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Br. J. Surg. 1987, Vol.

74, June,
449454 The future of external beam
irradiation as initial treatment of
rectal cancer
Several trials have demonstrated that pre-operative irradiation for rectal
cancer decreases signijcantly the incidence of pelvic recurrence.
However, this method is far @om being generally accepted. I t is now
possible to enhance the effectiveness of external beam irradiation and to
use it to extend the j e l d of sphincter-saving and conservative procedures.
Our protocol consists of a split-course regimen with a short course of
cobalt40 arc rotation (3000cGy in 12 days). After 2 months rest, the
second stage of treatment depends upon the pressure of residual disease
and the site of the tumour. I t consists of either radical surgery (82 cases)
or conservative treatment by intracavitary irradiation in the event of a
favourable initial response or in the case of poor risk patients (73 cases).
I n the radiotherapy-surgical group, the subsequent operative specimens
were tumour p e e in 17 per cent of cases and assigned to Dukes’ A
category in 32 per cent of cases. Of 91 patients with T, or T3 tumour
involving the lower third of the rectum (followed up for more than 3
J. Papillon years) 72 (84 per cent) had no recurrence. Thirty-three of these patients
(46 per cent) underwent a colostomy while 39 (54 per cent) had normal
University of Lyon and Centre
Leon Bbrard, 69008 Lyon, France
anal function. These results demonstrate the major place that a properly
Correspondence to: Dr J Papillon,
planned external beam irradiation can have in the curative management
12, Quai Gbnbral Sarrail, 69006 of cancers of the low rectum.
Lyon, France Keywords: Rectal cancer, radiotherapy, surgery, conservative treatment

Optimal treatment of rectal cancer aims to give patients the best disease. However, in elderly poor risk surgical patients with
chance of cure while retaining normal anal function. Substantial intermediate tumours, it would be rational to try to avoid
progress has been made in the development of restorative abdominoperineal resection by using external beam irradiation
procedures. However, tumours of the lower third of the rectum, to convert the tumours into lesions amenable to conservative
which represent approximately 40 per cent of cancers of the treatment.
rectum are usually treated by abdominoperineal resection, and The first important work devoted to pre-operative
have a poorer prognosis than those situated in the upper or irradiation dates back to 1959 with the publication of a
middle third because of a higher rate of locoregional retrospective study from the Memorial Sloan-Kettering Cancer
recurrences. Center by Stearns et al.’. This report aroused much interest, and
The results of radical surgery, whether abdominoperineal a large number of studies have since been published. Many of
resection or low anterior resection, have not improved them are non-randomized, the figures are not convincing, and a
significantly during the past 30 years. The average 5 year bewildering variety of conclusions has been drawn3-”. Most
survival rate remains fairly constant at about 50 per cent. Local studies have been conducted according to two principles: (1)
recurrence is one of the principal causes of failure following homogeneous doses of radiation are distributed to large target
surgery. The main purpose of pre-operative irradiation is not to volumes which include most, if not all, of the pelvic cavity. The
alter the surgical procedure, but to improve the cure rate by tumour does not receive a higher dose than the surrounding
increasing resectability rates and reducing the incidence of normal structures. ( 2 ) Surgery is performed shortly after
pelvic recurrences due to seeding at the time of surgery or the completion of irradiation.
presence of cancer cells in the perirectal tissues. The decision to When conservative treatment can be used in patients with
use pre-operative irradiation may be made on the basis of the rectal cancer it must be stressed that, regardless of the method
clinical evaluation at the time of diagnosis. employed (local excision, electrocoagulation or intracavitary
Nicholls et a[.’ have shown that the clinician is able to assess irradiation),the approach is only applicable to selected patients
the extent of palpable rectal cancers with satisfactory accuracy. with tumours less than 4 cm in size. At present these indications
Rectal carcinomas suitable for curative treatment may be embrace less than 10 per cent of all patients with rectal cancer
divided into three general groups. The early or limited cancers suitable for curative management, whereas more than
are well differentiated adenocarcinomas not larger than 4 cm in 90 per cent of patients will undergo radical s ~ r g e r y ’ ~ . ’ ~ .
diameter, freely mobile and confined to the bowel wall. For The purpose of the present article is to evaluate a new
these cancers conservative treatment such as local excision, protocol of external beam irradiation in the treatment of rectal
electrocoagulation or intracavitary irradiation may be an cancer. Patient tolerance and treatment efficacy are assessed
alternative to radical surgery. At the other extreme are advanced with particular reference to the possibility of avoiding
cases with large tumours deeply infiltrating the perirectal fat, abdominoperineal resection in favour of sphincter saving
some degree of stenosis of the rectal lumen and impaired resection or conservative treatment.
mobility. Between these groups is an ‘intermediate group’ made
up of tumours larger than 4 cm, moderately infiltrating, freely
Patients and methods
mobile and with little or no extrarectal spread. Currently,
intermediate and advanced cases are treated by radical surgery, Radiotherapy technique
which is considered to be the only means of controlling the A particular treatment technique has been applied at the Centre Leon

