epidermoid carcinomas of the anal canal

PURPOSE: To evaluate our data concerning the prognostic factors for locoregional control, survival, late complications, and sphincter conservation in a series of epidermoid cancers of the anal canal without clinical evidence of metastasis. METHODS AND MATERIALS: Between June 1972 and January 1997, 305 patients were treated with curative-intent radiotherapy (RT). The T stage according to the 1987 International Union Against Cancer classification was T1 in 26, T2 in 141, T3 in 104, and T4 in 34. Forty-nine patients had nodal involvement at presentation. The pretreatment anal function score, according to our in-house system, was 0 for 22 patients, 1 for 182, 2 for 74, 3 for 7, and 4 for 11 patients; for 9 patients, scores were unavailable. The treatment started with external beam radiotherapy (EBRT) in 303 patients (median dose 45 Gy). After a rest period of 4-6 weeks, a boost of 20 Gy was delivered by EBRT in 279 patients and by interstitial (192)Ir brachytherapy in 17 patients. Seven patients received only one course of EBRT (mean dose 49.5 Gy), and 2 patients were treated with interstitial (192)Ir brachytherapy alone (55 Gy and 60 Gy). Concomitant chemotherapy (5-fluorouracil and either mitomycin C or cisplatin) was delivered to 19 patients. The mean follow-up was 103 months (median 84). RESULTS: At the end of RT, the local tumor clinical complete response rate was 96% for T1, 87% for T2, 79% for T3, and 44% for T4. Of the 61 locally progressive tumors, 27 (44%) were salvaged with abdominoperineal resection. The rate of local tumor relapse was 12%. Among 37 local tumor relapses, 20 (54%) were salvaged with abdominoperineal resection and one with interstitial (192)Ir brachytherapy. The overall local control rate (with or without salvage local therapy) was 84%. The local control rate with good anal function (score 0 or 1) was 56.5%. Of 181 available patients with their anus preserved, 94% had good anal function. For a subgroup of 15 patients with a tumor length of <2 cm and without nodal involvement, the clinical complete response rate after RT completion was 100%, the local control rate with or without local salvage treatment was 100%, and among 13 available patients with their anus preserved, the anal function score was good in 12 patients (92%). The 10-year disease-free survival rate was 74%. After multivariate analysis, three independent predictive factors significantly influenced disease-free survival: the interval between the two courses of RT (>38 days vs. < or =38 days, p = 0.0025), pretreatment anal function score (0 vs. 1 vs. 2 vs. 3 vs. 4, p = 4.4.10(-6)), and clinical complete response after RT completion (no complete response vs. complete response, p = 2.5.10(-14)). CONCLUSION: We confirm the excellent results with RT in T1 and T2 lesions. However, to improve survival without colostomy with good anal sphincter function, chemoradiotherapy should be preferred for tumors > or =2 cm in length and for locally advanced tumors.     

High dose preoperative radiation and sphincter preservation in the treatment of rectal cancer

Abdominoperineal resection and permanent colostomy have been the mainstay of treatment for rectal cancer. Automatic stapling devices have widened the scope of low anterior resection, permitting sphincter preservation for tumors originating in the upper and middle thirds of the rectum. Attempts at sphincter preservation in low rectal cancer has resulted in higher recurrence in the pelvic/perineal tissues (41%, MSKCC). In 1976, we undertook a study to expand the scope of sphincter preservation in patients with rectal cancer. Patients were selected because of the presence of unfavorable tumors or low level of rectal area (3 and 6 cm from the dentate line). Forty-three patients were treated in this program. Follow-up ranges from 24 to 96 months, with a median follow-up of 36 months. Fifteen patients were selected for unfavorable tumor types and 28 patients were selected for low level of tumor, between 3 and 6 cm. Twenty of the 28 patients with low level tumors also had unfavorable tumors. All patients received the full course of preoperative radiation (4000 to 4500 cGy in 5 weeks). Surgery was carried out 4 to 6 weeks following radiation and consisted of a sphincter saving procedure, usually by combined abdominotranssacral resection. There was no perioperative mortality. A single anastomotic breakdown required reconstruction. Thirteen patients in this group have died, 9 of these with disease and 3 without evidence of tumor. There were 6 (14%) local recurrences in the pelvic/perineal area. Survival of all patients at 4 years is 66%. This early experience indicates that the high dose preoperative radiation can minimize local recurrence in unfavorable cancers and allows sphincter saving surgery to be performed with small, safe margins in the lower rectal cancers.     

