| Japanese Journal of Clinical Oncology | Pages |
External Beam Radiotherapy for Pelvic Node Recurrence After Curative Resection of Colon Cancer: Report of a Case
Introduction
Case report
Discussion
References
External Beam Radiotherapy for Pelvic Node Recurrence After Curative Resection of Colon Cancer: Report of a Case
INTRODUCTION
The role of preoperative or postoperative radiotherapy for locally advanced rectal cancer has been well documented (1-3). Several randomized trials have shown that radiotherapy reduces the local recurrence rate (4,5) and a recent Swedish rectal cancer trial has also shown that it improves 5-year survival rates with statistical significance (6). However, its role in the treatment of locally advanced or recurrent colon cancer has not been determined. Some institutions have used postoperative radiotherapy in an adjuvant setting with promising results (7,8); however, the results obtained in a palliative setting are not satisfactory (9-11). Here we report a case of recurrent colon cancer in which external-beam radiotherapy resulted in a partial response without any side effects.
CASE REPORT
A 59-year-old man had a positive fecal occult blood test at a regular check-up. A barium enema study and colonoscopy revealed a circular ulcerated mass in the descending colon and histological examination of the biopsy specimens showed a well differentiated adenocarcinoma. The serum level of carcinoembryonic antigen (CEA) was 24.4 ng/ml (normal range: <5 ng/ml). Abdominal computed tomography (CT) did not reveal any abnormality in the liver or around the abdominal aorta. He underwent laparotomy on April 18, 1996. The tumor extended beyond the serosal surface and slightly invaded the mesentery of the small intestine. No lymph node metastasis was observed in the intermediate, central nodes and paraaortic nodes. Left hemicolectomy with high ligation of the inferior mesenteric artery and partial resection of the jejunal mesentery were performed with curative intent. Pathological examination of the resected specimen revealed cancer deposits in two paracolic lymph nodes; however, the circumferential surgical margin was negative for cancer. Mild ileus occurred postoperatively, which resolved with conservative treatment.
He underwent postoperative adjuvant chemotherapy (continuous i.v. infusion of 500 mg/day of 5-fluorouracil for 14 days, intermittent i.v. bolus infusion of 10 mg of mitomycin C, twice weekly and then three times bimonthly for 6 months and 200 mg/day of 5-fluorouracil p.o. for 6 months). As shown in Fig. 1, the postoperative serum CEA level did not return to the normal range and gradually increased. An abdominal CT scan in September 1996 showed a lymph node metastasis, 25 mm in size, along the left common iliac artery (Fig. 2). A second operation was not attempted because the disease was not assumed to be localized and intravenous chemotherapy was initiated using continuous i.v. infusion of 500 mg/day of 5-fluorouracil for 14 days and bolus i.v. infusion of 100 mg of CDDP on the first day, which was repeated bimonthly for 7 months. However, the serum CEA level remained abnormal (Fig. 1) and the pelvic node gradually enlarged (Fig. 2). From June 3 to July 10, 1997, external beam radiotherapy was performed by use of the rotational conformal technique, with 6 MV accelerator X-radiation. A total dose of 50 Gy was delivered in 25 fractions, with a daily dose of 2 Gy, five fractions per week, over 5 weeks. The treatment field
Figure 1. Changes in serum CEA level. OP, initial operation (left hemicolectomy); C, intravenous chemotherapy; RAD, external beam radiotherapy.
a
b
c
d
Figure 2. Abdominal CT findings. (a) A 25 mm lymph node was detected along the left common iliac artery in September 1996 (arrow). (b) The pelvic lymph node had enlarged to 30 mm in June 1997 (arrow). (c) The irradiated node was apparently reduced in size (21 mm) with calcification in December 1997 (arrow). (d) No significant change was observed in the irradiated pelvic node in August 1998 (arrow).covered the left internal and external iliac lymph node regions, the lower part of the paraaortic lymph node and left common iliac node metastasis. As a result, the field length was as large as 20 cm. Performance status was ECOG grade 0 before and after radiotherapy and no acute or chronic radiation injury was observed. The serum CEA level gradually decreased and returned to the normal range. An abdominal CT in December 1997 showed apparent shrinkage of the metastatic pelvic node with calcification. An abdominal CT in August 1998 showed no enlargement of the irradiated pelvic node (Fig. 2). The patient maintained a partial response (PR) for at least 12months. The patient was well without any sign of recurrence in October 1998 (2.5 years postoperatively).
DISCUSSION
To reduce locoregional recurrence after potentially curative resection of advanced colon cancer, some institutions have used postoperative radiotherapy in the adjuvant setting 7,8,12-14). As shown in Table 1, colon cancer patients with Astler-Coller B2 or C are good candidates for postoperative external beam radiotherapy with a dose of 40-60 Gy with or without a locoregional boost. Kopelson (7) showed a higher local control rate in irradiated cases than in unirradiated cases (91 versus 70%) and an improved 5-year survival for irradiated Astler-Coller B2 and B3 cases versus unirradiated B2 and B3 cases (100 versus 64%, P < 0.05). Astler-Coller C2 and C3 cases with pelvic irradiation showed no survival advantage in Kopelson's series. Duttenhaver et al. (8) reported the Massachusetts General Hospital experience and found that postoperative irradiation reduced the local failure rate in Astler-Coller B2, B3 and C2 colon cancer cases and improved survival in B3, C2 and C3 cases.
Locoregional recurrence with or without distant metastasis is encountered in 6-25% of colon cancer patients undergoing potentially curative resection. Surgical resection provides the best chance of cure, if curatively performed; however, early detection of recurrent tumor at the curative stage is still difficult in the clinical setting and many patients with such locoregional failure die of these recurrences.
