Intensity-modulated radiotherapy (IMRT) in the treatment of squamous cell anal canal cancer: acute and early-late toxicity, outcome, and efficacy

High-Tailored Anal canal Radiotherapy (HIT-ART): Long term results of MR image-guided interventional radiotherapy (brachytherapy) boost

PURPOSE

The aim of this study is to investigate the outcomes in terms of survival, treatment compliance and toxicity in a cohort of patients treated with personalized chemoradiation (RCT) followed by image guided Interventional Radiotherapy (IG-IRT), stratified by clinical baseline stage and treatment response.

METHODS AND MATERIALS

We analyzed patients with histologically proven squamous anal carcinoma treated using intensity modulated radiation therapy (IMRT) with curative intent, and IRT boost. External beam radiation was delivered using personalized IMRT technique with a simultaneous-integrated boost (SIB) to deliver 45 to 55 Gy in 25 fractions according to clinical stage. After the end of the RCT patients underwent clinical and imaging re-evaluation, and according to initial stage of disease and tumor response, a radiotherapy boost was administered through IG-IRT, performing MRI with IRT applicator on site (trans-anal position) and defining GTV on MRI imaging. All patients' treatments and outcomes data were collected by an internal database. The endpoints were in terms of overall treatment time (OTT), toxicity, clinical complete response (cCR), locoregional failure (LRF), colostomy free survival, overall survival (OS) and disease-free survival (DFS). Univariate survival analysis with Kaplan- Meier curves was performed to allow between-group comparison.

RESULTS

73 patients treated between February 2012 and January 2023 were included in the analysis. 72.6 % were female, with a median age of 65.4 years (range 39.1-89). 62 were staged T2-T4 (T2 42.5.5%, T3 19.2%, T4 27.4%) and 50 (68.5%) had positive nodes. Combined RCT was administered mainly using mitomycin C and 5-fluorouracil. The mean dose received by patients was 50 Gy; after a median time of 43 days (range 9-128) a sequential boost dose was delivered in 1-2 fractions (median dose of 4 Gy). OTT median was 85 days (range 44-225). The median follow-up period was 50.6 months. LRF was 17.8%, and at 3 and 5 years LC was 80.1% and 77.2%, CFS was 80.5 and 77.8%, DFS was 79.3% and 75.9% and OS 95.1%, 84.3% and 61.4% at 10 years. Moreover, we verified that OS was higher in patients who had an OTT lower than 93 days. Toxicity was acceptable: 45.2% of patients experienced a G1-G2 abdominal discomfort (only 5.5% had G3).

CONCLUSIONS

Our experience confirms that MR Image Guided Interventional Radiotherapy boost is a feasible treatment option with a significant impact on outcomes.

Comparative analysis of toxicity in patients with anal cancer undergoing definitive simultaneous integrated boost (SIB) or sequential integrated boost (SeqB) radiotherapy

PURPOSE

To compare toxicity of radiotherapy (RT) with concomitant chemotherapy (CHT) in patients (pts) with anal cancer treated with simultaneous integrated boost (SIB) versus sequential boost (SeqB).

METHODS

Sixty-six patients were treated from 2007 to 2021. Thirty patients underwent to SeqB concurrent to CHT and 37 to SIB-group. Toxicity assessment has been considered in acute and in late toxicities for gastrointestinal (GI), genitourinary (GU), cutaneous (CU) districts, according to Common Terminology Criteria for Adverse Events (CTCAE), Version 5.0. The Wexner scale among summary scoring systems has been used as a tool to measure fecal incontinence. The chi-square test for ordinal variables were used to evaluate the association between patient and treatment characteristics and acute or late severe toxicity. Univariable logistic regression models were fit to evaluate predictive factors associated with fecal incontinence.

RESULTS

Median follow-up was 61.5 months (IQR, 27.1-121.7 months) for all patients. Severe acute toxicity (≥ G2) was observed in 49 patients (74.2%). Late toxicity (≥ G2) occurred in 13 cases (19.6%). In assessment of cutaneous toxicity, there was also a significant reduction in ≥ G1 in SIB group with 29 patients (80.5%) vs SeqB group with 29 patients (96.6%) (p-value = 0.046). Of both groups 11 patients (16.6%) developed fecal incontinence, 8 (22%) in the SIB group and 3 (10%) in the SeqB.

