Rectal and Anal Cancers: Conservative Treatment by Irradiation — an Alternative to Radical Surgery

212 Pages·1982·6.95 MB·English

by  Jean Papillon M.D. (auth.)

1.Papillon
Rectal and Anal
Cancers
Conservative Treatment
by Irradiation -
an Alternative to Radical Surgery
Foreword by O. H. Beahrs
With 35 Figures and 6 Color Plates
Springer-Verlag
Berlin Heidelberg New York 1982
Jean Papillon, M. D.
Professor of Radiology
University of Lyon,
Head of Radiotherapy Department,
Centre Leon Berard
F-69008 Lyon
ISBN -13 :978-3-642-68615-3 e-ISBN -13: 978-3-642-68613-9
DOl: 10.1007/978-3-642-68613-9
Library of Congress Cataloging in Publication Data.
Papillon, Jean.
Rectal and anal cancers.
Bibliography: p.
Includes index.
1. Rectum -Cancer -Radiotherapy. 2. Anus -Cancer -Radiotherapy. I. Title. [DNLM:
1. Anus neoplasms-Radiotherapy. 2. Rectal neoplasms -Radiotherapy. WI 610 P216rj
RC280.R37P36 1982 616.99'4350642 82-10805
ISBN-13:978-3-642-68615-3 CU.S.)
This work is subject to copyright. All rights are reserved, whether the whole or part of the material is con
cerned, specificaJly those of translation, reprinting, fe-use ofillustrations, broadcasting, reproduction by pho
tocopying machine or similar means, and storage in data banks. Under § 54 of the German Copyright Law
where copies are made for other than private use a fee is payable to "Verwertungsgesellschaft Wort", Munich.
© by Springer-Verlag Berlin Heidelberg 1982
Softcover reprint of the hardcover 1st edition 1982
The use of general descriptive names, trade marks, etc. in this publication, even if the fonner are not especially
identified, is not to be taken as a sign that such names, as understood by the Trade Marks and Merchandise
Marks Act, may accordingly by used freely by anyone.
2124/3140-543210
To Dr. Rupert B. Tumbulljr.,
surgeon at the Cleveland Clinic,
who gave me much help and
encouragement in the
writing oft his monograph.
Foreword
Although attempts at radical removal of cancers of the rectum
had been performed earlier, it was not until W. E. Miles in 1908 re
ported his experience in the management of cancer in this ana
tomic part, that the combined abdominoperineal resection be
came the recognized and accepted approach for the treatment of
this cancer. Miles reasoned that proctectomy removed the cancer,
bearing a segment oflarge bowel but also the regional lymphatics
into which the cancer spread, not only proximally, but laterally
and distally as well. In his monograph in 1926 he stated:
...T here are, I hold, two main principles to be observed in the surgical treatment of
cancer of the rectum and indeed of all cancers wherever they are found, first, ope
ration should be based on a knowledge of the demonstrable facts of pathology,
and, second, the most extensive operation possible in conformity with that knowl
edge should be performed on all patients no matter how small or early the local
manifestation of the disease may seem to be ...
This philosophy was appropriate in his time but today, with
increased knowledge regarding the biological behavior of cancer
of the rectum, the recognition of the importance of the extent of
the primary lesion and staging of cancer, and the availability of
multiple modalities in the management of neoplastic disease, the
philosophy has appropriately changed.
Previously, local treatment of cancers of the rectum was asso
ciated with a high incidence of failure or recurrence, and the mor
tality and morbidity associated with resection and an intra-ab
dominal anastomosis was unacceptably high. So, for the early
part of the twentieth century, the combined abdominoperineal re
section of the rectum in one or multiple stages remained almost
the sole method of treatment of cancer of the rectum. Although ra
diation treatment was used after its discovery and since the
1920s, it did not prove to be the panacea hoped for, largely be
cause of lack of sophistication in its use and its application most
often for advanced lesions.
The overall mortality rate for colon and rectal surgery was 20%
or greater until the decades of the thirties and forties. When che
motherapeutic agents and, later, antibiotics became available for
preoperative bowel preparation and the treatment of infections,
the mortality rate gradually dropped to 5%. Today rates of2% are
VIII Foreword
frequently reported. With improved safety of colon and rectal
surgery, lesser procedures were again tried. Anterior resection has
become the procedure of choice for cancers of the lower sigmoid,
rectosigmoid, most lesions of the upper one third and some le
sions of the mid third of the rectum. This procedure eliminates the
need of a permanent colostomy. If normal anatomy and bowel
function can be preserved without reducing the chance of cure,
the patient is well served. It is unfortunate, though, if a lesser
procedure has been carried out to prevent a colostomy resulting in
inadequate treatment of a cancer. However, it is also unfortunate
if a colostomy is the result of treatment and in creating it, the co
lostomy has not contributed to the cure of the cancer.
