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Li C, Xiao YP, Huang L, Jing W, Zhang B, Huang SH, Yang LB, Qiu SF. High buttocks supine position to reduce small bowel exposure in gynecological radiotherapy. Radiat Oncol 2024; 19:131. [PMID: 39334494 PMCID: PMC11428566 DOI: 10.1186/s13014-024-02522-6] [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: 06/25/2024] [Accepted: 09/10/2024] [Indexed: 09/30/2024] Open
Abstract
PURPOSE To minimize radiation exposure to the small bowel (SB) in patients undergoing treatment for gynecological tumors by adopting a comfortable positioning method. METHODS AND PATIENTS All 76 women undergoing Intensity-Modulated Radiation Therapy (IMRT) were included in this study. Patients were immobilized in a supine position using a vacuum bag and thermoplastic cast formation. In the trial group (n = 36), patients raised their buttocks and a solid foam pad was placed under the sacral tail before immobilization. The control group (n = 40) received treatment in the standard supine position. The SB was delineated from the pubic symphysis to the total iliac bifurcation in computed tomography (CT) scans. RESULT In the trial group, a significant reduction in SB volume within the pelvic cavity was observed (mean 399.17 ± 158.7 cc) compared to the control group (mean 547.48 ± 166.9 cc), with a p-value less than 0.001. The trial group showed a statistically significant reduction in the absolute volume of irradiated SB at each dose, ranging from the low dose (10 Gy) to the high dose (45 Gy). In the control group, a negative correlation was found between SB and bladder volumes (R = -0.411, P = 0.008), whereas in the trial group, this correlation was weaker (R = -0.286, P = 0.091), with no significant relationship observed between bladder volume and SB. CONCLUSION The high buttocks supine position effectively reduces SB radiation exposure without the need for bladder distension. This positioning method holds promise for reducing SB irradiation in various pelvic tumors.
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Affiliation(s)
- Chao Li
- College of Clinical Medicine for Oncology, Fujian Medical University, Fujian, China
- Department of Oncology, Second Hospital of Sanming City, Sanming, Fujian, China
| | - You-Ping Xiao
- Department of Radiology, Fujian Medical University Cancer Hospital & Fujian Cancer Hospital, Fuzhou, China
| | - Lin Huang
- Department of Oncology, Second Hospital of Sanming City, Sanming, Fujian Province, China
| | - Wang Jing
- Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, China
| | - Bin Zhang
- Department of Oncology, Second Hospital of Sanming City, Sanming, Fujian Province, China
| | - Song-Hua Huang
- Department of Oncology, Second Hospital of Sanming City, Sanming, Fujian Province, China
| | - Li-Bao Yang
- Department of Oncology, Second Hospital of Sanming City, Sanming, Fujian Province, China
| | - Su-Fang Qiu
- Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, China.
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Goh Y, Kim D, Kim JY, Kim HS, Jeong JH, Lee SU, Youn SH, Oh ES, Ha BR, Yeo AU, Kim M, Shin D, Lee SB, Kim YJ, Kim TH, Lim YK. Active small bowel sparing in intracavitary brachytherapy for cervical cancer. Jpn J Clin Oncol 2021; 52:266-273. [PMID: 34958091 DOI: 10.1093/jjco/hyab197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 11/26/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To propose and evaluate an active method for sparing the small bowel in the treatment field of cervical cancer brachytherapy by prone position procedure. METHODS The prone position procedure consists of five steps: making bladder empty, prone-positioning a patient on belly board, making the small bowel move to abdomen, filling the bladder with Foley catheter and finally turning the patient into the supine position. The proposed method was applied for the treatment of seven cervical cancer patients. Its effectiveness was evaluated and a correlation between the patient characteristics and the volumetric dose reduction of small bowel was also investigated. Brachytherapy treatment plans were built before and after the proposed method, and their dose-volume histograms were compared for targets and organs-at-risk. In this comparison, all plans were normalized to satisfy the same D90% for high-risk clinical target volume. RESULTS For the enrolled patients, the average dose of small bowel was significantly reduced from 75.2 ± 4.9 Gy before to 60.2 ± 4.0 Gy after the prone position procedure, while minor dosimetric changes were observed in rectum, sigmoid and bladder. The linear correlation to body mass index, thickness and width of abdominopelvic cavity and bladder volume were 76.2, 69.7, 28.8 and -36.3%, respectively. CONCLUSIONS The application of prone position procedure could effectively lower the volumetric dose of the small bowel. The dose reduction in the small bowel had a strong correlation with the patient's obesity and abdominal thickness. This means the patients for whom the proposed method would be beneficial can be judiciously selected for safe brachytherapy.
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Affiliation(s)
- Youngmoon Goh
- Department of Radiation Oncology, Asan Medical Center, Seoul, Korea
| | - Dohyeon Kim
- Department of Radiation Oncology, National Cancer Center, Goyang, Korea
| | - Joo-Young Kim
- Department of Radiation Oncology, National Cancer Center, Goyang, Korea
| | - Hak Soo Kim
- Department of Radiation Oncology, National Cancer Center, Goyang, Korea
| | - Jong Hwi Jeong
- Department of Radiation Oncology, National Cancer Center, Goyang, Korea
| | - Sung Uk Lee
- Department of Radiation Oncology, National Cancer Center, Goyang, Korea
| | - Sang Hee Youn
- Department of Radiation Oncology, National Cancer Center, Goyang, Korea
| | - Eun Sang Oh
- Department of Radiation Oncology, National Cancer Center, Goyang, Korea
| | - Bo Ram Ha
- Department of Radiation Oncology, Hallym University Dongtan Sacred Heart Hospital, Dongtan, Korea
| | - Adam Unjin Yeo
- Department of Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Myeongsoo Kim
- Department of Radiation Oncology, National Cancer Center, Goyang, Korea
| | - Dongho Shin
- Department of Radiation Oncology, National Cancer Center, Goyang, Korea
| | - Se Byeong Lee
- Department of Radiation Oncology, National Cancer Center, Goyang, Korea
| | - Yeon-Joo Kim
- Department of Radiation Oncology, National Cancer Center, Goyang, Korea
| | - Tae Hyun Kim
- Department of Radiation Oncology, National Cancer Center, Goyang, Korea
| | - Young Kyung Lim
- Department of Radiation Oncology, National Cancer Center, Goyang, Korea
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Esmati E, Barzegartahamtan M, Maddah A, Alikhassi A, Vaezzadeh V, Mohammadpour R. The effect of patient positioning (prone or supine) on the dose received by small bowel in pelvic radiotherapy in rectal cancer patients. Cancer Radiother 2021; 25:419-423. [PMID: 33812778 DOI: 10.1016/j.canrad.2020.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 02/20/2020] [Accepted: 04/30/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE The small bowel is a main dose-limiting organ in pelvic radiotherapy in the patients with rectal cancer. Conventionally, pelvic radiotherapy of patients with rectal cancer is performed in the prone position. MATERIAL AND METHODS Thirty-nine patients underwent CT planning scan in the treatment position (20 patients in prone position group and 19 patients in supine position group). After radiation treatment planning optimization, the volumes of the irradiated small intestines were investigated. RESULTS The volume of irradiated small bowel was higher in the supine position (mean difference; 36,274 cm3). However, it was not statistically significant (P value=0.187) CONCLUSION: Supine position could be accepted for the patients undergoing preoperative rectal cancer chemo-radiation.
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Affiliation(s)
- E Esmati
- Radiation Oncology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - M Barzegartahamtan
- Clinical Research Center, Loghamn Hakim Hospital, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - A Maddah
- Radiation Oncology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - A Alikhassi
- Cancer Institute, Imam Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - V Vaezzadeh
- Cancer Institute, Imam Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - R Mohammadpour
- Department of Biostatistics, Faculty of Health, Mazandaran University of Medical Sciences, Sari, Iran
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Simple calculation using anatomical features on pre-treatment verification CT for bladder volume estimation during radiation therapy for rectal cancer. BMC Cancer 2020; 20:942. [PMID: 33004026 PMCID: PMC7528380 DOI: 10.1186/s12885-020-07405-z] [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: 07/21/2020] [Accepted: 09/14/2020] [Indexed: 11/25/2022] Open
Abstract
Background Despite detailed instruction for full bladder, patients are unable to maintain consistent bladder filling during a 5-week pelvic radiation therapy (RT) course. We investigated the best bladder volume estimation procedure for verifying consistent bladder volume. Methods We reviewed 462 patients who underwent pelvic RT. Biofeedback using a bladder scanner was conducted before simulation and during treatment. Exact bladder volume was calculated by bladder inner wall contour based on CT images (Vctsim). Bladder volume was estimated either by bladder scanner (Vscan) or anatomical features from the presacral promontory to the bladder base and dome in the sagittal plane of CT (Vratio). The feasibility of Vratio was validated using daily megavoltage or kV cone-beam CT before treatment. Results Mean Vctsim was 335.6 ± 147.5 cc. Despite a positive correlation between Vctsim and Vscan (R2 = 0.278) and between Vctsim and Vratio (R2 = 0.424), Vratio yielded more consistent results than Vscan, with a mean percentage error of 26.3 (SD 19.6, p < 0.001). The correlation between Vratio and Vctsim was stronger than that between Vscan and Vctsim (Z-score: − 7.782, p < 0.001). An accuracy of Vratio was consistent in megavoltage or kV cone-beam CT during treatment. In a representative case, we can dichotomize for clinical scenarios with or without bowel displacement, using a ratio of 0.8 resulting in significant changes in bowel volume exposed to low radiation doses. Conclusions Bladder volume estimation using personalized anatomical features based on pre-treatment verification CT images was useful and more accurate than physician-dependent bladder scanners. Trial registration Retrospectively registered.
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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]
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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.
