Treatment Of Rectal Carcinoma Research Articles

A Retrospective Comparison of Toxicity, Response and Survival of Intensity-Modulated Radiotherapy Versus Three-Dimensional Conformal Radiation Therapy in the Treatment of Rectal Carcinoma

A Retrospective Comparison of Toxicity, Response and Survival of Intensity-Modulated Radiotherapy Versus Three-Dimensional Conformal Radiation Therapy in the Treatment of Rectal Carcinoma

Outcomes in rectal cancer care in Uruguay: A study on quality indicators.

234 Background: For years, rectal cancer has been considered a model oncologic entity and significant therapeutic improvements have been made in the last two decades. However, evidence suggests there are important differences in quality of care between countries, institutions and teams. Therefore, population-based audits are of great importance to ensure quality cancer care. Quality indicators (QIs) provide information on safety and quality of cancer screening, diagnosis and treatment. Aim: To describe and analyze quality indicators for diagnosis and treatment of rectal carcinoma at a high-volume cancer center in Uruguay. Methods: A retrospective descriptive study was performed as a sub-analysis of a cohort of 971 patients. A total of 497 rectal or rectosigmoid-junction carcinoma patients treated between 2008 and 2020 at the Uruguayan National Cancer Institute were included. Previously validated target values formed the basis of the QIs used in this study. Each QI was reported as the proportion (% 95% CI) of patients fulfilling the criteria out of eligible patients. Kaplan–Meier method was used to calculate overall survival rates. Results: Mean age was 62 years, 59.5% were male, and 78% showed no evidence of disseminated disease at diagnosis. Diagnosis and staging: combined contrast-enhanced CT TAP scan was performed in 66% of the sample, 51% of cases had a total colonoscopy before elective curative intent surgery. Locoregional c-TN staging was assessed by high resolution MRI in 64% of cases. Only 30% and 63% of patients in the preoperatively irradiated and the nonirradiated groups had a minimum of 12 lymph nodes examined. Multimodal treatment: preoperative chemo-radiation was delivered for stages II and III middle/low-third rectal cancers in 81% of the cases. Adjuvant therapy was prescribed in 75% and 47% of stages III and II receiving surgery as upfront treatment, respectively. 78% of cStage IV patients received palliative chemotherapy. Surrogate indicators of outcome: 82% had distal tumor-free margins, although only 72% had a pathological circumferential radial margin ((y)pCRM) mentioned in the pathology report. Non-curative (R1,2) resections in M0 rectal carcinoma in our cohort was below the target value of <20%. 15% of our cases had a positive (y)pCRM. Treatment-outcomes: Our cumulative overall local recurrence was 12.6% and the 3-year overall survival rate was 84.8%. Conclusions: Continuous analysis of QIs in rectal cancer is necessary for internal quality management and for external quality assessment, to improve and compare treatment outcomes. Our results highlight the positive aspects of rectal cancer care at our center and reveal the weak points in diagnosis and treatment that need special attention. They will serve as a guide in the implementation of new strategies and programs that will aim to improve safety and quality of rectal cancer care for Uruguayan patients, regardless of where they live or are treated.

Sonographic Imaging of Surgically Transpositioned Ovaries in the Treatment of Rectal Carcinoma

Pelvic radiation therapy in patients with advanced rectal carcinoma improves oncological outcomes, but often raises infertility concerns in reproductive-age patients. Laparoscopic ovarian transposition is a surgical method which may offer preservation of ovarian function during and after cancer treatment. Sonographic evaluation of the ovaries post transposition gives insight into their condition and the efficacy of ovarian transposition in the continuation of ovarian function after radiation. This case describes how sonography was used to identify and evaluate surgically transpositioned ovaries in a patient with rectal adenocarcinoma.

THE EARLY RESULTS OF RADICAL SURGERY IN TREATMENT OF RECTAL CANCER

Objectives: To evaluate the early result of radical surgical treatment of rectal carcinoma. Subjects and methods: Longitudinal follow-up study on 109 patients diagnosed with rectal carcinoma who were surgically treated at Department of colorectal and perineal surgery, Viet Duchospital from October 2016 to May 2019. Results: Complications of anastomotic leakage (2.75%). Postoperative bleeding (1.83%). Abdominal wound infection (10.09%). Postoperative enteroplegia (5.50%). Urinary retention (4.59%). Intestinal obstruction (2.75%). Bladder leakage and psychosis both accounted for 1.83%. Intra-abdominal bleeding, pelvic abscess, acute pancreatitis all accounted for 0.92%. Parastomal hernia had a patient,accounting for 0.92%. There were 18.37% of patients relapse after surgery. There were 11.22% of patients with distant metastasis detected after surgery, the metastatic organs were liver and lung metastasises.Conclusion: Complications of radical surgery for rectal cancer were mainly anastomic leakage, wound infection, postoperative enteroplegia. The postoperative recurrence rate was 18.37% in allfollowing (11.22% of patients had distant metastases after surgery).

