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Can all Patients with Locally Advanced Rectal Cancer Benefit from Preoperative Radiotherapy or Chemoradiotherapy?
I. J. Radiation Oncology d Biology d Physics
S328
Volume 78, Number 3, Supplement, 2010
Gy. No grade 3/4/5 related acute toxicity was observed. No radiation-induced liver disease (RILD) was observed. Other toxicity within 3 months following CRT included grade 2: anemia (1), liver capsular pain (1), nausea (1) fatigue (2) and skin toxicity (1). Fifteen patients had at least 3 months of follow-up, in-field response assessed using CT at 3 months was: PR (6), MR/SD (5), PD (4). Median follow-up was 8.7 months (1.5 to 40 months). Median in field progression-free survival was 8.9 months. Median overall survival (OS) 17.7 months; 1 year OS 42% (95% CI 18-64%). On progression, 6 patients were re-challenged with chemotherapy. No late toxicities grades 3-5 were seen. Conclusions: In a heavily pretreated population with large liver burden disease this approach of individual dose CRT appears safe; with no additional toxicity observed in higher dose bin (40 Gy). Author Disclosure: M. Hawkins, None; C. Coolens, None; C. Ockwell, None; K. Burke, None; D.M. Tait, None.
2279
Can all Patients with Locally Advanced Rectal Cancer Benefit from Preoperative Radiotherapy or Chemoradiotherapy?
C. Lai1, M. Chen1, C. Yeh1, W. Huang1, C. Chin1, Y. Kuo1, J. Wang2, S. Lee3, H. Chen4, W. Chen1 1 Chang Gung Memorial Hospital, Putz City Chiayi, Taiwan, 2Chang Gung Memorial Hospital, Taoyuan, Taiwan, 3University of California, Los Angeles, Los Angeles, CA, 4Helen F Graham Cancer Center, Delaware, DE
Purpose/Objective(s): In our hospital, surgery alone, preoperative radiotherapy (RT) and preoperative chemoradiotherapy (CCRT) followed by surgery were used in the treatment of locally advanced rectal cancer after the introduction of TME. In this study, we analyze the efficacies of these three treatment approaches in terms of patient survival, loco-regional recurrence (LRR), distant metastasis (DM), resectability and sphincter preservation outcomes. Materials/Methods: This retrospective study included 151 consecutive patients with clinical T3, T4 or node-positive rectal cancer from January 2005 to December 2007. Eighty-six patients underwent surgery alone (surgery group), 28 patients received preoperative RT (RT group, 25 Gy in 5 fractions) followed by surgery in 1 week, and 37 patients received preoperative CCRT (CCRT group, 50.4 Gy in 28 fractions) followed by surgery in 4 to 6 weeks. Results: The median follow-up time was 3 years (range, 0.26-5.16 years). The 3-year overall and disease-free survival rates in the surgery, RT, and CCRT groups were 91.9%, 88.6%, 86.1% (p = 0.72) and 75.3%, 66.6%, and 64.3% (p = 0.33), respectively. The 3-year LRR and DM rates in the surgery, RT, and CCRT groups were 10.5%, 4%, 9.7% (p = 0.69), and 19%, 30.7%, 31.1% (p = 0.21), respectively. The R0 resection and sphincter preservation rates in the surgery, RT, and CCRT groups were 97.7%, 100%, 94.6% (p = 0.50) and 97.7%, 100%, and 97.3% (p = 1.0). By multivariate analysis, pT4, distal pathological margin\2 cm, the ratio of positive LN to total LN (pLNR) . 0.2 and non-R0 resection were significant prognostic factors for LRR, while pLNR . 0.2 was the only prognostic factor for DM. For a subgroup of patients (66 of the 151 patients) with all the favorable prognostic factors (distal pathological margin $ 2cm, pLNR # 0.2, non-pT4 and with R0 resection), the LRR is only 3.5% as compared to 14% for the others (p = 0.045). Conclusions: In the era of modern TME surgery, neoadjuvant RT or CCRT might not alter the ultimate treatment outcome for patients with locally advanced rectal cancer. Nevertheless, achieving downstaging and favorable histology (non-T4, pLNR # 0.2) with clear and wide resection margins (R0, distal pathological margin $ 2 cm) by neoadjuvant RT or CCRT may still be beneficial in gaining adequate loco-regional control of the disease. Author Disclosure: C. Lai, None; M. Chen, None; C. Yeh, None; W. Huang, None; C. Chin, None; Y. Kuo, None; J. Wang, None; S. Lee, None; H. Chen, None; W. Chen, None.