Common iliac nodes (No. 273) are categorized as belonging to N4 in descending colon cancer cases (15) and recurrence in this region is usually assumed to be `a generalized disease', which is beyond the control of surgical interventions, as is the case with paraaortic lymph node metastasis. In this situation, chemotherapy is most often used in the clinical setting. As shown in Table 2, the response rates in the previous studies ranged from 2 to 42.9% and the complete response rates were extremely low (0-4.8%) (16-19).
Table 1.
| Ref. | No. of cases | Stage | Method | Dose | FU | Local control (%) | 5-yr survival (%) |
| 12 | 78 rectosigmoid 47 colon |
B2, C1, C2 | External | 46Gy + 10-15 Gy boost | Av. 38 mo | R0: 86 R1: 84 R2: 50 |
R0: 67 R1: 77 R2: 39 |
| 7 | 17 sigmoid colon | B2, B3; 10 C2, C3; 7 |
External | 45-51 Gy | >3 yr | 91(vs 70) | B2, B3: 100 (vs 64)* C2, C3: 60 (vs 55) |
| 8 | 80 colon | B2, B3 C2, C3 |
External | 43-63 Gy | Median 39 mo Mean 42 mo |
B2: 60 (vs 65) B3: 78 (vs 51)* C3: 57 (vs 39)* C3: 49 (vs 29)* |
|
| 13 | 18 colon | B2-C3 | External | Whole abdomen 30 Gy + locoregional boost 9.6-16 Gy |
Median 36 mo | 78 | |
| 14 | 78 colon | B2-C | External | <45 Gy: 28 50-55 Gy: 50 |
>3 yr | Overall: 88 <50 Gy: 76 50-55 Gy: 96 |
B2: 67 B3: 90 C1: 100 C2: 61 C3: 36 |
Table 2.
| Ref. | No. of cases | Method | Dose | FU | Response rate (%) | Survival |
| 16 | 30 colon and rectum | I.V. once weekly ×4 + 2 weeks rest |
LV 500 mg/m2/1 h + CDDP 20 mg/m2/15 min + 5-Fu 500 mg/m2/bolus |
nd | PR 23 | Median 8.5 mo |
| 17 | 42 colon and rectum | C.I.V. weekly | LV 300 mg/m2/24 h | Median 22mo | CR 4.8 PR 38.1 |
Median 10 mo |
| 18 | 42 colon and rectum | C.I.V. once weekly ×6 + 2 weeks rest |
LV 500 mg/m2/2 h + 5-Fu 2600 mg/m2/24 h |
nd | PR 14 | Median 11.6 mo 1-yr 46% |
| 19 | 49 colon and rectum | C.I.V. 5 days + 3 weeks rest |
MMC 20 mg/m2/5days | nd | PR 2 | Median 4.7 mo 6-mo 36.5% |
Table 3.
| Ref. | No. of cases | Method | Dose | FU | Local control (%) | Survival (%) |
| 20 | 9 colon (liver only 5 liver + peritoneum 2 liver + local 2) |
External | 21 Gy (liver) 30 Gy (upper abdomen) 40-50 Gy (pelvis) |
nd | nd | 1-yr: 23% |
| 21 | 25 sigmoid colon and rectum | External ± Chemo | 45 Gy | nd | Overall: CR 6%, PR 22% 3 LN meta: CR 1 case, PR 1 case |
5-yr: 6% |
| 22 | 143 sigmoid colon and rectum | External | <40 Gy (53 pts) 40-50 Gy (44 pts) >50 Gy (46 pts) |
nd | nd | 2-yr: 17.5% <40 Gy: 15% 40-50 Gy: 15.9% >50 Gy: 21.7% |
| 9 | 21 colon and rectum | External + Chemo | nd | nd | 5-yr: 15.3% | |
| 10 | 59 colon and rectum | External ± Chemo | 50 Gy + 10-20 Gy boost | nd | CR 13%, PR 19% | 3-yr: 9% |
| 23 | 11 colon and rectum | IORT ± Resection + External |
10-15 Gy + 46-50 Gy | Median 11 mo | 63% | nd |
| 24 | 10 colon and rectum | IORT + IOHT | 12-17.5 Gy | 13.8 mo | nd | nd |
| 11 | 27 colon and rectum | IORT + Resection + External ± Chemo |
15-20 Gy + 40-50 Gy | Median 25 mo | 26% | 5-yr: 12% |
External beam radiotherapy or intraoperative radiotherapy (IORT) with or without surgical resection or chemotherapy has been adopted as a palliative treatment for recurrent or residual colorectal cancer. As shown in Table 3, external beam radiotherapy and IORT achieved response rates of 28-32 and 26-62%, respectively (9-11,20-24). Asakawa et al. (21) treated three patients with paraaortic or left supraclavicular lymph node metastasis using external beam radiotherapy and obtained a complete response in one and a partial response in another patient. Overgaard et al. (10) conducted a randomized study evaluating the effect of radiotherapy alone or combined with 5-fluorouracil for locally recurrent or inoperable colorectal carcinomas and showed that addition of 5-fluorouracil did not influence either the objective or symptomatic response or the development of distant metastases. In the present case, intravenous chemotherapy was apparently ineffective in controlling the pelvic node recurrence. In contrast, 50 Gy external beam radiotherapy for the pelvic node recurrence achieved a partial response for at least 12 months in this patient. Although there have been no randomized studies comparing the efficacy of chemotherapy alone and radiotherapy alone for progressive or recurrent colorectal cancers, all these results might imply that, if feasible, radiotherapy has a more crucial role in the treatment of a subgroup of recurrent colorectal tumors.
References
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Last modification: 13 Apr 1999
Copyright© 1999 Foundation for Promotion of Cancer Research.
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