High-dose rate brachytherapy in the management of operable rectal cancer : A systematic review
A partir d'une revue systématique de la littérature publiée entre 1990 et 2016 (12 études), cette étude analyse le rôle d'une curiethérapie endorectale à haut débit de dose dans le traitement d'un cancer du rectum opérable
Purpose : To evaluate the role of high-dose rate endorectal brachytherapy (HDREBT) in the preoperative and definitive management of operable rectal cancer in terms of clinical outcomes and toxicities using a systematic review. Methods and materials : A review of published articles from January 1990 to December 2016 was conducted using the PubMed, EMbase and SCOPUS databases using the search terms ‘rectal’ or ‘rectum’ in combination with ‘brachytherapy’ ‘high dose rate’, ‘HDR’ and ‘endorectal’. Additional publications were identified by scanning references. Only studies published in English reporting clinical outcomes with a least 30 patients treated with HDREBT were included. Results : The search identified 1688 articles, of which 22 met our inclusion criteria. Twelve studies were included in this systematic review. Following, preoperative HDREBT with chemoradiotherapy (CRT) the pathological complete response (pCR) rate ranged between 18% to 31% (weighted–mean rate 21.1%), R0 resection rate between 80% to 99% (weighted-mean 95.5%)and sphincter preservation rate between 29% to 57% (weighted-mean 46.4%). The weighted-mean 2-year progression-free-survival (PFS) and overall survival (OS) were 68.1% and 76.2% respectively. After preoperative HDREBT alone, the pCR rate ranged between 10.4% t0 27% (weighted-mean 23.8%), R0 rate of 96.5% (one study), and sphincter preservation rate between 53.8% to 75.8% (weighted-mean 59.4%). The weighted-mean 5-year PFS and OS were 66.6% and 70.8% respectively. There was only one study of HDREBT for non-surgical management of rectal cancer, which reported a 2-year OS of 100%. Conclusions : Preoperative HDREBT either alone or in combination with CRT may result in a better pCR, but may not necessarily translate into a better survival, which is similar to outcomes seen following pre-operative CRT alone. There were significant variations across studies in terms of patient selection, treatment approaches, and evaluation of clinical outcomes, suggesting the need for an international consensus on the dosimetric parameters and techniques of HDREBT, timing and methods of response assessment, definitions and assessment of toxicities, and the optimal timing of surgery before further prospective studies. Future studies should include evaluation of the role of HDRE in the non-surgical curative treatment of screen-detected early cancers and organ preservation in lower rectal cancers.
http://www.redjournal.org/article/S0360-3016(17)30944-6/fulltext