Lavan Naomi A, Kavanagh Dara O, Martin Joseph, Small Cormac, Joyce Myles R, Faul Clare M, Kelly Paul J, O'Riordain Michael, Gillham Charles M, Armstrong John G, Salib Osama, McNamara Deborah A, McVey Gerard, O'Neill Brian D P
1 St Luke's Radiation Oncology Network, Dublin, Ireland.
2 St Vincent's University Hospital, Dublin, Ireland.
Br J Radiol. 2016;89(1057):20150292. doi: 10.1259/bjr.20150292. Epub 2015 Nov 5.
Neoadjuvant "long-course" chemoradiation is considered a standard of care in locally advanced rectal cancer. In addition to prostatectomy, external beam radiotherapy and brachytherapy with or without androgen suppression (AS) are well established in prostate cancer management. A retrospective review of ten cases was completed to explore the feasibility and safety of applying these standards in patients with dual pathology. To our knowledge, this is the largest case series of synchronous rectal and prostate cancers treated with curative intent.
Eligible patients had synchronous histologically proven locally advanced rectal cancer (defined as cT3-4Nx; cTxN1-2) and non-metastatic prostate cancer (pelvic nodal disease permissible). Curative treatment was delivered to both sites simultaneously. Follow-up was as per institutional guidelines. Acute and late toxicities were reviewed, and a literature search performed.
Pelvic external beam radiotherapy (RT) 45-50.4 Gy was delivered concurrent with 5-fluorouracil (5FU). Prostate total dose ranged from 70.0 to 79.2 Gy. No acute toxicities occurred, excluding AS-induced erectile dysfunction. Nine patients proceeded to surgery, and one was managed expectantly. Three relapsed with metastatic colorectal cancer, two with metastatic prostate cancer. Five patients have no evidence of recurrence, and four remain alive with metastatic disease. With a median follow-up of 2.2 years (range 1.2-6.3 years), two significant late toxicities occurred; G3 proctitis in a patient receiving palliative bevacizumab and a G3 anastomotic stricture precluding stoma reversal.
Patients proceeding to synchronous radical treatment of both primary sites should receive 45-50.4 Gy pelvic RT with infusional 5FU. Prostate dose escalation should be given with due consideration to the potential impact of prostate cancer on patient survival, as increasing dose may result in significant late morbidity. Review of published series explores the possibility of prostate brachytherapy as an alternative method of boost delivery. Frequent use of bevacizumab in metastatic rectal cancer may compound late rectal morbidity in this cohort.
To our knowledge, this is the largest case series of synchronous rectal and prostate cancers treated with curative intent. This article contributes to the understanding of how best to approach definitive treatment in these patients.
新辅助“长疗程”放化疗被认为是局部晚期直肠癌的标准治疗方法。除前列腺切除术外，外照射放疗和近距离放疗（无论有无雄激素抑制）在前列腺癌治疗中已得到广泛应用。我们完成了一项对10例病例的回顾性研究，以探讨在患有双重病理的患者中应用这些标准的可行性和安全性。据我们所知，这是最大的一组以治愈为目的治疗同步性直肠癌和前列腺癌的病例系列。
符合条件的患者患有同步经组织学证实的局部晚期直肠癌（定义为cT3 - 4Nx；cTxN1 - 2）和非转移性前列腺癌（允许盆腔淋巴结转移）。对两个部位同时进行根治性治疗。按照机构指南进行随访。对急性和晚期毒性反应进行了评估，并进行了文献检索。
盆腔外照射放疗（RT）剂量为45 - 50.4 Gy，同时给予5 - 氟尿嘧啶（5FU）。前列腺总剂量范围为70.0至79.2 Gy。除雄激素抑制引起的勃起功能障碍外，未发生急性毒性反应。9例患者接受了手术，1例进行了观察等待。3例出现转移性结直肠癌复发，2例出现转移性前列腺癌复发。5例患者无复发证据，4例仍患有转移性疾病存活。中位随访时间为2.2年（范围1.2 - 6.3年），出现了2例严重的晚期毒性反应；1例接受姑息性贝伐单抗治疗的患者发生3级直肠炎，1例出现3级吻合口狭窄导致无法回纳造口。
对两个原发部位进行同步根治性治疗的患者应接受45 - 50.4 Gy的盆腔放疗并静脉输注5FU。在增加前列腺剂量时应充分考虑前列腺癌对患者生存的潜在影响，因为剂量增加可能导致严重的晚期并发症。对已发表系列研究的回顾探讨了前列腺近距离放疗作为一种替代增敏方法的可能性。在转移性直肠癌中频繁使用贝伐单抗可能会加重该队列患者的晚期直肠并发症。
据我们所知，这是最大的一组以治愈为目的治疗同步性直肠癌和前列腺癌的病例系列。本文有助于理解如何最好地对这些患者进行确定性治疗。
