Preoperative radiotherapy and local excision of rectal cancer with immediate radical re-operation for poor responders.

BACKGROUND AND PURPOSE: To report an early analysis of prospective study exploring preoperative radiotherapy and local excision in rectal cancer. MATERIALS AND METHODS: Mucosa at tumour edges was tattooed. Patients with cT1-3N0 tumour <3-4 cm were treated with either 5x5Gy+4Gy boost (N=31) or chemoradiation (50.4Gy+5.4Gy boost, 1.8Gy per fraction+5-fluorouracyl and leucovorin; N=13). Thirteen patients from the short-course group were unfit for chemotherapy. The interval from radiation to full-thickness local excision was 6 weeks. The protocol called for conversion to a transabdominal surgery in case of ypT2-3 disease or positive margin. RESULTS: The postoperative complications requiring hospitalization were recorded in 9% of patients. The rate of pathological complete response was 41%. The rate of patients requiring conversion was 34%; however, 18% actually underwent conversion and the remaining 16% refused or were unfit. During the 14 months of median follow-up, local recurrence was detected in 7% of patients and all underwent salvage surgery. Of 19 patients in whom initially anterior resection was likely, 16% had abdominoperineal resection performed for a conversion or as a rescue procedure. CONCLUSION: Our study suggests that the short-course radiation prior to local excision is a treatment option for high-risk patients.

Prediction of mesorectal nodal metastases after chemoradiation for rectal cancer: results of a randomised trial: implication for subsequent local excision.

BACKGROUND AND PURPOSE: For patients with rectal cancer treated with full thickness local excision the risk of mesorectal nodal metastases has to be very low. The aim was to assess this risk after preoperative radiotherapy in relation to pathological T-category. PATIENTS AND METHODS: Three hundred sixteen patients with resectable cT3-4 low rectal carcinoma were randomised to receive either pre-operative 5 x 5 Gy irradiation with subsequent surgery performed within 7 days or chemoradiation (50.4, 1.8 Gy per fraction plus bolus 5-fluorouracil and leucovorin) followed by surgery after 4-6 weeks. The pathological reports of patients who fulfilled entry criteria and had preoperative irradiation followed by transabdominal surgery were analysed. RESULTS: Significant downstaging of primary tumour (P<0.001) and of nodal disease (P=0.007) was observed after chemoradiation in comparison with short-course irradiation. In chemoradiation group, for patients with complete pathological response and for ypT1 category, the rate of nodal metastases was low - 5% (95% confidence interval [CI] 0-14%) and 8% (95% CI 0-24%), respectively. The rate of ypN-positive disease in chemoradiation group was similar to that recorded in short-course irradiation group for ypT2 category 26% (95% CI 14-38%) vs. 28% (95% CI 16-40%), P=0.83 and for ypT3-4 category 55% (95% CI 41-69%) vs. 64% (95% CI 54-74%), respectively, P=0.37. For ypT2 category after chemoradiation, the rate of nodal disease remained high even in subgroup with low residual cancer cells density (20%, 95% CI 4-36%). CONCLUSIONS: For patients with tumours downstaged by chemoradiation to ypT0 and ypT1 full thickness local excision may be considered as an acceptable approach, because the risk of mesorectal lymph nodes metastases is low. The selection criteria for preoperative radio(chemo)therapy and local excision are discussed.

[Timing and duration of postoperative radiotherapy in patients with laryngeal cancer]. / Czynnik czasu w uzupelniajacej radioterapii u chorych po calkowitym usunieciu krtani z powodu raka krtani.

Aim of this was an evaluation of the impact of prolongation of combined treatment time on the local-regional control laryngeal cancer patients treated with surgery and postoperative radiotherapy. Study was based on retrospective analysis of 254 patients with T3/T4 and N0-N2 laryngeal cancer who were treated between January 1993 and December 1996 with surgery and postoperative radiotherapy (RT). Median age of investigated group was 56.3 years. Surgery consisted of total laryngectomy in all cases and with selective neck dissection. RT began 22 to 78 days postoperatively (median 45 days) and continued for a median of 47 days (range, 40-74 days). The primary tumor bed and all lymph neck nodes were treated in all patients. The total dose to the primary tumor bed was about 60 Gy, fraction dose was 2 Gy. All lymph nodes were irradiated with a dose of 50 Gy. The factors studied for prognostic importance for a local-regional failure included: overall combined treatment time, interval between surgery and the start of radiotherapy, radiotherapy treatment time, age, sex, T and N categories. The 5-year actuarial disease-free local-regional survival was 50%. On univariate analysis, using log rank test, only N status, sex were predicted for the locoregional control of postoperative radiotherapy. Overall treatment time longer than 90 days and especially 100 days was correlated with worse locoregional results of combined treatment respectively (p = 0.003 and p = 0.0007). Also prolongation of interval time between surgery and postoperative radiotherapy beyond 50 days was connected with higher rate of failures (p = 0.02). The same trend was observed when time of irradiation was longer than 47 days (p = 0.01). This analysis indicated that the prolongation of the overall treatment time of combined modality, the the time between surgery, and radiotherapy and time of postoperative radiotherapy were correlated with increased of local regional failures.