2280
Twenty-year Experience in the Management of Anal Carcinoma with Interstitial Brachytherapy
J. L. Lopez Guerra1, A. J. Lozano2, J. Pera3, C. Gutie´rrez3, M. Cambray3, F. Ferrer3, M. J. Ortiz1, F. Guedea3 1
Hospitales Universitarios Virgen del Rocı´o, Sevilla, Spain, 2Hospital Universitario Son Dureta, Mallorca, Spain, 3Institut Catala` d’Oncologia, Barcelona, Spain Purpose/Objective(s): The management of anal cancer has undergone an interesting transformation over the last three decades. The idea of organ preservation emerged following the discovery of a high complete response rate from preoperative combined chemoradiation prior to abdominal-perineal resection. Radiotherapy, with concomitant chemotherapy for advanced tumors, is now the standard first-line treatment for anal carcinoma. The combination of external beam radiotherapy with interstitial brachytherapy increases the dose to the tumor volume and limits the volume of irradiated normal tissue, thereby decreasing late toxicity. We present an analysis of a series of patients treated with iridium 192 low-dose rate (LDR) or pulsed-dose rate (PDR) interstitial brachytherapy for anal carcinoma. Materials/Methods: From 1989 to 2009, 38 patients with anal carcinoma were treated with brachytherapy at the Catalan Institute of Oncology in Spain, in 26 cases with LDR and in 12 cases with PDR. The median age was 62 years (range, 38-86), with a male/ female gender ratio of 20/18. The TNM classification was as follows: 10 T1, 22 T2, 5 T3, and 1 T4; 32 N0, 3 N1, and 3 N2. Treatment started with concomitant chemoradiotherapy in 22 patients or radiotherapy alone in 10 patients. The mean dose of external beam irradiation given to the posterior pelvis was 45 Gy (range, 32-50 Gy). The median dose for interstitial brachytherapy was 20 Gy (range, 15-35) for the boost and 60-65 Gy if monotherapy. Results: Of the 38 patients, 34 (89.4%) were recorded as complete response, 2 (5.3%) as partial response and 2 (5.3%) as progression disease. The procedure was well tolerated. With a median follow-up of 30 months (range, 3.7-200.7), 2 and 5-year overall survival was 87% (95% CI: 74-98%) and 76% (95% CI: 59-93%), respectively. The 2, 5, and 10-year local progression-free survival rate was 91% (95% CI: 81-100%), 87% (95% CI: 75-99%), and 81% (95% CI: 67-97%), respectively. Twelve relapses occurred (3 regional and distant, 3 distant alone, 1 regional alone, and 5 local). Two patients had chronic mucositis grade III/IV (Radiation Therapy Oncology Group scale). No colostomy was required for necrosis. Two patients experienced serious late toxicity grade 3/4 mucositis and only three patients (7.8%) had incontinence after brachytherapy. No correlation was found between the dose rate and late mucositis (p = 1) or dermatitis (p = 0.4).
S328
Volume 78, Number 3, Supplement, 2010
Gy. No grade 3/4/5 related acute toxicity was observed. No radiation-induced liver disease (RILD) was observed. Other toxicity within 3 months following CRT included grade 2: anemia (1), liver capsular pain (1), nausea (1) fatigue (2) and skin toxicity (1). Fifteen patients had at least 3 months of follow-up, in-field response assessed using CT at 3 months was: PR (6), MR/SD (5), PD (4). Median follow-up was 8.7 months (1.5 to 40 months). Median in field progression-free survival was 8.9 months. Median overall survival (OS) 17.7 months; 1 year OS 42% (95% CI 18-64%). On progression, 6 patients were re-challenged with chemotherapy. No late toxicities grades 3-5 were seen. Conclusions: In a heavily pretreated population with large liver burden disease this approach of individual dose CRT appears safe; with no additional toxicity observed in higher dose bin (40 Gy). Author Disclosure: M. Hawkins, None; C. Coolens, None; C. Ockwell, None; K. Burke, None; D.M. Tait, None.
2279
Can all Patients with Locally Advanced Rectal Cancer Benefit from Preoperative Radiotherapy or Chemoradiotherapy?