CONCLUSION

SIB for anal cancer treatment results in reduced acute and late cutaneous toxicity compared to SeqB. According to our results the rate of other acute and late toxicities are low and comparable between the two groups.

Intensity-modulated radiotherapy and cisplatin-based chemotherapy for anal cancer: long-term outcomes at a single institution

PURPOSE

To evaluate oncological outcomes and late toxicities in a retrospective series of patients with locally-extended anal squamous cell carcinoma (ASCC), treated with curative Intensity Modulated Radiotherapy (IMRT) and chemotherapy.

METHODS

ASCC patients who underwent chemo-radiotherapy with IMRT from 2010 to 2020 were included. Oncological outcomes were assessed in terms of overall survival (OS), disease-free survival (DFS), colostomy-free survival (CFS) and event-free survival (EFS). Late toxicity was detected according to CTCAE v.5.0 and RTOG late radiation morbidity scoring system.

RESULTS

Ninety-five patients were included. Most patients (83%) received chemotherapy with oral Fluoropyrimidine plus Cisplatin. The median follow-up was 5.5 years. The OS was 85.2%, 82.1% and 79.3% at 3, 5 and 8 years, respectively. The DFS was 73.1%, 70%, and 65.3% at 3, 5 and 8 years, respectively; 3, 5 and 8 years CFS was 86.2%, 84.3% and 84.3%, respectively. The EFS was 71%, 67.9% and 63.1%, at 3, 5 and 8 years, respectively. On univariable analysis, a statistically significant lower OS was found for patients with T3-T4 stage (HR = 4.58, p = 0.005) and overall treatment time (OTT) ≥ 47 days (HR = 3.37, p = 0.038). A statistically significant lower DFS was reported for patients with T3-T4 stage (HR = 2.72, p = 0.008) and Serum Squamous Cell Carcinoma Antigen (SCC) value post-RT > 1.5 (HR = 2.90, p = 0.038.). Ten severe late toxicity (≥ G3) events were reported in 8 patients (8.6%).

CONCLUSIONS

Our data confirm IMRT concomitant with a Cisplatin-based chemotherapy as an effective treatment of ASCC, ensuring acceptable long-term toxicities and good oncological outcomes.

Anal squamous cell carcinoma: Impact of radiochemotherapy evolution over years and an explorative analysis of MRI prediction of tumor response in a mono-institutional series of 131 patients

Introduction

Radiochemotherapy (RCHT) for the treatment of anal squamous cell carcinoma (ASCC) has evolved dramatically, also thanks to intensity-modulated RT (IMRT) and 3D image guidance (3D IGRT). Despite most patients presenting fair outcomes, unmet needs still exist. Predictors of poor tumor response are lacking; acute toxicity remains challenging; and local relapse remains the main pattern of failure.

Patients and methods

Between 2010 and 2020, ASCC stages I–III treated with 3D conformal radiotherapy or IMRT and CDDP-5FU or Mytomicine-5FU CHT were identified. Image guidance accepted included 2D IGRT or 3D IGRT. The study endpoints included freedom from locoregional recurrence (FFLR), colostomy free survival (CFS), freedom from distant metastasis (FFDM), overall survival (OS), and acute and late toxicity as measured by common terminology criteria for adverse events (CTCAE) version 5.0. An exploratory analysis was performed to identify possible radiomic predictors of tumor response. Feature extraction and data analysis were performed in Python™, while other statistics were performed using SPSS^® v.26.0 software (IBM^®).

Results

A total of 131 patients were identified. After a median FU of 52 months, 83 patients (63.4%) were alive. A total of 35 patients (26.7%) experienced locoregional failure, while 31 patients (23.7%) relapsed with distant metastasis. Five year FFLR, CFS, DMFS and PS resulted 72.3%, 80.1%, 74.5% and 64.6%. In multivariate analysis, 2D IGRT was associated with poorer FFLR, OS, and CFS (HR 4.5, 4.1, and 5.6, respectively); 3DcRT was associated with poorer OS and CFS (HR 3.1 and 6.6, respectively). IMRT reduced severe acute gastro-intestinal (GI) and severe skin acute toxicity in comparison with 3DcRT. In the exploratory analysis, the risk of relapse depended on a combination of three parameters: Total Energy, Gray Level Size Zone Matrix’s Large Area High Gray Level Emphasis (GLSZM’s LAHGLE), and GTV volume.

