1
|
Verweij ME, Franzen J, van Grevenstein WMU, Verkooijen HM, Intven MPW. Timing of rectal cancer surgery after short-course radiotherapy: national database study. Br J Surg 2023; 110:839-845. [PMID: 37172197 PMCID: PMC10364516 DOI: 10.1093/bjs/znad113] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 02/13/2023] [Accepted: 03/29/2023] [Indexed: 05/14/2023]
Abstract
BACKGROUND Previous randomized trials found that a prolonged interval between short-course radiotherapy (SCRT, 25 Gy in 5 fractions) and surgery for rectal cancer (4-8 weeks, SCRT-delay) results in a lower postoperative complication rate and a higher pCR rate than SCRT and surgery within a week (SCRT-direct surgery). This study sought to confirm these results in a Dutch national database. METHODS Patients with intermediate-risk rectal cancer (T3(mesorectal fascia (MRF)-) N0 M0 and T1-3(MRF-) N1 M0) treated with either SCRT-delay (4-12 weeks) or SCRT-direct surgery in 2018-2021 were selected from a Dutch national colorectal cancer database. Confounders were adjusted for using inverse probability of treatment weighting (IPTW). The primary endpoint was the 90-day postoperative complication rate. Secondary endpoints included the pCR rate. Endpoints were compared using log-binomial and Poisson regression. RESULTS Some 664 patients were included in the SCRT-direct surgery and 238 in the SCRT-delay group. After IPTW, the 90-day postoperative complication rate was comparable after SCRT-direct surgery and SCRT-delay (40.1 versus 42.3 per cent; risk ratio (RR) 1.1, 95 per cent c.i. 0.9 to 1.3). A pCR occurred more often after SCRT-delay than SCRT-direct surgery (10.7 versus 0.4 per cent; RR 39, 11 to 139). CONCLUSION There was no difference in surgical complication rates between SCRT-delay and SCRT-direct, but SCRT-delay was associated with more patients having a pCR.
Collapse
Affiliation(s)
- Maaike E Verweij
- Division of Imaging and Oncology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Jolien Franzen
- Division of Imaging and Oncology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | | | - Helena M Verkooijen
- Division of Imaging and Oncology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Martijn P W Intven
- Division of Imaging and Oncology, University Medical Centre Utrecht, Utrecht, the Netherlands
| |
Collapse
|
2
|
Ingle M, White I, Chick J, Stankiewicz H, Mitchell A, Barnes H, Herbert T, Nill S, Oelfke U, Huddart R, Ng-Cheng-Hin B, Hafeez S, Lalondrelle S, Dunlop A, Bhide S. Understanding the Benefit of Magnetic Resonance-guided Adaptive Radiotherapy in Rectal Cancer Patients: a Single-centre Study. Clin Oncol (R Coll Radiol) 2023; 35:e135-e142. [PMID: 36336579 DOI: 10.1016/j.clon.2022.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 09/01/2022] [Accepted: 10/12/2022] [Indexed: 11/06/2022]
Abstract
AIMS Neoadjuvant chemoradiotherapy followed by surgery is the mainstay of treatment for patients with rectal cancer. Standard clinical target volume (CTV) to planning target volume (PTV) margins of 10 mm are used to accommodate inter- and intrafraction motion of target. Treating on magnetic resonance-integrated linear accelerators (MR-linacs) allows for online manual recontouring and adaptation (MRgART) enabling the reduction of PTV margins. The aim of this study was to investigate motion of the primary CTV (CTVA; gross tumour volume and macroscopic nodes with 10 mm expansion to cover microscopic disease) in order to develop a simultaneous integrated boost protocol for use on MR-linacs. MATERIALS AND METHODS Patients suitable for neoadjuvant chemoradiotherapy were recruited for treatment on MR-linac using a two-phase technique; only the five phase 1 fractions on MR-linac were used for analysis. Intrafraction motion of CTVA was measured between pre-treatment and post-treatment MRI scans. In MRgART, isotropically expanded pre-treatment PTV margins from 1 to 10 mm were rigidly propagated to post-treatment MRI to determine overlap with 95% of CTVA. The PTV margin was considered acceptable if overlap was >95% in 90% of fractions. To understand the benefit of MRgART, the same methodology was repeated using a reference computed tomography planning scan for pre-treatment imaging. RESULTS In total, nine patients were recruited between January 2018 and December 2020 with T3a-T4, N0-N2, M0 disease. Forty-five fractions were analysed in total. The median motion across all planes was 0 mm, demonstrating minimal intrafraction motion. A PTV margin of 3 and 5mm was found to be acceptable in 96 and 98% of fractions, respectively. When comparing to the computed tomography reference scan, the analysis found that PTV margins to 5 and 10 mm only acceptably covered 51 and 76% of fractions, respectively. CONCLUSION PTV margins can be reduced to 3-5 mm in MRgART for rectal cancer treatment on MR-linac within an simultaneous integrated boost protocol.
Collapse
Affiliation(s)
- M Ingle
- The Royal Marsden Hospital NHS Trust, London, UK; The Institute of Cancer Research, London, UK.
| | - I White
- Guys and St Thomas NHS Trust, London, UK
| | - J Chick
- The Royal Marsden Hospital NHS Trust, London, UK
| | | | - A Mitchell
- The Royal Marsden Hospital NHS Trust, London, UK
| | - H Barnes
- The Royal Marsden Hospital NHS Trust, London, UK
| | - T Herbert
- The Royal Marsden Hospital NHS Trust, London, UK
| | - S Nill
- The Institute of Cancer Research, London, UK
| | - U Oelfke
- The Institute of Cancer Research, London, UK
| | - R Huddart
- The Royal Marsden Hospital NHS Trust, London, UK; The Institute of Cancer Research, London, UK
| | | | - S Hafeez
- The Royal Marsden Hospital NHS Trust, London, UK; The Institute of Cancer Research, London, UK
| | - S Lalondrelle
- The Royal Marsden Hospital NHS Trust, London, UK; The Institute of Cancer Research, London, UK
| | - A Dunlop
- The Royal Marsden Hospital NHS Trust, London, UK
| | - S Bhide
- The Royal Marsden Hospital NHS Trust, London, UK; The Institute of Cancer Research, London, UK
| |
Collapse
|
3
|
Carbonara R, Surgo A, Ciliberti MP, Gregucci F, Bonaparte I, Nicosia L, Meldolesi E, Caliandro M, Ferraro V, Inchingolo R, Memeo R, Ludovico E, Calbi R, Lavalle M, Gambacorta MA, Alongi F, Fiorentino A. Impact of preoperative chemoradiation with higher dose intensity modulated radiotherapy on pathological complete response for locally advanced rectal cancer: a systematic review. Expert Rev Anticancer Ther 2022; 22:1249-1259. [PMID: 36174658 DOI: 10.1080/14737140.2022.2130895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Neoadjuvant chemoradiation (CRT) followed by total mesorectal excision is the current standard-of-care for locally advanced UICC II-III stage rectal cancer (LARC). A pathological complete response (pCR) correlates with survival. Improvements of pCR, including dose escalation, should be explored. The aim of this explorative analysis is to assess the impact on pCR of intensity-modulated radiotherapy (IMRT) with simultaneous integrated boost (SIB). AREAS COVERED A literature search via PICO (Population, Intervention, Comparison, Outcome) in MEDLINE/PubMed and EMBASE and a systematic review according to PRISMA (Preferred Reporting Items for Systematic Reviews and Metanalysis) methodology were performed. Studies that reported pCR rate in patients with LARC in clinical stage T2N+M0 or cT3/4 N0/+M0 treated with preoperative CRT with SIB-IMRT/VMAT (Volumetric Modulated Arc Therapy) were included. Sixty-two studies were identified, but only eight clinical trials with a total of 311 patients were included . Median follow-up was 16-61 months. pCR reached the value of 38%. Good survival outcomes were observed with a mild toxicity profile. EXPERT OPINION Radiotherapy dose intensification in LARC showed a slight increase of pCR compared to historical studies. Prospective evaluations are necessary to define which patients would benefit most.
Collapse
Affiliation(s)
- Roberta Carbonara
- Radiation Oncology Department, General Regional Hospital F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - Alessia Surgo
- Radiation Oncology Department, General Regional Hospital F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - Maria Paola Ciliberti
- Radiation Oncology Department, General Regional Hospital F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - Fabiana Gregucci
- Radiation Oncology Department, General Regional Hospital F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - Ilaria Bonaparte
- Radiation Oncology Department, General Regional Hospital F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - Luca Nicosia
- IRCCS, Advanced Radiation Oncology Department, Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy
| | - Elisa Meldolesi
- Radiation Oncology Department, Fondazione Policlinico Universitario A.Gemelli, IRCCS, Rome, Italy
| | - Morena Caliandro
- Radiation Oncology Department, General Regional Hospital F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - Valentina Ferraro
- Hepatobiliary and Pancreatic Surgery Unit, General Regional Hospital F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - Riccardo Inchingolo
- Hepatobiliary and Pancreatic Surgery Unit, General Regional Hospital F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - Riccardo Memeo
- Hepatobiliary and Pancreatic Surgery Unit, General Regional Hospital F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - Elena Ludovico
- Radiology Department, General Regional Hospital F. Miulli, Acquaviva delle Fonti (BA), Bari, Italy
| | - Roberto Calbi
- Radiology Department, General Regional Hospital F. Miulli, Acquaviva delle Fonti (BA), Bari, Italy
| | - Mariadea Lavalle
- Nuclear Medicine Department, General Regional Hospital F. Miulli, Acquaviva delle Fonti (BA), Bari, Italy
| | | | - Filippo Alongi
- IRCCS, Advanced Radiation Oncology Department, Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy.,Medicine Faculty, University of Brescia, Brescia, Italy
| | - Alba Fiorentino
- Radiation Oncology Department, General Regional Hospital F. Miulli, Acquaviva delle Fonti, Bari, Italy
| |
Collapse
|
4
|
Ingle M, Blackledge M, White I, Wetscherek A, Lalondrelle S, Hafeez S, Bhide S. Quantitative analysis of diffusion weighted imaging in rectal cancer during radiotherapy using a magnetic resonance imaging integrated linear accelerator. Phys Imaging Radiat Oncol 2022; 23:32-37. [PMID: 35756883 PMCID: PMC9214864 DOI: 10.1016/j.phro.2022.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 05/16/2022] [Accepted: 06/02/2022] [Indexed: 11/25/2022] Open
Abstract
Background and purpose Magnetic resonance imaging integrated linear accelerator (MR-Linac) platforms enable acquisition of diffusion weighted imaging (DWI) during treatment providing potential information about treatment response. Obtaining DWI on these platforms is technically different from diagnostic magnetic resonance imaging (MRI) scanners. The aim of this project was to determine feasibility of obtaining DWI and calculating apparent diffusion coefficient (ADC) parameters longitudinally in rectal cancer patients on the MR-Linac. Materials and methods Nine patients undergoing treatment on MR-Linac had DWI acquired using b-values 0, 30, 150, 500 s/mm2. Gross tumour volume (GTV) and normal tissue was delineated on DWI throughout treatment and median ADC was calculated using an in-house tool (pyOsirix ®). Results Seven out of nine patients were included in the analysis; all demonstrated downstaging at follow-up. A total of 63 out of 70 DWI were analysed (7 excluded due to poor image quality). An increasing trend of ADC median for GTV (1.15 × 10-3 mm2/s interquartile range (IQ): 1.05-1.17 vs 1.59 × 10-3 mm2/s IQ: 1.37 - 1.64; p = 0.0156), correlating to treatment response. In comparison ADC median for normal tissue remained the same between first and last fraction (1.61 × 10-3 mm2/s IQ: 1.56-1.71 vs 1.67 × 10-3 mm2/s IQ: 1.37-2.00; p = 0.9375). Conclusions DWI assessment in rectal cancer patients on MR-Linac is feasible. Initial results provide foundations for further studies to determine DWI use for treatment adaptation in rectal cancer.
