High dose rate brachytherapy as a boost after preoperative chemoradiotherapy for more advanced rectal tumours - the Clatterbridge experience
High dose rate brachytherapy as a boost after preoperative chemoradiotherapy for more advanced rectal tumours - the Clatterbridge experience
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DOI：
10.1016/j.clon.2007.07.018
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发表时间：
2007-11-01
影响因子：
3.4
通讯作者：
Wong, H.
中科院分区：
文献类型：
--
作者：
Myint, A. Sun;Lee, C. D.;Wong, H.
在一项来自22项随机试验的8507例患者的系统评价中，与单纯手术相比，放疗已被证明可以降低直肠癌局部复发和死亡的风险。最近的大型随机试验证实放化疗优于单独放疗。在里昂092试验中，接触放疗作为外部14束放疗（不含化疗）后的增强疗法也被证明可以改善局部控制和括约肌保存。目前，近距离放射疗法已被用于直肠癌的术前治疗，并显示出类似的结果。瑞典和荷兰的短期术前放疗的试验结果显示，局部控制的改善有利于放疗组。与斯堪的纳维亚组相似，蒙特利尔麦吉尔大学的研究人员采用了短程治疗，而不是外部放射疗法。然而，手术延迟了4-8周，以达到降低分期的目的。辐射剂量直接传递到肿瘤上，周围的正常组织不受辐射的影响。这种方法已被证明可以减少短期外束放射治疗的副作用，但仍能保持局部控制的改善。丹麦的研究小组在体外放化疗后使用近距离放疗作为更晚期直肠肿瘤的促进，并显示出病理完全缓解和R0切除率的改善。Mount Vernon组对不能手术的直肠癌患者使用了类似的直肠涂抹器，取得了良好的局部和症状控制。Clatterbridge的近距离放疗组采用与丹麦组相同的方法，但减少了外束放疗剂量，并增加了近距离放疗剂量，以降低副作用。所有16例患者（100%）都进行了RO切除术，而术前常规放化疗使用5-氟尿嘧啶丸方案的患者为63%。7例（44%）患者达到病理性完全缓解，而常规放化疗为2-12%。放疗没有增加3-4级毒性，也没有延迟伤口愈合或吻合口渗漏。纳入高剂量率近距离放射治疗似乎增加了病理完全缓解率，提高了RO切除率，而没有损害副作用，因为高剂量率增强带来的辐射剂量增加主要局限于肿瘤。这种治疗可能特别适用于不适合强化放化疗方案的老年患者。计划进行几项试验，以确定术前高剂量率近距离放疗在直肠癌中的作用，并对结果充满兴趣。
In a systemic review of 8507 patients from 22 randomised trials, radiotherapy has been shown to reduce the risk of local recurrence and death from rectal cancer compared with surgery alone. Recent large randomised trials confirmed that chemoradiotherapy was better than radiotherapy alone. Contact radiotherapy as a boost after external beam 14 radiotherapy (without chemotherapy) has also been shown to improve local control and sphincter preservation in the Lyon 092 trial. Brachytherapy has now been used as preoperative treatment for rectal cancer and showed similar results. The Swedish and Dutch trial results of short-course preoperative radiotherapy have shown improved local control in favour of the radiotherapy group. Similar to the Scandinavian group, investigators from McGill University in Montreal adopted a short course using brachytherapy instead of external beam radiotherapy. However, surgery was delayed for 4-8 weeks to achieve downstaging. The radiation dose was delivered directly on to the tumour and the surrounding normal tissues were spared the effects of radiation. This approach has been shown to reduce the side-effects seen with external beam short-course radiotherapy, but maintains the benefit of improved local control. The Danish group used brachytherapy as a boost after external beam chemoradiotherapy for more advanced rectal tumours and have shown improved pathological complete remission and R0 resection rates. The Mount Vernon group used a similar rectal applicator for inoperable rectal cancer patients and achieved good local and symptom control. The brachytherapy group at Clatterbridge used the same approach as the Danish group, but reduced the external beam radiotherapy dose and increased the brachytherapy dose to lower the side-effects. All 16 patients (100%) had RO resection compared with 63% A with conventional preoperative chemoradiotherapy using a bolus 5-fluorouracil regimen. Pathological complete remission was achieved in seven (44%) patients compared with 2-12% with conventional chemoradiotherapy. There was no increase in grade 3-4 toxicity from radiotherapy and no delay in wound healing or anastamotic leakage. The inclusion of high dose rate brachytherapy seems to increase the pathological complete remission rates and improves the RO resection rates with no detriment to the side-effects as the increased dose of radiation from the high dose rate boost is confined mainly to the tumour. This treatment may be particularly suitable for elderly patients where intensive chemoradiotherapy regimens are not suitable. Several trials are planned to define the role of preoperative high dose rate brachytherapy in rectal cancer and the results are awaited with interest.