Incidence Of Pelvic Recurrence Research Articles

Impact of external beam pelvic radiotherapy of endometrial carcinoma: A focus on chronic digestive toxicity

PurposeThe standard treatment for endometrial cancer is surgery, although depending on the risk factors, adjuvant radiation therapy may also be given. It is proposed for high-risk carcinomas for which an improvement in progression-free survival though not overall survival has been shown. However, despite the development of radiotherapy treatments with intensity modulation and image guidance, adjuvant radiation therapy remains toxic to the digestive system. We aimed to investigate the incidence of digestive toxicity and the presence of any predictive factors. Materials and methodsData were retrospectively collected from patients treated with adjuvant radiotherapy for endometrial carcinoma at the Institut de cancérologie de Lorraine and centre hospitalier Émile-Durkheim between January 2010 and October 2016 and analyzed to identify factors associated with chronic digestive toxicity. ResultsOne hundred and thirty-nine patients received a total dose of 50Gy fractionated into 25 sessions, five per week for five weeks. The median follow-up after irradiation completion was 38 months. The incidence of gastrointestinal and rectal toxicity in all patients treated with pelvic irradiation for endometrial carcinoma was 11.1% (95% confidence interval [95%CI]: 5.4–19%) for grade 3–4 and 25.6% (95%CI: 17.0–34.9%) for grade 2–4. No factor was found to be significantly predictive of chronic digestive toxicity. At five years, the overall survival was 74.3%, (95%CI: 65.3–81.4%), progression-free survival was 69.6% (95%CI: 60.1–77.3%) and incidence of pelvic recurrence was 7.9% (95%CI: 3.8–13.9%). ConclusionOur results confirmed that pelvic radiotherapy can induce a relatively high rate of digestive toxicity but failed to identify relevant factors able to predict it.

Receipt of vaginal brachytherapy is associated with improved survival in women with stage I endometrioid adenocarcinoma of the uterus: A National Cancer Data Base study.

Randomized controlled trials have consistently shown that the use of postoperative radiotherapy (RT) for stage I endometrial cancer leads to a reduction in the incidence of pelvic recurrences without a corresponding reduction in overall mortality. It was hypothesized that a reduction in mortality associated with the receipt of RT could be identified in a large data set with greater statistical power. Women with surgically staged IA or IB endometrial adenocarcinoma who were treated with total hysterectomy between 2003 and 2011 were identified in the National Cancer Data Base. Chi-square tests and multivariate logistic regression were performed to analyze factors associated with the treatment type. A survival analysis was performed with log-rank testing, Cox proportional hazards regression, and Kaplan-Meier estimates. A total of 44,309 eligible women were identified (33,380 at stage IA and 10,929 at stage IB): 88.4% of the women with stage IA tumors and 51.6% of the women with stage IB tumors received no RT. Older age, comorbid disease, a higher histologic grade, and a larger tumor size were independently associated with an increase in mortality. The receipt of vaginal brachytherapy (VB) was independently associated with a reduction in mortality for both stage IA disease (hazard ratio [HR], 0.81; 95% confidence interval [CI], 0.67-0.97) and stage IB disease (HR, 0.62; 95% CI, 0.51-0.74). Analyses of this large database support the utility of postoperative VB for many women with stage I endometrial cancer. Unfortunately, RT appears to be underused in this population. Greater adherence to consensus guidelines may lead to improved outcomes. Cancer 2016;122:3724-31. © 2016 American Cancer Society.