Determination of Tumor Location in Rectosigmoid Carcinomas: Difficulties in Preoperative Diagnostics

Differentiation between rectal and sigmoid carcinomas is a diagnostic challenge with important implications for further treatment. Depending on the tumor stage, treatment for rectal carcinoma consists of preoperative (chemo)radiotherapy and surgery. Sigmoid carcinomas are treated with surgery alone. We established the diagnostic accuracy of flexible endoscopy, MRI and/or CT scan, and both modalities combined as reflected by the conclusion of our multidisciplinary team (MDT). Furthermore, we assessed the treatment consequences of misdiagnosis. Consecutive patients were included who underwent surgery from January 2012 to January 2017 for colorectal carcinoma located ≤20 cm from the anal verge as determined by flexible colonoscopy. Diagnostic accuracy of MRI/CT, flexible endoscopy and the final MDT conclusion were analyzed as index test. The location of the tumor during surgery and the type of surgery was the reference standard. We included 293 patients. Flexible endoscopy had a diagnostic accuracy of 90% and for MRI/CT scanning this was 86–87%. Combination of both modalities improved diagnostic accuracy to 96%. Due to misdiagnosis during initial staging, three patients (1%) erroneously underwent neoadjuvant treatment and in two patients neoadjuvant treatment was potentially erroneously omitted. In conclusion, the combination of both flexible endoscopy and MRI/CT (the MDT conclusion) improves diagnostic accuracy. Erroneous clinical diagnosis can lead to under- and overtreatment.

Acquis et objectifs de la recherche clinique sur le cancer du rectum

The treatment of rectal carcinoma is based on multidisciplinary strategy and multimodal approaches including gastrointestinal tract specialists, medical oncologists, radiation oncologists and surgery. The different objectives should be declined according to the characteristics of the tumours. The aim of the therapist would be to select the best strategy offering to the patient to be cured with as less as possible late adverse toxicity. The challenge of the treatment of small tumours is to maintain a functional anal sphincter while minimizing the risk of local recurrence. The standard treatment of locally advanced disease is aiming firstly to cure the patient and secondly to prevent late complications. Each of these clinical presentations of the disease has to be considered as a whole taking into account the new surgical techniques and a personalized approach adapted to the tumour. Nowadays they should be studied with dedicated clinical trials.

Rectal carcinoma and multiple gastrointestinal stromal tumors (GIST) of the small intestine in a patient with neurofibromatosis type 1: a case report

BackgroundNeurofibromatosis type 1 (NF1) is an autosomally dominant inherited disorder characterized by multiple pigmented skin spots (café-au-lait spots) and neurofibroma. NF1 is associated with a wide variety of benign or malignant tumors. We report a NF1 patient who received surgical treatment for rectal carcinoma and multifocal small intestinal gastrointestinal stromal tumors (GISTs).Case presentationA 70-year-old female patient with NF1 was referred to our hospital after a positive fecal occult blood test. Locally advanced rectal carcinoma was detected in the upper rectum using colonoscopy. A submucosal tumor 20 mm in diameter was detected in the duodenal bulb during the upper gastrointestinal endoscopy. The biopsy specimen from the duodenum was GIST with positive immunostaining of KIT and CD34 microscopically. Laparoscopic low anterior resection for rectal carcinoma and local excision of the duodenal GIST were performed successfully. During the operation, five white small nodules were found on the serosa of the jejunum. One nodule was excised for histological examination. The resected rectal tumor was a well-differentiated adenocarcinoma with multiple lymph nodes metastases according to the histology. The duodenal tumor was found to be low-risk GIST. Moreover, the nodule from the jejunum was very low risk GIST. An excised skin wart was neurofibroma according to the histology.ConclusionsGIST or carcinomas have been reported to occasionally occur in the digestive tract of the patients with NF1. We present a rare case of a NF1 patient with GISTs and colorectal carcinoma.