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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
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White R, Foroudi F, Sia J, Marr MA, Lim Joon D. Reduced dose to small bowel with the prone position and a belly board versus the supine position in neoadjuvant 3D conformal radiotherapy for rectal adenocarcinoma. J Med Radiat Sci 2016; 64:120-124. [PMID: 27741381 PMCID: PMC5454325 DOI: 10.1002/jmrs.187] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 06/04/2016] [Accepted: 06/18/2016] [Indexed: 12/18/2022] Open
Abstract
Introduction No consensus exists regarding the optimal treatment setup for neoadjuvant radiotherapy of rectal cancer using a 3D conformal (3D CRT) technique. Positioning the patient prone with a belly board aims to reduce the amount of small bowel irradiated. Methods Twenty‐five patients with locally advanced rectal cancer underwent computed tomography (CT) planning for neoadjuvant chemoradiotherapy. Patients were simulated prone with a belly board and then in the supine position. Questionnaires rating the comfort of each position were completed. 3D CRT plans were generated for both positions to a prescribed dose of 50.4 Gy in 1.8 Gy daily fractions. Dose–volume parameters in 5 Gy increments for small bowel, large bowel and bladder wall were compared. Results Small bowel V5 Gy, V10 Gy, V15 Gy and V20 Gy values were significantly higher in the supine position (398, 366, 245, 151 cm3 for supine vs. 243, 213, 161, 122 cm3 for prone respectively; P < 0.001, <0.001, <0.001 and 0.025). Large bowel V5 Gy, V10 Gy and V15 Gy values were significantly higher in the supine position (266, 209, 147 cm3 supine, 175, 139, 108 cm3 prone respectively; P = 0.001, <0.001, 0.003). There was a significant difference in comfort scores favouring the supine position (P = 0.015). Conclusion A significant increase in small and large bowel dose was seen in the supine plans. Treatment in the prone position with a belly board may reduce toxicity when using a 3D CRT technique. Whilst both setup positions were tolerable the supine was more comfortable.
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Affiliation(s)
- Rohen White
- Radiation Oncology Department, Olivia Newton John Cancer and Wellness Centre, Heidelberg, Victoria, Australia
| | - Farshad Foroudi
- Radiation Oncology Department, Olivia Newton John Cancer and Wellness Centre, Heidelberg, Victoria, Australia
| | - Joseph Sia
- Radiation Oncology Department, Olivia Newton John Cancer and Wellness Centre, Heidelberg, Victoria, Australia
| | - Mary Ann Marr
- Radiation Oncology Department, Olivia Newton John Cancer and Wellness Centre, Heidelberg, Victoria, Australia
| | - Daryl Lim Joon
- Radiation Oncology Department, Olivia Newton John Cancer and Wellness Centre, Heidelberg, Victoria, Australia
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8
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Role of belly board device in the age of intensity modulated radiotherapy for pelvic irradiation. Med Dosim 2016; 41:300-304. [DOI: 10.1016/j.meddos.2016.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 07/15/2016] [Accepted: 07/20/2016] [Indexed: 11/19/2022]
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Frøseth TC, Strickert T, Solli KS, Salvesen Ø, Frykholm G, Reidunsdatter RJ. A randomized study of the effect of patient positioning on setup reproducibility and dose distribution to organs at risk in radiotherapy of rectal cancer patients. Radiat Oncol 2015; 10:217. [PMID: 26508131 PMCID: PMC4624657 DOI: 10.1186/s13014-015-0524-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 10/16/2015] [Indexed: 02/02/2023] Open
Abstract
Background The patient positioning in pelvic radiotherapy (RT) should be decided based on both reproducibility and on which position that yields the lowest radiation dose to the organs at risk (OAR), and thereby less side effects to patients. The present randomized study aimed to evaluate the influence of patient positioning on setup reproducibility and dose distribution to OAR in rectal cancer patients. Methods Ninety-one patients were randomized into receiving RT in either supine or prone position. The recruitment period was from 2005 to 2008. Position deviations were derived from electronic portal image registrations, and setup errors were defined as deviations between the expected and the actual position of bony landmarks. Setup deviations were expressed into three table shift values (∆x, ∆y, ∆z) from which the deviation vector \documentclass[12pt]{minimal}
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\begin{document}$$ \left|\overrightarrow{v}\right| $$\end{document}v→ were calculated. The estimated lengths of \documentclass[12pt]{minimal}
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\begin{document}$$ \left|\overrightarrow{v}\right| $$\end{document}v→ defined the main outcome and were compared between prone and supine positions using linear mixed model statistics. The mean volume of each 5 Gy increments between 5 and 45 Gy was calculated for the small bowel and the total bowel, and the dose volumes were compared between prone and supine position. Results and conclusion Data from 83 patients was evaluable. The mean \documentclass[12pt]{minimal}
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\begin{document}$$ \left|\overrightarrow{v}\right| $$\end{document}v→ was 5.8 mm in supine position and 7.1 mm in prone position (p = 0.024), hence the reproducibility was significantly superior in supine position. However, the difference was marginal and may have borderline clinical importance. The irradiated volumes of the small bowel and the total bowel were largest in the supine position for all dose levels, but none of those were significantly different. The patient positioning in RT of rectal cancer patients may therefore be decided based on other factors such as the most comfortable position for the patients.
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Affiliation(s)
- Trude C Frøseth
- Department of Oncology, St. Olavs University Hospital, Trondheim, Norway
| | - Trond Strickert
- Department of Oncology, St. Olavs University Hospital, Trondheim, Norway
| | - Kjersti S Solli
- Department of Oncology, St. Olavs University Hospital, Trondheim, Norway
| | - Øyvind Salvesen
- Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
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Cho Y, Chang JS, Kim MS, Lee J, Byun H, Kim N, Park SJ, Keum KC, Koom WS. Morphologic change of rectosigmoid colon using belly board and distended bladder protocol. Radiat Oncol J 2015; 33:134-41. [PMID: 26157683 PMCID: PMC4493425 DOI: 10.3857/roj.2015.33.2.134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 05/15/2015] [Accepted: 05/20/2015] [Indexed: 12/18/2022] Open
Abstract
Purpose This study investigates morphologic change of the rectosigmoid colon using a belly board in prone position and distended bladder in patients with rectal cancer. We evaluate the possibility of excluding the proximal margin of anastomosis from the radiation field by straightening the rectosigmoid colon. Materials and Methods Nineteen patients who received preoperative radiotherapy between 2006 and 2009 underwent simulation in a prone position (group A). These patients were compared to 19 patients treated using a belly board in prone position and a distended bladder protocol (group B). Rectosigmoid colon in the pelvic cavity was delineated on planning computed tomography (CT) images. A total dose of 45 Gy was planned for the whole pelvic field with superior margin of the sacral promontory. The volume and redundancy of rectosigmoid colon was assessed. Results Patients in group B had straighter rectosigmoid colons than those in group A (no redundancy; group A vs. group B, 10% vs. 42%; p = 0.03). The volume of rectosigmoid colon in the radiation field was significantly larger in group A (56.7 vs. 49.1 mL; p = 0.009). In dose volume histogram analysis, the mean irradiated volume was lower in patients in group B (V45 27.2 vs. 18.2 mL; p = 0.004). In Pearson correlation coefficient analysis, the in-field volume of rectosigmoid colon was significantly correlated with the bladder volume (R = 0.86, p = 0.003). Conclusion Use of a belly board and distended bladder protocol could contribute to exclusion of the proximal margin of anastomosis from the radiation field.
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Affiliation(s)
- Yeona Cho
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
| | - Jee Suk Chang
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
| | - Mi Sun Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
| | | | - Hwakyung Byun
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
| | - Nalee Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
| | - Sang Joon Park
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
| | - Ki Chnag Keum
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
| | - Woong Sub Koom
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
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Reis T, Khazzaka E, Welzel G, Wenz F, Hofheinz RD, Mai S. Acute small-bowel toxicity during neoadjuvant combined radiochemotherapy in locally advanced rectal cancer: determination of optimal dose-volume cut-off value predicting grade 2-3 diarrhoea. Radiat Oncol 2015; 10:30. [PMID: 25636703 PMCID: PMC4324657 DOI: 10.1186/s13014-015-0336-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 01/21/2015] [Indexed: 12/18/2022] Open
Abstract
Background Current therapeutic standard for locally advanced rectal cancer is the neoadjuvant radiochemotherapy with total mesorectal excision. Diarrhoea is the main acute side effect, induced by the dose to the small-bowel, frequently leading to a treatment modification. Aim of this study was to analyse the differences between the irradiated small-bowel volumes and the occurrence of acute diarrhea during combined radiochemotherapy for rectal cancer. Methods 45 patients treated with a neoadjuvant radiochemotherapy (three-field box 50.4 Gy; Cetuximab, Capecitabine, Irinotecan) for locally advanced rectal cancer within a prospective phase I/II study were evaluated. Based on the dose-volume histograms, the small-bowel volumes receiving doses of 5, 10 … 45 Gy (V5, V10 …V45) were calculated and compared with the prospectively documented small- bowel toxicities. Results There was a statistically significant difference between irradiated small-bowel volumes and the severity of therapy related diarrhoea. The strongest validity concerning the risk of developing a grade 2–3 diarrhoea was seen at a dose level of 5 Gy (V 5) with a small-bowel volume of 291.94 cc. Patients with V 5 > 291.94 cc had significantly more often grade 2–3 diarrhoea, than patients with V5 below this cut-off value (82% vs. 29%; p < 0.0001). Conclusions In the inverse treatment planning of rectal caner patients the small-bowel volume receiving 5 Gy should be limited to about 300 cc.
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Affiliation(s)
- Tina Reis
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany.
| | - Edwin Khazzaka
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany.
| | - Grit Welzel
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany.
| | - Frederik Wenz
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany.
| | - Ralf-Dieter Hofheinz
- Medical Clinic, University Medical Center Mannheim, University of Heidelberg, Heidelberg, Germany.
| | - Sabine Mai
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany.
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An investigation of rotational issues for rectal carcinoma treated with radiotherapy. JOURNAL OF RADIOTHERAPY IN PRACTICE 2014. [DOI: 10.1017/s146039691300023x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractPurposeTo quantify the amount of inter-fractional pitch for rectal carcinoma patients, to investigate the dosimetric impact of pitch on the target volume and critical structures and to determine a tolerance where no pitch correction is required.Materials and methodsDaily pre-treatment images of rectal carcinoma patients were analysed to determine the residual pitch compared with the computed tomography (CT) planning scan. The dosimetric impact of pelvic rotation was modelled. The dose coverage of the clinical target volume (CTV) and small bowel were evaluated using dose–volume histograms.ResultsPre-treatment images had a mean of 0·27° and standard deviation was 2·23°. The volume of CTV receiving 95% of the prescription dose altered by 0·1% when up to ±10° of pitch was simulated.ConclusionsNo clinically significant change in CTV coverage was found (when ±10° of pitch was simulated). A tolerance of ±10° of pitch has been implemented for rectal carcinoma patients treated with three-dimensional conformal radiotherapy in our institution, when daily pre-treatment imaging with a zero action threshold for translational shifts is used.
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Cetin E, Ozturk AS, Orhun H, Ulger S. Role of triamcinolone in radiation enteritis management. World J Gastroenterol 2014; 20:4341-4344. [PMID: 24764671 PMCID: PMC3989969 DOI: 10.3748/wjg.v20.i15.4341] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Accepted: 01/02/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the role of triamcinolone in the management of acute and chronic enteritis caused by pelvic radiotherapy.
