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

Gérard, Jean-Pierre; Barbet, N.; Gal, Jocelyn; Dejean, C.; Evesque, Ludovic; Doyen, J.; Coquard, R.; Gugenheim, Jean; Benizri, Emmanuel; Schiappa, Renaud; Baudin, G.; Bénézéry, K.; François, Ετιεννε

doi:10.1016/j.ejca.2018.11.022

Cited by 58 publications

(61 citation statements)

References 27 publications

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“…22,23,[26][27][28][29][30][31][32][33] Studies of both these techniques have included steps toward clinical implementation such as computed tomography or magnetic resonance imaging compatibility, 27,33,34,78,137 optimal planning algorithms to decrease planning and delivery times, 23,26,32,67,75,77 and optimal sources and shielding materials. 4,[29][30][31][32]71,138 Commercially available IMBT techniques include staticshielded applicators 6,7,14,17,20,[35][36][37][38][39][40][41][42][43][44][46][47][48][49][50][51]…”

Section: Discussionmentioning

confidence: 99%

“…35,39,43,94 Static-shielded applicators can also be pressed against the breast, as with AccuBoost (Advanced Radiation Therapy, Inc, Billerica, MA), 37,41,42,44,47 or against colorectal tissue, as with Papillon devices (Ariane, Alfreton, UK). 36,38,40,45,46,48,49,[84][85][86][87][88]95,96 Leipzig applicators have been studied and used clinically for nonmelanoma skin cancer or Kaposi's sarcoma, 43 are conically shaped with tungsten or tungsten alloy shields of 10 to 30 mm in inner diameter, and use a 192 Ir source in either parallel or perpendicular orientation to the treated surface ( Fig. 1J).…”

Section: Static-shielded Applicatorsmentioning

confidence: 99%

“…25,107 Clinically, cup-or D-shaped static IMBT applicators with Papillon devices have been the most widely used to provide boosts to early-stage colorectal cancers for more than 30 years. 36,38,40,46,48,49,[84][85][86][87][88]95,96 Studies have demonstrated favorable incidence rates for 3-year local recurrence (6%-16.9%), clinical complete response (63.8%-96%), organ preservation (62%-96%), grade 3 acute toxicity (constipation/diarrhea or incontinence, 6.7%-9%) and late toxicity (bleeding, 9%-28%), and good-excellent bowel function (85%) at 2.5 to 3 years of median followup. 38,40,48,49 Other, multiple, or no specific disease site Studies of IMBT have also included other sites such as the pancreas, 63 multiple malignant sites (an ongoing clinical trial of any solid tumor of the abdomen or pelvis), 58 no specific disease sites, 55,62 and nonmalignant applications, such as intravascular BT for coronary artery disease.…”

Section: Oculocutaneous Diseasementioning

confidence: 99%

“…"Static" IMBT approaches include those in which the shield does not move relative to the source or surrounding tissues during BT delivery, such as shielded applicators (eg, shielded cylinders, [3][4][5][6][7][8][9][10][11] shielded tandem and ovoids, [12][13][14][15][16][17][18][19][20] Strut-Adjusted Volume Implants [SAVI], 21 intracavitary mold applicators [ICMA], [22][23][24][25][26] direction-modulated brachytherapy [DirMBT], 21,25,[27][28][29][30][31][32][33][34] and cup or D-shaped applicators [35][36][37][38][39][40][41][42][43][44][45][46][47][48][49]…”

Section: Introductionmentioning

confidence: 99%

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Systematic Review of Intensity-Modulated Brachytherapy (IMBT): Static and Dynamic Techniques

Callaghan

Adams

Flynn

et al. 2019

International Journal of Radiation Oncology*Biology*Physics

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Purpose: To systematically review scientific literature on the use of intensity-modulated brachytherapy (IMBT), including static and dynamic shielding approaches, to enhance therapeutic ratio. Studies were evaluated for technique, disease site, dosimetry, applicators, dosimetric calculations, and planning algorithms. Comparisons with standard-of-care brachytherapy techniques, alternative IMBT methods, or both were performed for dose-to-target volumes, organs at risk (OARs), and treatment planning or delivery times. Methods and Materials: Inclusion criteria were any peer-reviewed journal articles on IMBT published from January 1, 1980, to January 1, 2019, on PubMed, Google Scholar, Cochrane Library, and EBSCO databases. Two independent investigators reviewed each article for inclusion and exclusion criteria and scope. Data collected on each study included technique, source or shield material, disease site, n of study (n Z number of simulated plans/treated patients), doseto-target/OARs, and planning or delivery times. This review adhered to the Preferred Reporting Items for Systemic reviews and Meta Analyses (PRISMA). Results: Database queries yielded 1734 results, which were reduced to 436 after exclusion criteria and 78 peer-reviewed journal articles after evaluation of scope. Studies per disease site were 31 for cervical; 16 for rectal; 10 for oculocutaneous; 7 for breast; 6 for prostate; and 8 for other, multiple, or no specific disease site. Eighteen studies demonstrated a significant decrease in dose to OARs (5.1%-68.2%), 11 improved treatment planning or delivery times (7.6%-99.7%), and 6 increased target coverage (18.6%-71.6%) relative to standard-of-care or alternative IMBT technique. IMBT consistently decreased dose to OAR compared with the standard of care at the cost of increased planning or delivery times. Innovations in dose calculation or planning algorithms and applicators were capable of ameliorating prolonged treatment intervals.

