三维适形放射治疗结合化疗治疗直肠癌术后复发疗效观察

目的 探讨三维适形放射治疗结合化疗治疗直肠癌术后复发的疗效。方法 回顾性分析56例直肠癌术后复发患者采取三维适形放射治疗(2Gy／次,5次／周,总剂量66～68Gy,6～7周完成)结合化疗(5-氟尿嘧啶0．75g／m^2,d1-5和d29-33;顺铂40mg／m^2,d1-3和d29-31)的疗效,生存分析采用Kaplan-Meier法。结果 患者1、2、3年肿瘤局部控制率分别为87．5％、66．1％、38．2％;1、2、3年生存率分别为88．3％、66．8％、44．2％,中位生存期25．3个月;1、2、3年无瘤生存率分别为82．7％、56．6％、30．1％。急性放射反应主要是急性放射性肠炎,多为1～2级。无晚期放射反应发生。结论 三维适形放射治疗结合化疗是治疗直肠癌术后复发的有效治疗方法。     

Preoperative chemotherapy and radiotherapy for locally advanced rectal cancer

BACKGROUND: The adjuvant treatment of rectal cancer is a rapidly evolving field. The standard approach is a combination of chemotherapy and radiotherapy, with the optimal treatment combination and sequencing yet to be determined. Here, we report our early experience of preoperative chemotherapy and radiotherapy (CRT) in locally advanced rectal cancer at Radiation Oncology Victoria to determine its efficacy and the rate of sphincter preservation. METHODS: Sixty-nine patients (46 men and 23 women) with locally advanced rectal cancer (T3-4 or N1) were treated with preoperative CRT followed by surgical resection of disease. Chemotherapy consisted of either bolus or continuous venous infusion of 5-fluorouracil (5-FU). Radiotherapy to a dose of 45 Gy was delivered to the pelvis followed by a boost of 5.4-14.4 Gy in the majority of patients. Surgical resection was carried out 4-8 weeks following completion of preoperative CRT. Univariate and multivariate analyses were performed to examine variables that may influence local recurrence and overall survival rates. RESULTS: All patients underwent a complete macroscopic resection, including the three patients that had unrecognized distant metastases discovered at the time of operation. Only two patients had microscopic residual disease. Sphincter preservation was achieved in 16 of 25 patients who were thought to require an abdominoperineal resection. Tumour and/or nodal downstaging were achieved in 47 patients (68%), with a pathological complete response in 12 (17%). At a median follow up of 29 months post-surgery, five patients (7.2%) have developed a local recurrence. Overall 21 patients (30%) have progressed and 12 (18%) have died. Treatment-related toxicity was acceptable and there was no treatment-related mortality. There was no significant relationship found between the pathological response to treatment and any clinical endpoint. CONCLUSIONS: Our results confirm the high response rates and acceptable toxicity of preoperative treatment. Further studies are required to better define the impact of preoperative chemotherapy and radiotherapy on long-term outcomes.     

T4-Rektumkarzinom Operative und multimodale Therapie

BACKGROUND: In locally advanced rectal cancer with infiltration of neighbouring organs (uT4), resectability and local control are difficult to achieve. Combined preoperative radiochemotherapy may result in increased resectability and reduced local recurrence rates. PATIENTS AND METHODS: Thirty-four patients with biopsy-proven locally advanced rectal cancer were treated by preoperative radiochemotherapy. All tumours had been staged as uT4 lesions by endorectal ultrasound or computed tomography. Radiotherapy was applied in standard blocks, 5 x 1.8 Gy up to 45 Gy. Chemotherapy consisted of two cycles of 5-fluorouracil (300-350 mg/m2/day) and leucovorin (50 mg). In 20 patients, additional thermotherapy was carried out using the Sigma 60 applicator BSD 2000 once a week prior to radiotherapy. Surgery was performed 4-6 weeks after radiochemotherapy. Postoperatively, all patients received four cycles of 5-fluorouracil and leucovorin. RESULTS: Treatment-induced toxicity occurred in 26% of the patients (WHO grade III (n = 6) and IV (n = 3)). The resectability rate was 76% (26/34 patients) (R0 resectability n = 21; 62%). The pathological complete response rate was 6% (n = 2) and the partial response rate was 47% (n = 16). A local failure was observed in six patients after median time of 16 months (range 7-36 months). Patients with R0 resection achieved a 5-year disease-free survival rate of 55% and a survival rate of 71%. The overall 5-year survival rate for all patients with advanced uT4 rectal cancer was 49%. CONCLUSIONS: Our data on preoperative combined treatment in locally advanced T4 rectal cancer revealed encouraging downstaging, local control, and survival rates.     

