Contact X-ray brachytherapy for rectal cancer: Past, present, and future

Gérard, Jean Pierre; Barbet, N.; Dejean, C.; Montagné, Lucile; Bénézery, Karen; Coquard, R.; Doyen, J.; Labrunie, J. Durand; Hannoun-Lévi, J.-M.

doi:10.1016/j.canrad.2021.04.006

Cited by 10 publications

(6 citation statements)

References 24 publications

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“…With a total dose of 90 Gy (D1: 35, D14: 30, D28: 25), the biologically equivalent mean dose with 2 Gy per fraction (EQD2) is close to 90 Gy (α/β tumor = 10). It is also important to stress that the dose to the rest of the rectal wall or pelvic OAR is close to zero, which explains the good tolerance of this treatment [ 6 ].…”

Section: Methodsmentioning

confidence: 99%

Targeted Radiotherapy Using Contact X-ray Brachytherapy 50 kV

Gérard

Myint

Barbet³

et al. 2022

Cancers

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Rectal adenocarcinoma is a quite radioresistant tumor. In order to achieve non-operative management (NOM) radiotherapy plays a major role. Targeted radiotherapy aiming at high precision 3D radiotherapy uses stereotactic image-guided external beam radiotherapy machines. To further safely increase the tumor dose, endocavitary brachytherapy (ECB) is an original approach. There are two different ways to perform such an ECB: contact X-ray brachytherapy (CXB) using a 50 kV X-ray generator with an X-ray tube positioned under eye guidance into the rectal cavity and high-dose-rate brachytherapy (HDRB) using iridium-192 sources positioned into the rectal cavity under image guidance. This study focused on CXB. CXB uses a small mobile generator that produces 50 kV X-rays with limited penetration. This technique is well adapted to accessible tumors of limited size and especially needs a high dose rate (≥15 Gy/minutes) for rectal tumors. It is performed on an ambulatory basis. A total dose between 80–110 Gy is delivered in 3–4 fractions over 3 to 6 weeks into a small volume (5 cm3). CXB was pioneered in the 1970s by Papillon using the Philips RT 50TM. Since 2009, the Papillon P50TM has been used in 11 institutions in Europe. The OPERA Phase III trial tested the hypothesis that a CXB boost (90 Gy/3 fr) compared to an EBRT boost (9 Gy/5 fr) for T2–T3 ab < 5 cm and N0–N1 < 8 mm will increase the 3-year organ preservation (OP) rate when combined with 45 Gy/5 weeks with concomitant capecitabine. Out of more than 300 patients with tumors < 3 cm (1962–1992), Papillon reported a long-term local control close to 85%. Similar results were published in Europe and USA at that time. The Lyon R96-2 Phase III trial (2004) demonstrated that, when combined with preoperative EBRT, a CXB boost (90 Gy/3 fr) significantly increased the rate of clinical complete response (cCR) and sphincter preservation, with some patients having OP at 10 years. With more than 2000 patients treated in Europe (2010–2020) using the Papillon 50TM, organ preservation appears possible in close to 80% of cases in selected early T2–T3. The OPERA trial closed after 141 inclusions (2015–2020) after an independent data monitoring committee recommendation because of promising results. At the 2-year follow-up (blinded data), the rate of cCR and OP were 77% and 72%, respectively, for the 141 tumors, and for T < 3 cm (61 pts), they were 86% and 85%, respectively, with good bowel function. The final results should be available in 2022. Organ preservation using NOM appears to be a promising approach for rectal cancer. A CXB boost with chemoradiotherapy in selected early T2–T3 could become an attractive option to achieve a planned OP. This approach should be proposed to well-informed patients after discussion in an MDT.

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Section: Methodsmentioning

confidence: 99%

Targeted Radiotherapy Using Contact X-ray Brachytherapy 50 kV

Gérard

Myint

Barbet³

et al. 2022

Cancers

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“…Since the 1990s, CXB has been progressively abandoned as the Philips RT 50™ contact machine was no longer manufactured and also with the development of interventional techniques in endoscopic treatment which became the standard treatment for small T1N0 rectal lesions. In 2009, a new machine called Papillon 50™, which produces low-energy 50-kV X-rays, was introduced in the UK and France, marking the renaissance of this technique [ 21 ].…”

