References were selected from our own collections. A search of Medline for articles published since 2000 was done with the search terms “rectal cancer”, “radiotherapy”, “contact x-ray”, “brachytherapy”, and “sphincter preservation”. Only papers published in English or French were selected. Abstracts were selected if direct communication with the author was possible. Preoperative radiotherapy to increase the chance of sphincter preservation is not included in this review.
ReviewRadiotherapy alone in the curative treatment of rectal carcinoma
Section snippets
High dose, small volume
The main goal in the treatment of rectal adenocarcinoma by radiation alone, is to kill the primary gross tumour. Endocavitary irradiation (contact x-ray therapy, brachytherapy) is the main technique used to deliver high doses to the tumour but low doses to normal tissue (figure 1 figure 2). External-beam radiotherapy is a complementary technique used to control subclinical disease in the rectal wall and perirectal lymph nodes.
Contact radiotherapy or Papillon's technique
Papillon's technique was developed in the 1950s and is done with a 50 kV hand-held tube. A maximum energy beam of 50 kV delivers a dose of 20 Gy per min. The percentage dose is 100% at 0 mm and about 50% at 5 mm depth, but only 20% at 10 mm; the scatter from the tube is negligible.
The treatment is done on an outpatient basis and does not require general anaesthesia. A T1N0 lesion should be treated with four sessions: 35 Gy on day 1 (dose at the surface of the tumour with a 3 cm applicator), 30
Brachytherapy
Brachytherapy is used as a supplementary method to deliver a boost dose to the tumour bed after contact therapy; various techniques are used. One such technique is a perineal implant, in which five needles are implanted in a single curved plane with iridium-192 spaced at 1 cm under general or epidural anaesthetic. Five 192Ir 5–6 cm wires are then inserted. The correct dose is 15–30 Gy over 1–2 days. An alternative technique is a iridium “fork” implant, which is most suitable for rectal tumours
External-beam radiotherapy
This method is used to supplement the dose deep within the primary tumour and to the perirectal lymph nodes. The patient is generally in a prone position to allow clear visualisation of the anal verge. Close control of the field positioning is necessary for precise positioning of the lower limits of the field. A three or four-field technique is used to deliver a dose of 50 Gy in 25 fractions over 5 weeks in addition to endocavitary irradiation. A concomitant boost (a field within a field
Selection of patients
Since surgery is the treatment of choice for rectal cancer, patients suitable for radiation alone must be selected very carefully. The clinical examination must be done in the knee–chest position with the rectal ampulla prepared by use of an enema. Digital rectal examination and proctoscopy with a rigid tube are essential. The proctoscope should be of the same size as that to be used for treatment (2·5–3·0 cm in diameter). An important point to check is whether the patient can remain in the
T1N0 stage tumours
Contact x-ray, like endoanal surgical excision, can be used to control T1N0 rectal cancer. This technique is restricted to patients with a very low risk of perirectal lymph-node involvement. The tumour stage should be T1N0 with a well or moderately well differentiated adenocarcinoma. A very important selection factor is the response of the tumour on day 21 after two sessions of radiotherapy. If the tumour shows a complete response at this stage, the chance of control by irradiation alone after
T2–3N0–1 tumours
The standard treatment for these tumours is radical surgery (anterior resection or abdominoperineal resection). However, there are two situations in which surgery is not an option: when the patient has poor general health and when an abdominoperineal resection is possible for low rectal cancer but the patient refuses to have a permanent colostomy. In these situations, contact therapy alone cannot control the disease because the dose to deeper layers of the rectal wall is not high enough and no
Discussion
Currently, there are sufficient data to show that endocavitary irradiation (contact therapy with or without iridium brachytherapy) can be safely combined with external-beam radiotherapy (45–55 Gy over 4–6 weeks). Such radiotherapy can also be used for carcinoma of the anal canal, and good anorectal function is preserved in most patients. The main side-effects are rectal bleeding, which can sometimes necessitate local treatment such as plasma argon laser therapy, and some bowel frequency and
Technology
An important point for the future of radiotherapy alone in the curative treatment of rectal cancer is the development of a new contact x-ray machine. Philips no longer produces the RT50 machine that has been used in all the studies of contact therapy discussed here. A few radiological companies are currently looking into such a device, and new machine should be available in the next few years. Such a device (delivering a 50 kV x-ray beam) could also treat tumours of the skin and eyelids as well
Chemoradiotherapy
Concurrent chemoradiotherapy could have a better therapeutic index than radiotherapy alone for the cure of rectal adenocarcinoma. The current EORTC 29921 and the FFCD 9203 trials of fluorouracil and folinic acid should yield more information.53 New cytotoxic drugs such as oxaliplatin54 and irinotecan can be safely combined with radiotherapy in rectal cancer and give encouraging response rates. Combination of radiotherapy with new biological radiosensitisers, such as antiangiogenic,
Clinical approach
Local control in rectal cancer is currently achieved in more than 90% of patients with surgery, in many combined with preoperative radiotherapy.6, 55 Improved survival owing to prevention of liver metastasis is a crucial endpoint. Quality of life, which in rectal carcinoma relates to the preservation of a well-functioning sphincter, will become more and more important. Surgical techniques are likely to improve to preserve more sphincters—eg, low coloanal anastomosis, intersphincteric
Search strategy and selection criteria
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Cited by (60)
Planned organ preservation for early T2-3 rectal adenocarcinoma: A French, multicentre study
2019, European Journal of CancerCitation Excerpt :Endoluminal radiation dose escalation is a strategy to increase the cCR rate [8,9]. Contact X-ray brachytherapy (CXB) was pioneered in the 1970s by Papillon [10] and was used in Europe and the US [11]. The Lyon R 96-02 randomised trial proved that when compared with neoadjuvant external beam radiotherapy (EBRT) alone, a CXB boost combined with EBRT was able to increase cCR and sphincter preservation rates [12,13].
Personalized management of elderly patients with rectal cancer: Expert recommendations of the European Society of Surgical Oncology, European Society of Coloproctology, International Society of Geriatric Oncology, and American College of Surgeons Commission on Cancer
2018, European Journal of Surgical OncologyDecision-Making Strategy for Rectal Cancer Management Using Radiation Therapy for Elderly or Comorbid Patients
2018, International Journal of Radiation Oncology Biology PhysicsCitation Excerpt :Of the patients treated, 54 had prior endoscopic removal of macroscopic disease; 71% of patients were treated with RT alone, whereas some underwent salvage surgery afterward (135). Similarly, the French experience at Lyon Sud reported a primary local tumor control rate of 60% to 95% for T2-T3 rectal cancer in elderly patients with median age of 77 years treated with a combination of EBRT and endocavitary brachytherapy alone; approximately 27% of the patients treated were medically inoperable (136-139). Although these data are only retrospective, they provide a glimpse of a potential treatment regimen for frail patients for whom therapeutic options are otherwise limited.
Advances in organ preserving strategies in rectal cancer patients
2018, European Journal of Surgical Oncology