Collapse
Affiliation(s)
- Manasi Ingle
- The Royal Marsden Hospital NHS Trust, 203 Fulham Road, London SW3 6JJ, UK
- The Institute of Cancer Research, 123 Old Brompton Road, London SW7 3RP, UK
| | - Matthew Blackledge
- The Institute of Cancer Research, 123 Old Brompton Road, London SW7 3RP, UK
| | - Ingrid White
- Guys and St Thomas NHS Trust, Great Maze Pond, London SE1 9RT, UK
| | - Andreas Wetscherek
- The Institute of Cancer Research, 123 Old Brompton Road, London SW7 3RP, UK
| | - Susan Lalondrelle
- The Royal Marsden Hospital NHS Trust, 203 Fulham Road, London SW3 6JJ, UK
- The Institute of Cancer Research, 123 Old Brompton Road, London SW7 3RP, UK
| | - Shaista Hafeez
- The Royal Marsden Hospital NHS Trust, 203 Fulham Road, London SW3 6JJ, UK
- The Institute of Cancer Research, 123 Old Brompton Road, London SW7 3RP, UK
| | - Shreerang Bhide
- The Royal Marsden Hospital NHS Trust, 203 Fulham Road, London SW3 6JJ, UK
- The Institute of Cancer Research, 123 Old Brompton Road, London SW7 3RP, UK
| |
Collapse
|
5
|
Preoperative intensity-modulated chemoradiotherapy with simultaneous integrated boost in rectal cancer: five-year follow-up results of a phase II study. Radiol Oncol 2021; 55:439-448. [PMID: 34821132 PMCID: PMC8647794 DOI: 10.2478/raon-2021-0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 04/26/2021] [Indexed: 11/20/2022] Open
Abstract
Background We conducted a phase II study to investigate the feasibility and safety of preoperative radiochemo-therapy experimental fractionation, using intensity-modulated radiation therapy with simultaneous integrated boost (IMRT SIB) to shorten the overall treatment time without dose escalation in intermediate/locally advanced rectal cancer with the aim to improving treatment outcome. Patients and methods A total of 51 patients with operable stage II–III rectal carcinoma were included between January 2014 and January 2015. Fifty patients completed preoperative IMRT treatment with an elective dose of 41.8 Gy and simultaneously delivered 46.2 Gy to T2/T3 and 48.4 Gy to T4 tumour in 22 fractions, with concomitant capecitabine (825 mg/m2/12 h, including at weekends). Median follow-up was 70 months (range 11–80 m). Results Forty-seven patients completed treatment per protocol. Acute toxicity occurred in 2 (4%) patients. R0 resection was achieved in all but 1 and pathologic complete response (pCR) in 12 (25.5%) patients who had 5-year overall survival (OS), disease-free survival (DFS) and local control (LC) of 91.7%, 100% and 100%, respectively. The intention-to-treat analysis showed that the type of surgery significantly moderated OS and DFS, while total downstaging and pN were predictive for DFS only. For treatment per protocol 5-year OS, DFS and LC were 80.9% (95% confidence interval [CI] 69.7–92.1), 77.1% (95% CI 65.1–89.1) and 95.2% (95% CI 88.7–100), respectively. The proportion of patients with severe late (CTCAE G ≥ 3) gastrointestinal, urinary and sexual toxicity was 15%, 2% and 8% respectively, with one reported secondary carcinoma. Conclusions Preoperative IMRT-SIB without dose escalation was well tolerated, with a low acute toxicity profile, we achieved a high rate of pCR and showed encouraging 5-year OS, DFS and LC.
Collapse
|
6
|
Feasibility of Conebeam CT-based online adaptive radiotherapy for neoadjuvant treatment of rectal cancer. Radiat Oncol 2021; 16:136. [PMID: 34301300 PMCID: PMC8305875 DOI: 10.1186/s13014-021-01866-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 07/16/2021] [Indexed: 11/23/2022] Open
Abstract
Background Online adaptive radiotherapy has the potential to reduce toxicity for patients treated for rectal cancer because smaller planning target volumes (PTV) margins around the entire clinical target volume (CTV) are required. The aim of this study is to describe the first clinical experience of a Conebeam CT (CBCT)-based online adaptive workflow for rectal cancer, evaluating timing of different steps in the workflow, plan quality, target coverage and patient compliance. Methods Twelve consecutive patients eligible for 5 × 5 Gy pre-operative radiotherapy were treated on a ring-based linear accelerator with a multidisciplinary team present at the treatment machine for each fraction. The accelerator is operated using an integrated software platform for both treatment planning and delivery. In all directions for all CTVs a PTV margin of 5 mm was used, except for the cranial/caudal borders of the total CTV where a margin of 8 mm was applied. A reference plan was generated based on a single planning CT. After aligning the patient the online adaptive procedure started with acquisition of a CBCT. The planning CT scan was registered to the CBCT using deformable registration and a synthetic CT scan was generated. With the support of artificial intelligence, structure guided deformation and the synthetic CT scan contours were adapted by the system to match the anatomy on the CBCT. If necessary, these contours were adjusted before a new plan was generated. A second and third CBCT were acquired to validate the new plan with respect to CTV coverage just before and after treatment delivery, respectively. Treatment was delivered using volumetric modulated arc treatment (VMAT). All steps in this process were defined and timed. Results On average the timeslot needed at the treatment machine was 34 min. The process of acquiring a CBCT, evaluating and adjusting the contours, creating the new plan and verifying the CTV on the CBCT scan took on average 20 min. Including delivery and post treatment verification this was 26 min. Manual adjustments of the target volumes were necessary in 50% of fractions. Plan quality, target coverage and patient compliance were excellent. Conclusions First clinical experience with CBCT-based online adaptive radiotherapy shows it is feasible for rectal cancer. Trial registration Medical Research Involving Human Subjects Act (WMO) does not apply to this study and was retrospectively approved by the Medical Ethics review Committee of the Academic Medical Center (W21_087 # 21.097; Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, The Netherlands). Supplementary Information The online version contains supplementary material available at 10.1186/s13014-021-01866-7.
Collapse
|
7
|
Liu T, Chang W, Wang J, Ren L, Wei Y, Zhang X, Chen Y, Tang W, Wang M, Zeng Z, Xu J. Efficacy of conversion therapy on initially unresectable locally advanced rectal cancer. J Cancer 2021; 12:4418-4423. [PMID: 34093842 PMCID: PMC8176423 DOI: 10.7150/jca.53824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 05/11/2021] [Indexed: 11/18/2022] Open
Abstract
Background and purpose: Research on the efficacy of conversion therapy for initially unresectable mid-low rectal cancer (IURC) remained limited. This study aimed to assess the efficacy and safety of the conversion regimen for IURC and analyze the long-term outcomes of these patients. Methods: We retrospectively analyzed the data of clinically diagnosed IURC patients who received conversion therapy between October 2010 and April 2017. The conversion therapy consisted of long-term radiation, concurrent chemotherapy, delayed surgery and consolidation chemotherapy. The primary end point was the rate of R0 resection, and other short- and long-term outcomes were analyzed. Results: Sixty-one patients were enrolled in this study. After conversion therapy, 51 (83.6%) patients received R0 resection. The rates of pathologic complete response and downstaging were 16.4% and 62.3%, respectively. The rate of grade 3-4 chemoradiotherapy-related toxicity events was 13.1%. The overall survival at 3 years was 75.4% in all patients, and the disease-free survival at 3 years was 72.5% in patients who received R0 resection. Conclusion: The conversion regimen showed a high conversion resection rate and good survival outcomes in IURC patients, and might benefit the patients if recommended in clinical practice.
Collapse
Affiliation(s)
- Tianyu Liu
- Colorectal Cancer Center, Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wenju Chang
- Colorectal Cancer Center, Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Engineering Research Center of Colorectal Cancer Minimally Invasive Technology (17DZ2252600), Shanghai, China
| | - Jian Wang
- Department of Radiotherapy; Zhongshan Hospital, Fudan University, Shanghai, China
| | - Li Ren
- Colorectal Cancer Center, Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Engineering Research Center of Colorectal Cancer Minimally Invasive Technology (17DZ2252600), Shanghai, China
| | - Ye Wei
- Colorectal Cancer Center, Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Engineering Research Center of Colorectal Cancer Minimally Invasive Technology (17DZ2252600), Shanghai, China
| | - Xian Zhang
- Department of Radiotherapy; Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yijiao Chen
- Colorectal Cancer Center, Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wentao Tang
- Colorectal Cancer Center, Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Mingliang Wang
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhaochong Zeng
- Department of Radiotherapy; Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jianmin Xu
- Colorectal Cancer Center, Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Engineering Research Center of Colorectal Cancer Minimally Invasive Technology (17DZ2252600), Shanghai, China
| |
Collapse
|
8
|
Slevin F, Hanna C, Appelt A, Muirhead R. Launch of the National Rectal Cancer Intensity-Modulated Radiotherapy Guidance. Clin Oncol (R Coll Radiol) 2021; 33:209-213. [PMID: 33341331 DOI: 10.1016/j.clon.2020.11.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 11/17/2020] [Indexed: 12/18/2022]
Affiliation(s)
- F Slevin
- University of Leeds, Leeds, UK; Leeds Teaching Hospitals NHS Trust, Leeds, UK.
| | - C Hanna
- Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - A Appelt
- University of Leeds, Leeds, UK; Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - R Muirhead
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| |
Collapse
|
9
|
Agas RAF, Co LBA, Sogono PG, Jacinto JCKM, Yu KKL, Jacomina LE, Bacorro WR, Sy Ortin TT. Assessing the Effect of Radiotherapy in Addition to Surgery in Colon Adenocarcinomas: a Systematic Review and Meta-analysis of Contemporary Evidence. J Gastrointest Cancer 2021; 51:445-460. [PMID: 31463890 DOI: 10.1007/s12029-019-00300-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE This study aims to review the contemporary evidence investigating radiotherapy (RT) in addition to surgery for colon adenocarcinomas. METHODS We searched the following databases: PubMed, Science Direct, Scopus, ASCOpubs, the Cochrane Library, and Google Scholar. Studies (since January 2005) comparing outcomes of high-risk colon adenocarcinomas who underwent RT in addition to surgery versus no RT were eligible. Pooling of outcomes from published results or from analysis of survival curves was done. Subgroup analysis was conducted to determine if the efficacy of RT varies with RT timing. RESULTS Eight studies were included (five retrospective cohorts, three population-based studies). Pooled analysis from retrospective cohorts showed a reduction in 5-year LR (OR 0.41; 95% CI 0.21-0.79; p = 0.007) in the RT group. A benefit in 3-year (OR 1.81; 95% CI 1.15-2.87; p = 0.01) and 5-year (OR 2.10; 95% CI 1.21-3.63; p = 0.008) DFS and in 3-year (OR 2.55; 95% CI 1.43-4.54; p = 0.001) and 5-year (OR 2.00; 95% CI 1.17-3.41; p = 0.01) OS was seen in the RT group. The OS benefit was demonstrated in the subgroup analysis of neoadjuvant RT, but not with adjuvant RT. The improvement in OS with neoadjuvant RT was supported by a population-based study from NCDB, while results from two population-based studies investigating adjuvant RT were conflicting. CONCLUSION Taking into account the limitations of the studies, our review of evidence suggests a possible role of RT in improving oncologic outcomes of select colon adenocarcinomas. Prospective studies are needed to definitively assess the value of RT for colon cancer.