Visceral obesity, muscle mass and outcome in rectal cancer surgery after neo-adjuvant chemo-radiation

BackgroundPreoperative chemoradiation has become a routine modality in the treatment of rectal carcinoma that may impair a patients general condition. In these patients, it is important to identify factors that influence postoperative recovery. Visceral obesity(VO) as a metabolic risk factor was studied in rectal cancer patients receiving preoperative chemoradiation. AimThe impact of VO on post-operative outcome in rectal carcinoma surgery after preoperative chemoradiation was studied. In addition, the effect of chemoradiation on body composition was studied. MethodThe visceral fat area(VFA), total fat area(TFA) and skeletal muscle area(SMA) were measured on cross-sectional CT-slides in 74 patients who underwent rectal cancer surgery after chemoradiation. CT-scans taken before and after chemoradiation were analysed. Associations between VFA, per- and postoperative complications were studied. A VFA of 100 cm2 and 130 cm2 was used to differentiate between non-VO and VO. ResultsUsing a VO cut-off point of a VFA of 100 cm2, the VO patients had more per-operative blood loss(471 mL vs 271 mL p = 0.020), a higher complication rate(10% vs 49% p = 0.001), more ileus(2% vs 28% p = 0.027) and a longer length of stay(9.7days vs 13days p = 0.027). When a VFA of 130 cm2 was used, VO patients showed more complications(17% vs 55%, p = 0.001) and ileus(10% vs 32% p = 0.017).During chemoradiation the SMA increased(Mean difference: 2.2 cm2 p = 0.024), while the VFA showed no change. ConclusionIt appears that VO is associated with co-morbidity and poor outcome in rectal cancer patients. Using different cutoff values for VO different associations with outcome were found. SMA increased during chemoradiation, a phenomenon that remains to be explained.

Combination of three-gene immunohistochemical panel and magnetic resonance imaging-detected extramural vascular invasion to assess prognosis in non-advanced rectal cancer patients.

AIMTo identify a small, clinically applicable immunohistochemistry (IHC) panel that could be combined with magnetic resonance imaging (MRI)-detected extramural vascular invasion (EMVI) for assessment of prognosis concerning the non-advanced rectal cancer patients prior to operation.METHODSAbout 329 patients with pathologically confirmed rectal carcinoma (RC) were screened in this research, all of whom had been examined via an MRI and were treatment-naïve from July 2011 to July 2014. The candidate proteins that were reported to be altered by RC were examined in tissues by IHC. All chosen samples were adopted from the fundamental cores of histopathologically confirmed carcinomas during the initial surgeries.RESULTSOf the three proteins that were tested, c-MYC, PCNA and TIMP1 were detected with relatively significant expression in tumors, 35.9%, 23.7% and 58.7% respectively. The expression of the three proteins were closely connected with prognosis (P = 0.032, 0.003, 0.021). The patients could be classified into different outcome groups according to an IHC panel (P < 0.01) via these three proteins. Taking into consideration known survival covariates, especially EMVI, the IHC panel served as an independent prognostic factor. The EMVI combined with the IHC panel could categorize patients into different prognostic groups with distinction (P < 0.01).CONCLUSIONThese studies argue that this three-protein panel of c-MYC, PCNA, coupled with TIMP1 combined with MRI-detected EMVI could offer extra prognostic details for preoperative treatment of RC.

Citrulline as a biomarker of gastrointestinal toxicity in patients with rectal carcinoma treated with chemoradiation.

Gastrointestinal toxicity is the principal toxicity of chemoradiation in the treatment of rectal carcinoma. The assessment of this toxicity still relies mostly on the symptoms reported by the patient. Plasma citrulline, serum neopterin and urinary neopterin were followed weekly in 49 patients with rectal carcinoma during chemoradiation. Citrulline significantly (p<0.05) decreased while serum and urinary neopterin concentrations increased during therapy. Irradiated gut volume correlated significantly inversely with citrulline and positively with urinary neopterin. Statistically significant inverse correlations were also observed between urinary neopterin and plasma citrulline concentrations during the treatment. Urinary neopterin concentrations were significantly higher and citrulline concentrations were lower in patients who experienced grade ≥3 gastrointestinal toxicity. Citrulline represents a promising biomarker of gastrointestinal toxicity. Moreover, the volume of irradiated gut correlated with urinary neopterin concentrations and an association was observed between gastrointestinal toxicity evidenced by lower citrulline concentrations and systemic immune activation reflected in increased concentrations of urinary neopterin.