0007-1323/87/060449-06$3.00 0 1987 Butterworth & Co (Publishers) Ltd 449


External beam irradiation in the treatment of rectal cancer: J. Papillon

9 years (mean follow-up, 3 years). All patients were considered clinically


to have resectable, biopsy proven T, or T3tumours ofthe rectum, that is
tumours with involvement of muscle wall or serosa only (T,), or
tumours involving all layers with extension to immediately adjacent
structures (T3).
Patients given palliative treatment for unresectable or disseminated
tumours were excluded from this study. The following results were
observed in 82 patients who were subsequently operated on, and in 73
patients who were treated conservatively.The 82operations consisted of
abdominoperineal resection in 65 cases and low anterior resection in 17
cases. All operative specimens were examined to define the Dukes' grade
of the tumour.
Patients were only selected for conservative treatment after
radiotherapy if any of the following criteria were fulfilled:
(1) well or moderately well differentiated adenocarcinoma
(2) tumours of the lower third of the rectum which were too large
(4-6cm) or too close to the anus to be treated by intracavitary
irradiation
(3) tumours which were mobile and moderately infiltrating in that there
was little or no detectable extrarectal spread
(4) absence of palpable metastatic lymph nodes
(5) normal carcinoembryonic antigen (CEA) levels and CT scan
(6) patients considered to be high surgical risks because of their age or
general condition
(7) limited residual disease detectable 2 months after completing
Figure 1 Isodose distribution of pre-operative irradiation by cobalt40 external beam irradiation.
for cancer of the rectum. Irradiation is performed by 120" arc rotation
through a 9 x 12cm sacral $eld. The patient is in the prone position with
$11 bladder. A dow of3000 cGy calculated at isocentre which is at 10 cm Results
depth is delivered in I0 fractions within I2 days. Note that a hot spot at
3500-3900 cGy is centred on the tumour area and that the target volume Tolerance of radiotherapy
includes most of the posterior pelvic area with satisfactory protection of This radiotherapy course was well tolerated despite the
small bowel, urinary bladder and bony structures advanced age of many of the patients. After irradiation, proctitis
rarely lasts more than 3 weeks and responds rapidly to
symptomatic management. There is no cystitis and no skin
Bkrard, Lyon, France since 1977, the main features of which are as
reaction in the sacral area. When the tumour is located close to
follows' 3 . 1 4 .
(1) The target volumeis limited yet includes the most important sites the sphincter area, the perineal skin is included in the target
of regional spread of rectal cancer and the main lymphatic drainage volume, but its reaction is easily relieved by ointment. After this
areas of the rectum, especially the presacral area, the sidewalls of the 3 week period, the symptoms related to the rectal tumour
posterior pelvic cavity, and the soft tissues anterior to the rectum. (2) decrease and gradually disappear. After the 2 months rest most
Satisfactory protection of the urinary bladder and the small bowel is patients have gained weight and are in good condition.
essential. (3) A short course of intensive irradiation delivers a minimum
turnour dose of 3000cGy in 10fractions of 300cGy within 12 days. The Eficacy of radiotherapy
treatment starts on a Monday and ends on the Friday of the following
week. This treatment is at least equivalent to a dose of 4500cGy in 4.5 Of the 82 patients who underwent radical surgery, no technical
weeks. (4) A non-homogeneous dose distribution delivers a 2& difficulties were encountered in defining fascia1 planes or due to
30 per cent higher dose in the tumour area. ( 5 )Surgery is not performed fibrosis or excessive bleeding related to the irradiation. In many
immediately following irradiation but after 2 months rest which cases the surgeon stated that the excision was especially easy.
allows optimal shrinkage of the tumour. No particular delay in perineal wound healing was noted. Two
The irradiation is given by cobalt40 using 120" arc rotation through patients (2.4per cent) died within 30 days of operation. The
a 9 x 12 cm sacral field and with the patient in the prone position. The efficacy of pre-operative irradiation was evaluated by the study
doseof3000cGyiscalculatedat theisocentrewhichis lOcmdeep to the of operative specimens and the status of patients followed up for
posterior surface. The isodose distribution shows that the tumour
receives a dose of about 35W3900cGy (Figure 1).
more than 3 years. In 14 cases (17 percent) the operative
One of the advantages of this method is its flexibility and the specimen was tumour free; this is the highest rate ever published.
possibility of adapting the isodose distribution and its 'hot spot' to the In 27 cases (33 per cent) the tumour was confined to the bowel
site and spread of the tumour. This adaptation can be achieved by wall. This high figure suggests that some Dukes' B tumours with
changing parameters such as the field size or the depth of axis of extension through the serosa may have shrunk to become
rotation. In very frail patients the overall treatment time may be Dukes' A tumours. The relatively low incidence of Duke's C
protracted to 16 days by treating only four times a week. tumours (27 per cent)may be interpreted as due to the control of
The small bowel is protected by bladder distension, which displaces some metastatic lymph nodes.
the small bowel anteriorly and superiorly. Patients are asked to drink as Fifty patients treated by radiotherapy and surgery have been
much water as possible 2 h before treatment and to keep a full
bladder. Small bowel X-ray films are taken after opacification with
followed-up for more than 3 years; 42 underwent an
barium sulphate, the patient being in the treatment position to simulate abdominoperineal resection, eight a low anterior resection.
accurately the relative position of the small bowel with respect to the Four patients died of intercurrent diseaie but were apparently
planned isodoses. Small bowel is excluded from the target volume. cancer free, six developed distant metastasis but were locally
Delaying operation for 8 weeks after completion of the short-term controlled, four (8.3 per cent) died of local failure after total
irradiation is a key factor in the method, because at this time the rectal excision. These figures demonstrate that the protocol can
inflammatory phase following radiation has subsided, the fibrotic achieve the usual objective of pre-operative irradiation, namely a
reaction has not begun and the optimal effect of the irradiation has been reduced incidence of pelvic recurrence after surgery (Table 1).
achieved. The clinician is able to take advantage of any tumour
regression in assessing tumour spread and can make a more enlightened
choice between radical, restorative and conservative treatment options. Extension of the applicability of restorative procedures
Of the 17 patients who underwent a low anterior resection, 10
Patients had tumours within 6 cm of the anal verge. Operative specimens
This protocol of irradiation has been applied to 155 patients (median were tumour free in six cases (Figure 2), and allocated to Dukes'
age, 69 years) who have now been followed up for periods of 6 months to A, B and C categories respectively in five, four and two cases.