术前,术后放疗的直肠癌治疗中作用的评估和比较

目的：评估和比较辅助性术前、术后放疗在直肠癌治疗中的作用。方法：１９８８年２月～１９９５年２月收治经病理证实的直肠癌１７６例,配合手术分别采用术前单次放疗、术前常规放疗和术后放疗。术前单次放疗组３８例,剂量为５Ｇｙ,并于放疗后４８ｈ内手术;术前４０Ｇｙ常规放疗组４３例,多为临床晚期（Ｔ３～４占６０．５％）,中位剂量４０Ｇｙ,放疗后休４周再行手术;术后放疗组９５例,以病变晚期和淋巴结阳性为主（Ｔ３～４占６２．１％,Ｔ２～４Ｎ＋占８１．１％）,采用中位剂量５４Ｇｙ常规分割,疗程约６周,手术后３～４周开始接受放疗。结果：全部病例平均随访８４个月,Ｋａｐｌａｎ－Ｍｅｉｅｒ法计算生存率。术前单次放疗组３年、５年局部复发率分别为７８．９％和５０．０％,常规术前４０Ｇｙ放疗组为６７．４％和５１．１％;术后放疗组为５８．９％和     

A Simplified Tumor Regression Grade Correlates with Survival in Locally Advanced Rectal Carcinoma Treated with Neoadjuvant Chemoradiotherapy

Background  Locally advanced rectal cancer is frequently treated with neoadjuvant chemoradiotherapy to reduce local recurrence and possibly improve survival. The tumor response to chemoradiotherapy is variable and may influence the prognosis after surgery. This study assessed tumor regression and its influence on survival in patients with rectal cancer treated with chemoradiotherapy followed by curative surgery. Methods  One hundred twenty-six patients with locally advanced rectal cancer (T3/T4 or N1/N2) were treated with chemoradiotherapy followed by total mesorectal excision. Patients received long-course radiotherapy (50 Gy in 25 fractions) in combination with 5-flourouracil over 5 weeks. By means of a standardized approach, tumor regression was graded in the resection specimen using a 3-point system related to tumor regression grade (TRG): complete or near-complete response (TRG1), partial response (TRG2), or no response (TRG3). Results  The 5-year disease-free survival was 72% (median follow-up 37 months), and 7% of patients had local recurrence. Chemoradiotherapy produced downstaging in 60% of patients; 21% of patients experienced TRG1. TRG1 correlated with a pathological T0/1 or N0 status. Five-year disease-free survival after chemoradiotherapy and surgery was significantly better in TRG1 patients (100%) compared with TRG2 (71%) and TRG3 (66%) (P = .01). Conclusion  Tumor regression grade measured on a 3-point system predicts outcome after chemoradiotherapy and surgery for locally advanced rectal cancer.     

