Abstract
Although useful palliation can often be achieved when external beam irradiation and chemotherapy are used to treat locally advanced gastrointestinal malignancies, local control and long-term survival are infrequent in view of the limited tolerance of surrounding organs and tissues. In view of dose limitations of external beam irradiation, intraoperative irradiation (IORT) with electrons has been used as a supplement to external treatment in an attempt to improve the therapeutic ratio of local control versus complications. An IORT dose of 10 to 20 Gy has been combined with fractionated external beam doses of 45 to 55 Gy in 1.8 Gy fractions in studies performed in the United States, Japan, Europe, and Scandinavian countries. In this paper the indications for and the results of aggressive combined techniques that include IORT are discussed. Results obtained with external beam techniques alone or with chemotherapy and resection are presented by site to demonstrate the need for higher doses of irradiation. When results from IORT series are compared to standard treatment with regard to disease control and survival, local control appears better with locally advanced colorectal, gastric, and pancreatic cancer; and survival appears better with colorectal ± biliary cancers. With pancreatic cancer, improvements in local control do not translate into increased survival in view of the high incidence of subsequent liver and peritoneal failures. Implications for future strategies in all sites are discussed.
Résumé
Bien que l'irradiation externe et la chimiothérapie peuvent procurer une bonne palliation dans certains cancers digestifs étendus, le contrôle local et la survie à long terme ne sont pas souvent améliorés en raison de la tolérance limitée des organes et des tissus de voisinage. En raison de ces limitations, l'irradiation intra-opératoire a été utilisée pour pallier les inconvénients de l'irradiation locale et augmenter les effets locaux. Dans les essais faits au Japon, en Europe, dans les pays Scandinaves comme aux Etats Unis, l'irradiation intra-opératoire comporte une dose de 10 à 20 Gy combinée avec des doses d'irradiation externe de 45 à 55 Gy par fractions de 1.8 Gy. Dans ce travail, les indications d'un traitement agressif comprenant une irradiation intra-opératoire sont discutées. Les résultats obtenus par irradiation externe seule ou avec la résection associéé à la chimiothérapie sont présentés selon le site du cancer primitif pour démontrer le besoin d'accroître le doses d'irradiation. Lorsque les résultats de l'irradiation intraopératoire sont comparés aux résultats du traitement standard, le contrôle local apparaît meilleur en cas de cancers colorectal, gastrique et pancréatique alors que la survie semble meilleure lorsque le cancer est colorectal ou biliaire. En cas de cancer pancréatique, l'amélioration du contrôle local ne retentit pas sur la survie car le taux d'ensemencement hépatique ou péritonéal est élevé. Les implications pour l'avenir sont discutées site par site.
Resumen
Aunque es común lograr una paliación útil en pacientes sometidos a irradiación y quimioterapia como tratamiento de los neoplasmas gastrointestinales localmente avanzados, son infrecuentes tanto el control local como la sobrevida a largo plazo, en razón de la limitada tolerancia de los órganos y tejidos vecinos. En vista de las limitaciones de dosificación de la irradiación externa, se ha utilizado irradiación intraoperatoria (IIOP) con electrones como terapia suplementaria de la irradiación externa en un intento por mejorar la relación entre el control local y las complicaciones. En diversos estudios realizados en Estados Unidos, Japón, Europa y los países escandinavos se han utilizado dosis IIOP de 10 a 20 Gy en combinación con dosis fraccionadas de irradiación externa de 45 a 55 Gy, en fracciones de 1.8 Gy. En el presente artículo se discuten las indicaciones y resultados de agresivas técnicas combinadas, incluyendo IIOP. Se presentan los resultados obtenidos con las técnicas de irradiación externa o con quimioterapia e irradiación de acuerdo con la ubicación del neoplasma, para demostrar la necesidad de dosis más altas de irradiación. Cuando se comparan los resultados de la serie de IIOP con el tratamiento estándar en relación al control de la enfermedad y a la supervivencia, el control local aparece mejor en el cáncer colorrectal localmente avanzado, el cáncer gástrico y el cáncer pancreático y la sobrevida aparece mejor en los cánceres colorrectal ± cánceres biliares. Con el cáncer pancreático, los superiores resultados en cuanto al control local no se traducen en prolongación de la sobrevida por razón de la alta incidencia de fallas hepáticas y peritoneales subsiguientes. Se discuten las implicaciones para futuras estrategias en las diversas ubicaciones del cáncer gastrointestinal.
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Gunderson, L.L., Nagorney, D.M., Martenson, J.A. et al. External beam plus intraoperative irradiation for gastrointestinal cancers. World J. Surg. 19, 191–197 (1995). https://doi.org/10.1007/BF00308625
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DOI: https://doi.org/10.1007/BF00308625