For cancers of the lower one third of the rectum and many of
the mid-rectum, the combined abdominoperineal resection is the
only feasible radical operation, from the technical standpoint, to
remove a cancer. This always means a colostomy. Dukes in 1932
recognized that a cancer goes through stages in its growth, and in
his report classified cancers as Stage A when localized to the rectal
wall, B when through the wall but without regional lymph node
involvement, and C when regional lymph node metastases are
present. The Dukes' classification has been modified by many,
and other staging recommendations have been made, but the ori
ginal classification by Dukes remains the simplest and possibly
the best. If a surgical specimen is available after radical resection,
then accurate pathologic staging can be determined. Unfortu
nately, on clinical grounds, there is an error in classifying a lesion
accurately. In about 10% to 12% of cases of cancer of the rectum
clinically considered to be Dukes Stage A or B, regional node
metastasis will be present. In all lesions about 50% will have as
sociated nodal metastasis. In arriving at a judgement as to treat
ment, this error must be kept in mind.
Excision, electrocoagulation, cryosurgery, and intracavitary
irradiation have all been shown to destroy primary lesions of the
rectum. Therefore, if cancers of the lower rectum are properly se
lected as most likely being in situ lesions or Dukes A or B, then
conservative treatment is reasonable to consider. Results can be
excellent. For example, assuming only a 10% error in clinical stag
ing with destruction of the primary lesion, 90% of patients should
be cured. If patients so treated are followed carefully, and if the
conservative measures should fail or if regional disease becomes
apparent, a radical operation can still be done, with frequent fa
vorable results. In patients with more advanced lesions of the rec
tum in whom there is medical disease increasing significantly the
risk of anesthesia and surgical, conservative treatment can be
used. If the primary lesion is successfully treated, about 50%
should survive the cancer, since approximately that number of pa
tients will have localized disease.
Foreword IX
The type of conservative treatment is not necessarily all-im
portant in curing selected lesions. Excision should remove the en
tire gross lesion and this has advantage in that the whole tumor is
available for the pathologic study. If fulguration or intracavitary
irradiation is to be used, either total excision on a small lesion
should be done as a biopsy, or at least an adequate extensive biop
sy done, so pathologically the tumor can be staged as accurately as
possible. While excision and fulguration frequently require hos
pitalization on one or several occasions, the use of intracavitary ir
radiation does not. Because of the high cost of medical care, this
becomes an important factor in deciding in favour of one method
of treatment versus another, assuming each has equal results.
The author, Jean Papillon, in this treatise nicely discusses the
biological behavior of cancer of the rectum and anus, the staging
of cancer, and the proper selection of cases for less than radical
treatment. As a proponent of intracavitary irradiation treatment
of selected cases of cancer of the rectum, he has established his
position very well with solid data and sound judgement. Likewise,
he extends his thinking to the management of epidermoid carcin
oma of the anal and perianal region. Also included is information
on the appropriate place of radiation therapy as an additive to
surgery or as a part of multiple-modality approach to the treat
ment of cancer.
Dr. Papillon through his research and clinical experience has
contributed greatly to the understanding oft he behavior of cancer
of the rectum and anus, to the appropriate management of those
lesions by less than radical surgical procedures, and in particular
by the use of intracavitary irradiation. Most importantly, he has
contributed to an improved quality of life for many patients with
neoplastic disease of the distal large intestine.
Rochester, June 1982 Oliver H. Beahrs
Professor of Surgery, Emeritus
Mayo Medical School
Consultant, Department of Surgery
(retired)
Mayo Clinic
Rochester, Minnesota, USA
Preface
This monograph is the result of my experience in the management
of cancer oft he rectum and anus at the Centre Leon Berard, Lyon,
during the past 30 years. In the early years, irradiation made only
a small contribution to the conservative treatment of these diseas
es, and surgeons were reluctant to refer their patients for treat
ment because there was little experience in this field. Since then
there has been a great increase in our knowledge of the natural
history of these tumours and their response to irradiation.
Carefully controlled schedules of irradiation (external or in
tracavitary) have now been developed which are capable of cur
ing certain tumours oft he rectum and the anus. The tumours must
be selected according to strict criteria, which will be described in
this monograph. Only a small proportion of rectal adenocarcino
mas are suitable for conservative irradiation, whereas a high pro
portion of squamous cancers of both anal canal and margin re
spond to this modality of treatment.
