The conservative management of anorectal cancer by radiotherapy

The Conservative Management of Anorectal Cancer by Radiotherapy P. Ager, MD,* Bronx, New York E. Samala, MD, Bronx, New York J. Bosworth, MD,* Bronx, New York M. Rubin, MD,+ Bronx, New York N. A. Ghossein, MD, Bronx, New York

The classic treatment for anal or low rectal carcinoma is radical surgery. Radiation therapy has not been used often for these lesions because it is commonly believed that these tumors are radioresistant [I]. However, recent studies have shown that microscopic colorectal cancer is eradicated by moderate radiation doses delivered either preoperatively [%5] or postoperatively [6]. Using radical doses of radiation delivered,either by megavoltage equipment alone or in combination with interstitial implants, these tumors may be locally controlled. Our experience with primary radiation treatment of low rectal and anal cancers is presented herein. Material and Methods From May 1968 to July 1976, thirteen patients were referred to the Radiotherapy Section of the Albert Einstein College of Medicine for definitive radiotherapy for biopsy-proven anal or rectal carcinoma. Patients who were referred for palliative treatment because of bleeding, obstruction, or pain were not included in this study. There were six males and seven females, with ages ranging between forty-seven and eighty-seven years (average, 65 years). The surgical procedures performed prior to irradiation were: biopsy only (4 patients); subtotal excision (4); and fulguration and/or total excision (5). Nine tumors were adenocarcinomas and four were squamous cell cancers. Four patients had medically inoperable disease and one had surgically inoperable disease. The remaining eight patients refused an abdominoperineal procedure. All patients received external radiotherapy on a supervoltage unit, either a cobalt 60 or an 8 mev accelerator. Six patients received external radiotherapy only. The pelvis From the Department of Radiology, Section of Radiotherapy, Albert Einstein College of Medicine, Bronx, New York. Reprint requests should be addressed to Jay L. Bosworlh, M), Department of Radiotherapy, Albert Einstein Hospital, 1825 Eastchester Road, Bronx, New York 10461. Presented at the Nineteenth Annual Meeting of the American Society of Therapeutic Radiologists, Denver, Colorado, November 2, 1977. * Junior Faculty Clinical Fellow, American Cancer Society. t Fellow, Cancer-Leukemia Grant.

228

was treated either by parallel opposing portals or by four oblique fields. A total tumor dose of 4,000 to 6,000 rad was delivered over four to seven weeks. Patients with anal lesions also had a direct perineal field. The remaining seven patients underwent external radiotherapy, 2,000 to 4,600 rad, followed by an additional dose of 3,200 to 5,000 rad by interstitial implant. Implantation of tumors that were located up to 6 cm from the anus was either by cesium needles (5 patients) or by nylon tubes loaded with iridium 192 ribbons (2 patients). The technic used for the iridium 192 implantation is similar to that used for the “blind-end” procedure described by Hilaris [7]. Briefly, with the patient in the lithotomy position, stainless steel needles, 15 cm long, were introduced into the pararectal tissues. The depth of penetration of the needles was controlled by the index finger, which was placed in the rectum. Needles were placed 1 cm from each other in a horseshoe patten in the tumor area. Hollow nylon tubes with a sealed proximal end were introduced into the needles to the desired length. The stainless steel needles were then removed while the nylon tubes were held in place. A button was fixed over the protruding end of the nylon tube without occluding the tube. This button was then sutured to the perianal skin. Iridium 192 was later placed into the hollow nylon tubes. The patient received opiates and a low residue diet for the three to five days usually necessary to deliver the desired dose, calculated to the average dose rate in the implant. Results Of the thirteen patients treated, nine (69 per cent) are alive without evidence of disease from fifteen to fifty-five months (average, 30 months). In Table I the results of the six patients who received external radiation only are shown. All but two patients received 6,000 rad. Three patients are alive without evidence of disease twelve to fifty-five months after treatment. One of these (patient 3) had a local recurrence and was salvaged by abdominoperineal resection. Of the three patients who died, two had local recurrence and distant disease, and one had distant disease only. The American Journal of Surgery

Radiotherapy

TABLE I Patient

for Anorectal

Cancer

Results of Treatment with External Radiotherapy Only Size of Lesion (largest diameter)

1 2 3 4 5 6

Circumferential Circumferential 3cm 3 cm, polypoid 9cm Circumferential

Surgical Procedure

Dose to Primary (rad)

Status

Biopsy Biopsy Excision Excision Subtotal excision Biopsy

6,000 6,000 5,400 6,000 6.000 4,000

Dead, local and distant failure, 18 mo NED 12 mo NED 26 mot NED 55 mo Dead, distant failure, 11 mo Dead, local and distant failure, 22 mo

Operability Operable* Surgically inoperable Operable* Operable+ Medically inoperable Medically inoperable

Note: NED = no evidence of disease. Patient refused surgery. t Local recurrence salvaged by abdominoperineal l

resection.

