Successful Irradiation Treatment of Eight Cases of Inoperable Rectal Carcinoma

SUCCESSFUL IRRADIATION TREATMENT OF EIGHT CASES OF INOPERABLE RECTAL CARCINOMA

BERNARD F. SCHRELNER, M.D., F.A.C.S.

(Front the State Institiite fnr the Study of Malignant Dkense, Buffalo, N. Y., Bzirtoii T. Simpson, M.D., Director) It is not the purpose of this paper to enter into the discussion of the treatment of cancer of the rectum but merely to record eight cases of inoperable cancer of the rectum which were treated successfully by means of irradiation. These cases were treated between 1919 and 1929, during which time methods employed in irradiation were rapidly chang- ing. No doubt many radiologists have had some success in the treatment of inoperable rectal carcinoma. It is hoped by this report to stimulate interest among the profession so that more data can be accumulated on the treatment of cases of this class. Binkley (l),in speaking of radiation therapy, says : “These physical agents are capable of producing clinical cures in selected operable and inoperable cases ; they provide greater palliation in the advanced stages of the disease than that offered by any other present-day method. . . , In fact, radiation therapy appears to have a wider field of usefulness in the treatment of rectal cancer than have radical surgical methods.’’ In the cases here reported the method of application has varied. Glass seeds, filtered radon in tubes, and external irradiation were all employed in some combination. In only one case was implantation of gold seeds of radon done. The results in these eight cases have definitely established the fact thal, it is possible, at least in some cases, to effect healing without colostomy or other surgical intervention. While our percentage of healings, which will be reported in another paper, has not been remarkable, we believe that we have learned a great deal more about treatment in the past few years than formerly was known. It is our belief at the present time, that as soon as the diagnosis of rectal carcinoma is made and is verified by biopsy, the patient should have a thorough course of roentgen irradiation or should be treated externally by tele-curie-therapy. This latter method of external irradiation, as described by the author in collaboration with Reinhard and Wehr (a),will cause, in a large percentage of cases, remarkable regression of the tumor in the course of four to five weeks. The remnants of the tumor can then be implanted with gold seeds of radon. It is worth mentioning that we have seen complete regression of carcinoma of the rectum following external irradiation by this method, without other measures, but whether such regression will be permanent it is too early to state. 320 ITIIiADIATION TREATMENT OF RECTAL CARCINOMA 327

CASE REPORTS CASE I: W. C. (No. 5943), a male aged Afty-six, was admittkd in August 1919. One year earlier he had been operated on for a carcinoma of the lower end of the rectum, which was removed through the perineum. A recurrence followed, with bloody and mucous discharge. On examination a hard, indurated, nodular growth was found involving the anal canal and the right and posterior lower rectal walls. Biopsy showed adenocarcinoma (Fig. 1). The Wassermann reaction was one plus. Treatmeat: August 1919: 50 mg. of radium placed in the anal canal for one hour, filtered through 1 mm. brass and 1 mm. rubber. September 1919: Same treatment for two hours. October 1919 : Same treatment for six hours. November 1919 : 51 mg. radium for three hours. December 4, 1919: 51 mg. radium for two and a half hours. Decem- ber 23, 1919: 51 mg. radium for four hours. January 1920: 51 mg. for six hours. February 1920 : 51 mg. for nine hours (3 places for three hours each place). May 1920 : One platinum iridium needle for 40 mg. hr. August 1921: Low-power, unfiltered x-rays over anal ring. December 1921: Low-powcr unfiltered x-rays over anal ring.

FIG.1. CASE I (No. 5943): BIOPSYSPECIMEN

Result: This treatment resulted in a sclerosed strictured lesion in the anal ring, necessitating a colostomy in 1923. The patient died in 1931 from pneumonia. At the time of death there was a marked fibrosis, with some mucous discharge from the rectum. Palliation lasted eleven years and nine months. CASE11: I<. I<. (No. 6625), a male aged fifty-three, was admitted in February 1921. Three months prior to admiwion he complained of a dull ache low in the rectum, diarrhea, and blood and mucus in the stools. He was unable to sit with any comfort and had difaculty in urinating. Rectal examination revealed a nodular, ulcerating tumor mass occupying the anterior and right rectal walls, extending up from the anal ring for a distance of 2% inches. The growth was Axed. Biopsy showed carcinoma (Fig. 2). Treatment: February 1921: 65.9 mc. radon Altered through 0.5 mm. silver, 1.0 mm. brass and 1.0 mm. rubber, applied in four places for two hours each, for a total of 527.2 mc. hrs. At the same time 13 glass see& containing from 0:5 to 0.7 mc. radon were implanted into the lesion for a total of 963.6 me. hr. Result: Three weeks after treatment regression of the lesion was observed, the 328 BERNARD F. SCHREINER growth being reduced to 50 per cent of the original size. Six weeks after this there was still evidence of radium reaction, but the tumor mass had completely disappeared. Ten weeks after admission there remained only a slightly indurated scar occupying the pro- static and right wall of the lower rectum. Our last report of this patient, August 1934, states that there was no recurrence of the original trouble, thirteen years and six months after admission. ' CASE111: E. E. (No. 6815), a female aged fifty-three, was admitted in April 1921. She had had a bloody discharge from the rectum three years prior to admission, which was ascribed by her physician to peptic ulcer. In the winter of 1920 she complained of pain in the hips, a discharge of blood and mucus from the rectum, and constipation. She was referred by her family surgeon with a diagnosis of inoperable carcinoma of the rectum. Rectal examination revealed an infiltrating carcinoma of the upper end of the rectum, involving the left rectal wall, fixed and obstructing about 50 per cent of the lumen of the gut. Biopsy showed papillary adenocarcinoma (Fig. 3).

