Coatmeur Olivier, Truc Gilles, Barillot Isabelle, Horiot Jean-Claude, Maingon Philippe
Department of Radiotherapy, Centre Georges-François Leclerc, 1, rue Pr. Marion, 21079 Dijon, France.
Radiother Oncol. 2004 Feb;70(2):177-82. doi: 10.1016/j.radonc.2004.01.016.
We retrospectively analysed our experience of contact therapy alone and/or combined with interstitial brachytherapy as exclusive treatment of low lying rectal tumours.
From 1971 to 2001, 124 patients (103 adenocarcinomas, 21 villous tumours) were treated by contact therapy alone or combined with interstitial brachytherapy. All patients were staged according to the Dijon classification. The average size of the lesions was 2.4 cm (max 7 cm), clinical aspect was polypoïd in 75% of the cases, flat in 17%. Sixty four patients received contact therapy in three fractions and 44 patients received four fractions, for an average delivered dose of 95 Gy. Interstitial brachytherapy boost delivered 24 Gy on a reference isodose of 55 cGy/h in 10 patients.
The local control was 83% for T1 and 38% for T2 tumours (p=0.004). For mobile tumours, the local control rate is 76%, significantly higher than for tumours with impaired mobility (55%, P=0.03). Thirty-nine patients experienced a local failure (31%). For patients amenable to surgery, a Miles procedure was performed in 25 patients. Ultimate local control rate is 93% for T1, 69% for T2 (P<0.05), 15 patients failed despite treatment for local recurrence (15%). No significant differences were observed in a comparison of adenocarcinoma and villous tumours according to initial and ultimate local control. The mean disease free survival rate for the whole population is 66 months. The 5-year disease free survival for T1a and T1b is, respectively, 82 and 78%, 40 and 25% for T2a and T2b, respectively. The overall 5-year survival for the whole group is 62.4%. At the end of the treatment, 75% of the patients described a very good sphincter function. No deleterious effect on continence was reported during the follow-up.
The control rate for T1 rectal cancer treated with contact therapy with or without brachytherapy is comparable to surgical series. The sphincter was preserved in 80% of the patients. Radiotherapy remains an efficient and cheap alternative to surgery, mainly for old and fragile patients, or refusing colostomy. The results of these approaches for tumors larger than 3 cm (T2) are not satisfactory. For patients not amenable to surgery, external beam radiation therapy and/or combined modality with chemoradiation should be discussed to increase the loco-regional control rate. A careful selection of patients based on rectal examination and trans-rectal ultrasound could select more accurately patients amenable to such an approach.
我们回顾性分析了单独采用接触疗法和/或联合组织间近距离放射疗法作为低位直肠肿瘤唯一治疗方法的经验。
1971年至2001年期间，124例患者（103例腺癌，21例绒毛状肿瘤）接受了单独接触疗法或联合组织间近距离放射疗法。所有患者均根据第戎分类法进行分期。病变的平均大小为2.4厘米（最大7厘米），75%的病例临床表现为息肉样，17%为扁平状。64例患者分三次接受接触疗法，44例患者分四次接受接触疗法，平均给予剂量为95 Gy。10例患者接受组织间近距离放射疗法强化治疗，参考等剂量线为55 cGy/h，给予剂量24 Gy。
T1期肿瘤的局部控制率为83%，T2期肿瘤为38%（p = 0.004）。对于可活动肿瘤，局部控制率为76%，显著高于活动受限肿瘤（55%，P = 0.03）。39例患者出现局部复发（31%）。对于适合手术的患者，25例行腹会阴联合切除术。T1期最终局部控制率为93%，T2期为69%（P < 0.（此处原文有误，应为P < 0.05）05），15例患者尽管接受了局部复发治疗仍失败（15%）。根据初始和最终局部控制情况，腺癌和绒毛状肿瘤的比较未观察到显著差异。整组人群的平均无病生存率为66个月。T1a和T1b的5年无病生存率分别为82%和78%，T2a和T2b分别为40%和25%。全组总体5年生存率为62.4%。治疗结束时，75%的患者表示括约肌功能非常好。随访期间未报告对控便有有害影响。
采用或不采用近距离放射疗法的接触疗法治疗T1期直肠癌的控制率与手术系列相当。80%的患者保留了括约肌。放射治疗仍然是一种有效且廉价的手术替代方法，主要适用于老年和体弱患者或拒绝结肠造口术的患者。对于大于3厘米（T2）的肿瘤，这些方法的结果并不令人满意。对于不适合手术的患者，应讨论采用外照射放疗和/或放化疗联合模式以提高局部区域控制率。基于直肠指检和经直肠超声仔细选择患者可以更准确地筛选出适合这种治疗方法的患者。
