Dose escalation using contact X-ray brachytherapy (Papillon) for rectal cancer: does it improve the chance of organ preservation?

OBJECTIVE: A watch and wait policy for patients with a clinical complete response (cCR) after external beam chemoradiotherapy (EBCRT) for rectal cancer is an attractive option. However, approximately one-third of tumours will regrow, which requires surgical salvage for cure. We assessed whether contact X-ray brachytherapy (CXB) can improve organ preservation by avoiding surgery for local regrowth. METHODS: From our institutional database, we identified 200 of 573 patients treated by CXB from 2003 to 2012. Median age was 74 years (range 32-94), and 134 (67%) patients were males. Histology was confirmed in all patients and was staged using CT scan, MRI or endorectal ultrasound. All patients received combined CXB and EBCRT, except 17 (8.5%) who had CXB alone. RESULTS: Initial cCR was achieved in 144/200 (72%) patients. 38/56 (68%) patients who had residual tumour received immediate salvage surgery. 16/144 (11%) patients developed local relapse after cCR, and 124/144 (86%) maintained cCR. At median follow up of 2.7 years, 161 (80.5%) patients were free of cancer. The main late toxicity was bleeding (28%). Organ preservation was achieved in 124/200 (62%) patients. CONCLUSION: Our data suggest that CXB can reduce local regrowth to 11% compared with around 30% after EBCRT alone. Organ preservation of 62% achieved was higher than reported in most published watch and wait studies. Advances in knowledge: CXB is a promising treatment option to avoid salvage surgery for local regrowth, which can improve the chance of organ preservation in patients who are not suitable for or refuse surgery.

Rectosigmoid gallstone coleus: a rare emergency presentation.

An elderly woman presented with abdominal pain and vomiting, was known to have gallstones. A CT scan was arranged identifying gallstone ileus and cholecystitis. Ensuing sepsis precipitated fast atrial fibrillation delaying the planned laparotomy. Her symptoms subsequently resolved with conservative management. Ten days following admission her abdomen became distended. A repeat CT scan showed large bowel dilation with intramural air suggestive of obstruction and bowel ischaemia. Emergency laparotomy was performed identifying a large 23 mm gallstone impacted at the rectosigmoid junction (gallstone coleus). The stone was milked back to the transverse colon where it was retrieved and a transverse loop colostomy was formed. Gallstone ileus is rare; gallstone coleus is even rarer. On review of the published literature both entities have not been seen in the same patient during the same admission or indeed caused by the same gallstone.