Squamous cell carcinoma of the anal canal: treatment by external beam irradiation

External beam radiation therapy alone or in combination with curietherapy is the recommended treatment for anal canal carcinoma in some countries. In others, surgery is the sole accepted treatment. The results for 64 patients treated by external radiotherapy alone show excellent survival for stage T1T2 tumors but results are poor for large tumors (stage T4). The overall 5 year crude survival rate is 46%. The 5-year results are better for stage T1T2 (72%) than for stage T3T4 (35%). The presence of inguinal node involvement at first examination is a very poor prognostic sign. Local recurrences and metastases are infrequent for stage T1T2, but are more common for stage T3 and T4. Complications follow radiotherapy more frequently in those with stage T3 and T4 tumors. The analysis of local recurrences, complications and survival shows that radiation therapy may be sufficient treatment for stage T1 and T2 and for some stage T3 tumors. The importance of anal sphincter involvement and the poor quality of life for patients who are cured but develop complications, shows the need for combined treatment with surgery and perhaps with chemotherapy. For small tumors the results obtained by external radiotherapy alone are comparable with those obtained by external radiotherapy and curietherapy in terms of survival and complications.     

N0期食管鳞癌术后预防性放疗价值探讨

目的 评价N0期食管鳞癌术后预防性放疗价值.方法 分析1993年1月至2006年12月我院收治的食管癌术后病理诊断证实鳞癌、无淋巴结转移及远处转移的N0期患者859例,其中单纯手术760例,术后放疗99例.术后3～4周开始放疗,放疗中位总剂量50 Gy,分25次,2 Gy/次,5次/周,5周完成.结果 5年生存率手术组和术后放疗组分别为72.2%和77.4%(x2=0.13,P>0.05).分层分析术后放疗较单纯手术可提高pT4期及病变长度>5cm的生存率,5年生存率分别为67.1%对34.6%(x2=7.72,P<0.05)和81.3%对70.2%(x2=4.01,P<0.05),并能降低pT4期瘤床复发率.结论 N0期食管鳞癌术后预防性放疗可明显提高pT4期及病变长度>5cm的生存率和降低pT4期瘤床复发率.     

影响低位直肠癌局部切除选择的因素分析

目的探讨低位直肠癌局部切除选择的影响因素。方法回顾性分析101例局部切除治疗低位直肠癌患者的临床资料。Kaplan-Meier法计算生存率,并对预后进行单因素及多因素分析。结果经肛门切除91例,经骶骨切除9例,经阴道切除1例,并发症发生率为5.9%,全组无手术死亡病例。术前放疗5例,术后放疗34例。5年生存率为91.0%,Tis、T1、T2及T3或T4病变的5年生存率分别为100%、92.6%、77.1%和83.3%;局部复发率为15.8%。单因素分析显示,肿瘤的侵袭深度、直径>3 cm、有脉管瘤栓、溃疡型癌、放射治疗和局部复发与预后有关(P<0.05)。多因素分析显示,肿瘤直径>3 cm、局部复发是影响预后最重要的因素(P<0.05)。结论低位直肠癌病理为高中分化、直径≤3 cm、无脉管瘤栓的T1病变及原位癌,是局部切除术的合理适应证。     

Response to preoperative chemoradiation increases the use of sphincter-preserving surgery in patients with locally advanced low rectal carcinoma