METHODS: Twenty-eight patients with rectum adenocarcinoma or endometrium adenocarcinoma were studied. We compared the results of 14 patients treated with injected triamcinolone acetonide (TA) with those of 14 patients who were not treated with TA. For the TA group, 40 mg of TA was injected intramuscularly on the 1st, 11th and 21st d of radiotherapy; the control group received no injections. All of the study participants had a median age of 65 years, had undergone postoperative radiotherapy and were evaluated weekly using Radiation Therapy Oncology Group and the European Organization for Research and Treatment of Cancer Acute Morbidity Score Criteria, and complete blood counts for every 10 d.
RESULTS: Triamcinolone was found to effectively prevent and treat radiation-induced acute gastrointestinal (enteritis) and genitourinary (cystitis) side effects (P = 0.022 and P = 0.023). For the lower GI side effect follow up, 11 patients in the control group had Grade 2 toxicity and 3 patients had Grade 1 toxicity. In the TA group, 5 patients had Grade 2 toxicity and 9 patients had Grade 1 toxicity. For the genitourinary system side effect follow up, 4 patients had Grade 2 toxicity and 6 patients had Grade 1 toxicity. Additionally, 2 patients had Grade 2 toxicity and 2 patients had Grade 1 toxicity. The neutrophil counts did not differ between the TA group and the control group. There was no meaningful difference between age groups and primary cancers. At the 12th mo of follow up, there were no differences between groups for chronic side effects.
CONCLUSION: Triamcinolone is a moderately potent steroid, that is inexpensive and has a good safety profile. It would be beneficial for reducing medical expenses related to treatment of radiation induced enteritis.
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Délinéation des volumes cibles anatomocliniques pour la radiothérapie des cancers du col utérin. Cancer Radiother 2013; 17:486-92. [DOI: 10.1016/j.canrad.2013.06.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Accepted: 06/05/2013] [Indexed: 11/19/2022]
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Terashima K, Nakamura K, Shioyama Y, Sasaki T, Ohga S, Nonoshita T, Yoshitake T, Atsumi K, Asai K, Hirakawa M, Anai S, Yoshikawa H, Honda H. Can a Belly Board Reduce Respiratory-Induced Prostate Motion in the Prone Position? — Assessed by Cine-Magnetic Resonance Imaging. Technol Cancer Res Treat 2013; 12:447-53. [DOI: 10.7785/tcrt.2012.500334] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The purpose of this study is to evaluate the real-time respiratory motion of the prostate and surrounding tissues/organs in the supine and prone positions and to investigate, using cine-MRI, whether a belly board can reduce respiratory-induced motion in the prone position. Cine-MRI scans were made of 13 volunteers in the supine and prone positions on a flat board and in two different prone positions using a belly board. Images in cine mode were recorded for 20 seconds. For each session, the points of interest (POIs) were located at the apex, base, mid-anterior surface and mid-posterior surface of the prostate; the tip of the seminal vesicle; the pubic symphysis; and the sacrum. The maximum range and standard deviation (SD) of the displacement from the mean value were calculated. The SDs for each of the four different positions were compared using a paired t-test. Respiratory-induced prostate motion was significantly larger in the prone position than in the supine position. However, when a belly board was used in the prone position, motion in the prostate and surrounding tissues/organs was significantly reduced. There were no significant differences between the two different positions using a belly board in any of the POIs.
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Affiliation(s)
- K. Terashima
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - K. Nakamura
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Y. Shioyama
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - T. Sasaki
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - S. Ohga
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - T. Nonoshita
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - T. Yoshitake
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - K. Atsumi
- Department of Radiology, Kyushu University Hospital at Beppu, Beppu, Japan
| | - K. Asai
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - M. Hirakawa
- Department of Radiology, Kyushu University Hospital at Beppu, Beppu, Japan
| | - S. Anai
- Department of Radiology, Kyushu University Hospital at Beppu, Beppu, Japan
| | - H. Yoshikawa
- Department of Radiology, Kyushu University Hospital at Beppu, Beppu, Japan
| | - H. Honda
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Chung Y, Yoon HI, Keum KC, Kim JH, Choi WH, Nam KC, Koom WS. Effect of belly board with bladder compression device on small bowel displacement from the radiotherapy field for rectal cancer. ACTA ACUST UNITED AC 2013; 36:241-6. [PMID: 23689217 DOI: 10.1159/000350299] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The aim of this study was to investigate the effect of a belly board (BB) with the addition of a bladder compression device (BCD) for small bowel (SB) displacement from the radiotherapy field for rectal cancer. PATIENTS AND METHODS Computed tomography (CT) scans of 38 rectal cancer patients positioned on a BB were analyzed and compared with CT scans from the same patients after the addition of a BCD. The BCD moves the inferior border of the BB from the pubic symphysis to the lumbosacral junction. The treated and irradiated volumes of the SB and bladder were compared. The irradiated volume ratio of SB to abdominopelvic cavity (APC) and that of bladder to APC were analyzed. RESULTS With the BCD, the treated and irradiated volumes of SB decreased significantly (49.1 ± 48.0 vs. 60.9 ± 50.9 cc, p = 0.006 and 207.5 ± 140.8 vs. 482.8 ± 214.2 cc, p < 0.001, respectively). The irradiated volume ratio of bladder to APC with the BCD increased considerably compared to that without the BCD (25.2 ± 11.5 vs. 18.7 ± 10.5%, p < 0.001), and the ratio of irradiated volume of SB to APC decreased significantly with the BCD (18.8 ± 12.4 vs. 31.8 ± 12.1%, p < 0.001). CONCLUSION This study showed that the addition of a BCD to the BB could effectively provide further displacement of SB from the rectal cancer radiotherapy field.
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Affiliation(s)
- Yoonsun Chung
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, South Korea
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Qiu H, Herman JM, Ahuja N, DeWeese TL, Song DY. Neoadjuvant chemoradiation followed by interstitial prostate brachytherapy for synchronous prostate and rectal cancer. Pract Radiat Oncol 2012; 2:e77-e84. [PMID: 24674189 DOI: 10.1016/j.prro.2011.11.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2011] [Revised: 11/03/2011] [Accepted: 11/03/2011] [Indexed: 11/28/2022]
Abstract
PURPOSE To describe outcomes with the use of neoadjuvant pelvic chemoradiation followed by prostate interstitial brachytherapy for the treatment of synchronous prostate and rectal cancers. METHODS AND MATERIALS An Internal Review Board approved retrospective review was undertaken of 4 patients with synchronous prostate and rectal cancer treated between 2006 and 2008. Patients underwent pelvic chemoradiation followed by prostate brachytherapy, then low anterior resection of the rectum with diverting loop ileostomy and adjuvant chemotherapy. Follow-up evaluation included imaging and laboratory analysis of cancer markers in addition to routine interval history and physical examination. RESULTS At 38-62 months postdiagnosis (24-53 months post-treatment), 6 of 8 cancers remained without evidence of relapse. One patient had rising carcinoembryonic antigen levels but no clinically evident rectal cancer relapse; another developed bony metastasis of his high-risk prostate cancer. Three patients experienced grade 1-2 treatment-related toxicity; one patient had grade 3 gastrointestinal toxicity from radiation and surgery, which precluded his receiving adjuvant chemotherapy and ileostomy reversal. CONCLUSIONS Chemoradiation followed by prostate brachytherapy, surgery, and adjuvant chemotherapy may be utilized to manage patients with synchronous prostate and rectal cancers.
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Affiliation(s)
- Haoming Qiu
- The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joseph M Herman
- Department of Radiation Oncology, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Nita Ahuja
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Theodore L DeWeese
- Department of Radiation Oncology, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Danny Y Song
- Department of Radiation Oncology, The Johns Hopkins Hospital, Baltimore, Maryland.
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18
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Wiesendanger-Wittmer EM, Sijtsema NM, Muijs CT, Beukema JC. Systematic review of the role of a belly board device in radiotherapy delivery in patients with pelvic malignancies. Radiother Oncol 2012; 102:325-34. [PMID: 22364650 DOI: 10.1016/j.radonc.2012.02.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2011] [Revised: 02/01/2012] [Accepted: 02/07/2012] [Indexed: 11/19/2022]
Abstract
PURPOSE This review analyses the literature concerning the influence of the patient position (supine, prone and prone on a belly board device (BB) on the irradiated small-bowel-volume (SB-V)) and the resulting morbidity of radiation therapy (RT) in pelvic malignancies. METHODS A literature search was performed in MEDLINE, web of science and Scopus. RESULTS Forty-six full papers were found, of which 33 met the eligibility criteria. Fifteen articles focussed on the irradiated SB-V using dose volume histograms (DVHs). Twenty-seven articles studied the patient setup in different patient positions. This review showed that a prone treatment position can result in a lower irradiated SB-V as compared to a supine position, but a more significant reduction of the SB-V can be reached by the additional use of a BB in prone position, for both 3D-CRT and IMRT treatment plans. This reduction of the irradiated SB-V might result in a reduced GI-morbidity. The patient position did not influence the required PTV margins for prostate and rectum. CONCLUSIONS The irradiated SB-V can be maximally reduced by the use of a prone treatment position combined with a BB for both 3D-CRT and IMRT, which might individually result in a reduction of GI-morbidity.
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Volumetric modulated arc therapy with simultaneous integrated boost for locally advanced rectal cancer. Clin Oncol (R Coll Radiol) 2011; 24:261-8. [PMID: 21820294 DOI: 10.1016/j.clon.2011.07.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Revised: 06/08/2011] [Accepted: 06/09/2011] [Indexed: 11/21/2022]
Abstract
AIMS To report the feasibility of volumetric modulated arc therapy (VMAT) for neoadjuvant radiotherapy in locally advanced rectal cancer in a dose-escalation protocol and simultaneous integrated boost (SIB) approach. Moreover, the VMAT technique was compared with three-dimensional conformal radiotherapy (3D-CRT) and fixed-field intensity modulated radiotherapy (IMRT), in terms of target coverage and irradiation of organs at risk. MATERIALS AND METHODS Eight patients with locally advanced rectal cancer were treated with the SIB-VMAT technique. The VMAT plans were compared with 3D-CRT and IMRT techniques in terms of several clinically dosimetric parameters. The number of monitor units and the delivery time were analysed to score the treatment efficiency. All plans were verified in a dedicated solid water phantom using a two-dimensional array of ionisation chambers. RESULTS All techniques meet the prescription goal for planning target volume coverage, with VMAT showing the highest level of conformality. VMAT is associated with 40, 53 and 58% reduction in the percentage of volume of small bowel irradiated to 30, 40 and 50Gy, compared with 3D-CRT. No significant differences were found with respect to SIB-IMRT. VMAT plans showed a significant reduction of monitor units by nearly 20% with respect to IMRT and reduced treatment time from 14 to 5min for a single fraction. CONCLUSIONS SIB-VMAT plans can be planned and carried out with high quality and efficiency for rectal cancer, providing similar sparing of organs at risk to SIB-IMRT and resulting in the most efficient treatment option. SIB-VMAT is currently our standard approach for radiotherapy of locally advanced rectal cancer.
