Diseases of the Colon & Rectum

, Volume 41, Issue 2, pp 169–176 | Cite as

New method of radiotherapy for anal cancer with three-dimensional tumor reconstruction based on endoanal ultrasound and ultrasound-guided afterloading therapy

  • Mathias Löhnert
  • Julius Marek Doniec
  • György Kovács
  • Jörg Schröder
  • Peter Dohrmann
Original Contributions
  • 33 Downloads

Abstract

PURPOSE: Standard treatment of anal cancer is a protocol of combined chemotherapy and percutaneous radiotherapy. We developed a new endosonography-based radiation target simulation method, because endoanal sonography gives the best opportunity to stage the tumor accurately. Based on this method, an afterloading needle application procedure could be performed to optimize the radiation target geometry and to control the application of afterloading needles. In a prospective study, this new method was evaluated, with special regard for complications and tumor recurrence. METHODS: Anal cancer was restaged endosonographically six weeks after external beam radiation with 45 Gy. A computer-generated three-dimensional reconstruction of the tumor and radiation target simulation was performed based on endoanal sonographic imaging. By using a new type of applicator, which is permeable to ultrasound waves, the transperineal implantation procedure of afterloading needles could be controlled. Application needles were inserted into the target area according to the endoanal sonography-based dosimetry planing. The dose of the (high-dose rate) brachytherapy boost was started with two 6-Gy fractions, each within eight days. The fraction dose was reduced to 4 Gy to minimize side effects. Lymph node-positive tumors got additional chemotherapy (5-fluorouracil and mitomycin C). RESULTS: From January 1992 until August 1996, we performed 42 endosonography-guided afterloading procedures in 18 patients. One patient underwent percutaneous radiation two years before and was treated only by afterloading radiation. In every patient, we found complete tumor remission at the end of radiotherapy. Three patients with a high-dose rate of 2×6 Gy developed radiogenic proctitis, and two patients developed ulceration, which lead to reduction of the dose. After reduction to 4 Gy per fraction, no more side effects could be seen. In follow-up (median, 24 (range, 1–56) months), we detected two anal cancer recurrences (2/18 patients). CONCLUSION: The radiation target field can be optimized by individual endosonography-based three-dimensional tumor reconstruction and radiotherapy simulation. Endosonography-guided transperineal implantation of afterloading needles can be performed according to the computer-generated simulation by using a new type of applicator. We could achieve total primary tumor remission in every patient. After reduction of the afterloading dose to 2×4 Gy, no brachytherapy-related side effects could be seen.

Key words

Endoanal sonography Three-dimensional endosonography Anal cancer Interstitial radiotherapy Afterloading therapy 

