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Li Y, Gong Z, Liu M, Li H, Gao H, Guo C, Yu L, Zhu C, Sun Z, Sun L, Xu H, He X. 3D-US and CBCT Dual-guided Radiotherapy for Postoperative Uterine Malignancy: A Primary Workflow Set-up. Technol Cancer Res Treat 2023; 22:15330338231212082. [PMID: 37993995 PMCID: PMC10666818 DOI: 10.1177/15330338231212082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 09/09/2023] [Accepted: 09/26/2023] [Indexed: 11/24/2023] Open
Abstract
Introduction: The consistency of clinical target volume is essential to guiding radiotherapy with precision for postoperative uterine malignancy patients. By introducing a three-dimensional ultrasound system (3D-US) into image-guided radiation therapy (IGRT), this study was designed to investigate the initial workflow set-up, the therapeutic potential, and the adverse events of 3D-US and cone-beam computed tomography (CBCT) dual-guided radiotherapy in postoperative uterine malignancy treatment. Methods: From April 2021 to December 2021, postoperative uterine malignancy patients were instructed to follow the previously standard protocol of daily radiation treatment, particularly a 3D-US (Clarity system) guiding was involved before CBCT. Soft-tissue-based displacements resulting from the additional US-IGRT were acquired in the LT (left)/RT (right), ANT (anterior)/POST (posterior), and SUP (superior)/INF(inferior) directions of the patient before fractional treatment. Displacement distributions before and after treatment either from 3D-US or from CBCT were also estimated and compared subsequently, and the urinary and rectal toxicity was further evaluated. Results: All the patients completed radiation treatment as planned. The assessment of 170 scans resulted in a mean displacement of (0.17 ± 0.24) cm, (0.19 ± 0.23) cm, (0.22 ± 0.26) cm for bladder in LT/RT, ANT/POST, and SUP/INF directions. A mean deviation of (0.26 ± 0.22) cm, (0.58 ± 0.5) cm, and (0.3 ± 0.23) cm was also observed for the bladder centroid between the CBCT and computed tomography -simulation images in three directions. Paired comparison between these two guidance shows that the variations from 3D-US are much smaller than those from CBCT in three directions, especially in ANT/POST and SUP/INF directions with significance (P = 0.000, 0.001, respectively). During treatment, and 0, 3, 6, 9, and 12 months after treatment, there was no severe urinary and rectal toxicity happened. Conclusion: A primary workflow of 3D-US and CBCT dual-guided radiotherapy has been established, which showed great therapeutic potential with mild to moderate urinary and rectal toxicity for postoperative uterine malignancy patients. But the clinical outcomes of this non-invasive technique need to be investigated further.
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Affiliation(s)
- Yang Li
- Department of Radiation Oncology, The Affiliated Cancer Hospital of Nanjing Medical University & Jiangsu Cancer Hospital & Jiangsu Institute of Cancer Research, Nanjing, China
| | - Zhen Gong
- Department of Gynecology, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
| | - Mengyu Liu
- Department of Radiation Oncology, The Affiliated Cancer Hospital of Nanjing Medical University & Jiangsu Cancer Hospital & Jiangsu Institute of Cancer Research, Nanjing, China
| | - Huixin Li
- Department of Gynecology, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
| | - Han Gao
- Department of Radiation Oncology, The Affiliated Cancer Hospital of Nanjing Medical University & Jiangsu Cancer Hospital & Jiangsu Institute of Cancer Research, Nanjing, China
| | - Chang Guo
- Department of Radiation Oncology, The Affiliated Cancer Hospital of Nanjing Medical University & Jiangsu Cancer Hospital & Jiangsu Institute of Cancer Research, Nanjing, China
| | - Le Yu
- Department of Radiation Oncology, The Affiliated Cancer Hospital of Nanjing Medical University & Jiangsu Cancer Hospital & Jiangsu Institute of Cancer Research, Nanjing, China
| | - Chenjing Zhu
- Department of Radiation Oncology, The Affiliated Cancer Hospital of Nanjing Medical University & Jiangsu Cancer Hospital & Jiangsu Institute of Cancer Research, Nanjing, China
| | - Zhihua Sun
- Department of Radiation Oncology, The Affiliated Cancer Hospital of Nanjing Medical University & Jiangsu Cancer Hospital & Jiangsu Institute of Cancer Research, Nanjing, China
| | - Li Sun
- Department of Radiation Oncology, The Affiliated Cancer Hospital of Nanjing Medical University & Jiangsu Cancer Hospital & Jiangsu Institute of Cancer Research, Nanjing, China
| | - Hanzi Xu
- Department of Radiation Oncology, The Affiliated Cancer Hospital of Nanjing Medical University & Jiangsu Cancer Hospital & Jiangsu Institute of Cancer Research, Nanjing, China
| | - Xia He
- Department of Radiation Oncology, The Affiliated Cancer Hospital of Nanjing Medical University & Jiangsu Cancer Hospital & Jiangsu Institute of Cancer Research, Nanjing, China
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Bertuccelli M, Cartei F, Falcone A, Campoccia S, Sainato A, Ducci F, Moda S, Pfanner E, Lencioni M, Brunetti I, Giulianotti PC, Mosca F, Laddaga M, Conte PF. Postoperative Adjuvant Chemoradiotherapy for Rectal Cancer: Analysis of Acute and Chronic Toxicity. TUMORI JOURNAL 2018; 83:599-603. [PMID: 9226028 DOI: 10.1177/030089169708300224] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aims and background The aim of the study was to evaluate acute and chronic toxicity of combined postoperative standard radiation therapy to the pelvis and 5-fluorouracil plus levamisole in resectable rectal cancer. Methods Between July 1990 and September 1993, 58 patients with histologically confirmed adenocarcinoma of the rectum entered the prospective study. The schedule consisted of 5-fluorouracil, 450 mg/m2 i.v. for 5 days, and from day 28 5-fluorouracil, 450 mg/m2 i.v. weekly for 24 weeks, plus levamisole given orally at the dose of 150 mg every day for 3 days every 2 weeks for 6 months; radiotherapy (180 cGy/day) 5 days a week for a total dose of 45 Gy was administered from day 28. Results After the first cycle of chemotherapy (before radiotherapy), overall toxicity was mild. During chemoradiotherapy, dose-limiting toxicity was grade 3 diarrhea and proctitis, for which the combined treatment was interrupted for more than 7 cumulative days in 28 patients. During the 24 weeks of weekly 5-fluorouracil (after radiotherapy), no severe toxicity was reported. Three-year survival and progression-free survival were 65% and 50–55%, respectively. Conclusions Although adjuvant chemoradiotherapy is usually feasible, in our study toxicity was severe in a substantial proportion of patients, probably due to the schedule applied. We are evaluating the feasibility and toxicity of a combined treatment which includes 5-fluorouracil in continuous chronomodulated infusion during radiotherapy.
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Affiliation(s)
- M Bertuccelli
- Division of Medical Oncology, St. Chiara Hospital, Pisa, Italy
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Lupattelli M, Maranzano E, Bellavita R, Tarducci R, Latini R, Castagnoli P, Bufalari A, Corgna E, Pinaglia D, Rossetti R, Ribacchi R, Latini P. Adjuvant Radiochemotherapy in High-Risk Rectal Cancer Results of a Prospective Non-Randomized Study. TUMORI JOURNAL 2018; 87:239-47. [PMID: 11693802 DOI: 10.1177/030089160108700406] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims and Background In 1990 the National Institutes of Health Consensus Conference recommended adjuvant combined therapy for patients with radically resected rectal cancer at high risk for relapse (ie, stage II-III). The purpose of our prospective non-randomized study was to verify the feasibility and effectiveness of postoperative radiochemotherapy in terms of improvement in disease-free and overall survival in this patient subgroup. Study design From January 1990 to October 1998, 191 consecutive patients with radically resected stage II-III rectal cancer were treated. A total of 159 patients with a 24-month follow-up were assessable for toxicity and survival. Anterior resection was performed in 129 (81%) and abdomino-perineal resection in 30 (19%) patients. Fifty-four (34%) stage II and 105 (66%) stage III patients entered the study. Within 45-60 days of surgery, all patients received 5-fluorouracil chemotherapy at the dose of 500 mg/m2 as an iv bolus on days 1-5, every 4 weeks, for 6 cycles. Chemotherapy cycles III and IV were administered at the same daily dose on radiotherapy days 1-3 and 29-31. Radiotherapy consisted of 45 Gy/25 fractions plus a boost dose of 5.4 Gy. Results After a median follow-up of 57 months (range, 25-123), overall recurrent disease was reported in 58 (36%) patients: local, systemic, and both local and systemic relapses in 12 (8%), 37 (23%) and 9 (6%) cases, respectively. According to local extension, recurrence rates were 15% and 48% in stage II and III, respectively. Five-year overall and disease-free survival were 71% and 66%, respectively. Overall survival was 87% in stage II and 62% in stage III patients, and disease-free survival was 84% and 56% in stage II and III disease, respectively. According to univariate and multivariate analyses, significant prognostic factors for better tumor control were: stage (II vs III, P <0.001), the number of involved nodes (≤3 vs >3, P <0.0001), and no extracapsular node invasion (P <0.0001). The recommended dose of the combined radiochemotherapy regimen was generally well tolerated. The incidence of any ≥ grade 3 acute toxicity (according to the WHO scale) was 13% diarrhea, 11% proctitis, 5% perineal dermatitis and 4% myelosuppression. Four (3%) patients had radiotherapy-related severe late toxicity which required surgery. Conclusions The study provided recurrence rates and survival similar to other adjuvant radiochemotherapy regimens published in the literature. However, in view of the low 5-year survival rate recorded in stage III patients, a different approach should be investigated.
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Affiliation(s)
- M Lupattelli
- Radiation Oncology Center, Policlinico Hospital of Perugia, Italy
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Boldrini L, Placidi E, Dinapoli N, Azario L, Cellini F, Massaccesi M, Chiesa S, Gambacorta MA, Mattiucci GC, Piccari D, Teodoli S, De Spirito M, Valentini V. Hybrid Tri-Co-60 MRI radiotherapy for locally advanced rectal cancer: An in silico evaluation. Tech Innov Patient Support Radiat Oncol 2018; 6:5-10. [PMID: 32095572 PMCID: PMC7033778 DOI: 10.1016/j.tipsro.2018.02.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Revised: 02/26/2018] [Accepted: 02/26/2018] [Indexed: 12/25/2022] Open
Abstract
Tri-Co-60 MRI radiotherapy (RT) is feasible in locally advanced rectal cancer. Larger volumes of normal tissue receive low-moderate doses in Tri-Co-60 MRI RT. Further studies on functional imaging applications and LinacMRI approach are needed. Tri-Co-60 MRI might represent a safe irradiation technique for pelvic tumors.
