Radiotherapy For Rectal Carcinoma Research Articles

Comparison of pathological response of standard chemoradiotherapy versus short course radiotherapy in rectal carcinoma: A pilot study

Comparison of pathological response of standard chemoradiotherapy versus short course radiotherapy in rectal carcinoma: A pilot study

Impact of Age and Comorbidity on Multimodal Management and Survival from Colorectal Cancer: A Population-Based Study.

This retrospective population-based study examined the impact of age and comorbidity burden on multimodal management and survival from colorectal cancer (CRC). From 2000 to 2015, 1479 consecutive patients, who underwent surgical resection for CRC, were reviewed for age-adjusted Charlson comorbidity index (ACCI) including 19 well-defined weighted comorbidities. The impact of ACCI on multimodal management and survival was compared between low (score 0–2), intermediate (score 3) and high ACCI (score ≥ 4) groups. Changes in treatment from 2000 to 2015 were seen next to a major increase of laparoscopic surgery, increased use of adjuvant chemotherapy and an intensified treatment of metastatic disease. Patients with a high ACCI score were, by definition, older and had higher comorbidity. Major elective and emergency resections for colon carcinoma were evenly performed between the ACCI groups, as were laparoscopic and open resections. (Chemo)radiotherapy for rectal carcinoma was less frequently used, and a higher rate of local excisions, and consequently lower rate of major elective resections, was performed in the high ACCI group. Adjuvant chemotherapy and metastasectomy were less frequently used in the ACCI high group. Overall and cancer-specific survival from stage I-III CRC remained stable over time, but survival from stage IV improved. However, the 5-year overall survival from stage I–IV colon and rectal carcinoma was worse in the high ACCI group compared to the low ACCI group. Five-year cancer-specific and disease-free survival rates did not differ significantly by the ACCI. Cox proportional hazard analysis showed that high ACCI was an independent predictor of poor overall survival (p < 0.001). Our results show that despite improvements in multimodal management over time, old age and high comorbidity burden affect the use of adjuvant chemotherapy, preoperative (chemo)radiotherapy and management of metastatic disease, and worsen overall survival from CRC.

Clinical Target Volume Definition in Preoperative Radiotherapy of Rectal Carcinoma: a Systematic Review

Preoperative radiotherapy (RT) or chemoradiation represents a standard option in neoadjuvant treatment of rectal cancer (RC). The aim of this analysis is to present a systematic review of clinical target volume (CTV) definition in preoperative RT of RC. A systematic review of published literature was performed. Studies providing clear indications for CTV definition in preoperative RT of RC were eligible. Only studies published as full text were considered. The search was restricted to English, German, and French languages. The CTV delineation, based on the different guidelines, was drawn on selected slices of a CT scan and the CTV definition based on different guidelines was reported in a table to facilitate the comparison. A total of six publications containing indications for CTV delineation fulfilled the selection criteria and were included in our review. The studies showed a large variability in available indications between CTV contouring guidelines of RC, partly arising from differences in methods used to propose the single guidelines: expert opinion, systematic review, computer-generated consensus, and 3D modeling of recurrence sites. In our systematic analysis, the available indications for CTV definition in preoperative RT of RC were reviewed. A large variation in target volume delineation was observed.

The value of TRUS in the staging of rectal carcinoma before and after radiotherapy and comparison with the staging postoperative pathology

To compare the effectiveness of transrectal ultrasonography (TRUS) with that of postoperative pathological examination in staging rectal carcinoma before surgery and before and after radiotherapy. A prospective study was undertaken comprising 62 patients with stage T3 or T4 rectal carcinoma confirmed by endoscopic biopsy. TRUS showed significant differences (p < 0.01) in tumour echogenicity and volume, border delineation, local invasion, and draining lymph node involvement before and after radiotherapy, and significant reduction in blood flow resistance index after radiotherapy but no difference (p > 0.05) in the classification of tumour blood flow. In ultrasonographic assessments, 53 of the 62 cases (85.5%) showed lower T stages after radiotherapy. TRUS showed an accuracy of 94.1% for T2 cases, 77.3% for T3 cases, and 83.3% for T4 cases, and an overall accuracy of 87.1% in comparison with the results of postoperative pathological examination. TRUS is expected to play a vital role in the accurate preoperative staging of rectal carcinoma with the increasing utilization of adjuvant radiotherapy in rectal carcinoma and to contribute to the assessment of treatment.