Collapse
Affiliation(s)
- Ryan Anthony F Agas
- Department of Radiation Oncology, Benavides Cancer Institute, University of Santo Tomas Hospital, España Boulevard, 1008, Manila, Philippines.
| | - Lester Bryan A Co
- Department of Radiation Oncology, Benavides Cancer Institute, University of Santo Tomas Hospital, España Boulevard, 1008, Manila, Philippines
| | - Paolo G Sogono
- Department of Radiation Oncology, Benavides Cancer Institute, University of Santo Tomas Hospital, España Boulevard, 1008, Manila, Philippines
| | - J C Kennetth M Jacinto
- Department of Radiation Oncology, Benavides Cancer Institute, University of Santo Tomas Hospital, España Boulevard, 1008, Manila, Philippines
| | - Kelvin Ken L Yu
- Department of Radiation Oncology, Benavides Cancer Institute, University of Santo Tomas Hospital, España Boulevard, 1008, Manila, Philippines
| | - Luisa E Jacomina
- Department of Radiation Oncology, Benavides Cancer Institute, University of Santo Tomas Hospital, España Boulevard, 1008, Manila, Philippines
| | - Warren R Bacorro
- Department of Radiation Oncology, Benavides Cancer Institute, University of Santo Tomas Hospital, España Boulevard, 1008, Manila, Philippines
| | - Teresa T Sy Ortin
- Department of Radiation Oncology, Benavides Cancer Institute, University of Santo Tomas Hospital, España Boulevard, 1008, Manila, Philippines
| |
Collapse
|
10
|
Intven M, de Mol van Otterloo S, Mook S, Doornaert P, de Groot-van Breugel E, Sikkes G, Willemsen-Bosman M, van Zijp H, Tijssen R. Online adaptive MR-guided radiotherapy for rectal cancer; feasibility of the workflow on a 1.5T MR-linac: clinical implementation and initial experience. Radiother Oncol 2021; 154:172-178. [DOI: 10.1016/j.radonc.2020.09.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 09/13/2020] [Accepted: 09/14/2020] [Indexed: 10/23/2022]
|
11
|
Antelo G, Hierro C, Fernández JP, Baena E, Bugés C, Layos L, Manzano JL, Caro M, Mesia R. Rectal neuroendocrine carcinoma: case report of a rare entity and perspective review of promising agents. Drugs Context 2020; 9:dic-2020-2-4. [PMID: 32477420 PMCID: PMC7233296 DOI: 10.7573/dic.2020-2-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/23/2020] [Accepted: 04/24/2020] [Indexed: 01/07/2023] Open
Abstract
Neuroendocrine neoplasms (NENs) comprise a heterogeneous group of tumours, which can be classified into neuroendocrine tumours (NETs), neuroendocrine carcinomas (NECs) and mixed neuroendocrine non-neuroendocrine neoplasms (MiNENs). To date, there is no consensus regarding the optimal therapy, which usually depends on the primary location and classification, according to morphological features of differentiation and proliferation rates. Nevertheless, multidisciplinary strategies combining medical treatments and locoregional strategies have yielded better efficacy results. Here, we report the case of a patient diagnosed with a nonfunctional rectal NECs with metastatic widespread to pelvic lymph nodes and bilateral lung metastases. The patient received three cycles of platinum-etoposide, concomitantly with palliative radiotherapy. Although CT scan after three cycles showed a significant partial response, there was an early fatal progression only 3 months after having stopped systemic therapy. As formerly described in the literature, this case highlights the aggressive behaviour of NECs, rare tumours that often present in advanced stages at diagnosis. Lately, new insights into the molecular biology of NECs have unveiled the possibility of using novel drugs, such as targeted agents or immunotherapy, in molecularly selected subgroups of patients. In this review, we discuss the current management of this rare entity and provide an overview of the most relevant molecular findings, whilst illustrating the potential value that prescreening panels can offer, searching for actionable targets (MSI/dMMR, PD-L1, BRAFv600E) to guide therapy with promising agents that could fill a void in this disease.
Collapse
Affiliation(s)
- Gabriela Antelo
- Radiation Oncology Department, Catalan Institute of Oncology (ICO)-Badalona; Germans Trias i Pujol University Hospital (HUGTiP), Badalona, Barcelona, Spain
| | - Cinta Hierro
- Medical Oncology Department, Catalan Institute of Oncology (ICO)-Badalona; Badalona-Applied Research Group in Oncology (B-ARGO)-Germans Trias i Pujol Institute (IGTP); Germans Trias i Pujol University Hospital (HUGTiP), Badalona, Barcelona, Spain
| | - Juan Pablo Fernández
- Pathology Department, Germans Trias i Pujol University Hospital (HUGTiP), Badalona, Barcelona, Spain
| | - Eduardo Baena
- Radiation Oncology Department, Catalan Institute of Oncology (ICO)-Badalona; Germans Trias i Pujol University Hospital (HUGTiP), Badalona, Barcelona, Spain
| | - Cristina Bugés
- Medical Oncology Department, Catalan Institute of Oncology (ICO)-Badalona; Badalona-Applied Research Group in Oncology (B-ARGO)-Germans Trias i Pujol Institute (IGTP); Germans Trias i Pujol University Hospital (HUGTiP), Badalona, Barcelona, Spain
| | - Laura Layos
- Medical Oncology Department, Catalan Institute of Oncology (ICO)-Badalona; Badalona-Applied Research Group in Oncology (B-ARGO)-Germans Trias i Pujol Institute (IGTP); Germans Trias i Pujol University Hospital (HUGTiP), Badalona, Barcelona, Spain
| | - José Luis Manzano
- Medical Oncology Department, Catalan Institute of Oncology (ICO)-Badalona; Badalona-Applied Research Group in Oncology (B-ARGO)-Germans Trias i Pujol Institute (IGTP); Germans Trias i Pujol University Hospital (HUGTiP), Badalona, Barcelona, Spain
| | - Mónica Caro
- Radiation Oncology Department, Catalan Institute of Oncology (ICO)-Badalona; Germans Trias i Pujol University Hospital (HUGTiP), Badalona, Barcelona, Spain
| | - Ricard Mesia
- Medical Oncology Department, Catalan Institute of Oncology (ICO)-Badalona; Badalona-Applied Research Group in Oncology (B-ARGO)-Germans Trias i Pujol Institute (IGTP); Germans Trias i Pujol University Hospital (HUGTiP), Badalona, Barcelona, Spain
| |
Collapse
|
12
|
Cone-beam computed tomography for organ motion evaluation in locally advanced rectal cancer patients. Radiol Med 2020; 126:147-154. [PMID: 32297096 DOI: 10.1007/s11547-020-01193-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 03/30/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE Due to a reported dose-response relationship in rectal cancer radiotherapy, a greater interest in dose intensification on small boost volume arises. Considering the need of an appropriate target movements evaluation, this retrospective study aimed to use cone-beam computed tomography (CBCT) for GTV and mesorectum organ motion (OM) evaluation, in locally advanced rectal cancer (LARC) patients treated with neoadjuvant chemo-radiotherapy, in prone and supine position. METHODS Thirty-two LARC patients were analyzed. GTV and mesorectum were delineated on MRI co-registrated with CT simulation. GTV and mesorectum OM was estimated on all CBCTs, performed during treatment, co-registrated with CT simulation. OM evaluation was obtained, as mean shift in left and right (L-R), postero-anterior (P-A) and cranio-caudal (Cr-C) directions. Volumes variability was calculated by DICE index. RESULTS A total of 296 CBCTs were analyzed. Mean shifts of the GTV and mesorectum in prone position were - 0.16 cm and 0.15 cm in L-R direction, 0.28 cm and - 0.40 cm in P-A direction, and 0.14 cm and - 0.21 cm, in Cr-C direction; for supine position the mean shifts of the GTV were - 0.10 cm and 0.17 cm in R-L direction, 0.26 cm and - 0.23 cm in A-P direction, 0.09 cm and - 0.11 cm in Cr-C direction. Mean DICE index for GTV and mesorectum was 0.74 and 0.86, in prone position, and 0.78 and 0.89 in supine position, respectively. CONCLUSION GTV and mesorectum OM was less than 4 mm in all directions in both positions, with a 1 mm less deviation in supine position. CBCTs resulted effective for OM assessment, and it could be an appropriate method for the implementation on an intensification treatment.
Collapse
|
13
|
Kundel Y, Ben Hur R, Shochat Z, Stanislav Z, Fenig E, Brenner B, Popovtzer A. What is the Best Way to Plan Rectum Three-Dimensional Conformal Radiotherapy in Prone Position-Classic Anatomical Landmark, Three Dimensional Fitting the Planning Target Volume, or Volumetric Modulated Arc? J Med Imaging Radiat Sci 2020; 51:103-107. [PMID: 32067961 DOI: 10.1016/j.jmir.2019.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 11/17/2019] [Accepted: 12/04/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Traditionally, rectal cancer radiation therapy uses bony landmark fields to cover common lymphatic drainage sites, including the internal iliac, presacral, and perirectal lymph nodes. We aimed to investigate if bony landmark borders sufficiently cover the internal iliac nodes and to compare tumor volume and normal tissue avoidance using classic bony landmarks (c3DCRT), contoured elective clinical target volume (f3DCRT), and volumetric modulated arc therapy (VMAT) planning in locally advanced rectal cancer. METHODS Computed tomography datasets of 11 patients with locally advanced rectal cancer who had completed treatment in the prone position on a bellyboard in c3DCRT technique. The elective clinical target volumes and organs at risk were contoured, and a f3DCRT VMAT plan generated for all patients. Planning target volume, gross tumor volume, and normal tissue dose limits were evaluated. RESULTS The mean planning target volume 95% coverages were significantly lower for c3DCRT plans, and the lymph node coverage was better for f3DCRT. No differences were found in PTV coverages between f3DCRT and volumetric modulated arc therapy plans. No significant differences among all techniques were found for organs-at-risk constraints. The bladder dosage was higher in the VMAT plan. The c3DCRT technique missed coverage of the internal iliac lymph nodes and exposed smaller bowel, compared with the other methods. DISCUSSION AND CONCLUSION Tumor volume coverage was improved by f3DCRT planning, without significant differences in doses to critical structures compared with c3DCRT and was noninferior to VMAT planning. It is recommended that f3DCRT be used in routine clinical practice in radiotherapy treatments for locally advanced rectal cancer.
Collapse
Affiliation(s)
- Yulia Kundel
- Davidoff Cancer Center, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Ran Ben Hur
- Physics Unit, Davidoff Cancer Center, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
| | - Zipora Shochat
- Statistical Counseling Unit, Rabin Medical Center, Beilinson Hospital, Petach, Israel
| | - Zakharov Stanislav
- Department of Radiation Oncology, JSC Medicina Clinic, Russian National Research Medical University, Moscow, Russia
| | - Eyal Fenig
- Davidoff Cancer Center, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Baruch Brenner
- Davidoff Cancer Center, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Aron Popovtzer
- Davidoff Cancer Center, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
14
|
Abstract
Radiotherapy (RT) has remained an important pillar in the multi-modality management of rectal cancer. Adjuvant RT with concurrent chemotherapy (chemo-RT) was once the standard of care for locally advanced rectal cancer, but with time, that has now changed and neoadjuvant chemo-RT followed by total mesorectal excision (TME) surgery is the new standard. Alternatively, neoadjuvant RT alone remains an option and clinicians are tasked to choose between the two. In an era of personalised oncological management, it is unsurprising that the treatment for rectal cancer is following suit and upcoming trials are studying ways to improve outcomes and minimise toxicity for patients while tailoring treatments specific to each patient's tumour. We review the evolution of the role of RT in rectal cancer and look forward to what the future holds.
Collapse
Affiliation(s)
- Michelle Tseng
- Department of Radiation Oncology, National University Cancer Institute, Singapore (NCIS), National University Health Systems (NUHS), Singapore, Singapore
| | - Yu Yang Soon
- Department of Radiation Oncology, National University Cancer Institute, Singapore (NCIS), National University Health Systems (NUHS), Singapore, Singapore
| | - Balamurugan Vellayappan
- Department of Radiation Oncology, National University Cancer Institute, Singapore (NCIS), National University Health Systems (NUHS), Singapore, Singapore
| | - Francis Ho
- Department of Radiation Oncology, National University Cancer Institute, Singapore (NCIS), National University Health Systems (NUHS), Singapore, Singapore
| | - Jeremy Tey
- Department of Radiation Oncology, National University Cancer Institute, Singapore (NCIS), National University Health Systems (NUHS), Singapore, Singapore
| |
Collapse
|
15
|
Chiloiro G, Boldrini L, Meldolesi E, Re A, Cellini F, Cusumano D, Corvari B, Mantini G, Balducci M, Valentini V, Gambacorta MA. MR-guided radiotherapy in rectal cancer: First clinical experience of an innovative technology. Clin Transl Radiat Oncol 2019; 18:80-86. [PMID: 31341981 PMCID: PMC6630154 DOI: 10.1016/j.ctro.2019.04.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 04/03/2019] [Accepted: 04/05/2019] [Indexed: 12/15/2022] Open
Abstract
•This study represents one of the first reports of online MRgRT.•Integrated Low-field MR provides better anatomical visualization than CBCT or MVCT.•Better visualization of the target can help to reduce the margins from CTV to PTV.•MRgRT appears a feasible option in rectal cancer treatment offering potential benefits.•MRgRT represents a promising technology for rectal cancer management.