Introduction Aim of this paper is to investigate the plan quality of a tri-Co-60 MRI-Hybrid system for intensity-modulated radiation therapy (IMRT) in patients affected by locally advanced rectal cancer (LARC) undergoing neo-adjuvant radiotherapy. Materials and methods Ten consecutive LARC patients were selected. Tri-Co-60 step and shoot IMRT plans were generated simulating the presence of the magnetic field (Bon) or not (Boff) with the dedicated treatment planning system (TPS). The total planned dose was 45 Gy in 25 fractions to the mesorectum and the pelvic nodes (planning target volume 2, PTV2) and 55 Gy to the tumor and correspondent mesorectum (PTV1) through simultaneous integrated boost (SIB). Tri-Co-60 IMRT plans were compared with Volumetric Modulated Arc Therapy (VMAT) and IMRT plans for Linear Accelerator (Linac). Results Bon and Boff tri-Co-60 IMRT plans showed no relevant differences. Mean values of PTV1 and PTV2 receiving at least 95% of the Dp (V95%) were higher than 95% in all treatment plans. All plans met the V105% constraint for the PTV1. Mean values of V105% for the PTV2 were 14.8, 5.0, and 7.3% respectively for tri-Co-60, VMAT and IMRT. Mean Wu’s HI values were similar in all plans (7.4–7.8%). All plans met the V45Gy constraint for small bowel, but mean V45Gy value was higher with tri-Co-60. Bladder irradiation was comparable and always lower than the chosen D max 65 Gy constraint. Mean values of V5Gy and V20Gy to the body and median skin doses were higher with tri-Co-60 plans. Discussion Treatment plans with Tri-Co-60 step and shoot IMRT met the dose-volume objectives in patients with LARC. Nevertheless, a larger volume of normal tissue received low-moderate doses when compared with Linac based VMAT and IMRT.
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Affiliation(s)
- Luca Boldrini
- Polo Scienze Oncologiche ed Ematologiche, Istituto di Radiologia, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Largo Francesco Vito, 1 - 00168 Roma, Italy
| | - Elisa Placidi
- Polo Scienze delle immagini, di laboratorio e infettivologiche, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Largo Francesco Vito, 1 - 00168 Roma, Italy
| | - Nicola Dinapoli
- Polo Scienze Oncologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Largo Francesco Vito, 1 - 00168 Roma, Italy
| | - Luigi Azario
- Polo Scienze delle immagini, di laboratorio e infettivologiche, Istituto di Fisica, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Largo Francesco Vito, 1 - 00168 Roma, Italy
| | - Francesco Cellini
- Polo Scienze Oncologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Largo Francesco Vito, 1 - 00168 Roma, Italy
| | - Mariangela Massaccesi
- Polo Scienze Oncologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Largo Francesco Vito, 1 - 00168 Roma, Italy
| | - Silvia Chiesa
- Polo Scienze Oncologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Largo Francesco Vito, 1 - 00168 Roma, Italy
| | - Maria Antonietta Gambacorta
- Polo Scienze Oncologiche ed Ematologiche, Istituto di Radiologia, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Largo Francesco Vito, 1 - 00168 Roma, Italy
| | - Gian Carlo Mattiucci
- Polo Scienze Oncologiche ed Ematologiche, Istituto di Radiologia, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Largo Francesco Vito, 1 - 00168 Roma, Italy
| | - Danila Piccari
- Polo Scienze Oncologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Largo Francesco Vito, 1 - 00168 Roma, Italy
| | - Stefania Teodoli
- Polo Scienze delle immagini, di laboratorio e infettivologiche, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Largo Francesco Vito, 1 - 00168 Roma, Italy
| | - Marco De Spirito
- Polo Scienze delle immagini, di laboratorio e infettivologiche, Istituto di Fisica, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Largo Francesco Vito, 1 - 00168 Roma, Italy
| | - Vincenzo Valentini
- Polo Scienze Oncologiche ed Ematologiche, Istituto di Radiologia, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Largo Francesco Vito, 1 - 00168 Roma, Italy
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Missohou F. Use of expanders for bowel protection in pediatric pelvic tumor radiation therapy: 15 years of tolerance results. Pract Radiat Oncol 2018; 8:e224-e230. [PMID: 29452875 DOI: 10.1016/j.prro.2017.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 12/01/2017] [Accepted: 12/04/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Bowel is often the dose-limiting organ in curative pelvic irradiation because of radiation enteritis when dose exceeds 40 to 45 Gy. To limit radiation enteritis, a silicone tissue-expander prothesis (STEP) connected to a subcutaneous self-sealing valve was prospectively used in children undergoing pelvic or abdominal radiation therapy. This study reports the 15-year long-term outcomes of this prospective series. METHODS AND MATERIALS Between 1987 and 2008, 29 children from 3 Paris institutions received pelvic radiation therapy after surgical placement of a STEP in the pelvis. The median prescribed dose was 50.4 Gy (44.1-55 Gy) using 5 daily fractions of 1.8 Gy per week, except for 1 patient receiving 4 fractions of 2.5 Gy per week. The median treatment duration was 40 days (29-49 days). After 2000, computed tomography (CT) conformal 3-dimensional radiation therapy was used, and 12 patients had CT simulation. Four had CT before and after insertion of the STEP, enabling us to compare pre- and postprosthesis insertion bowel dose-volume histograms. Acute and late toxicities were captured using the Radiation Therapy Oncology Group or the National Cancer Institute Common Terminology Criteria for Adverse Events 4.0 scale. RESULTS No patient experienced significant perioperative complications. Pre- and post-STEP insertion small bowel dose-volume histograms show significant reductions in small bowel: 51%, 45%, and 64%, respectively, in V10, V15, and V40 (Vx = irradiated volume by x Gy). Twenty-five patients (86%) completed their radiation therapy with no or minimal small bowel toxicity. One patient also treated with neutrons developed delayed grade 4 toxicities. The 15-year complication-free survival for those surviving was 70.3%. CONCLUSIONS We report the long-term follow-up of STEP prosthesis insertion in children to reduce the small bowel volume in the radiation field. The acute and long-term tolerances were excellent. The STEP reduced the bowel dose over 40 Gy by 64%.
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Affiliation(s)
- Fernand Missohou
- Radiation Oncology, Institut de Cancérologie, Libreville, Gabon.
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Peca S, Sinha RS, Brown DW, Smith WL. In vivo Portal Imaging Dosimetry Identifies Delivery Errors in Rectal Cancer Radiotherapy on the Belly Board Device. Technol Cancer Res Treat 2017; 16:956-963. [PMID: 28585490 PMCID: PMC5762054 DOI: 10.1177/1533034617711519] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Purpose: We recently developed a novel, open-source in vivo dosimetry that uses the electronic portal imaging device to detect dose delivery discrepancies. We applied our method on patients with rectal cancer treated on a belly board device. Methods: In vivo dosimetry was performed on 10 patients with rectal cancer treated prone on the belly board with a 4-field box arrangement. Portal images were acquired approximately once per week from each treatment beam. Our dosimetry method used these images along with the planning CT to reconstruct patient planar dose at isocenter depth. Results: Our algorithm proved sensitive to dose discrepancies and detected discordances in 7 patients. The majority of these were due to soft tissue differences between planning and treatment, present despite matching to bony anatomy. As a result of this work, quality assurance procedures have been implemented for our immobilization devices. Conclusion: In vivo dosimetry is a powerful quality assurance tool that can detect delivery discrepancies, including changes in patient setup and position. The added information on actual dose delivery may be used to evaluate equipment and process quality and to guide for adaptive radiotherapy.
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Affiliation(s)
- Stefano Peca
- Department of Physics and Astronomy, University of Calgary, Calgary, AB, Canada.,Department of Medical Physics, Tom Baker Cancer Centre, Calgary, AB, Canada
| | | | - Derek Wilson Brown
- Department of Physics and Astronomy, University of Calgary, Calgary, AB, Canada.,Department of Radiation Medicine and Applied Sciences, Moores Cancer Center, UC San Diego, La Jolla, CA, USA
| | - Wendy Lani Smith
- Department of Physics and Astronomy, University of Calgary, Calgary, AB, Canada.,Department of Medical Physics, Tom Baker Cancer Centre, Calgary, AB, Canada.,Department of Radiation Oncology, University of Calgary, Calgary, AB, Canada
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Morris KAL, Haboubi NY. Pelvic radiation therapy: Between delight and disaster. World J Gastrointest Surg 2015; 7:279-88. [PMID: 26649150 PMCID: PMC4663381 DOI: 10.4240/wjgs.v7.i11.279] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 08/10/2015] [Accepted: 10/01/2015] [Indexed: 02/07/2023] Open
Abstract
In the last few decades radiotherapy was established as one of the best and most widely used treatment modalities for certain tumours. Unfortunately that came with a price. As more people with cancer survive longer an ever increasing number of patients are living with the complications of radiotherapy and have become, in certain cases, difficult to manage. Pelvic radiation disease (PRD) can result from ionising radiation-induced damage to surrounding non-cancerous tissues resulting in disruption of normal physiological functions and symptoms such as diarrhoea, tenesmus, incontinence and rectal bleeding. The burden of PRD-related symptoms, which impact on a patient's quality of life, has been under appreciated and sub-optimally managed. This article serves to promote awareness of PRD and the vast potential there is to improve current service provision and research activities.