直肠癌术后局部复发综合治疗的疗效分析

目的：分析直肠癌根治术后局部复发的类型、综合治疗的疗效及预后。方法：对直肠癌术后局部复发、以往未接受过放疗的66例病人进行疗效分析。原手术方式为经腹直肠切除术45例(Dixon术40例，Parks术5例)，腹会阴直肠切除术21例。经腹直肠切除术后复发以吻合口为主(37／45，82．2％)，腹会阴直肠切除术后复发则以盆腔或会阴为主(19／21，90．5％)。复发后盆腔放疗中位剂量为40(20—64）Gy，临床症状缓解中位剂量26(10～52)Gy。其中26例在放疗过程中或之后接受过中位7个(2～12)疗程以5-FU为主的化疗。有22例放疗后获补救手术机会。结果：全组中位生存期24个月。Kaplan-Merier法计算生存率，放疗后1、3年总生存率分别为72．2％、17．9％。单因素分析并Log rank检验生存率差异，显示生存率与原发病变的期别、术后复发时间、复发部位及是否加用化疗无关，而仅与是否再次行补救手术有关。放疗后加用补救手术者3年生存期明显较长，为36．0％比8．8％(P=0．016)。结论：直肠癌根治术后局部复发者，放疗具有良好的姑息减症的作用；对部分经腹直肠切除术后的复发病例，放射治疗加补救手术能明显延长生存期。     

Preoperative radiotherapy as adjuvant treatment in rectal cancer. Final results of a randomized study of the European Organization for Research and Treatment of Cancer (EORTC).

A randomized clinical trial was conducted by the European Organization for Research and Treatment for Cancer (EORTC) Gastrointestinal Cancer Cooperative Group to study the effectiveness of irradiation therapy administered in a dosage of 34.5 Gy, divided into 15 daily doses of 2.3 Gy each before radical surgery for rectal cancer (T2, T3, T4, NX, MO). Four hundred sixty-six patients were entered in the clinical trial between June 1976 and September 1981. Tolerance and side effects of preoperative irradiation were acceptable. The overall 5-year survival rates were similar in both groups. When considering only the 341 patients treated by surgery with a curative aim, the 5-year survival rates were 59.1% and 69.1% in the control group and in the combined modality group, respectively (p = 0.08). The local recurrence rates at 5 years were 30% and 15% in the control group and the adjuvant radiotherapy group, respectively (p = 0.003). Although this study did not show preoperative radiotherapy to have a statistically significant benefit on overall survival, it does have a clear effect on local control of rectal cancer. Therefore, before performing radical surgery, this adjuvant therapy should be administered to patients who have locally extended rectal cancer.     

Total pelvic exenteration with preoperative irradiation for advanced primary and recurrent rectal cancer.

OBJECTIVE: To study the complication rate, local recurrence rate, and survival after total pelvic exenteration for primary advanced and recurrent rectal cancer. DESIGN: Prospective study. SETTING: Tertiary referral university hospital, Norway. SUBJECTS: 25 patients who were operated on for primary advanced and 22 for recurrent rectal cancer since 1991; 42 men and 5 women, mean age 64 years (range 44-78). All had preoperative irradiation of 46-50 Gy. MAIN OUTCOME MEASURES: Incidence of major complications, and actuarial 5-year survival and local recurrence rate. RESULTS: Twenty patients had RO resection in the primary group versus seven in the recurrent group. No R2 resections were done in the primary group compared with four in the recurrent group. Half the primary cases (n = 13) had abdominoperineal resections. Hartmann's procedures were common in both groups (n = 8 in each). Postoperative mortality at 30 days was 4% (n = 2) and in-hospital 13% (n = 6). 18 patients had major complications and 12 were reoperated on. Overall 5-year actuarial survival for 43 patients without distant metastases was 28%-those with primary tumours 36%, and those with recurrent tumours 18%-similar to the figures for RO and R1 resections. Actuarial local recurrence at 5 years for primary cancers was 18% compared with 68% for recurrent cancers, again nearly identical to the figures for R0/R1 operations (p = 0.008 and p = 0.03). CONCLUSION: Some patients with advanced rectal cancer either primary or recurrent may benefit from simultaneous en-bloc cystectomy. The higher postoperative morbidity and mortality indicate the need for well-defined indications for this procedure and the necessity for thorough preoperative staging.     

