Intraoperative radiotherapy for locally advanced or locally recurrent rectal cancer: Does it work at all?

Figures & data

Figure 1. Flow chart showing reason for excluding references from PubMed, EMBASE and own database from inclusion in Tables I and III.

Table I. Studies with IORT on primary rectal cancer compared with non-IORT studies. Author with reference number in square brackets. Observation time (Obs) is given in months. Percentages are given for the following parameters: risk stage, surgical R stage, patients given intraoperative radiotherapy (IORT), external radiotherapy (EBRT), and chemotherapy (ChT). The effect of IORT is given as percent of overall survival (OS), cancer specific survival (CSS) or disease-free survival (DFS) and local recurrence (LR) percentage for the total group and R stages.

						Treatment				Survival at 5 years			Local recurrence
Author	No. operated	Risk staging	Imaging	Levels of evidence	R stage %	IORT % Dosage	EBRT % Dosage	CT %	Observation months	OS	CSS	DFS	3 years	5 years	At observation
non-IORT/non-comparing
Larsen [43]	204	LA	CT	V	R0 75 R1 15 R2 10	0	100 46–50 Gy	0	?	total 52 R0 60 R1 31 R2 0				total 15 R0 13 R1 24 R2
Harris [60]	42 M1 6	LA- 100	MRI	V	R0 79	0	74 45 Gy	CRT 74 Adj 38	19	total R0 48 R1-2 33			total 13 R0 R1-2
Park [30]	113	IR -96	CT	V	R0 99	0	100 50 Gy	CRT 75 Adj 58	52	total 85 Ro 85				total 6 R0 6
Lim S-B [29]	581	IR/LA	MRI	V	R0 97 R1 3	0	100 50.4 Gy	CRT 100 Adj 99	58	total 78					total 6
Sauer [5]	415	IR - 68 LA - 6 ? - 21	CT	V	R0 91	0	100	CRT 100	46	total 76 R0 91				total 6 R0
Bosset [35]	506	IR -90 LA 10	CT	V	?+	0	100 45 Gy	CRT 100	63	total 65				total 9
Gerard [36]	375	IR -86 LA -11	?	V	R0-1 93	0	100 45 Gy	CRT 100	81	R0-1 68				R0-1 8
non-IORT comparing
Dubois [17]	69	IR -91 LA- 7	CT	II	R0-1 93	0	100 40–48 Gy	Adj 19	60	total 70 R0 70				total 7
Nakfoor [41]	72	LA -100	?	III	R0 92 R1 8	0	100 50.4 Gy	Adj 25	53		total 77 R0 80 R1-2 0			R0 18 R1-2 83
Pacelli [11]	42	IR -100	CT	III	?	0	0	Adj 52	41	total 57				total 23
Ratto [37]	24-	IR-13 LA-87	MRI	III	?	0	100 45 Gy	CRT 100	74			R0 39 R1 0		R0 43 R1-2 74
Valentini [46]	59-	LA -100	CT/MRI	III	R0 100	0	100 50.4 Gy	CRT 100						R0 19
Ferenschild [14]	93	IR/LA	CT/MRI	III	R0 91	0	100 25–50 Gy	0	25	R0 56 R1-2 0				R0 29 R1-2 100
IORT comparing
Dubois [17]	72	IR-89 LA-7	CT	II	R0-1 100	93 18 Gy	100 40–48 Gy	Adj 25	60	75				total 8
Nakfoor [41]	73	LA-100	CT	III	R0 62	100 10–20 Gy	100 50.4 Gy	CRT 100	53		R0 63 R1 40 R2 14 R1-2 32			R0 11 R1 32 R2 43 R1-2 35
Pacelli [11]	66	IR-100	CT	III	?	100 10 Gy	100 38 Gy	Adj 39	63	total 81				total 7
Ratto [37]	19-	IR-? LA-100 ?	MRI	III	?	100 10–15 Gy	100 45 Gy	CRT 100	74		R0 47			R0 9
Valentini [46]	29-	LA-100	CT/MRI	III	R0 100	100 10–15 Gy	100 50.4 Gy	CRT 100						R0 0
Ferenschild [14]	27	IR/LA	CT/MRI	III	R0 63	100 10G	100 50 Gy		25	R0 66 R1-2 38				R0 28 R1-2 42
IORT non-comparing
Kusters [64]	290	IR-39 LA-61	CT/MRI	V	R0 85 R1 13 R2 2	83 10–17.5 Gy	100 45–50.4 Gy	70	45		total 68 R0 73 R1-2 31			total 13 R0 8 R1-2 38
Kusters [34]	605	IR-71 LA-29	CT/MRI	V	R0 70	100 10–12.5 Gy	100 45–50 Gy	CRT 64 Adj 42	56	total 67 R0 R1-2	R0 74 R1-2 38			total 12 R0 10 R1-2 45
Roeder [31]	243	IR-66 LA-20	CT/MRI	V	R0 92 R1 7 R2 1	100 10–15 Gy	86 16–57 Gy postop 50	86	59					total 8 R0 6 R1-2 18
Palmer [28]	58	LA	CT/MRI	V	R0 59	33	100 50 Gy	CRT 100	64	total 29 R0 34 R1-2 24					R0 47 R1-2 29
Diaz-Gonzales [38]	62	I-83 LA-17	CT	V	?	100 10–15 Gy	100 50.4 Gy	CRT 100 Adj 57	46	total 74				total 6
Huber [39]	38	IR-50 LA-50	?	V	R0 68 R1 16 R2 16	100 15 Gy	100 40.50 Gy T3-poCRT T4-preCRT		26	total 28				total 13
Sadahiro [33]	99	IR-88 LA-12	CT	V		100 15–25 Gy	100 20 Gy	CRT 33	67	total 83				total 2
Mathis [27]	146 Rectum 119 Colon 27	LA-100	?	V	R0 68 R1 19 R2 12	100 7.5–20 Gy	100 50.4 Gy	CRT 100 Adj 40	44	total 52 R0 R2		R0 45 R2 26		total 14 R0 R2
Ratto [37]	43	IR-7 LA-93	MRI	V	R0 88	44 10–15 Gy	100 45 Gy	CRT 100	74			total 39 R0 43 R1 0 R2 0		total 31 R0 26 R1 R2
Valentini [46]	86	LA-100	CT/MRI	V	R0 78	29 10–15 Gy	100 50.4G	CRT 100	31	total 59 R0 68 R1-2 29				total 10 R0 R1-2
Ferenscild [14]	123	IR/LA	CT/MRI	V	R0 85 R1 14 R2 1	22 10 Gy	100 25–52 Gy	0	25	total 50				total 35
Sanfilippo [32]	32	LA-100	CT	V	R0 91	9 15 Gy	100 25–63 Gy	CRT 100 Adj 73	31	total 50 R0				total 20 R0 29