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McDonald F, Waters R, Gulliford S, Hall E, James N, Huddart RA. Defining bowel dose volume constraints for bladder radiotherapy treatment planning. Clin Oncol (R Coll Radiol) 2015; 27:22-9. [PMID: 25445550 DOI: 10.1016/j.clon.2014.09.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 09/01/2014] [Accepted: 09/23/2014] [Indexed: 10/24/2022]
Abstract
AIMS Increases to radiotherapy dose are constrained by normal tissue effects. The relationship between bowel dose volume data and late bowel toxicity in patients with muscle-invasive bladder cancer treated with radical radiotherapy was assessed. MATERIALS AND METHODS The bowel was contoured retrospectively on radiotherapy plans of 47 patients recruited to the BC2001 trial (CRUK/01/004). The relationship between bowel volume at various dose levels and prospectively collected late bowel toxicity was explored. RESULTS Fifteen per cent and 6% of patients experienced grade 1 and grade 2 or more late bowel toxicity, respectively. The mean bowel volume was significantly less at doses ≥50 Gy in those treated with reduced high dose volume radiotherapy compared with standard radiotherapy. The probability of late bowel toxicity increased as bowel volume increased (P ≤ 0.05 for dose levels 30-50 Gy). No grade 2 or more late bowel toxicity was observed in patients with bowel volumes under the thresholds given in the model that predict for 25% probability of late bowel toxicity. CONCLUSIONS There is a dose volume effect for late bowel toxicity in radical bladder radiotherapy. We have modelled the probability of late bowel toxicity from absolute bowel volumes to guide clinicians in assessing radical bladder radiotherapy plans. Thresholds predicting for a 25% probability of late bowel toxicity are proposed as dose volume constraints.
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Affiliation(s)
- F McDonald
- Academic Radiotherapy Unit, Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK
| | - R Waters
- Clinical Trials and Statistics Unit, Institute of Cancer Research, London, UK
| | - S Gulliford
- Joint Department of Physics, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK
| | - E Hall
- Clinical Trials and Statistics Unit, Institute of Cancer Research, London, UK
| | - N James
- Clinical Trials Unit Gibbet Hill Campus, University of Warwick, Coventry, UK
| | - R A Huddart
- Academic Radiotherapy Unit, Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK.
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The Impact of Body Mass Index on Radiotherapy Technique in Patients With Early-Stage Endometrial Cancer. Int J Gynecol Cancer 2014; 24:1607-15. [DOI: 10.1097/igc.0000000000000298] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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Bockbrader M, Kim E. Role of intensity-modulated radiation therapy in gastrointestinal cancer. Expert Rev Anticancer Ther 2014; 9:637-47. [DOI: 10.1586/era.09.16] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Dominello MM, Nalichowski A, Paximadis P, Kaufman I, McSpadden E, Joiner M, Miller S, Konski A. Limitations of the bowel bag contouring technique in the definitive treatment of cervical cancer. Pract Radiat Oncol 2014; 4:e15-20. [DOI: 10.1016/j.prro.2013.04.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2012] [Revised: 04/10/2013] [Accepted: 04/17/2013] [Indexed: 11/27/2022]
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Consensus statement on the multidisciplinary management of patients with recurrent and primary rectal cancer beyond total mesorectal excision planes. Br J Surg 2013; 100:E1-33. [PMID: 23901427 DOI: 10.1002/bjs.9192_1] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The management of primary rectal cancer beyond total mesorectal excision planes (PRC-bTME) and recurrent rectal cancer (RRC) is challenging. There is global variation in standards and no guidelines exist. To achieve cure most patients require extended, multivisceral, exenterative surgery, beyond conventional total mesorectal excision planes. The aim of the Beyond TME Group was to achieve consensus on the definitions and principles of management, and to identify areas of research priority. METHODS Delphi methodology was used to achieve consensus. The Group consisted of invited experts from surgery, radiology, oncology and pathology. The process included two international dedicated discussion conferences, formal feedback, three rounds of editing and two rounds of anonymized web-based voting. Consensus was achieved with more than 80 per cent agreement; less than 80 per cent agreement indicated low consensus. During conferences held in September 2011 and March 2012, open discussion took place on areas in which there is a low level of consensus. RESULTS The final consensus document included 51 voted statements, making recommendations on ten key areas of PRC-bTME and RRC. Consensus agreement was achieved on the recommendations of 49 statements, with 34 achieving consensus in over 95 per cent. The lowest level of consensus obtained was 76 per cent. There was clear identification of the need for referral to a specialist multidisciplinary team for diagnosis, assessment and further management. CONCLUSION The consensus process has provided guidance for the management of patients with PRC-bTME or RRC, taking into account global variations in surgical techniques and technology. It has further identified areas of research priority.
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Sprawka A, Pietrzak L, Garmol D, Tyc-Szczepaniak D, Kepka L, Bujko K. Definitive radical external beam radiotherapy for rectal cancer: evaluation of local effectiveness and risk of late small bowel damage. Acta Oncol 2013; 52:816-23. [PMID: 22860980 DOI: 10.3109/0284186x.2012.707786] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
AIM To present a retrospective analysis of results of definitive radiotherapy for rectal cancer. MATERIAL AND METHODS Forty-one consecutive patients with rectal cancer (32% primary, 61% pelvic recurrence and 7% after R2 resection) who could not be treated with surgery underwent external beam radiotherapy. A median tumour dose of 64 Gy was given with 1.8-2.5 Gy per fraction using 2D or 3D technique. In 46% of patients, concurrent 5-Fu-based chemotherapy was given. The median follow-up was 54 months. RESULTS Clinical complete response was achieved in 39% of patients. Five-year cumulative incidence of local failure, overall survival and cancer specific survival were 76%, 26% and 30%, respectively. Of 11 patients with local control, in five cases the tumour was larger than 5 cm and in the other five the tumour was fixed. Two patients, regarded as locally controlled had non-progressive tumour without local symptoms at the last follow-up of 54 and 118 months post-radiotherapy. Late toxicity occurred in 22% of patients, all with acceptable severity. There was no bowel obstruction requiring surgery despite that in 18 patients the small bowel dose was >60 Gy to a mean volume of 51 cm(3). CONCLUSION Definitive radio(chemo)therapy provides a chance for local control even in patients with large fixed or recurrent rectal cancer.
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Affiliation(s)
- Arkadiusz Sprawka
- Department of Radiotherapy Maria Sklodowska-Curie Memorial Cancer Centre, Warsaw, Poland.
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Shadad AK, Sullivan FJ, Martin JD, Egan LJ. Gastrointestinal radiation injury: Symptoms, risk factors and mechanisms. World J Gastroenterol 2013; 19:185-98. [PMID: 23345941 PMCID: PMC3547560 DOI: 10.3748/wjg.v19.i2.185] [Citation(s) in RCA: 161] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2011] [Revised: 03/31/2012] [Accepted: 12/15/2012] [Indexed: 02/06/2023] Open
Abstract
Ionising radiation therapy is a common treatment modality for different types of cancer and its use is expected to increase with advances in screening and early detection of cancer. Radiation injury to the gastrointestinal tract is important factor working against better utility of this important therapeutic modality. Cancer survivors can suffer a wide variety of acute and chronic symptoms following radiotherapy, which significantly reduces their quality of life as well as adding an extra burden to the cost of health care. The accurate diagnosis and treatment of intestinal radiation injury often represents a clinical challenge to practicing physicians in both gastroenterology and oncology. Despite the growing recognition of the problem and some advances in understanding the cellular and molecular mechanisms of radiation injury, relatively little is known about the pathophysiology of gastrointestinal radiation injury or any possible susceptibility factors that could aggravate its severity. The aims of this review are to examine the various clinical manifestations of post-radiation gastrointestinal symptoms, to discuss possible patient and treatment factors implicated in normal gastrointestinal tissue radiosensitivity and to outline different mechanisms of intestinal tissue injury.
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Yavas G, Yavas C, Acar H, Buyukyoruk A, Cobanoglu G, Kerimoglu OS, Yavas O, Celik C. Dosimetric comparison of 3-dimensional conformal and field-in-field radiotherapy techniques for the adjuvant treatment of early stage endometrial cancer. Phys Med 2012; 29:577-82. [PMID: 23219336 DOI: 10.1016/j.ejmp.2012.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Revised: 10/30/2012] [Accepted: 11/12/2012] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The purpose of this study is to compare field-in-field radiotherapy (FIF) with conformal radiotherapy (CRT) in terms of dosimetric benefits for early stage endometrial cancer patients. MATERIALS AND METHODS Ten consecutive early stage endometrial cancer patients who underwent adjuvant external beam radiotherapy were included in the study. For each patient, two different treatment plans were created. FIF and CRT plans were compared for doses in the planning target volume (PTV), the organ at risk (OAR) volumes including rectum, bladder, bowel, bilateral femurs and bone marrow, the dose homogeneity index, and the monitor unit counts required for the treatment. RESULTS The FIF technique significantly reduced the maximum dose of the PTV, rectum, bladder, bowel, left femur, right femur and bone marrow (p values were: <0.001, 0.031, 0.003, <0.001, 0.001, 0.001 and <0.001 respectively). When the OAR volumes irradiated with >30 and >45 Gy were compared, the results were in favor of the FIF technique. The volumes of rectum, bladder, bowel, left femur, right femur and bone marrow receiving more than the prescription dose of 45 Gy were significantly reduced with FIF technique (p values were 0.016, 0.039, 0.01, 0.04, 0.037 and 0.01 respectively). The dose homogeneity index (DHI) was significantly improved with FIF technique (p < 0.001). CONCLUSIONS FIF allowed more homogeneous dose distribution in the PTV and reduced the doses received by OAR. Considering the lower maximum doses in the OAR and PTV, FIF technique seems to be more advantageous than CRT during adjuvant radiotherapy for early stage endometrial cancer patients.
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Affiliation(s)
- Guler Yavas
- Selcuk University, Faculty of Medicine, Department of Radiation Oncology, 42075 Konya, Turkey.
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Samuelian JM, Callister MD, Ashman JB, Young-Fadok TM, Borad MJ, Gunderson LL. Reduced Acute Bowel Toxicity in Patients Treated With Intensity-Modulated Radiotherapy for Rectal Cancer. Int J Radiat Oncol Biol Phys 2012; 82:1981-7. [DOI: 10.1016/j.ijrobp.2011.01.051] [Citation(s) in RCA: 135] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2010] [Revised: 01/12/2011] [Accepted: 01/26/2011] [Indexed: 12/12/2022]
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Wiesendanger-Wittmer EM, Sijtsema NM, Muijs CT, Beukema JC. Systematic review of the role of a belly board device in radiotherapy delivery in patients with pelvic malignancies. Radiother Oncol 2012; 102:325-34. [PMID: 22364650 DOI: 10.1016/j.radonc.2012.02.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2011] [Revised: 02/01/2012] [Accepted: 02/07/2012] [Indexed: 11/19/2022]
Abstract
PURPOSE This review analyses the literature concerning the influence of the patient position (supine, prone and prone on a belly board device (BB) on the irradiated small-bowel-volume (SB-V)) and the resulting morbidity of radiation therapy (RT) in pelvic malignancies. METHODS A literature search was performed in MEDLINE, web of science and Scopus. RESULTS Forty-six full papers were found, of which 33 met the eligibility criteria. Fifteen articles focussed on the irradiated SB-V using dose volume histograms (DVHs). Twenty-seven articles studied the patient setup in different patient positions. This review showed that a prone treatment position can result in a lower irradiated SB-V as compared to a supine position, but a more significant reduction of the SB-V can be reached by the additional use of a BB in prone position, for both 3D-CRT and IMRT treatment plans. This reduction of the irradiated SB-V might result in a reduced GI-morbidity. The patient position did not influence the required PTV margins for prostate and rectum. CONCLUSIONS The irradiated SB-V can be maximally reduced by the use of a prone treatment position combined with a BB for both 3D-CRT and IMRT, which might individually result in a reduction of GI-morbidity.