An unusual case of foreskin phimosis after radiotherapy for rectal carcinoma

Phimosis of the foreskin after radiotherapy for rectal carcinoma is extremely rare and has previously been described only once (2006) in the English-language literature. Combination chemo/radiotherapy is currently the treatment of choice and widely used in the management of various pelvic malignancies. In this report, we describe a rare complication on male genitalia following the radiotherapy for lower rectal cancers. Few days following the completion of radiotherapy, patient developed phimosis of the foreskin, which was successfully treated medically without the need for circumcision. Radiotherapy can bring a great risk of injury to anorectum and its adjacent structures. Risk of phimosis should be considered under the current radiation guidelines and we support the concept of using penile shielding for all radiotherapy procedures in colorectal carcinoma patients.

Intensity-Modulated Radiation Therapy for Rectal Carcinoma Can Reduce Treatment Breaks and Emergency Department Visits

Purpose. To compare the acute toxicities of IMRT to 3D-conformal radiation therapy (3DCRT) in the treatment of rectal cancer. Methods and Materials. Eighty-six patients with rectal cancer preoperatively treated with IMRT (n = 30) and 3DCRT (n = 56) were retrospectively reviewed. Rates of acute toxicity between IMRT and 3DCRT were compared for anorexia, dehydration, diarrhea, nausea, vomiting, weight loss, radiation dermatitis, fatigue, pain, urinary frequency, and blood counts. Fisher's exact test and chi-square analysis were applied to detect statistical differences in incidences of toxicity between these two groups of patients. Results. There were fewer hospitalizations and emergency department visits in the group treated with IMRT compared with 3DCRT (P = 0.005) and no treatment breaks with IMRT compared to 20% with 3DCRT (P = 0.0002). Patients treated with IMRT had a significant reduction in grade ≥3 toxicities versus grade ≤2 toxicities (P = 0.016) when compared to 3DCRT. The incidence of grade ≥3 diarrhea was 9% among 3DCRT patients compared to 3% among IMRT patients (P = 0.31). Conclusions. IMRT for rectal cancer can reduce treatment breaks, emergency department visits, hospitalizations, and all grade ≥3 toxicities compared to 3DCRT. Further evaluation and followup is warranted to determine late toxicities and long-term results of IMRT.

Preoperative Short-course (20 Gy/5 Fractions) Radiotherapy for Rectal Carcinoma: Washington University Experience

Preoperative Short-course (20 Gy/5 Fractions) Radiotherapy for Rectal Carcinoma: Washington University Experience

Mitomycin-C/5-Fluorouracil/Leucovorin and Hyperfractionated Radiation Therapy for Rectal Carcinoma: A Phase II Study with Long-Term Follow-up

Purpose Preoperative chemotherapy followed by surgery and adjuvant chemotherapy is a standard treatment for most patients with rectal cancer. We aimed to determine efficacy and tolerability of preoperative mitomycin, fluorouracil (5-FU), and leucovorin (LV) concurrent with hyperfractionated radiation therapy (RT) followed by surgery and adjuvant chemotherapy. Patients and Methods Patients with clinical stage II/III disease were treated with mitomycin 10 mg/m 2 on day 1, continuous venous infusion 5-FU 600 mg/m 2 per day for 96 hours, and oral LV 25 mg every 6 hours on days 1–5. All patients received concurrent RT in fractions of 150 cGy twice daily beginning on day 1. Unfixed tumors received 3000 cGy, whereas fixed tumors received a dose of 4500 cGy. Patients then underwent resection and postoperative adjuvant chemotherapy with oral LV and continuous venous infusion 5-FU 600 mg/m 2 per day on days 1–5 on a 28-day cycle for 6 cycles. Primary endpoints were to determine the rate of pathologic response and downstaging, long-term locoregional control, progression-free survival, and overall survival. Results Between the years 1993 and 2000, 83 patients were enrolled. Eighteen patients (31%) were downstaged. Six patients (7%) had pathologic complete response. Median follow-up was 62 months with a 5-year overall survival of 71%. Local control rate was 96%. Treatment was well tolerated with stomatitis, diarrhea, and radiation proctitis being the most common toxicities. Conclusion This regimen is effective in the treatment of rectal carcinoma. The favorable toxicity profile of mitomycin and hyperfractionated RT allows these strategies to be utilized with the newer chemotherapies for this disease.

Adjuvant Radiation Therapy for Rectal Carcinoma

Adjuvant Radiation Therapy for Rectal Carcinoma

Radiotherapy for rectal carcinoma: An unusual cause of foreskin phimosis

Phimosis of the foreskin secondary to radiotherapy for a pelvic malignancy has not been previously described in the world literature. However, as radiotherapy is ever more widely used in the treatment of various pelvic malignancies, it is important to ensure that this complication is prevented by the use of appropriate penile shielding.