FI~.2. CASE I1 (No. GG25): BIOPSY~PECIMEN

Treatment: In April 1921, 8 glass seeds containing radon, 4.8 me., were implanted into the tumor for a total of 638.4 me. hr. Following this a radium pack at 6 om. distance, containing 1618 me. of radon filtered through 0.5 mm. silver, 1 mm. lead, 1 mm. aluminum, and 1 om. rubber, was applied to the left and right sacral and left lower abdominal regions for a total of 6472 ma. hrs. to each of the three areas. Following this there was no discharge and the patient suffered very little discomfort. Two months later, June 1921, further irradiation with a similar pack for 4668 mc. hrs., over the lower abdomen, was given. In July the same pack was applied over the lower abdomen and sacrum for 5,464 me. brs. to each site. In October there was a recurrence of bloody and mucous discharge. Subsequent treatment was ap follows. December 1921 : Same pack over lower abdomen and sacrum, 5692 me. hrs. to each place. May 1922: High-voltage x-rays, 198 kv., 4 ma., filter 0.5 mm. copper, and 1.0 mm. aluminum, over the abdomen at 50 em. distance, 10 X 15 em. fleld, for three and a quarter hours; over perineal region at 70 em. distance, 20 X 20 em. field, for one hour and thirty-six minutes; over baak, 20 X 20 pm. fleld, at 80 em. distance, for two hours and a half. Result: Following this lafit treatment there has been no recurrence of symptoms in a period of thirteen years and ten months. FIG. 3. CASE ILI (NO. 6815): BIOPSYSPECIMEN

FIG.4. CASE IV (No. 8525): BIOPSYSPECIMEN

329 330 BERNARD F. SCHREINER

CASE IV: T. W. (No. 8525), a female aged fifty-seven, was admitted in May 1934. She had had diarrhea, with blood and mucus in the stool for two years, and had lost 80 pounds in weight. Rectal examination showed a fixed, annular tumor mass about 3 inches from the anal ring, which was ulcerating and infiltrating. Biopsy showed carcinoma (Fig. 4). Treatment: In May 1924, high-voltage x-ray therapy was given: 200 kv., 30 ma., filter 0.5 mm. copper and 1.0 mm. aluniinnm, 80 em. distance, 20 X 20 em. fields, one anterior and one posterior, 25.5 min. eurh field. At the same time tandeni tuhes containing 93 me. and 82.7 mc. radon, flltererl through 2 mm. brass and 1 mni. rubber, were inserted into the strictured area for six hours and eight minutes, a total of 1064 me. hrs., and 12 glass seeds were implanted into the tumor for a total of 1465 me. hrs. Reault: One month later there was almost complete regression of the tumor. At the end of two months there was a stricture at the site of the tumor mass. The bowels were moving normally. In January 1935, ten years and eight months after admission, there

FIG. 5. GIBE V (NO. 8739): BIOPSYSPECIMEN

had been no recurrence; the patient had normal bowel movements and a smooth stricture in the rectum, weighed 200 pounds, and felt well. CASE V: R. G. (No. 8739), female aged sixty-eight, was admitted in October 1924. Two years earlier she had been operated on for duodenal ulcer; a gastro-enterostomy was done. Shortly after operation there was bloody discharge from the rectum, which con- tinued. On rectal examination an adenocarcinoma was found in the upper end of the rectum, annular and fixed. Biopsy showed adenocarcinoma (Fig. 5). Treatment: In October 1924, 6 glass seeds of radon were implanted for a total of 580 me. hrs. At the same time one tube containing 134 me. radon filtered through 2 mm. brass and 1 mm. rubber was placed in the rectum for a total of 805 me. hrs., and high- voltage x-ray therapy was given: 200 kv., 30 ma., filter of 0.5 mm. copper and 1.0 mm. aluminum, 80 em. distance, 20 X 20 em. fields, one anterior and one posterior, 25.5 min. each field. There was a strictured tumor mass still present in the rectum in January 1935 and 2 tubes containing 65 me. and 60 mc. of radon filtered through 0.5 mm. gold, 0.5 mm. brass, and 1 mm. rubber were packed into the strictured area for a total of 1500 me. hrs. FIQ. 6. CASE VI (No. 9454) : BIOPSYSPECIMEN