The future of external beam irradiation as initial treatment of rectal cancer

Several trials have demonstrated that pre-operative irradiation for rectal cancer decreases significantly the incidence of pelvic recurrence. However, this method is far from being generally accepted. It is now possible to enhance the effectiveness of external beam irradiation and to use it to extend the field of sphincter-saving and conservative procedures. Our protocol consists of a split-course regimen with a short course of cobalt-60 arc rotation (3000 cGy in 12 days). After 2 months rest, the second stage of treatment depends upon the pressure of residual disease and the site of the tumour. It consists of either radical surgery (82 cases) or conservative treatment by intracavitary irradiation in the event of a favourable initial response or in the case of poor risk patients (73 cases). In the radiotherapy-surgical group, the subsequent operative specimens were tumour free in 17 per cent of cases and assigned to Dukes' A category in 32 per cent of cases. Of 91 patients with T2 or T3 tumour involving the lower third of the rectum (followed up for more than 3 years) 72 (84 per cent) had no recurrence. Thirty-three of these patients (46 per cent) underwent a colostomy while 39 (54 per cent) had normal anal function. These results demonstrate the major place that a properly planned external beam irradiation can have in the curative management of cancers of the low rectum.

The Stockholm II trial on preoperative radiotherapy in rectal carcinoma: long-term follow-up of a population-based study

BACKGROUND The Stockholm II trial is a population-based prospective randomized trial on preoperative radiotherapy in rectal carcinoma. METHODS Eligibility criteria were age younger than 80 years and biopsy-proven adenocarcinoma of the rectum judged resectable for cure with an abdominal procedure. Between 1987 and 1993, 557 patients were included. Patients were randomized to preoperative radiotherapy (RT+) followed by surgery within a week (n = 272) or surgery alone (RT−; n = 285). Radiotherapy was given with 25 grays in 1 week to the rectum and pararectal tissues. Curative resection was performed in 481 patients (86%). Median follow-up was 8.8 years. RESULTS Among patients who underwent curative surgery, the incidence of pelvic recurrence was 12% (RT+) and 25% (RT−), respectively (P < 0.001). The overall survival rate in irradiated patients who underwent curative surgery was improved (46%) versus (39%; P < 0.03). For all included patients, the difference was 39% (RT+) compared with 36% (RT−; P = 0.2). Within 6 months of surgery, 13 of 272 (5%) of the irradiated patients died of intercurrent disease versus 4 of 285 (1%) of the nonirradiated (P = 0.02). Cardiovascular death was the main cause of intercurrent death and occurred in 35 of 272 (13%) of the irradiated patients compared with 20 of 285 (7%) among the nonirradiated (P = 0.07). CONCLUSIONS Preoperative short-term radiotherapy reduces the risk of pelvic recurrence and can improve survival after curative surgery for rectal carcinoma. An increased risk of intercurrent death may reduce the benefit especially in elderly patients. Cancer 2001;92:896–902. © 2001 American Cancer Society.

Surgical treatment of lower rectal cancer with sphincter preservation using handsewn coloanal anastomosis.

The present study was designed to evaluate the technical feasibility and oncologic results of performing handsewn coloanal anastomosis (CAA). A total of 46 patients treated for lower rectal cancer using CAA were retrospectively studied, and the oncologic results were compared with those of 105 patients treated with abdominoperineal resection (APR). CAA was performed in patients who had both good mobility of the tumor and a distal clearance margin of more than 1.0 cm. No significant difference was noted in the mortality rates following the two operations (CAA 2.2% vs APR 1.9%). Pelvic recurrence was detected in two patients (4.5%) after CAA and in six patients (7.2%) after APR. The 5-year survival rate after CAA was 79.2% and that after APR was 72.6%. No significant difference was noted in the incidence of pelvic recurrence or the survival rates between the two operations. These results show that CAA could be an excellent reconstructive option in the treatment of lower rectal carcinoma for selected patients.

Postoperative radiotherapy and surgery in stage I endometrial carcinoma: a 10-year experience.

Data from the literature show that the incidence of pelvic recurrences in poor prognosis endometrial carcinoma is significantly reduced by combined surgery and radiotherapy compared to surgery alone. In this paper we analyze the results of the combined treatment surgery plus adjuvant Irradiation in patients with endometrial carcinoma with regard to survival, site of progression, and toxicity. The surgical treatment consisted of total abdominal hysterectomy and bilateral salpingo-oophorectomy. Pelvic and para-aortic node dissection was performed. The overall 5-year survival was 88%. Three patients had local failure. Ten patients with local control of disease had distant metastases and 2 had local and distant recurrences. Our experience confirms the data of the literature. Postoperative irradiation is a safe and well tolerated treatment which can achieve good local control in high-risk stage I endometrial carcinoma. The control of distant metastases remains an open issue.