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Andreyev HJN, Wotherspoon A, Denham JW, Hauer-Jensen M. "Pelvic radiation disease": new understanding and new solutions for a new disease in the era of cancer survivorship. Scand J Gastroenterol 2011; 46:389-97. [PMID: 21189094 DOI: 10.3109/00365521.2010.545832] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Cancer therapies increasingly achieve cure, but result in chronic moderate or severe gastrointestinal side effects in millions of patients worldwide. Paradoxically, modern therapies threaten to increase the burden of chronic gastrointestinal toxicity, not reduce it. AIM To define pelvic radiation disease. METHODS A reinterpretation of published data. RESULTS The lack of interest in patients with pelvic radiation disease is startling. Symptoms after radiotherapy are only a manifestation of new onset gastrointestinal physiological deficits induced by the radiotherapy. With proper diagnosis and treatment of these deficit(s), the symptoms are curable. Science suggests that much radiotherapy-induced gastrointestinal morbidity is preventable. Once the true nature of radiation injury is understood, straightforward solutions emerge and inaccurate dogmas can be discarded. Imprecise language is a fundamental barrier to progress in complex disorders. CONCLUSIONS Radiation-induced gastrointestinal toxicity is bedeviled by inappropriate terminology, causing confusion, and myth which legitimizes inappropriate clinical behavior. We must address honestly the uncomfortable reality that doctors, sometimes do harm. Not to do so in an era where survivorship is a reality, will deny millions often with severe symptoms from "pelvic radiation disease", the care which will help them.
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One Size Does Not Fit All: Planning Volumes for Radiotherapy in Rectal Cancer—Should We Tailor Radiotherapy Fields to Stage and Risk? CURRENT COLORECTAL CANCER REPORTS 2011. [DOI: 10.1007/s11888-010-0075-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Corner C, Khimji F, Tsang Y, Harrison M, Glynne-Jones R, Hughes R. Comparison of conventional and three-dimensional conformal CT planning techniques for preoperative chemoradiotherapy for locally advanced rectal cancer. Br J Radiol 2011; 84:173-8. [PMID: 21257837 DOI: 10.1259/bjr/33089685] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES We assessed the impact of three-dimensional (3D) conformal planning vs conventional planning of preoperative chemoradiotherapy (CRT) for locally advanced rectal cancer (LARC) on small bowel and bladder sparing and in optimising coverage of tumour target volume. METHODS Conformal and conventional plans were created for 50 consecutive patients. The conformal plan delineated a gross tumour volume (GTV), a clinical target volume (CTV) 1 to cover potential subclinical disease spread, a CTV2 to outline the mesorectum and lymph node areas at risk, and a planning target volume (PTV) to cover set-up error and organ movement. The conventional plan was created using digitally reconstructed radiographs (DRRs). Patients were treated with a dose of 45 Gy in 25 fractions with concurrent chemotherapy over 5 weeks. Dose-volume histograms (DVHs) were created and compared for GTV, PTV, small bowel and bladder. The GTV was covered by the conventional plan in all patients. RESULTS Significant differences were shown for median PTV coverage with conformal planning compared with conventional planning: 99.2% vs 94.2% (range 95.9-100% vs 75.5-100%); p<0.05. The median volume of irradiated small bowel was significantly lower for CT plans at all DVH levels. Median bladder doses did not differ significantly. CONCLUSION 3D conformal CT planning is superior to conventional planning in terms of coverage of the tumour volume. It significantly reduces the volume of small bowel irradiated with no decrease in the rate of R0 resection compared with published data, and at the present time should be considered as the standard of care for rectal cancer planning.
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Affiliation(s)
- C Corner
- Mount Vernon Cancer Centre, Northwood, Middlesex, UK.
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Abstract
SBO is a common disease with multiple causes. The most significant advances over the past several years have involved, first, decision-making techniques to promptly and accurately identify patients who will require exploration, and, second, the increasing use of laparoscopic techniques. "Complete" bowel obstruction is becoming an outdated term, as treatment algorithms use predictive models and oral contrast challenges to select patients for operation without recourse to the notion of "complete obstruction." Laparoscopic techniques are gaining acceptance as a primary modality in the treatment of SBO. Appropriate patient selection is necessary for success, but successful laparoscopic SBO management can reduce postoperative pain, minimize hospital stay, and may lead to fewer adhesions, possibly preventing further adhesive SBO. Strangulation obstruction is the major cause of morbidity and mortality in SBO. Although unrecognized strangulation obstructions remain, their incidence is decreasing with the new protocols in development. Future efforts should focus on incorporating predictive models into management with the goal of eliminating unrecognized strangulation obstructions. Further refinement of the predictive models incorporating outcomes of oral contrast challenges and molecular biomarker data may allow surgeons to reach this goal. In addition, the benefit of the elimination of interpractitioner variability conferred by standardized protocols will in itself improve patient outcomes.
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Abstract
Pre-operative radiotherapy may induce radiation colitis and tumour regression. Histological evaluation of radiation colitis needs to be reproducible to assess disease progression. The severity of radiation colitis can be assessed and graded according to its histological features. Increased severity of disease appears to be associated with a higher degree of cellular atypia and a lesser eosinophilic infiltrate. The severity of histological changes does not appear to be associated with post-operative complications. Tumour regression is an interesting phenomenon, the histological grading of which is of prognostic importance. Patients treated with long course radiotherapoy appear to have more incidences of postoperative complications. However, these are though to be related to the degree of tumour regression rather than to the type of radiotherapy.
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Kavanagh BD, Pan CC, Dawson LA, Das SK, Li XA, Ten Haken RK, Miften M. Radiation dose-volume effects in the stomach and small bowel. Int J Radiat Oncol Biol Phys 2010; 76:S101-7. [PMID: 20171503 DOI: 10.1016/j.ijrobp.2009.05.071] [Citation(s) in RCA: 362] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2008] [Revised: 05/06/2009] [Accepted: 05/06/2009] [Indexed: 01/12/2023]
Abstract
Published data suggest that the risk of moderately severe (>or=Grade 3) radiation-induced acute small-bowel toxicity can be predicted with a threshold model whereby for a given dose level, D, if the volume receiving that dose or greater (VD) exceeds a threshold quantity, the risk of toxicity escalates. Estimates of VD depend on the means of structure segmenting (e.g., V15 = 120 cc if individual bowel loops are outlined or V45 = 195 cc if entire peritoneal potential space of bowel is outlined). A similar predictive model of acute toxicity is not available for stomach. Late small-bowel/stomach toxicity is likely related to maximum dose and/or volume threshold parameters qualitatively similar to those related to acute toxicity risk. Concurrent chemotherapy has been associated with a higher risk of acute toxicity, and a history of abdominal surgery has been associated with a higher risk of late toxicity.
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Affiliation(s)
- Brian D Kavanagh
- Department of Radiation Oncology, University of Colorado-Denver School of Medicine, Aurora, CO 80045, USA.
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Theis V, Sripadam R, Ramani V, Lal S. Chronic Radiation Enteritis. Clin Oncol (R Coll Radiol) 2010; 22:70-83. [DOI: 10.1016/j.clon.2009.10.003] [Citation(s) in RCA: 131] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2009] [Revised: 09/01/2009] [Accepted: 09/22/2009] [Indexed: 02/07/2023]
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Rápolti E, Szigeti A, Farkas R, Bellyei S, Boronkai A, Papp A, Gömöri E, Horváth OP, Mangel L. [Neoadjuvant radiochemotherapy in the treatment of locally advanced rectal tumors]. Magy Onkol 2010; 53:345-9. [PMID: 20071306 DOI: 10.1556/monkol.53.2009.4.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
We investigated the response rate and side effects of simultaneous, neoadjuvant radiochemotherapy (RCT) in locally advanced rectal cancer. Between 2005 and 2007, we treated 112 patients in stage II-III rectal carcinoma at the Institute of Oncotherapy, University of Pécs. For staging abdomino-pelvic CT (112) and transrectal US (49) or pelvic MR (10), or PET-CT (1) was performed. Radiation therapy was delivered with 3D CRT-based technique using belly-board with 18 MV photon energy, while patients in prone position. A total dose of 45 Gy (single dose 1.8 Gy) was delivered to the tumor and the pelvic lymph nodes. 5-FU and Ca-folinate was administered concomitantly in the 1st and 5th week of radiotherapy. Four weeks after delivering neoadjuvant RCT the patients' control CT was evaluated according to RECIST criteria. RCT was followed by surgery in 6-9 weeks. We graded the histology using the Mandard regression score system. Side effects were registered using CTCAE v 3.0. Grade 1, 2 or 3 acute gastrointestinal toxicity occurred in 12%, grade 3 hematological toxicity in 9.5% of the patients. The response rate determined by using control CT was 64.85%. According to the Mandard regression score, TRG1 occurred in 15%, TRG2 in 30.4%, TRG3 in 28%, TRG4 in 24% and TRG5 in 2.6% of the cases. Radical surgery was performed in 89 cases, 72 with R0 resection. By assessing the histological samples we found downstaging in 46% of the T and 34.5% of the N stage. We have no information on increased postoperative complications. We followed 86 patients after neoadjuvant therapy. Until March 2009 there was no progression in 48 of our patients. In 13 cases local relapse occurred, and in 25 cases the disease progressed because of distant metastasis, although local control was maintained. 10 patients had local relapse and distant metastases. 17 patients passed away. As a conclusion, neoadjuvant RCT of Stage II-III patients is an effective and well tolerated treatment, allowing for high R0 resection rate and bearing no higher risk for postoperative morbidity.
