Intraoperative Radiotherapy for Locally Advanced Rectal Cancer

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Abstract

Purpose

Although intraoperative radiotherapy (IORT) is known to be a method that can reduce local recurrence in locally advanced colorectal cancer, it is not widely used. The aim of this study was to report our experience with IORT for locally advanced rectal cancer.

Methods

From 1991 to 1994, nine patients with locally advanced rectal cancer received IORT. External beam radiotherapy was given postoperatively in five patients and preoperatively in three. Seven patients received chemotherapy. IORT was done with 6-MeV or 9-MeV electrons, and 12 Gy was irradiated at the tumor bed. The median follow-up period was 84 months (range, 15 to 208 months).

Results

The median age of patients was 51 years (range, 42 to 73 years). All patients had advanced clinical T-stage (cT3/4) cancer. The overall and the disease-free survival rates were 66.7% and 66.7% at 5 years, respectively. One patient developed a local recurrence near the anastomosis site, which was out of the IORT field. Four patients died before the last follow-up; three from distant metastasis and one from secondary primary cancer. Adverse effects related to IORT did not occur.

Conclusion

Although the number of patients was small in this study, IORT is thought to be safe and effective in reducing local recurrence in locally advanced rectal cancer. However, the role of IORT should be refined in the era of preoperative radio-chemotherapy followed by total mesorectal excision.

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Most cited references 19

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What is the role for the circumferential margin in the modern treatment of rectal cancer?

Iris Nagtegaal, Phil Quirke (2008)

Treatment of rectal cancer has changed dramatically over the last decade. The worldwide introduction of total mesorectal excision in combination with the increasing use of radio(chemo)-therapy has led to an improved prognosis. One of the main prognostic factors in rectal cancer is the circumferential resection margin (CRM). Since the initial description of its clinical importance in 1986, the involvement of this margin (also called lateral or radial resection margin) has been associated with a poor prognosis. In the current review, the evidence for the importance of the CRM in more than 17,500 patients is reviewed, and the relevance of this assessment to modern treatment is assessed. We demonstrate that, after neoadjuvant therapy (both radiotherapy and radiochemotherapy), the predictive value of the CRM for local recurrence is significantly higher than when no preoperative therapy has been applied (hazard ratio [HR] = 6.3 v 2.0, respectively; P < .05). Furthermore, involvement of the CRM is a powerful predictor of both development of distant metastases (HR = 2.8; 95% CI, 1.9 to 4.3) and survival (HR = 1.7; 95% CI, 1.3 to 2.3). In addition to the prognostic data, this review describes different modes of margin involvement, exact definitions, and factors influencing its presence. CRM involvement is one of the key factors in rectal cancer treatment.

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Mesorectal fascia invasion after neoadjuvant chemotherapy and radiation therapy for locally advanced rectal cancer: accuracy of MR imaging for prediction.

Klaas van Gisbergen, Geerard Beets, R. Vliegen … (2008)

