LOCALLY ADVANCED RECTAL-CANCER - RESECTION AND INTRAOPERATIVE RADIOTHERAPY USING THE FLAB METHOD COMBINED WITH PREOPERATIVE OR POSTOPERATIVE RADIOCHEMOTHERAPY

PURPOSE: Surgery often falls to achieve local control in advanced rect al cancer. Additional measures are necessary to prevent local recurren ce. The aim of this study was to evaluate intraoperative radiation the rapy (IORT) (flab technique) combined with preoperative or postoperati ve radiochemotherapy. PATIENTS/METHODS: IORT is performed using a flex ible flab containing hollow plastic tubes that are connected to a mult ichannel afterloading device with a 370 Gbq-192-Ir source. Patients re ceive an intraoperative dose of 15 Gy. Target volumes were measured in a cadaver experiment. From 1989 to 1993, 38 patients were included in this study. Nineteen patients were staged as T3 tumors by preoperativ e endosonography (Group 1) and 19 as T4 tumors (Group ii). Patients in Group I underwent resection (abdominoperineal resection (APR), 16; an terior resection, 3) and IORT, followed by postoperative radiochemothe rapy (50 Gy/5-fluorouracil), whereas patients in Group II received pre operative radiochemotherapy (40 Gy/5-fluorouracil) followed by resecti on (APR, 18; anterior resection, 1) and IORT. Mean follow-up was 25.5 months. RESULTS: Operative radicality in Group I was RO (13), R1 (3), and R2 (3), and in Group II it was RO (14), R1 (3), R2 (2). R2 resecti ons were attributable to preoperative undetected distant metastases. P erioperative mortality was 0 percent in Group I and 10.5 percent (n = 2) in Group II. Postoperative morbidity was 53 percent (n = 10) in Gro up I and 84 percent (n = 16) in Group II with delayed sacral wound hea ling being the predominant problem. Stenosis of the ureter occurred in two patients (Group II). Late or persistent therapy-related complicat ions were seen in two patients in Group I and in six patients in Group II. Local recurrence developed in three patients in Group I (15.8 per cent) and in two patients in Group II (10.5 percent). Survival data do not reach statistical significance between the two groups because of small numbers but show a favorable trend for the preoperative radioche motherapy group. When compared with a matched historical control group of patients receiving resection only, adjuvant/neoadjuvant radiothera py with resection/IORT improves survival significantly. CONCLUSION: Th e flab method is a simple but especially practical technique for IORT in the pelvis. Adjuvant/neoadjuvant therapy combined with resection/IO RT is associated with high morbidity but acceptable mortality. Prelimi nary survival data are encouraging and call for a controlled prospecti ve randomized trial.