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Affiliation(s)
- Edit Rápolti
- Pécsi Tudományegyetem Onkoterápiás Intézet 7623 Pécs Ifjúság út 13
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Hoffe SE, Shridhar R, Biagioli MC. Radiation Therapy for Rectal Cancer: Current Status and Future Directions. Cancer Control 2010; 17:25-34. [DOI: 10.1177/107327481001700104] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Sarah E. Hoffe
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Ravi Shridhar
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Matthew C. Biagioli
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
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Di Fiore F, Van Cutsem E. Acute and long-term gastrointestinal consequences of chemotherapy. Best Pract Res Clin Gastroenterol 2009; 23:113-24. [PMID: 19258191 DOI: 10.1016/j.bpg.2008.11.016] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
There are many anti-neoplastic agents in cancer treatment. Combination regimens are often the main standard treatment, particularly for gastrointestinal malignancies. The introduction of new regimens that combine fluoropyrimidines with irinotecan or oxaliplatin and recently also with antibodies against the Epidermal Growth Factor Receptor (EGFR) (cetuximab and panitumumab) and against the Vascular Endothelial Growth Factor (VEGF) (bevacizumab) pathways, has dramatically improved the progression free survival and survival of patients with metastatic colorectal cancer. This rapid extension of available anti-neoplastic drugs has, however, also highlighted the urgent need for clinicians to better understand and identify the spectrum of acute and late toxicities of these drugs. Acute and long-term adverse effects are inherent to non-surgical cancer treatment using chemotherapy and/or radiation therapy, which can profoundly affect the gastrointestinal tract leading to a wide spectrum of acute and late toxicities. An improved knowledge of the aetiology, incidence, supportive measures and of the prevention of these toxicities is warranted to improve patient care. We herein review and discuss the main acute and late gastrointestinal toxicities of chemotherapy and/or radiotherapy for patients with gastrointestinal malignancies.
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Affiliation(s)
- Frédéric Di Fiore
- Digestive Oncology Unit, University Hospital Gasthuisberg, Herestraat 49, 3000 Leuven, Belgium
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28
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Radiation damage to the gastrointestinal tract: mechanisms, diagnosis, and management. Curr Opin Support Palliat Care 2008; 1:23-9. [PMID: 18660720 DOI: 10.1097/spc.0b013e3281108014] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
PURPOSE OF REVIEW To summarize current knowledge about gastrointestinal radiation toxicity, with emphasis on mechanisms and clinical diagnosis and management. RECENT FINDINGS While there has been only modest change in cancer incidence and cancer mortality rates during the past 30 years, the number of cancer survivors has more than doubled. Moreover, the recognition of uncomplicated cancer cure as the ultimate goal in oncology has intensified efforts to prevent, diagnose, and manage side effects of radiation therapy. These efforts have been facilitated by recent insight into the underlying pathophysiology. SUMMARY The risk of injury to the intestine is dose limiting during abdominal and pelvic radiation therapy. Delayed bowel toxicity is difficult to manage and adversely impacts the quality of life of cancer survivors. More than 200,000 patients per year receive abdominal or pelvic radiation therapy, and the estimated number of cancer survivors with postradiation intestinal dysfunction is 1.5-2 million. Worthwhile progress towards reducing toxicity of radiation therapy has been made by dose-sculpting treatment techniques. Approaches derived from an improved understanding of the pathophysiology of bowel injury, however, will result in further advances. This article discusses the mechanisms of radiation-induced bowel toxicity and reviews current principles in diagnosis and management.
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Birgisson H, Påhlman L, Gunnarsson U, Glimelius B. Late adverse effects of radiation therapy for rectal cancer - a systematic overview. Acta Oncol 2008; 46:504-16. [PMID: 17497318 DOI: 10.1080/02841860701348670] [Citation(s) in RCA: 163] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE The use of radiation therapy (RT) together with improvement in the surgical treatment of rectal cancer improves survival and reduces the risk for local recurrences. Despite these benefits, the adverse effects of radiation therapy limit its use. The aim of this review was to present a comprehensive overview of published studies on late adverse effects related to the RT for rectal cancer. METHODS Meta-analyses, reviews, randomised clinical trials, cohort studies and case-control studies on late adverse effects, due to pre- or postoperative radiation therapy and chemo-radiotherapy for rectal cancer, were systematically searched. Most information was obtained from the randomised trials, especially those comparing preoperative short-course 5 x 5 Gy radiation therapy with surgery alone. RESULTS The late adverse effects due to RT were bowel obstructions; bowel dysfunction presented as faecal incontinence to gas, loose or solid stools, evacuation problems or urgency; and sexual dysfunction. However, fewer late adverse effects were reported in recent studies, which generally used smaller irradiated volumes and better irradiation techniques; although, one study revealed an increased risk for secondary cancers in irradiated patients. CONCLUSIONS These results stress the importance of careful patient selection for RT for rectal cancer. Improvements in the radiation technique should further be developed and the long-term follow-up of the randomised trials is the most important source of information on late adverse effects and should therefore be continued.
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Affiliation(s)
- Helgi Birgisson
- Department of Surgery, University Hospital, University of Uppsala, Uppsala, Sweden.
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30
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Birgisson H, Påhlman L, Gunnarsson U, Glimelius B. Late gastrointestinal disorders after rectal cancer surgery with and without preoperative radiation therapy. Br J Surg 2008; 95:206-13. [PMID: 17849380 DOI: 10.1002/bjs.5918] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The aim of the study was to analyse late gastrointestinal disorders necessitating hospital admission following rectal cancer surgery and to determine their relationship to preoperative radiation therapy. METHODS Curatively treated patients participating in the Swedish Rectal Cancer Trial during 1987-1990, randomized to preoperative irradiation (454 patients) or surgery alone (454), were matched against the Swedish Hospital Discharge Registry. Hospital records for patients admitted with gastrointestinal diagnoses were reviewed. RESULTS Irradiated patients had an increased relative risk (RR) of late small bowel obstruction (RR 2.49 (95 per cent confidence interval (c.i.) 1.48 to 4.19)) and abdominal pain (RR 2.09 (95 per cent c.i. 1.03 to 4.24)) compared with patients treated by surgery alone. The risk of late small bowel obstruction requiring surgery was greatly increased (RR 7.42 (95 per cent c.i. 2.23 to 24.66)). Irradiated patients with postoperative anastomotic leakage were at increased risk for late small bowel obstruction (RR 2.99 (95 per cent c.i. 1.07 to 8.31)). The risk of small bowel obstruction was also related to the radiation technique and energy used. CONCLUSION Small bowel obstruction is more common in patients with rectal cancer treated with preoperative radiation therapy.
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Affiliation(s)
- H Birgisson
- Department of Surgery, Radiology and Clinical Immunology, University Hospital, University of Uppsala, Uppsala, Sweden.
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Abstract
The chance of lymph node involvement in T(3) and T(4) rectal cancers is 20% to 60%, a risk sufficiently high that most clinicians favor mesorectal excision rather than less aggressive approaches. Patients who have a complete clinical response of the primary lesions to neoadjuvant therapy may represent a special case. Total mesorectal excision can be accomplished without sacrifice of the anal sphincters, and continence can be preserved. Evolving understanding of patterns of tumor spread and mechanisms of anal continence have resulted in increased use of continence-preserving procedures. Removal of the anal sphincters seems to be advantageous only if the sphincters are directly involved. A few small series suggest that a segmental sphincter resection could result in good local control and continence preservation, even if the sphincters are involved. Areas of controversy currently include the role of neoadjuvant therapy for high rectal lesions, the role of lateral lymph node dissection, and methods of improving anal continence after rectal resection.
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Affiliation(s)
- Robert W Beart
- Department of Colorectal Surgery, University of Southern California, Keck School of Medicine, Los Angeles, CA 90033, USA.
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Andreyev HJN. Gastrointestinal problems after pelvic radiotherapy: the past, the present and the future. Clin Oncol (R Coll Radiol) 2007; 19:790-9. [PMID: 17904338 DOI: 10.1016/j.clon.2007.08.011] [Citation(s) in RCA: 149] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2007] [Accepted: 08/19/2007] [Indexed: 12/23/2022]
Abstract
Up to 300,000 patients per year undergo pelvic radiotherapy worldwide. Nine out of 10 will develop a permanent change in their bowel habit as a result. Five out of 10 of all patients will say that this change in their bowel habit affects quality of life and two to three out of 10 will say that this effect on quality of life is moderate or severe. Between one in 10 and one in 20 patients will develop very serious complications within the first 10 years after treatment. This number will increase to two out of 10 by 20 years from the end of treatment. Although research carried out into the basic molecular, cytokine and physiological changes underlying radiation-induced bowel symptoms and the optimal treatment that should be provided to symptomatic patients is scant, it does seem probable that a significant proportion of these patients can be cured or improved by specialist gastroenterological intervention. However, most patients never get referred to a specialist gastroenterologist and research into late radiation bowel damage has not been considered a priority. With the advent of more effective cancer therapies leading to greater numbers of affected long-term survivors, much more emphasis is urgently required to provide better information to patients at the start and after treatment, developing techniques that might reduce the frequency of significant bowel toxicity and researching better ways of measuring and treating late-onset side-effects.
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Affiliation(s)
- H J N Andreyev
- Department of Medicine, Royal Marsden Hospital, Fulham Road, London, UK.
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Iraha S, Ogawa K, Moromizato H, Shiraishi M, Nagai Y, Samura H, Toita T, Kakinohana Y, Adachi G, Tamaki W, Hirakawa M, Kamiyama K, Inamine M, Nishimaki T, Aoki Y, Murayama S. Radiation Enterocolitis Requiring Surgery in Patients With Gynecological Malignancies. Int J Radiat Oncol Biol Phys 2007; 68:1088-93. [PMID: 17449197 DOI: 10.1016/j.ijrobp.2007.01.040] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2006] [Revised: 01/18/2007] [Accepted: 01/22/2007] [Indexed: 11/19/2022]
Abstract
PURPOSE To identify the characteristics, risk factors, and clinical outcomes of radiation enterocolitis requiring surgery in patients with gynecologic malignancies. METHODS AND MATERIALS The records of 1,349 patients treated with pelvic radiotherapy were retrospectively reviewed. The majority of the patients (88%) were treated with 50 Gy or 50.4 Gy pelvic irradiation in conventional fractionations with anteroposterior fields. RESULTS Forty-eight patients (3.6%) developed radiation enterocolitis requiring surgery. Terminal ileum was the most frequent site (50%) and most of the lesions had stenosis or perforation. On univariate analysis, previous abdominopelvic surgery, diabetes mellitus (DM), smoking and primary site had an impact on the complications, and on multivariate analysis, abdominopelvic surgery, DM, and smoking were independent predictors of the complications requiring surgery. After the surgical intervention, the frequency of Grade 2 or more bleeding was significantly lower in patients treated with intestinal resection in addition to decompression than those treated with intestinal decompression alone. CONCLUSIONS Severe radiation enterocolitis requiring surgery usually occurred at the terminal ileum and was strongly correlated with previous abdominopelvic surgery, DM, and smoking. Concerning the management, liberal resection of the affected bowel appears to be the preferable therapy.
