A cohort study of local excision followed by adjuvant therapy incorporating a contact X‐ray brachytherapy boost instead of radical resection in 180 patients with rectal cancer

Abstract

Aim Recent data have suggested near‐equivalent oncological results when treating early rectal cancer by local excision followed by radio‐ ± chemotherapy rather than salvage radical surgery. The aim of this retrospective study was to assess the use of contact X‐ray brachytherapy within this paradigm. Method All patients had undergone local excision and were referred to our radiotherapy centre for treatment with contact X‐ray brachytherapy. Postoperative (chemo)radiotherapy was also given in their local hospital in most cases. Variables assessed were local excision method, postoperative therapy received, follow‐up duration, disease‐free survival, salvage surgery and stoma‐free survival. Results In total, 180 patients with a median age of 70 (range 36–99) years were assessed. Following local excision, pT stages were pT1 = 131 (72%), pT2 = 44 (26%), pT3 = 5 (2%). All patients received contact X‐ray brachytherapy boosting at our centre and, in addition, 110 received chemoradiotherapy and 60 received radiotherapy alone. After a median follow‐up of 36 months (range 6–48), 169 patients (94%) remained free of local recurrence. Of the 11 patients with local recurrence (three isolated nodal), five underwent salvage abdominoperineal excision. Eight patients developed distant disease, of whom five underwent metastasis surgery. At last included follow‐up 173 (96%) patients were free of all disease and 170 (94%) were stoma free. Conclusions Contact therapy can be offered in addition to external beam radio (±chemo) therapy instead of radical surgery as follow‐on treatment after local excision of early rectal cancer. This combination can provide equivalent outcomes to radical surgery. The added value of contact therapy should be formally assessed in a clinical trial.

Oncologic Nomogram for Stage I Rectal Cancer to Assist Patient Selection for Adjuvant (Chemo)Radiotherapy Following Local Excision

“…However, after LR failure, the highest 5-year survival rate of patients receiving remedial surgery is only 58% (21)(22)(23). The latest research shows that AT can achieve the same long-term prognosis as remedial surgery (24). Compared with remedial surgery, AT has advantages in trauma and postoperative complications and can eliminate subclinical lesions so as to improve the local control rate.…”

Propensity score analysis of radical proctectomy versus organ preservation using contact X-ray brachytherapy for rectal cancer

“…In observational studies reporting W&W strategies the local recurrence rate varies between 5% and 60% and the metastases rate between 6% and 30% being more elevated in cases of local recurrence (21). In elderly and comorbid patients the competing effects of oncological and surgical risk may argue in favor of a W&W approach as a safe alternative (23) Estimation of conditional survival using the large IWWD (international Watch and Wait Database) in 768 patients has suggested that after sustained cCR for 3 years the risk of late local recurrence does not exceed 5% (22) Smith compared 136 patients with RP-TME and ypCR after nCRt and 113 patients with cCR and W&W. At 5 years overall survival was 73% in W&W vs 94% in ypCR with a higher rate of distant metastasis in W&W (21). In the OPRA study a NOM was possible in up to 60% of patients with no 3-year Disease-Free-Survival difference when compared with historical series (4).…”

“…Estimation of conditional survival using the large IWWD (international Watch and Wait Database) in 768 patients has suggested that after sustained cCR for 3 years the risk of late local recurrence does not exceed 5% [22] …”

GEC ESTRO ACROP consensus recommendations for contact brachytherapy for rectal cancer

“…Patients that have undergone excision of malignant polyps can also be offered CXB +/- EBRT to decrease the risk of local regrowth, level 2b [24] . Patients with low-risk (see Table 2 ) incompletely excised or close margins pT1 tumours following local excision (R1 resection) can have CXB to the tumour site if they are not fit for further surgery.…”