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20
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Nijkamp J, Doodeman B, Marijnen C, Vincent A, van Vliet-Vroegindeweij C. Bowel exposure in rectal cancer IMRT using prone, supine, or a belly board. Radiother Oncol 2011; 102:22-9. [PMID: 21723637 DOI: 10.1016/j.radonc.2011.05.076] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Revised: 05/03/2011] [Accepted: 05/23/2011] [Indexed: 01/28/2023]
Abstract
PURPOSE To investigate bowel exposure using prone, supine, or two different belly boards for rectal cancer intensity modulated RT plans using a full bladder protocol. METHODS AND MATERIALS For 11 volunteers four MR scans were acquired, on a flat table in prone, supine, and on two different belly boards (IT-V Medizintechnik GmbH® (BB1) and CIVCO® (BB2)), using a full bladder protocol. On each scan a 25×2 Gy IMRT plan was calculated. RESULTS BB2 led to an average bowel area volume reduction of 20-30% at any dose level compared to prone. BB1 showed a smaller dose reduction effect, while no differences between prone and supine were found. Differences between BB2 and prone, supine or BB1 were significant up to a level of respectively, 45, 35, and 30 Gy. The reducing effect varied among individuals, except for the 50 Gy region, where no effect was found. An increase in bladder volume of 100 cc led to a significant bowel area V15 reduction of 16% independent of scan type. CONCLUSIONS In the low and intermediate dose region a belly board still attributes to a significant bowel dose reduction when using IMRT and a full bladder protocol. A larger bladder volume resulted in a significant decreased bowel area dose.
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Affiliation(s)
- Jasper Nijkamp
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
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21
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Brierley JD, Dawson LA, Sampson E, Bayley A, Scott S, Moseley JL, Craig T, Cummings B, Dinniwell R, Kim JJ, Ringash J, Wong R, Brock KK. Rectal Motion in Patients Receiving Preoperative Radiotherapy for Carcinoma of the Rectum. Int J Radiat Oncol Biol Phys 2011; 80:97-102. [DOI: 10.1016/j.ijrobp.2010.01.042] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2009] [Revised: 01/09/2010] [Accepted: 01/16/2010] [Indexed: 11/26/2022]
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22
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López Rodríguez M, Martín Martín M, Cerezo Padellano L, Marín Palomo A, Ibáñez Puebla Y. Gastrointestinal toxicity associated to radiation therapy. Clin Transl Oncol 2010; 12:554-61. [DOI: 10.1007/s12094-010-0553-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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23
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Martin E, Pointreau Y, Roche-Forestier S, Barillot I. [Normal tissue tolerance to external beam radiation therapy: small bowel]. Cancer Radiother 2010; 14:350-3. [PMID: 20598616 DOI: 10.1016/j.canrad.2010.03.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2010] [Revised: 02/22/2010] [Accepted: 03/03/2010] [Indexed: 01/12/2023]
Abstract
The small bowel is a hollow organ involved in the transit and absorption of food. In relation to its anatomical location, a significant amount of this organ is exposed in whole or in part to ionizing radiation in external radiotherapy during abdominal or pelvic irradiation either for primary cancers or metastasis. The acute functional changes during external beam radiation are mainly leading to diarrhea, abdominal pain and bloating. The main late side effects of irradiation of the small intestine are chronic diarrhea, malabsorption with steatorrhea, abdominal spasms, intestinal obstruction, bleeding and fistulas. The architecture of the small intestine may be considered as parallel with a significant correlation between the irradiated volume of small bowel and the likelihood of acute toxicity, whatever the dose. The literature analysis recommends to consider the volume of small bowel receiving 15 Gy (threshold of 100 to 200 cm(3)) but also 30 and 50 Gy (thresholds of 35 to 300 cm(3), depending on the level of dose considered). Modern techniques of conformal radiotherapy with modulated intensity will probably have beneficial impact on small bowel toxicity.
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Affiliation(s)
- E Martin
- Département de Radiothérapie, Centre Georges-Francois-Leclerc, 1 Rue du Professeur-Marion, 21079 Dijon cedex, France
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24
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Nijkamp J, Kusters M, Beets-Tan RGH, Martijn H, Beets GL, van de Velde CJH, Marijnen CAM. Three-dimensional analysis of recurrence patterns in rectal cancer: the cranial border in hypofractionated preoperative radiotherapy can be lowered. Int J Radiat Oncol Biol Phys 2010; 80:103-10. [PMID: 20646849 DOI: 10.1016/j.ijrobp.2010.01.046] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2009] [Revised: 01/15/2010] [Accepted: 01/15/2010] [Indexed: 12/22/2022]
Abstract
PURPOSE The aim of this study was to determine whether and where the radiotherapy (RT) clinical target volume (CTV) could be reduced in short-course preoperative treatment of rectal cancer patients. METHODS AND MATERIALS Patients treated in the Dutch total mesorectal excision trial, with a local recurrence were analyzed. For 94 (25 who underwent radiation therapy 69 who did not) of 114 patients with a local recurrence, the location of the recurrence was placed in a three-dimensionalthree (3D) model. The data in the 3D model were correlated to the clinical trial data to distinguish a group of patients eligible for CTV reduction. Effects of CTV reduction on dose to the small bowel was tested retrospectively in a dataset of 8 patients with three-field conformal plans and intensity-modulated RT (IMRT). RESULTS The use of preoperative RT mainly reduces anastomotic, lateral, and perineal recurrences. In patients without primary nodal involvement, no recurrences were found cranially of the S2-S3 interspace, irrespective of the delivery of RT. In patients without primary nodal involvement and a negative circumferential resection margin (CRM), only one recurrence was found cranial to the S2-S3 interspace. With a cranially reduced CTV to the S2-S3 interspace, over 60% reduction in absolute small bowel exposure at dose levels from 15 to 35 Gy could be achieved with three-field conventional RT, increasing to 80% when IMRT is also added. CONCLUSIONS The cranial border of the CTV can safely be lowered for patients without expected nodal or CRM involvement, yielding a significant reduction of dose to the small bowel. Therefore, a significant reduction of acute and late toxicity can be expected.
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Affiliation(s)
- Jasper Nijkamp
- Department of Radiation Oncology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
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25
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Combination of a model-deformation method and a positional MRI to quantify the effects of posture on the anatomical structures of the trunk. J Biomech 2010; 43:1269-78. [DOI: 10.1016/j.jbiomech.2010.01.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2009] [Revised: 01/27/2010] [Accepted: 01/27/2010] [Indexed: 11/22/2022]
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26
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Theis V, Sripadam R, Ramani V, Lal S. Chronic Radiation Enteritis. Clin Oncol (R Coll Radiol) 2010; 22:70-83. [DOI: 10.1016/j.clon.2009.10.003] [Citation(s) in RCA: 131] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2009] [Revised: 09/01/2009] [Accepted: 09/22/2009] [Indexed: 02/07/2023]
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27
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Nijkamp J, de Jong R, Sonke JJ, van Vliet C, Marijnen C. Target volume shape variation during irradiation of rectal cancer patients in supine position: Comparison with prone position. Radiother Oncol 2009; 93:285-92. [DOI: 10.1016/j.radonc.2009.08.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2009] [Revised: 07/27/2009] [Accepted: 08/11/2009] [Indexed: 11/25/2022]
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28
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Jhaveri PM, Teh BS, Paulino AC, Smiedala MJ, Fahy B, Grant W, McGary J, Butler EB. Helical Tomotherapy Significantly Reduces Dose to Normal Tissues When Compared to 3D-CRT for Locally Advanced Rectal Cancer. Technol Cancer Res Treat 2009; 8:379-85. [DOI: 10.1177/153303460900800508] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Combined modality treatment (neoadjuvant chemoradiotherapy followed by surgery) for locally advanced rectal cancer requires special attention to various organs at risk (OAR). As a result, the use of conformal dose delivery methods has become more common in this disease setting. Helical tomotherapy is an image-guided intensity modulated delivery system that delivers dose in a fan-beam manner at 7 degree intervals around the patient and can potentially limit normal tissue from high dose radiation while adequately treating targets. In this study we dosimetrically compare helical tomotherapy to 3D-CRT for stage T3 rectal cancer. The helical tomotherapy plans were optimized in the TomoPlan system to achieve an equivalent uniform dose of 45 Gy for 10 patients with T3N0M0 disease that was at least 5cm from the anal verge. The GTV included the rectal thickening and mass evident on colonoscopy and CT scan as well as with the help of a colorectal surgeon. The CTV included the internal iliac, obturator, and pre-sacral lymphatic chains. The OAR that were outlined included the small bowel, pelvic bone marrow, femoral heads, and bladder. Anatom-e system was used to assist in delineating GTV, CTV and OAR. These 10 plans were then duplicated and optimized into 3-field 3D-CRT plans within the Pinnacle planning system. The V[45], V[40], V[30], V[20], V[10], and mean dose to the OAR were compared between the helical tomotherapy and 3D-CRT plans. Statistically significant differences were achieved in the doses to all OAR, including all volumes and means except for V[10] for the small bowel and the femoral heads. Adequate dosimetric coverage of targets were achieved with both helical tomotherapy and 3D-CRT. Helical tomotherapy reduces the volume of normal tissue receiving high-dose RT when compared to 3D-CRT treatment. Both modalities adequately dose the tumor. Clinical studies addressing the dosimetric benefits are on-going.