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Section: Discussionmentioning

confidence: 99%

Section: Static-shielded Applicatorsmentioning

confidence: 99%

Section: Oculocutaneous Diseasementioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Systematic Review of Intensity-Modulated Brachytherapy (IMBT): Static and Dynamic Techniques

Callaghan

Adams

Flynn

et al. 2019

International Journal of Radiation Oncology*Biology*Physics

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“…With patient selection and safe CXB dose escalation, it is possible to propose this treatment option for rectal cancer as it is standard for squamous cell carcinoma of the anus. This approach can be called " planned" organ preservation for early rectal cancer [9]. In summary two different strategies can be discussed.…”

Section: Jéan-pierre Gérard Nicolas Barbet and Karen Benezerymentioning

confidence: 99%

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2019

Oncotarget

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The standard treatment of T2-3 Nx M0 rectal adenocarcinoma is proctectomy with total mesorectal excision (TME) often combined with neoadjuvant chemoradiotherapy (nCRT). Such radical surgery can be responsible for significant morbidity or suboptimal bowel function when anterior resection is performed. To improve these outcomes organ preservation using a non-operative modality (NOM) is gaining interest in clinical research.Historically organ preservation was initiated with two different approaches. In the 1960s Papillon used contact X-ray brachytherapy 50 kV (CXB) to control T1 tumor [1]. The lyon R96-02 phase III trial demonstrated that adding CXB to external beam radiotherapy (EBRT) for T2 T3 rectal cancer significantly increased the rate of clinical complete response (cCR), sphincter and organ preservation [2]. In the 1970s Habr Gama initiated a conservative approach using nCRT with a "watch and Wait" strategy in case of cCR [3]. This strategy is presently the world reference. Habr Gama using an extensive CRT regiment achieves a cCR rate of 72% and 63% respectively in T2 and T3 and a local recurrence rate of 8% and 40% [3]. Most of the other experiences are collected in the IWWD (international W-W data base) [4] reporting more than 1000 patients. When treating locally advanced rectal cancer (LARC) with nCRT the rate of cCR is between 15% to 40% and local recurrence between 20 to 35%.To achieve rectal preservation a cCR must be assessed after nCRT. This requires an intense surveillance protocol combining digital rectal examination, endoscopy and MRI. There is no consensus on the definition of cCR and a grey zone exists between cCR and partial response (PR) called near clinical complete response (ncCR). As the definition of ncCR is still more uncertain than cCR, the extension of the surveillance period from 6 to 12 weeks demonstrated that it could change ncCR in cCR and facilitate a NOM decision [5]. An observation period between 3 to 6 months appears recommended to optimally select patients candidate for NOM. The IWWD showed that the rate of organ preservation at the end of this long period is between 15% to 40% with a risk of local recurrence (sometimes called "regrowth") close to 20% after NOM.These suboptimal results can be explained by two main arguments:-Adenocarcinoma of the rectum is a radioresistant tumor. The model of Appelt is confirming this concept [6]. When correlating radiation dose escalation with pCR rate a dose of 92 Gy appears necessary to sterilize only 50% of T3 tumor. Such a high dose cannot be reached with EBRT alone without severe radiation toxicity. A possible technique to increase safely the RT dose is CXB endocavitary approach. In 2009 of a new CXB machine (Papillon 50 TM ) made possible a renaissance of this technique. Five centers in France and UK using this new system showed that a boost dose of 90 Gy in 3 fractions could be safely delivered with nCRT [7-9]. -Tumor selection. It is a well-known radiobiology concept that the tumor volume is a key parameter for irradiation to achieve st...

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Image-guided high-dose-rate brachytherapy for rectal cancer: technical note and first clinical experience on an organ-preserving approach

et al. 2022

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Purpose As the population ages, the incidence of rectal cancer among elderly patients is rising. Due to the risk of perioperative morbidity and mortality, alternative nonoperative treatment options have been explored in elderly and frail patients who are clinically inoperable or refuse surgery. Methods Here we present technical considerations and first clinical experience after treating a cohort of six rectal cancer patients (T1‑3, N0‑1, M0; UICC stage I-IIIB) with definitive external-beam radiation therapy (EBRT) followed by image-guided, endorectal high-dose-rate brachytherapy (HDR-BT). Patients were treated with 10–13 × 3 Gy EBRT followed by HDR-BT delivering 12–18 Gy in two or three fractions. Tumor response was evaluated using endoscopy and magnetic resonance imaging of the pelvis. Results Median age was 84 years. All patients completed EBRT and HDR-BT without any high-grade toxicity (> grade 2). One patient experienced rectal bleeding (grade 2) after 10 weeks. Four patients (67%) demonstrated clinical complete response (cCR) or near cCR, there was one partial response, and one residual tumor and hepatic metastasis 8 weeks after HDR-BT. The median follow-up time for all six patients is 42 weeks (range 8–60 weeks). Sustained cCR without evidence of local regrowth has been achieved in all four patients with initial (n)cCR to date. Conclusion Primary EBRT combined with HDR-BT is feasible and well tolerated with promising response rates in elderly and frail rectal cancer patients. The concept could be an integral part of a highly individualized and selective nonoperative treatment offered to patients who are not suitable for or refuse surgery.

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

Cited by 58 publications

References 27 publications

Systematic Review of Intensity-Modulated Brachytherapy (IMBT): Static and Dynamic Techniques

Systematic Review of Intensity-Modulated Brachytherapy (IMBT): Static and Dynamic Techniques

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Image-guided high-dose-rate brachytherapy for rectal cancer: technical note and first clinical experience on an organ-preserving approach

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