BACKGROUND: Although controversial, some believe that preoperative chemoradiation increases the use of sphincter-preserving surgery in low rectal carcinoma patients. This article investigates the relationship between objective tumor response and sphincter preservation in low rectal carcinoma patients. METHODS: The authors reviewed the records of 238 patients with T3 or T4 low rectal carcinoma (< or = 6 cm from the anal verge) who underwent preoperative pelvic chemoradiation (45 Gy/25 fractions/5 weeks, n = 182 or 52.5 Gy/30 fractions/5 weeks, n = 56 with continuous infusion 5-fluorouracil at 300 mg/m(2), Monday to Friday) followed by mesorectal (n = 223) or local excision (n = 15). A logistic regression analysis was used to analyze the influence of objective tumor response (defined as complete clinical response) and other prognostic factors on sphincter preservation. Because degrees of partial response could not be objectively defined retrospectively, the influence of partial response on sphincter preservation could not be evaluated. RESULTS: Overall, 49% of patients (117 of 238) had sphincter-preserving surgery. The clinical complete response rate was 47%. Independent predictors of sphincter preservation included the year of surgery, tumor distance from the anal verge, circumferential tumor involvement, and response to chemoradiation. The sphincter preservation rate increased over the period of the study (from 28% [December 1989 to December 1992] to 44% [January 1993 to December 1996] to 67% [January 1997 to December 2000]). The difference in the rates of sphincter preservation according to response was most striking among patients with tumors 3 cm or less from the anal verge (44% vs. 22%, P = 0.01). The pelvic disease recurrence rate among patients undergoing sphincter-preserving surgery has been less than 10% since January 1993 and was not statistically different between the groups treated from January 1993 to December 1996 and from January 1997 to December 2000. CONCLUSIONS: There has been an increase in the use of sphincter-preserving surgery without an increase in pelvic disease recurrence over the past decade. Although not necessary for sphincter preservation, clinical response to preoperative chemoradiation independently contributed to sphincter-preserving surgery, particularly in patients with low rectal tumors.     

Treatment of T1-T2 rectal tumors by contact therapy and interstitial brachytherapy.

BACKGROUND AND PURPOSE: We retrospectively analysed our experience of contact therapy alone and/or combined with interstitial brachytherapy as exclusive treatment of low lying rectal tumours. PATIENTS AND METHODS: From 1971 to 2001, 124 patients (103 adenocarcinomas, 21 villous tumours) were treated by contact therapy alone or combined with interstitial brachytherapy. All patients were staged according to the Dijon classification. The average size of the lesions was 2.4 cm (max 7 cm), clinical aspect was polypo?d in 75% of the cases, flat in 17%. Sixty four patients received contact therapy in three fractions and 44 patients received four fractions, for an average delivered dose of 95 Gy. Interstitial brachytherapy boost delivered 24 Gy on a reference isodose of 55 cGy/h in 10 patients. RESULTS: The local control was 83% for T1 and 38% for T2 tumours (p=0.004). For mobile tumours, the local control rate is 76%, significantly higher than for tumours with impaired mobility (55%, P=0.03). Thirty-nine patients experienced a local failure (31%). For patients amenable to surgery, a Miles procedure was performed in 25 patients. Ultimate local control rate is 93% for T1, 69% for T2 (P<0.05), 15 patients failed despite treatment for local recurrence (15%). No significant differences were observed in a comparison of adenocarcinoma and villous tumours according to initial and ultimate local control. The mean disease free survival rate for the whole population is 66 months. The 5-year disease free survival for T1a and T1b is, respectively, 82 and 78%, 40 and 25% for T2a and T2b, respectively. The overall 5-year survival for the whole group is 62.4%. At the end of the treatment, 75% of the patients described a very good sphincter function. No deleterious effect on continence was reported during the follow-up. CONCLUSIONS: The control rate for T1 rectal cancer treated with contact therapy with or without brachytherapy is comparable to surgical series. The sphincter was preserved in 80% of the patients. Radiotherapy remains an efficient and cheap alternative to surgery, mainly for old and fragile patients, or refusing colostomy. The results of these approaches for tumors larger than 3 cm (T2) are not satisfactory. For patients not amenable to surgery, external beam radiation therapy and/or combined modality with chemoradiation should be discussed to increase the loco-regional control rate. A careful selection of patients based on rectal examination and trans-rectal ultrasound could select more accurately patients amenable to such an approach.     