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Affiliation(s)
- Shiro Iraha
- Department of Radiology, University of the Ryukyus, 207 Uehara, Nishihara-cho, Okinawa 903-0215, Japan
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Lee SH, Kim TH, Kim DY, Cho KH, Kim JY, Park SY, Kim DH, Lim SB, Choi HS, Chang HJ. The Effect of Belly Board Location in Rectal Cancer Patients Treated with Preoperative Radiotherapy. Clin Oncol (R Coll Radiol) 2006; 18:441-6. [PMID: 16909966 DOI: 10.1016/j.clon.2006.05.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
AIMS To evaluate the effect of the belly board aperture location on the irradiated small bowel volume in rectal cancer patients treated with preoperative pelvic radiotherapy. MATERIALS AND METHODS Twenty patients with rectal cancer scheduled to receive preoperative pelvic radiotherapy were evaluated prospectively. Each patient underwent computed tomography with the belly board aperture lower border at three different locations relative to patient anatomy: the lumbosacral junction (location I), the lower end of the sacroiliac joint (location II) and the upper end of the symphysis pubis (location III). The irradiated small bowel volume was calculated for doses between 10 and 100% of the prescribed dose at 10% intervals. For each 10% dose increment, the effect of the belly board aperture at the three different locations on the irradiated small bowel volume was analysed using Wilcoxon signed rank and Wilcoxon rank sum tests. RESULTS At 10-20% dose levels, the irradiated small bowel volume increased in the order of locations I, II and III, and the differences between each location were significant. At > or = 30% dose levels, the irradiated small bowel volume increased in the order of locations III, II and I, and the differences between locations I and II were significant, but the differences between locations II and III were not significant. CONCLUSION The belly board aperture location can influence the irradiated small bowel volume differently at each dose level. When considering the use of a belly board in routine clinical practice, we recommend that the clinician take into account the patterns of irradiated small bowel volume according to belly board aperture location.
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Affiliation(s)
- Seok Ho Lee
- Research Institute and Hospital, National Cancer Centre, Goyang, Republic of Korea
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35
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Tho LM, Glegg M, Paterson J, Yap C, MacLeod A, McCabe M, McDonald AC. Acute small bowel toxicity and preoperative chemoradiotherapy for rectal cancer: investigating dose-volume relationships and role for inverse planning. Int J Radiat Oncol Biol Phys 2006; 66:505-13. [PMID: 16879928 DOI: 10.1016/j.ijrobp.2006.05.005] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2006] [Revised: 05/05/2006] [Accepted: 05/06/2006] [Indexed: 02/07/2023]
Abstract
PURPOSE The relationship between volume of irradiated small bowel (VSB) and acute toxicity in rectal cancer radiotherapy is poorly quantified, particularly in patients receiving concurrent preoperative chemoradiotherapy. Using treatment planning data, we studied a series of such patients. METHODS AND MATERIALS Details of 41 patients with locally advanced rectal cancer were reviewed. All received 45 Gy in 25 fractions over 5 weeks, 3-4 fields three-dimensional conformal radiotherapy with daily 5-fluorouracil and folinic acid during Weeks 1 and 5. Toxicity was assessed prospectively in a weekly clinic. Using computed tomography planning software, the VSB was determined at 5 Gy dose intervals (V5, V10, etc.). Eight patients with maximal VSB had dosimetry and radiobiological modeling outcomes compared between inverse and conformal three-dimensional planning. RESULTS VSB correlated strongly with diarrheal severity at every dose level (p<0.03), with strongest correlation at lowest doses. Median VSB differed significantly between patients experiencing Grade 0-1 and Grade 2-4 diarrhea (p<or=0.05). No correlation was found with anorexia, nausea, vomiting, abdominal cramps, age, body mass index, sex, tumor position, or number of fields. Analysis of 8 patients showed that inverse planning reduced median dose to small bowel by 5.1 Gy (p=0.008) and calculated late normal tissue complication probability (NTCP) by 67% (p=0.016). We constructed a model using mathematical analysis to predict for acute diarrhea occurring at V5 and V15. CONCLUSIONS A strong dose-volume relationship exists between VSB and acute diarrhea at all dose levels during preoperative chemoradiotherapy. Our constructed model may be useful in predicting toxicity, and this has been derived without the confounding influence of surgical excision on bowel function. Inverse planning can reduce calculated dose to small bowel and late NTCP, and its clinical role warrants further investigation.
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Affiliation(s)
- Lye Mun Tho
- Colorectal Cancer Team, Beatson Oncology Centre, Western Infirmary, University of Glasgow, United Kingdom.
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Guerrero Urbano MT, Henrys AJ, Adams EJ, Norman AR, Bedford JL, Harrington KJ, Nutting CM, Dearnaley DP, Tait DM. Intensity-modulated radiotherapy in patients with locally advanced rectal cancer reduces volume of bowel treated to high dose levels. Int J Radiat Oncol Biol Phys 2006; 65:907-16. [PMID: 16751073 DOI: 10.1016/j.ijrobp.2005.12.056] [Citation(s) in RCA: 145] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2005] [Revised: 12/06/2005] [Accepted: 12/06/2005] [Indexed: 11/19/2022]
Abstract
PURPOSE To investigate the potential for intensity-modulated radiotherapy (IMRT) to spare the bowel in rectal tumors. METHODS AND MATERIALS The targets (pelvic nodal and rectal volumes), bowel, and bladder were outlined in 5 patients. All had conventional, three-dimensional conformal RT and forward-planned multisegment three-field IMRT plans compared with inverse-planned simultaneous integrated boost nine-field equally spaced IMRT plans. Equally spaced seven-field and five-field and five-field, customized, segmented IMRT plans were also evaluated. RESULTS Ninety-five percent of the prescribed dose covered at least 95% of both planning target volumes using all but the conventional plan (mean primary and pelvic planning target volume receiving 95% of the prescribed dose was 32.8 +/- 13.7 Gy and 23.7 +/- 4.87 Gy, respectively), reflecting a significant lack of coverage. The three-field forward planned IMRT plans reduced the volume of bowel irradiated to 45 Gy and 50 Gy by 26% +/- 16% and 42% +/- 27% compared with three-dimensional conformal RT. Additional reductions to 69 +/- 51 cm(3) to 45 Gy and 20 +/- 21 cm(3) to 50 Gy were obtained with the nine-field equally spaced IMRT plans-64% +/- 11% and 64% +/- 20% reductions compared with three-dimensional conformal RT. Reducing the number of beams and customizing the angles for the five-field equally spaced IMRT plan did not significantly reduce bowel sparing. CONCLUSION The bowel volume irradiated to 45 Gy and 50 Gy was significantly reduced with IMRT, which could potentially lead to less bowel toxicity. Reducing the number of beams did not reduce bowel sparing and the five-field customized segmented IMRT plan is a reasonable technique to be tested in clinical trials.
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Guckenberger M, Flentje M. Late small bowel toxicity after adjuvant treatment for rectal cancer. Int J Colorectal Dis 2006; 21:209-20. [PMID: 16052309 DOI: 10.1007/s00384-005-0765-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/17/2005] [Indexed: 02/04/2023]
Abstract
BACKGROUND For locally advanced rectal cancer surgery as sole treatment results in poor local control and survival. After adjuvant radiotherapy for locally advanced rectal cancer, small bowel toxicity has been the most frequent and serious side effect. The gain in survival and local control was accompanied by severe late chronic toxicity reducing the benefit of adjuvant treatment. REVIEW Clinical factors, pathology and treatment of late small bowel toxicity after adjuvant radiotherapy for locally advanced rectal cancer will be discussed. This review will focus on different surgical and radiotherapeutic means reducing the risk of late small bowel damage.
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Affiliation(s)
- Matthias Guckenberger
- Department of Radiation Oncology, Klinik und Poliklinik für Strahlentherapie der Universität Würzburg, Josef-Schneider-Strasse 11, 97080 Würzburg, Germany.
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Schmidt CE, Bestmann B, Küchler T, Longo WE, Rohde V, Kremer B. Gender differences in quality of life of patients with rectal cancer. A five-year prospective study. World J Surg 2006; 29:1630-41. [PMID: 16311851 DOI: 10.1007/s00268-005-0067-0] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
To determine how quality of life changes over time and to assess gender-related differences in quality of life of rectal cancer patients we conducted a 5-year study. Little is known about how quality of life (QoL) changes over time in patients after surgery for rectal cancer, and whether gender of the patients is associated with a different perception of QoL. The aim of this study was to assess prospectively, changes in quality of life after surgery for rectal cancer, with a focus on gender related differences. Over a 5-year period, the EORTC-QLQ-C-30 and a tumor-specific module were prospectively administered to patients before surgery, at discharge, 3, 6, 12, and 24 months postoperatively. Comparisons were made between female and male patients. A total of 519 patients participated in the study, 264 men and 255 women. The two groups were comparable in terms of surgical procedures, adjuvant treatment, tumor stage, and histology. Most QoL scores dropped significantly below baseline in the early postoperative period. From the third month onward, global health, emotional and physical functioning, improved. Female gender was associated with significantly worse global health and physical functioning and with higher scores on treatment strain and fatigue. Men reported difficulties with sexual enjoyment; furthermore, over time, sexual problems created high levels of strain in men, worse than baseline levels in the early postoperative period. These problems tended to continue over the course of time. The findings in this study confirm that QoL changes after surgery and differs between men and women. Women appear to be affected by impaired physical functioning and global health. Female gender is associated with significantly higher fatigue levels and increased strain values after surgery. Through impaired sexual enjoyment, men are put more under strain than woman.
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Affiliation(s)
- Christian E Schmidt
- Department of General and Thoracic Surgery, University Clinic of Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 7, Kiel, 24105, Germany.