Ischaemic strictures in patients treated with a low anterior resection and perioperative radiotherapy for rectal carcinoma

In five (6 per cent) of 78 consecutive patients treated with an anterior resection for rectal carcinoma, a stenosis of the sigmoid colon just above the anastomosis was observed. Four patients had received preoperative radiotherapy over a period of 1 week to a total dose of 25.5 Gy and one patient had received postoperative radiotherapy (60 Gy) over a total of 8 weeks. The length of the stenosis varied from 4 to 120 cm. Two patients subsequently underwent reoperation with an abdominoperineal resection and three patients with a Hartmann procedure. In all patients the inferior mesenteric artery had been ligated close to the aorta. It is proposed that the stenosis may have been due to insufficient circulation in the marginal artery. This insufficiency may have been aggravated by the irradiation, as the retained part of the sigmoid colon was partly included in the irradiation target.

Sentinel node detection after preoperative short-course radiotherapy in rectal carcinoma is not reliable

Sentinel node (SN) detection may be used in patients with colonic carcinoma. However, its use in patients with rectal carcinoma may be unreliable. To address this, SN detection was evaluated in patients with rectal carcinoma after short-course preoperative radiotherapy. Patent Blue V (1-2 ml) was injected peritumorally and submucosally directly after total mesorectal excision (TME) in 34 patients. The first one to four blue lymph nodes were categorized as SNs. All lymph nodes (non-SNs and SNs) were examined by conventional haematoxylin and eosin stained sections. If the SN was negative for metastasis, additional sections were immunostained with anticytokeratin CK7/8. In addition, SN detection was performed in 57 patients with colonic carcinoma. A SN was identified in 26 of 34 patients with rectal carcinoma. In three the SN was the only positive lymph node. There were six false-negative SNs (sensitivity 40 per cent) and two patients were upstaged. By contrast, SN detection was possible in 56 of 57 patient with colonic carcinoma with a sensitivity of 90 per cent, and four patients were upstaged. The SN procedure for rectal carcinoma is not reliable in combination with TME and preoperative short-course radiotherapy.

P53 status and response to radiotherapy in rectal cancer: a prospective multilevel analysis

The aim of this study was to evaluate, in a prospective study, the predictive role of p53 status analysed at four different levels in identifying the response to preoperative radiotherapy in rectal adenocarcinoma. Before treatment, 70 patients were staged and endoscopic forceps biopsies from the tumour area were taken. p53 status was assessed by total cDNA sequencing, allelic loss analysis, immunohistochemistry, and p53 antibodies. Neoadjuvant treatment was based on preoperative radiotherapy or radiochemotherapy. Response to therapy was evaluated after surgery by both pathologic downstaging and histologic tumour regression grade. In all, 35 patients (50.0%) had p53 gene mutations; 44.4% of patients had an allelic loss; nuclear p53 overexpression was observed in 39 patients (55.7%); and p53 antibodies were detected in 11 patients (16.7%). In the multilevel analysis of p53 status, gene mutations correlated with both nuclear protein overexpression (P<0.0001) and loss of heterozygosity (P=0.013). In all, 29 patients (41.4%) were downstaged by pathologic analysis, and 19 patients (29.2%) were classified as tumour regression grade 1. Whatever the method of evaluation of treatment response, no correlation between p53 alterations and response to radiotherapy was observed. Our results do not support the use of p53 alterations alone as a predictive marker for response to radiotherapy in rectal carcinoma.

Prognostic values of radiation-induced p53 in adjacent normal mucosa and p21WAF1/CIP1 expression in rectal cancer patients

DNA damage induces p53-mediated cell cycle arrest in which p21WAF1/CIP1, a cyclin-dependent kinase inhibitor, may play a critical role by being regulated via wild-type p53. Although adjuvant preoperative radiotherapy in rectal carcinoma is generally believed to improve the prognosis, it remains unclear which factors control the response. We investigated the interactions between the underlying mechanisms of cell cycle perturbation in response to radiotherapy, and local recurrence and distant metastasis in patients undergoing radical surgery for rectal carcinoma. A retrospective review was carried out in which 63 cases of Dukes' B or C, well or moderately differentiated rectal carcinomas in the lower two-thirds of the rectum, with or without preoperative radiotherapy, were immunohistochemically analyzed using antibodies to p53 and p21WAF1/CIP1. Induced p53 expression in adjacent normal mucosa, as seen in seven of 35 cases with radiotherapy, and mutually exclusive p21WAF1/CIP1 immunoreactivity, was strongly associated with local recurrence (P=0.0001). Furthermore, high p21WAF1/CIP1 expression was associated with a lack of distant metastasis (P=0.032). Our data suggest that there are some cases in which p53 overexpression in adjacent normal mucosa induced by radiotherapeutic treatment might heighten the risk of local recurrence, and that p21WAF1/CIP1 induction independent of the status of the p53 gene showing radiosensitivity might lead to a less distant metastasis.