FIG. 7. CABE VII (No. 9474): BIOPSYSPECIMEN

331 332 BERNARD F. SCHREINER

Resvlt: Since the latter date there has been no recurrence of symptoms. Tho bowels move daily, and no blood or mucus is observed. Nine years and seven months have elapsed since the last treatment. CASEVI: C. S. (No. 9454), a female aged forty-three, was admitted in February 1926. For one year she had complained of a dull ache in the lower abdomen and back and discharge of mucus from the rectum. She was seen by a proctologist, who made a diagnosis of carcinoma of the upper end of the rectum. On rectal exaniination there was found, 31/2 to 4 inches from the anal ring, an adenocarcinoma which was fixed to the sacral region. Biopsy Bhowed adenocarcinoma (Fig. 6). Tnmtmcnt: In February 1926 high-power x-ray therapy was given : 200 kv., 30 ma., 0.5 mm. copper and 1.0 mm. aluminum filter, 80 om. distance, 20 X 20 em. field, 2 sittings anteriorly for 12 minutes and 3 minutes respectively, and 2 sittings posteriorly for 12 minutes and 3.9 minutes respectively. At the same time 8 glass seeds were implanted for 514 me. hm. and two tandem tubes containing 169 and 155 me. radon, fil-

FIG.8. CASE VIII (No. 11614): BIOPSYSPECIMEN tcid through 0.5 111111. gold, 0.5 mm. brass, 1 mm. rubber, for a total of 1625 mc. hrs. were inserted. Two months later there was stricture of the rectum but bowel movements were normal. In June 1926 high-power x-ray therapy was again given, with the same factors as above, 20 X 24 cm. field, 18 minutes anteriorly and 18.6 minutes posteriorly. Result: At present there is a small stricture high in the rectum, the size of a lead penril, but in spite of this, bowel movements are satisfactory without the use of cathartics. There is no recurrence, nine years after treatment. CASE VII: C. C. (No. Q474),a male aged fifty-five, was admitted in March 1926. For two weeks he had complained of pain in the rectum, with blood and mucus in the stools. About 3% inches from the anal ring, on the posterior wall, was a large poly- poitl-like tumor. Another nodule was found below the mucosa. Biopsy showed adenocarcinoma (Fig. 7). Traatment: In March 1926, 15 glass seeds, varying from 0.5 me. to 0.8 mc., werc implanted into the tumor mass in the postcrior wall of the rectum, for a total of 1138 me. hrs. At the same time high-power x-ray therapy was given: 200 kv., 30 ma., 80 cm. distanee, 0.5 mrn. copper and 1.0 mm. aluminum fllter, over a 20 x 24 em. fleld, 2 sittings anteriorly for 12 and 17.4 minutes, respectively; posteriorly, twice for 14.7 mixi. IRRADIATION TREATMENT OF RECTAL OARCINOMA 333

Result: One month later there was almost complete regression of the tumor. The site was occupied by an indurated nodule. Following this the radium and x-ray reaction subsided, and subsequent examinations showed scar with a Hlightly indurated nodule at the site of the former tumor. Five and a half years after treatment the patient complained of vague pain in the upper abdomen, and rectal examination showed a puckered scar in the posterior wall of the mid-rectum, but there was no blood or mucus. The liver was palpable. In view of the fact that metastases in the liver were suspected, the abdomen was explored and metastatic deposits throughout the liver were revealed. Their nature was confirmed micro- scopically. The patient died August 24, 1933. In spite of the metastases, which manifested themselves five years and a half after the lesion in the rectum had healed, this patient did not succumb until seven and a half years after admission. Post-mortem examination showed no recurrence in the scar in the rectum. CABEVIII: I. M. (No. 11614), a male aged sixty-five, was admitted in February 1929. He had had diarrhea, with mucus but no blood in the stools, for a year and a half. Examination revealed a fixed adenocarcinoma involving the anterior and lateral walls of the rectum over the prostate and almost surrounding the bowel. Biopsy showed carcinoma (Fig. 8). Treatment: Twelve gold seeds containing 1.4 and 1.7 me. were implanted for a total of 2653 me. hrs. Two doses of x-rays were given: 200 kv., 30 ma., filtered through 0.5 mm. copper and 1.0 mm. aluminum, 80 cm. distance, 20 x 25 em. fields, one anterior and one posterior, 15 minutes and 13.8 minutes. Result: Examination of the rectum two months after treatment showed marked regression of the tumor but considerable radium reaction, Subsequent examinations, thmughout a period of five years and four months, show that there has been no recurrence.

REFERENCES 1. BINKLEY,GEOROE E.: Radiation therapy of rectal cancer, Am. J. Surg. 21: 78, 1933. 2. SCHREINER,BERNARD F., REINHARD,MELVIN C., AND WEHR, WILLIANH. : Tele-Curie- Therapy, Am. J. Cancer 24: 386, 1935.