三维适形放疗治疗直肠癌术后复发病例临床观察

目的：观察三维适形放疗治疗直肠癌术后复发病例的疗效。方法：选择直肠癌术后复发患者54例接受三维适形放疗，其中低分化腺癌4例，中分化腺癌37例，高分化腺癌7例，粘液腺癌6例。放疗总剂量在60－72GY／22－24F／每周4－5次，其毒性作用用血液学、生化试验、胃肠道和泌尿系统反应进行评价。观察有无放射性肠淡症状，监测血细胞。每3月复查MRCT1次，二年生每6月复查MR或CT1次。结果：迄2000年12月25日止共随访54例，随访到53例（98.1%），失访1例（1.9%）；中位随访时间为15.4个月，平均访时间为14.3个月（3－30个月）。疗效判定标准：按WHO制订标准，完全缓解5例，占9.3%；部分缓解27例，占50.0%。稳定15例，占27.8%；进展6例占11.1%。有效率为59.3%。一年生存率61.1%（33/54），症状缓解率92.6%（50／54）。放射性肠炎发生率约为5.6%。均未出现白细胞减少和肝、肾功能降低与尿频、尿急、尿痛和血尿。结论：三维适形放射治疗直肠癌术后复发患者具有明显的剂量分布优势，局部控制率和症状缓解率高，放射性肠炎发生率低。     

Development of an irradiation method of intraoperative radiation therapy for curatively resected rectal cancer

Background. Intraoperative radiation therapy (IORT) has been performed to prevent local recurrence of rectal cancer only when positive margins are suspected. To further reduce local recurrence, we attempted to develop a new IORT irradiation method in which electron beam irradiation is administered as uniformly as possible to the intrapelvic dissection surfaces. Methods. Low anterior resection and abdominoperineal resection were performed in one male and one female cadaver. Electron beam irradiation was administered by four different methods, and absorbed doses were measured at 15 sites within the pelvis. We also attempted to measure absorbed doses at nine sites within the pelvis in 14 patients treated with IORT. Results. The cadaver study revealed low absorbed doses in the lateral walls of the pelvis when a single irradiation was delivered from the anterior. When the lateral walls of the pelvis were irradiated twice, once each time on the right and left, the absorbed doses were low in the central pelvis and presacrum. Relatively high absorbed doses were achieved in all of these areas by a technique that combined these two methods. Adequate absorbed doses were not achieved by a single irradiation administered from the perineum. Conclusion. This study suggests that electron beam irradiation administered three times to the dissected surfaces in the pelvis after resection of rectal cancer (i.e., to the central pelvis and presacrum from the anterior, and to the left and right lateral walls of the pelvis) is the most suitable method for achieving adequate absorbed doses. Received: May 6, 1998 / Accepted: December 15, 1998     

直肠癌术后局部复发的治疗与预后分析

目的 分析直肠癌根治术后局部复发患者的生存状况及影响因素.方法 回顾性分析四川省肿瘤医院2013年10月至2018年1月收治的35例单纯性直肠癌局部复发患者的资料,分析其生存状况,并采用多因素Cox回归分析影响预后的相关因素.结果 35例患者中男20例,女16例;中位生存期125(6～144)个月,5年存活率为53.1...     

Patterns of local recurrence in locally advanced rectal cancer after intra-operative radiotherapy containing multimodality treatment

Background and purpose

The purpose of this study is to analyze the patterns of local recurrence (LR) after intra-operative radiotherapy (IORT) containing multimodality treatment of locally advanced rectal carcinoma (LARC).

Methods and materials

Two hundred and ninety patients with LARC who underwent multimodality treatment between 1994 and 2006 were studied. For patients who developed LR, the subsite was classified into presacral, postero-lateral, lateral, anterior, anastomotic or perineal. Patient and treatment characteristics were related to subsite of LR.

Results

After 5 years, 34 patients (13.2%) developed LR. The most prominent subsite of LR was the presacral subsite. 47% of the local recurrences occurred outside the IORT field. Most recurrences developed when IORT was given dorsally, while least occurred when IORT was given ventrally. Especially after dorsal IORT a high amount of infield recurrences were observed (6 of 8; 75%). In multi-variate analysis tumor distance of more than 5 cm from the anal verge and a positive circumferential margin were associated with presacral local recurrence.

Conclusions

Multimodality treatment is effective in the prevention of local recurrence in LARC. IORT application to the area most at risk is feasible and seems effective in the prevention of local recurrence. Dorsal tumor location results in unfavourable oncologic results.     