Kolorektale Karzinome - personalisierte, stadienadaptierte Tumortherapie

Colorectal cancer (CRC) is the second leading cause of cancer death in the western world. Every second patient dies of the disease. The introduction of new and effective chemotherapeutic substances and biologics during the past decade has significantly improved the systemic treatment of patients with CRC. In stage III colon cancer combination chemotherapy with oxaliplatin is the standard of care. Primary resection of metastases or resection after combination therapy and downsizing of lesions offers a chance for cure for some patients. In the treatment of rectal carcinoma, multimodality and neoadjuvant treatment concepts have replaced adjuvant chemoradio-therapy for locally advanced rectal cancer. In the palliative setting intensive combination treatment is indicated in colorectal cancer if tumor related symptoms or a rapid progress of the disease occur. The aim of palliative therapy is the prolongation of survival and the improvement of quality of life. The introduction of the mutational status of the KRAS oncogene as the first predictive marker into clinical care is an important step towards the personalization of treatment in CRC.

SU-E-T-337: Intensity Modulated Brachytherapy for Rectal Cancer Using A Novel Grooved Shielding Design

Purpose: To create a novel HDR (192‐Ir) brachytherapy applicator for treatment of rectal carcinomas that uses tungsten shielding to make it dosimetrically superior to all commercially available applicators, despite being no larger than them. Methods: A set of 16 new applicators were designed and simulated using Monte Carlo (MCNPX). All designs were made of a 16‐mm diameter, high density tungsten alloy cylinder with inset grooves running along its length for the source to travel along. The designs varied regarding the number and depth of these grooves. Each design was optimized on 36 clinically treated plans (using 8‐channel Intracavitary Mold Applicator (Nucletron)) with asymmetrical CTVs, on in‐house written intensity modulated brachytherapy planning optimization software. Additionally, a 10 channel device with two channels per groove at varying depths was considered. All results were compared against the clinically treated plans. Results: First, all device designs outperformed the Intracavitary Mold Applicator in EVERY metric, except the total dwell times (about 30% increase). There were clear but relative tradeoffs regarding both the number of channels and the depth of each channel. Overall, the 12‐channel, 1‐mm depth design had the best results of the simpler designs, sparing the healthy rectal tissues the most while achieving comparable CTV coverage. All designs significantly outperformed the clinically treated plans using the Intracavitary Mold Applicator. Conclusions: Our extensive simulations and planning showed that our device designs have the ability to conform to the CTV and spare OAR with previously unmatched quality compared to existing commercial brachytherapy devices.

614P - Neoadjuvant Treatment in Rectal Cancer: Long- VS Short-Course Radiotherapy

ABSTRACT Introduction Two schemes for pre-operative radiotherapy (RT) in locally advanced rectal carcinoma (RC) are possible: long-course irradiation (45 – 50.4 Gy / 25 – 28 fr) with chemotherapy (CHT), followed by surgery after 6 to 8 weeks; and short-course irradiation (25 Gy / 5 fr), followed by surgery usually 1 week after. Some studies have shown a downstaging effect with delayed surgery in short-course irradiation Goal: Compare results of different irradiation schemes for neoadjuvant treatment of RC in a Radiation Oncology Department. Methods Patients with RC treated pre-operatively between 2002 and 2012 were included. RT was performed according to 2 schemes: long-course scheme (GROUP 1) using only RT (GROUP 1A), with oral CHT (GROUP 1B) or infusion CHT (GROUP 1C); and short-course scheme (GROUP 2). Results 265 patients were included, 227 in GROUP 1. GROUP 1A were older than GROUP 1B and 1C (p 1 week) there were significant differences in locoregional response (28.6% vs 75.0%, p = 0.033), with 2 complete responses in those with greater time to surgery. Conclusions These results are according to literature: long-course scheme with concomitant CHT provided better locoregional response, although with some acute toxicity; a higher time to surgery in short-course scheme appears to have better results, with no increase in surgical complications. Short-course irradiation with surgery delay appears to be a useful alternative to long-course radiochemotherapy, namely in patients with advanced age and associated comorbidities. Disclosure All authors have declared no conflicts of interest.