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Birgisson H, Påhlman L, Gunnarsson U, Glimelius B. Adverse effects of preoperative radiation therapy for rectal cancer: long-term follow-up of the Swedish Rectal Cancer Trial. J Clin Oncol 2006; 23:8697-705. [PMID: 16314629 DOI: 10.1200/jco.2005.02.9017] [Citation(s) in RCA: 255] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
PURPOSE To analyze the occurrence of subacute and late adverse effects in patients treated with preoperative irradiation for rectal cancer. PATIENTS AND METHODS The study population included 1,147 patients randomly assigned to preoperative radiation therapy or surgery alone in the Swedish Rectal Cancer Trial conducted 1987 through 1990. Patient data were matched against the Swedish Hospital Discharge Register to identify patients admitted to hospital after the primary treatment of the rectal cancer. Patients with known residual disease were excluded, and patients with a recurrence were censored 3 months before the date of recurrence. Relative risks (RR) with 95% CIs were calculated. RESULTS Irradiated patients were at increased risk of admissions during the first 6 months from the primary treatment (RR = 1.64; 95% CI, 1.21 to 2.22); these were mainly for gastrointestinal diagnoses. Overall, the two groups showed no difference in the risk of admissions more than 6 months from the primary treatment (RR = 0.95; 95% CI, 0.80 to 1.12). Regarding specific diagnoses, however, RRs were increased for admissions later than 6 months from the primary treatment in irradiated patients for unspecified infections, bowel obstruction, abdominal pain, and nausea. CONCLUSION Gastrointestinal disorders, resulting in hospital admissions, seem to be the most common adverse effect of short-course preoperative radiation therapy in patients with rectal cancer. Bowel obstruction was the diagnosis of potentially greatest importance, which was more frequent in irradiated than in nonirradiated patients.
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Affiliation(s)
- Helgi Birgisson
- Department of Surgery, Akademiska Sjukhuset, S-751 85 Uppsala, Sweden.
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Kim TH, Chie EK, Kim DY, Park SY, Cho KH, Jung KH, Kim YH, Sohn DK, Jeong SY, Park JG. Comparison of the belly board device method and the distended bladder method for reducing irradiated small bowel volumes in preoperative radiotherapy of rectal cancer patients. Int J Radiat Oncol Biol Phys 2005; 62:769-75. [PMID: 15936558 DOI: 10.1016/j.ijrobp.2004.11.015] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2004] [Revised: 11/02/2004] [Accepted: 11/03/2004] [Indexed: 11/21/2022]
Abstract
PURPOSE To determine the most effective method to reduce the irradiated small bowel volume when using a belly board device (BBD), a distended bladder (DB), or both in patients with rectal cancer undergoing preoperative pelvic radiotherapy (RT). METHODS AND MATERIALS The study involved 20 patients with rectal cancer who were scheduled to receive preoperative pelvic RT. Patients were asked to empty their bladders and then drink 300 mL of water 2 h before the treatment planning computed tomographic (CT) scan. To identify the small bowel, an oral contrast solution (450 mL) was given 1 h before the CT scan. Two sets of transverse images were taken at 1-cm-thickness intervals with patients in the prone position with or without the BBD. After voiding, two additional sets of CT scans were obtained in prone positions with or without BBD. The conventional three-field treatment plan, composed of a 6-MV photon posterior-anterior field and 15-MV photon opposed lateral fields with wedges of 45 degrees, was made using a three-dimensional treatment planning system. The beam weights of the three-field plan were equal. The volume of irradiated small bowel was calculated for doses between 10% and 100% of the prescribed dose at 10% intervals. For each 10% dose increment, the effect of the BBD and the DB on the irradiated volume was analyzed using Kruskal-Wallis, Wilcoxon signed rank, and Wilcoxon rank-sum tests. RESULTS All patients underwent four sets of CT scan under the conditions of four different methods as follows: Group I = empty bladder without the use of belly board; Group II = empty bladder with the use of belly board; Group III = distended bladder without the use of belly board; Group IV = distended bladder with the use of belly board. We found that the volume of irradiated small bowel decreased in the order of Group I, Group II, Group III, and Group IV at all dose levels (p < 0.05). Compared with Group I, the mean volume reduction rate (reduced volume) of irradiated small bowel in Group II varied between 14.5% and 65.4% (15.5-80.4 cm(3)), in Group III it varied between 48.1% and 82.0% (21.6-163.1 cm(3)), and in Group IV between 51.4% and 96.4% (28.6-167.1 cm(3)). CONCLUSIONS The DB was more effective than the BBD for reducing the volume of irradiated small bowel in rectal cancer patients receiving pelvic RT. The combination of the BBD and DB showed an additive effect and was the most effective method for reducing the irradiated small bowel volume.
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Affiliation(s)
- Tae Hyun Kim
- Research Institute and Hospital, National Cancer Center, Goyang, Gyeonggi, South Korea
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Martin J, Fitzpatrick K, Horan G, McCloy R, Buckney S, O'Neill L, Faul C. Treatment with a belly-board device significantly reduces the volume of small bowel irradiated and results in low acute toxicity in adjuvant radiotherapy for gynecologic cancer: results of a prospective study. Radiother Oncol 2005; 74:267-74. [PMID: 15763307 DOI: 10.1016/j.radonc.2004.11.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2004] [Revised: 10/20/2004] [Accepted: 11/03/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND PURPOSE To determine whether treatment prone on a belly-board significantly reduces the volume of small bowel irradiated in women receiving adjuvant radiotherapy for gynecologic cancer, and to prospectively study acute small bowel toxicity using an accepted recording instrument. MATERIAL AND METHODS Thirty-two gynecologic patients underwent simulation with CT scanning supine and prone. Small bowel was delineated on every CT slice, and treatment was prone on the belly-board using 3-5 fields-typically Anterior, Right and Left Lateral, plus or minus Lateral Boosts. Median prescribed dose was 50.4 Gy and all treatments were delivered in 1.8 Gy fractions. Concomitant Cisplatin was administered in 13 patients with cervical carcinoma. Comparison of small bowel dose-volumes was made between supine and prone, with each subject acting as their own matched pair. Acute small bowel toxicity was prospectively measured using the Common Toxicity Criteria: Version 2.0. RESULTS Treatment prone on the belly-board significantly reduced the volume of small bowel receiving > or = 100; > or = 95; > or = 90; and > or = 80% of the prescribed dose, but not > or = 50%. This was found whether volume was defined in cubic centimeters or % of total small bowel volume. Of 29 evaluable subjects, 2 (7%) experienced 1 episode each of grade 3 diarrhoea. All other toxicity events were grade 2 or less and comprised diarrhoea (59%), abdominal pain or cramping (48%), nausea (38%), anorexia (17%), vomiting (10%). There were no Grade 4 events and no treatment days were lost due to toxicity. CONCLUSIONS Treatment prone on a belly-board device results in significant small bowel sparing, during adjuvant radiotherapy for gynecologic cancer. The absence of Grade 4 events or Treatment Days Lost compares favorably with the published literature.
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Affiliation(s)
- Joseph Martin
- Department of Radiation Oncology, Princess Margaret Hospital, 5th Floor, 610 University Avenue, Toronto, Ont., Canada M5G 2M9
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Schmidt CE, Bestmann B, Küchler T, Longo WE, Kremer B. Ten-year historic cohort of quality of life and sexuality in patients with rectal cancer. Dis Colon Rectum 2005; 48:483-92. [PMID: 15747079 DOI: 10.1007/s10350-004-0822-6] [Citation(s) in RCA: 134] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE In various studies, type of surgery, age, and gender had different impact on sexuality and quality of life in patients with rectal cancer. This study was designed to investigate how sexuality and quality of life are affected by age, gender, and type of surgery. METHODS A total of 516 patients who had undergone surgery for rectal cancer in our department from 1992 to 2002 were included. Within one year after the operation, 117 patients died. Questionnaires were sent to 373 patients 12 to 18 months after surgery. We received quality of life data from 261 patients. Comparisons were made after adjusting age, gender, and type of surgical procedure. RESULTS For patients receiving abdominoperineal resection sexuality was most impaired. Significant differences were seen in symptom and function scales between males and females. Females reported more distress from the medical treatment insomnia, fatigue, and constipation. Both genders had impaired sexual life; however, males had significantly higher values and felt more distressed by this impairment. Younger females felt more distress through impaired sexuality. In males sexuality was impaired independent of age. Adjuvant therapy had no influence on sexuality but on quality of life one year after surgery. CONCLUSIONS Assessing quality of life with general and specific instruments is helpful to determine whether patients improved through the treatment. The study showed that gender, age, and type of surgery influence sexuality and that quality of life after surgery for rectal cancer is impacted. Because quality of life is a predictor for complications and survival, availability of such data may help to direct supportive treatment to improve outcome.
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Affiliation(s)
- Christian E Schmidt
- Department of General and Thoracic Surgery, University of Kiel, Kiel, Germany.
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Abstract
The most significant advances in the management of small-bowel obstruction are developments in imaging modalities available to assist in the diagnosis itself, as well as to possibly assist in the early identification of those cases requiring urgent operative decompression. The most marked of these have been in the use and interpretation of contrast-enhanced CT. This has decreased the use of barium studies and has largely supplanted ultrasound and magnetic resonance imaging in the management of these patients. Diagnostic and therapeutic laparoscopic techniques are also growing in both capability and popularity. Laparoscopic adhesiolysis and the adjuvant of bioresorbable membranes each hold promise but have yet to become established as standard treatment. Further progress is needed in the detection of early, reversible strangulation. As a consequence, the fundamentals of the surgical management of small-bowel obstruction have evolved little over the past 15 years. With our persistent inability to detect reversible ischemia, a substantial risk of progression to irreversible ischemia remains when surgery is delayed, particularly in the setting of suspected complete obstruction.
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Affiliation(s)
- Awori J Hayanga
- Johns Hopkins Hospital, Department of Surgery, Baltimore, Maryland, USA
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Akyürek S, Yildiz F, Cengiz M, Onal C, Yildiz O, Genc M, Atahan IL. Importance of timing of antiaggregant treatment in the prevention of radiation induced enteropathy. Med Hypotheses 2005; 65:736-9. [PMID: 15953694 DOI: 10.1016/j.mehy.2005.04.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2005] [Accepted: 04/03/2005] [Indexed: 11/18/2022]
Abstract
Chronic radiation enteropathy (CRE) is an undesirable radiation-induced toxicity and a common health problem in patients with pelvic or abdominal malignancies. Damage to microvascular endothelial cells and connective tissue is blamed to cause this adverse effect. It is shown that platelets are the first cellular elements that initiate the homeostatic and inflammatory responses and release of several proinflammatory and fibrinogenic mediators. Antiplatelet agents such as ticlopidine and clopidogrel were shown to prevent CRE and this effect is believed to be directed by their activities against thrombocytes. However, recent studies have shown that these drugs also induce apoptosis in endothelial cells and may lead to decreased expression of endothelial prostacyclin and thrombomodulin (TM) and increased release of von Willebrand factor which are shown to be major contributors of coagulation process. Assuming that radiation induced apoptosis occur 6-10h after irradiation, we think that timing of these antiaggregant drugs with irradiation is important and a 6-10h interval between these may be beneficial to avoid this adverse interaction.