Site-specific risk factors for local recurrence after rectal cancer surgery

BackgroundQuite few studies examined risk factors for local recurrence after rectal cancer surgery with respect to local recurrence sites.MethodsLocal recurrence sites were categorized into axial, anterior, posterior, and lateral (pelvic sidewall), and axial, anterior, and posterior type were combined as the “other” type of local recurrence. Among 76 patients enrolled into our prospective randomized controlled trial to determine the indication for pelvic autonomic nerve preservation (PANP) in patients with advanced lower rectal cancer (UMIN000021353), multivariate analyses were conducted to elucidate risk factors for either lateral or the “other” type of local recurrence.ResultsUnivariate analyses showed that tumor distance from the anal verge was significantly (p = 0.017), and type of operation (sphincter preserving operation (SPO) vs. abdominoperineal resection (APR)) was marginally (p = 0.065) associated with pelvic sidewall recurrence. Multivariate analysis using these two parameters showed that tumor distance from the anal verge was significantly and independently correlated with pelvic sidewall recurrence (p = 0.017). As for the “other” type of local recurrence, univariate analyses showed that depth of tumor invasion (p = 0.011), radial margin status (p < 0.001), and adjuvant chemotherapy (p = 0.037) were significantly associated, and multivariate analysis using these three parameters revealed that depth of tumor invasion (p = 0.004) and radial margin status (p < 0.001) were significantly and independently correlated with the “other” type of local recurrence.ConclusionRisk factors for local recurrence after rectal cancer surgery were totally different with respect to the intra-pelvic recurrent sites. Site-specific probability of local recurrence can be inferred using these risk factors.Trial registration numberUMIN000021353.     

Early local recurrence and one-year mortality of rectal cancer after restricting the neoadjuvant therapy regime

IntroductionTo reduce the risk of local recurrence after rectal cancer surgery, neoadjuvant radiotherapy (RT) can be applied. However, as this causes morbidity and increases mortality, new Dutch guidelines withhold RT in low-risk patients. The aim of this study is to investigate if early local recurrence and one-year mortality in rectal cancer patients has changed since this more restricting indication for neoadjuvant RT was introduced in 2014.MethodsThis retrospective study included all consecutive patients treated with a mesorectal excision for primary rectal cancer in the Amphia Hospital, the Netherlands, between January 2011 and July 2016. Data were extracted from the electronic patient records. Survival data were collected from the Municipal Personal Records Database.ResultsBetween 2011 and July 2016, 407 resections of primary rectal cancer without synchronic metastases were performed, 225 under the old guidelines and 182 under the new guidelines. Significantly fewer patients received neoadjuvant treatment under the new guidelines (89% vs 41%, p < 0.001). Both clinical tumour stage (p = 0.001) and clinical lymph node stage (p < 0.001) were lower in the new group, but no difference in pathologic TN-stage was found. There was no difference in one-year local recurrence (2.2% in both groups, p = 0.987), nor in one-year mortality (5.3% vs 3.8%, p = 0.479).ConclusionIntroducing a new guideline and thereby restricting the indication for neoadjuvant RT in rectal cancer patients did not increase the early local recurrence rate or decreased one-year mortality in our hospital.     

Long-term outcomes following salvage surgery for locally recurrent rectal cancer: A 15-year follow-up study

BackgroundLocally recurrent rectal cancer (LRRC) is a complex problem requiring multidisciplinary consultation and specialized surgical care. Given the paucity of published longer-term survival data, skepticism persists regarding the benefit of major extirpative surgery. We investigated ultra-long-term (~15 years) outcomes following radical resection of LRRC and sought relevant clinicopathologic prognostic variables.MethodsA cohort of 52 consecutive patients who underwent resection of LRRC at our institution between 1997 and 2005 were followed with serial exams and imaging up to the point of death, or 30/06/2019.ResultsMedian follow-up time was 16.5 years (9.9–18.3) for patients who were alive at last follow-up; only one patient was lost to follow-up, at 9.9 years. For the entire cohort of 52 patients, disease-specific survival (DSS) at 5, 10, and 15 years following salvage surgery was 41%, 33%, and 31%, respectively. All patients who had distant metastatic disease at the time of LRRC resection (n = 6) subsequently died of cancer, at a median of 21 months (4−46). In those without distant metastases at time of salvage surgery (n = 46), DSS at 5, 10, and 15 years was 47%, 38%, and 35%, respectively, median 60 months. Negative resection margin (R0) was independently predictive of superior outcomes. In patients with M0 disease who had R0 resection (n = 37), DSS at 5, 10 and 15 years was 58%, 47%, and 44%, respectively, median 73 months. No patient developed re-recurrence after 5.5 years.ConclusionsThis study demonstrates exceptionally durable long-term cancer-free survival following salvage surgery for LRRC, indicating that cure is possible.     