450 Br. J. Surg., Vol. 74, No. 6, June1987


External beam irradiation in the treatment of rectal cancer: J. Papillon

The apparent tumour regression following radiotherapy and that some of the 27 patients with Dukes’ A tumour could
improved the prospects for a low anterior resection in lOof these have been treated conservatively given that tumour regression
17 cases, mostly with colo-anal anastomosis. Three patients had was significant.
a diverting loop colostomy, which was closed after 3 months. For patients unfit for surgery and for frail, poor surgical risk
Three patients developed anastomotic leakages; one following patients with low-lying tumours the usual choice lies between
resection for a high located tumour, two after resection of low- radical surgery and palliative treatment. The theoretical
lying lesions. These three patients underwent temporary advantage of radical surgery may be offset by its mortality” and
colostomy which was closed 3 4 months later. No failure, either it is rational to consider a third option, namely concentrated
local or distant, occurred in these 17 patients. Of eight patients irradiation followed by a wait of 2 months before a final decision
followed up for more than 3 years, one died within 30 days of is made about the most appropriate form of further treatment.
operation while seven are still alive and apparently disease-free, Seventy-three patients with T, tumours of the lower half of
three of them after colo-anal anastomosis for low-lying cancer. the rectum belonging to the ‘intermediate group’ were
irradiated according to the above protocol. Their median age
was 75 years. After 2 months rest the tumour shrinkage was
E x t e n s i o n of the role of conservative treatment substantial, the residual disease was limited and the great
In retrospect it can be argued that the 14 patients with tumour- reparative capacity of the normal rectal mucosa was evident. In
free surgical specimens could have been spared radical surgery, such cases abdominoperineal resection was abandoned in
favour of a conservative procedure such as intracavitary
irradiation (72 cases) or local excision and electrocoagulation
(one case). Intracavitary irradiation was used to deliver a
Table 1 Outcome in 50 patients treated by pre-operative irradiation and booster dose to the tumour bed to optimize local control. It
radical surgery (minimum follow-up: 3 years)
consisted of one application of contact X-ray therapy with the
Dead 50 kV Philips machine to a dose of 2500 cGy and an iridium
Dead of of cancer implant to a dose of 2000 cGy. Local excision was performed in
No. of Alive and intercurrent or alive Postoperative one patient with residual tumour on the posterior wall in the
cases well disease with cancer death sacral concavity and not easily accessible to intracavitary
irradiation (Figure 3 ) .
50 34 (68%) 4 (8%) 10 (20%) 2 (4%) In this group of 73 patients treated conservatively but with
curative intent, 45 have been followed up for more than 3 years.