Comparion of the postoperative radiotherapy of rectal carcinoma and with only operation

Objective To study the influence of the postoperative radiotherapy(PORT) on the local recurrent rate of rectal carcinoma .Methods All patients were treated by Mile , s or Dixon operations ; and randomized into two groups after operation , PORT group (58 cases) were given radiotherapy to a total dose of 45Gy in posterior field and both side field for 4.5～5 weeks ,then followed by 10～15Gy, the other group (45 cases) were treated with only operation.Results The 1/2\| ?1\| and 2 years local recurrent rates were 8.89%?17.78%?35.56% in only operation group; and 1.72%?5.17%?12.07%in PORT group , respectively .The differences of local recurrent rates were significant between both groups after 1 year, and after 2 years .Conclusion The local recurrent rate of PORT group was obviously decreased in comparison with the only operation group.

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.

Bilateral Long Ureteral Strictures, as an Early Complication, Following Short-term Preoperative Pelvic Radiotherapy for Rectal Carcinoma

Bilateral Long Ureteral Strictures, as an Early Complication, Following Short-term Preoperative Pelvic Radiotherapy for Rectal Carcinoma

Local excision and post-operative radiotherapy for rectal carcinoma

Local excision and post-operative radiotherapy for rectal carcinoma

The locoregional recurrence of rectal carcinoma. A computed tomographic analysis and a target volume concept for adjuvant radiotherapy

In the adjuvant postoperative radiotherapy of rectal carcinoma the knowledge of the predominant areas of recurrences is of major importance for the definition of the target volume. We analysed the pattern and locations of tumor recurrences in the CT scans of 155 patients and correlated the findings with the primary tumor location (above and below the peritoneal duplication) and the operating method (abdominoperineal extirpation, anterior resection. Hartmann procedure). Hundred and fifty-five patients with the diagnosis of rectal carcinoma recurrences were treated in our institution between 1980 and 1995. To determine the extension of the recurrent tumor within the pelvic levels (presacral levels S1-S5, precoccygeal, pelvic floor level and perineal level) and the tumor infiltration of pelvic organs and muscles we analysed the pretherapeutic CT images. The lymph node recurrences were classified as: pararectal, presacral, iliac internal, iliac external, iliac communis and para-aortal recurrences. Sixty-one percent of the patients with rectum extirpation and 66% with anterior resection showed a combined local and nodal recurrence. Isolated lymph node recurrences were rare (4% and 5%) (Tables 2 and 3). The local recurrence was mostly situated in the presacral pelvis, predominantly there was an infiltration of the presacral space at the level of S4, S5 and os coccygis regardless of the operating method and the primary tumor location (Figure 1). The anastomosis was involved in the tumor recurrence in 93% of the anteriorly resected patients (Table 3). In 9 out of 96 patients after rectum extirpation the pelvic region caudal of the tip of the coccyx was the origin of the recurrent tumor (Table 2, Figure 2). Primarily all 9 patients had a deep-seated carcinoma (< 6 cm ab ano). Only 2 patients showed an isolated perineal recurrence after rectum extirpation (Table 2. Figure 2). Two thirds of the deep-seated tumors showed a vaginal involvement (Figures 3 and 4). The incidence of iliac internal and presacral nodal recurrence was 47 to 59% (Figures 3 and 4). The incidence of iliac external lymph node recurrences was 7% after rectum extirpation and 2% after anterior resection/Hartmann procedure. Our data demonstrate that 2/3 of the patients with tumor-bed recurrences also show lymph node recurrences predominantly in the iliac internal and presacral groups. This has to be considered in the definition of the boost target volume. The target volume must also include the dorsal wall of the urogenital organs. A ventral extension of target volume up to iliac external lymph nodes is not necessary.

