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7The role of radiation therapy in anal canal carcinoma (ACC)
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5 C O M B I N E D T R E A T M E N T M O D A L I T I E S IN EOSOPHAGUS CANCER
THE ROLE OF RADIATION THERAPY FOR COLORECTAL CANCER IN LIGHT OF NEW TRENDS IN SURGERY AND ADJUVANT CHEMO'rHERAPY
J.F. Bosset and J.J. Pavy We shall consider combined treatment modalities as a function of the clinical stage and the patient operability. First situation : TI-T2, NX/NI operable patients. The standard treatment is a trans-thoracic oesophagectomy and 2 field lymp nodes resection. The median survival is - 50, 30 and 24 months respectively for stage I, IIA and liB. The quality of resection (RO versus RI/R2) and the nodal involvement are the major prognosis factor. The pre operative mortality should be < 5%. Pre or post operative adjuvant treatment did not demonstrate any evidence of efficacy in this situation. An US phase Ill trial compared oesophagectomy to pre-op XRT-CT. 100 patients entered into the trial. With a median FU of 1.84 years no survival difference was observed. A European phase III trial compared surgery to pre-op XRT-CT. 285 patients entered into the trial. With a median FU of 3.4 years, no survival differences was observed. The XRT-CT arm was associated with a significant decrease of cancer death but a significant increase of post-op death. Second situation : resectable T3, operable patients, combined XRTCT have been emerged as primary treatment. An ongoing phase 11I trial questions the role of surgery. Third situation : unresectable T3 or inoperable patients. Some trials EORTC and RTOG, demonstrated a benefit for XRT-CT versus XRT alone. Further ways of development for the combined XRT-CT : I. increasing the XRT dose (external or endoluminal brachytherapy); 2. other CT delivery modality; 3. new combined drugs. Quality of life is emerging as a new additional end-point.
OLAV DAHL, Dept. of Oncology, Haukeland Hospital. Bergen, Norway
Local recurrence rate remains in the range 15-35 % for rectal cancer, while distant (mostly hepatic) metastases is the main problem in colon cancer after curative resection. Rectal cancer. The standard surgical procedures has been challenged by total mesorectat excision which seems to yield local recurrence rates less than 10 % of the patients combined with reduced distant metastases. Radiation for all patients may further deminish the recurrence rate to 0-5 %. The role of adjuvant radiation, either as a preoperative or a postoperative procedure, must therefore be redefined in this setting. Some American studies indicate a benefit for combination of radiation and chemotherapy added to surgery. The main question is now whether it is indicated to give a potential hazardous treatment to all patients which will benefit less than 10 % of them. For advanced tumores preoperative radiation alone or combined with hyperthermia and drugs seems approapriate. For early cancer the role of sphincter saving local excision or contract radiation should be further evaluated. Colon cancer. The role of adjuvant chemotherapy (fluorouracil combined with levamlsole or leucovorin (tetrahydrofolate)) is now generally accepted for patients with lymph node metastases (Dukes stage C turnouts), based chiefly on American studies. However, this fact seems to be challenged by the interim analysis of two newer randomized studies including about 3000 patients with a surgery alone control arm. Chemotherapy for colon cancer Dukes' stage B remains experimental. Radiotherapy has a limited role. but may become more important after marginal resections. The increased knowledge of pro et cons for the parucular therapies, underlines the need for better selection of patients for local therapy tradiatloa) or systemic therapy (chemotherapy). Clinical data seems to indicate that the pattern of recurrence can be predicted. Unrevealing the underlying mechanisms is a major challenge for molecular biologists and clinicians. Some guidelines for treatment of early and late colorectal cancer will be given.
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THE ROLE OF RADIATION THERAPY IN ANAL CANAL CARCINOMA (ACC) J.P GERARD, R. COQUARD - Service de Radioth~rapieOncologie - Centre Hospitalier LYON SUD - 69495 PIERRE BENITE CEDEX, France • Some twenty years ago, ACC was often confused with adenocarcinoma of the low rectum and standard treatment was abdomino perineal amputation. Dramatic changes have occured regarding : The knowledge of this rare disease with unexplained large female predominance, the potential roles of HPV16 virus, specific chromosomal mutation, specific histopathological presentation. - The treatment : radiation therapy Is at the present time, regarded as the treatment of choice by all the experts giving 5 years survival rate around 60% and avoiding permanent colostomy. It is interesting to notice that this important change has been made without any randomized trial. • Recent phase III tdals have demonstrated that for advanced tumor (> 4 cm in diameter) concomitant radio chemotherapy with 5 FU - Mitomycin is improving colostomy free survival (EORTC UKCCCR) over radiotherapy alone. 5 FU Mitomycin is also supedor to 5 FU alone (RTOG). Ongoing tdals are evaluating the role of 5 FU - Cisplatinum. • The lecture will focus on 3 Importants problems : The diagnosis and treatment of pararectal metastatic lymph nodes which is poorely studied in the lifterature. - The technique of radioatherapy which varies widely from one center to another, what Is the optimal dose, in which volume ? Is iddium 192 brachytherapy usefull to boost the pdmary ? What is the role of surgery to control the primary tumor and inguinal lymph nodes. In conclusion, ACC Itiustrates the important role of radiation therapy in the curative and conservative approach of cancer. It deserves great clinical expedence, meticulous technique and close follow up.