Conclusions

Advances in radiotherapy have independently improved the prognosis of ASCC patients over years while decreasing acute GI and skin toxicity. IMRT and daily 3D image guidance may be considered standard of care in the management of ASCC. A combination of three pre-treatment MRI parameters such as low signal intensity (SI), high GLSZM’s LAHGLE, and GTV volume could be integrated in risk stratification to identify candidates for RT dose-escalation to be enrolled in clinical trials.

Radiodermatitis: severity, predictive factors and discontinuation of radiotherapy in patients with anal and rectal cancer

OBJECTIVE

to determine the prevalence of radiodermatitis, severity grades and predictive factors of its occurrence in patients with anal and rectal cancer followed up by the nursing consultation, and to analyze the association of severity grades of radiodermatitis with temporary radiotherapy interruption.

METHOD

a quantitative, cross-sectional and retrospective study, carried out with 112 medical records of patients with anal and rectal cancer undergoing curative radiotherapy followed up in the nursing consultation. Data were collected using a form and analyzed using analytical and inferential statistics.

RESULTS

99.1% of patients had radiodermatitis, 34.8% of which were severe. The predictive factors were female sex, age greater than 65 years, anal canal tumor, treatment with cobalt device and IMRT technique. Treatment interruption occurred in 13% of patients, associated with severe radiodermatitis.

CONCLUSION

there was a high prevalence of radiodermatitis, mainly severe, which resulted in treatment interruption.

Radiodermatite: severidade, fatores preditivos e interrupção da radioterapia em pacientes com câncer anal e de reto

RESUMO Objetivo: determinar a prevalência da radiodermatite, os graus de severidade e os fatores preditivos da sua ocorrência em pacientes com câncer de canal anal e reto acompanhados pela consulta de enfermagem, e analisar a associação dos graus de severidade da radiodermatite com a interrupção temporária da radioterapia. Método: pesquisa quantitativa, seccional e retrospectiva, realizada com 112 prontuários de pacientes com câncer de canal anal e reto submetidos à radioterapia curativa acompanhados na consulta de enfermagem. Dados foram coletados por formulário e analisados empregando-se estatística analítica e inferencial. Resultados: 99,1% dos pacientes apresentaram radiodermatite, sendo 34,8% graus severos. Os fatores preditivos foram sexo feminino, idade maior que 65 anos, tumor de canal anal, tratamento com aparelho de cobalto e técnica IMRT. A interrupção do tratamento ocorreu em 13% dos pacientes, associada à radiodermatite severa. Conclusão: houve alta prevalência de radiodermatite, principalmente grau severo, que resultou em interrupção do tratamento.

Morbidity in Patients with Nasopharyngeal Carcinoma and Radiation-Induced Skin Lesions: Cause, Risk Factors, and Dermatitis Evolution and Severity

OBJECTIVE

Radiation-induced skin injuries such as lesions (RSLs) and dermatitis are the most common complication during radiotherapy (RT) for nasopharyngeal carcinoma, but little is known about risk factors unique to oncology. This study sought a greater understanding of these risk factors to stratify patients based on risk and guide clinical decision-making.

METHODS

Investigators analyzed the data of 864 consecutive patients referred to the RT center of the Southern Theater General Hospital for a new RSL from 2013 to 2019. These patients were followed up for an average of approximately 16 months until their death or March 30, 2020, whichever came first. Multivariate logistic regression analysis and Cox proportional hazards model were used to identify predictors of grade 3 or 4 dermatitis.

RESULTS

The main causes of treatment interruption included dermatitis and oral mucositis. Significant patient-specific risk factors for RSLs included current smoking, current drinking, and lower Karnofsky Performance Scale score and significant procedure-specific risk factors included receiving intensity-modulated radiation therapy (IMRT), hyperfractionated RT, induction chemotherapy, multicycle chemotherapy, and taxol- and cisplatin-based drugs. The three factors that independently predicted risk of RSL were IMRT, lower Karnofsky Performance Scale score, and multicycle chemotherapy. Comparing predictive factors among patients with severe RSL revealed that patients who received IMRT were more likely to develop grade 3 or 4 dermatitis.