Survival and recurrence after low anterior resection and abdominoperineal resection for rectal cancer: The results of a long-term study with a review of the literature

Morbidity, survival, and recurrence in 203 patients treated with curative low anterior resection (LAR) were compared with those in 100 patients treated with curative abdominoperineal resection (APR). The overall 5-year survival figures for the total number of, LAR and APR patients were 75.6 +/- 5.7%, 79.8 +/- 6.4% and 67.7 +/- 9.6%, respectively. The prognosis for cancers situated low enough in the rectum to involve the anal canal was poor even when managed by APR, as evidenced by a low survival at 5 years of 59.0 +/- 9.6% and a high pelvic recurrence rate of 34%. For all except these tumors, LAR proved at least equal to, or better than APR as a curative surgical method for middle and low rectal cancers, on the basis of 5-year survival being 79.8 +/- 6.4% vs 78.7 +/- 5.2%, operative mortality being 1.5% vs 1.0%, morbidity being 39.4% vs 59.0%, and the incidence of pelvic recurrence being 8.9% vs 13.5%. When deciding upon the most appropriate surgical procedure for rectal cancer, especially for middle or low rectal lesions, the patient should not simply be condemned to a permanent colostomy. Thus, we first attempt LAR for every lesion except those which are very advanced or those with anal canal involvement, if technically feasible and suitable for the individual patient.

Pelvic recurrence after surgical treatment of rectal and sigmoid cancer

The aim of this collaborative prospective study was to verify the incidence of pelvic recurrence (PR) after radical surgery for cancer of the rectum and sigmoid. Very low anterior resection (VLAR) was usually performed, with the aim of preserving anal function and obtaining the maximum of radicality by means of en bloc excision of the mesorectum. Between 1984 and 1987, 274 patients underwent curative surgery for rectal and sigmoid cancer, 230 (84%) of whom underwent anterior resection (AR) and 44 (16%) abdominoperineal resection (APR). Post-operative mortality was 2.5%. Follow-up ranged from 24 to 72 months (mean 37 m); 248 cases (90.5%) were included in the final prospective study. PR occurred in 41/248 cases (16%), within 24 months in 80% of cases. PR occurred in 15.8% (33/208) after AR and in 20% (8/40) after APR, p = NS. Nevertheless in middle and low rectal tumours at stage C the incidence of PR in patients who had VLAR was 34.5% (10/29) and 12% (3/25) in those who had APR (p < 0.05). PR rates in VLAR patients was 40% for stage C low rectal tumours and 54.5% for low rectal tumours at Astler Coller stage C2. The PR incidence for stage C1 tumours of the low rectum was zero after VLAR and APR, allowing the assumption that lymphnode metastases in non-penetrating tumours do not compromise the results when the mesorectum is completely excised. We can assume that the choice of VLAR as a substitute for APR whenever possible limits the comparison of their results.(ABSTRACT TRUNCATED AT 250 WORDS)

Preoperative short-term radiation therapy in operable rectal carcinoma: A prospective randomized trial

From 1980 to 1987, 849 patients with clinically resectable rectal adenocarcinoma were randomized into a controlled clinical trial of radiation therapy (2500 cGy over 5 to 7 days) before surgery versus surgery alone. At a median follow-up time of 53 months (range, 8 to 90) the incidence of pelvic recurrence among 679 curatively operated upon patients was significantly lower among those allocated to radiation therapy (P less than 0.01). A reduction was observed in all Dukes' stages. No significant difference between the treatment groups was observed with regard to frequency of distant metastases or overall survival. Among all randomized patients as well as the radically operated patients the recurrence-free interval, i.e., time to local recurrence or distant metastasis, was significantly prolonged in the preoperatively irradiated group. The radically operated patients also had a significantly prolonged survival related to rectal cancer (P = 0.05). The postoperative morbidity, however, was significantly higher among irradiated patients. The postoperative mortality was 8% in the radiation therapy group compared to 2% in the surgery alone group (P less than 0.01).

