Journal club
Download
1 / 21

Journal Club - PowerPoint PPT Presentation


  • 194 Views
  • Updated On :

Journal Club. 17 th March, 2003 Dr Ramon Varcoe. Which rectal cancers should. be treated with . PREOPERATIVE RADIATION ?. Background… “ There is evidence to support the rationale of giving radiotherapy before surgery while the SI is mobile and not fixed in the pelvis with adhesions..”.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Journal Club' - kolton


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Journal club l.jpg

Journal Club

17th March, 2003

Dr Ramon Varcoe


Slide2 l.jpg

Which rectal cancers should

be treated with

PREOPERATIVE RADIATION ?


Slide3 l.jpg

Background…“There is evidence to support the rationale of giving radiotherapy before surgery while the SI is mobile and not fixed in the pelvis with adhesions..”

Swedish Rectal Cancer Trial. NEJM. 1997…

  • 1168 patients with rectal cancer stages I-III

  • Preop short course RT improved LR (11 vs 27%) and survival (58 vs 48%)

    Camma etal. (meta-analysis) JAMA. 2000…

  • 14 studies/6426 patients

  • Improved LR (OR 0.49/P<0.001) and overall mortality (OR 0.84/P0.03) with PRT


Background l.jpg
Background …

Camma etal. (meta-analysis) JAMA 2000…

  • 14 studies, 6426 patients

  • Early rectal cancers (T1/T2) show no benefit from preop radiation therapy

    Lopez-Kostner etal. (Cleveland) Surgery 1998…

  • Upper third rectal cancer behave like colon cancer in terms of LR and disease profile

    Marsh etal. (Manchester) DCR 1994…

  • 284 patients. Prospective, randomized controlled trial

  • Locally advanced (T4) low rectal cancers show reduced LR with preop RT but overall survival is similar


Problems l.jpg
PROBLEMS

  • Inaccurate PREOPERATIVE STAGING

    (ERUS is most sensitive for bowel wall invasion, 86% by Napoleon etal BJS 1991)

  • At the time of publication all trials that demonstrate benefits of PreopRT do not describe formal TME.

    Most Trials therefore have LR 25-50% instead of the expected 4-9% with TME

    Nb.The Dutch Colorectal Cancer Group Trial has since been published using TME and confirming the survival benefits seen in the Swedish trial


Slide6 l.jpg
“Preoperative Radiotherapy Improves Survival for Patients Undergoing Total Mesorectal Excision for Stage T3 Low Rectal Cancers”

by C.Delaney, I.Lavery, A.Brenner, J.Hammel, A.Senagore, R.Noone and V.Fazio

Cleveland Clinic, Ohio, USA

Annals of Surgery

236(2), 2002, 203-7


Objective l.jpg
OBJECTIVE Undergoing Total Mesorectal Excision for Stage T3 Low Rectal Cancers”

  • Examine effects of Preoperative Radiotherapy (PRT)

    ON

  • T3 low rectal cancers

  • Undergoing TME rectal excision


Study design l.jpg
STUDY DESIGN Undergoing Total Mesorectal Excision for Stage T3 Low Rectal Cancers”

  • Retrospective

  • 1980-2001

  • Adenocarcinoma of rectum <8cm from AV

  • Undergoing Anterior Resection or APR

  • T3 tumours on histology

  • T3 on ERUS (cohort group)

    Excluded if…

  • Proven metastatic disease

  • Had Post-op radiotherapy or chemotherapy


Study design9 l.jpg
STUDY DESIGN… Undergoing Total Mesorectal Excision for Stage T3 Low Rectal Cancers”

  • “Long course radiotherapy”

    40-50 Gy over 4-6 weeks then surgery 4-6 weeks later

  • “Total mesorectal excision (TME) surgery”

    Excision of the mesorectum with its investing fascial layer preserving the pre-sacral autonomic nerves and Denonvillier’s fascia


Results l.jpg
RESULTS Undergoing Total Mesorectal Excision for Stage T3 Low Rectal Cancers”

  • 259 patients

  • 92 had PRT, 167 did not

  • Matched with similar but not identical demographic data (see table 1), similar tumour details and surgical procedures

  • An ultrasound control group was incorporated to attempt to nullify the potential for histological down staging with PRT


Slide11 l.jpg

The treatment group is Undergoing Total Mesorectal Excision for Stage T3 Low Rectal Cancers”

significantly younger


Slide12 l.jpg

Overall survival benefit after treatment with PRT Undergoing Total Mesorectal Excision for Stage T3 Low Rectal Cancers”

Cancer specific survival benefit also dominated by node negative tumours

Local recurrence rates were also marginally reduced with PRT


Slide13 l.jpg

Overall survival is significantly improved by giving radiation in this 2-5 cm group

Show me the money

In the same group cancer specific survival is also significantly improved



Conclusions l.jpg
CONCLUSIONS node negative group

  • T3 tumours less than 8 cm from AV should be treated with PRT

    • Especially node negative tumours

    • Especially tumours 2-5 cm

  • Insufficient evidence to exclude subgroups of T3 tumours from treatment at this stage


Trial strengths l.jpg
Trial strengths… node negative group

  • Two established surgeons

  • Standardised technique of TME

  • Large numbers


Problems with this trial l.jpg
Problems with this trial… node negative group

  • Retrospective

  • 38 of the 92 that had PRT also had simultaneous chemotherapy (interestingly they had a worse OS; 53.2 vs 71.0%)

  • Downstaging effect of PRT may affect histology

    This potential histology inaccuracy creates a crucial flaw in the study design


Slide18 l.jpg

The next question is node negative group

"Do we use long course

or short course radiation ?"


Slide19 l.jpg

The Trans-Tasman Radiation Oncology Group (TROG) Trial node negative group“A Randomised Trial of Preoperative Radiotherapy for Stage T3 Adenocarcinoma of Rectum”


Trog trial l.jpg
TROG trial node negative group

  • Commenced July 2001

  • Multicentre (17 so far)

  • More than 100 patients recruited


Slide21 l.jpg

The End node negative group


ad