Section: Resultsmentioning

confidence: 99%

Organ preservation strategy: new therapeutic alternative in rectal cancer

Safini

Amaoui

Semghouli

et al. 2023

J Egypt Natl Canc Inst

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Background The therapeutic modalities for nonmetastatic rectal cancer are presently undergoing major changes. The standard treatment is multidisciplinary, combining radiotherapy, chemotherapy, and surgery. The aim of this minireview is to provide an update on the place of organ preservation in the treatment of nonmetastatic rectal cancer in 2022. Main text The multimodal strategy based on initial radiochemotherapy followed by radical surgery with excision of the mesorectum has improved oncological results but at the expense of morbidity and sequelae altering life quality. The strategy of rectal preservation has been proposed since the 2000s after the publication of the results of the Brazilian study that proposed a simple surveillance after radiochemotherapy without surgery in good responders. In fact, preoperative radiochemotherapy was able to obtain a complete histological response in 10 to 30% of case. In view of this non-negligible percentage of tumor sterilization, which may well increase with the standardization of total neoadjuvant treatment, a strategy of organ preservation can be proposed in these patients to avoid morbidity and postoperative sequelae. Short conclusion This nonoperative approach is currently widely studied in certain patients who have a complete response (clinical, endoscopic, and radiological). However, the selection of these patients is not simple and still complex.

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“…Several studies have addressed the role of contact brachytherapy as a boost to external beam radiotherapy (EBRT), or as a monotherapy in non-operative management of early-stage rectal cancer [4]. Lyon R96-02 trial showed that 50 kV contact X-ray brachytherapy is effective and safe in non-operative management of clinical T1 and early T2-3 rectal cancers to improve complete clinical response and local control [5,6]. High-dose-rate endorectal brachytherapy (HDR-BRT) was first utilized for palliative or adjuvant treatment of rectal malignancies [7].…”

Section: Purposementioning

confidence: 99%

Complication and response assessment of high-dose-rate endorectal brachytherapy boost in neo-adjuvant chemoradiotherapy of locally advanced rectal cancer with long-term outcomes

Saeedian¹,

Lashkari²,

Ghalehtaki³

et al. 2023

jcb

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Purpose: To identify efficacy, complication, and pathologic response of high-dose-rate endorectal brachytherapy (HDR-BRT) boost in neo-adjuvant chemoradiotherapy (nCRT) of locally advanced rectal cancer.Material and methods: Forty-four patients who met eligibility criteria were included in this non-randomized comparative study. Control group was recruited retrospectively. nCRT (50.40 Gy/28 fr. plus capecitabine 825 mg/m 2 twice daily) was administered to both groups before surgery. In the case group, HDR-BRT (8 Gy/2 fr.) was supplemented after chemoradiation. Surgery was done 6-8 weeks after completion of neo-adjuvant therapy. Pathologic complete response (pCR) was the study's primary endpoint.Results: From 44 patients in the case and control groups, pCR was 11 (50%) and 8 (36.4%), respectively (p = 0.27). According to Ryan's grading system, tumor regression grade (TRG) TRG1, TRG2, and TRG3 were 16 (72.7%), 2 (9.1%), and 4 (18.2%) in the case, and 10 (45.5%), 7 (31.8%), and 5 (22.7%) in the control group (p = 0.118). T down-staging was found in 19 (86.4%) and 13 (59.1%) patients in the case and control groups, respectively. No grade > 2 toxicity was identified in both the groups. Organ preservation was achieved in 42.8% and 15.3% in the case and control arm (p = 0.192). In the case group, 8-year overall survival (OS) and disease-free survival (DFS) were 89% (95% CI: 73-100%) and 78% (95% CI: 58-98%), respectively. Our study did not reach median OS and median DFS.Conclusions: Treatment schedule was well-tolerated, and neo-adjuvant HDR-BRT could achieve better T downstaging as a boost comparing with nCRT, without significant complication. However, the optimal dose and fractions in the context of HDR-BRT boost needs further studies.

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Contact X-ray brachytherapy for rectal cancer: Past, present, and future

Cited by 10 publications

References 24 publications

Targeted Radiotherapy Using Contact X-ray Brachytherapy 50 kV

Targeted Radiotherapy Using Contact X-ray Brachytherapy 50 kV

Organ preservation strategy: new therapeutic alternative in rectal cancer

Complication and response assessment of high-dose-rate endorectal brachytherapy boost in neo-adjuvant chemoradiotherapy of locally advanced rectal cancer with long-term outcomes

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