A 5- to 21-year follow-up and analysis of 250 patients with rectal adenocarcinoma.

A total of 250 patients with rectal adenocarcinoma were operated on at the University of Chicago Medical Center between 1965 and 1981. The operation performed was curative resection in 154 patients, palliative resection in 16 patients, diverting colostomy in 21 patients, exploratory laparotomy in 11 patients, and transanal removal in 48 patients. Of the 154 curative resections, 115 were abdomino-perineal (APR), three were total proctocolectomies, and 36 were low anterior resections (LAR). No anastomotic complications were observed in this latter group. Operative mortality was 3%. Complete follow-up was obtained in 152 patients (98.7%). Five- and 10-year actuarial survival rates were 68.8 and 59.4%, respectively, for patients with Dukes' B1 adenocarcinoma (n = 32), 55.8 and 44.2% for Dukes' B2 tumors (n = 52), and 42.9% and 25.4% for Dukes' C tumors (n = 63). Distant metastases developed in 59 patients (39.6%), and pelvic recurrence developed in another 18 patients (12%); 5-year survival rates were 23.6% and 22.2%, respectively. Multivariate analysis with Cox regression showed that stage (p = 0.0001), race (p = 0.03), tumor morphology (p = 0.02), and vascular and/or lymphatic microinvasion (p = 0.001) were statistically significant in their association with survival. Logistic regression analysis confirmed these results and allowed for the estimation of 5-year survival probabilities in 16 groups of patients defined by various associations of these four factors. These estimates ranged from a high of 92% in Caucasian patients with Stage B, exophytic tumors with no vascular or lymphatic microinvasion, to a low of 14% in black patients with Stage C, nonexophytic tumors and with the presence of vascular and/or lymphatic microinvasion. Univariate analysis showed that histologic type (p = 0.0006), stage (p = 0.05) and vascular and/or lymphatic microinvasion (p less than 0.001) were significantly associated with the incidence of pelvic recurrence. Analysis of the extent of the operation revealed that the incidence of pelvic recurrence was reduced by the performance of a wide pelvic lymphadenectomy (9.4% vs. 16.4%), but the result did not reach statistical significance (p = 0.16). In conclusion, this study confirms the well-established prognostic value of the Dukes' staging classification of rectal carcinoma. Further, the analysis reveals that race, tumor morphology, and the presence or absence of lymphatic and/or vascular microinvasion significantly influence outcome. By associating these four statistically significant and independent variables, the prognosis for any individual patient can be estimated more precisely than by using Dukes' staging alone.(ABSTRACT TRUNCATED AT 400 WORDS)

Analysis of pelvic tumor control and impact on survival in carcinoma of the uterine cervix treated with radiation therapy alone