C. Lai1, M. Chen1, C. Yeh1, W. Huang1, C. Chin1, Y. Kuo1, J. Wang2, S. Lee3, H. Chen4, W. Chen1 1 Chang Gung Memorial Hospital, Putz City Chiayi, Taiwan, 2Chang Gung Memorial Hospital, Taoyuan, Taiwan, 3University of California, Los Angeles, Los Angeles, CA, 4Helen F Graham Cancer Center, Delaware, DE
Purpose/Objective(s): In our hospital, surgery alone, preoperative radiotherapy (RT) and preoperative chemoradiotherapy (CCRT) followed by surgery were used in the treatment of locally advanced rectal cancer after the introduction of TME. In this study, we analyze the efficacies of these three treatment approaches in terms of patient survival, loco-regional recurrence (LRR), distant metastasis (DM), resectability and sphincter preservation outcomes. Materials/Methods: This retrospective study included 151 consecutive patients with clinical T3, T4 or node-positive rectal cancer from January 2005 to December 2007. Eighty-six patients underwent surgery alone (surgery group), 28 patients received preoperative RT (RT group, 25 Gy in 5 fractions) followed by surgery in 1 week, and 37 patients received preoperative CCRT (CCRT group, 50.4 Gy in 28 fractions) followed by surgery in 4 to 6 weeks. Results: The median follow-up time was 3 years (range, 0.26-5.16 years). The 3-year overall and disease-free survival rates in the surgery, RT, and CCRT groups were 91.9%, 88.6%, 86.1% (p = 0.72) and 75.3%, 66.6%, and 64.3% (p = 0.33), respectively. The 3-year LRR and DM rates in the surgery, RT, and CCRT groups were 10.5%, 4%, 9.7% (p = 0.69), and 19%, 30.7%, 31.1% (p = 0.21), respectively. The R0 resection and sphincter preservation rates in the surgery, RT, and CCRT groups were 97.7%, 100%, 94.6% (p = 0.50) and 97.7%, 100%, and 97.3% (p = 1.0). By multivariate analysis, pT4, distal pathological margin\2 cm, the ratio of positive LN to total LN (pLNR) . 0.2 and non-R0 resection were significant prognostic factors for LRR, while pLNR . 0.2 was the only prognostic factor for DM. For a subgroup of patients (66 of the 151 patients) with all the favorable prognostic factors (distal pathological margin $ 2cm, pLNR # 0.2, non-pT4 and with R0 resection), the LRR is only 3.5% as compared to 14% for the others (p = 0.045). Conclusions: In the era of modern TME surgery, neoadjuvant RT or CCRT might not alter the ultimate treatment outcome for patients with locally advanced rectal cancer. Nevertheless, achieving downstaging and favorable histology (non-T4, pLNR # 0.2) with clear and wide resection margins (R0, distal pathological margin $ 2 cm) by neoadjuvant RT or CCRT may still be beneficial in gaining adequate loco-regional control of the disease. Author Disclosure: C. Lai, None; M. Chen, None; C. Yeh, None; W. Huang, None; C. Chin, None; Y. Kuo, None; J. Wang, None; S. Lee, None; H. Chen, None; W. Chen, None.
2280
Twenty-year Experience in the Management of Anal Carcinoma with Interstitial Brachytherapy
J. L. Lopez Guerra1, A. J. Lozano2, J. Pera3, C. Gutie´rrez3, M. Cambray3, F. Ferrer3, M. J. Ortiz1, F. Guedea3 1
Hospitales Universitarios Virgen del Rocı´o, Sevilla, Spain, 2Hospital Universitario Son Dureta, Mallorca, Spain, 3Institut Catala` d’Oncologia, Barcelona, Spain Purpose/Objective(s): The management of anal cancer has undergone an interesting transformation over the last three decades. The idea of organ preservation emerged following the discovery of a high complete response rate from preoperative combined chemoradiation prior to abdominal-perineal resection. Radiotherapy, with concomitant chemotherapy for advanced tumors, is now the standard first-line treatment for anal carcinoma. The combination of external beam radiotherapy with interstitial brachytherapy increases the dose to the tumor volume and limits the volume of irradiated normal tissue, thereby decreasing late toxicity. We present an analysis of a series of patients treated with iridium 192 low-dose rate (LDR) or pulsed-dose rate (PDR) interstitial brachytherapy for anal carcinoma. Materials/Methods: From 1989 to 2009, 38 patients with anal carcinoma were treated with brachytherapy at the Catalan Institute of Oncology in Spain, in 26 cases with LDR and in 12 cases with PDR. The median age was 62 years (range, 38-86), with a male/ female gender ratio of 20/18. The TNM classification was as follows: 10 T1, 22 T2, 5 T3, and 1 T4; 32 N0, 3 N1, and 3 N2. Treatment started with concomitant chemoradiotherapy in 22 patients or radiotherapy alone in 10 patients. The mean dose of external beam irradiation given to the posterior pelvis was 45 Gy (range, 32-50 Gy). The median dose for interstitial brachytherapy was 20 Gy (range, 15-35) for the boost and 60-65 Gy if monotherapy. Results: Of the 38 patients, 34 (89.4%) were recorded as complete response, 2 (5.3%) as partial response and 2 (5.3%) as progression disease. The procedure was well tolerated. With a median follow-up of 30 months (range, 3.7-200.7), 2 and 5-year overall survival was 87% (95% CI: 74-98%) and 76% (95% CI: 59-93%), respectively. The 2, 5, and 10-year local progression-free survival rate was 91% (95% CI: 81-100%), 87% (95% CI: 75-99%), and 81% (95% CI: 67-97%), respectively. Twelve relapses occurred (3 regional and distant, 3 distant alone, 1 regional alone, and 5 local). Two patients had chronic mucositis grade III/IV (Radiation Therapy Oncology Group scale). No colostomy was required for necrosis. Two patients experienced serious late toxicity grade 3/4 mucositis and only three patients (7.8%) had incontinence after brachytherapy. No correlation was found between the dose rate and late mucositis (p = 1) or dermatitis (p = 0.4).