Adj, adjuvant chemotherapy; CRT, chemoradiotherapy; IR, intermediary risk group; LA, locally advanced group; Nadj, neoadjuvant chemotherapy.

Table II. Primary cancer. Limits, mean and number of studies giving overall survival and local recurrence for the total group of patients and the separate R stages.

	Limits		Mean		No. studies
Operated	IORT	non-IORT	IORT	non-IORT	IORT	non-IORT
OS total	28–76	52–85	60	72	12	8
R0	34–68	48–91	56	70	3	7
R1	0	31	0	31	1	1
R2	0	0	0	0	1	1
R1-2	0–38	0–33	30	17	3	2
LR total	2–35	5–9	13	8	12	6
R0	0–28	5–43	12	17	8	8
R1		24		24	0	1
R2					0	0
R1-2	18–45	74–100	33	82	3	3

LR, local recurrence at 5 years; OS, overall survival.

Table III. Studies with IORT on locally recurrent rectal cancer compared with non-IORT studies. Author with reference number in square brackets. Observation time (Obs) is given in months. Percentages are given for the following parameters: surgical R stage achieved, patients given intraoperative (IORT), external radiotherapy (EBRT), and chemotherapy (ChT). The effect of IORT is given as overall survival (OS), cancer specific survival (CSS), disease free survival (DFS) and local recurrence (LR) percentage for the total group and R stages.