A total of 1054 patients with histologically confirmed invasive carcinoma of the uterine cervix were treated with radiation therapy alone between 1959 and 1982. All patients are available for a minimum of 3 years follow-up. Radiation therapy consisted of external irradiation to the whole pelvis (1000–2000 cGy) and parametria (for a total of 4000–6000 cGy) combined with two intracavitary radioactive source insertions (6000–7500 cGy to point A). Patients with Stage IIB, III, and IVA have been consistently treated with somewhat higher doses of external irradiation and intracavitary insertions. A small group of 54 patients with Stage IIB or IIIB had pelvic lymphadenectomy following the irradiation (1960–1964). There was a strong correlation between the tumor regression within 30 days from completion of radiotherapy and the incidence of pelvic recurrences or distant metastases for each of the anatomical stages. The 10-year survival rate for Stage III was 76%, Stage IIA 60%, Stage IIB 145%, and Stage III 25%. Many of the deaths were due to intercurrent disease. Thus, the 10-year tumor-free survival was 80% for Stage IB, 60% for Stages IIA and IIB and 35% for Stage III. In Stage IB total doses of 6000 cGy or higher to point A resulted in 94% pelvic tumor control. In Stage IIA, the pelvic tumor control was 87% with doses of 6000 cGy to point A or higher. However, in Stage IIB the pelvic tumor control was 58% with doses below 6000 cGy, 78% with 6001–7500 cGy and 82% with higher doses. In Stage IIIB the pelvic tumor control was 42% with doses below 6000 cGy, 57% with 6001–7500 cGy and 68% with higher doses. Tumor control in the pelvis was correlated with the following 5 year survivals: Stage IB-95% (353 patients); Stage IIA-84% (116 patients); Stage IIB-84% (308 patients); Stage IIIB-74% (245 patients). The 5-year survival for patients that recurred in the pelvis was 30% for Stage IB, about 15% for Stages IIA-B and only 5% in Stage 111. Patients with tumor control in the pelvis had a significantly lower incidence of distant metastases than patients who initially failed in the pelvis (9.3% vs. 58.6% in Stage IB, 21.6% vs 52.6% in Stage IIA, 19.8% vs 16.7% in Stage IIB, and 31.2% vs 50% in Stage III). In Stage IIB the figures were 19.8% and 16.7% because the initial pelvic recurrence was frequently concurrent with distant metastases. Adequate initial therapy is crucial in determining the probability of pelvic tumor control and survival in patients with invasive carcinoma of the cervix. Salvage procedures for pelvic recurrences, even in the absence of distant metastases, yields a low long-term survival.

Tumor control in definitive irradiation of localized carcinoma of the prostate

At the Mallinckrodt Institute of Radiology, Washington University, 343 patients with carcinoma of the prostate were treated with definitive radiotherapy. All patients are available for minimal 3 year follow-up; the median period of observation is 5.2 years. The incidence of pelvic recurrence with or without distant metastases was 0% in 10 patients with Stage A 2,11% in 113 patients with Stage B, 34% in 204 patients with Stage C, and 40% in 16 patients with Stage D1. There was no significant difference in pelvic tumor control when correlated with the degree of differentiation of the tumors in each stage. In Stage B, patients who exhibited complete regression 3 months after completion of therapy had a pelvic failure rate of 5%, those with 50–75% regression-8% and less than 50% regression—18%. In Stage C, patients with more than 50% tumor regression had a pelvic failure rate of 25%, in contrast to 37% when less than 50% regression was noted at 3 months after completion of irradiation. However, there was no correlation between tumor regression and NED survival. In patients with Stage B, there was no significant correlation between doses of irradiation ranging from 6000 to 7000 cGy and pelvic tumor control. In Stage C, patients receiving doses higher than 6500 cGy had a probability of failure rate in the pelvis of 25% ( 40 173 ), in comparison with 44% with doses between 6000–6500 cGy (15/32). The 10 year NED survival for Stage A 2 was 100%, Stage B-70%, and Stage C-40%. In Stage B, there was no correlation between local tumor control and 5 year overall survival. However, at 10 years 88 patients without evidence of local failure or distant metastases had a survival rate of 70% in contrast to only 25% if they recurred. In Stage C, 110 patients without local recurrence or distant metastases had a 40% 10 year survival in contrast to 20% in 55 patients who had pelvic recurrence (with or without distant metastases) and 39 patients with distant metastases only. In 105 patients with Stage B tumor controlled in the pelvis, the incidence of distant metastases was 16%, in contrast to 50% in eight patients with pelvic failure. In Stage C, only 26% of 149 patients with pelvic tumor controlled developed distant disease, versus 60% in 55 patients failing in the pelvis. Ninety-five percent of the pelvic failures and 80% of the distant metastases appeared within 5 years after therapy. The administration of hormones did not significantly influence either the probability of pelvic tumor control or the appearance of distant metastases.