新辅助放化疗在局部进展期低位直肠癌中的疗效

目的探讨新辅助放化疗对局部进展期低位直肠癌的治疗效果。方法2001年5月至2005年8月共收治105例局部进展期（T3、T4期）低位直肠癌患者,术前给予中等剂量放疗40—46Gy,分次剂量2Gy／d,每周5d,共4—5周完成放疗;放疗开始同时给予卡培他滨1250mg·m^-2·d^-1,分2次I=I服,持续服用至手术。放疗结束后休息6周进行手术,手术均按直肠系膜全切除操作规范进行。结果全组105例患者均按计划完成预定的放化疗。其中36例出现各种不良反应,但Ⅲ级不良反应仅见2例手足综合征。13例患者放化疗后经复查后提示肿瘤消失未行手术。其余92例患者则施行了根治性手术,其中低位前切除术71例,结肠肛管吻合术（Parks术）17例,腹会阴切除术4例,全组总保肛率为96．2％。术后标本病理检查显示11例未见癌细胞及阳性淋巴结。肿瘤TNM分期为TON0者24例,T2N0者23例,BNo者43例,T4N0者2例,T2N1者5例,T3N1者8例;按Dworak肿瘤消退分级,TGR05例,TGR129例,TGR247例,TGR324例。全组共有82例（78．1％）达到降期。全组无手术死亡,术后出现3例直肠阴道漏,2例吻合口漏。所有患者均获随访,随访时间为16—67个月。随访期间肺转移4例,肝转移2例,局部复发4例,其中3例死亡。全组病死率为2．9％,3年无瘤生存率为82．8％,3年总生存率为96．5％。结论新辅助放化疗可有效达到肿瘤降期的目的,提高了局部进展期低位直肠癌的根切率和保肛率,进一步降低了局部复发率和总复发率,并明显提高了无瘤生存率和总生存率。     

Surgery and pre-operative irradiation for locally advanced or recurrent rectal cancer in patients over 75 years of age

OBJECTIVE: Reports of multimodal treatment regimens especially focusing on locally advanced or recurrent rectal cancer in the elderly, aged>75 years, are unavailable. We have tried to identify and evaluate pre- and peri-operative risk factors for morbidity and mortality and outcome after irradiation/surgery regimens in such patients. PATIENTS AND METHODS: Prospective registration of 86 consecutive patients aged>75 years undergoing elective surgery after irradiation 46-50 Gy for either primary locally advanced rectal cancer (n=51) or recurrent rectal cancer (n=35) from January 1991 to August 2003, 51 men and 35 women, median age 78 years (range 75-85 years) in a national cancer hospital. RESULTS: Multivisceral resections were needed in 63% of patients and 70% R0 resections were obtained in locally advanced cases and 46% in recurrent ones. Both in-hospital- and 30-day-mortality was 3.5%. Sixty-two postoperative complications occurred in 38 patients, three of them fatal. Both operation times over 5 h and transfusion of more than 3 SAG were prognostic factors regarding infections. Estimated five-year survival in R0 patients was 46%. Estimated five-year survival for patients with nonmetastatic tumours with locally advanced primary cancer was 29% and for locally recurrent rectal cancer 32%. Old males had a higher mortality rate the first year after surgery than females with only 65% relative survival compared to a matched normal population. The estimated five-year local recurrence rates were 24% for R0 resections and 54% for R1 resections (P=0.434 ns) and 24% and 45% for locally advanced and recurrent rectal cancer (P=0.248 ns), respectively. CONCLUSION: Thorough pre-operative evaluation and preparation and judicious surgery are important for achieving potentially curative treatment with acceptable morbidity in locally advanced and recurrent rectal cancer in patients over 75 years of age. We suggest that these patients should be evaluated and considered for treatment by multidisciplinary teams as younger patients.     

