Dose escalation using contact X-ray brachytherapy (Papillon) for rectal cancer: does it improve the chance of organ preservation?

Arthur Sun Myint, Fraser McLean Smith, Simon William Gollins, Helen Wong, Christopher Rao, Karen Whitmarsh, Raj Sripadam, Paul Rooney, Michael Jeremy Hershman, Zsolt Fekete, Kate Perkins, D Mark Pritchard, Arthur Sun Myint, Fraser McLean Smith, Simon William Gollins, Helen Wong, Christopher Rao, Karen Whitmarsh, Raj Sripadam, Paul Rooney, Michael Jeremy Hershman, Zsolt Fekete, Kate Perkins, D Mark Pritchard

Abstract

Objective: A watch and wait policy for patients with a clinical complete response (cCR) after external beam chemoradiotherapy (EBCRT) for rectal cancer is an attractive option. However, approximately one-third of tumours will regrow, which requires surgical salvage for cure. We assessed whether contact X-ray brachytherapy (CXB) can improve organ preservation by avoiding surgery for local regrowth.

Methods: From our institutional database, we identified 200 of 573 patients treated by CXB from 2003 to 2012. Median age was 74 years (range 32-94), and 134 (67%) patients were males. Histology was confirmed in all patients and was staged using CT scan, MRI or endorectal ultrasound. All patients received combined CXB and EBCRT, except 17 (8.5%) who had CXB alone.

Results: Initial cCR was achieved in 144/200 (72%) patients. 38/56 (68%) patients who had residual tumour received immediate salvage surgery. 16/144 (11%) patients developed local relapse after cCR, and 124/144 (86%) maintained cCR. At median follow up of 2.7 years, 161 (80.5%) patients were free of cancer. The main late toxicity was bleeding (28%). Organ preservation was achieved in 124/200 (62%) patients.

Conclusion: Our data suggest that CXB can reduce local regrowth to 11% compared with around 30% after EBCRT alone. Organ preservation of 62% achieved was higher than reported in most published watch and wait studies. Advances in knowledge: CXB is a promising treatment option to avoid salvage surgery for local regrowth, which can improve the chance of organ preservation in patients who are not suitable for or refuse surgery.

Figures

Figure 1.
Figure 1.
Treatment algorithm. cCR, clinical complete response; EBCRT, external beam chemoradiotherapy; EBRT, external beam radiotherapy.
Figure 2.
Figure 2.
Patient care pathway. cCR, clinical complete response; CXB, contact X-ray brachytherapy; DSS, delayed salvage surgery; EBRT, external beam radiotherapy; ISS, immediate salvage surgery.
Figure 3.
Figure 3.
Contact X-ray brachytherapy treatment position.
Figure 4.
Figure 4.
Contact X-ray treatment schematic diagram. FSD, focal surface distance
Figure 5.
Figure 5.
Treatment response for early stage malignant polyp. CXB, contact X-ray brachytherapy;
Figure 6.
Figure 6.
Treatment response for more advanced tumour.
Figure 7.
Figure 7.
Disease-free survival.
Figure 8.
Figure 8.
Local recurrence free survival.
Figure 9.
Figure 9.
Overall survival.

Source: PubMed

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