Abstract
A review is made of the clinical experience of preoperative radiotherapy in patients with operable cancer of the rectum or rectosigmoid. The randomized clinical trials that have been reported are evaluated. It is concluded that preoperative irradiation using a dose of no less than 34.5 gray in 15 daily fractions [Nominal Standard Dose (NSD) 1,290] can reduce locoregional recurrences and improve disease-free survival. Doses of this order are not associated with any significant increase of morbidity. The administration of lower doses has not been confirmed to be of any benefit.
It is suggested that patients with fixed or partially fixed cancers of the rectum or rectosigmoid should be selected for preoperative adjuvant radiotherapy. This group has a low probability of undergoing curative resection without adjuvant treatment. Local recurrence is high and survival poor in this group of patients.
Patients with mobile cancer of the rectum should probably proceed to definitive resection and be considered for postoperative radiotherapy (perhaps combined with chemotherapy) if found to have Dukes' stage B or C cancer. This policy also minimizes the probability of irradiating patients with Dukes' A cancer who are unlikely to benefit from such adjuvant treatment.
Résumé
Une revue de l'expérience clinique de la radiothérapie préopératoire pour cancer du rectum et du recto-sigmoide a été effectuée par l'auteur. Les essais cliniques randomisés qui concernent la méthode, déjà publiés, ont été étudiés. Il est possible à partir de cette étude d'affirmer que l'irradiation préopératoire avec une dose supérieure à 34.5 gray fractionnée en 15 jours (NSD 1,290) peut entrainer une réduction des récidives locales et améliorer le taux de guérison. Une irradiation de cet ordre de grandeur ne s'accompagne d'aucune augmentation significative de la morbidité. Le recours à des doses inférieures n'a été d'aucun bénéfice.
L'auteur conseille de traiter les malades qui présentent un cancer fixé du rectum ou du recto-sigmoide par la radiothérapie pré-opératoire car les chances de guérison dans ces cas sont faibles, en l'absence de ce traitement complémentaire. Le taux des récidives est élevé et celui de la survie est faible.
Les malades qui présentent une tumeur mobile du rectum devraient être soumis à la radiothérapie post-opératoire et éventuellement à la chimiothérapie si le cancer répond aux types B et C de la classification de Dukes. En revanche, le cancer de type A ne relève pas de ce traitement complémentaire.
Resumen
Se hace una revisión de la experiencia con radioterapia preoperatoria en pacientes con cáncer operable del recto o del recto-sígmoide y se valoran los ensayos clínicos aleatorizados que han sido informados por diferentes instituciones. Se llega a la conclusión de que la irradiación preoperatoria utilizando una dosis de no menos de 34.5 gray en 15 fracciones diarias (NSD 1,290) puede reducir la tasa de recurrencia locorregional y mejorar la supervivencia libre de enfermedad. Dosis de este orden no están asociadas con un incremento significativo de la morbilidad. La administración de dosis menores no ha probado ser de beneficio.
Se sugiere que los pacientes con cánceres fijos o parcialmente fijos del recto o del recto-sigmoide deben ser seleccionados para radioterapia preoperatoria adyuvante. Este grupo tiene una baja probabilidad de resección curativa sin terapia adyuvante; la tasa de recurrencia local es elevada y la supervivencia es pobre.
En los pacientes con cánceres móviles del recto probablemente se puede proceder con la resección definitiva y pueden ser considerados para radioterapia postoperatoria (tal vez combinada con quimioterapia) si son cánceres en estados Dukes B o C. Esta política también minimiza la probabilidad de irradiar pacientes con cáncer Dukes A, quienes generalmente no se benefician con este tipo de terapia adyuvante.
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Duncan, W. Preoperative radiotherapy in rectal cancer. World J. Surg. 11, 439–445 (1987). https://doi.org/10.1007/BF01655807
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DOI: https://doi.org/10.1007/BF01655807