Use of adjuvant,preoperative chemo-radiotherapy in patients with locally advanced rectal cancer

Background: The objective of this study was to perform a non‐randomised prospective examination of the efficacy of adjuvant, preoperative chemo‐radiotherapy in patients with locally advanced rectal cancer. Methods: Between 1996 and 2001, patients presenting with biopsy‐proven, locally advanced, rectal cancers within 12 cm of the anal verge were referred for a long course of adjuvant chemo‐radiotherapy prior to their surgery. Locally advanced lesions were defined by either: (i) endoanal ultrasound showing at least full thickness penetration of the rectal wall (i.e. T3, T4); (ii) abdominal computed tomography scan showing infiltration of adjacent structures, or; (iii) clinical examination demonstrating a fixed lesion. All patients were followed through the hospital colorectal unit. A Kaplan?Meier survival analysis was used to determine survival and local recurrence rates. Results: There were 60 patients with a mean age of 61.5 years (range 33?77 years) with a sex distribution of males to females of 1.7?1.0. Curative resections were performed in 81% of these patients. The remainder (n = 12) were found to have either metastatic disease at operation (n = 5), inoperable disease (n = 2), or had positive resection margins on histology (n = 7). The mean follow up was 2.1 years (maximum 5.1 years). The overall 2‐year survival rate was 86.1% (95% CI ±5.4%). In patients undergoing curative resections, the overall 2‐year survival rate was 91.4% (95% CI ±4.8%), and the 2‐year disease free survival rate was 85.1% (95% CI ±6.2%). The 2‐year local recurrence rate was 7.5%. Conclusions: The use of adjuvant, preoperative, chemo‐radiotherapy in patients with locally advanced rectal cancer is associated with high short‐term survival and a low recurrence rate.     

Preoperative chemoradiation therapy and anal sphincter preservation with locally advanced rectal adenocarcinoma

Preoperative irradiation has been used to produce tumor regression and allow complete resection of rectal cancer with a sphincter-saving procedure. To evaluate the associated toxicity, the response in the primary tumor, and the postsurgical morbidity in a group of patients with locally advanced rectal cancer treated with preoperative chemoradiation therapy and low anterior resection, 120 patients were treated with 45 Gy of preoperative radiotherapy and a bolus infusion of 5-fluorouracil 450 mg/m² on days 1 to 5 and 28 to 32 of radiotherapy. Four to six weeks later, 16 lesions were found unresectable; 36 patients underwent abdominoperineal resection or pelvic exenteration, and in the remaining 68 a low anterior resection was performed. For the purpose of this study only the latter group was included. There were 38 men and 30 women, with a mean age of 54.7 ± 13.1 years. Gastrointestinal and hematologic acute toxicity grade 3 to 4 occurred in 12 and 7 patients, respectively. The mean distance of the tumor above the anal verge was 8.2 ± 2.6 cm. In 10 patients the surgical resection included neighboring pelvic organs; 16 patients (23.5%) required a temporary diverting colostomy. The main causes of surgical morbidity were clinical anastomotic leakage in seven (10%), abdominal wall infection in five (7.4%), anastomotic stenosis in three (4.5%), and intraabdominal abscess in one (1.5%). No operative deaths occurred. The postsurgical stages were as follows: no tumor in the specimen, 17 (25%); T1, 4 (6%); T2, 12 (17%); T3, 17 (25%); T4, 5 (7%); any T with N+, 9 (13%); and any T, N with M+, 4 (6%). The median and mean follow-ups were 30.0 months and 37.4 ± 25.0 months, respectively. The local recurrence rate was 2.9%, and the distant recurrence rate was 17%. The administration of preoperative chemoradiation therapy for locally advanced rectal cancer is associated with tolerable toxicity, a high rate of response in the primary tumor that allowed anal sphincter preservation, and a low rate of local recurrence.     

The TME trial after a median follow-up of 6 years: increased local control but no survival benefit in irradiated patients with resectable rectal carcinoma

