Huber F T, Stepan R, Zimmermann F, Fink U, Molls M, Siewert J R
Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Germany.
Dis Colon Rectum. 1996 Jul;39(7):774-9. doi: 10.1007/BF02054443.
Surgery often fails to achieve local control in advanced rectal cancer. Additional measures are necessary to prevent local recurrence. The aim of this study was to evaluate intraoperative radiation therapy (IORT) (flab technique) combined with preoperative or postoperative radiochemotherapy.
PATIENTS/METHODS: IORT is performed using a flexible flab containing hollow plastic tubes that are connected to a multichannel afterloading device with a 370 Gbq-192-Ir source. Patients receive an intraoperative dose of 15 Gy. Target volumes were measured in a cadaver experiment. From 1989 to 1993, 38 patients were included in this study. Nineteen patients were staged as T3 tumors by preoperative endosonography (Group I) and 19 as T4 tumors (Group II). Patients in Group I underwent resection (abdominoperineal resection (APR), 16; anterior resection, 3) and IORT, followed by postoperative radiochemotherapy (50 Gy/5-fluorouracil), whereas patients in Group II received preoperative radiochemotherapy (40 Gy/5-fluorouracil) followed by resection (APR, 18; anterior resection, 1) and IORT. Mean follow-up was 25.5 months.
Operative radicality in Group I was RO (13), R1 (3), and R2 (3), and in Group II it was RO (14), R1 (3), R2 (2). R2 resections were attributable to preoperative undetected distant metastases. Perioperative mortality was 0 percent in Group I and 10.5 percent (n = 2) in Group II. Postoperative morbidity was 53 percent (n = 10) in Group I and 84 percent (n = 16) in Group II with delayed sacral wound healing being the predominant problem. Stenosis of the ureter occurred in two patients (Group II). Late or persistent therapy-related complications were seen in two patients in Group I and in six patients in Group II. Local recurrence developed in three patients in Group I (15.8 percent) and in two patients in Group II (10.5 percent). Survival data do not reach statistical significance between the two groups because of small numbers but show a favorable trend for the preoperative radiochemotherapy group. When compared with a matched historical control group of patients receiving resection only, adjuvant/neoadjuvant radiotherapy with resection/IORT improves survival significantly.
The flab method is a simple but especially practical technique for IORT in the pelvis. Adjuvant/neoadjuvant therapy combined with resection/IORT is associated with high morbidity but acceptable mortality. Preliminary survival data are encouraging and call for a controlled prospective randomized trial.
手术常常无法实现晚期直肠癌的局部控制。需要采取额外措施来预防局部复发。本研究的目的是评估术中放射治疗（IORT）（平板技术）联合术前或术后放化疗的效果。
患者/方法：使用一种包含中空塑料管的柔性平板进行IORT，这些塑料管连接到一个带有370 Gbq - 192铱源的多通道后装装置。患者术中接受15 Gy的剂量。在尸体实验中测量靶体积。1989年至1993年，本研究纳入了38例患者。19例患者术前经内镜超声检查分期为T3肿瘤（I组），19例为T4肿瘤（II组）。I组患者接受手术切除（腹会阴联合切除术（APR），16例；前切除术，3例）和IORT，随后进行术后放化疗（50 Gy/5 - 氟尿嘧啶），而II组患者先接受术前放化疗（40 Gy/5 - 氟尿嘧啶），然后进行手术切除（APR，18例；前切除术，1例）和IORT。平均随访时间为25.5个月。
I组的手术根治性为R0（13例）、R1（3例）和R2（3例），II组为R0（14例）、R1（3例）、R2（2例）。R2切除归因于术前未检测到的远处转移。I组围手术期死亡率为0%，II组为10.5%（n = 2）。I组术后发病率为53%（n = 10），II组为84%（n = 16），主要问题是骶骨伤口愈合延迟。两名患者（II组）出现输尿管狭窄。I组有两名患者、II组有六名患者出现晚期或持续性治疗相关并发症。I组有三名患者（15.8%）、II组有两名患者（10.5%）发生局部复发。由于样本量小，两组生存数据未达到统计学意义，但术前放化疗组显示出良好趋势。与仅接受手术切除的匹配历史对照组相比，辅助/新辅助放疗联合手术切除/IORT可显著提高生存率。
平板法是盆腔IORT的一种简单但特别实用的技术。辅助/新辅助治疗联合手术切除/IORT发病率高但死亡率可接受。初步生存数据令人鼓舞，需要进行对照前瞻性随机试验。