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Affiliation(s)
- Pavan M. Jhaveri
- Baylor College of Medicine Department of Radiology, Section of Radiation Oncology One Baylor Plaza, Houston TX, 77030, USA
| | - Bin S. Teh
- The Methodist Hospital Department of Radiation Oncology,
- The Methodist Hospital Research Institute, 6565 Fannin, Houston, TX, 77030, USA
| | - Arnold C. Paulino
- The Methodist Hospital Department of Radiation Oncology,
- The Methodist Hospital Research Institute, 6565 Fannin, Houston, TX, 77030, USA
| | | | - Bridget Fahy
- The Methodist Hospital, Department of Surgery 6550 Fannin, Smith #1661 Houston, TX, 77030, USA
| | - Walter Grant
- Baylor College of Medicine Department of Radiology, Section of Radiation Oncology One Baylor Plaza, Houston TX, 77030, USA
| | - John McGary
- Baylor College of Medicine Department of Radiology, Section of Radiation Oncology One Baylor Plaza, Houston TX, 77030, USA
| | - E. Brian Butler
- The Methodist Hospital Department of Radiation Oncology,
- The Methodist Hospital Research Institute, 6565 Fannin, Houston, TX, 77030, USA
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Robertson JM, Campbell JP, Yan D. Generic Planning Target Margin for Rectal Cancer Treatment Setup Variation. Int J Radiat Oncol Biol Phys 2009; 74:1470-5. [DOI: 10.1016/j.ijrobp.2008.10.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2008] [Revised: 09/25/2008] [Accepted: 10/07/2008] [Indexed: 10/21/2022]
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30
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Drzymala M, Hawkins MA, Henrys AJ, Bedford J, Norman A, Tait DM. The effect of treatment position, prone or supine, on dose-volume histograms for pelvic radiotherapy in patients with rectal cancer. Br J Radiol 2009; 82:321-7. [PMID: 19188240 DOI: 10.1259/bjr/57848689] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Patients undergoing radiotherapy for rectal cancer are generally treated in a prone position, with a full bladder, to reduce the volume of normal bowel in the high-dose volume. This position is difficult to maintain, and is not consistently reproducible. This study evaluates the volume of bowel and dose received in the prone and supine positions in patients undergoing pre-operative rectal cancer chemoradiation. Using CT planning, 19 consecutive patients with rectal cancer with a full bladder underwent CT scanning first in the prone position and then immediately afterwards in the supine position. The planning target volume was outlined for the prone position and transcribed to the supine scan using pre-set criteria. The bladder and small bowel were outlined in both positions. Radiotherapy was planned using three-dimensional conformal planning, and treatment was delivered using three fields with multileaf collimators in two phases: phase I, pelvis 45 Gy/25 fractions; and phase II, tumour 9 Gy/five fractions. For both positions, the volume of bowel receiving doses in 5 Gy increments from 5-45 Gy was calculated using dose-volume histograms. At 5 Gy and 10 Gy dose levels, a significantly higher volume of bowel was irradiated in the supine position (p<0.001). At 15 Gy, it was marginally significant (p = 0.018). From 20-45 Gy, there was no significant difference in the volume of bowel irradiated with each 5 Gy increment. This study demonstrates that the volume of bowel irradiated at doses associated with bowel toxicity in concurrent chemoradiation is not significantly higher in the supine position. This position could be adopted for patients undergoing pre-operative rectal cancer chemoradiation.
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Affiliation(s)
- M Drzymala
- Department of Clinical Oncology, The Royal Marsden Foundation NHS Trust, Sutton, UK
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31
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Hille A, Herrmann MKA, Kertesz T, Christiansen H, Hermann RM, Pradier O, Schmidberger H, Hess CF. Sodium butyrate enemas in the treatment of acute radiation-induced proctitis in patients with prostate cancer and the impact on late proctitis. A prospective evaluation. Strahlenther Onkol 2008; 184:686-92. [PMID: 19107351 DOI: 10.1007/s00066-008-1896-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2008] [Accepted: 08/14/2008] [Indexed: 12/17/2022]
Abstract
PURPOSE To evaluate prospectively the effect of sodium butyrate enemas on the treatment of acute and the potential influence on late radiation-induced proctitis. PATIENTS AND METHODS 31 patients had been treated with sodium butyrate enemas for radiation-induced acute grade II proctitis which had developed after 40 Gy in median. During irradiation the toxicity was evaluated weekly by the Common Toxicity Criteria (CTC) and subsequently yearly by the RTOG (Radiation Therapy Oncology Group) and LENT-SOMA scale. RESULTS 23 of 31 patients (74%) experienced a decrease of CTC grade within 8 days on median. A statistical significant difference between the incidence and the severity of proctitis before start of treatment with sodium butyrate enemas compared to 14 days later and compared to the end of irradiation treatment course, respectively, was found. The median follow-up was 50 months. Twenty patients were recorded as suffering from no late proctitis symptom. Eleven patients suffered from grade I and 2 of these patients from grade II toxicity, too. No correlation was seen between the efficacy of butyrate enemas on acute proctitis and prevention or development of late toxicity, respectively. CONCLUSION Sodium butyrate enemas are effective in the treatment of acute radiation-induced proctitis in patients with prostate cancer but have no impact on the incidence and severity of late proctitis.
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Affiliation(s)
- Andrea Hille
- Department of Radiotherapy and Radiooncology, University Hospital, Goettingen, Germany.
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Siddiqui F, Shi C, Papanikolaou N, Fuss M. Image-guidance protocol comparison: supine and prone set-up accuracy for pelvic radiation therapy. Acta Oncol 2008; 47:1344-50. [PMID: 18663650 DOI: 10.1080/02841860802304564] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE To investigate the impact of prone versus supine patient set-up and use of various image-guidance protocols on residual set-up error for radiation therapy of pelvic malignancies. We aim to identify an optimal frequency and protocol for image-guidance. MATERIALS Using daily online image-guidance mega-voltage CT data from 30 patients (829 MVCT; 299 prone set-up on belly board, 530 supine set-up), we retrospectively assessed the impact of various image-guidance protocols on residual set-up error. We compared daily image-guidance with three different No Action Level protocols (NAL), alternate day image-guidance with running mean and weekly image-guidance. RESULTS Of 5 IGRT protocols analyzed, the protocol with the highest imaging frequency, alternate day imaging with a running mean (50% imaging frequency), provided the best set-up error reduction. This protocol would have reduced the average length of 3D corrective vector shifts derived from daily image-guidance from 15.2 and 13.5 mm for prone and supine set-up, to 5 and 5.4 mm, respectively. A NAL protocol, averaging shifts of the first 3 fractions (NAL3), would have reduced the respective set-up variability to 6.3 (prone), and 7.5 mm (supine). An extended NAL (eNAL) protocol, averaging shifts of the first 3 fractions plus weekly imaging, would have reduced the daily positioning variability to 6 mm for both prone and supine set-ups. Daily image-guidance yielded set-up corrections >10 mm in 64.3% for prone and 70.3% for supine position. Use of the NAL3 protocol would have reduced the respective frequency to 14.4%, and 21.2% for prone, and supine positioning. In comparison, the alternate day running mean protocol would have reduced the frequency of shifts >10 mm to 5.5% (prone), and 8.3% (supine), respectively. DISCUSSION In this comparison, high frequency image-guidance provided the highest benefit with respect to residual set-up errors. However, both NAL and eNAL protocols provided significant set-up error reduction with lowered imaging frequency. While the mean 3D vector of corrective shifts was longer for prone set-up compared to the supine set-up, using any image-guidance protocol would have reduced shifts for prone set-up to a greater extent than for the supine set-up. This indicates a greater risk for systematic set-up errors in prone set-up, and larger random errors using a supine patient set-up.
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Conformal and intensity-modulated radiotherapy for cervical cancer. Clin Oncol (R Coll Radiol) 2008; 20:417-25. [PMID: 18558480 DOI: 10.1016/j.clon.2008.04.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2008] [Revised: 04/01/2008] [Accepted: 04/17/2008] [Indexed: 12/28/2022]
Abstract
Three-dimensional radiotherapy planning techniques, including conformal radiotherapy and intensity-modulated radiotherapy, have potential for improving outcomes in cervical cancer. Accurate target volume definition is essential in order to maximise normal tissue sparing while minimising the risk of a geographical miss. This reduction in toxicity provides the option of dose escalation, particularly with simultaneous integrated boost intensity-modulated radiotherapy. The evidence for the current use and potential applications of these techniques in the treatment of cervical cancer are discussed.
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Gunnlaugsson A, Kjellén E, Nilsson P, Bendahl PO, Willner J, Johnsson A. Dose-volume relationships between enteritis and irradiated bowel volumes during 5-fluorouracil and oxaliplatin based chemoradiotherapy in locally advanced rectal cancer. Acta Oncol 2008; 46:937-44. [PMID: 17851844 DOI: 10.1080/02841860701317873] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE Radiation enteritis is the main acute side-effect during pelvic irradiation. The aim of this study was to quantify the dose-volume relationship between irradiated bowel volumes and acute enteritis during combined chemoradiotherapy for rectal cancer. MATERIAL AND METHODS Twenty-eight patients with locally advanced rectal cancer received chemoradiotherapy. The radiation therapy was given with a traditional multi-field technique to a total dose of 50 Gy, with concurrent 5-Fluorouracil (5-FU) and oxaliplatin (OXA) based chemotherapy. All patients underwent three-dimensional CT-based treatment planning. Individual loops of small and large bowel as well as a volume defined as "whole abdomen" were systematically contoured on each CT slice, and dose-volume histograms were generated. Diarrhea during treatment was scored retrospectively according to the NCR common Toxicity Criteria scale. RESULTS There was strong correlation between the occurrence of grade 2 + diarrhea and irradiated small bowel volume, most notably at dose > 15 Gy. Neither irradiated large bowel volume, nor irradiated "whole abdomen" volume correlated significantly with diarrhea. Clinical or treatment related factors such as age, gender, hypertension, previous surgery, enterostomy, or dose fractionation (1.8 vs. 2.0 Gy/fraction) did not correlate with grade 2 + diarrhea. DISCUSSION This study indicates a strong dose-volume relationship between small bowel volume and radiation enteritis during 5-FU-OXA-based chemoradiotherapy. These findings support the application of maneuvers to minimize small bowel irradiation, such as using a "belly board" or the use of IMRT technique aiming at keeping the small bowel volume receiving more than 15 Gy under 150 cc.