Figure 2 (a) Female aged 44 years. Barium enema showing a bulky well differentiuted adenocarcinoma 7 c m in length locuted 5-11 cm from the dentate
line before pre-operative irradiation. (b) Same patient. Tumour-jkee operative specimen of low anterior resection 2 months after short course of irradiation.
The tumour has disappeared and is replaced by a shallow ulceration. Patient alive and well 4 years after treatment

8 r . J. Surg., Vol. 74, No. 6, June 1987 451


External beam irradiation in the treatment of rectal cancer: J. Papillon

Figure 3 a Male aged 60 years, poor surgical risk because of medical illness. Barium enema shows a bulky and ulcerative adenocarcinoma of the lower
half of the rectum, 7 c m in length, located 3-10 cm from the dentate line before irradiation. b Same patieni after split-course irradiation. The substantiul
shrinkage of tumour 2 months after a short course of irradiation allowed conservative treatment by intracauitary irradiation (Contact X-ray and iridium-1YZ
implant). Patient clinically controlled 3 years after treatment.

Table 2 Results afier conversion j o m radical into conservative Table 3 Overall results following external beam irradiation as initial
treatment. Policy applied to 45 poor risk patients with moderately treatment for T2 and T3 cancers involving the lower third of the rectum
infiltrating cancer of the lower rectum (minimum follow-up: 3 years) (minimum follow-up: 3 years)

Dead from Dead from


No. of Alive and intercurrent Dead from Postoperative No. of Alive and intercurrent Dead from Postoperative
cases well disease cancer death cases well disease cancer death

45 25 (55%) 13 (28.9%) 6 (13.3%) 1 (2.2%) 91 55 (60.4%) 17 (18.7%) 16 (17.6%) 3 (3.3%)

The results are reported in Table 2. Of eight patients for restorative surgery and 91 had T, or T, tumours ofthe lower
(17-8per cent) who developed local failure, three are alive and third of the rectum treated either by radiotherapy and surgery
well after subsequent abdominoperineal resection (2) or (46)or by conservative method (45).Fifty-five (60-4per cent) are
electrocoagulation (l), one aged 84 died within 30 days of alive and well, 17 died of intercurrent disease but were cancer-
operation, and four died from cancer (three of them were free; 16 (17.6 per cent) died of cancer (Table 3 ) .No patients were
deemed inoperable because of their general condition). Two lost to follow-up. Among the 72 patients who had no failure,
patients died from distant metastasis but were locally neither local nor distant, 39 (54.1 per cent) had no colostomy.
controlled. Thirteen (28.9 per cent) died from intercurrent
disease. This high figure reflects the advanced age of patients.
Twenty-five patients are alive and well after 3-8 years of follow- Discussion
up, 23 with normal anal function, and as previously mentioned, The revival of interest in radiotherapy in the management of
two after salvage surgery, Of these 45 patients, the disease has rectal cancer is due to the increased effectiveness of irradiation of
been controlled in 36 (80 per cent) with preservation of a normal a tumour which, 25 years ago, was considered to be
anal sphincter (Figure 3). radioresistant. Among the numerous studies devoted to pre-
During the first years of this study only elderly patients were operative irradiation, the most informative is the second trial of
accepted into this extension of conservative treatment. Analysis the European Organization for Research on Treatment of
of the results prompted us to enlarge the indications during the Cancer in which 318 patients were randomized to receive
past 2 years to middle-aged, good risk patients. To answer 3450cGy in 19 days pre-operatively, or surgery alone. In the
possible criticism concerning the question of lymphatic spread, radiotherapy group, operation was performed 2 weeks after the
three patients underwent an inferior mesenteric and completion of irradiation. The results published by Gerard et
extramesenteric lymphadenectomy. This operation, initiated at ul1’ showed that 85percent of patients were free of local
the Centre Leon Berard13,16,aims to check the main lymphatic recurrence at 5 years after radiotherapy as opposed to only
drainage areas of the rectum and to explore the pelvis without 65 per cent in the surgery alone group ( P = 0401). There is also
bowel excision. The operation was performed 3 months after a significant differencein the survival between the two treatment
control of the primary tumour had been achieved. No involved groups, and the percentage of patients disease free at 5 years is
nodes were found and all these patients are clinically well. 70 per cent for the radiotherapy group verws 60 per cent for the
control group (P=O,O32). It must be noted that in this trial
Overall outcome 13 per cent of patients underwent a restorative procedure,
Of the 95 patients followed up for more than 3 years, 4 had 81 per cent an abdominoperineal resection and 6 per cent other
turnour located in the upper two-thirds of the rectum suitable surgical procedures. These figures contrast with those of the