Collapse
Affiliation(s)
- Giuditta Chiloiro
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Roma, Italy
| | - Luca Boldrini
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Roma, Italy
| | - Elisa Meldolesi
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Roma, Italy
| | - Alessia Re
- Unità di Radioterapia Oncologica, Fondazione di Ricerca e Cura Giovanni Paolo II, Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Francesco Cellini
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Roma, Italy
| | - Davide Cusumano
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Fisica Sanitaria, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Roma, Italy
| | - Barbara Corvari
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Roma, Italy
| | - Giovanna Mantini
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Roma, Italy
- Università Cattolica del Sacro Cuore, Istituto di Radiologia, Roma, Italy
| | - Mario Balducci
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Roma, Italy
- Università Cattolica del Sacro Cuore, Istituto di Radiologia, Roma, Italy
| | - Vincenzo Valentini
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Roma, Italy
- Università Cattolica del Sacro Cuore, Istituto di Radiologia, Roma, Italy
| | - Maria Antonietta Gambacorta
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Roma, Italy
- Università Cattolica del Sacro Cuore, Istituto di Radiologia, Roma, Italy
| |
Collapse
|
16
|
Parikh K, DeNittis AS, Marks G, Zeger E, Cho D, Marks J. Neoadjuvant chemotherapy and high-dose radiation using intensity-modulated radiotherapy followed by rectal sparing TEM for distal rectal cancer. ACTA ACUST UNITED AC 2019. [DOI: 10.1007/s13566-019-00389-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
|
17
|
Phase 1 Study of Neoadjuvant Short-Course Radiation Therapy Concurrent With Infusional 5-Fluorouracil for the Treatment of Locally Advanced Rectal Cancer. Adv Radiat Oncol 2019; 4:605-612. [PMID: 31673654 PMCID: PMC6817539 DOI: 10.1016/j.adro.2019.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 04/19/2019] [Accepted: 04/24/2019] [Indexed: 01/19/2023] Open
Abstract
Purpose To assess the safety and feasibility of neoadjuvant short-course radiation therapy (RT) concurrent with continuous infusion 5-fluorouracil (5-FU) for the treatment of locally advanced rectal cancer. Methods and Materials Patients with cT3-4 or N + rectal adenocarcinoma based on ultrasound or magnetic resonance imaging were prospectively enrolled in this study. Study treatment consisted of continuous infusion 5-FU combined with short-course RT (5 Gy x 5 fractions) followed by 4 cycles of mFOLFOX, total mesorectal excision (TME), and 6 cycles of adjuvant mFOLFOX. To mitigate the potential added toxicity from concurrent 5-FU, intensity modulated RT was used. Using the continual reassessment method, the dose of 5-FU was escalated from 100 to a maximum-tolerated dose of 200 mg/m2/d. Results Fourteen patients were accrued. All patients completed continuous infusion 5-FU and short-course RT and the 5-FU dose was safely escalated to 200 mg/m2/d with no dose-limiting toxicity. Thirteen patients received the neoadjuvant mFOLFOX, and only 1 patient went straight to surgery after chemoradiation. Clinical response was 21% complete, 63% partial, 14% stable disease, and no patients had progression. Three patients with cCR had negative biopsies and did not have TME. Pathologic response was 64% partial response and 14% stable disease. No patients had pathologic progression. The most common grade 3 and 4 toxicities were cytopenias. The most common grade 1 and 2 toxicities were cytopenia, fatigue, diarrhea, and nausea. Conclusions Our findings suggest that concurrent chemotherapy with neoadjuvant short-course RT is feasible and can be safely given with concurrent continuous infusion 5-FU. This works adds to the growing evidence that short-course RT is not only equivalent to long-course RT, but also may provide additional benefits, such as allowing for a transition to full dose systemic therapy in the neoadjuvant setting, selective organ preservation in complete responders, and providing a more convenient and cost-effective way of delivering pelvic RT.
Collapse
|
18
|
Neoadjuvant chemoradiotherapy delivered with helical tomotherapy under daily image guidance for rectal cancer patients: efficacy and safety in a large, multi-institutional series. J Cancer Res Clin Oncol 2019; 145:1075-1084. [PMID: 30830296 PMCID: PMC6584215 DOI: 10.1007/s00432-019-02881-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 02/25/2019] [Indexed: 01/14/2023]
Abstract
Purpose Helical tomotherapy (HT) has been recently introduced in the neoadjuvant treatment of locally advanced rectal cancer. Aim of this study is to report the toxicity and local control rates of a large series of locally advanced rectal cancer patients treated with neoadjuvant chemotherapy and HT under daily image guidance followed by surgery. Methods Data from 117 locally advanced rectal cancer patients treated at two Swiss Radiotherapy departments were collected and analyzed. Radiotherapy consisted of 45 Gy (1.8 Gy/fraction, 5 fractions/week delivered in 5 weeks) to the regional pelvic lymph nodes. Seventy patients also received a simultaneous integrated boost (SIB) up to 50 Gy to the tumor and involved nodes (2 Gy/fraction, 5 fractions/week delivered in 5 weeks). Chemotherapy consisted of capecitabine 825 mg/m2, twice daily, during the irradiation days. After a median interval of 59 days [95% confidence interval (CI) 53–65 days), all patients underwent surgery. Results Median follow-up was 45 months (range 4–90 months). The overall rate of acute grade 2–4 toxicity was 18.8% (n = 22). Four patients (3.4%) presented a grade 3 dermatitis (n = 1) or diarrhea (n = 3), and 1 (0.8%) demonstrated grade 4 rectal toxicity. No patients presented with grade ≥ 3 hematologic toxicity. Six patients (5.1%) had late grade 3 gastrointestinal toxicity. The 4-year local control rate was 88.4% (95% CI 87.5–88.5%). Conclusions Neoadjuvant chemoradiotherapy delivered with HT under daily image guidance is well tolerated and shows a high 4-year local control rates.
Collapse
|
19
|
Brennan VS, Curran B, Skourou C, McVeigh E, Dunne M, O'Sullivan L, O'Neill BDP. A novel dynamic arc treatment planning solution to reduce dose to small bowel in preoperative radiotherapy for rectal cancer. Med Dosim 2018; 44:258-265. [PMID: 30360940 DOI: 10.1016/j.meddos.2018.09.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 09/22/2018] [Accepted: 09/25/2018] [Indexed: 12/18/2022]
Abstract
Preoperative radiotherapy or combined chemoradiotherapy for locally advanced rectal cancer (LARC) can cause acute and late gastrointestinal (GI) side-effects. There is thought to be a dose-volume relationship between small bowel irradiation and the development of these effects. A planning study was undertaken to compare small bowel sparing for a range of 3D conformal and dynamic arc planning solutions. A planning study was carried out for 20 LARC patients. Organs at risk (OAR) contoured included bowel loops and peritoneal space (PS). For each of the 20 patients, 5 plans were created: (1) standard 3D conformal plan; (2) standard dual dynamic arc plan; (3) dual dynamic arc plan with 90° avoidance sector through the anterior portion of the patient; (4) dual dynamic arc plan with an anterior avoidance structure in the optimizer; (5) dual dynamic arc plan with both an anterior avoidance structure and an avoidance sector. The prescription was 50.4 Gy in 28 fractions to the planning target volume (PTV). Five Dose Volume Levels (DVLs; V15 Gy, V20 Gy, V25 Gy, V35 Gy, V40 Gy, and V50.4 Gy) for bowel and PS were selected. The DVLs were compared between the plans using Friedman Tests and Wilcoxon Signed Rank Tests. Comparison of the 5 plans revealed that a dual dynamic arc plan containing both an anterior avoidance sector and structure significantly improved the dose to the bowel compared to a standard 3D conformal plan and to a standard dual dynamic arc plan. This improvement was achieved while maintaining PTV coverage. This novel dual dynamic arc planning technique that uses both an avoidance sector and structure reduces the dose to the bowel and PS, which may lead to a reduction in GI toxicity.
Collapse
Affiliation(s)
- Victoria S Brennan
- St Luke's Radiation Oncology Network, Beaumont Hospital, Dublin D06 HH36, Ireland.
| | - Brendan Curran
- St Luke's Radiation Oncology Network, Beaumont Hospital, Dublin D06 HH36, Ireland
| | - Christina Skourou
- St Luke's Radiation Oncology Network, Beaumont Hospital, Dublin D06 HH36, Ireland
| | - Emma McVeigh
- St Luke's Radiation Oncology Network, Beaumont Hospital, Dublin D06 HH36, Ireland
| | - Mary Dunne
- St Luke's Radiation Oncology Network, Beaumont Hospital, Dublin D06 HH36, Ireland
| | - Lydia O'Sullivan
- St Luke's Radiation Oncology Network, Beaumont Hospital, Dublin D06 HH36, Ireland
| | - Brian D P O'Neill
- St Luke's Radiation Oncology Network, Beaumont Hospital, Dublin D06 HH36, Ireland
| |
Collapse
|
20
|
Gurdal N, Fayda M, Alishev N, Bakir B, Tastekin D, Aykan F, Gezer U, Balik E, Saglam EK, Oral EN, Gulluoglu M, Kizir A. Neoadjuvant volumetric modulated arc therapy in rectal cancer and the correlation of pathological response with diffusion-weighted MRI and apoptotic markers. TUMORI JOURNAL 2018; 104:266-272. [PMID: 29218690 DOI: 10.5301/tj.5000702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE In this prospective observational study, we aimed to report the applicability and tolerability of neoadjuvant volumetric modulated arc therapy with simultaneous integrated boost (SIB-VMAT) and concurrent chemotherapy in patients with locally advanced rectal cancer (LARC), and to evaluate the correlation of pathological response with apparent diffusion coefficient (ADC) measurements on diffusion-weighted magnetic resonance imaging (DW-MRI) and apoptotic markers. METHODS The study enrolled 30 patients with T3 to T4 and/or N+ rectal cancer who preoperatively received SIB-VMAT and concurrent chemotherapy. Before and after the neoadjuvant treatment, apoptotic markers including the nucleosomes and cell-free DNA fragments in the serum samples were examined; DNA integrity was assessed by amplifying the ACTB gene; and the ADC measurements on the DW-MRI were analyzed. RESULTS No patients had acute or chronic grade III-IV toxicity. Pathologic complete response (pCR) was achieved in 8 patients (27%), while in 10 patients (33%) near-complete pathological response was obtained. Posttreatment ADC was significantly higher in patients with pCR compared with the others (1.28 vs. 1.10, p = 0.017). ROC curve analysis showed that posttreatment ADC values had a sensitivity of 75% and a specificity of 77.3% for distinguishing the patients with pCR from other responders. On the other hand, posttreatment DNA integrity values were revealed lower than the pretreatment values (p = 0.36). Also, the results revealed an insignificant increase in the posttreatment serum level of nucleosomes (p = 0.72). CONCLUSIONS Neoadjuvant SIB-VMAT with concurrent chemotherapy was proved to be a feasible treatment regimen in LARC with tolerable side effects, and improved local control rate and pCR rate.
Collapse
Affiliation(s)
- Necla Gurdal
- 1 Department of Radiation Oncology, Institute of Oncology, Istanbul University, Istanbul - Turkey
| | - Merdan Fayda
- 2 Department of Radiation Oncology, Istinye University, Faculty of Medicine, Istanbul - Turkey
| | - Nijat Alishev
- 3 Department of Radiology, Istanbul University, Istanbul Faculty of Medicine, Istanbul - Turkey
| | - Baris Bakir
- 3 Department of Radiology, Istanbul University, Istanbul Faculty of Medicine, Istanbul - Turkey
| | - Didem Tastekin
- 4 Department of Medical Oncology, Institute of Oncology, Istanbul University, Istanbul - Turkey
| | - Faruk Aykan
- 4 Department of Medical Oncology, Institute of Oncology, Istanbul University, Istanbul - Turkey
| | - Ugur Gezer
- 5 Department of Basic Oncology, Institute of Oncology, Istanbul University, Istanbul - Turkey
| | - Emre Balik
- 6 Department of General Surgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul - Turkey
| | - Esra Kaytan Saglam
- 1 Department of Radiation Oncology, Institute of Oncology, Istanbul University, Istanbul - Turkey
| | - Ethem Nezih Oral
- 1 Department of Radiation Oncology, Institute of Oncology, Istanbul University, Istanbul - Turkey
| | - Mine Gulluoglu
- 7 Deparment of Pathology, Istanbul University, Istanbul Faculty of Medicine, Istanbul - Turkey
| | - Ahmet Kizir
- 1 Department of Radiation Oncology, Institute of Oncology, Istanbul University, Istanbul - Turkey
| |
Collapse
|
21
|
Alsuhaibani A, Elashwah A, Mahmood R, Abduljabbar A, Alhomoud S, Ashari L, Bazarbashi S, Aljubran A, Alzahrani A, Mohiuddin M, Almanea H, Alhussaini H, AlSanea N. Dose Escalation with Simultaneous Integrated Boost (SIB) Using Volumetric Modulated Arc Therapy (VMAT) in Rectal Cancer. J Gastrointest Cancer 2018; 50:10.1007/s12029-018-0133-0. [PMID: 30006679 DOI: 10.1007/s12029-018-0133-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE Assess feasibility-rate of PCR, short-term toxicity after neoadjuvant concurrent chemoradiation (NACRT) delivered via simultaneous integrated boost (SIB) using volumetric modulated arc therapy (VMAT) technique for locally advanced rectal cancer. METHODS Retrospective evaluation of patients with locally advanced rectal cancer treated with VMAT-SIB technique preoperatively at an academic tertiary care center in Riyadh, Saudi Arabia between February 2013 and March 2017. RESULTS One hundred patients with depth of invasion staged as T3/T4 or T2 in 93 and seven patients, respectively. Lymph node metastasis was staged as N1/N2 or N0 in 87 and 13 patients, respectively. Circumferential radial margin (CRM) was involved radiologically prior to treatment in 50 patients. A dose of 55 or 50 Gy was given to 71 and 29 patients, respectively. All treatments were completed without interruption. Grade 3/4 toxicity was not observed. Low anterior resection and abdominoperineal resection were performed with negative proximal, distal, and radial margins in 72 and 28 patients, respectively. There were no immediate significant postoperative complications. Histologically, no residual tumor (grade 0) was noted in 20 patients (pCR). Regression grade 1, 2, and 3 were noted in 31, 34, and 15 patients. Average number of lymph nodes retrieved in the surgical specimen was 12 (range 6-22). Lymph nodes were negative for cancer in 80 patients. CONCLUSION Dose escalation with SIB-VMAT as NACRT for rectal cancer is feasible. Moreover, it can increase the rate of pathological complete response with a favorable toxicity profile. Clinical benefit of this approach needs to be validated in a larger cohort of patients with longer follow-up.