OBJECTIVE: To investigate the efficacy of preoperative short-term radiotherapy in patients with mobile rectal cancer undergoing total mesorectal excision (TME) surgery. SUMMARY BACKGROUND DATA: Local recurrence is a major problem in rectal cancer treatment. Preoperative short-term radiotherapy has shown to improve local control and survival in combination with conventional surgery. The TME trial investigated the value of this regimen in combination with total mesorectal excision. Long-term results are reported after a median follow-up of 6 years. METHODS: One thousand eight hundred and sixty-one patients with resectable rectal cancer were randomized between TME preceded by 5 x 5 Gy or TME alone. No chemotherapy was allowed. There was no age limit. Surgery, radiotherapy, and pathologic examination were standardized. Primary endpoint was local control. RESULTS: Median follow-up of surviving patients was 6.1 year. Five-year local recurrence risk of patients undergoing a macroscopically complete local resection was 5.6% in case of preoperative radiotherapy compared with 10.9% in patients undergoing TME alone (P < 0.001). Overall survival at 5 years was 64.2% and 63.5%, respectively (P = 0.902). Subgroup analyses showed significant effect of radiotherapy in reducing local recurrence risk for patients with nodal involvement, for patients with lesions between 5 and 10 cm from the anal verge, and for patients with uninvolved circumferential resection margins. CONCLUSIONS: With increasing follow-up, there is a persisting overall effect of preoperative short-term radiotherapy on local control in patients with clinically resectable rectal cancer. However, there is no effect on overall survival. Since survival is mainly determined by distant metastases, efforts should be directed towards preventing systemic disease.     

Is pre‐operative radiotherapy necessary in T1‐T3 rectal cancer with TME?

OBJECTIVE: The indications for pre-operative radiotherapy in rectal cancer are still unclear with the exception of T4 tumours. The aim of this study was to assess local and overall recurrence in patients with T1-T3 rectal cancers undergoing total mesorectal excision (TME). METHODS: Prospective data was collected from 150 patients with rectal cancer treated in one surgical centre between July 1997 and July 2002. One hundred and twenty-nine primary resections were carried of which 102 were with curative intent. Seventy-nine patients with T1-T3 tumours were included in the analysis. Nine had local resections and 70 underwent TME; 19 of the 70 patients were node positive and 51 were node negative. RESULTS: At a median follow-up of 37 months (range 19-79 months) there were 3 (4.3%) isolated local recurrences. One node positive patient developed isolated local recurrence compared with 2 node negative patients. The node positive patient died from a myocardial infarction while the two node negative patients died as a consequence of local recurrence. Three (4.3%) of 70 patients developed systemic relapse all of whom were node positive. The cancer specific mortality rate over the same follow-up period was 3/19 for node positive patients and 2/51 for node negative patients. Of 9 patients who had local resections, none developed local recurrence or systemic relapse. CONCLUSIONS: With TME the rate of local recurrence in T1-T3 tumours is low. Our results do not support the use of pre-operative radiotherapy for these patients.     

Long-term results of local excision for rectal cancer

OBJECTIVE: To review the authors' experience with local excision of early rectal cancers to assess the effectiveness of initial treatment and of salvage surgery. SUMMARY BACKGROUND DATA: Local excision for rectal cancer is appealing for its low morbidity and excellent functional results. However, its use is limited by inability to assess regional lymph nodes and uncertainty of oncologic outcome. METHODS: Patients with T1 and T2 adenocarcinomas of the rectum treated by local excision as definitive surgery between 1969 to 1996 at the authors' institution were reviewed. Pathology slides were reviewed. Among 125 assessable patients, 74 were T1 and 51 were T2. Thirty-one patients (25%) were selected to receive adjuvant radiation therapy. Fifteen of these 31 patients received adjuvant radiation in combination with 5-fluorouracil chemotherapy. Median follow-up was 6.7 years. One hundred fifteen patients (92%) were followed until death or for greater than 5 years, and 69 patients (55%) were followed until death or for greater than 10 years. Recurrence was recorded as local, distant, and overall. Survival was disease-specific. RESULTS: Ten-year local recurrence and survival rates were 17% and 74% for T1 rectal cancers and 26% and 72% for T2 cancers. Median time to relapse was 1.4 years (range 0.4-7.0) for local recurrence and 2.5 years (0.8-7.5) for distant recurrence. In patients receiving radiotherapy, local recurrence was delayed (median 2.1 years vs. 1.1 years), but overall rates of local and overall recurrence and survival rates were similar to patients not receiving radiotherapy. Among 26 cancer deaths, 8 (28%) occurred more than 5 years after local excision. On multivariate analysis, no clinical or pathologic features were predictive of local recurrence. Intratumoral vascular invasion was the only significant predictor of survival. Among 34 patients who developed tumor recurrence, the pattern of first clinical recurrence was predominantly local: 50% local only, 18% local and distant, and 32% distant only. Among the 17 patients with isolated local recurrence, 14 underwent salvage resection. Actuarial survival among these surgically salvaged patients was 30% at 6 years after salvage. CONCLUSIONS The long-term risk of recurrence after local excision of T1 and T2 rectal cancers is substantial. Two thirds of patients with tumor recurrence have local failure, implicating inadequate resection in treatment failure. In this study, neither adjuvant radiotherapy nor salvage surgery was reliable in preventing or controlling local recurrence. The postoperative interval to cancer death is as long as 10 years, raising concern that cancer mortality may be higher than is generally appreciated. Additional treatment strategies are needed to improve the outcome of local excision.     

