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Discussion on Preoperative Radiotherapy in the Treatment of Rectal CancerBY: Ritu Choudhary | Category: Colon and Rectal Cancer | Submitted: 2010-10-10 18:27:09
These are guidelines for the treatment of rectal cancer after regional consultations. Local recurrence after Radiotherapy: After 5 years follow-up within the TME study a clear reduction in the number of local recurrences seen: for the entire patient population, there is a reduction of 11.4% in the TME only group to 5.8% in the RT group. This finding underscores the excellent results that can be achieved with optimal treatment of resectable rectal cancer. It should be considered that (yet) no difference in overall survival is found. The most serious morbidity of local recurrence is the difficulty in treatment of rectal cancer local recurrence is very relevant. Subgroup analysis by TNM stage of rectal cancer: The analysis by TNM stage show that there is a reduction in local recurrence occurs in elk-stadium. The results are significant only in stage III. In the lower stages, the number of relapses in the fresh group is already very low, so the gain in absolute rates is limited. One problem with this analysis however is that the TNM stage is based on the postoperative and pathological TNM stages. The accuracy of preoperative determination of T stage is with 89% endo-echo and the N-stage up to 74% (endo-ultrasound or MRI). These results illustrate that the correct determination of TNM stage with current radiological techniques is still limited. The relevance given the lack of circumferential margin in the TNM classification is limited. Subgroup analysis by type of operation involved in rectal cancer The TME trial was stratified for the expected type of surgery, LAR or APR. Maybe this subgroup analysis therefore ought to find a place. This analysis is significant reduction of local recurrence after preoperative radiotherapy (5x5 Gy) only seen in the LAR patients. The recurrence rate in APR patients is high and is not significantly different for the two randomization arms. This result is in contrast with the Swedish results, where there is indeed an effect of 5x5 Gy in APR patients seen. A possible explanation for the results in the TME trial is the large number of APR patients with positive resection margin, which it is unclear whether this is on a resectietechniek with too narrow margins or the extent of the tumor. Subgroup analysis by tumor localization associated with rectal cancer: When looking at the distance of the tumor from the anal sphincter, it becomes clear that the patients with tumors 5-10 cm from the anal sphincter most benefit from radiotherapy. Local recurrence is reduced to 11% in this case. These are precisely the patients, with most faecal incontinence. At the higher distant tumor and not the effect is less significant. Problem with this analysis, however, that the distance from the tumor is not well documented, and that even today still many discrepancies are observed. With tumors of 0-5 cm, the effect of low radiation, which, given the results of the APR is not surprising. Therefore remains difficult to demarcate the proximal tumors. The rule that a transverse enema photo / CT scan / MRI line determines the decision is handled is currently the most practical. Subgroup analysis of circumferential resection margin: Short-term preoperative radiotherapy is not effective in patients with a positive CRM: the local recurrence rate is 23.3% and 15.5% for non-irradiated tumors irradiated tumors. Both percentages are by today's standards for rectal carcinoma unacceptable. The Working Group therefore considers that in patients on the basis of MRI or multislice CT scan is expected that in operation a positive CRM may arise, 5x5 Gy radiotherapy schedule was not suitable. It is recommended that patients with a preoperative conventional schedule (28x1.8 Gy or 25x2 Gy) infection. The addition of chemotherapy may be considered, but its value has not yet been proven in a randomized setting. Article Source: http://www.cancer-surgery.com/ About Author / Additional Info: Comments on this article: (0 comments so far)
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