Collapse
Affiliation(s)
- Abdullah Alsuhaibani
- Oncology Center ,University Medical City, King Saud University, Riyadh, Saudi Arabia.
| | - Ahmed Elashwah
- Section of Radiation Oncology, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
- Kasr Al-Eini Center of Clinical Oncology (NEMROCK), Cairo University, Cairo, Egypt
| | - Rana Mahmood
- Section of Radiation Oncology, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Alaa Abduljabbar
- Section of Colon and Rectal Surgery, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Samar Alhomoud
- Section of Colon and Rectal Surgery, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Luai Ashari
- Section of Colon and Rectal Surgery, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Shouki Bazarbashi
- Section of Medical Oncology, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Ali Aljubran
- Section of Medical Oncology, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Ahmed Alzahrani
- Section of Medical Oncology, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Muhamed Mohiuddin
- Section of Radiation Oncology, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Hadeel Almanea
- Pathology and Laboratory Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Hussah Alhussaini
- Pathology and Laboratory Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Nasser AlSanea
- Section of Colon and Rectal Surgery, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| |
Collapse
|
22
|
Pre-clinical experience of an adaptive plan library strategy in radiotherapy of rectal cancer: An inter-observer study. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2018; 6:89-93. [PMID: 33458395 PMCID: PMC7807563 DOI: 10.1016/j.phro.2018.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 05/28/2018] [Accepted: 06/01/2018] [Indexed: 12/14/2022]
Abstract
Background and purpose The clinical target volume (CTV) in radiotherapy of rectal cancer is subject to large deformations. With a plan library strategy, the treatment may be adapted to these deformations. The purpose of this study was to determine feasibility and consistency in plan selection for a plan library strategy in radiotherapy of rectal cancer. Material and methods Thirty rectal cancer patients were included in this retrospective study with in total 150 CBCT scans. A library of CTVs was constructed with in-house built software using population statistics on daily rectal deformations. The library consisted of five plans based on: the original CTV, two larger, and two smaller CTVs. An inter-observer study (study-I) was performed to test the consistency in plan choices between four observers (all RTTs). After five months the observers were asked to re-evaluate (study-II) the same set of scans based on refined guidelines. Results In study-I the observers reached accordance with the majority choice in 69% of cases. This improved to 87% in study-II. The consensus meeting revealed that inconsistency in choices mainly arose from inadequate instructions, which were later clarified and formulated more accurately. Conclusion Plan selection based on daily CBCT scans for rectal cancer patients is feasible, and can be performed consistently by well-trained RTTs.
Collapse
|
23
|
A treatment planning study of prone vs. supine positions for locally advanced rectal carcinoma. Strahlenther Onkol 2018; 194:975-984. [DOI: 10.1007/s00066-018-1324-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 05/18/2018] [Indexed: 12/11/2022]
|
24
|
Wee CW, Kang HC, Wu HG, Chie EK, Choi N, Park JM, Kim JI, Huang CM, Wang JY, Ng SY, Goodman KA. Intensity-modulated radiotherapy versus three-dimensional conformal radiotherapy in rectal cancer treated with neoadjuvant concurrent chemoradiation: a meta-analysis and pooled-analysis of acute toxicity. Jpn J Clin Oncol 2018; 48:458-466. [DOI: 10.1093/jjco/hyy029] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Affiliation(s)
- Chan Woo Wee
- Department of Radiation Oncology, Seoul National University College of Medicine
| | - Hyun-Cheol Kang
- Department of Radiation Oncology, Seoul National University College of Medicine
| | - Hong-Gyun Wu
- Department of Radiation Oncology, Seoul National University College of Medicine
- Cancer Research Institution, Seoul National University College of Medicine
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Eui Kyu Chie
- Department of Radiation Oncology, Seoul National University College of Medicine
- Cancer Research Institution, Seoul National University College of Medicine
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Noorie Choi
- Department of Radiation Oncology, Seoul National University College of Medicine
| | - Jong Min Park
- Department of Radiation Oncology, Seoul National University College of Medicine
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Jung-in Kim
- Department of Radiation Oncology, Seoul National University College of Medicine
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Chun-Ming Huang
- Department of Radiation Oncology, Kaohsiung Medical University Hospital, Kaohsiung Medical University
| | - Jaw-Yuan Wang
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shu Y Ng
- Alfred Health Radiation Oncology, Victoria, Australia
| | - Karyn A Goodman
- Department of Radiation Oncology, University of Colorado Denver School of Medicine, Aurora
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| |
Collapse
|
25
|
Lin JC, Tsai JT, Chen LJ, Li MH, Liu WH. Compared planning dosimetry of TOMO, VMAT and IMRT in rectal cancer with different simulated positions. Oncotarget 2018; 8:42020-42029. [PMID: 28159930 PMCID: PMC5522046 DOI: 10.18632/oncotarget.14923] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 12/27/2016] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES To compare treatment plans for helical tomotherapy (TOMO), volumetric modulated arc therapy (VMAT) and intensity-modulated radiotherapy (IMRT) for locally advanced rectal cancer (LARC). MATERIALS AND METHODS This retrospective study from December 2010 to June 2013 included 20 patients with LARC who received neoadjuvant concurrent chemoradiotherapy (CCRT) with radiation doses of greater than 50.4 Gy. Dosimetric quality was evaluated based on doses to organs at risk (OARs), including small bowel, urinary bladder and bilateral femoral head, over the same coverage of the clinical target volume (CTV). RESULTS In supine comparison of IMRT with VMAT, VMAT treatment plan had a lower hot spot dose (p=0.0154) and better conformity index (CI, p=0.0036) and homogeneity index (HI, p=0.0246). Lower bladder V34.98 (p=0.0008), V40 (p=0.0058), mean dose (p<0.0001), femoral head mean dose (p=0.0089), V30 (p<0.0001), V40 (p=0.0013) and better CI (p<0.0001) and HI (p=0.0001) were observed for TOMO compared with IMRT. Patients with LARC receiving TOMO planning had lower bladder V34.98 (p=0.0021), V40 (p=0.0055), mean dose (p=0.0039), femoral head mean dose (p=0.0060), V30 (p<0.0001), and V40 (p=0.0044) and better CI (p=0.0157) and HI (p=0.0292) than VMAT. Comparing prone and supine position image planning, there were no significant differences, including in OARs in the three planning systems, except for lower bladder V34.98 (p=0.0403) in the supine position using TOMO. CONCLUSIONS Using modern radiation techniques, neither prone nor supine positions provide better values for OARs. TOMO was superior to IMRT and VMAT in sparing OARs and planning quality parameters.
Collapse
Affiliation(s)
- Jang-Chun Lin
- Department of Radiation Oncology, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan, ROC.,Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, ROC.,Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, ROC.,Department of Radiation Oncology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Jo-Ting Tsai
- Department of Radiation Oncology, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan, ROC.,Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, ROC
| | - Li-Jhen Chen
- Department of Radiation Oncology, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan, ROC
| | - Ming-Hsien Li
- Department of Radiation Oncology, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan, ROC
| | - Wei-Hsiu Liu
- Department of Neurological Surgery, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, ROC.,Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan, ROC
| |
Collapse
|
26
|
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.
Collapse
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
| |
Collapse
|
27
|
But-Hadzic J, Velenik V. Preoperative Intensity-modulated Chemoradiation Therapy with Simultaneous Integrated Boost in Rectal Cancer: 2-year Follow-up Results of Phase II Study. Radiol Oncol 2018. [PMID: 29520202 PMCID: PMC5839078 DOI: 10.1515/raon-2018-0007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background The aim of the study was to investigate the feasibility and safety of experimental fractionation using intensity modulated radiation therapy with a simultaneous integrated boost (IMRT-SIB) to shorten the overall treatment time without dose escalation in preoperative radiochemotherapy of locally advanced rectal cancer. Patients and methods Between January 2014 and November 2015, a total of 51 patients with operable stage II-III rectal adenocarcinoma were treated. The preoperative treatment with intensity modulated radiation therapy (IMRT) and a pelvic dose of 41.8 Gy and simultaneously delivered 46.2 Gy to T2/3 and 48.4 Gy to T4 tumour in 22 fractions, with standard concomitant capecitabine, was completed in 50 patients out of whom 47 were operated. The median follow-up was 35 months. Results The rate of acute toxicity G ≥ 3 was 2.4%. The total downstaging rate was 89% and radical resection was achieved in 98% of patients. Pathologic complete response (pCR) was observed in 25.5% of patients, with 2-year local control (LC), disease free survival (DFS), and overall survival (OS) of 100% for this patient group. An intention-to-treat analysis revealed pN to be a significant prognostic factor for DFS and OS (P = 0.005 and 0.030, respectively). LC for the entire group was 100%, and 2-year DFS and OS were 90% (95 % CI 98.4–81.6) and 92.2% (95% CI 99.6–84.7), respectively. Conclusions The experimental regime in this study resulted in a high rate of pCR with a low acute toxicity profile. Excellent early results translated into encouraging 2-year LC, DFS, and OS.
Collapse
Affiliation(s)
- Jasna But-Hadzic
- Department of Radiotherapy, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Vaneja Velenik
- Department of Radiotherapy, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| |
Collapse
|
28
|
Contraintes de doses aux organes à risque en radiothérapie conformationnelle et stéréotaxique : intestin grêle et duodénum. Cancer Radiother 2017; 21:613-618. [DOI: 10.1016/j.canrad.2017.07.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 07/02/2017] [Indexed: 12/25/2022]
|
29
|
Tey J, Leong CN, Cheong WK, Sze TG, Yong WP, Tham IWK, Lee KM. A phase II trial of preoperative concurrent chemotherapy and dose escalated intensity modulated radiotherapy (IMRT) for locally advanced rectal cancer. J Cancer 2017; 8:3114-3121. [PMID: 29158782 PMCID: PMC5665026 DOI: 10.7150/jca.21237] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 08/11/2017] [Indexed: 02/06/2023] Open
Abstract
Objectives: To determine the pathological response rates and toxicity and in patients with locally advanced rectal cancer treated with concurrent capecitabine and dose escalated intensity modulated radiotherapy (IMRT) Methods: Patients with stage II or III adenocarcinoma of the rectum were treated with preoperative concurrent capecitabine and IMRT. Dose of capecitabine was 825mg/m2, 5 days a week for 5 weeks. IMRT was used to deliver a dose of 45Gy in 25 fractions (1.8Gy per fraction daily, 5 days a week over 5 weeks) to the regional lymphatics and areas at risk of harbouring microscopic disease. A concomitant synchronous integrated boost (SIB) to the gross tumour with a margin to a total dose of 55Gy in 25 fractions was also delivered in the same period. TME surgery was performed 8 weeks after preoperative therapy. The primary endpoint is pathological complete response rate (pCR) and the secondary endpoint was downstaging rates, Sphincter preservation rates (SPR), disease free survival (DFS) at 2 years and toxicity graded using the CTCAE v3.0. Results: Twenty three patients were enrolled. Three were not evaluable; one did not complete treatment due to logistic issues and two declined surgery. The remaining 20 patients completed preoperative chemoIMRT followed by TME surgery. At a median follow-up of 38.2 months (17.5-53.2 months), 90% (18 of 20) patients were alive. The 2 year overall survival and DFS were 90% and 90% respectively. 35%(7/20) of patients had a pCR. 65% (13 of 20) patients had successful downstaging of their rectal tumours. There was no local recurrence. Sphincter preservation rate was 85%. Treatment was well tolerated with only one patient (5%) having Grade 3 radiation proctitis. Conclusions: Preoperative concurrent capecitabine and dose escalated IMRT is well tolerated and results in high rates of pCR. A randomized trial comparing this regimen with standard 3D conformal chemoradiotherapy is warranted.