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Birgisson H, Påhlman L, Gunnarsson U, Glimelius B. Late adverse effects of radiation therapy for rectal cancer - a systematic overview. Acta Oncol 2008; 46:504-16. [PMID: 17497318 DOI: 10.1080/02841860701348670] [Citation(s) in RCA: 163] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE The use of radiation therapy (RT) together with improvement in the surgical treatment of rectal cancer improves survival and reduces the risk for local recurrences. Despite these benefits, the adverse effects of radiation therapy limit its use. The aim of this review was to present a comprehensive overview of published studies on late adverse effects related to the RT for rectal cancer. METHODS Meta-analyses, reviews, randomised clinical trials, cohort studies and case-control studies on late adverse effects, due to pre- or postoperative radiation therapy and chemo-radiotherapy for rectal cancer, were systematically searched. Most information was obtained from the randomised trials, especially those comparing preoperative short-course 5 x 5 Gy radiation therapy with surgery alone. RESULTS The late adverse effects due to RT were bowel obstructions; bowel dysfunction presented as faecal incontinence to gas, loose or solid stools, evacuation problems or urgency; and sexual dysfunction. However, fewer late adverse effects were reported in recent studies, which generally used smaller irradiated volumes and better irradiation techniques; although, one study revealed an increased risk for secondary cancers in irradiated patients. CONCLUSIONS These results stress the importance of careful patient selection for RT for rectal cancer. Improvements in the radiation technique should further be developed and the long-term follow-up of the randomised trials is the most important source of information on late adverse effects and should therefore be continued.
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Affiliation(s)
- Helgi Birgisson
- Department of Surgery, University Hospital, University of Uppsala, Uppsala, Sweden.
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Birgisson H, Påhlman L, Gunnarsson U, Glimelius B. Late gastrointestinal disorders after rectal cancer surgery with and without preoperative radiation therapy. Br J Surg 2008; 95:206-13. [PMID: 17849380 DOI: 10.1002/bjs.5918] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The aim of the study was to analyse late gastrointestinal disorders necessitating hospital admission following rectal cancer surgery and to determine their relationship to preoperative radiation therapy. METHODS Curatively treated patients participating in the Swedish Rectal Cancer Trial during 1987-1990, randomized to preoperative irradiation (454 patients) or surgery alone (454), were matched against the Swedish Hospital Discharge Registry. Hospital records for patients admitted with gastrointestinal diagnoses were reviewed. RESULTS Irradiated patients had an increased relative risk (RR) of late small bowel obstruction (RR 2.49 (95 per cent confidence interval (c.i.) 1.48 to 4.19)) and abdominal pain (RR 2.09 (95 per cent c.i. 1.03 to 4.24)) compared with patients treated by surgery alone. The risk of late small bowel obstruction requiring surgery was greatly increased (RR 7.42 (95 per cent c.i. 2.23 to 24.66)). Irradiated patients with postoperative anastomotic leakage were at increased risk for late small bowel obstruction (RR 2.99 (95 per cent c.i. 1.07 to 8.31)). The risk of small bowel obstruction was also related to the radiation technique and energy used. CONCLUSION Small bowel obstruction is more common in patients with rectal cancer treated with preoperative radiation therapy.
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Affiliation(s)
- H Birgisson
- Department of Surgery, Radiology and Clinical Immunology, University Hospital, University of Uppsala, Uppsala, Sweden.
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Hille A, Schmidt-Giese E, Hermann RM, Herrmann MKA, Rave-Fränk M, Schirmer M, Christiansen H, Hess CF, Ramadori G. A prospective study of faecal calprotectin and lactoferrin in the monitoring of acute radiation proctitis in prostate cancer treatment. Scand J Gastroenterol 2008; 43:52-8. [PMID: 18938774 DOI: 10.1080/00365520701579985] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Acute radiation proctitis is a relevant complication of pelvic radiation. The purpose of this study was to investigate two markers of gut inflammation as non-invasive diagnostic tools to evaluate acute radiation proctitis. MATERIAL AND METHODS Twenty patients who underwent radiotherapy for prostate cancer took part in this prospective study. Radiation-induced toxicity was evaluated weekly during radiotherapy in compliance with the CTC toxicity criteria. Stool samples from patients were examined before treatment, weekly during radiotherapy and 2 weeks after the end of radiotherapy using enzyme-linked immunosorbent assay for calprotectin and lactoferrin and correlated with the CTC toxicity. RESULTS Calprotectin and lactoferrin faecal values increased significantly during radiation treatment and decreased about 2 weeks after cessation of radiation. Faecal concentrations of calprotectin and lactoferrin correlated with the documented radiation proctitis symptoms (all grades together) in 15/20 patients (75%). With respect to changes in faecal concentrations and correspondence to proctitis symptoms, both markers showed parallel results in 90% of the patients. On comparing calprotectin and lactoferrin concentrations between the 4th week of radiation and the 1st week, it was found that patients with any grade of toxicity exhibited a significantly higher increase in calprotectin (p = 0.044) and lactoferrin (p = 0.05), respectively, compared with those without toxicity. CONCLUSIONS Calprotectin and lactoferrin faecal values changed during radiation treatment and after cessation of radiation, with correlation to acute proctitis symptoms in most of the patients. Before markers are used to monitor acute radiation proctitis, further experience should be acquired. Patients will be followed to determine the predictive value of the two tested markers for chronic radiation proctitis.
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Affiliation(s)
- Andrea Hille
- Department of Radiotherapy and Radio-oncology, University of Göttingen, Göttingen, Germany.
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Kim JY, Kim DY, Kim TH, Park SY, Lee SB, Shin KH, Pyo H, Kim JY, Cho KH. Intensity-modulated radiotherapy with a belly board for rectal cancer. Int J Colorectal Dis 2007; 22:373-9. [PMID: 16802067 DOI: 10.1007/s00384-006-0166-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2006] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIM Intensity-modulated radiotherapy (IMRT) techniques can reduce the irradiated small bowel volume in rectal cancer patients, but combined use of IMRT and a belly board is yet to be reported on for rectal cancer patients. The aim of this study was to determine whether additional use of a belly board reduced the irradiated small bowel volume observed using IMRT alone in rectal cancer patients. MATERIALS AND METHODS Twenty patients scheduled to receive preoperative radiotherapy for rectal cancer underwent two series of CT scans, with and without a belly board. IMRT planning was performed using 6-MV photon beams and seven equispaced fields. The bladder, small bowel, and planning target volume (PTV) were analyzed for doses between 10% and 100% of the prescribed dose at 10% intervals. Data were analyzed using Wilcoxon signed rank tests. RESULTS There were no significant differences between patients undergoing IMRT with a belly board and those without a belly board in terms of total small bowel volumes, bladder, and PTV (p=0.571, p=0.841, and p=0.870, respectively). Statistical analysis showed that the irradiated small bowel volume with a belly board was smaller than that without a belly board (p<0.05 at 20-100% dose levels), with the mean relative reduction in the irradiated small bowel volume being 37.8+/-32.8%. CONCLUSION IMRT with a belly board is more effective than IMRT alone in reducing the irradiated small bowel volume. These findings suggest that the use of a belly board with IMRT may reduce small bowel complications in preoperative radiotherapy.
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Affiliation(s)
- Joo Young Kim
- Research Institute and Hospital, National Cancer Center, Goyang, South Korea
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Beriwal S, Jain SK, Heron DE, de Andrade RS, Lin CJ, Kim H. Dosimetric and toxicity comparison between prone and supine position IMRT for endometrial cancer. Int J Radiat Oncol Biol Phys 2007; 67:485-9. [PMID: 17084548 DOI: 10.1016/j.ijrobp.2006.08.067] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2006] [Revised: 08/28/2006] [Accepted: 08/28/2006] [Indexed: 10/24/2022]
Abstract
PURPOSE To determine the dosimetric and toxicity differences between prone and supine position intensity-modulate radiotherapy in endometrial cancer patients treated with adjuvant radiotherapy. METHODS Forty-seven consecutive endometrial cancer patients treated with adjuvant RT were analyzed. Of these, 21 were treated in prone position and 26 in the supine position. Dose-volume histograms for normal tissue structures and targets were compared between the two groups. Acute and chronic toxicity were also compared between the cohorts. RESULTS The percentage of volume receiving 10, 20, 30, 40, 45, and 50 Gy for small bowel was 89.5%, 69%, 33%, 12.2%, 5%, and 0% in the prone group and 87.5%, 62.7%, 26.4%, 8%, 4.3%, and 0% in the supine group, respectively. The difference was not statistically significant. The dose-volume histograms for bladder and rectum were also comparable, except for a slightly greater percentage of volume receiving 10 Gy (1.5%) and 20 Gy (5%) for the rectum in the prone group. Acute small bowel toxicities were Grade 1 in 7 patients and Grade 2 in 14 patients in the prone group vs. Grade 1 in 6 patients and Grade 2 in 19 patients in the supine group. Chronic toxicity was Grade 1 in 7 patients and Grade 3 in 1 patient in the prone group and Grade 1 in 5 patients in the supine group. CONCLUSION These preliminary results suggest that no difference exists in the dose to the normal tissue and toxicity between prone and supine intensity-modulated radiotherapy for endometrial cancer. Longer follow-up and more outcome studies are needed to determine whether any differences exist between the two approaches.
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Affiliation(s)
- Sushil Beriwal
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA.
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Gervaz P, Lavertu S, Kazemba B, Pemberton JH, Haddock MG, Gunderson LL. Sphincter-preserving radiation therapy for rectal cancer: a simulation study using three-dimensional computerized technology. Colorectal Dis 2006; 8:570-4. [PMID: 16919108 DOI: 10.1111/j.1463-1318.2006.01015.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The acquisition of detailed computerized tomography (CT) imaging at the time of simulation, along with three-dimensional (3D) treatment planning software has been integrated with radiation delivery hardware to create the modality known as 3D conformal radiotherapy (3DXRT). This approach provides, in theory, a means to selectively subtract the anal sphincter from the high-dose field of irradiation in patients with stage II and III adenocarcinomas of the mid-rectum scheduled for low anterior resection (LAR). HYPOTHESIS Implementation of 3DXRT with sphincter blocking may be a feasible strategy to reduce the dose of radiation distributed to the anal canal without reduction in the dose distribution to the gross tumour volume (GTV) plus adequate margins. METHODS Pretreatment simulation CT scans of 10 patients with rectal cancers located between 5 and 10 cm from the anal verge were retrieved from a computerized database. Radiation oncologists and colorectal surgeons defined the contours of the GTV and the anal sphincter, respectively, on successive CT scan slices. These contours provided the volumetric data required to quantify dose distribution and compute dose-volume histograms. The standard mode of pelvic irradiation planned with CT simulation was compared with a 'virtual CT simulation' approach, in which a sphincter block was added to the protocol. RESULTS The mean distance of tumours from the anal verge was 6.3 cm. In the virtual simulation treatment plan, a 2-cm margin separated the sphincter block from the lower limit of the GTV. The mean volume of the anal sphincter was 16.1 +/- 3.5 cm(3). The dose distributed to the GTV in the real plan and in the virtual simulated block plan were 51.7 +/- 1.4 and 51.6 +/- 1.4 Gy respectively (P = 0.85). By comparison the mean dose distributed to the anal sphincter was dramatically reduced by using a sphincter block (33.2 +/- 12 Gy vs 6.4 +/- 4.1 Gy, P < 0.001). CONCLUSION During a course of radiotherapy for most low- or mid-rectal cancers, the anal canal is included within the field of irradiation with a mean dose distribution to the sphincter of 33 Gy. Evaluation of 3DXRT with full sphincter block (mid-rectum) and partial sphincter block (distal rectum) is a feasible strategy to decrease the volume of anal sphincter carried to full dose without reduction in dose to the GTV. This approach, by minimizing treatment-induced damage to the anal sphincter, might improve functional outcome of LAR.