CONCLUSIONS

Oncology providers should note that IMRT is an aggressive technique with a trend toward increased RSL. Providers should pay special attention to adverse effects to skin in patients with nasopharyngeal carcinoma.

Management of late adverse effects after chemoradiation for anal cancer

BACKGROUND AND PURPOSE

Significant improvements in the treatment of anal cancer have produced a growing population of anal cancer survivors. These patients often experience late adverse effects related to their treatment. Research has revealed substantial unmet needs because of long-term symptoms and functional impairments after treatment that may negatively affect health-related quality of life. The purpose of the present guidelines is to review the scientific evidence for the management of late adverse effects after (chemo)radiotherapy ([C]RT) for anal cancer and to extrapolate knowledge from other pelvic malignancies treated with pelvic (C)RT so that they may guide the clinical management of late adverse effects.

MATERIALS AND METHODS

Relevant studies were systematically searched in four databases from their inception to June 2020 (no language limitation) and guidelines were searched in 16 databases, focussing on bowel dysfunction, psychosocial aspects, pain, and sexual and urinary dysfunction. The guidelines were developed by a panel of experts using the Oxford Centre for Evidence-based Medicine, levels of evidence, and grades of recommendations.

SCIENTIFIC EVIDENCE

Late adverse effects after (C)RT for anal cancer are associated with a low overall quality of life among survivors. The most pronounced late adverse effects are bowel dysfunction (present in up to 78%), urinary dysfunction (present in up to 45%), and sexual dysfunction (present in up to 90% of men and up to 100% of women). Only indirect data on adequate treatment options of these late adverse effects for anal cancer are available.

CONCLUSION

Quality of life and late adverse effects should be monitored systematically following treatment for anal cancer to identify patients who require further specialist evaluation or support. Increased awareness of the extent of the problem may serve to stimulate and facilitate multidisciplinary collaboration, which is often required.

Anal squamous cell carcinoma: standards of care, new data and ongoing clinical trials

PURPOSE OF REVIEW

To summarize current standards of care, discuss results of recent studies and present ongoing clinical trials for anal squamous cell carcinoma (ASCC).

RECENT FINDINGS

Over the last year, no practice changing studies have been reported in the setting of localised ASCC. A number of retrospective analyses, however, have provided practice-informing data, such as those confirming the negative impact of low compliance to chemoradiotherapy (CRT) on patient outcomes. In contrast, and for the first time, randomized evidence has become available to inform the management of advanced tumours. The InterAACT trial represents a key milestone in the evidence-building process for this disease, establishing carboplatin plus paclitaxel as a new standard of care for treatment-naïve advanced ASCC patients. Furthermore, more data have accumulated about the value of triplet chemotherapy in the first-line setting and of immune checkpoint inhibitors (either as single agents or in combination with other agents) in the refractory setting.

SUMMARY

Recent findings have the potential to improve the treatment quality standards and overall outcome of patients with either localised or advanced ASCC. Results from ongoing clinical trials will hopefully provide useful insights into the management of this disease and further shape current treatment paradigms.

Safety considerations with new treatment regimens for anal cancer

Introduction: Anal cancer is a rare malignancy, but incidence rates are rising. Primary chemoradiation is the standard of care for early disease with surgery reserved for salvage. Despite success in terms of survival, patients suffer significant morbidity. Research is underway to advance the field and improve outcomes for these patients.Areas covered: This review aims to discuss the safety and efficacy of new approaches to treat anal cancer. A literature search was performed from January 1950 through November 2020 via PubMed and ClinicalTrials.gov databases to obtain data from ongoing or published studies examining new regimens for the treatment of anal cancers. Pertinent topics covered include miniature drug conjugates, epidermal growth factor receptor inhibitors, checkpoint inhibitor combinations, and novel immunomodulators.Expert opinion: Based on emerging clinical data, the treatment paradigm for anal cancer is likely to shift in the upcoming years. One of the largest areas of investigation is the field of immunotherapy, which may emerge as an integral component of anal cancer for all treatment settings.