Five of the seven patients treated by external radiation plus interstitial implant are alive without evidence of disease fifteen to thirty-four months. (Table II.) One of the remaining two patients died at twelve months from myocardial infarction. Rectal biopsies performed one week prior to death were negative for tumor. The remaining patient is alive with local recurrence at thirty months. Nine of the thirteen patients treated (69_per cent) were controlled locally twelve to fifty-five months after treatment. Five patients underwent either complete excision or fulguration prior to irradiation, with only one local failure. Of the eight patients who underwent either a biopsy only or subtotal excision, there were three local failures. Only one patient had significant complications. The patient was markedly obese and had diabetes, hypertension, and azotemia. A rectal ulcer developed in this patient, and a colostomy was required for relief of symptoms. Comments

In the first half of the twentieth century, radiation treatments for carcinoma of the rectum consisted of insertion of a radium-containing apparatus directly into the rectum [S]. Technics included insertion of radon seeds and interstitial implantation of radium needles. It was found that 4 to 8 per cent of patients with inoperable disease were alive at five years. Twelve per cent of patients with operable disease were alive for the same length of time. Sir Charles Watson’s remarks [8] made in 1939 may be recalled today: “It may be said about radium that it has the power to do things which surgery cannot accomplish. It can destroy an early operable growth and leave an intact rectum. It can occasionally so overwhelm an advanced, fixed, inoperable growth that all symptoms cease and so allow a patient to carry on his normal occupation and be alive in good health ten years later . . . .” Recently, intracavitary Volume 137, February 1979

irradiation alone had been used by Papillon [9,10] for selected cases of rectal lesions. He obtained a 78 per cent five year survival free of disease. Megavoltage radiation has improved local control of deep-seated tumors. This has resulted in rekindled interest in radiotherapeutic management of anal and rectal cancers [11,12]. The Miles procedure (abdominoperineal resection for rectal and anal cancers) was first described in 1908. It has a mortality which varies between 1.3 to 17 per cent and a complication rate of approximately 35 per cent [13]. The overall five year survival for patients with all stages of disease was reported to be 52 per cent [13]. However, a high rate of impotence is associated with the procedure, and permanent colostomy is required. Crile and Turnbull [14] compared the five year results obtained in 226 patients who underwent abdominoperineal resection with results in sixty-two patients who underwent electrocoagulation only. The posttreatment survival rate obtained with electrocoagulation was similar to that obtained with surgical resection. They urged that patients with a low lying carcinoma of the rectum not exceeding 5 cm in diameter be treated initially by electrocoagulation. Similar results were obtained by Salvati and Rubin [15], who reported 48 per cent local control of selected cases of rectal carcinoma by electrocoagulation alone. Rider [I I] recently challenged the exclusivity of the Miles procedure in the treatment of anorectal cancers. He treated a series of sixty-five patients with carcinoma of the rectum with a total dose of 4,500 to 5,500 delivered over four to five weeks. Seventy-five per cent of these patients had cancers deemed inoperable; 25 per cent are alive at five years. The reason for delivering moderate doses of external radiation after excision or fulguration of the primary tumor and prior to interstitial implantation is twofold: (1) to decrease the size of the primary tumor so that a smaller area may be implanted; and (2) to eradicate subclinical disease, particularly in regional lymph nodes. Low doses of preoperative radiation have resulted in a decrease in the expected 229

Ager et al

TABLE II

Patient

Results of Treatment by External Radlatlon and Interstitial Implant

Location

Surgical Procedure

Operability Medically inoperable

Subtotal excision

3,000

3,500 cs

Dead, other

Operable+

Subtotal, excision Biopsy

3,000

3,250 Cs

NED 20 mo

3,000

4,000 Ir

NED 28 mo

2,000 4,200

5,000 cs 3,500 cs

2,500

3,000 cs

NED 15 mo Alive, local recurrence 30 mo NED 30 mo

4,600

4,000 Ir

NED 34 mo

Anal, squamous

8

Anal, squamous

Anus and rectovaginal septum 3cm

9

Anorectal, squamous

6 cm

Anal, squamous Rectal, adenocarcinoma Rectal, adenocarcinoma Rectal, adenocarcinoma

1 cm 4cm

Medically inoperable Operable+ Operable?