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Affiliation(s)
- S Akyürek
- Ankara University School of Medicine, Faculty of Medicine, Department of Radiation Oncology, Dikimevi, 06100 Ankara, Turkey.
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Hollenhorst H, Schaffer M, Romano M, Reiner M, Siefert A, Schaffer P, Quanz A, Dühmke E. Optimized radiation of pelvic volumes in the clinical setting by using a novel bellyboard with integrated gonadal shielding. Med Dosim 2004; 29:173-8. [PMID: 15324913 DOI: 10.1016/j.meddos.2004.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2003] [Accepted: 04/05/2004] [Indexed: 10/26/2022]
Abstract
The purpose of this study was to determine the feasibility of a custom-made, modified bellyboard to reduce radiotherapy side effects on small bowel, bladder, skin, and male gonads. Two groups of 10 consecutive patients each were treated from January 2003 through April 2003 with neoadjuvant (45 Gy) or adjuvant (54 Gy) radio(chemo)therapy in single fractions of 5 days a week 1.8 Gy for rectal carcinoma, using a photon energy of 15 MV. One group was positioned in a prone position without an immobilization device, the other group was positioned on our bellyboard. Treatment planning was calculated by using a 4- and a 3-field box technique. Differences in the dose of organs of risk were calculated. For 1 male patient, a gonadal shielding was developed and integrated. All patients examined with the bellyboard demonstrated an anterior and cranial dislocation of the small bowel. Using a 4-field box, the mean dose to the small bowel of patients treated on our bellyboard was 56.5% as compared to 63.1% when treated without the bellyboard. When a 3-field box was used, the mean dose to the small bowel was 52.4% when the bellyboard was used, as compared to a mean dose of 63.1% without the bellyboard. Regarding the dose volume effects to the bladder, the mean dose for patients treated with a 4-field box was about 14.5% higher as compared to patients treated with a 3-field box. The mean dose to the hip joints and skin also depended on the radiation technique. The patient who received gonadal shielding received a maximal total gonadal dose of about 75.0 cGy in single fractions of maximal 3.0 cGy (TL-dosimeters). Daily setup variations evaluated by a beam's-eye view were similar in both groups and ranged from 0.5 cm 1.0 cm. For daily use, our bellyboard appears to be an ideal compromise due to effectiveness, its easy handling, and reproductive positioning; moreover, it can also be used in combination with gonadal shielding.
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Affiliation(s)
- Helmut Hollenhorst
- Department of Radiation Oncology, Ludwig-Maximilians University, Munich, Germany
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Occelli B, Zafrani Y, Narducci F, Bigotte A, Leblanc E, Querleu D. Comparaison des adhérences postopératoires après lymphadénectomies para-aortiques par laparotomie avec versus sans Intergel. ACTA ACUST UNITED AC 2004; 33:110-8. [PMID: 15052176 DOI: 10.1016/s0368-2315(04)96409-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Advanced cancers of the cervix are treated by external radiotherapy within range limits which depend on the para-aortic ganglion metastases found during surgical staging. The presence of postoperative intraperitoneal adhesions increases the risk of postradical enteritis. The aim of this study is to investigate the efficacy of an anti-adhesive substance (Intergel) undergoing para-aortic lymphadenectomy by laparotomy. MATERIALS AND METHODS We conduced a prospective, randomized study on 60 pigs divided into 2 groups (with and without Intergel) undergoing para-aortic lymphadenectomy by laparotomy to compare the efficacy of an anti-adhesive substance using an adhesion scoring system based on density and surface area in question. RESULTS There was no difference between the 2 groups in terms of duration of surgery, number of ganglia removed, postoperative mortality and per and postoperative morbidity, especially the adhesion process. CONCLUSION Administration of an anti-adhesive substance such as Intergel does not reduce the adhesion process after para-aortic lymphadenectomy in animals. However, perhaps we can not interpret these results because of the too much quantity of anti-adhesive substance for the animal weight, and because of the too precocious control.
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Affiliation(s)
- B Occelli
- Service de Chirurgie Gynécologique, Hôpital de Valenciennes, avenue de Monaco, BP 479, 59322 Valenciennes Cedex.
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Crane CH, Skibber J. Preoperative chemoradiation for locally advanced rectal cancer: rationale, technique, and results of treatment. ACTA ACUST UNITED AC 2004; 21:265-70. [PMID: 14648785 DOI: 10.1002/ssu.10046] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Over the past decade, 392 patients with stage II and III rectal cancer have been managed with preoperative chemoradiation and surgery at the M. D. Anderson Cancer Center (MDACC). Aggressive surgical techniques such as total mesorectal excision, proctectomy with coloanal anastamosis, and multivisceral excisions have been used. Initial pelvic chemoradiation is also used in patients who present with metastases. Preoperative chemoradiation followed by surgery has resulted in excellent sphincter preservation (SP) and pelvic control with minimal acute, perioperative, and late morbidity. SP has been achieved in greater numbers of patients over the past 3 years due to the increased use of coloanal anastamosis in very low tumors. There has been no increase in pelvic failure or perioperative morbidity with this practice. Patients with clinical T4 disease have significantly worse pelvic control. An assessment of the impact of CB on pelvic control and survival requires further follow-up. Poor differentiation and poor response to preoperative therapy predict a worse overall survival. Durable symptom control without colostomy has been achieved using initial chemoradiation in patients who present with metastases. Aggressive bowel management and skin care can minimize hospitalization and treatment interruption due to acute toxicity. Multidisciplinary therapy using preoperative chemoradiation and aggressive surgery has resulted in excellent SP and pelvic control. However, more effective systemic therapies are needed, especially for patients who do not respond well to preoperative chemoradiation.
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Affiliation(s)
- Christopher H Crane
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA.
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Abstract
The role of 3-dimensional treatment planning in the management of rectal cancer is not well defined. This report reviews technical guidelines for simulation, defining target volumes, and suggested beam configurations. Outcome from pilot clinical trials, with emphasis on the impact of volume and dose on tumor response and treatment morbidity is discussed.
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Affiliation(s)
- Robert Myerson
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO 63110, USA
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Heron DE, Gerszten K, Selvaraj RN, King GC, Sonnik D, Gallion H, Comerci J, Edwards RP, Wu A, Andrade RS, Kalnicki S. Conventional 3D conformal versus intensity-modulated radiotherapy for the adjuvant treatment of gynecologic malignancies: a comparative dosimetric study of dose–volume histograms☆. Gynecol Oncol 2003; 91:39-45. [PMID: 14529660 DOI: 10.1016/s0090-8258(03)00461-x] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The goals of this study were to evaluate the feasibility of pelvic intensity-modulated radiotherapy (IMRT) in the adjuvant treatment of gynecologic malignancies and to compare the dose-volume histograms (DVHs) and determine the potential impact on acute and long-term toxicity based on the dose to target and nontarget tissues for both planning techniques. METHODS Ten consecutive patients referred for adjuvant radiotherapy for gynecologic malignancies at the University of Pittsburgh School of Medicine and Magee-Womens Hospital were selected for CT-based treatment planning using the ADAC 3D version 4.2g and the NOMOS Corvus IMRT version 4.0. Normal tissues and critical structures were contoured on axial CT slices by both systems in conjunction with a gynecologic radiologist. These regions included internal, external, and common iliac nodal groups, rectum, upper 4 cm of vagina, bladder, and small bowel. Conventional treatment planning included 3D four-field box using 18-MV photons designed to treat a volume from the L(5)/S(1) border superiorly to the bottom of the ischial tuberosity on the AP/PA field and shaped blocks on the lateral fields to minimize the dose to the rectum and small bowel. A seven-field technique using 6-MV photons was used for IMRT. Restraints on small bowel for IMRT were set at 23.0 Gy +/- 5% and 35.0 Gy+/- 5% for the rectum and 37.5 Gy +/- 5% for the bladder while simultaneously delivering full dose (45.0 Gy) to the intrapelvic nodal groups in 1.8-Gy daily fractions. The dose-volume histograms where then compared for both treatment delivery systems. RESULTS The volume of each organ of interest (small bowel, bladder, and rectum) receiving doses in excess of 30 Gy was compared in the 3D and IMRT treatment plans. The mean volume of small bowel receiving doses in excess of 30 Gy was reduced by 52% with IMRT compared with 3D. A similar advantage was noted for the rectum (66% reduction) and the bladder (36% reduction). The nodal regions at risk and the upper vagina all received the prescribed dose of 45.0 Gy. CONCLUSIONS Intensity-modulated radiotherapy appears to offer several advantages over conventional 3D radiotherapy (3D CRT) planning for adjuvant radiotherapy for gynecologic malignancies. These include a significant reduction in treatment volume for bladder, rectum, and small bowel. It is anticipated that this reduction in volume of normal tissue irradiated would translate into overall reduction in acute and potentially late treatment-related toxicity. Prospective trials are necessary to better evaluate the advantages in a larger group of patients.
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Affiliation(s)
- D E Heron
- University of Pittsburgh Cancer Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA 15232, USA.
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Koelbl O, Vordermark D, Flentje M. The relationship between belly board position and patient anatomy and its influence on dose-volume histogram of small bowel for postoperative radiotherapy of rectal cancer. Radiother Oncol 2003; 67:345-9. [PMID: 12865185 DOI: 10.1016/s0167-8140(03)00164-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
The influence of three different belly board (BB) positions in radiotherapy of rectal cancer on the dose-volume histogram of the small bowel (SB) were analysed for 20 patients. Placing the lower border of the BB opening near the lumbosacral junction, both the volume of SB within the pelvis and the volume of SB within all tested dose levels were lower compared to its position near the symphysis or the lumbosacral junction.
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Affiliation(s)
- Oliver Koelbl
- Department of Radiotherapy, University of Wuerzburg, Josef-Schneider-Strasse 11, 97080 Wuerzburg, Germany
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