To retrospectively assess sensitivity and specificity of magnetic resonance (MR) imaging after chemotherapy and radiation therapy for predicting tumor invasion of the mesorectal fascia (MRF) in locally advanced primary rectal cancer, by using results of histologic examination and surgery as the reference standard, and to determine morphologic MR imaging criteria for MRF invasion. The Ethical Committee of University Hospital Maastricht approved this study and waived informed consent. Two observers independently scored postchemoradiation MR images in 64 patients with rectal cancer (38 male [mean age, 60 years] and 26 female [mean age, 64 years] patients) for MRF tumor invasion with a confidence level scoring system defined by subjective criteria. In a subsequent consensus reading session, morphologic MR criteria for invasion were defined by comparing morphologic changes with histologic findings. These criteria were evaluated and compared with the subjective criteria by comparing areas under the receiver operating characteristic curves (AUCs). AUCs of postchemoradiation MR imaging for predicting MRF tumor invasion were 0.81 and 0.82 for observers 1 and 2, respectively. The following four types of morphologic tissue patterns at MR imaging were associated with whether or not MRF invasion was present at histologic examination: (a) development of fat pad larger than 2 mm (seen in no quadrants with and in four quadrants without invasion), (b) development or persistence of spiculations (seen in no quadrants with and in 22 quadrants without invasion), (c) development of diffuse hypointense "fibrotic" tissue (seen in 21 quadrants with and in 32 quadrants without invasion), and (d) persistence of diffuse iso- or hyperintense tissue (seen in 19 quadrants with and in two quadrants without invasion). AUC of postchemoradiation MR imaging for predicting MRF invasion on the basis of morphologic criteria was 0.80. There was no significant difference between the performance of subjective and morphologic criteria (P = .73-.76). Postchemoradiation MR imaging findings have moderate accuracy for predicting tumor invasion of the MRF related to the limitation in differentiating between diffuse "fibrotic" tissue with and that without small tumor foci. Specific other types of morphologic patterns at MR imaging can highly predict a tumor-free or invaded MRF. (c) RSNA, 2008.

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Intraoperative radiation therapy.

Andrea Tyler, Brian Czito, G Willett (2007)

Intraoperative radiation therapy (IORT) is the delivery of irradiation at the time of an operation. This is performed by different techniques including intraoperative electron beam techniques and high-dose rate brachytherapy. IORT is usually given in combination with external-beam radiation therapy with or without chemotherapy and surgical resection. IORT excludes part or all dose-limiting sensitive structures, thereby increasing the effective dose to the tumor bed (and therefore local control) without significantly increasing normal tissue morbidity. Despite best contemporary therapy, high rates of local failure occur in patients with locally advanced or recurrent rectal cancer, retroperitoneal sarcoma, select gynecologic cancers, and other malignancies. The addition of IORT to conventional treatment methods has improved local control as well as survival in many disease sites in both the primary and locally recurrent disease settings. More recently, there has been interest in the use of IORT as a technique of partial breast irradiation for women with early breast cancer. Given newer and lower cost treatment devices, the use of IORT in clinical practice will likely grow, with increasing integration into the treatment of nonconventional malignancies. Optimally, phase III randomized trials will be carried out to prove its efficacy in these disease sites.

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Author and article information

Journal

Journal ID (nlm-ta): J Korean Soc Coloproctology

Journal ID (publisher-id): JKSC

Title: Journal of the Korean Society of Coloproctology

Publisher: The Korean Society of Coloproctology

ISSN (Print): 2093-7822

ISSN (Electronic): 2093-7830

Publication date (Print): August 2010

Publication date (Electronic): 31 August 2010

Volume: 26

Issue: 4

Pages: 274-278

Affiliations

Department of Radiation Oncology, Yeungnam University College of Medicine, Daegu, Korea.

[1 ]Department of Surgery, Yeungnam University College of Medicine, Daegu, Korea.

Author notes

Correspondence to: Min Kyu Kang, M.D. Department of Radiation Oncology, Yeungnam University College of Medicine, 317-1 Daemyeong-dong, Nam-gu, Daegu 705-717, Korea. Tel: +82-53-620-3376, Fax: +82-53-624-3599, mkkang@ 123456ynu.ac.kr

Article

DOI: 10.3393/jksc.2010.26.4.274

PMC ID: 2998003

PubMed ID: 21152229

SO-VID: 999e2bbb-e9a2-48e8-a37e-e2620e06af70

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

History

Date received : 24 November 2009

Date accepted : 07 June 2010

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Intraoperative Radiotherapy for Locally Advanced Rectal Cancer

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Abstract

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Karger: Oncology

Most cited references 19

What is the role for the circumferential margin in the modern treatment of rectal cancer?

Mesorectal fascia invasion after neoadjuvant chemotherapy and radiation therapy for locally advanced rectal cancer: accuracy of MR imaging for prediction.

Intraoperative radiation therapy.

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