Pedunculated hamartomatous polyp of the appendix: report of a case

We experienced a rare case of a pedunculated polyp of the appendix, which had been incidentally found by preventive appendectomy performed when providing surgical treatment for rectal carcinoma. A pathological investigation of this polypoid lesion demonstrated branches of fibro-muscular stalks connecting with the lamina muscularis covered by a hyperplastic mucosa, which proved to be consistent with the features of hamartoma. The patient had no external characteristics of Peutz-Jeghers syndrome, including mucocutaneous pigmentation and gastrointestinal polyposis, observed by endoscopy. This case is considered to be a Peutz-Jeghers type polyp of the appendix with a pedunculated form, which is very rare.

Quality management in rectal carcinoma: what is feasible?

A cohort study was carried out to analyse quality indicators in the diagnosis and treatment of rectal carcinoma. A total of 2,470 patients with rectal carcinoma treated between 1985 and 2007 at the Department of Surgery, University of Erlangen, were analysed and compared within four time intervals. Most of the indicators analysed from 2004 to 2007 fulfilled the defined target values. The indicators for process quality of surgical treatment and the surrogate indicators of outcome quality in surgery showed excellent results. Comparing this to previous data, it displays the new developments such as introduction of multimodal treatment for high-risk patients. While the rate of locoregional recurrences decreased, no significant improvement in survival was found. Careful analysis of quality indicators is important for both quality management and comparison of treatment results. The progress in diagnosis and treatment requires a continuous update of definitions and target values.

Neoadjuvant Treatment of Rectal Carcinoma: Assessment of Health Care Services by Physicians and Lay Persons

Because of demographic changes, an increase in malignant diseases can be expected in the coming decades. Colorectal cancer has become the second most common form of cancer in both sexes. Standards for the diagnosis and treatment of colorectal cancer have changed considerably during the last decade, for example, the number of examined lymph nodes and routine total mesorectal excision. Multimodal treatment strategies such as neoadjuvant radiotherapy or radio-chemotherapy should further improve prognosis. Preoperative therapy reduces the local recurrence rate by half but also causes considerable long-term morbidity without influencing the prognosis. There is a variety of data sets, some of which focus on recurrence rates and prognosis, and some of which focus on quality-of-life issues. This complex situation creates difficulties in making treatment decisions for both experts and, to a greater degree, patients and lay persons. Therefore, we completed a project to summarize and present the data from several clinical trials in a way that lay persons can also understand the most important aspects, thus enhancing patient involvement in the decision-making process. The final presentation for the patients was based on published data from five major prospective, randomized, double-arm, multicentric studies on neoadjuvant treatment of rectal cancer with long-term follow-up. The target population consisted of patients who were to undergo surgery for rectal cancer, either with or without additional neoadjuvant radiotherapy or radio-chemotherapy. End points were postoperative and total mortality, rates of local relapses, and distant metastases, as well as long-term morbidity, such as frequency of fecal incontinence, cardiovascular diseases, disturbance of sexual functions, and secondary cancers resulting from radiotherapy. A detailed summary of the long-term morbidity was published separately. The summarized data of the five studies and the side effects reported for each study (summarized in Kornmann and HenneBruns) were presented in a graphical form consisting of four squares (quadrants) as shown in Figure 1. The two quadrants on the left side showed the results of treatment with preoperative radiation and the two quadrants on the right side showed the results of treatment without preoperative radiation. The two upper quadrants displayed the results that were reported in the initial publication for mortality and recurrences. The two lower quadrants showed the results for longterm morbidity, generally reported as separate publications (summarized in Kornmann and Henne-Bruns). Each of the end points was displayed in a different color. The graphically displayed results of the five studies were presented as POWERPoint presentation or colored tables to different groups of test persons. An example of a colored table is shown in Figure 1. The first group of test persons consisted of German lay persons (n 59). The second group consisted of 20 Brazilian guests of the Brazil Center Baden-Wurttemberg. Eighteen physicians participating in a seminar during the 8th Annual Convention of the German Network of Evidence-Based Medicine in Berlin, Germany, in March 2007, constituted the third group. The fourth group consisted of participants at the Congress of Health Networkers—principally health insurance managers, employees in hospital administration, and employees of the pharmaceutical industry (n 34). The fifth group consisted of 21 persons affiliated with health care politics. In the first group, the participants were requested to vote on the treatment options in the five studies after a 20-minute introduction to the topic of rectal cancer. This introduction gave a brief overview about the anatomy, pathogenesis, treatment options, possible side effects, and life with cancer recurrence. After this introduction, the participants had the chance to discuss and ask questions before voting. Each study was then presented as an animated POWERPoint slide (Fig 1). The test persons had to vote for their preferred approach, surgery with (A) or without (B) neoadjuvant treatment, immediately after the presentation of the summarized data of each study. Only the five tables with the two different therapeutic concepts were shown to the second to fifth test groups. The 152 test persons made a total of 760 decisions, of which 86% (minimum, 73%; maximum, 93%) would choose not to receive neoadjuvant therapy. In only one of the five studies, a 10% survival benefit in favor of the radiotherapy group had been reported. Nevertheless, only 24% of all participants in this study preferred the treatment with preoperative radiation. When summarizing and presenting the data, we realized the difficulties in understanding the details and reported differences in the various studies. Preparing such a presentation involves considerable time and effort, because the necessary information had to be extracted and summarized from different publications with different subgroup analyses (eg, patients who underwent R0 resection or long-term survivors). JOURNAL OF CLINICAL ONCOLOGY COMMENTS AND CONTROVERSIES VOLUME 26 NUMBER 30 OCTOBER 2

