Individualized Determination of Lower Margin in Pelvic Radiation Field after Low Anterior Resection for Rectal Cancer Resulted in Equivalent Local Control and Radiation Volume Reduction Compared with Traditional Method

Park, Suk Won; Ahn, Yong Chan; Huh, Seung Jae; Chun, Ho Kyung; Kang, Won Ki; Kim, Dae Yong; Lim, Do Hoon; Noh, Young Ju; Lee, Jung Eun

Abstract

PURPOSE
When determining the lower margin of post-operative pelvic radiation therapy field according to the traditional method (recommended by Gunderson), the organs located in the low pelvic cavity and the perineum are vulnerable to unnecessary radiation. This study evaluated the effect of individualized determination of the lower margin at 2 cm to 3 cm below the anastomotic site on the failure patterns.
MATERIALS AND METHODS
Authors included 88 patients with modified Astler-Coller (MAC) stages from B2 through C3, who received low anterior resection and post-operative pelvic radiation therapy from Sept. 1994 to May 1998 at Samsung Medical Center, Sungkyunkwan University. The numbers of male and female patients were 44 and 44, and the median age was 57 years (range: 32-81 years). Three field technique (posterior-anterior and bilateral portals) by 6, 10, 15 MV X-rays was used to deliver 4,500 cGy to the whole pelvis followed by 600 cGy's small field boost to the tumor bed over 5.5 weeks. Sixteen patients received radiation therapy by traditional field margin determination, and the lower margin was set either at the low margin of the obturator foramen or at 2 cm to 3 cm below the anastomotic site, whichever is lower. In 72 patients, the lower margin was set at 2 cm to 3 cm below the anastomotic site, irrespectively of the obturator foramen, by which the reduction of radiation volume was possible in 55 patients (76%). Authors evaluated and compared survival, local control, and disease-free survival rates of these two groups.
RESULTS
The median follow-up period was 27 months (range : 7-58 months). MAC stages were B2 in 32 (36%), B3 in 2 (2%), C1 in 2 (2%), C2 in 50 (57%), and C3 in 2 (2%) patients, respectively. The entire patients' overall survival rates at 2 and 4 years were 94% and 68%, respectively, and disease-free survival rates at 2 and 4 years were 86% and 58%, respectively. The first failure sites were local only in 4, distant only in 14, and combined local and distant in 1 patient, respectively. There was no significant difference with respect to local control and disease-free survival rates ( p=0.42, p=0.68) between two groups of different lower margin determination policies.
CONCLUSION
The new concept in the individualized determination of the lower margin depending on the anastomotic site has led to the equivalent local control and disease-free survival rates, and is expected to contribute to the reduction of unnecessary radiation-related morbidity by reduction of radiation volume, compared with the traditional method of lower margin determination.