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Residual, unresectable or recurrent colorectal cancer: external beam irradiation and intraoperative electron beam boost ± resection
Proceedings
7
RESIDUAL,
of the 23rd Annual
UNRESECTABLE OR RECURRENT IATION AND INTRAOPERATIVE
Gunderson, Hedberg, Departments General ‘Department
L.L.‘“, S.E.2,
ASTR Meeting
1205
EXTERNAL BEAM COLORECTAL CANCER: ELECTRON BEAH BOOST + RESECTION
I RRAD-
Shipley, W.U.‘, Cohen, A.C.2, Dosoretz, D.D.1 Wood, W.C.2, Rodkey, G.V.2 and Suit, H.D.1
of Radiation Hospital and of Therapeutic
Medicine’ and Surgery’; Harvard Medical School; Radiology; Mayo Clinic;
Massachusetts Boston, MA Rochester,
MN
At present, combinations of surgery and irradiation (2 chemotherapy) offer the most hope of palliation and cure in colorectal patients with residinitially unresectable or locally recurrent lesions. ual after resection, With conventional methods of combining these modalities, local persistence or recurrence occurs in > 50% of patient in most series. From May 1578 to-December 1580, 58 patients were treated at our institution with a combination of external beam irradiation and boost dose intraoperative electrons + resection. Thirty-two of the 58 had colorectal cancers in the above disease-categories (primary resected, residual-6; primary unresectable-17; recurrence resected, residual-l; recurrence, unresectable-8). Four field Radiation methods were fairly standard in the 32 patients. external beam techniques were used to deliver 4500-5000 rad in 25 to 28 fractions over 5-5 l/2 weeks. Patients were explored 4-6 weeks after completion of irradiation and an intraoperative boost was given to the tumor bed (IO00 rad) or remaining tumor (1500 red). For those who had presented with unresectable lesions, resection was done after the preoperative irradiation inall 17 patients in the primary unresectable group and 5 of 8 with recurrence, although sharp dissection was required in a majority of patients. In 15 patients treated for recurrent disease or residual after resection, local failure within the intraoperative boost field has occurred in 2 of the 3 without resection after preop irradiation vs. O/l2 in those patients with resection of bulk disease at some point. In one of the two patients, disease recurred as a small focus in the center of the previous perineal recurrence 23 months after the start of external beam XRT and 21 months after the intraThis has been surgically removed with good margins. In 1 of the 6 op boost. a marginal recurrence occurred in the patients with residual after resection, sacral canal at the edge of the lateral irradiation field. All 17 patients with initially unresectable lesions have disease controlled within both the external beam and intraoperative boost fields with a followup of 6-28 months. In our previously reported series of unresectable patients treated with preoperative irradiation (4500-5000 rad) plus surgery, the local recurrence rate in the group who survived resection was 45% (6/141 at 4 years (3/14 or 22.5% by 12 mo; 4/14 or 28.5% by 24 mo). When survival curves in the 2 sequentially treated groups are compared, the group with the intraoperative boost is doing better at the one and two year intervals even when patients with postop deaths are deleted from the earlier group (100% vs. Longer followup will be 86% and 63% - p < 0.01 at the 2 year interval). necessary to determine whether these differences will persist. Discussion will center around 1) the possible need for the addition of radiation dose modifiers when resection cannot be performed (more apparent when our entire intraop patient group is analyzed) and 2) the need for randomized trials in these disease categories to compare conventional external beam treatment with external beam plus an intraoperative boost.
a
A RANDOMIZED STUDY OF POST-OPERATIVE RADIOTHERAPY CHEMOTHERAPY IN RECTAL CARCINOMA: AN EASTERN COOPERATIVE
COMBINED ONCOLOGY
WITH GROUP
STUDY
R. Johnson, J. MacIntyre, E. Mansour, P. Engstrom, B. Keller and P. Carbone Roswell Park Memorial Institute, Sidney Farber Cancer Institute, Case Western Reserve University, American Oncologic Hospital, Strong Memorial Hospital and Chairman, ECOG Two hundred sixty one patients with Dukes' B or C carcinoma of the rectosigmoid have been randomized from August 1966 to April 1 1981. The treatment arms are (A) 5-FU 325mg/M2 IV on day 1-5 and 375mg/M2 on day 36-50 plus Methyl CCNU 13Dmg/M2 PO on day 1; (B) postoperative radiation 4500 R in five weeks or 5100 R in six weeks; and (C) both A and B; in patients having curative resection for rectal carcinoma, treated within 21-60 days after surgery.
