Planned organ preservation for early T2-3 rectal adenocarcinoma: A French, multicentre study

• Published in: European journal of cancer (1990) Vol. 108; pp. 1 - 16
• Main Authors: Gérard, Jean-Pierre, Barbet, Nicolas, Gal, Jocelyn, Dejean, Catherine, Evesque, Ludovic, Doyen, Jérôme, Coquard, Régis, Gugenheim, Jean, Benizri, Emmanuel, Schiappa, Renaud, Baudin, Guillaume, Benezery, Karène, François, Eric
• Format: Journal Article
• Language: English
• Published: England Elsevier Ltd 01-02-2019; Elsevier Science Ltd
• Subjects: Acute toxicity; Adenocarcinoma; Adenocarcinoma - pathology; Adenocarcinoma - therapy; Adult; Aged; Aged, 80 and over; Antimetabolites, Antineoplastic - therapeutic use; Bleeding; Brachytherapy; Brachytherapy - methods; Cancer; Capecitabine - therapeutic use; Chemoradiotherapy; Chemoradiotherapy - methods; Clinical complete response; Colorectal cancer; Contact X-ray brachytherapy; Digital imaging; Female; France; Humans; Intestine; Magnetic Resonance Imaging; Male; Mastectomy; Middle Aged; Neoadjuvant Therapy; Neoplasm Recurrence, Local - epidemiology; Neoplasm Staging; NMR; Nuclear magnetic resonance; Organ preservation; Organ Sparing Treatments; Patients; Preservation; Proctectomy; Radiotherapy, Intensity-Modulated - methods; Rectal cancer; Rectal Neoplasms - pathology; Rectal Neoplasms - therapy; Rectum; Retrospective Studies; Salvage; Survival Rate; Toxicity; Tumor Burden; Tumors; Ultrasound; France; Organ preservation; Contact X-ray brachytherapy; Rectal cancer; Clinical complete response
• ISSN: 0959-8049; 1879-0852
• DOI: 10.1016/j.ejca.2018.11.022

Neoadjuvant chemoradiotherapy (nCRT) and watch-and-wait policy as reported by Habr-Gama are references for organ preservation in rectal cancer. To increase the clinical complete response (cCR) and reduce the local recurrence rates, we report a retrospective analysis of a prospective cohort of selected T2-3 tumours treated in three French institutions using contact X-ray brachytherapy (CXB) with nCRT.
Tumour selection was based on digital rectal examination (DRE), rigid rectoscopy, magnetic resonance imaging (MRI) and/or endorectal ultrasound. Adenocarcinoma T2-3 < 5 cm largest diameter, M0 were treated, all with organ preservation intent. CXB delivering 90 Gy/3 fractions/4 weeks was combined with CRT (capecitabine 50). Strict evaluation of tumour response using DRE and rectoscopy ± MRI was performed at regular interval with prolonged surveillance.
Between 2002 and 2016, 74 consecutive patients were treated (median age: 74 years. T2: 45 and T3: 29). A cCR or near-cCR (mainly rectal wall ulceration) was noted at week 14 in 71 patients (95%). A local excision was performed in 13 patients. Of three partial responses (PRs), one salvage anterior resection was performed. With a median follow-up of 3 years, local recurrence (mainly in the rectal wall) was seen in seven patients. The 3-year local recurrence rate was 10%, and the cancer-specific survival, 88%. Two patients underwent radical proctectomy for PR or local recurrence and 96% preserved their rectum. Grade III acute toxicity was recorded in five patients. Rectal bleeding was the main late toxicity (grade III in 12%). Bowel function was scored as good or excellent in 85% of patients.
Combining CXB and nCRT in selected early T2-T3 rectal cancers may safely provide a high rate of cCR, organ preservation, and good bowel function with a risk of local recurrence below 15%. Such an approach could be offered to operable patients as a planned option for organ preservation.
•In rectal T2-3 contact X-Ray 50 kV with CRT provides a complete (or near) clinical response at week 14 in 95% of cases.•Out of 74 patients organ preservataion was possible in 96% of cases with 3-year local recurrence rate of 10%.•Good bowel function was achieved ibn 85% of patients. Main toxicity was radiation rectal bleeding (grade III) in 12% of cases.•In operable patients with T2T3a-b ncot exceeding 4 cm, a planned organ preservation can be proposed if using CXB with CRT.