Collapse
Affiliation(s)
- Jeremy Tey
- Department of Radiation Oncology, National University Cancer Institute, Singapore
| | - Cheng Nang Leong
- Department of Radiation Oncology, National University Cancer Institute, Singapore
| | - Wai Kit Cheong
- Department of Colorectal Surgery, National University Hospital, Singapore
| | - Tay Guan Sze
- Department of Colorectal Surgery, Tan Tock Seng Hospital, Singapore
| | - Wei Peng Yong
- Department of Medical Oncology, National University Cancer Institute, Singapore
| | - Ivan Weng Keong Tham
- Department of Radiation Oncology, National University Cancer Institute, Singapore
| | - Khai Mun Lee
- Department of Radiation Oncology, Farrer Park Hospital, Singapore
| |
Collapse
|
30
|
The Impact of Novel Radiation Treatment Techniques on Toxicity and Clinical Outcomes In Rectal Cancer. CURRENT COLORECTAL CANCER REPORTS 2017; 13:61-72. [PMID: 29445322 DOI: 10.1007/s11888-017-0351-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Purpose of review Three-dimensional conformal radiation therapy (3DCRT) has been the standard technique in the treatment of rectal cancer. The use of new radiation treatment technologies such as intensity-modulated radiation therapy (IMRT), proton therapy (PT), stereotactic body radiation therapy (SBRT) and brachytherapy (BT) has been increasing over the past 10 years. This review will highlight the advantages and drawbacks of these techniques. Recent findings IMRT, PT, SBRT and BT achieve a higher target coverage conformity, a higher organ at risk sparing and enable dose escalation compared to 3DCRT. Some studies suggested a reduction in gastrointestinal and hematologic toxicities and an increase in the complete pathologic response rate; however, the clinical benefit of these techniques remains controversial. Summary The results of these new techniques seem encouraging despite conclusive data. Further trials are required to establish their role in rectal cancer.
Collapse
|
31
|
Huang CM, Huang MY, Tsai HL, Huang CW, Ma CJ, Lin CH, Huang CJ, Wang JY. A retrospective comparison of outcome and toxicity of preoperative image-guided intensity-modulated radiotherapy versus conventional pelvic radiotherapy for locally advanced rectal carcinoma. JOURNAL OF RADIATION RESEARCH 2017; 58:247-259. [PMID: 27738080 PMCID: PMC5571614 DOI: 10.1093/jrr/rrw098] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 08/18/2016] [Indexed: 05/12/2023]
Abstract
The aim of the study was to compare clinical outcomes and toxicity between 3D conformal radiotherapy (3DCRT) and image-guided intensity-modulated radiotherapy (IG-IMRT) administered through helical tomotherapy in locally advanced rectal cancer (LARC) patients receiving preoperative chemoradiotherapy. We reviewed 144 patients with Stage II-III rectal cancer receiving preoperative fluoropyrimidine-based chemoradiotherapy followed by radical resection. Tumor responses following chemoradiotherapy were evaluated using the Dworak tumor regression grade (TRG). Of the 144 patients, 45 received IG-IMRT and 99 received 3DCRT. A significant reduction in Grade 3 or 4 acute gastrointestinal toxicity (IG-IMRT, 6.7%; 3DCRT, 15.1%; P = 0.039) was observed by IG-IMRT. The pathologic complete response (pCR) rate did not differ between the IG-IMRT and the 3DCRT group (17.8% vs 15.1%, P = 0.52). Patients in the IG-IMRT group had the trend of favorable tumor regressions (TRG 3 or 4) compared with those in the 3DCRT group (66.7% vs 43.5%, P = 0.071). The median follow-up was 53 months (range, 18-95 months) in the 3DCRT group and 43 months (range, 17-69 months) in the IG-IMRT group. Four-year overall, disease-free, and local failure-free survival rates of the IG-IMRT and 3DCRT groups were 81.6% and 67.9% (P = 0.12), 53.8% and 51.8% (P = 0.51), and 88% and 75.1% (P = 0.031), respectively. LARC patients treated with preoperative IG-IMRT achieved lower acute gastrointestinal adverse effects and a higher local control rate than those treated with 3DCRT, but there was no prominent difference in distant metastasis rate and overall survival between two treatment modalities.
Collapse
Affiliation(s)
- Chun-Ming Huang
- Department of Radiation Oncology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
| | - Ming-Yii Huang
- Department of Radiation Oncology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
- Department of Radiation Oncology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
| | - Hsiang-Lin Tsai
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
- Division of General Surgery Medicine, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
- Division of Gastroenterology and General Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
- Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
| | - Ching-Wen Huang
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
- Division of Gastroenterology and General Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
| | - Cheng-Jen Ma
- Division of Gastroenterology and General Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
| | - Chih-Hung Lin
- Department of Pathology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
| | - Chih-Jen Huang
- Department of Radiation Oncology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
- Department of Radiation Oncology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
| | - Jaw-Yuan Wang
- Division of Gastroenterology and General Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
- Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
- Cancer Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
- Center for Biomarkers and Biotech Drugs, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
- Center for Environmental Medicine, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
- Corresponding author. Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 807, Taiwan. Tel: +88-6-7-312-2805; Fax: +88-6-7-311-4679; ;
| |
Collapse
|
32
|
Small bowel protection in IMRT for rectal cancer. Strahlenther Onkol 2017; 193:578-588. [DOI: 10.1007/s00066-017-1107-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 01/27/2017] [Indexed: 12/25/2022]
|
33
|
Gonzalez VJ, Hullett CR, Burt L, Rassiah-Szegedi P, Sarkar V, Tward JD, Hazard LJ, Huang YJ, Salter BJ, Gaffney DK. Impact of prone versus supine positioning on small bowel dose with pelvic intensity modulated radiation therapy. Adv Radiat Oncol 2017; 2:235-243. [PMID: 28740937 PMCID: PMC5514253 DOI: 10.1016/j.adro.2017.01.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 01/11/2017] [Indexed: 01/15/2023] Open
Abstract
Purpose To report the results of a prospective study that compares small bowel doses during prone and supine pelvic intensity modulated radiation therapy. Methods and materials Ten patients receiving pelvic radiation therapy each had 2 intensity modulated radiation therapy plans generated: supine and prone on a belly board (PBB). Computed tomography on rails was performed weekly throughout treatment in both positions (10 scans per patient). After image fusion, doses to small bowel (SB) loops and clinical target volume were calculated for each scan. Changes between the planned and received doses were analyzed and compared between positions. The impact of bladder filling on SB dose was also assessed. Results Prone treatment was associated with significantly lower volumes of SB receiving ≥20 Gy. On average, prone on a belly board positioning reduced the volume of SB receiving a given dose of radiation by 28% compared with supine positioning. Target coverage throughout the treatment course was similar in both positions with an average minimum clinical target volume dose of 88% of the prescribed prone dose and 89% of the supine (P = .54). For supine treatment, SB dose was inversely correlated with bladder filling (P = .001-.013; P > .15 for prone). For 96% of treatments, the volume of SB that received a given dose deviated >10% from the plan. The deviation between the planned and delivered doses to SB did not differ significantly between the positions. Conclusions Prone positioning on a belly board during pelvic IMRT consistently reduces the volume of SB that receives a broad range of radiation doses. Prone IMRT is associated with interfraction dose variation to SB that is similar to that of supine positioning. These findings suggest that prone positioning with daily image guided radiation therapy is an effective method for maximizing SB sparing during pelvic IMRT.
Collapse
Affiliation(s)
- Victor J Gonzalez
- Department of Radiation Oncology, University of Arizona, Tucson, Arizona
| | - Craig R Hullett
- Department of Radiation Oncology, University of Wisconsin, Madison, Wisconsin
| | - Lindsay Burt
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Prema Rassiah-Szegedi
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Vikren Sarkar
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Jonathan D Tward
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | | | - Y Jessica Huang
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Bill J Salter
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - David K Gaffney
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| |
Collapse
|
34
|
Dosimetric comparisons of VMAT, IMRT and 3DCRT for locally advanced rectal cancer with simultaneous integrated boost. Oncotarget 2017; 7:6345-51. [PMID: 26621840 PMCID: PMC4868761 DOI: 10.18632/oncotarget.6401] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Accepted: 11/15/2015] [Indexed: 01/14/2023] Open
Abstract
The simultaneous integrated boost radiotherapy for preoperative locally advanced rectal cancer (LARC) can improve the local control and overall survival rates. The purpose of this study is to compare the dosimetric differences among volumetric modulated arc therapy (VMAT), fixed-field intensity modulated radiotherapy (IMRT) and three-dimensional conformal radiotherapy (3DCRT) for the LARC. Ten LARC patients treated in our department using the simultaneous escalate strategy were retrospectively analyzed in this study. All patients had T3 with N+/− and were treated with IMRT. Two additional VMAT and 3DCRT plans were created for each patient. VMAT plans were designed using SmartArc planning module. Both IMRT and SmartArc had similar optimization objectives. The prescription was 50 Gy to the planning clinical target volume (PTV-C) and 56 Gy to the planning gross target volume (PTV-G). The target coverage and organs at risk (OARs) were compared for all the techniques. The paired, two-tailed Wilcoxon signed-rank test was applied for statistical analysis. Results of this study indicate that IMRT and SmartArc were all significantly superior to 3DCRT in most of the relevant values evaluated of target response, OARs and normal tissue sparing. They provided comparable dosimetric parameters for target volume. But IMRT shows better sparing for OARs and normal tissue.
Collapse
|
35
|
Abstract
The primary therapy for any potentially curative rectal cancer is surgery. For locally advanced tumors (i.e., T3-4 and/or node positive), the very high rate of local and distant recurrences has necessitated a standard adjuvant regimen of preoperative chemoradiation and postoperative chemotherapy. Several controversies regarding this approach remain, including the technique and fractionation scheme of radiation therapy prior to surgery, the choice of concomitant chemotherapy, and whether all patients require postoperative systemic therapy. Furthermore, in an era of improving staging imaging and surgical techniques, an opportunity for de-escalation of therapy to improve patient morbidity and quality of life may arise. At the same time, advances in radiation and systemic therapy may help facilitate less invasive, sphincter-preserving surgery. This review addresses these questions and others that remain areas of active clinical investigation.
Collapse
|
36
|
Simson DK, Mitra S, Ahlawat P, Sharma MK, Yadav G, Mishra MB. Dosimetric Comparison between Intensity Modulated Radiotherapy and 3 Dimensional Conformal Radiotherapy in the Treatment of Rectal Cancer. ASIAN PACIFIC JOURNAL OF CANCER PREVENTION : APJCP 2016; 17:4935-4937. [PMID: 28032499 PMCID: PMC5454699 DOI: 10.22034/apjcp.2016.17.11.4935] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Objective: To compare dosimetric parameters of 3 dimensional conformal radiotherapy (3 DCRT) and intensity modulated radiotherapy (IMRT) in terms of target coverage and doses to organs at risk (OAR) in the management of rectal carcinoma. Methods: In this prospective study, conducted between August 2014 and March 2016, all patients underwent CT simulation along with a bladder protocol and target contouring according to the Radiation Therapy Oncology Group (RTOG) guidelines. Two plans were made for each patient (3 DCRT and IMRT) for comparison of target coverage and OAR. Result: A total of 43 patients were recruited into this study. While there were no significant differences in mean Planning Target Volume (PTV) D95% and mean PTV D98% between 3 DCRT and IMRT, mean PTV D2% and mean PTV D50% were significantly higher in 3 DCRT plans. Compared to IMRT, 3 DCRT resulted in significantly higher volumes of hot spots, lower volumes of cold spots, and higher doses to the entire OAR. Conclusion: This study demonstrated that IMRT achieves superior normal tissue avoidance (bladder and bowel) compared to 3 DCRT, with comparable target dose coverage.