Short-course preoperative radiation therapy for operable rectal cancer

BACKGROUND: Short course neoadjuvant radiation has been shown to provide improved local control of rectal cancer in a clinical trial population even in the presence of standardized surgical techniques. However, this use of hypofractionated radiotherapy has been limited in North America owing to concerns over toxicity.METHODS: Patients considered to have locally advanced rectal carcinoma received a radiation dose of 25 Gy given in five fractions to the posterior pelvis. Definitive surgery was then performed within 2 weeks. Retrospective analysis was performed. RESULTS: Sixty-three patients, of whom 60 were assessable, were treated with preoperative short course radiotherapy at the British Columbia Cancer Agency between 1991 and 1998, and 97% proceeded to R0 resection. Local recurrence developed in 3 patients (5%). Five-year actuarial overall and relapse-free survival rates for the group were 71% and 69%, respectively. The actuarial rates of relapse-free survival by stage at 5 years were stage 1 83%, stage II 75%, stage III 62%, and stage 4 0%. Eleven patients (18%) experienced a postoperative complication.CONCLUSION: Short course preoperative radiotherapy for operable rectal cancer can be delivered to a general population and produce high pelvic control rates with acceptable toxicity.     

Effect of Adjuvant Radiotherapy on Local Recurrence in Stage II Rectal Cancer

Background Prospective trials have demonstrated that chemotherapy combined with radiotherapy decreases local recurrence rates in stage II and stage III rectal cancer. Some patients with stage II lesions, however, have relatively low risks of local recurrence. We evaluated the effect of radiotherapy on local recurrence in patients with stage IIA rectal cancer. Methods From the colorectal cancer database, we identified 390 stage IIA rectal cancer patients who underwent curative resection followed by adjuvant therapy from 1995 to 2002; a total of 72 patients who received preoperative chemoradiotherapy and who did not receive adjuvant therapy were excluded. Mean follow-up period was 65 months (range, 2–133 months). Results Of the 390 patients, 110 had primary tumors in the upper rectum, 136 in the midrectum, and 144 in the lower rectum. Lymphovascular invasion was observed in 35 patients (9.0%). Mean (± SD) number of examined lymph nodes was 18 (± 12). Adjuvant chemotherapy was provided to 180 patients (46.2%), and chemotherapy plus radiotherapy was provided to 210 patients (53.8%). Radiotherapy was significantly more common in younger patients (P = .01) and those with lower rectal cancer (P < .001). Local recurrence rate did not differ between patients who did and did not receive radiotherapy. In patients with mid and lower rectal cancer, the local recurrence rate was not affected by radiotherapy. Conclusions Radiotherapy did not seem to provide additional benefit in decreasing local recurrence rate of stage IIA rectal cancers. In selected patients, however, the role of radiotherapy needs to be carefully evaluated.     