A d j u v a n s t r e a t m e n t after r e s e c t i o n for p a n c r e a t i c cancer: Results o f a E u r o p e a n r a n d o m i z e d s t u d y
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Ref. WAGNER J.P - GERARD J.P. Radiation Therapy of anal canal carcinoma. I.J.R.O.B.P, 1994, 29 : 17-23
Name of authors: Jeeket J. Klinkenbijl JHG. Academic Hospital Rotterdam, Rotterdam, the Netherlands The Whipple's resection for pancreatic cancer can be considered as a lumpectomy'. After such an operation Ioco-regional recurrence occurs in a high percentage and is mainly responsible for failure of treatment. Survival in pancreatic cancer may be improved by better prevention of Ioco-regional recurrence. This can be obtained either by more extensive surgery or by adjuvans treatment with radiotherapy or perfusion therapy. More extended surgery may lead to more complications and mortality. Radiotherapy and 5-FU treatment has shown to be effective in controlling locally advanced pancreatic cancer. This treatment form may be useful as an adluvans treatment in pancreatic cancer. The toxicity of this treatment is very low. We have treated 34 patients with localized non-resectable pancreatic cancer with radiotherapy and 5-FU and obtained a 5-years survival of 6 % We performed a second look operation in 9 patients after treatment with radiotherapy and 5-FU and could perform a Whipple resection in 4 of these patients. A prospective randomized study was performed in 221 patients with pancreatic cancer in which one group was treated after resection with radiotherapy and 5-FU and the other group was not treated. The toxicity was very low. The expectation was that survival benefit would be found in the group treated with radiotherapy and 5-FU as was found in the GITSG study where in 21 patients a 5-year survival rate of 19% was found and in 21 patients without adluvans treatment a 5-year survival of 4,5 %.
5 C O M B I N E D T R E A T M E N T M O D A L I T I E S IN EOSOPHAGUS CANCER
THE ROLE OF RADIATION THERAPY FOR COLORECTAL CANCER IN LIGHT OF NEW TRENDS IN SURGERY AND ADJUVANT CHEMO'rHERAPY
J.F. Bosset and J.J. Pavy We shall consider combined treatment modalities as a function of the clinical stage and the patient operability. First situation : TI-T2, NX/NI operable patients. The standard treatment is a trans-thoracic oesophagectomy and 2 field lymp nodes resection. The median survival is - 50, 30 and 24 months respectively for stage I, IIA and liB. The quality of resection (RO versus RI/R2) and the nodal involvement are the major prognosis factor. The pre operative mortality should be < 5%. Pre or post operative adjuvant treatment did not demonstrate any evidence of efficacy in this situation. An US phase Ill trial compared oesophagectomy to pre-op XRT-CT. 100 patients entered into the trial. With a median FU of 1.84 years no survival difference was observed. A European phase III trial compared surgery to pre-op XRT-CT. 285 patients entered into the trial. With a median FU of 3.4 years, no survival differences was observed. The XRT-CT arm was associated with a significant decrease of cancer death but a significant increase of post-op death. Second situation : resectable T3, operable patients, combined XRTCT have been emerged as primary treatment. An ongoing phase 11I trial questions the role of surgery. Third situation : unresectable T3 or inoperable patients. Some trials EORTC and RTOG, demonstrated a benefit for XRT-CT versus XRT alone. Further ways of development for the combined XRT-CT : I. increasing the XRT dose (external or endoluminal brachytherapy); 2. other CT delivery modality; 3. new combined drugs. Quality of life is emerging as a new additional end-point.
