Abstract
PURPOSE: The following study was done to evaluate the therapeutic value of radiotherapy as an adjunct to surgery for rectal cancer patients. METHODS: One-hundred twenty-four patients underwent curative resection by one surgeon (RC) from 1982 to 1991. Forty patients received combined preoperative and postoperative (sandwich) radiotherapy, 30 patients received postoperative radiotherapy, and 54 patients were treated by surgery alone. During the study period sandwich radiotherapy was primarily offered as a free treatment option for patients with tumors which were believed to be transmurally invasive, whereas postoperative radiotherapy was an alternative therapeutic option offered to patients with tumor classified as Dukes B and C at histopathologic examination. RESULTS: Operative mortality was 2 percent in the sandwich radiotherapy group vs. 7 percent in the surgery alone group. After a median follow-up of 60 months, the actuarial locoregional recurrence rate at five years was 3 percent for the sandwich radiotherapy group compared with 18 and 30 percent for the postoperative radiotherapy and surgery alone groups, respectively (P =0.019). A multivariate analysis using the Cox model confirmed the favorable independent influence of sandwich radiotherapy on local tumor control, especially in distal tumors. The therapeutic benefit of sandwich radiotherapy translated into increased survival in the low-rectum Dukes B subgroup of patients. The actuarial five-year survival rates were 86 percent, 50 percent, and 28 percent in the sandwich radiotherapy, postoperative radiotherapy and surgery alone groups, respectively (P =0.05). CONCLUSIONS: Preoperative radiotherapy has a significant effect on the prognosis of rectal cancer patients.
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Bentzen SM, Balsev I, Pedersen M,et al. A regression analysis of prognostic factors after resection of Dukes B and C carcinoma of the rectum and rectosigmoid. Does post-operative radiotherapy change the prognosis? Br J Cancer 1988;58:195–201.
Heald RJ, Karanjia ND. Results of radical surgery for rectal cancer. World J Surg 1992;16:848–57.
McDermott FT, Hughes ES, Phil E, Johnson WR, Price AB. Local recurrence after potentially curative resection for rectal cancer in a series of 1008 patients. Br J Surg 1985;72:34–7.
Michelassi F, Vannucci L, Ayala JJ, Chappel R, Goldberg R, Block GE. Local recurrence after curative resection of colorectal adenocarcinoma. Surgery 1990;108:787–93.
Philipsen SJ, Heilweil IL, Quan SH, Sternberg SS, Enker WE. Patterns of pelvic recurrence following definitive resections of rectal cancer. Cancer 1984;53:1354–62.
Rich T, Gunderson LL, Lew R, Galdibini JJ, Cohen AM, Donaldson G. Patterns of recurrence of rectal cancer after potentially curative surgery. Cancer 1983;52:1317–29.
Gerard A, Buyse M, Nordlinger B,et al. Preoperative radiotherapy as adjuvant treatment in rectal cancer. Ann Surg 1988;208:606–14.
Stockholm Rectal Cancer Study Group. Short-term preoperative radiotherapy for adenocarcinoma of the rectum. Am J Clin Oncol 1987;10:369–75.
Jones DJ, Zaloudik J, James RD, Haboubi N, Moore M, Schofield PF. Predicting local recurrence of the rectum after preoperative radiotherapy and surgery. Br J Surg 1989;76:1172–5.
Reis Neto JA, Quilici FA, Reis JA Jr. A comparison of nonoperativevs. preoperative radiotherapy in rectal carcinoma: a 10-year randomized trial. Dis Colon Rectum 1989;32:702–10.
Zybina MA, Nabatich NN. Results of combination treatment for rectal cancer. Vestn Khir 1975;114:67–70.
Dedkov IP, Zybina MA. Intensive preoperative gammatherapy in combined treatment of cancer of the rectum. Am J Proctol 1976;7:43–7.
Simbertseva LP, Sneshko LL, Smirnov NM. Results of intensive combined therapy for cancer of the rectum. Vop Onkol 1975;21:7–12.
Balsev I, Pedersen M, Teglbjaerg PS,et al. Postoperative radiotherapy in Dukes1 B and C carcinoma of the rectum and rectosigmoid. A randomized multicenter study. Cancer 1986;58:22–8.
Douglass HO, Moertel CG, Mayer RJ,et al. Survival after postoperative combination treatment of rectal cancer. N Engl J Med 1986;315:1294–5.
Fisher B, Wolmark N, Rockette HE,et al. Adjuvant chemotherapy or postoperative radiation for rectal cancer. Results from NSABP Protocol R-01. J Natl Cancer Inst 1988;80:21–9.
Mohiuddin M, Kramer S, Marks G, Dobelbower R. Combined pre and postoperative radiation for carcinoma of the rectum. Int J Radiat Oncol Biol Phys 1982;8:133–6.