Collapse
Affiliation(s)
- David K Simson
- Department of Radiation Oncology, Action Cancer Hospital, Paschim Vihar, Delhi, India.
| | | | | | | | | | | |
Collapse
|
37
|
Novel Radiation Approaches for the Treatment of Rectal Cancer: Where Are We Now? CURRENT COLORECTAL CANCER REPORTS 2016. [DOI: 10.1007/s11888-016-0337-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
|
38
|
But-Hadzic J, Anderluh F, Brecelj E, Edhemovic I, Secerov-Ermenc A, Hudej R, Jeromen A, Kozelj M, Krebs B, Oblak I, Omejc M, Vogrin A, Velenik V. Acute Toxicity and Tumor Response in Locally Advanced Rectal Cancer After Preoperative Chemoradiation Therapy With Shortening of the Overall Treatment Time Using Intensity-Modulated Radiation Therapy With Simultaneous Integrated Boost: A Phase 2 Trial. Int J Radiat Oncol Biol Phys 2016; 96:1003-1010. [PMID: 27727065 DOI: 10.1016/j.ijrobp.2016.08.031] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 08/16/2016] [Accepted: 08/23/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE This phase 2 study investigated the efficacy and safety of preoperative intensity modulated radiation therapy with a simultaneous integrated boost (IMRT-SIB) without dose escalation, concomitant with standard capecitabine chemotherapy in locally advanced rectal cancer. METHODS AND MATERIALS Between January 2014 and March 2015, 51 patients with operable stage II-III rectal adenocarcinoma received preoperative IMRT with pelvic dose of 41.8 Gy and simultaneously delivered 46.2 Gy to T2/3 and 48.4 Gy to T4 tumor in 22 fractions, concomitant with capecitabine, 825 mg/m2/12 hours, including weekends. The primary endpoint was pathologic complete response (pCR). RESULTS Fifty patients completed preoperative treatment according to the protocol, and 47 underwent surgical resection. The sphincter preservation rate for the low rectal tumors was 62%, and the resection margins were free in all but 1 patient. Decrease in tumor and nodal stage was observed in 32 (68%) and 39 (83%) patients, respectively, with pCR achieved in 12 (25.5%) patients. There were only 2 G ≥ 3 acute toxicities, with infectious enterocolitis in 1 patient and dermatitis over the sacral area caused by the bolus effect of the treatment table in the second patient. CONCLUSIONS Preoperative IMRT-SIB without dose escalation is well tolerated, with a low acute toxicity profile, and can achieve a high rate of pCR and downstaging.
Collapse
Affiliation(s)
- Jasna But-Hadzic
- Division of Radiotherapy, Institute of Oncology, Ljubljana, Slovenia.
| | - Franc Anderluh
- Division of Radiotherapy, Institute of Oncology, Ljubljana, Slovenia
| | - Erik Brecelj
- Division of Surgery, Institute of Oncology, Ljubljana, Slovenia
| | | | | | - Rihard Hudej
- Division of Radiotherapy, Institute of Oncology, Ljubljana, Slovenia
| | - Ana Jeromen
- Division of Radiotherapy, Institute of Oncology, Ljubljana, Slovenia
| | - Miran Kozelj
- Division of Surgery, University Medical Centre Maribor, Maribor, Slovenia
| | - Bojan Krebs
- Division of Surgery, University Medical Centre Maribor, Maribor, Slovenia
| | - Irena Oblak
- Division of Radiotherapy, Institute of Oncology, Ljubljana, Slovenia
| | - Mirko Omejc
- Division of Surgery, University Medical Centre Lubljana, Ljubljana, Slovenia
| | - Andrej Vogrin
- Division of Diagnostics, Institute of Oncology, Ljubljana, Slovenia
| | - Vaneja Velenik
- Division of Radiotherapy, Institute of Oncology, Ljubljana, Slovenia
| |
Collapse
|
39
|
Li Y, Wang J, Ma X, Tan L, Yan Y, Xue C, Hui B, Liu R, Ma H, Ren J. A Review of Neoadjuvant Chemoradiotherapy for Locally Advanced Rectal Cancer. Int J Biol Sci 2016; 12:1022-31. [PMID: 27489505 PMCID: PMC4971740 DOI: 10.7150/ijbs.15438] [Citation(s) in RCA: 125] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 06/04/2016] [Indexed: 12/19/2022] Open
Abstract
Neoadjuvant chemoradiotherapy has become the standard treatment for locally advanced rectal cancer. Neoadjuvant chemoradiotherapy not only can reduce tumor size and recurrence, but also increase the tumor resection rate and anus retention rate with very slight side effect. Comparing with preoperative chemotherapy, preoperative chemoradiotherapy can further reduce the local recurrence rate and downstage. Middle and low rectal cancers can benefit more from neoadjuvant chemradiotherapy than high rectal cancer. It needs to refine the selection of appropriate patients and irradiation modes for neoadjuvant chemoradiotherapy. Different therapeutic reactions to neoadjuvant chemoradiotherapy affect the type of surgical techniques, hence calling for the need of much attention. Furthermore, many problems such as accurate staging before surgery, selection of suitable neoadjuvant chemoradiotherapy method, and sensitivity prediction to preoperative radiotherapy need to be well settled.
Collapse
Affiliation(s)
- Yi Li
- 2. Department of Chemotherapy, Oncology Department, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Ji Wang
- 3. Intensive Care Unit, China Mei Tan General Hospital, ChaoYang, Beijing 100028, P.R. China
| | - Xiaowei Ma
- 4. Medical School, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Li Tan
- 4. Medical School, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Yanli Yan
- 4. Medical School, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Chaofan Xue
- 4. Medical School, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Beina Hui
- 1. Department of Radiotherapy, Oncology Department, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Rui Liu
- 1. Department of Radiotherapy, Oncology Department, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Hailin Ma
- 1. Department of Radiotherapy, Oncology Department, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Juan Ren
- 1. Department of Radiotherapy, Oncology Department, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| |
Collapse
|
40
|
Technological advances in radiotherapy of rectal cancer: opportunities and challenges. Curr Opin Oncol 2016; 28:353-8. [DOI: 10.1097/cco.0000000000000306] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
41
|
Preoperative Chemoradiation With VMAT-SIB in Rectal Cancer: A Phase II Study. Clin Colorectal Cancer 2016; 16:16-22. [PMID: 27435759 DOI: 10.1016/j.clcc.2016.06.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 06/07/2016] [Accepted: 06/10/2016] [Indexed: 01/09/2023]
Abstract
PURPOSE The aim of this study was to investigate the efficacy and toxicity of volumetric modulated arc therapy (VMAT)-simultaneous integrated boost (SIB) in preoperative combined treatment of locally advanced rectal cancer. METHODS Radiation therapy was performed using the VMAT-SIB technique. The dose to mesorectum and pelvic lymph nodes was 45 Gy (1.8 Gy/fraction). A concomitant boost was delivered on GTV + 2-cm margin with a total dose of 57.5 Gy (2.3 Gy/fraction). The following concomitant chemotherapy was administered: capecitabine (825 mg/m2 twice daily, 5 days per week) and oxaliplatin (130 mg/m2 on days 1, 17, and 35). Efficacy was evaluated in terms of complete pathological response (pCR). Acute toxicities were evaluated according to Common Terminology Criteria for Adverse Events version 3.0 criteria. RESULTS A total of 18 patients (7 women; median age 62 years; clinical stage: 4 local recurrences, 6 cT4, 5 cT3, 3 cT2, 2 cN0, 7 cN1, 9 cN2) were enrolled. Sixteen patients underwent surgical resection (9 low anterior resection, 6 abdominal perineal amputations; 1 transanal excision) and 2 patients did not undergo surgery for early metastatic progression or death from acute pulmonary edema. R0 resection was achieved in all patients who underwent surgery. Overall, 4 patients had a pCR and 7 patients only a microscopic residual of disease (pT0-Tmic: 11/18 = 61.1%; 95% CI, 36.2-86.1). Acute grade ≥ 3 toxicity was as follows: 1 case of leukopenia, 1 skin toxicity, 1 genitourinary toxicity, and 5 gastrointestinal toxicities, with an overall incidence of 8 (44.4%) of 18 patients. One-, 3-, and 5-year cumulative local control was 100%, 68.6%, and 68.6%, respectively. One-, 3-, and 5-year cumulative disease-free survival was 88.9%, 66.7%, and 66.7%, respectively. One-, 3-, and 5-year cumulative overall survival was 85%, 63.8%, and 63.8%, respectively. CONCLUSION The regimen used in this study showed excellent results in terms of pathologic responses. However, despite the use of the VMAT technique, more than one-third of patients had severe acute toxicity.
Collapse
|
42
|
Al Hussein Al Awamlh B, Nguyen DP, Otto B, O'Malley P, Khan F, Brooks S, Scherr DS. The safety of robot-assisted cystectomy in patients with previous history of pelvic irradiation. BJU Int 2016; 118:437-43. [DOI: 10.1111/bju.13464] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | - Daniel P. Nguyen
- Department of Urology; Weill Cornell Medical College; New York-Presbyterian Hospital; New York NY USA
- Bern University Hospital; Bern Switzerland
| | - Brandon Otto
- Department of Urology; Weill Cornell Medical College; New York-Presbyterian Hospital; New York NY USA
| | - Padraic O'Malley
- Department of Urology; Weill Cornell Medical College; New York-Presbyterian Hospital; New York NY USA
| | - Farehin Khan
- Department of Urology; Weill Cornell Medical College; New York-Presbyterian Hospital; New York NY USA
| | - Savanah Brooks
- Department of Urology; Weill Cornell Medical College; New York-Presbyterian Hospital; New York NY USA
| | - Douglas S. Scherr
- Department of Urology; Weill Cornell Medical College; New York-Presbyterian Hospital; New York NY USA
| |
Collapse
|
43
|
Abstract
Since the advent of radiation therapy for rectal cancer, there has been continual investigation of advancing technologies and techniques that allow for improved dose conformality to target structures while limiting irradiation of surrounding normal tissue. For locally advanced disease, intensity modulated and proton beam radiation therapy both provide more highly conformal treatment volumes that reduce dose to organs at risk, though the clinical benefit in terms of toxicity reduction is unclear. For early stage disease, endorectal contact therapy and high-dose rate brachytherapy may be a definitive treatment option for patients who are poor operative candidates or those with low-lying tumors that desire sphincter-preservation. Finally, there has been growing evidence that supports stereotactic body radiotherapy as a safe and effective salvage treatment for the minority of patients that locally recur following trimodality therapy for locally advanced disease. This review addresses these topics that remain areas of active clinical investigation.
Collapse
Affiliation(s)
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
| |
Collapse
|
44
|
Xu B, Guo Y, Chen Y, Lu H, Tang T, Yue Z, Guan G, Chi P, Lin C. Is the irradiated small bowel volume still a predictor for acute lower gastrointestinal toxicity during preoperative concurrent chemo-radiotherapy for rectal cancer when using intensity-modulated radiation therapy? Radiat Oncol 2015; 10:257. [PMID: 26684643 PMCID: PMC4683870 DOI: 10.1186/s13014-015-0566-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 12/10/2015] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND The small bowel (SB) represents the most important dose-limiting structure in pelvic radiotherapy (RT). However, we observed that the majority of rectal cancer patients who received preoperative pelvic intensity modulated RT (IMRT) developed acute tenesmus without watery diarrhea. The objective of this study is to determine if the RT dose to SB affects the acute lower gastrointestinal toxicity (ALGIT) in rectal cancer patients who received neoadjuvant concurrent chemotherapy-IMRT. We will also evaluate if patient and tumor factors affect the ALGIT. METHODS We retrospectively analyzed 63 rectal cancer patients that consecutively received preoperative IMRT (45 Gy for pelvis and 50 Gy for gross tumor in 25 fractions) with concurrent chemotherapy (oxaliplatin 130 mg/m(2) on day 1 and capecitabine 825 mg/m(2), twice per day from day 1 to day 14, week 1 and 4) between May 2012 and May 2013. The ALGIT was assessed with Common Terminology Criteria for Adverse Events version 3. The patients were stratified into two groups (with and without grade ≥2 ALGIT). The effect of SB volume receiving 5 to 40 Gy (V5 to V40) at a 5 Gy interval dose level on grade ≥2 ALGIT was evaluated. The volume of small bowel is defined as the volume of the small bowel loop. Other factors evaluated include patient's age and gender, tumor size and location and preexisting number of daily bowel movements. RESULTS Overall, grade ≥2 ALGIT occurred in 57 % (36/63) patients. There was no significant difference between the two groups of patients (with and without grade ≥2 ALGIT) in SB V5 to V40, patient's age and gender, tumor location and preexisting number of daily bowel movements. There was a significant difference between the two groups of patients in tumor volume (with grade ≥2 ALGIT: 115.5 ± 85.5 cm(3) versus without grade ≥2 ALGIT: 58.5 ± 25.2 cm(3), p = 0.0001). Multivariate analysis revealed no association between the dose SB received (V5 to V40) and the grade ≥2 ALGIT after adjusting for the tumor volume. CONCLUSIONS With IMRT technique used in rectal cancer patients undergoing preoperative chemo-radiotherapy, the acute lower GI toxicity is not associated with small bowel V5 to V40; instead it is associated with rectal tumor size.
