Highlights
- •Patterns of local and nodal spread were determined for pT2 rectal cancer.
- •Regional recurrence pattern after organ preservation was established.
- •CTV delineation rules for organ preservation in cT2 disease were proposed.
- •The proposed rules resulted in smaller CTV than current guidelines.
Abstract
Background
There are no guidelines on clinical target volume (CTV) delineation for cT2 rectal
cancer treated with organ preservation.
Materials and methods
A systematic review and meta-analysis were performed to determine the extent of distal
mesorectal (DMS) and distal intramural spread (DIS), the risk of lateral lymph node
(LLN) metastases in pT2 tumours, and regional recurrence pattern after organ preservation.
Results
The rate of DMS > 1 cm was 1.9% (95% CI: 0.4–5.4%), maximum extent: 1.3 cm. The rate
of DIS > 0.5 cm was 4.7% (95% CI: 1.3–11.5%), maximum extent: 0.8 cm. The rate of
LLN metastases was 8.2% (95% CI: 6.7–9.9%) for tumours below or at peritoneal reflexion
and 0% for higher tumours. Regional nodal recurrences alone were recorded in 1.0%
(95% CI: 0.5–1.7%) of patients after watch-and-wait and in 2.1% (95% CI: 1.2–3.4%)
after preoperative radiotherapy and local excision. Thus, the following rules for
CTV delineation are proposed: caudal border 1.5 cm from the tumour to account for
DMS or 1 cm to account for DIS, whichever is more caudal; cranial border at S2/S3
interspace; inclusion of LLN for tumours at or below peritoneal reflexion. A planning
study was performed in eight patients to compare dose–volume parameters obtained using
these rules to that obtained using current guidelines for advanced cancers. The proposed
rules led to a mean 18% relative reduction of planning target volume, which resulted
in better sparing of organs-at-risk.
Conclusion
This meta-analysis suggests a smaller CTV for cT2 tumours than the current guidelines
designed for advanced cancers.
Keywords
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Article info
Publication history
Published online: January 14, 2019
Accepted:
December 21,
2018
Received in revised form:
December 20,
2018
Received:
November 3,
2018
Identification
Copyright
© 2019 Elsevier B.V. All rights reserved.