低位直肠癌术前放化疗或单纯放疗加前切除术与Miles手术远期疗效对比

目的分析局部进展期低位直肠癌术前放化疗加前切除术或术前放疗加前切除术与Miles手术的远期效果。方法157例低位直肠癌患者为1983年1月至2000年12月收治,原发肿瘤距肛门中位距离6.1cm,临床分期Ⅱ期69例,Ⅲ期88例(TNM,UICC)。放疗方法为术前直线加速器的盆腔四野照射,35～45Gy/4～5周;化疗方法为以氟尿嘧啶为主的联合化疗。予以术前放、化疗加前切除术52例(A组);术前单纯放疗加前切除术51例(B组);单纯Miles手术54例(C组)。对全部患者的临床资料和随访结果进行回顾性分析。结果本组随访率91.7%。5年生存率A组71.1%,B组47.1%,C组42.6%;A组明显高于B和C组(P<0.05)。无瘤生存率A组61.5%,B组37.3%,C组35.2%;A组仍明显高于B和C组(P<0.05)。局部复发率A组13.5%,B组15.7%,C组11.1%;3组之间差异无统计学意义(P>0.05)。远处转移率(包括局部复发加远处转移)A组23.1%,B组49.0%,C组46.3%;A组明显低于B和C组(P<0.05)。但B组与C组的差异无统计学意义(P>0.05)。结论术前放、化疗加前切除手术治疗低位直肠癌的方法可改善5年生存率和无瘤生存率,降低远处转移率。     

Value of Extended Resection and Intraoperative Radiotherapy for Resectable Pancreatic Cancer

Since 1984 intraoperative radiotherapy (IORT) combined with extended resection for pancreatic cancer has been performed in our clinic to prevent local recurrence. Following extended resection, a dose of 30 Gy of 9- to 12-MeV electrons is administered to the operative field, including the paraaortic area from the diaphragm above to the inferior mesenteric artery below. The 5-year survival rate was 15.3% in all 37 cases, 20.2% in patients who had macroscopic tumor clearance, and 16.9% in patients with stage IVa tumor according to the Japanese classification. In autopsies of 10 patients who underwent combined therapy, four had local recurrence enclosed by thick, firm connective tissue. There was no local control recurrence in two patients who underwent noncurative resection. Enhanced local control induced by the combined therapy, however, has only a limited impact on overall survival because of the systemic spread of disease, especially hepatic metastases. At present, as we have no effective treatment for hepatic metastases, it is important to perform an extended resection with IORT on carefully selected patients. The combined therapy may offer the best approach to control local recurrence when dealing with advanced, but not highly advanced, cancer as defined by the stage of tumor. Therefore a combination of IORT and extended resection can have an impact on the results of surgical treatment for pancreatic cancer when anticancer treatment of hepatic metastases is established.     

Radical resection of rectal cancer primary tumor provides effective local therapy in patients with stage IV disease

Background The optimal use of radical surgery to palliate primary rectal cancers presenting with synchronous distant metastases is poorly defined. We have reviewed stage IV rectal cancer patients to evaluate the effectiveness of radical surgery without radiation as local therapy. Methods Eighty stage IV patients with resectable primary rectal tumors treated with radical rectal surgery without radiotherapy were identified. Sixty-one (76%) patients received chemotherapy; response information was available for 34 patients. Results Radical resection was accomplished by low anterior resection (n=65), abdominoperineal resection (n=11), and Hartmann’s resection (n=4). Surgical complications were seen in 12 patients (15%), with 1 death and 4 reoperations. The local recurrence rate was 6% (n=5), with a median time to local recurrence of 14 months. Only one patient received pelvic radiotherapy as salvage treatment. One patient required subsequent diverting colostomy. Median survival was 25 months. On multivariate analysis, the extent of metastasis and response to chemotherapy were determinants of prolonged survival. Conclusions For patients who present with distant metastases and resectable primary rectal cancers, radical surgery without radiotherapy can provide durable local control with acceptable morbidity. The extent of metastatic disease and the response to chemotherapy are the major determinants of survival. Effective systemic chemotherapy should be given high priority in the treatment of stage IV rectal cancer.