Chemoradiation with or without intraoperative radiation therapy in patients with locally recurrent rectal carcinoma: prognostic factors and long term outcome.

BACKGROUND: Rectal carcinoma patients with local recurrence are reported to have a dismal prognosis. The purpose of this study was to evaluate the effect of combined modality therapy on clinical outcome and to determine the prognostic impact of a "presurgical" staging system. METHODS: Between September 1989 and June 1997, 47 patients (with a median follow-up of 80 months) with locally recurrent, nonmetastatic rectal carcinoma were classified according to the extent of pelvic sidewall involvement as determined by pretreatment computed tomography (CT) scan. They received preoperative external beam radiation (45-47 grays [Gy] in 34 patients; 23.4 Gy in 13 preirradiated patients) plus concomitant 5-fluorouracil (1000 mg/m(2)/day as a 96-hour continuous infusion on Days 1-4 + 29-32) and mitomycin C (10 mg/m(2) as a bolus intravenously on Day 1 + 29). After 4-6 weeks, the patients were evaluated for surgical resection and intraoperative radiation therapy (IORT) procedure (10-15 Gy) or, in unresectable patients, a boost dose was planned by chemoradiation (23.4 Gy) or brachytherapy. Thereafter, adjuvant chemotherapy (5-fluorouracil and leucovorin for a total of six to nine courses) was prescribed. RESULTS: During chemoradiation, 2 patients (4.3%) developed Radiation Therapy Oncology Group Grade 3-4 acute toxicity. Twenty-five patients (53. 2%) had an objective response after chemoradiation. Twenty-one patients (45%) underwent radical surgical resection. The overall 5-year survival and local control rates were 22% and 32%, respectively. The classification system significantly predicted survival (P = 0.008). Radically resected patients had better local control and survival (P < 0.0001); in patients treated with IORT, the 5-year local control and survival rates were 79% and 41%, respectively. CONCLUSIONS: The data from the current study suggest that combined modality therapy was well tolerated and improved resectability, local control, and survival. The classification system appears to be a reliable tool with which to predict clinical outcome in patients with locally recurrent rectal carcinoma.

Tension-free hernioplasty: technical remarks and personal experience.

The authors report their experience with 463 tension free hernioplasty procedures for inguinal and femoral hernias. The surgical technique included the insertion of both a polypropylene plug and a polypropylene mesh, and was carried out mostly in local anesthesia (84.2%) using bupivacaine 0.25% for ileoinguinal and ileohypogastric blockage and mepivacaine 0.5% for local infiltration. There was no major intraoperative complication; local postoperative complications were rare (10%) and easily managed; postoperative pain was frequently observed (66%), though mild and transient; resumption of working activity occurred within a month in 96.6% of cases; there were only 3 post-operative recurrences (respectively, at 1, 6 and 12 months). The authors conclude that the tension free hernioplasty is a simple, rapid, low-cost and effective technique, easily performed under local anesthesia.

Preoperative radiotherapy and IORT in resectable rectal cancer at high risk for local recurrence.

Over a 4-year period 35 patients with mid- (15 patients) and low (20 patients) rectal cancer clinically staged as T2 N1-2, T3 N0-2 underwent a protocol of combined surgery and radiotherapy. The protocol included: preoperative external beam radiotherapy (38 Gy, ICRU50); surgical resection; IORT on tumor bed (10 Gy). Toxicity of preoperative treatment was mild with a single case (2.9%) of grade 3 gastrointestinal toxicity. 18 patients underwent anterior resection and 17 abdominoperineal resection. Perioperative mortality and morbidity were 0% and 17.1% respectively. At a mean follow-up of 25 months all patients were alive. The single anastomotic recurrence observed was rescued with abdominoperineal resection.

Preoperative concomitant radiochemotherapy and IORT in locally advanced rectal cancer.

34 patients with locally advanced (T4) or recurrent rectal cancer have been treated with: 1. external beam radiotherapy (45-48 Gy) + 5FU(1000 mg/m2/daily iv continuous infusion day 1-4) + MMC (10 mg/m2/daily iv, day 1); 2. surgical resection (if feasible) + IORT (10-15 Gy); 3. adjuvant chemotherapy (5FU+leucovorin, 6-8 cycles). Grade 3 acute hematological toxicity was observed in 1 case only. 23 of 34 patients underwent radical surgery. Perioperative mortality and morbidity was 0% and 17% respectively. In the 23 operated patients with a mean follow-up of 18.6 months there were 2 local recurrences, 5 blood metastases, (1 death of disease). 16 patients were shown to be NED (3-36 months).