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Affiliation(s)
- P Gervaz
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA
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Lee SH, Kim TH, Kim DY, Cho KH, Kim JY, Park SY, Kim DH, Lim SB, Choi HS, Chang HJ. The Effect of Belly Board Location in Rectal Cancer Patients Treated with Preoperative Radiotherapy. Clin Oncol (R Coll Radiol) 2006; 18:441-6. [PMID: 16909966 DOI: 10.1016/j.clon.2006.05.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
AIMS To evaluate the effect of the belly board aperture location on the irradiated small bowel volume in rectal cancer patients treated with preoperative pelvic radiotherapy. MATERIALS AND METHODS Twenty patients with rectal cancer scheduled to receive preoperative pelvic radiotherapy were evaluated prospectively. Each patient underwent computed tomography with the belly board aperture lower border at three different locations relative to patient anatomy: the lumbosacral junction (location I), the lower end of the sacroiliac joint (location II) and the upper end of the symphysis pubis (location III). The irradiated small bowel volume was calculated for doses between 10 and 100% of the prescribed dose at 10% intervals. For each 10% dose increment, the effect of the belly board aperture at the three different locations on the irradiated small bowel volume was analysed using Wilcoxon signed rank and Wilcoxon rank sum tests. RESULTS At 10-20% dose levels, the irradiated small bowel volume increased in the order of locations I, II and III, and the differences between each location were significant. At > or = 30% dose levels, the irradiated small bowel volume increased in the order of locations III, II and I, and the differences between locations I and II were significant, but the differences between locations II and III were not significant. CONCLUSION The belly board aperture location can influence the irradiated small bowel volume differently at each dose level. When considering the use of a belly board in routine clinical practice, we recommend that the clinician take into account the patterns of irradiated small bowel volume according to belly board aperture location.
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Affiliation(s)
- Seok Ho Lee
- Research Institute and Hospital, National Cancer Centre, Goyang, Republic of Korea
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Tho LM, Glegg M, Paterson J, Yap C, MacLeod A, McCabe M, McDonald AC. Acute small bowel toxicity and preoperative chemoradiotherapy for rectal cancer: investigating dose-volume relationships and role for inverse planning. Int J Radiat Oncol Biol Phys 2006; 66:505-13. [PMID: 16879928 DOI: 10.1016/j.ijrobp.2006.05.005] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2006] [Revised: 05/05/2006] [Accepted: 05/06/2006] [Indexed: 02/07/2023]
Abstract
PURPOSE The relationship between volume of irradiated small bowel (VSB) and acute toxicity in rectal cancer radiotherapy is poorly quantified, particularly in patients receiving concurrent preoperative chemoradiotherapy. Using treatment planning data, we studied a series of such patients. METHODS AND MATERIALS Details of 41 patients with locally advanced rectal cancer were reviewed. All received 45 Gy in 25 fractions over 5 weeks, 3-4 fields three-dimensional conformal radiotherapy with daily 5-fluorouracil and folinic acid during Weeks 1 and 5. Toxicity was assessed prospectively in a weekly clinic. Using computed tomography planning software, the VSB was determined at 5 Gy dose intervals (V5, V10, etc.). Eight patients with maximal VSB had dosimetry and radiobiological modeling outcomes compared between inverse and conformal three-dimensional planning. RESULTS VSB correlated strongly with diarrheal severity at every dose level (p<0.03), with strongest correlation at lowest doses. Median VSB differed significantly between patients experiencing Grade 0-1 and Grade 2-4 diarrhea (p<or=0.05). No correlation was found with anorexia, nausea, vomiting, abdominal cramps, age, body mass index, sex, tumor position, or number of fields. Analysis of 8 patients showed that inverse planning reduced median dose to small bowel by 5.1 Gy (p=0.008) and calculated late normal tissue complication probability (NTCP) by 67% (p=0.016). We constructed a model using mathematical analysis to predict for acute diarrhea occurring at V5 and V15. CONCLUSIONS A strong dose-volume relationship exists between VSB and acute diarrhea at all dose levels during preoperative chemoradiotherapy. Our constructed model may be useful in predicting toxicity, and this has been derived without the confounding influence of surgical excision on bowel function. Inverse planning can reduce calculated dose to small bowel and late NTCP, and its clinical role warrants further investigation.
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Affiliation(s)
- Lye Mun Tho
- Colorectal Cancer Team, Beatson Oncology Centre, Western Infirmary, University of Glasgow, United Kingdom.
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Guerrero Urbano MT, Henrys AJ, Adams EJ, Norman AR, Bedford JL, Harrington KJ, Nutting CM, Dearnaley DP, Tait DM. Intensity-modulated radiotherapy in patients with locally advanced rectal cancer reduces volume of bowel treated to high dose levels. Int J Radiat Oncol Biol Phys 2006; 65:907-16. [PMID: 16751073 DOI: 10.1016/j.ijrobp.2005.12.056] [Citation(s) in RCA: 145] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2005] [Revised: 12/06/2005] [Accepted: 12/06/2005] [Indexed: 11/19/2022]
Abstract
PURPOSE To investigate the potential for intensity-modulated radiotherapy (IMRT) to spare the bowel in rectal tumors. METHODS AND MATERIALS The targets (pelvic nodal and rectal volumes), bowel, and bladder were outlined in 5 patients. All had conventional, three-dimensional conformal RT and forward-planned multisegment three-field IMRT plans compared with inverse-planned simultaneous integrated boost nine-field equally spaced IMRT plans. Equally spaced seven-field and five-field and five-field, customized, segmented IMRT plans were also evaluated. RESULTS Ninety-five percent of the prescribed dose covered at least 95% of both planning target volumes using all but the conventional plan (mean primary and pelvic planning target volume receiving 95% of the prescribed dose was 32.8 +/- 13.7 Gy and 23.7 +/- 4.87 Gy, respectively), reflecting a significant lack of coverage. The three-field forward planned IMRT plans reduced the volume of bowel irradiated to 45 Gy and 50 Gy by 26% +/- 16% and 42% +/- 27% compared with three-dimensional conformal RT. Additional reductions to 69 +/- 51 cm(3) to 45 Gy and 20 +/- 21 cm(3) to 50 Gy were obtained with the nine-field equally spaced IMRT plans-64% +/- 11% and 64% +/- 20% reductions compared with three-dimensional conformal RT. Reducing the number of beams and customizing the angles for the five-field equally spaced IMRT plan did not significantly reduce bowel sparing. CONCLUSION The bowel volume irradiated to 45 Gy and 50 Gy was significantly reduced with IMRT, which could potentially lead to less bowel toxicity. Reducing the number of beams did not reduce bowel sparing and the five-field customized segmented IMRT plan is a reasonable technique to be tested in clinical trials.
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Burton S, Brown G, Daniels I, Norman A, Swift I, Abulafi M, Wotherspoon A, Tait D. MRI identified prognostic features of tumors in distal sigmoid, rectosigmoid, and upper rectum: treatment with radiotherapy and chemotherapy. Int J Radiat Oncol Biol Phys 2006; 65:445-51. [PMID: 16690432 DOI: 10.1016/j.ijrobp.2005.12.027] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2005] [Revised: 12/15/2005] [Accepted: 12/15/2005] [Indexed: 02/07/2023]
Abstract
PURPOSE Neoadjuvant therapy is traditionally reserved for locally advanced mid and low rectal cancers. In tumors above this level, the need for adjuvant treatment is based on poor histopathologic features, but this approach has potential disadvantages. The aim of this study was to determine whether magnetic resonance imaging (MRI) could accurately stage tumors of the distal sigmoid, rectosigmoid, and upper rectum and help direct preoperative treatment. MATERIALS AND METHODS A total of 75 patients with distal sigmoid, rectosigmoid, and upper rectal tumors were assessed preoperatively by MRI. If tumor extended beyond the planned surgical resection plane, chemoradiotherapy was offered. RESULTS Of the 75 patients, 57 (76%) underwent primary surgery. Agreement between the MRI prognosis and histopathologic findings was 84% (95% confidence interval [CI], 72.6-92.7%). The other 18 patients underwent neoadjuvant chemoradiotherapy for poor prognostic features with predicted surgical resection margin involvement. The histopathologic examination confirmed tumor downstaging in 9 of the 18 patients who underwent chemoradiotherapy. The 3-year survival rate in the good prognosis group (91%; 95% CI, 77.1-97.3%) was not significantly different from that of the chemoradiotherapy group (81.4%; 95% CI, 52.4-93.6%). The poor prognosis group undergoing primary surgery had significantly worse survival (62.2%; 95% CI, 30.3-82.8%, p < 0.03). CONCLUSION Our findings indicate that tumors of the distal sigmoid, rectosigmoid, and upper rectum can be staged accurately using high spatial resolution MRI and that those with poor prognostic disease may benefit from preoperative therapy.
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Affiliation(s)
- Sarah Burton
- Division of Colorectal Surgery, Mayday University Hospital, Croydon, UK
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Guckenberger M, Flentje M. Late small bowel toxicity after adjuvant treatment for rectal cancer. Int J Colorectal Dis 2006; 21:209-20. [PMID: 16052309 DOI: 10.1007/s00384-005-0765-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/17/2005] [Indexed: 02/04/2023]
Abstract
BACKGROUND For locally advanced rectal cancer surgery as sole treatment results in poor local control and survival. After adjuvant radiotherapy for locally advanced rectal cancer, small bowel toxicity has been the most frequent and serious side effect. The gain in survival and local control was accompanied by severe late chronic toxicity reducing the benefit of adjuvant treatment. REVIEW Clinical factors, pathology and treatment of late small bowel toxicity after adjuvant radiotherapy for locally advanced rectal cancer will be discussed. This review will focus on different surgical and radiotherapeutic means reducing the risk of late small bowel damage.
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Affiliation(s)
- Matthias Guckenberger
- Department of Radiation Oncology, Klinik und Poliklinik für Strahlentherapie der Universität Würzburg, Josef-Schneider-Strasse 11, 97080 Würzburg, Germany.