452 Br. J. Surg., Vol. 74, No. 6, June 1987


External beam irradiation in the treatment of rectal cancer: J. Papillon

Rectal Cancer Group reported by Porter and Nicholls'8 who (5000cGy) and the interval of 4 7 weeks between the
cited a 52.9 per cent incidence of anterior resection, showing the completion of irradiation and the surgery.
recent progress made in the development of sphincter-saving Wang and Schulz'' in 1962 were among the first to report
procedures. However, in almost all studies of combined cure at 5 years after irradiation therapy alone and considered
treatment the irradiation does not interfere with the surgery and that 6 of their 58 inoperable patients may have been cured in this
the type of operation is only chosen according to the site and way. Rider et al.29 and C ~ m m i n g showed
s ~ ~ that protracted
spread of the tumour and to the local and general conditions at irradiation is able to control mobile rectal tumours in
the time of surgery. 38 per cent of cases. They emphasized that the tumour response
In spite of technical progress, pelvic recurrence remains the is particularly slow and that an early decision may be
main cause of treatment failure after restorative surgery. The inadequate. The present series corroborates these data, but the
incidence of locoregional recurrences is mainly related to the technique of irradiation used in our centre is quite different from
distance of the primary tumour from the dentate line. In the those previously employed. When assessed 6 8 weeks after the
Mayo Clinic experience", this rate is 9 per cent for tumours completion of treatment the effectivenessof a short but intensive
located between 8 and lOcm from the dentate line and course of irradiation is greater than expected. The tumour
22.2 per cent for low-lying lesions. In the same institution the response allows the most appropriate approach to be selected
rates are between 10 and 26 per cent according to the suture for each patient.
technique". The results obtained by combining irradiation and The low rate of local failures after surgery among patients
abdominoperineal resection may strengthen the case for pre- followed up more than 3 years, and the results obtained in
operative radiotherapy before restorative surgery in order to patients with low-lying tumours treated either by sphincter
decrease the rate of pelvic failure. However, the fear of increased preserving surgery or by irradiation alone support a plea for
postoperative morbidity, particularly anastomotic leakage, has external beam irradiation as the initial treatment in most cases
deterred many surgeons from using external beam irradiation of non-obstructive rectal cancers suitable for curative
before anterior resection for tumours of the upper and middle management. The results in terms of the extension of the role of
thirds of the rectum. They consider that the safety of an restorative surgery and of conservative treatment are
intestinal anastomosis in irradiated bowel has not yet been encouraging. It is now possible to spare a larger number of
established. elderly patients a permanent colostomy without jeopardizing
Nicholls" has highlighted the high incidence of anastomotic their chance of cure.
leakage after surgery alone when the anastomosis is made below
the peritoneal reflection. The frequency ranges from 5 to
30 per cent of cases. The literature contains only relatively
limited statistics on patients who have actually received References
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EM. Preoperative radiation therapy for clinically resectable Paper accepted 11 February 1987

Announcement

Overseas Doctors Training Scheme (Surgery)


At the request of the Department of Health and Social Security (DHSS), the Royal
College of Surgeons of England is setting up a training scheme in general surgery
and orthopaedics for doctors from abroad. This will be under the arrangements for
double sponsorship introduced by the General Medical Council. The posts
included in the scheme will be established National Health Service posts subject to the
DHSS Terms and Conditions of Service and with Royal College recognition. In the
main overseas doctors will be appointed to rotational programmes of surgical training,
where possible including University Teaching Hospitals, in regions throughout
England and Wales, and Northern Ireland. The principle aim of this scheme is to
provide a high standard of surgical training for doctors outside the United Kingdom
and the European Community to help them in their work when they return home.
Further particulars can be obtained from the ODTS office, Royal College of Surgeons
of England, 3 5 4 3 Lincoln's Inn Fields, London WC2A 3PN, UK.

454 Br. J. Surg., Vol. 74, No. 6, June1987