Successful rectal cancer local recurrence radiofrequency ablation

Local rectal cancer recurrences represent a great challenge, as surgical re-excisions or re-irradiation procedures are not always feasible. Moreover, scar or local recurrence is hard to elucidate with conventional diagnosis techniques. Emerging diagnostic and therapeutic procedures may be useful in this setting. A local rectal cancer recurrence radiofrequency ablation is reported. PET scan confirmed the recurrence, defined the target volume and assessed the success of the local therapy.     

直肠癌术前放射治疗临床分析

目的探讨直肠癌术前放射治疗的疗效及在直肠癌治疗中的价值.方法 1995年6月至1998年6月收治Ⅱ～Ⅲ期直肠癌患者78例,随机分为术前放疗组和单纯手术组,每组39例.采用常规放疗方法,剂量为DT 50 Gy/5周,照射后4～5周行根治性手术.结果术前放疗组术后病理检查肿瘤细胞呈轻度反应者4例,中度反应者15例,重度反应者17例,肿瘤细胞消失者3例;临床分期变化:T期下降17例,占43.6%,N期下降7例,占33.3%.术前放疗组和单纯手术组的淋巴结转移率分别为15.4%和35.9%,差异有显著性(P=0.039);术前放疗组和单纯手术组的术后复发率分别为17.9%和41.0%,差异有显著性(P=0.015);术前放疗组和单纯手术组3,5年生存率分别为76.9%、53.8%和59.0%、35.9%,差异有显著性(P=0.034).术前放疗组的急性放疗反应可耐受,亦未出现由放疗造成的远期并发症.结论术前放疗可降低直肠癌的局部复发率,提高患者的生存率;急性放疗反应可耐受,并不增加手术难度及并发症.     

Oncologic outcomes of intersphincteric resection without preoperative chemoradiotherapy for very low rectal cancer

BackgroundWhen a rectal cancer is located at less than 4 cm from the anal verge, abdominoperineal resection (APR) is generally performed. If an ideal surgery that could replace APR were to be developed, it could contribute to anal preservation in patients with very low rectal cancer. The aim of this study was to investigate oncologically whether intersphincteric resection (ISR) could replace APR for a very low rectal cancer.MethodsBetween 2001 and 2011, ISR was curatively performed in 124 patients with a very low rectal cancer who might otherwise have been treated with APR. No patient received preoperative chemoradiotherapy. The median duration of follow-up was 65 months (range 14–122 months). Local recurrence was defined as only intra-pelvic recurrences including lateral lymph node metastasis. The survival rate was calculated using the Kaplan–Meier method.ResultsPostoperative morbidity including anastomotic leakage (5.6%) was 12%. There was no in-hospital mortality. In those patients with Stages I, II, and III disease, the local recurrence rate was 4.7%, 4.9%, and 5.0%, respectively. The recurrence-free 5-year survival rates were 92.2% (95% CI: 84–100%), 81.9% (95% CI: 70–94%) and 69.6% (95% CI: 53–87%) at each stage, respectively. The cancer-specific 5-year survival rates were 90.5% (95% CI: 81–100%), 91.0% (95% CI: 82–100%), and 83.6% (95% CI: 70–97%) at each stage, respectively. The overall recurrence-free survival and local recurrence rates after ISR were similar to those after APR.ConclusionsThe ISR procedure appears to be oncologically acceptable, replacing APR in selected patients. Accumulated experience supports this practice worldwide in future.     

Anorectal and sexual functions after preoperative radiotherapy and full-thickness local excision of rectal cancer

Aims

Local excision with preoperative radiotherapy may be considered as alternative management to abdominal surgery alone for small cT2-3N0 tumours. However, little is known about anorectal and sexual functions after local excision with preoperative radiotherapy. Evaluation of this issue was a secondary aim of our previously published prospective multicentre study.

Methods

Functional evaluation was based on a questionnaire completed by 44 of 64 eligible disease-free patients treated with preoperative radiotherapy and local excision. Additionally, ex post, these results were confronted with those recorded retrospectively in the control group treated with anterior resection alone (N = 38).

Results

In the preoperative radiotherapy and local excision group, the median number of bowel movements was two per day, incontinence of flatus occurred in 51% of patients, incontinence of loose stool in 46%, clustering of stools in 59%, and urgency in 49%; these symptoms occurred often or very often in 11%–21% of patients. Thirty-eight per cent of patients claimed that their quality of life was affected by anorectal dysfunction. Nineteen per cent of men and 20% of women claimed that the treatment negatively influenced their sexual life. The anorectal functions in the preoperative radiotherapy and local excision group were not much different from that observed in the anterior resection alone group.

Conclusions

Our study suggests that anorectal functions after preoperative radiotherapy and local excision may be worse than expected and not much different from that recorded after anterior resection alone. It is possible that radiotherapy compromises the functional effects achieved by local excision.     

Preoperative radiotherapy and local excision of rectal cancer with immediate radical re-operation for poor responders

Background and purpose

To report an early analysis of prospective study exploring preoperative radiotherapy and local excision in rectal cancer.

