[10 year results of preoperative radiotherapy in treatment of rectal carcinoma]. / 10-Jahres-Ergebnisse der präoperativen Radiotherapie in der Behandlung des Rectumcarcinoms.

BACKGROUND: We have previously reported improvements in survival and disease-free survival at five years using preoperative radiation in the treatment of rectal cancer. The current update was undertaken to determine if these favorable results were durable with longer follow-up. METHODS: Patients found to have resectable rectal cancer between 1972 and 1979 were treated with 40-45 Gy of preoperative radiation (40 patients) or resection alone (109 patients). Follow-up information beyond five years was obtained from the Tumor Registry, physician contact and a survey of the National Death Index. Of the 149 patients followed for five years, 144 were evaluable at ten years. RESULTS: After a median follow-up of 125 months, survival of the irradiated patients was significantly better than that of controls (77 versus 57% at 5 years and 74 versus 41% at 10 years, p = 0.0044). Disease-free survival of those patients whose resection margins were free was also superior for the irradiated group (85 versus 59% at 5 years and 80 versus 45% at 10 years, p = 0.0045). CONCLUSIONS: The results show that the survival advantage for 40 to 45 Gy preoperative radiation in the treatment of rectal cancer persist at 10 years follow-up.

The influence of local tumor ulceration on the effectiveness of endocavitary radiation for patients with early rectal carcinoma.

BACKGROUND: Endocavitary radiation therapy is an alternative to surgical therapy for some early rectal carcinomas. Careful patient selection is necessary to ensure good results. The purpose of this study was to examine the authors' experience with endocavitary radiation at their institution from 1984 to 1991 to determine which factors were associated with treatment failure to provide for better future patient selection. METHODS: Thirty-two patients with carcinoma of the rectum, not apparently involving the muscle wall, underwent 75-120 Gy of endocavitary radiation as potentially curative therapy. Treatment was given as a series of 2-4 doses of 30 Gy at three weekly intervals. Twenty-two patients had polypoid tumors, 5 sessile, and 5 ulcerated. RESULTS: After a mean follow-up of 43 months (range, 6-103 months), 4 of 5 patients (80%) with ulcerated tumors developed local recurrences, compared with only 4 of 27 (15%) with sessile or polypoid lesions. Not only was the incidence of local recurrence greater for patients with ulcerated tumors (P = 0.009), but the time to recurrence was shorter also (P = 0.0001). Tumor size, anterior or posterior location, and dose of radiation received did not affect the rate of recurrence. CONCLUSIONS: These results indicate that superficial polypoid and sessile rectal tumors can be managed successfully with endocavitary radiation. Ulcerating tumors are likely to recur locally within a short time and therefore should be considered for surgical treatment initially.

Long-term results and complications of preoperative radiation in the treatment of rectal cancer.

A retrospective study of 149 patients with rectal cancer diagnosed between 1972 and 1979 was undertaken to compare survival, disease-free survival, recurrence sites, and long-term complications of 40 patients who received 4000 to 4500 rads of preoperative adjuvant radiotherapy (radiation group) with those of 109 patients treated by resection alone (control group). After a mean follow-up of 84 months and 99 months, respectively, survival of the irradiated patients was significantly better than that of controls (68% versus 52%, p less than 0.05). Disease-free survival of those patients rendered free of disease by treatment was also superior for the irradiated group (84% versus 57%, p less than 0.005). Local recurrence without signs of distant metastases developed only one-third as often in irradiated patients (6% versus 18%). Distant metastases, alone or in combination with local recurrence, were also less common after radiation (12% versus 27%). Second primary tumors developed in 15% and 10% of the respective groups, a difference that was not statistically significant. When we consider the survival benefit of preoperative radiation therapy, long-term complications were relatively mild. Delayed healing of the perineum was noted in two irradiated patients. Persistent diarrhea was severe enough to warrant treatment in only one case, and one patient required a colostomy for intestinal obstruction from pelvic fibrosis.