Designing the optimal surgery for rectal carcinoma

CancerVolume 78, Issue 9 p. 1847-1850 EditorialFree Access Designing the optimal surgery for rectal carcinoma Warren E. Enker M.D., Corresponding Author Warren E. Enker M.D. Department of Surgery, and Division of Colorectal Surgery, Beth Israel Medical Center, New York, New York.350 East 17th Street, Baird Hall 1622, New York, NY 10003===Search for more papers by this author Warren E. Enker M.D., Corresponding Author Warren E. Enker M.D. Department of Surgery, and Division of Colorectal Surgery, Beth Israel Medical Center, New York, New York.350 East 17th Street, Baird Hall 1622, New York, NY 10003===Search for more papers by this author First published: 1 November 1996 https://doi.org/10.1002/(SICI)1097-0142(19961101)78:9<1847::AID-CNCR1>3.0.CO;2-CCitations: 23AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat References 1 Enker WE, Laffer UT, Block GE. Enhanced survival of patients with colon and rectal cancer is based upon wide anatomic resection. Ann Surg 1979; 190: 350– 60. 2 Heald RJ. A new approach to rectal cancer. Br J Hosp Med 1979; 277. 3 Sugihara K, Moriya Y, Akasu T, Fujita S. Pelvic autonomic nerve preservation for patients with rectal carcinoma: oncologic and functional outcome. Cancer 1996; 78: 1871– 80. 4 Church JM, Raudkivi PJ, Hill GL. The surgical anatomy of the rectum: a review with particular relevance to the hazards of rectal mobilization. Int J Colorectal Dis 1987; 2: 158– 66. 5 Beart RW, Steele GD, Menck HR, Chmiel JS, Ocwieja KE, Winchester DP. Management and survival of patients with adenocarcinoma of the colon and rectum: a national survey of the Commission on Cancer. J Am Coll Surg 1995; 181: 225– 36. 6 Enker WE, Thaler HT, Cranor ML, Polyak T. Total mesorectal excision in the operative treatment of rectal cancer. J Am Coll Surg 1995; 181: 335– 46. 7 Heald RJ, Husband EM, Ryall RDH. The mesorectum in rectal cancer surgery: the clue to pelvic recurrence. Br J Surg 1982; 69: 613– 6. 8 Quirke P, Durdey P, Dixon MF, Williams NS. Local recurrence of rectal adenocarcinoma due to inadequate surgical resection. Histopathological study of lateral tumor spread and surgical excision. Lancet 1986; 1: 996– 9. 9 Adam IJ, McHamdee MO, Martin IG. et al. Role of circumferential margin involvement in the local recurrence of rectal cancer. Lancet 1994; 344: 707– 11. 10 Paty PB, Enker WE, Cohen AM, Lauwers GY. Treatment of rectal cancer by low anterior resection with coloanal anastomosis. Ann Surg 1994; 219: 365– 73. 11 MacFarlane J, Ryall RDH, Heald RJ. Mesorectal excision for rectal cancer. Lancet 1993; 341: 457– 60. 12 Enker WE. Potency, cure, and local control in the operative treatment of rectal cancer. Arch Surg 1992; 127: 1396– 1402. 13 Havenga K, Enker WE, McDermott K, Cohen AM, Minsky BD, Guillem J. Male and female sexual and urinary function after total mesorectal excision with autonomic nerve preservation for carcinoma of the rectum. J Am Coll Surg 1996; 182: 495– 502. 14 Minsky BD. Preoperative combined modality treatment for rectal cancer. Oncology 1994; 8: 53– 8. 15 Swedish Rectal Cancer Trial. Local recurrence rates in a randomized multiculture trial of preoperative radiotherapy compared with operation alone in resectable rectal carcinoma. Eur J Surg 1996; 162: 397– 402. 16 Stockholm Colorectal Cancer Study Group. Randomized study on preoperative radiotherapy in rectal carcinoma. Ann Surg Oncology 1996; 3: 423– 30. 17 Dutch Colorectal Cancer Group. Total mesorectal excision (TME) with or without preoperative readiotherapy in the treatment of primary rectal cancer. A multicenter phase III study. January 1996. 18 Norstein J, Bergan A, Langmark F. Risk factors for local recurrence after radical surgery for rectal carcinoma: a prospective multicentre study. Br J Surg 1993; 80 (Suppl): 22. 19 Quirke P. The pathologist's role in the evaluation of local recurrence in rectal cancer. In: Surgical Workshop and Prosection Course, Royal College of Surgeons of London, London, United Kingdom, April 25–26, 1995. Citing Literature Volume78, Issue91 November 1996Pages 1847-1850 ReferencesRelatedInformation