Magnetic resonance imaging (MRI)-based indication for neoadjuvant treatment of rectal carcinoma and the surrogate endpoint CRM status

Is it possible to reduce the frequency of neoadjuvant therapy for rectal carcinoma and nevertheless achieve a rate of more than 90% circumferential resection margin (CRM)-negative resection specimens by a novel concept of magnetic resonance imaging (MRI)-based therapy planning? One hundred eighty-one patients from Berlin and Mainz, Germany, with primary rectal carcinoma, without distant metastasis, underwent radical surgery with curative intention. Surgical procedures applied were anterior resection with total mesorectal excision (TME) or partial mesorectal excision (PME; PME for tumours of the upper rectum) or abdominoperineal excision with TME. With MRI selection of the highest-risk cases, neoadjuvant therapy was given to only 62 of 181 (34.3%). The rate of CRM-negative resection specimens on histology was 170 of 181 (93.9%) for all patients, and in Berlin, only 1 of 93 (1%) specimens was CRM-positive. Patients selected for primary surgery had CRM-negative specimens on histology in 114 of 119 (95.8%). Those selected for neoadjuvant therapy had a lower rate of clear margin: 56 of 62 (90%). By applying a MRI-based indication, the frequency of neoadjuvant treatment with its acute and late adverse effects can be reduced to 30-35% without reduction of pathologically CRM-negative resection specimens and, thus, without the danger of worsening the oncological long-term results. This concept should be confirmed in prospective multicentre observation studies with quality assurance of MRI, surgery and pathology.

Analysis of management of rectal carcinoma (RC) after the establishment of Multidisciplinary Rectal Cancer Committee (MRCC)

15108 Background: Treatment of RC was heterogeneous before MRCC. Surgery was the standard treatment for rectal carcinoma (RC) with the help of radiochemotherapy (RCT) applied either before or after...

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.

Optimised surgery (so-called TME surgery) and high-resolution MRI in the planning of treatment of rectal carcinoma

Since November 1998, we have applied the concept of total mesorectal excision (TME) to rectal carcinoma together with a standardised pathological quality assessment. Participation in the European MERCURY study [The MERCURY Study Group Radiology (in press), 2006] required us to establish the indication for neoadjuvant radiochemotherapy on the basis of an magnetic resonance imaging (MRI) scan. The aim of the present retrospective study is to evaluate the quality of the surgery, the efficacy of the MRI and the oncological outcomes achieved. Between November 2001 and October 2005, 68 out of 109 patients with carcinoma of the rectum were submitted to radical surgery in curative intent and 23/68 (34%) were given neoadjuvant therapy. In an interdisciplinary study group, each patient was evaluated pre-operatively and post-operatively using standardised MRI and histopathological methods. The quality of surgery was established on the basis of the pathological examination of the surgical specimen. The rates of incomplete mesorectal excision, intra-operative tumour cell dissemination and positive circumferential margins were all low at 4%, 7% and 3%, respectively. The effectiveness of MRI proved to be greatest in predicting the tumour status at the circumferential resection margin: in the admittedly limited number of patients it proved possible to correctly predict the tumour status for every patient. The assessment of the anatomic extent of the primary tumour and of the regional lymph node metastasis according to the TNM system, in contrast, was considerably less successful at 73% and 75%, and 37% and 57%, respectively. By applying the TME concept and MRI-based therapy planning, excellent results can be achieved and, at the same time, the number of patients requiring neoadjuvant treatment is considerably reduced.