Elsevier

The Lancet Oncology

Volume 4, Issue 3, March 2003, Pages 158-166
The Lancet Oncology

Review
Radiotherapy alone in the curative treatment of rectal carcinoma

https://doi.org/10.1016/S1470-2045(03)01020-9Get rights and content

Summary

Surgery is the standard treatment for rectal adenocarcinoma. The tumour is resistant to radiation; doses above 80 Gy are necessary and have to be delivered by endocavitary irradiation. Contact radiotherapy is a basic method of delivering a high dose in a small volume. Brachytherapy can be used to deliver a boost of radiation into a residual lesion. External-beam radiotherapy can be used to supplement the dose to the deep part of the primary tumour and to the perirectal lymph nodes. T1N0 tumours have been treated by contact radiotherapy, and local control was achieved in 85–90% of patients with no severe toxic effects. Combined endocavitary irradiation and external-beam irradiation can achieve local control in 80% of patients with T2 tumours and 60% of patients with T3 tumours with only moderate toxic effects and a 60% 5-year overall survival. Radiotherapy alone is suitable for patients with T1N0 lesions (contact radiotherapy) or patients with T2–3 (combined endocavitary and external-beam radiotherapy) who cannot undergo surgery. For T2 or early T3 tumours of the lower rectum requiring surgery and a permanent colostomy, combined irradiation can be used as a first-line treatment in an attempt to avoid abdominoperineal amputation.

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

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.

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