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Observational Study
. 2017 Dec;90(1080):20170175.
doi: 10.1259/bjr.20170175. Epub 2017 Nov 10.

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

Arthur Sun Myint  1   2 , Fraser McLean Smith  3 , Simon William Gollins  4 , Helen Wong  1 , Christopher Rao  5 , Karen Whitmarsh  1 , Raj Sripadam  1 , Paul Rooney  3 , Michael Jeremy Hershman  6 , Zsolt Fekete  7 , Kate Perkins  1 , D Mark Pritchard  2   3
Affiliations
Observational Study

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

Arthur Sun Myint et al. Br J Radiol. 2017 Dec.

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.

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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.
See this image and copyright information in PMC

References

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