Radiotherapy with Intensity-Modulated (IMRT) Techniques in the Treatment of Anal Carcinoma (RAINSTORM): A Multicenter Study on Behalf of AIRO (Italian Association of Radiotherapy and Clinical Oncology) Gastrointestinal Study Group

Simple Summary

Concurrent chemo-radiotherapy is the standard treatment in anal cancer. Intensity-modulated radiotherapy (IMRT) was proved to reduce severe, acute and late toxicities. Moreover, IMRT techniques allow for the planning and delivery of a simultaneous integrated boost (SIB), with a differential dose per fraction given to selected sub-regions during the same treatment session. This boost modality provides the chance to employ a dose-painted approach with a reduction in overall treatment time that could result in a potential clinical advantage. Since a large variability in dose prescription to the primary tumor and elective or involved lymph nodes can be found in available guidelines and clinical practice, a multicenter analysis was conducted to evaluate the pattern of care and the impact of radiotherapy parameters on clinical outcomes for anal cancer patients treated with IMRT techniques within a national cohort.

Abstract

A multi-institutional retrospective study was conducted to evaluate the pattern of care and clinical outcomes of anal cancer patients treated with intensity-modulated radiotherapy (IMRT) techniques. In a cohort of 987 patients, the clinical complete response (CR) rate (beyond 6 months) was 90.6%. The 3-year local control (LC) rate was 85.8% (95% CI: 84.4–87.2), and the 3-year colostomy-free survival (CFS) rate was 77.9% (95% CI: 76.1–79.8). Three-year progression-free survival (PFS) and overall survival (OS) rates were 80.2% and 88.1% (95% CI: 78.8–89.4) (95% CI: 78.5–81.9), respectively. Histological grade 3 and nodal involvement were associated with lower CR (p = 0.030 and p = 0.004, respectively). A statistically significant association was found between advanced stage and nodal involvement, and LC, CFS, PFS, OS and event-free survival (EFS). Overall treatment time (OTT) ≥45 days showed a trend for a lower PFS (p = 0.050) and was significantly associated with lower EFS (p = 0.030) and histological grade 3 with a lower LC (p = 0.025). No statistically significant association was found between total dose, dose/fraction and/or boost modality and clinical outcomes. This analysis reports excellent clinical results and a mild toxicity profile, confirming IMRT techniques as standard of care for the curative treatment of anal cancer patients. Lymph node involvement and histological grade have been confirmed as the most important negative prognostic factors.

Dosimetric comparison of organs at risk in 5 different radiotherapy plans in patients with preoperatively irradiated rectal cancer

BACKGROUND

Intensity-modulated radiotherapy (IMRT) is a widely used irradiation technique in rectal cancer patients. We aimed to compare 4 different IMRT plans with 3-dimensional conformal radiotherapy (3D-CRT) considering organs at risk (OARs) in patients with rectal carcinoma.

METHODS

This retrospective study included 27 rectal cancer patients who were irradiated preoperatively between January 2016 and December 2018. Five different plans (4-field 3D-CRT in 2 phases, 7-field IMRT in 2 phases, 9-field IMRT in 2 phases, 7-field simultaneous integrated boost [SIB] IMRT, and 9-field SIB IMRT) were generated for each patient. Comparison of 5 different plans according to bladder and bilateral femoral head mean doses, bladder V40, bilateral femoral head V40, and small bowel V35 values were evaluated.

RESULTS

Most of the OAR parameters significantly favored IMRT plans compared to the 3D-CRT plan. The largest difference was observed in bladder V40 values (reduction of V40 value up to 51.2% reduction) in favor of IMRT. In addition, SIB plans showed significantly better reduction in OARs than phase plans except for small bowel V35 values.

CONCLUSIONS

IMRT plans reduced almost all the OARs doses compared with the 3D-CRT plan in rectal cancer patients. Furthermore, SIB plans demonstrated lower OAR doses than the phase plans. IMRT techniques, especially SIB plans, reduce OAR doses and provide safer doses for the treatment of rectal carcinoma.