Gunderson LL, Dosoretz DE, Hedberg SE,et al. Lowdose preoperative irradiation, surgery, and elective postoperative radiation therapy for resectable rectum and rectosigmoid carcinoma. Cancer 1983;52:446–51.
Shank B, Enker W, Santana J,et al. Local control with pre-operative radiotherapy alone vs. “sandwich” radiotherapy for rectal carcinoma. Int J Radiat Oncol Biol Phys 1987;13:111–5.
Phillips RK, Hittinger R, Blesovsky L, Fry JS, Fielding LP. Local recurrence following “curative” surgery for large bowel cancer: I. The overall picture. Br J Surg 1984;71:12–6.
Dershaw DD, Warren EE, Cohen AM, Sigurdson ER. Transrectal ultrasonography of rectal carcinoma. Cancer 1990;66:2336–40.
Goligher JC. Surgery of the anus, rectum and colon. 3rd ed. Springfield: Charles C Thomas, 1977.
Kaplan EL, Meier P. Nonparametric estimation from incomplete observations. J Am Stat Assoc 1958;53:457–8.
Mantel N, Haenszel W. Statistical aspects of the analysis of data from retrospective series of disease. J Natl Cancer Inst 1959;22:719–48.
Cox DR. Regression Models and life-tables. J R Stat Soc [B] 1972;34:187–220.
Dixon WJ, ed. BMDP Statistical Software. Berkley: University of California Press, 1985.
Adloff M, Arnaud JP, Schloegel M,et al. Factors influencing local recurrence after abdominoperineal resection for cancer of the rectum. Dis Colon Rectum 1985;28:413–5.
Danjoux CE, Catton GE. Delayed complications in colorectal carcinoma treated by combination radiotherapy and 5-fluorouracil: Eastern cooperative oncology group (ECOG) study. Int J Radiat Oncol Biol Phys 1979;5:311–5.
Rider WD, Palmer JA, Mahoney LJ, Robertson CT. Preoperative irradiation in operable cancer of the rectum: report of the Toronto trial. Can J Surg 1977;20:335–8.
Stearns MW Jr. Preor postoperative radiation in resectable tumors. In: Welvaart K, Blumgart LH, Kreuning J, eds. Colorectal cancer. The Hague: Leiden University Press, 1980:153–9.
Kligerman MM. Preoperative radiation therapy in rectal cancer. Cancer 1975;36:691–5.
Roswit B, Higgins GA, Keehn RJ. Preoperative irradiation for carcinoma of the rectum and rectosigmoid colon: report of a National Veterans Administration randomized studies. Cancer 1975;35:1597–602.
Medical Research Council Working Party. A trial of prospective radiotherapy in the management of operable rectal cancer. First report of an MCR Working Party. Br J Surg 1982;69:513–9.
Higgins GA, Humphrey EW, Dwight RW, Roswit B, Lee RE, Keehn RJ. Preoperative radiation and surgery for cancer of the rectum: Veterans Administration Surgical Oncology Trial II. Cancer 1986;58:352–9.
Kuntzner J, Bruckner R, Kempf P. Preoperative radiotherapy in rectal cancer. Strahlentherapie 1984;160:236–8.
Pahlman L, Glimelius B. Preor postoperative radiotherapy in rectal and rectosigmoid carcinoma. Ann Surg 1990;211:187–95.
Gastrointestinal Tumor Study Group. Prolongation of the disease-free interval in surgically treated rectal carcinoma. N Engl J Med 1985;312:1465–72.
Krook JE, Moertel CG, Gunderson LL,et al. Effective surgical adjuvant therapy for high-risk rectal carcinoma. N Engl J Med 1991;324:709–15.
Fielding LP, Stewart-Brown S, Dudley HA. Surgeonrelated variables and the clinical trial. Lancet 1979;2:778–81.
Mohiuddin M, Marks G. Patterns of recurrence following high-dose preoperative radiation and sphincter-preserving surgery for cancer of the rectum. Dis Colon Rectum 1993;36:117–26.
Cohen A, Minsky B. A phase I trial of preoperative radiation, proctectomy, and endoanal reconstruction. Arch Surg 1990;125:247–51.
Kodner IJ, Shemesh E, Fry RD,et al. Preoperative irradiation for rectal cancer. Ann Surg 1990;209:194–8.
Hagbin M, Sislhy B, Hinson J. Combined modality therapy in poor prognostic rectal adenocarcinoma. Radiother Oncol 1988;13:75–81.
Picciocchi A, Coco C, Magistrelli P,et al. Concomitant preoperative radiochemotherapy in operable locally advanced rectal cancer. Dis Colon Rectum 1994;37(Suppl):S69-S72.
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Botti, C., Cosimelli, M., Impiombato, F.A. et al. Improved local control and survival with the “sandwich” technique of pelvic radiotherapy for resectable rectal cancer. Dis Colon Rectum 37 (Suppl 2), S6–S15 (1994). https://doi.org/10.1007/BF02048425
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DOI: https://doi.org/10.1007/BF02048425