title: Results of intraoperative electron beam radiotherapy containing multimodality treatment for locally unresectable T4 rectal cancer: a pooled analysis of the Mayo Clinic Rochester and Catharina Hospital Eindhoven.
abstract: BACKGROUND
  The aim of this study is to analyse the pooled results of intraoperative electron beam radiotherapy (IOERT) containing multimodality treatment of locally advanced T4 rectal cancer, initially unresectable for cure, from the Mayo Clinic, Rochester, USA (MCR) and Catharina Hospital, Eindhoven, The Netherlands (CHE), both major referral centers for locally advanced rectal cancer. A rectal tumor is called locally unresectable for cure if after full clinical work-up infiltration into the surrounding structures or organs has been demonstrated, which would result in positive surgical margins if resection was the initial component of treatment. This was the reason to refer these patients to the IOERT program of one of the centers.
  
  
  METHODS
  In the period from 1981 to 2010, 417 patients with locally unresectable T4 rectal carcinomas at initial presentation were treated with multimodality treatment including IOERT at either one of the two centres. The preferred treatment approach was preoperative (chemo) radiation and intended radical surgery combined with IOERT. Risk factors for local recurrence (LR), cancer specific survival, disease free survival and distant metastases (DM) were assessed.
  
  
  RESULTS
  A total of 306 patients (73%) underwent a R0 resection. LRs and metastases occurred more frequently after an R1-2 resection (P<0.001 and P<0.001 respectively). Preoperative chemoradiation (preop CRT) was associated with a higher probability of having a R0 resection. Waiting time after preoperative treatment was inversely related with the chance of developing a LR, especially after R+ resection. In 16% of all cases a LR developed. Five-year disease free survival and overall survival (OS) were 55% and 56% respectively.
  
  
  CONCLUSIONS
  An acceptable survival can be achieved in treatment of patients with initially unresectable T4 rectal cancer with combined modality therapy that includes preop CRT and IOERT. Completeness of the resection is the most important predictive and prognostic factor in the treatment of T4 rectal cancer for all outcome parameters. IOERT can reduce the LR rate effectively, especially in R+ resected patients.
authors.affiliation: Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Fabian A
authors.initials: FA
authors.lastname: Holman
authors.affiliation: Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA.
authors.forename: Michael G
authors.initials: MG
authors.lastname: Haddock
authors.affiliation: Department of Radiation Oncology, Mayo Clinic, Scottsdale, AZ, USA.
authors.forename: Leonard L
authors.initials: LL
authors.lastname: Gunderson
authors.affiliation: Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands;
authors.forename: Miranda
authors.initials: M
authors.lastname: Kusters
authors.forename: Grard A P
authors.initials: GA
authors.lastname: Nieuwenhuijzen
authors.forename: Hetty A
authors.initials: HA
authors.lastname: van den Berg
authors.affiliation: Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA.
authors.forename: Heidi
authors.initials: H
authors.lastname: Nelson
authors.affiliation: ; GROW: School for Oncology and Developmental Biology, University of Maastricht, Maastricht, The Netherlands.
authors.forename: Harm J T
authors.initials: HJ
authors.lastname: Rutten
keywords: T4 rectal cancer; intraoperative irradiation; pooled results; re-irradiation