Intestinal anastomosis after preoperative radiation therapy for carcinoma of the rectum.

A retrospective review was conducted on 133 patients who underwent anterior resection and primary intestinal anastomosis for adenocarcinoma of the rectum from 1973 to 1983 at the Baystate Medical Center. Forty patients received a moderate dose, 4,500 rads, of radiation therapy preoperatively. Twenty-six of these patients (65 per cent) underwent protective colostomy at operation. An additional 93 patients underwent an operation without radiation and 38 of these (42 per cent) had a colostomy. We found no significant difference between patients who did or did not undergo radiation therapy in the over-all rate of complications (25 per cent for those who underwent radiation and 29 per cent for those who did not). Furthermore, there was no significant difference in anastomotic leak rates between the two groups (10 and 7 per cent respectively), even after controlling for the presence of a protective colostomy. We did find that leak rates for both groups were markedly higher for patients with a colostomy (14 per cent) than for patients without (1 per cent) (p less than 0.005). We conclude that a moderate dose of radiation therapy preoperatively does not increase the risk of anastomotic leakage or other operative complications with anterior resection. Colorectal intestinal anastomosis may be safely performed without routine colostomy after planned preoperative adjuvant radiation therapy if the anastomosis is technically satisfactory.

Survival following moderate-dose preoperative radiation therapy for carcinoma of the rectum.

We performed a retrospective study of patients with carcinoma of the rectum or rectosigmoid undergoing surgical resection. Forty-two patients received adjuvant preoperative radiation therapy (4000-4500 rad). One hundred twenty patients underwent surgical resection alone. Survival of radiation patients was significantly improved over that of Surgery Only patients, even after adjusting for nontreatment factors using Cox regression. Crude 5-year survival was 63% for radiation patients (74% adjusted) compared to 46% for surgery-only patients (48% adjusted) (P less than 0.025). Radiation patients also had longer disease-free survival than surgery-only patients (P less than 0.05) and fewer recurrences (14% versus 37%; P less than 0.025). Fewer radiation patients had lymph nodes involved with tumor than surgery-only patients (20% versus 35%; P = 0.07). Although 71% of radiation patients experienced radiation reactions, these were primarily mild and transitory. We believe that preoperative radiation is an effective and safe adjunct to surgery in the treatment of rectal cancer and that its use can lead to improved survival rates.

Jejunal carcinoma in a child.

A case of Peutz-Jeghers Syndrome in an 8-yr-old girl with an adenocarcinoma arising in the duodenum and jejunum is herein reported with a 9-yr follow-up. This carcinoma fulfills histologic criteria for malignancy in the Peutz-Jeghers Syndrome. We suggest that this represents a documented case of malignancy arising in a Peutz-Jeghers polyp.

Adjuvant radiation therapy in colorectal carcinoma.

A series of sixty-five patients with adenocarcinoma of the rectum and rectosigmoid is reviewed. Thirty-two patients had surgery alone, fourteen patients underwent postoperative radiation therapy, and nineteen patients underwent preoperative radiation therapy. A moderate dose program of 4,000 to 4,500 r was used. The postoperative treatment group had a higher incidence of stage C lesions and a higher recurrence rate, but there were no statistically significant differences in survival. Postoperative radiation therapy in patients with stage C lesions did not prolong life and is of little benefit. The preoperative treatment group tolerated the radiation very well, and there were no major complications. Eight patients underwent anterior resections in irradiated fields. Two minor anastomotic leaks subsequently healed spontaneously. There were no pelvic recurrences in the preoperative treatment group, and the incidence of lymph node metastases was 26% as opposed to 41% in controls. We conclude that preoperative moderate dose radiation is not associated with increased risk of morbidity or mortality. It may be useful in reducing the incidence of lymph node metastases and pelvic recurrence. The effect on survival is not determined in this study.