Neoadjuvant 'long-course' chemoradiation is considered a standard of care in locally advanced rectal cancer. In addition to prostatectomy, external beam radiotherapy and brachytherapy with or without androgen suppression (AS) are well established in prostate cancer management.
A retrospective review of ten cases was completed to explore the feasibility and safety of applying these standards in patients with dual pathology. To our knowledge this is the largest case series of synchronous rectal and prostate cancers treated with curative intent.
Eligible patients had synchronous histologically proven locally advanced rectal cancer (defined as cT3-4Nx; cTxN1-2) and non-metastatic prostate cancer (pelvic nodal disease permissible). Curative treatment was delivered to both sites simultaneously. Follow up was per institutional guidelines. Acute and late toxicities were reviewed and a literature search performed.
Pelvic EBRT 45- 50. 4Gy was delivered concurrent with 5-fluorouracil (5-FU). Prostate total dose ranged from 70- 79. 2Gy. No acute toxicities occurred, excluding AS-induced erectile dysfunction. Nine patients proceeded to surgery and one was managed expectantly. Three relapsed with metastatic colorectal cancer, two with metastatic prostate cancer. Five patients have no evidence of recurrence, four remain alive with metastatic disease. With median follow-up of 2. 2 years (range 1. 2- 6. 3 years) two significant late toxicities occurred; G3 proctitis in a patient receiving palliative bevacizumab and a G3 anastomotic stricture precluding stoma reversal.
Patients proceeding to synchronous radical treatment of both primary sites should receive 45- 50. 4Gy pelvic RT with infusional 5-FU. Prostate dose escalation should be given with due consideration to the potential impact of prostate cancer on patient survival as increasing dose may result in significant late morbidity. Review of published series explores the possibility of prostate brachytherapy as an alternative method of boost delivery. Frequent use of bevacizumab in metastatic rectal cancer may compound late rectal morbidity in this cohort. Advances in knowledge: To our knowledge this is the largest case series of synchronous rectal and prostate cancers treated with curative intent. This article contributes to the understanding of how best to approach definitive treatment in these patients.
The British journal of radiology. 2015 Nov 05 [Epub ahead of print]
Naomi Lavan, Dara O Kavanagh, Joseph Martin, Cormac Small, Myles R Joyce, Clare M Faul, Paul J Kelly, Michael O'Riordain, Charles M Gillham, John G Armstrong, Osama Salib, Deborah A McNamara, Gerard McVey, Brian D P O'Neill
1 St. Luke's Radiation Oncology Network, Dublin, Ireland. , 3 St. Vincent's University Hospital, Dublin, Ireland. , 4 Department of Radiation Oncology, University College Hospital Galway, Ireland. , 4 Department of Radiation Oncology, University College Hospital Galway, Ireland. , 5 Department of Surgery, University College Hospital Galway, Ireland. , 2 St. Luke's Institute of Cancer Research, Dublin, Ireland. , 6 Department of Radiation Oncology, Cork University Hospital, Ireland. , 7 Department of Surgery, Cork University Hospital, Ireland. , 1 St. Luke's Radiation Oncology Network, Dublin, Ireland. , 2 St. Luke's Institute of Cancer Research, Dublin, Ireland. , 1 St. Luke's Radiation Oncology Network, Dublin, Ireland. , 8 Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland. , 1 St. Luke's Radiation Oncology Network, Dublin, Ireland. , 1 St. Luke's Radiation Oncology Network, Dublin, Ireland.