Combined radiation therapy and extra-fascial hysterectomy in the treatment of stage IB barrel-shaped cervical cancer.

Seventy-five patients with bulky barrel-shaped Stage IB cervical cancers, treated at the University of Kentucky from 1965 to 1981, were the subjects of this investigation. Thirty-two of these patients were treated with radiation therapy alone and 43 were treated with radiation followed by extra-fascial hysterectomy. There were no significant differences in age, gravidity, or tumor cell type between the two treatment groups. Patients were seen at regular intervals from 2 to 11 years after treatment and none were lost to follow-up. Recurrent cancer was noted in 47% of patients treated by radiation alone as compared to 16% of those treated with combined therapy (P less than 0.01). The incidence of pelvic recurrence was reduced from 19% to 2% and extrapelvic recurrence from 16% to 7% in patients treated by combination therapy. No rectal or urinary tract fistulae were noted after extra-fascial hysterectomy. The findings of this study suggest that the use of extra-fascial hysterectomy following radiation therapy in patients with bulky Stage IB cervical cancer causes a significant reduction in tumor recurrence without producing an increase in treatment-related complications.

Early uterine body carcinoma: Has post-operative vaginal irradiation any value?

A retrospective study of 1703 Stage 1A and 1B adenocarcinomas of the uterine body, treated with and without post-hysterectomy vaginal irradiation in Birmingham between 1960 and 1974 inclusive, showed a vaginal failure rate of 3.76%. Vaginal irradiation eliminated recurrence in non-invasive tumours, and reduced the incidence in the invasive ones. Treatment had no influence on the incidence of pelvic recurrence, metastatic disease or the survival rate of any histological type of tumour, invasive or non-invasive. Treatment of late recurrence reduced the final vaginal failure rate to 0.83%. Prognosis depended on the size of uterine cavity, the histological grade and invasive character of the tumour, and was unrelated to post-operative local treatment.

Preoperative irradiation for unresectable rectal and rectosigmoid carcinomas.

The records of 25 patients with unresectable carcinoma of the rectum and rectosigmoid who received preoperative radiation therapy (RT) were reviewed. Twenty patients were considered to be resectable following RT (80%). Sixteen patients (64%) underwent curative resections. All patients with unresectable tumors following RT died with tumor within two and one half years (median survival, 11 months). For patients undergoing curative resection, the probability of two- and five-year survival was 56% and 43%, respectively. In this latter group, five of seven patients with treatment failures (71%) had a pelvic component of disease. The incidence of pelvic recurrence was correlated with the pathologic stage, extent of resection and preoperative radiation dose. The need for more aggressive treatment for patients with these advanced tumors is emphasized. Future treatment alternatives are discussed.

Preoperative Irradiation with High-Dose Fractionation in Adenocarcinoma of the Rectum and Rectosigmoid

The incidence of local pelvic recurrence after 'curative' resection for rectal carcinoma is high. Adjuvant irradiation given pre- or postoperatively has led to a decreased incidence of pelvic recurrences. In a series of 58 consecutive patients between 1979 and 1980, those with primarily operable rectal tumours received preoperative irradiation in a total dose of 25.5 Gy in fractions of 5.1 Gy daily for 5 days. A locally 'curative' resection was performed in 41 patients 2 to 5 days later. The radiation therapy was well tolerated without early or late complications. All patients were followed up every 6 months with computed tomography over the pelvic region; aspiration biopsies were taken whenever any possible pathology was made. A local recurrence occurred in only 2 patients during the follow-up period (24-42 months). In a retrospective material from 1976 to 1979, totally 107 patients were admitted for surgery. Of 81 patients operated upon for 'local cure', 38 (47%) have had local recurrence to date, 32 (40%) of them within 2 years. These results indicate that a high-dose fractionated preoperative irradiation reduces the incidence of local recurrences, is well tolerated and does not influence the period of hospitalization.