				Treatment				Survival				Local rerecurrence
Author	No. operated	Level of evidence	R stage %	IORT %	EBRT %	ChT %	Observation months	OS 3 year	OS 5 year	CSS 5 year	DSF 5 year	3 year	5 year	At observation
non-IORT/non-comparing
Lee [62]	45	V	42	0	100 post 45–72 Gy	Adj 88	41		total 49 R0 60 R1-2 43				total R0 22 R1-2 34
Mohiuddin [55]	34	V		0	100	100	24		total 22					total 56
Hansen [57]	185	V	R0 52 R1 48	0	71 50 Gy		15		total 15 R0 55 R1-2 20					R0 18 R1-2
Park [58]	38	V	R0 61 R1-2 39	0	100 50 Gy		31		total 14 R0 35 R1-2 0
Wells [49]	52	V	R0 79 R1 11	0	50 50.4 Gy	39CRT	29		total 17 R0 25 R1 0					total 64 R0 R1
nonIORT / Comparing
Suzuki [47]	64	V	R0 0	0	77 7–74 Gy	?	44		total 7 R1-2 7			R1-2 93
Mannaerts [10]	19	V	R0 37 R1 42 R2 21	0	100 25–50G	0	31	R0 29 R1-2 0	total 7 R0 R1-2			R0 71 R1-2 100	total 86 R0 R1-2
Wiig [12]	48	III	R0 54 R1 21 R2 25	0	100 46–50 Gy	0	?		total 35 R0 60 R1 23 R2 0				total 70 R0 30 R1 75
Hashiguchi [42]	22	III	R0 14 R1 23 R2 64	0	79 50 Gy	?	?		total 0 R0 0 R1-2 0					total 38 R0 R2
IORT/comparing
Suzuki [47]	42	V	R0 0 R1 19 R2 81	100 15–20 Gy	98 7–74 Gy	?	44		total 19 R1-2 19			R1-2 40
Mannaerts [10]	33	V	R0 64 R1 21 R2 20	100 10–17.5 Gy	100 25–50 Gy	0	> 32	R0 63 R1-2 52	total 46 R0 R1-2			R0 11 R1-2 55	total 28 R0 R1-2
Wiig [12]	59	III	R0 31 R1 49 R2 20	100 12–20 Gy	100 46–50 Gy	0	?		total 30 R0 63 R1 28 R2 0				total 50 R0 30 R1 53 R2
Hashiguchi [42]	25	III	R0 24 R1 12 R2 64	70 15–30 Gy	88 50 Gy				total 21					total 11
IORT/non-comparing
Abuchiabe [8]	27	V	30	100 15 Gy	74 46 Gy	0	R0 25 R1-2 65		total 12 R0 29 R1-2 7				total 74 R0 44 R1-2 87
Martinez-Monge [48]	80	V	R1 49 R1-2 51	100 IO/HD/ I125	35 45 Gy	24	48		total 4 R1 6 R2 7				total 74 R1 74 R2 71
Shoup [13]	100	V	R0 64 R1 30 R2 6	100 12–17.5 Gy	37	Adj 58	23			total 39 R0 51 R1-2 14
Lindel [53]	49	V	R0 51 R1 18 R2 31	100 10–20 Gy	94 50.4 Gy	CRT 73	4-150		total 27 R0 40 R1-2 14				total 65 R0 44 R1-2 83
Haddock [22]	607 Rectum 70 Colon 30	V	R0 37 R1 37 R2 26	100 7.5–30 Gy	96 5–65 Gy	CRT 81 Adj 18	44		total 30 R0 46 R1 27 R2 16				total 28 R0 21 R1 R1-2 32
Roeder [31]	97	V	R0 37 R1 33 R2 30	100 10–20 Gy	55 50 Gy	49 Adj 34	51	R1 18 R1-2	total 30 R0 63 R1 R1-2 11			R1 59 R2 82	total 59 R0 32 R1 R2
Kusters [44]	170	V	R0 54 R1-2 46	98 10–17.5 Gy	85 30 Gy 46 50 Gy 54	63	35		total 41 R0 R1-2	R0 58 R1-2 18			total 46 R0 32 R1-2 71
Hashiguchi [42]	37	V	R0 19 R1 17 R2 64	100 15–30 Gy	75 50 Gy	Adj 100			total 13 R0-1 35				R0-1 76
Rahbari [21]	92	V	R0 59 R1 27 R2 14	68 10-20 Gy	30% 50 Gy	CRT 27 Nadj 2	23			total 47 R0 65 R1 10 R2 0				total 25 R0 R1 R2
Palmer [28]	64	V	R0 34 R1 8 R2 52	66	64 50 Gy	CRT 48	63		total 16 R0 40 R1-2 4					R0 14 R1-2 55
Salo [51]	103	V	R0 69 R1 13 R2 18	52 12-15 Gy	100 pre/ post	CRT 26	23		R0 35 R1 23 R2 9
Bedrosian [59]	85	V	R0 76 R1 24	44	27	CRT 27 Adj 53	43		total 36 R0 45 R1 15				total 49 R0 R1
Wiig [52]	150	V	R0 44 R1 39 R2 17	39 12-20 Gy	100 46-50 Gy	11			total 27 R0 52 R1 14 R2 0				total 52 R0 27 R1 63 R2
Kanemitsu [50]	101	V	R0 60 R1 20 R2 20	18 10-20 Gy	41 45-50 Gy	41 CT/CRT				total 32 R0 43 R1 20 R2 10			total 35 R0 30 R1 45 R2 45

CRT, chemoradiotherapy; IR, intermediary risk group; LA, locally advanced, adjuvant chemotherapy; Nadj, neoadjuvant chemotherapy.

Table IV. Locally recurrent cancer. Limits, mean and number of studies giving overall survival and local rerecurrence for the total group of patients and the separate R stages.

	Limits		Mean		No. Studies
Operated	IORT	nonIORT	IORT	nonIORT	IORT	nonIORT
OS total	4–46	0–46	25	19	14	9
R0	29–63	0–60	45	39	10	6
R1	6–28	0–23	19	12	7	2
R2	0–16	0	6	0	7	1
R1-2	4–14	0–43	11	12	3	6
LR total	28–74	70–92	49	81	10	2
R0	21–44	22–30	37	26	8	2
R1	45–88	75	63	75	5	1
R2	45	45	45		1	0
R1-2	32–87	34	65	34	5	1

LR, local rerecurrence at 5 years; OS, overall survival.

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