Collapse
Affiliation(s)
- Benhua Xu
- Department of Radiation Oncology, The Fujian Medical University Union Hospital, Fuzhou, Fujian, P.R. China, 350001.
| | - Yuyan Guo
- Department of Radiation Oncology, The Fujian Medical University Union Hospital, Fuzhou, Fujian, P.R. China, 350001.
| | - Yuangui Chen
- Department of Radiation Oncology, The Fujian Medical University Union Hospital, Fuzhou, Fujian, P.R. China, 350001.
| | - Haijie Lu
- Department of Radiation Oncology, The Fujian Medical University Union Hospital, Fuzhou, Fujian, P.R. China, 350001.
| | - Tianlan Tang
- Department of Radiation Oncology, The Fujian Medical University Union Hospital, Fuzhou, Fujian, P.R. China, 350001.
| | - Zhicao Yue
- Institute of Life Sciences, Fuzhou University, Fuzhou, Fujian, P.R. China, 350108.
| | - Guoxian Guan
- Department of General Surgery, The Fujian Medical University Union Hospital, Fuzhou, Fujian, P.R. China, 350001.
| | - Pan Chi
- Department of General Surgery, The Fujian Medical University Union Hospital, Fuzhou, Fujian, P.R. China, 350001.
| | - Chi Lin
- Department of Radiation Oncology, University of Nebraska Medical Center, 987521 Nebraska Medical Center, Omaha, NE, 68106, USA.
| |
Collapse
|
45
|
Arbea L, Aristu J. The Role of Intensity-Modulated Radiotherapy to Optimize Outcomes in Locally Advanced Rectal Cancer. CURRENT COLORECTAL CANCER REPORTS 2015. [DOI: 10.1007/s11888-015-0289-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
46
|
Teoh S, Muirhead R. Rectal Radiotherapy--Intensity-modulated Radiotherapy Delivery, Delineation and Doses. Clin Oncol (R Coll Radiol) 2015; 28:93-102. [PMID: 26643092 DOI: 10.1016/j.clon.2015.10.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 10/28/2015] [Accepted: 10/29/2015] [Indexed: 02/06/2023]
Abstract
The use of intensity-modulated radiotherapy in rectal cancer is attractive in that it may reduce acute and late toxicities and potentially facilitate dose escalation. Intensity-modulated radiotherapy probably has a role in selected patients, but further investigation is required to identify the parameters for selection. Delineation of specific nodal groups allows maximal sparing of bladder and small bowel. In locally advanced tumours a simultaneous integrated boost allows dose escalation incorporating hypofractionation and a shorter overall treatment time. However, due to a sparsity of data on late toxicity in doses ≥ 60 Gy, doses at this level should be used with caution, ideally within prospective trials. Future studies investigating dose escalation must ascertain late toxicity as well as local control, as both can significantly affect quality of life and without both, the risk-benefit ratio cannot be calculated.
Collapse
Affiliation(s)
- S Teoh
- Department of Oncology, Oxford University Hospitals Trust, Oxford, UK
| | - R Muirhead
- The Oxford Institute for Radiation Oncology, University of Oxford, Oxford, UK.
| |
Collapse
|
47
|
Postoperative Capecitabine with Concurrent Intensity-Modulated Radiotherapy or Three-Dimensional Conformal Radiotherapy for Patients with Stage II and III Rectal Cancer. PLoS One 2015; 10:e0124601. [PMID: 25915948 PMCID: PMC4411062 DOI: 10.1371/journal.pone.0124601] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 03/04/2015] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND The aim of this study was to evaluate the survival outcomes and toxicity of postoperative chemoradiotherapy with capecitabine and concurrent intensity-modulated radiotherapy (IMRT) or three-dimensional conformal radiotherapy (3D-CRT) in patients with stage II and III rectal cancer. PATIENTS We recruited 184 patients with pathologically proven, stage II or III rectal cancer. Following total mesorectal excision (TME), the patients were treated with capecitabine and concurrent IMRT/3D-CRT. The treatment regimen consisted of two cycles of oral capecitabine (1600 mg/m2/day), administered twice daily from day 1-14 of radiotherapy, followed by a 7-day rest. The median pelvic dose was 50 Gy in 25 fractions. Oxaliplatin-based adjuvant chemotherapy was administered after the chemoradiotherapy. RESULTS The 5-year overall survival, disease-free survival and locoregional control (LRC) rates were 85.1%, 80% and 95.4%, respectively. Grade 3 and 4 toxicities were observed in 28.3% of patients during treatment. Grade 3 or 4 late toxicity, including neurotoxicity or gastrointestinal toxicity, was only observed in nine patients (4.9%). CONCLUSIONS This study demonstrated that capecitabine chemotherapy with concurrent IMRT/3D-CRT following TME is safe, is well tolerated and achieves superior LRC and favorable survival rates, with acceptable toxicity.
Collapse
|
48
|
Cai G, Zhu J, Palmer JD, Xu Y, Hu W, Gu W, Cai S, Zhang Z. CAPIRI-IMRT: a phase II study of concurrent capecitabine and irinotecan with intensity-modulated radiation therapy for the treatment of recurrent rectal cancer. Radiat Oncol 2015; 10:57. [PMID: 25889149 PMCID: PMC4353448 DOI: 10.1186/s13014-015-0360-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 02/16/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND This study investigated the local effect and acute toxicity of irinotecan and capecitabine with concurrent intensity-modulated radiation therapy (IMRT) for the treatment of recurrent rectal cancer without prior pelvic irradiation. METHODS Seventy-one patients diagnosed with recurrent rectal cancer who did not previously receive pelvic irradiation were treated in our hospital from October 2009 to July 2012. Radiotherapy was delivered to the pelvis, and IMRT of 45 Gy (1.8 Gy per fraction), followed by a boost of 10 Gy to 16 Gy (2 Gy per fraction), was delivered to the recurrent sites. The concurrent chemotherapy regimen was 50 mg/m(2) irinotecan weekly and 625 mg/m(2) capecitabine twice daily (Mon-Fri). Radical surgery was recommended for medically fit patients without extra-pelvic metastases. The patients were followed up every 3 months. Tumor response was evaluated using CT/MRIs according to the RECIST criteria or postoperative pathological findings. NCI-CTC 3.0 was used to score the toxicities. RESULTS Forty-eight patients (67.6%) had confirmed recurrent rectal cancer without extra pelvic metastases, and 23 patients (32.4%) had extra pelvic metastases. Fourteen patients (19.7%) underwent radical resections (R0) post-chemoradiation. A pathologic complete response was observed in 7 of 14 patients. A clinical complete response was observed in 4 patients (5.6%), and a partial response was observed in 22 patients (31.0%). Only 5 patients (7.0%) showed progressive disease during or shortly after treatment. Of 53 symptomatic patients, clinical complete and partial symptom relief with chemoradiation was achieved in 56.6% and 32.1% of patients, respectively. Only 2 patients (2.8%) experienced grade 4 leukopenia. The most common grade 3 toxicity was diarrhea (16 [22.5%] patients). The median follow-up was 31 months. The cumulative local progression-free survival rate was 74.2% and 33.9% at 1 and 3 years after chemoradiation, respectively. The cumulative total survival rate was 80.1% and 36.5% at 1 and 3 years after chemoradiation, respectively. CONCLUSIONS This study revealed that concurrent irinotecan and capecitabine with IMRT significantly relieves local symptoms and exhibits promising efficacy with manageable toxicities in recurrent rectal cancer without prior pelvic irradiation. Improving the rate of R0 resections will be investigated in a future study.
Collapse
Affiliation(s)
- Gang Cai
- Department of Radiation Oncology, Shanghai Cancer Center, Shanghai Medical College, Fudan University, 270 Dong An Road, Shanghai, China.
| | - Ji Zhu
- Department of Radiation Oncology, Shanghai Cancer Center, Shanghai Medical College, Fudan University, 270 Dong An Road, Shanghai, China.
| | - Joshua D Palmer
- Department of Radiation Oncology, Kimmel Cancer Center, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Ye Xu
- Department of Radiation Oncology, Shanghai Cancer Center, Shanghai Medical College, Fudan University, 270 Dong An Road, Shanghai, China.
| | - Weigang Hu
- Department of Radiation Oncology, Shanghai Cancer Center, Shanghai Medical College, Fudan University, 270 Dong An Road, Shanghai, China.
| | - Weilie Gu
- Department of Radiation Oncology, Shanghai Cancer Center, Shanghai Medical College, Fudan University, 270 Dong An Road, Shanghai, China.
| | - Sanjun Cai
- Department of Radiation Oncology, Shanghai Cancer Center, Shanghai Medical College, Fudan University, 270 Dong An Road, Shanghai, China.
| | - Zhen Zhang
- Department of Radiation Oncology, Shanghai Cancer Center, Shanghai Medical College, Fudan University, 270 Dong An Road, Shanghai, China.
| |
Collapse
|
49
|
Cai G, Zhu J, Hu W, Zhang Z. Accelerated hyperfractionated intensity-modulated radiotherapy for recurrent/unresectable rectal cancer in patients with previous pelvic irradiation: results of a phase II study. Radiat Oncol 2014; 9:278. [PMID: 25497847 PMCID: PMC4268809 DOI: 10.1186/s13014-014-0278-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Accepted: 11/26/2014] [Indexed: 01/04/2023] Open
Abstract
Background This study was conducted to investigate the local effects and toxicity of accelerated hyperfractionated intensity-modulated radiotherapy for recurrent/unresectable rectal cancer in patients with previous pelvic irradiation. Methods Twenty-two patients with recurrent/unresectable rectal cancer who previously received pelvic irradiation were enrolled in our single-center trial between January 2007 and August 2012. Reirradiation was scheduled for up to 39 Gy in 30 fractions using intensity-modulated radiotherapy plans. The dose was delivered via a hyperfractionation schedule of 1.3 Gy twice daily. Patient follow-up was performed by clinical examination, CT/MRI, or PET/CT every 3 months for the first 2 years and every 6 months thereafter. Tumor response was evaluated 1 month after reirradiation by CT/MRI based on the RECIST criteria. Adverse events were assessed using the National Cancer Institute (NCI) common toxicity criteria (version 3.0). Results The median time from the end of the initial radiation therapy to reirradiation was 30 months (range, 18-93 months). Overall local responses were observed in 9 patients (40.9%). None of the patients achieved a complete response (CR), and 9 patients (40.9%) had a partial response (PR). Thirteen patients failed to achieve a clinical response: 12 (54.5%) presented with stable disease (SD) and 1 (4.5%) with progressive disease (PD). Among all the patients who underwent reirradiation, partial or complete symptomatic relief was achieved in 6 patients (27.3%) and 13 patients (59.1%), respectively. Grade 4 acute toxicity and treatment-related deaths were not observed. The following grade 3 acute toxicities were observed: diarrhea (2 patients, 9.1%), cystitis (1 patient, 4.5%), dermatitis (1 patient, 4.5%), and intestinal obstruction (1 patient, 4.5%). Late toxicity was infrequent. Chronic severe diarrhea, small bowel obstruction, and dysuria were observed in 2 (9.1%), 1 (4.5%) and 2 (9.1%) of the patients, respectively. Conclusions This study showed that accelerated hyperfractionated intensity-modulated radiotherapy significantly relieved local symptoms and led to a promising local response with an acceptable toxicity profile in patients with recurrent/unresectable rectal cancer and previous pelvic irradiation. Innovative treatment regimens should be evaluated in future studies to improve the clinical outcome while avoiding excessive toxicity in patients with recurrent rectal cancer and previous pelvic irradiation.
Collapse
Affiliation(s)
- Gang Cai
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, China.
| | - Ji Zhu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, China.
| | - Weigang Hu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, China.
| | - Zhen Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, China.
| |
Collapse
|
50
|
Gao YH, Lin JZ, An X, Luo JL, Cai MY, Cai PQ, Kong LH, Liu GC, Tang JH, Chen G, Pan ZZ, Ding PR. Neoadjuvant Sandwich Treatment With Oxaliplatin and Capecitabine Administered Prior to, Concurrently With, and Following Radiation Therapy in Locally Advanced Rectal Cancer: A Prospective Phase 2 Trial. Int J Radiat Oncol Biol Phys 2014; 90:1153-60. [DOI: 10.1016/j.ijrobp.2014.07.021] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 07/10/2014] [Accepted: 07/14/2014] [Indexed: 12/21/2022]
|