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Combination of prone position and intensity-modulated radiation therapy (IMRT) reduces small bowel doses in radiation therapy for gynecologic malignancies. Chin J Cancer Res 2006. [DOI: 10.1007/s11670-006-0051-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Hille A, Schmidberger H, Hermann RM, Christiansen H, Saile B, Pradier O, Hess CF. A phase III randomized, placebo-controlled, double-blind study of misoprostol rectal suppositories to prevent acute radiation proctitis in patients with prostate cancer. Int J Radiat Oncol Biol Phys 2005; 63:1488-93. [PMID: 16137837 DOI: 10.1016/j.ijrobp.2005.05.063] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2004] [Revised: 05/25/2005] [Accepted: 05/26/2005] [Indexed: 01/21/2023]
Abstract
PURPOSE Acute radiation proctitis is the most relevant complication of pelvic radiation and is still mainly treated supportively. Considering the negative impact of acute proctitis symptoms on patients' daily activities and the potential relationship between the severity of acute radiation injury and late damage, misoprostol was tested in the prevention of acute radiation-induced proctitis. METHODS AND MATERIALS A total of 100 patients who underwent radiotherapy for prostate cancer were entered into this phase III randomized, placebo-controlled, double-blind study with misoprostol or placebo suppositories. Radiation-induced toxicity was evaluated weekly during radiotherapy using the Common Toxicity Criteria. RESULTS Between the placebo and the misoprostol groups, no significant differences in proctitis symptoms occurred: 76% of patients in each group had Grade 1 toxicity, and 26% in the placebo group and 36% in the misoprostol group had Grade 2 toxicity. No differences were found in onset or symptom duration. Comparing the peak incidence of patients' toxicity symptoms, significantly more patients experienced rectal bleeding in the misoprostol group (p = 0.03). CONCLUSION Misoprostol given as a once-daily suppository did not decrease the incidence and severity of radiation-induced acute proctitis and may increase the incidence of acute bleeding.
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Affiliation(s)
- Andrea Hille
- Department of Radiotherapy and Radiooncology, University of Goettingen, Goettingen, Germany.
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Jahraus CD, Bettenhausen D, Malik U, Sellitti M, St Clair WH. Prevention of acute radiation-induced proctosigmoiditis by balsalazide: a randomized, double-blind, placebo controlled trial in prostate cancer patients. Int J Radiat Oncol Biol Phys 2005; 63:1483-7. [PMID: 16099600 DOI: 10.1016/j.ijrobp.2005.04.032] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2005] [Revised: 04/28/2005] [Accepted: 04/28/2005] [Indexed: 12/20/2022]
Abstract
PURPOSE A common complication of pelvic radiotherapy (RT) is acute radiation-induced proctosigmoiditis (RIPS), for which a multitude of therapies have been tried. The 5-aminosalicylates (5-ASA), which are traditionally used to treat inflammatory bowel disease, have been tested; however, all but one prior randomized attempt to limit or prevent RIPS with 5-ASA-type agents have failed. We sought to evaluate balsalazide, a new 5-ASA drug, for its potential to prevent or limit RIPS in patients undergoing RT for carcinoma of the prostate, as a representative sample of pelvic RT patients. Balsalazide has a unique delivery system in that 99% of ingested drug is delivered to and activated in the colon, a higher yield than all other oral agents currently available in this class. Furthermore, it lacks the antigenic sulfa moiety present in sulfasalazine, the only other 5-ASA with demonstrated benefit in this setting. Thus, it was deemed an ideal candidate for preventing or limiting RIPS. METHODS AND MATERIALS Eligible patients included prostate cancer patients, American Joint Committee on Cancer Stage T1-3, M0 being treated with external beam radiotherapy in the University of Kentucky Department of Radiation Medicine. Between January 1, 2003 and July 1, 2004, 27 eligible patients were enrolled in the study. Patients were administered 2250 mg of balsalazide or an identical-appearing placebo twice daily beginning 5 days before RT and continuing for 2 weeks after completion. Toxicities were graded weekly according to National Cancer Institute Common Toxicity Criteria v. 2.0 for each of the following: proctitis, diarrhea, dysuria, weight loss, fatigue, nausea, and vomiting. A symptom index was formulated for each toxicity consisting of the toxicity's numeric grade multiplied by the number of days it was experienced, and summed for each grade experienced throughout the course of RT. RESULTS With the exception of nausea or vomiting, seen in 3 patients on balsalazide and 2 on placebo, all toxicities were appreciably lower in patients taking balsalazide. Proctitis was prevented most significantly with a mean proctitis index of 35.3 in balsalazide patients and 74.1 in placebo patients (p = 0.04). Placebo patients lost an average of 2.7 pounds, whereas balsalazide patients on average gained weight. Unexpectedly, dysuria was also lower in balsalazide-treated patients. CONCLUSIONS Balsalazide is a new-generation 5-ASA drug that yields a high concentration of active drug to the distal colon. Results of this pilot study suggest that it is able to prevent or reduce symptoms of RIPS in patients undergoing RT for prostate cancer. We feel that these results justify the formation of a cooperative group trial to assess its efficacy in a multi-institutional setting.
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Affiliation(s)
- Christopher D Jahraus
- Department of Radiation Medicine, University of Kentucky College of Medicine, Lexington, KY, USA.
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Kim TH, Chie EK, Kim DY, Park SY, Cho KH, Jung KH, Kim YH, Sohn DK, Jeong SY, Park JG. Comparison of the belly board device method and the distended bladder method for reducing irradiated small bowel volumes in preoperative radiotherapy of rectal cancer patients. Int J Radiat Oncol Biol Phys 2005; 62:769-75. [PMID: 15936558 DOI: 10.1016/j.ijrobp.2004.11.015] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2004] [Revised: 11/02/2004] [Accepted: 11/03/2004] [Indexed: 11/21/2022]
Abstract
PURPOSE To determine the most effective method to reduce the irradiated small bowel volume when using a belly board device (BBD), a distended bladder (DB), or both in patients with rectal cancer undergoing preoperative pelvic radiotherapy (RT). METHODS AND MATERIALS The study involved 20 patients with rectal cancer who were scheduled to receive preoperative pelvic RT. Patients were asked to empty their bladders and then drink 300 mL of water 2 h before the treatment planning computed tomographic (CT) scan. To identify the small bowel, an oral contrast solution (450 mL) was given 1 h before the CT scan. Two sets of transverse images were taken at 1-cm-thickness intervals with patients in the prone position with or without the BBD. After voiding, two additional sets of CT scans were obtained in prone positions with or without BBD. The conventional three-field treatment plan, composed of a 6-MV photon posterior-anterior field and 15-MV photon opposed lateral fields with wedges of 45 degrees, was made using a three-dimensional treatment planning system. The beam weights of the three-field plan were equal. The volume of irradiated small bowel was calculated for doses between 10% and 100% of the prescribed dose at 10% intervals. For each 10% dose increment, the effect of the BBD and the DB on the irradiated volume was analyzed using Kruskal-Wallis, Wilcoxon signed rank, and Wilcoxon rank-sum tests. RESULTS All patients underwent four sets of CT scan under the conditions of four different methods as follows: Group I = empty bladder without the use of belly board; Group II = empty bladder with the use of belly board; Group III = distended bladder without the use of belly board; Group IV = distended bladder with the use of belly board. We found that the volume of irradiated small bowel decreased in the order of Group I, Group II, Group III, and Group IV at all dose levels (p < 0.05). Compared with Group I, the mean volume reduction rate (reduced volume) of irradiated small bowel in Group II varied between 14.5% and 65.4% (15.5-80.4 cm(3)), in Group III it varied between 48.1% and 82.0% (21.6-163.1 cm(3)), and in Group IV between 51.4% and 96.4% (28.6-167.1 cm(3)). CONCLUSIONS The DB was more effective than the BBD for reducing the volume of irradiated small bowel in rectal cancer patients receiving pelvic RT. The combination of the BBD and DB showed an additive effect and was the most effective method for reducing the irradiated small bowel volume.
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Affiliation(s)
- Tae Hyun Kim
- Research Institute and Hospital, National Cancer Center, Goyang, Gyeonggi, South Korea
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Martin J, Fitzpatrick K, Horan G, McCloy R, Buckney S, O'Neill L, Faul C. Treatment with a belly-board device significantly reduces the volume of small bowel irradiated and results in low acute toxicity in adjuvant radiotherapy for gynecologic cancer: results of a prospective study. Radiother Oncol 2005; 74:267-74. [PMID: 15763307 DOI: 10.1016/j.radonc.2004.11.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2004] [Revised: 10/20/2004] [Accepted: 11/03/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND PURPOSE To determine whether treatment prone on a belly-board significantly reduces the volume of small bowel irradiated in women receiving adjuvant radiotherapy for gynecologic cancer, and to prospectively study acute small bowel toxicity using an accepted recording instrument. MATERIAL AND METHODS Thirty-two gynecologic patients underwent simulation with CT scanning supine and prone. Small bowel was delineated on every CT slice, and treatment was prone on the belly-board using 3-5 fields-typically Anterior, Right and Left Lateral, plus or minus Lateral Boosts. Median prescribed dose was 50.4 Gy and all treatments were delivered in 1.8 Gy fractions. Concomitant Cisplatin was administered in 13 patients with cervical carcinoma. Comparison of small bowel dose-volumes was made between supine and prone, with each subject acting as their own matched pair. Acute small bowel toxicity was prospectively measured using the Common Toxicity Criteria: Version 2.0. RESULTS Treatment prone on the belly-board significantly reduced the volume of small bowel receiving > or = 100; > or = 95; > or = 90; and > or = 80% of the prescribed dose, but not > or = 50%. This was found whether volume was defined in cubic centimeters or % of total small bowel volume. Of 29 evaluable subjects, 2 (7%) experienced 1 episode each of grade 3 diarrhoea. All other toxicity events were grade 2 or less and comprised diarrhoea (59%), abdominal pain or cramping (48%), nausea (38%), anorexia (17%), vomiting (10%). There were no Grade 4 events and no treatment days were lost due to toxicity. CONCLUSIONS Treatment prone on a belly-board device results in significant small bowel sparing, during adjuvant radiotherapy for gynecologic cancer. The absence of Grade 4 events or Treatment Days Lost compares favorably with the published literature.
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Affiliation(s)
- Joseph Martin
- Department of Radiation Oncology, Princess Margaret Hospital, 5th Floor, 610 University Avenue, Toronto, Ont., Canada M5G 2M9
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