7
RESIDUAL,
of the 23rd Annual
UNRESECTABLE OR RECURRENT IATION AND INTRAOPERATIVE
Gunderson, Hedberg, Departments General ‘Department
L.L.‘“, S.E.2,
ASTR Meeting
1205
EXTERNAL BEAM COLORECTAL CANCER: ELECTRON BEAH BOOST + RESECTION
I RRAD-
Shipley, W.U.‘, Cohen, A.C.2, Dosoretz, D.D.1 Wood, W.C.2, Rodkey, G.V.2 and Suit, H.D.1
of Radiation Hospital and of Therapeutic
Medicine’ and Surgery’; Harvard Medical School; Radiology; Mayo Clinic;
Massachusetts Boston, MA Rochester,
MN
At present, combinations of surgery and irradiation (2 chemotherapy) offer the most hope of palliation and cure in colorectal patients with residinitially unresectable or locally recurrent lesions. ual after resection, With conventional methods of combining these modalities, local persistence or recurrence occurs in > 50% of patient in most series. From May 1578 to-December 1580, 58 patients were treated at our institution with a combination of external beam irradiation and boost dose intraoperative electrons + resection. Thirty-two of the 58 had colorectal cancers in the above disease-categories (primary resected, residual-6; primary unresectable-17; recurrence resected, residual-l; recurrence, unresectable-8). Four field Radiation methods were fairly standard in the 32 patients. external beam techniques were used to deliver 4500-5000 rad in 25 to 28 fractions over 5-5 l/2 weeks. Patients were explored 4-6 weeks after completion of irradiation and an intraoperative boost was given to the tumor bed (IO00 rad) or remaining tumor (1500 red). For those who had presented with unresectable lesions, resection was done after the preoperative irradiation inall 17 patients in the primary unresectable group and 5 of 8 with recurrence, although sharp dissection was required in a majority of patients. In 15 patients treated for recurrent disease or residual after resection, local failure within the intraoperative boost field has occurred in 2 of the 3 without resection after preop irradiation vs. O/l2 in those patients with resection of bulk disease at some point. In one of the two patients, disease recurred as a small focus in the center of the previous perineal recurrence 23 months after the start of external beam XRT and 21 months after the intraThis has been surgically removed with good margins. In 1 of the 6 op boost. a marginal recurrence occurred in the patients with residual after resection, sacral canal at the edge of the lateral irradiation field. All 17 patients with initially unresectable lesions have disease controlled within both the external beam and intraoperative boost fields with a followup of 6-28 months. In our previously reported series of unresectable patients treated with preoperative irradiation (4500-5000 rad) plus surgery, the local recurrence rate in the group who survived resection was 45% (6/141 at 4 years (3/14 or 22.5% by 12 mo; 4/14 or 28.5% by 24 mo). When survival curves in the 2 sequentially treated groups are compared, the group with the intraoperative boost is doing better at the one and two year intervals even when patients with postop deaths are deleted from the earlier group (100% vs. Longer followup will be 86% and 63% - p < 0.01 at the 2 year interval). necessary to determine whether these differences will persist. Discussion will center around 1) the possible need for the addition of radiation dose modifiers when resection cannot be performed (more apparent when our entire intraop patient group is analyzed) and 2) the need for randomized trials in these disease categories to compare conventional external beam treatment with external beam plus an intraoperative boost.
a
A RANDOMIZED STUDY OF POST-OPERATIVE RADIOTHERAPY CHEMOTHERAPY IN RECTAL CARCINOMA: AN EASTERN COOPERATIVE
COMBINED ONCOLOGY
WITH GROUP
STUDY
R. Johnson, J. MacIntyre, E. Mansour, P. Engstrom, B. Keller and P. Carbone Roswell Park Memorial Institute, Sidney Farber Cancer Institute, Case Western Reserve University, American Oncologic Hospital, Strong Memorial Hospital and Chairman, ECOG Two hundred sixty one patients with Dukes' B or C carcinoma of the rectosigmoid have been randomized from August 1966 to April 1 1981. The treatment arms are (A) 5-FU 325mg/M2 IV on day 1-5 and 375mg/M2 on day 36-50 plus Methyl CCNU 13Dmg/M2 PO on day 1; (B) postoperative radiation 4500 R in five weeks or 5100 R in six weeks; and (C) both A and B; in patients having curative resection for rectal carcinoma, treated within 21-60 days after surgery.