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References

  1. 1.
    Papillon J. Rectal and anal cancer. Berlin: Springer, 1982:159.Google Scholar
  2. 2.
    Pipard G, Sauer R, eds. Interventional radiation therapy, brachytherapy. Berlin: Springer, 1991: 215–8.Google Scholar
  3. 3.
    Puthawala AJ, Syed N, Gates TC, Mc Nemara C. Definitive treatment of extensive anorectal carcinoma and interstitial radiation. Cancer 1982;50:1746–50.Google Scholar
  4. 4.
    Syed N, Puthawa AJ, Neblett B,et al. Primary treatment of carcinoma of the lower rectum and anal canal by a combination of external irradiation and interstitial implant. Radiology 1978;128:199–203.Google Scholar
  5. 5.
    Kovács G, Kohr P, Löhnert M, Schmücking M, Kimmig B. Ultrasound guided interstitial HDR brachytherapy for anal canal cancer using MRI based planning. Activity 1992;6:55–7.Google Scholar
  6. 6.
    Law PJ, Bartram CI. Anal endosonography: technique and normal anatomy. Gastrointest Radiol 1989;14:349–53.Google Scholar
  7. 7.
    Nielsen MB, Pedersen JF, Hauge C, Rasmussen O, Christiansen J. Endosonography of the anal sphincter: findings in healthy volunteers. AJR Am J Roentgenol 1991;157:1199–202.Google Scholar
  8. 8.
    Sultan AH, Nicholls RJ, Kamm MA, Hudson CN, Beynon J, Bartram CI. Anal endosonography and correlation within vitro andin vivo anatomy. Br J Surg 1993;80:508–11.Google Scholar
  9. 9.
    Fowler J. The radiobiology of brachytherapy. In: Martinez A, Orton CG, Mould RF, eds. Brachytherapy HDR and LDR. Columbia: Nucletron Corporation 1991:121–35Google Scholar
  10. 10.
    Warmelink C, Ezzel G, Orton C. Use of a timedose fractionation model to design high-dose-rate fractionation schemes. In: Mould RF, ed. Brachtherapy 2. Leersum: Nucletron International BV, 1989:41–8Google Scholar
  11. 11.
    Goldmann S, Arvidson H, Normig U, Lagerstedt U, Magnusson I, Frisell J. Transrectal ultrasound and computed tomography in preoperative staging of lower rectal adenocarcinoma. Gastrointest Radiol 1991;16:259–63.Google Scholar
  12. 12.
    Freeny PC, Marks WM, Ryan JA, Bolen JW. Colorectal carcinoma evaluation with CT: preoperative staging and detection of postoperative recurrence. Radiology 1986;158:347–53.Google Scholar
  13. 13.
    Rafaelsen SR, Kronborg O, Fenger C. Digital rectal examination and transrectal ultrasound in staging of rectal cancer. Eur J Cancer 1995;31A:1356–60.Google Scholar
  14. 14.
    de Lange EE, Fechner RE, Edge SB. Preoperative staging of rectal carcinoma with MRI-imaging. Radiology 1990;176:623–8.Google Scholar
  15. 15.
    Hildebrandt U, Feifel G. Preoperative staging of rectal cancer by intrarectal ultrasound. Dis Colon Rectum 1985;28:42–6.Google Scholar
  16. 16.
    Lindmark G, Elvin A, Pählmann L, Glimelius B. The value of endosonography in preoperative staging of rectal cancer. Int J Colorectalal Dis 1992;7:162–6.Google Scholar
  17. 17.
    Hünerbein M, Below C, Schlag PM. Three-dimensional endorectal ultrasonography for staging of obstructing rectal cancer. Dis Colon Rectum 1996;39:636–42.Google Scholar
  18. 18.
    Goldmann S, Norming U, Svensson Ch, Glimelius B. Transrectal ultrasound in the staging of anal epidermoid carcinoma. Int J Colorectal Dis 1991;6:152–7.Google Scholar
  19. 19.
    Löhnert M, Dohrmann P, Doniec JM. Diagnostik und Therapie des Analkarzinoms. Dtsch Med Wochenschr 1994;119:1701–5.Google Scholar
  20. 20.
    Kovács G, Kimmig B. Interstitielle HDR-Brachytherapie in der kombinierten Strahlenbehandlung von Anal-Karzinomen. GBK-Fortbildung Aktuell 1994;64:44–6.Google Scholar
  21. 21.
    Pipard G. Combination therapy of anal canal cancer: a report on external irradiation with or without chemotherapy followed by interstitial iridium 192. In: Sauer R, ed. Interventional radiation therapy: techniques—brachytherapy. Berlin: Springer, 1991:215–9.Google Scholar

Copyright information

© the American Society of Colon and Rectal Surgeons 1998

Authors and Affiliations

  • Mathias Löhnert
    • 1
  • Julius Marek Doniec
    • 1
  • György Kovács
    • 2
  • Jörg Schröder
    • 1
  • Peter Dohrmann
    • 1
  1. 1.Department of General and Thoracic SurgeryChristian-Albrechts-UniversityKielGermany
  2. 2.Department of Radiation TherapyChristian-Albrechts-UniversityKielGermany

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