It must be emphasized that the radiotherapist has joint clinical
responsibility with the surgeon for the decisions about the conser
vative treatment of rectal and anal cancers. Both clinicians must
consider the individual needs of each patient, and evaluate the re
spective roles of radiotherapy and surgery to define the best ap
proach in each case in an atmosphere of mutual respect and confi
dence.
I wish to express my deep gratitude to Mr. Christopher Marks,
surgeon in Guildford, Surrey, England, for his patience and devo
tion in correcting the manuscript of this monograph, and for the
constructive advice which he afforded me.
I would also like to thank Dr. Pierre Chapuis, surgeon in Syd
ney, Australia, whose help was greatly appreciated, and Dr.
Danielle Jaussaud, radiotherapist in Lyon, who undertook the
considerable task of compiling the bibliography.
Lyon, July 1982 Jean Papillon
Table of Contents
Introduction . . . . . . . . . . . . . 1
Section A. Carcinoma of the Rectum 3
I. General Considerations . . . . 5
1. Age and Sex Distribution . 6
2. Topographical Distribution 6
3. Stage Distribution . . 6
II. Pathology ..... . 8
1. Histology . . . . . . . 8
2. Natural History. . . . 9
3. Spread of Rectal Cancer . . . . . 11
a) Local ............... . 11
b) Lymphatic . . . . . 13
c) Venous ...... . 16
d) Distant Metastases 17
4. Staging ....... . 17
III. Surgical Treatment . . 19
1. Criteria Governing Choice of Procedure 19
2. Surgical Results ..... 20
a) Operative Mortality . . 22
b) Sequelae of Surgery . . 23
3. Additional Therapy ... 23
a) Pre-operative Irradiation 24
b) Pre-operative Chemotherapy and Radiotherapy
Combined . . . . . . . . . . 32
c) Post-operative Irradiation ......... 33
IV. Rationale of Conservative Treatmentfor Cure 39
1. Selection of Suitable Cases . . 40
a) Risk of Lymphatic Spread 40
b) Site ofT umour . . . . . . . 49
c) Status of Patient . . . . . . 50
2. Proper Schedules for Treatment . 51
3. Follow-up. . . . . . . . . . . . . 51
4. Modalities of Conservative Treatment for Rectal Cancer 52
XIV Table of Contents
V. Conservative Treatment by Surgery 53
1. Local Excision . . . 53
2. Electrocoagulation . 56
a) Results . . . . . . 57
3. Cryosurgery .... 61
VI. Conservative Treatment by Irradiation 63
1. Historical Background . . . . . . . . . 63
2. External Beam Irradiation . . . . . . . . . . 65
3. Intracavitary Irradiation of Rectal Tumours . 66
a) Contact X-ray Therapy . . . . . . . . . . . 66
b) Interstitial Curietherapy .......... 70
c) Development ofIntracavitary Irradiation . . . . . 75
d) Experience at the Centre Ikon Berard (Papillon) ... 77
e) Problem of Rectal Adenocarcinomas
ofthe Juxta-anal Area. . . . . . . . . . . . . . . . .. 95
f) Indications. . . . . . . . . . . . . . . . . . . . . . .. 98
VII. Comparison of Surgical and Radiotherapeutic Methods
of Local Therapy. . . . . . . . 100
1. Mode of Action. . . . . . . 100
2. Conditions of Application . . 101
3. Control ofT umour . . 101
4. Follow-up. . . . . . . . . . . 103
5. Conclusion . . . . . . . . . . 103
VIII. Intracavitary Irradiation as a Supplementary Procedure
After Local Excision - Problem of Villous Adenomas . . .. 104
1. Experience at the Centre Ikon Berard. . . . . . . . . .. 105
Section B. Epidermoid Carcinoma of the Anus . . . . . . .. 107
Topographical Distribution of Anal Cancers . 109
IX. Epidermoid Carcinoma of the Anal Canal 110
1. Introduction . . . . . . . . . . . . . . . . 110
2. Anatomical and Pathological Background 111
X. General Features . . . . . . . . . 114
1. Frequency and Sex Distribution . 114
2.Age ..... . 114
3. Site ...... . 114
4. Configuration . 115
5. Tumour Spread. 116
a) Local Spread .. 116
b) Regional Spread . . 117
c) DistantSpread ... 121
6. Symptoms and Diagnosis 121