Materials and methods

Mucosa at tumour edges was tattooed. Patients with cT1-3N0 tumour <3-4 cm were treated with either 5 × 5 Gy + 4 Gy boost (N = 31) or chemoradiation (50.4 Gy + 5.4 Gy boost, 1.8 Gy per fraction + 5-fluorouracyl and leucovorin; N = 13). Thirteen patients from the short-course group were unfit for chemotherapy. The interval from radiation to full-thickness local excision was 6 weeks. The protocol called for conversion to a transabdominal surgery in case of ypT2-3 disease or positive margin.

Results

The postoperative complications requiring hospitalization were recorded in 9% of patients. The rate of pathological complete response was 41%. The rate of patients requiring conversion was 34%; however, 18% actually underwent conversion and the remaining 16% refused or were unfit. During the 14 months of median follow-up, local recurrence was detected in 7% of patients and all underwent salvage surgery. Of 19 patients in whom initially anterior resection was likely, 16% had abdominoperineal resection performed for a conversion or as a rescue procedure.

Conclusion

Our study suggests that the short-course radiation prior to local excision is a treatment option for high-risk patients.     

直肠癌的三维适形放疗及多肿瘤标志物的变化

目的：探讨局部晚期和术后复发性直肠癌三维适形放射治疗（3D-CR）的临床疗效及多肿瘤标志物的变化.方法：60例局部晚期和术后复发性直肠癌均在外照射40Gv后随机分为后程适形放疗组（适形组）30例,常规放疗组（对照组）30例.适形组放疗前后及再次复发后查多肿瘤标志物.结果：适形组及对照组有效率分别为86.7%和70.0%,两组差异无显著性意义（P＞0.05）.适形组及对照组1、2、3年生存率分别为80.0%,53.3%,36.7%;56.7%,40.0%,13.3%,P=0.021 3;两组差异有显著性意义.适形组CEA、CA19-9、CA242、FER在放疗后较放疗前降低,P＜0.01,有显著性意义.再次复发后较未复发时升高,P＜0.01,有显著性意义.结论：局部晚期和术后复发性直肠癌常规外照射加三维适形放疗有较好疗效.多肿瘤标志物蛋白质芯片诊断系统可作为疗效及预后判断的一项有效指标.     

Racial disparities and standard treatment in locally advanced rectal cancer: a National Cancer Database study

BackgroundMortality rates in colorectal cancer (CRC) continue to be higher in Black compared to White patients. While standard treatment modalities for locally advanced rectal cancer have been shown to improve outcomes, there are limited studies assessing the receipt of standard treatment in rectal cancer based on race. Therefore, we sought to evaluate the use of standard treatment across racial groups in locally advanced rectal cancer and its effect on survival.MethodsThe National Cancer Database (NCDB) was queried for patients ≥18 years old with clinical and pathologic stage II–III rectal adenocarcinoma who received treatment from 2004 to 2014. Standard treatment was defined as complete surgical excision with either neoadjuvant or adjuvant concurrent chemoradiation. Multivariable logistic regressions were used to identify racial differences in receiving standard treatment. Cox proportional hazards were used to estimate the effects of standard vs. nonstandard treatment on survival differences based on race.ResultsA total of 70,677 patients with stage II (n=35,079) or stage III (n=35,598) rectal adenocarcinoma met the inclusion criteria. On multivariate analysis, Black [odds ratio (OR): 0.75; 95% confidence interval (CI): 0.71–0.79; P<0.001] and Hispanic White (OR: 0.86; 95% CI: 0.80–0.92; P>0.001) patients were less likely to receive standard treatment compared to non-Hispanic White patients. On multivariable Cox regression, nonstandard treatment was significantly associated with worse survival [hazard ratio (HR): 1.69; 95% CI: 1.65–1.73; P<0.001] compared to standard treatment. Even after adjusting for patient, demographic, and facility characteristics, Black patients had higher mortality rates compared to White patients in the whole population (HR: 1.15; 95% CI: 1.09–1.20; P<0.0001). This survival difference between Black and non-Hispanic White patients persisted in both the standard (HR: 1.10; 95% CI: 1.03–1.19; P=0.008) and nonstandard (HR: 1.17; 95% CI: 1.10–1.25; P<0.0001) treatment subgroups. Decreased survival outcomes in Black patients were more pronounced for those who underwent nonstandard treatment, particularly when treating stage III disease (HR: 1.30; 95% CI: 1.19–1.42; P<0.0001).ConclusionsNonstandard treatment in stage II and III rectal cancer is associated with worse survival compared to standard treatment regimens. Black patients are more likely to receive nonstandard treatment and have worse survival outcomes compared to White patients.     

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.