3cm

Operable+

Excision Subtotal, excision Excision

5cm

Operable+

Fulguration

12 13

Implant Dose (rad)

Size

7

10 11

External Radiation (rad; 3 times/ day)

Status l

12 mo

Note: NED = no evidence of disease; Cs = cesium; Ir = iridium. Negative biopsy 1 week prior to death from myocardial infarction. 7 Refused surgery. l

number of Dukes’ C lesions [3]. It should be pointed out that the dose delivered by external radiation be moderate enough to allow for subsequent abdominoperineal salvage surgery if necessary. In conclusion, gross removal of the primary lesion by electrocoagulation or excision followed by radiotherapy, particularly when interstitial implantation is used, has resulted in a high local control rate. For patients with medically or surgically inoperable disease and for patients who refuse abdominoperineal resection, this method of treatment may be considered for the control of local disease.

Summary

Thirteen patients with an anal or rectal carcinoma were given curative radiotherapy. Four had medically inoperable tumors, one had a surgically inoperable tumor, and eight refused abdominoperineal resection. Six patients received external radiotherapy only. Seven patients received external radiotherapy and an interstitial implant. Nine of thirteen patients (69 per cent) are alive without evidence of disease from fifteen to. fifty-five months (average, 30 months). Six of seven patients who received external radiotherapy combined with an interstitial implant were controlled locally, whereas three of six patients who received external radiotherapy only were controlled. Patients who underwent total excision and/or fulguration prior to irradiation had better local control than those who underwent either biopsy only or a subtotal excision. This treatment method may be offered as an alternative to abdominoperineal resection in patients who are medically unfit or who refuse surgery. 230

Acknowledgment: We are grateful to Mrs. Robin Kesztenbaum for her secretarial assistance in the preparation of the manuscript. References 1. Paterson JKR: The Treatment of Malignant Disease by Radiotherapy, 2nd Edition. London, Edward Arnold, 1963. 2. Allen CV, Fletcher WS: A pilot study on preoperative irradiation of rectosigmoid carcinoma. Am J Roentgenol Radium Ther Nucl Med 114: 504, 1972. 3. Kligerman MM, Urdaneta N, Knowlton A, Vidone R, Hartman PV, Vera R: Preoperative irradiation of rectosigmoid carcinoma including its regional lymph nodes. Am J Rot?n@?nol 114(3): 498, 1972. 4. Priestman TJ: The place of radiotherapy in the management of rectal adenocarcinoma. Cancer Treat Rev 4: 1, 1977. 5. Roswit B, Higgins G, Humphrey E, Robinette C: Preoperative irradiation of operable adenocarcinoma of rectum and rectosigmoid colon. Radiology 108: 389. 1973. 6. Turner SS, Vieira EF, Ager PJ, Alpert S, Efron G, Ragins H, Weil P, Ghossein NA: Elective postoperative radiotherapy for locally advanced colorectal cancer. A preliminary report. Cancer 40: 105, 1977. 7. Hilaris BS: Handbook of Interstitial Brachytherapy. Acton, Publishing Sciences Group, 1975, p 77. 8. Cade: Malignant Disease of Rectum and Anus, ~013. Textbook on Malignant Disease and Its Treatment by Radium. Baltimore, Williams & Wilkins, 1950. 9. Papillon J: Endocavitary irradiation in the curative treatment of early rectal cancers. Dis Colon Rectum 17: 172, 1974. 10. Papillon J: Resectable rectal cancers. Treatment by curative endocavitary irradiation. JAMA 231: 1385, 1975. 11. Rider WD: Is the Miles operation really necessary for the treatment of rectal cancer. J Can Assoc Radio/ 26(3): 167. 1975. 12. Rosseau J, Cuzin J, et al: La cobalt-therapie dans le cancer du rectum. Arch Fr Mal App Dig 58(9): 49, 1969. 13. MacLennan G, Stogtyn RD. Voitk AJ: Abdominoperineal resection. Treatment of choice for carcinoma of the rectum. Cancer 38: 953, 1978. 14. Crile G Jr, Turnbull RD: The role of electrocoagulation in the treatment of carcinoma of the rectum. Surgery Gynecol Obstet 135: 391, 1972. 15. Salvati E, Rubin R: Electrocoagulation as primary therapy for rectal carcinoma. Am J Surg 132: 583. 1976. The American Journal of Surgery