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