OLAV DAHL, Dept. of Oncology, Haukeland Hospital. Bergen, Norway
Local recurrence rate remains in the range 15-35 % for rectal cancer, while distant (mostly hepatic) metastases is the main problem in colon cancer after curative resection. Rectal cancer. The standard surgical procedures has been challenged by total mesorectat excision which seems to yield local recurrence rates less than 10 % of the patients combined with reduced distant metastases. Radiation for all patients may further deminish the recurrence rate to 0-5 %. The role of adjuvant radiation, either as a preoperative or a postoperative procedure, must therefore be redefined in this setting. Some American studies indicate a benefit for combination of radiation and chemotherapy added to surgery. The main question is now whether it is indicated to give a potential hazardous treatment to all patients which will benefit less than 10 % of them. For advanced tumores preoperative radiation alone or combined with hyperthermia and drugs seems approapriate. For early cancer the role of sphincter saving local excision or contract radiation should be further evaluated. Colon cancer. The role of adjuvant chemotherapy (fluorouracil combined with levamlsole or leucovorin (tetrahydrofolate)) is now generally accepted for patients with lymph node metastases (Dukes stage C turnouts), based chiefly on American studies. However, this fact seems to be challenged by the interim analysis of two newer randomized studies including about 3000 patients with a surgery alone control arm. Chemotherapy for colon cancer Dukes' stage B remains experimental. Radiotherapy has a limited role. but may become more important after marginal resections. The increased knowledge of pro et cons for the parucular therapies, underlines the need for better selection of patients for local therapy tradiatloa) or systemic therapy (chemotherapy). Clinical data seems to indicate that the pattern of recurrence can be predicted. Unrevealing the underlying mechanisms is a major challenge for molecular biologists and clinicians. Some guidelines for treatment of early and late colorectal cancer will be given.
7
8
THE ROLE OF RADIATION THERAPY IN ANAL CANAL CARCINOMA (ACC) J.P GERARD, R. COQUARD - Service de Radioth~rapieOncologie - Centre Hospitalier LYON SUD - 69495 PIERRE BENITE CEDEX, France • Some twenty years ago, ACC was often confused with adenocarcinoma of the low rectum and standard treatment was abdomino perineal amputation. Dramatic changes have occured regarding : The knowledge of this rare disease with unexplained large female predominance, the potential roles of HPV16 virus, specific chromosomal mutation, specific histopathological presentation. - The treatment : radiation therapy Is at the present time, regarded as the treatment of choice by all the experts giving 5 years survival rate around 60% and avoiding permanent colostomy. It is interesting to notice that this important change has been made without any randomized trial. • Recent phase III tdals have demonstrated that for advanced tumor (> 4 cm in diameter) concomitant radio chemotherapy with 5 FU - Mitomycin is improving colostomy free survival (EORTC UKCCCR) over radiotherapy alone. 5 FU Mitomycin is also supedor to 5 FU alone (RTOG). Ongoing tdals are evaluating the role of 5 FU - Cisplatinum. • The lecture will focus on 3 Importants problems : The diagnosis and treatment of pararectal metastatic lymph nodes which is poorely studied in the lifterature. - The technique of radioatherapy which varies widely from one center to another, what Is the optimal dose, in which volume ? Is iddium 192 brachytherapy usefull to boost the pdmary ? What is the role of surgery to control the primary tumor and inguinal lymph nodes. In conclusion, ACC Itiustrates the important role of radiation therapy in the curative and conservative approach of cancer. It deserves great clinical expedence, meticulous technique and close follow up.
A d j u v a n s t r e a t m e n t after r e s e c t i o n for p a n c r e a t i c cancer: Results o f a E u r o p e a n r a n d o m i z e d s t u d y
-
-
-
Ref. WAGNER J.P - GERARD J.P. Radiation Therapy of anal canal carcinoma. I.J.R.O.B.P, 1994, 29 : 17-23
Name of authors: Jeeket J. Klinkenbijl JHG. Academic Hospital Rotterdam, Rotterdam, the Netherlands The Whipple's resection for pancreatic cancer can be considered as a lumpectomy'. After such an operation Ioco-regional recurrence occurs in a high percentage and is mainly responsible for failure of treatment. Survival in pancreatic cancer may be improved by better prevention of Ioco-regional recurrence. This can be obtained either by more extensive surgery or by adjuvans treatment with radiotherapy or perfusion therapy. More extended surgery may lead to more complications and mortality. Radiotherapy and 5-FU treatment has shown to be effective in controlling locally advanced pancreatic cancer. This treatment form may be useful as an adluvans treatment in pancreatic cancer. The toxicity of this treatment is very low. We have treated 34 patients with localized non-resectable pancreatic cancer with radiotherapy and 5-FU and obtained a 5-years survival of 6 % We performed a second look operation in 9 patients after treatment with radiotherapy and 5-FU and could perform a Whipple resection in 4 of these patients. A prospective randomized study was performed in 221 patients with pancreatic cancer in which one group was treated after resection with radiotherapy and 5-FU and the other group was not treated. The toxicity was very low. The expectation was that survival benefit would be found in the group treated with radiotherapy and 5-FU as was found in the GITSG study where in 21 patients a 5-year survival rate of 19% was found and in 21 patients without adluvans treatment a 5-year survival of 4,5 %.