Portuguese Program of Intraoperative Radiotherapy in the Management of Locally Advanced and Recurrent Rectal Cancer: A 10-Year Single-Centre Experience
DOI:
https://doi.org/10.34635/rpc.1216Keywords:
Neoadjuvant Therapy, Neoplasm Recurrence, Local, Rectal Neoplasms/radiotherapy, Rectal Neoplasms/surgeryAbstract
Introduction: Intraoperative radiotherapy (IORT) delivers focused dose escalation to high-risk areas during rectal cancer surgery. Its precise contribution to locally advanced (LARC) and locally recurrent rectal cancer (LRRC) remains debated, with no randomized trial demonstrating a survival benefit. We report a 10-year experience of the Portuguese national IORT program at IPO-Porto, contextualized within the current evidence base.
Methods: Single-centre retrospective cohort study (January 2010–December 2020). We included 271 patients with LARC (cT3 CRM+, cT4, M0) receiving neoadjuvant chemoradiotherapy, radical surgery, and IORT, and 59 patients with LRRC (M0) treated with surgery and IORT. Primary endpoints: disease-specific survival (DSS), local recurrence-free survival (LRFS), and distant metastasis-free survival (DMFS).
Results: The 5-year DSS was 63.2% for primary LARC and 36.9% for LRRC (p<0.001). The 5-year LRFS was 87.6% for primary and 72.4% for recurrences (p=0.007). Local disease reappearance within the IORT field occurred in 8.8% of primary and 20.3% of recurrent cases. Clavien-Dindo grade ≥III complications occurred in 20.2%. Clavien-Dindo grade V (mortality) occurred in 0.7% of cases. Intraoperative frozen-section margin status correlated with IORT dose selection and influenced locoregional outcomes. In multivariate analysis, downstaging (HR 0.18; p<0.001) and R1 resection (HR 2.62; p<0.001) were independent predictors of DSS in primary LARC. RO resection and adjuvant chemotherapy were strongly associated with improved local control and survival.
Conclusion: IORT is safe and effective as a locoregional dose-escalation tool for LARC and LRRC. Outcomes are comparable to the best international benchmarks. RO resection remains the dominant prognostic factor. The future combination of IORT with total neoadjuvant therapy warrants prospective evaluation.
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