根治术后盆腔复发直肠癌疗效及预后因素分析

目的 分析直肠癌根治术后盆腔复发规律以及放疗疗效和影响预后的因素.方法 回顾分析2000-2006年直肠癌根治术后盆腔复发接受放疗患者93例,分别为单纯放疗21例、放化疗56例、放疗结合手术和(或)化疗16例.放疗采用60Co或加速器X线,中位剂量59.4Gy,其中90例采用常规分割技术.68例患者放疗后接受了1～8个(中位数3个)疗程化疗,42例行同步放化疗,多为氟尿嘧啶为主的化疗方案.16例患者在放疗后接受了复发灶切除术,其中RO切除7例,姑息性肿块切除9例.结果 全组共132处复发,常见复发部位为直肠周围(31.8%)和骶前区(30.3%),髂外淋巴结和腹股沟淋巴结少见(1.5%和3.0%).总随访率为92%,随访满2、5年者分别为39、4例.有局部症状的84例患者中83%(70例)放疗后症状缓解.全组2、5年局部无进展率分别为49%、22%,2、5年生存率分别为46%、14%.多因素分析结果显示复发后治疗方法是影响直肠癌根治术后复发的局部无进展率的独立预后因素,复发灶最大径、无病间期、放疗后有无远处转移是影响直肠癌根治术后复发患者生存率的独立顶后因素.结论 直肠周围区、骶前区、髂内淋巴结区是直肠癌主要复发部位;放疗可明显改善直肠癌根治术后盆腔复发患者的症状和提高生存质量,放疗联合手术和(或)化疗可提高直肠癌根治术后复发的局部无进展率,复发灶直径＞5 cm、无病间期＜2年、放疗后有远处转移是影响预后的因素.     

Phase I/II trial of capecitabine, oxaliplatin, and radiation for rectal cancer.

PURPOSE: The purpose of this study was to establish the feasibility and efficacy of preoperative radiotherapy (RT) with concurrent capecitabine and oxaliplatin (XELOX-RT) in patients with rectal cancer. PATIENTS AND METHODS: Thirty-two patients with locally advanced (T3/T4) or low-lying rectal cancer received preoperative RT (total dose, 50.4 Gy). Capecitabine was administered concurrently at 825 mg/m2 bid on days 1 to 14 and 22 to 35, with oxaliplatin starting at 50 mg/m2 on days 1, 8, 22, and 29 with planned escalation steps of 10 mg/m2. End points of the phase II study included downstaging, histopathologic tumor regression, resectability of T4 disease, and sphincter preservation in patients with low-lying tumors. RESULTS: Dose-limiting grade 3 gastrointestinal toxicity was observed in two of six patients treated with 60 mg/m2 of oxaliplatin. Thus, 50 mg/m2 was the recommended dose for the phase II study. Toxicities observed at this dose level were generally mild, with only two cases of short-lived grade 3 diarrhea. Myelosuppression, mainly leukopenia, was restricted to grade 2 in 19% of patients. T-category downstaging was achieved in 17 (55%) of 31 operated patients, and 68% of patients had negative lymph nodes. Pathologic complete response was found in 19% of the resected specimens. Radical surgery with free margins could be performed in 79% of patients with T4 disease, and 36% of patients with tumors < or = 2 cm from the dentate line had sphincter-saving surgery. CONCLUSION: Preoperative XELOX-RT is a feasible and well tolerated treatment. This regimen is proposed for phase III evaluation comparing standard fluorouracil-based therapy with XELOX chemoradiotherapy.     

Primary Radiotherapy for Glottic Laryngeal Carcinoma Stage I and Ii A Retrospective Study with Special Regard to Failure Patterns

A retrospective study has been made of 302 patients with vocal cord carcinoma stage I and II treated between 1963 and 1983, emphasizing treatment failure patterns. the primary treatment modalities were radiotherapy for 266 patients and surgery for 36 patients. the minimum follow-up was 4 years. After primary radiotherapy there were 63 local recurrences and 7 neck lymph node recurrences, all appearing outside the target volume. the actuarial loco-regional recurrence-free rates at 5 years were 78% for Tl, 76% for T2a (normal cord mobility) and 60% for T2b (imparied cord mobility) tumors. the actuarial regional lymph node recurrence-free rates at 5 years were 99, 100 and 93% for T1, T2a and T2b tumors respectively. the actuarial corrected survivals at 5 years were 95, 96 and 79% for T1, T2a and T2b tumors with primary radiotherapy and salvage surgery for recurrence. Salvage surgery was less successful in T2b compared to T1 and T2a tumors. in conclusion, after primary radiotherapy with salvage surgery the loco-regional control rate was high and very similar for glottic cancer T1 and T2a but less satisfactory for T2b tumors. Regional lymph node metastases were not a large problem in any of the subgroups. More effective radiotherapy with higher dose levels or an altered fractionation might increase the local control rate for T2 tumors with impaired cord mobility.